COVID-19 Digital Ambulatory Solutions

COVID-19 Digital Ambulatory Solutions Workgroup* (pending better name)

Group Leaders:

Julia Skapik, NACHC jskapik@nachc.com

Mindy Hangsleben, Telligen mhangsleben@telligen.com

Sharon Hibay, AHO, (clinical measures, evidence review, process design) shibay@archsystemsinc.com

 

Ground Rules:

  • Everyone should participate in the discussion as desired and multiple viewpoints make our output stronger

  • Mutual respect

  • Reuse don’t reinvent the wheel

  • Bring whatever resources you have to the table

  • The material created in this group will remain in the public domain and therefore should not be designated as intellectual property or commercialized without permission

Proposed use cases:

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

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.

  • Clinical SMEs to design/select workflow-- consider using CDC Clarabot +/- widget (Aaron)

    • Judson et al. at UCSF have just published in JAMIA a very relevant article on "....a patient self-triage and self-scheduling tool." (Elaine)

      • Consider patient self-scheduling tool

      • Epic patient portal workflow directs patients to options

      • Consider including in scope the administrative/coverage components (ie whether specific services are covered)

      • State Medicaid Agency (Brian K) in collaboration with OCHIN/Epic

  • VA collaboration (Virginia)

  • Engaging Kaiser?

  • KLAS published a report on tools for triaging COVID-19 (Andrew H)

  • https://asprtracie.hhs.gov/technical-resources/119/covid-19-hospital-triage-screening-resources/99

  • When a patient arrives at the clinic, there could be an in-person screening prior to their exposure to the clinic – this output could be integrated into the record

  • Fenway implementing ipad screeners which send alerts to the COVID team and pilots are in progress now (Chris G)

  • Standardized terminology for documentation of assessments, interventions, and outcomes is mapped for each provider/team member:  https://sites.google.com/view/omahasystemguidelines/covid-19-response

  •  

Use of self-administered surveys through QR code and same center telemedicine in a walk-in clinic in the era of COVID-19

Eduardo Perez-Alba, MD, Laura Nuzzolo-Shihadeh, MD, Jaime Eugenio Espinosa-Mora, MD, Adrián Camacho-Ortiz, MD

Journal of the American Medical Informatics Association, ocaa054, https://doi.org/10.1093/jamia/ocaa054

Published: 13 April 2020

 

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

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.

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.

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.

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

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.

 

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 HealthScreening Pandemic Support Assessment and Referral - by Sharon Hibay

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

06.05.2020 edits

Create a proactive Bio Psycho -Social Assessment of patients as a result of a pandemic from a wholistic case management perspective. (Added from initial share on webinar)

Bio - Medical

  • Chronic

  • Acute

  • New

  • COVID-19

  • Medication Adherence

Psycho - 

  • Existing MH

  • Social Isolation & Coping

  • New MH Needs

  • Beyond Normal

  • Self harm (needing immediate professional assistance)

Social -

  • Disease, Life & Living Density

  • Groceries & Hunger

  • Transportation

  • Access

    • Care

    • Medications

    • Equipment

  • Financial

    • Housing

    • Utilities

    • Other

  • Domestic Violence

    • Intimate Partner Safety

    • Child Abuse

AMA & UnitedHealth have created Z Codes for Social Determinants of Health may guide other health disparities information.

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.

Possible Constraints:

  • To create the predictive-analytic CDS tool which would power the solution, one must access a population that contains individuals who are uninfected, asymptomatic infected, and symptomatic infected and their EHR data

  • How to ensure the population to consistently wear the wearable

  • Funding to acquire wearables and build the needed database infrastructure

  • Time and effort required to get the research and development work through IRB approval at a clinical research organization

Possible link to use case for Risk Calculator for Existing Patients and Follow-Up Risk Reduction Tool

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

Organizational partners and home for content

ACTS – AHRQ-led initiative – COVID-19 website that shows the updates between guidance on the same sites day to day

C19HCC – MITRE-administered healthcare coalition

Home Care WG

ED/Inpatient/ICU WG - Link to join this group https://docs.google.com/spreadsheets/d/15ha2AkkOzMl33saZuqKUcGkWqoc-rPjl1WcUaJJme5Y/edit?usp=sharing

Manchester CPG site – converts paper guidelines to digital – follow up on COVID-19 content – @Jodi Wachs

ECRI Guidelines Trust – @Jeremy Michael-- updates on COVID guidelines-- summary content

Logica Health – COVID-19 FHIR IG –

ONC Interoperability Proving Ground – COVID-19 space

ONC ISA

ONC CRET , https://www.healthit.gov/sites/default/files/page/2020-02/ClinicalResponsethroughEmergingTechnologyCRET.pdf


ACS/ASA/AORN/AHA Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic: https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery @Joel Harder

American College of Surgeons "Local Resumption of Elective Surgery Guidance" (April 17, 2020): https://www.facs.org/covid-19/clinical-guidance/resuming-elective-surgery

 Alex Krist and colleagues identify 5 phases of pandemic care for primary care practices: https://deepblue.lib.umich.edu/bitstream/handle/2027.42/154687/Krist_deepblue.pdf

https://www.healthaffairs.org/do/10.1377/hblog20200415.293535/full/

 U Manchester team – if we arrive at a guidelines (or set of guidelines) to propose for use in the inpatient setting, the U Manchester team can evaluate for translation and specification, most likely into HL7 CQL (along the lines of the HL7 CPG IG). We suspect the best source of such guidelines may include the work underway in the AHRQ ACTS-Covid19 effort, perhaps among others.  http://mancar.co.uk/cpmgs.html

 

Next Steps

  • Team-members asked to provide feedback to the WG on the materials-- design plan, organizational partners

  • Updates to use cases by Thursday COB PT-- @Julia Skapik will send out poll for prioritization during the meeting and before or after for those who can’t attend

  • Plan for next meeting-- Friday April 24 10am ET to review use cases and discuss plan to create working teams and to define/refine the desired outcomes