How Texas Children’s Hospital successfully pivoted to eHealth amidst a global pandemic

Overview

Amidst the global COVID-19 pandemic, Texas Children’s Hospital rapidly innovated and expanded system-wide eHealth services to ensure the hospital could continue providing the best possible care to its patients. In this article, Dr. Robert Ball, medical director of eHealth at Texas Children’s and professor at Baylor College of Medicine, and Dr. Elizabeth Onugha, a pediatric nephrologist at Texas Children’s and assistant professor at Baylor College of Medicine, recount how they and their colleagues quickly and effectively pivoted to eHealth amid COVID-19.

How it all began: Texas Children’s measured foray into eHealth
Over the last few years, video visits were slowly becoming part of Texas Children’s approach to outpatient care, on a small scale.“About 40 providers performed about 15-20 visits a day. The plan was to systematically and slowly adopt video visits across departments in the system so we could learn from each rollout phase and perfect the model as we went along,” Ball said.

In the beginning of 2020, the Nephrology department, like several others at Texas Children’s, did not offer any virtual visits but, rather, had a steady flow of established and new patient in-person appointments. “That all changed by February, when our institutional and departmental leaders and staff started regular emergency meetings to get updates about a novel virus that was wrecking havoc in China. At that time, we still had no idea how widespread and damaging this event was going to become, or how dramatically it would alter the way we practice medicine and lead our lives,” Onugha shared.

The problem to solve: A burgeoning fear of medical settings
It wasn’t long after, by mid-March, many patients who were really sick and needed specialized procedures, like infusions, expressed fear of coming into even a safe hospital setting, and, at times would/would frequently, cancel or no-show appointments. Their fear was understandable - the pandemic was intensifying – cases and death counts were rising. Meanwhile, physicians and health care workers faced enormous challenges, not the least of which was the lack of credible information about how this virus was transmitted which led to anxiety about safety.

“Initially, my colleagues and I did some consultations over the phone, which was sufficient to refill prescriptions and answer urgent questions. This system worked well with established patients whose medical histories were known to us. However, in certain situations, and particularly for new patients, not being able to see them in person, limited our ability to provide comprehensive and high-quality care. At the same time, our list of referred patients was growing and, based on a review of their records, we knew a significant number had urgent or emergent issues – like nephrotic syndrome or kidney failure – which needed immediate intervention,” Onugha added.

Rapidly scaling up eHealth across a large health care system
With the COVID-19 pandemic bearing down on Texas, all providers at Texas Children’s were ready to jump onboard with eHealth options. The clinical staff prepared themselves for eHealth by taking webinars and online courses, doing mock visits amongst themselves and preparing as best they could to pivot their care models to virtual platforms quickly while ensuring the care delivered was as effective as in-person visits while maintaining the high quality standard Texas Children’s is recognized for. Simultaneously, the core eHealth team was urgently scaling up operations and infrastructure.

“We were fortunate that a core team was already in place and able, with the urgent help of many individuals across the system, to increase utilization exponentially. Within a few weeks, over 1,000 providers were completing thousands of eHealth visits a day. If the eHealth team, as small as we were at the start – three individuals, two of whom were full time employees – had not already existed, and technology and experience been in place, this would have been impossible, and we would have needed to outsource to get these solutions in place within such a short time,” Ball explained.

Fig 1: Rapid growth of eHealth visits during the pandemic

Another issue was that video visits and the software used to complete them were an unfamiliar territory for the vast majority of patients and providers before the pandemic. The speed with which both parties had to adopt and adapt, led to predictable challenges. A multipronged approach including online learning, emailing step-by-step instructions, having a separate dedicated help desk for providers and patients, in-person trainings, and online technology to test the hardware to be used during the visit, were all created in a short time to support the strategy and its success. In addition, in mid-May, a software upgrade allowed video visits to be initiated from within a patient’s electronic medical record, simplifying the process dramatically for both patients and providers.

Ensuring the quality of care patients know and trust via eHealth
“We had to come up with creative ways to examine our patients via video. We used parents as our surrogates to perform certain maneuvers, like palpating the abdomen of their child while looking at the child’s face and body language for signs of pain or discomfort. It is a little easier with older kids who can verbalize their symptoms. After a few minor glitches, our team and the families got into the flow of it and became experts at leveraging this new tech-savvy model for clinical care. By the end of March, eHealth visits accounted for 20% of our nephrology department’s total visits, which soon grew to 50% by May” Onugha explained.

The situation echoed throughout every department in the hospital system. While many patients still needed to be seen in-person for surgeries, procedures and infusions – including chemotherapy and dialysis, Texas Children’s provided care using eHealth options accounting for nearly 50% of the total completed provider appointments during the pandemic, and over 50% through the end of May; keeping all of those patient families safe at home.

eHealth expands across Texas Children’s health care system
In the outpatient setting, Texas Children’s Pediatrics (TCP) locations developed an eHealth model in early March to support all of its more than 50 sites across Houston and Austin. TCP trained 45 providers and made Saturday eHealth visits available with the goal of keeping COVID-19 out of their locations and to safely continue the management of children with chronic conditions. In May, TCP made on-demand scheduling for eHealth visits available via MyChart, a secure online health connection. Meanwhile, Texas Children’s Health Plan The Centers for Children and Women providers used AnywhereCare, an online, on-demand platform for urgent care visits in English and Spanish to meet the skyrocketing demand for virtual care. Other highlights of the pandemic-related growth of eHealth at Texas Children’s included creating a dedicated 24/7 COVID-19 triage phone line. Nurses would triage patients over the phone and refer patients for video visits as needed. This line fielded about 30 calls per day leading to 5-10 video visits, with very few needing an in-person encounter.

In the inpatient setting, Texas Children’s implemented eHealth to help keep patients and employees safe and conserve PPE. The hospital enabled chaplains, social workers and care coordinators to see inpatients by video and reduce infection risks. Pediatric subspecialists completed consults – sometimes from another campus – without entering the patient’s room. Physicians and medical staff engaged in eRounding, allowing large care teams to visit patients virtually, dramatically reducing the number of providers entering a room. Off-site family members were also able to visit the patient virtually, which was critical given visitor restrictions. Cardiac ICU, Neuro Critical Care, NICU and the pediatric hospitalists group were early adopters of these services.

Thus, concurrent implementation and evolution, and tireless efforts of countless individuals across the system, led to the success and speed of adoption of eHealth in a span of days to weeks, rather than months to years, by Texas Children’s and its patients and families.

Coordinated and comprehensive care delivered through eHealth

The physicians at Texas Children’s care for some of the most medically-complex pediatric cases. “Many of our patients need coordinated and simultaneous care from several specialists. We knew from the outset that the success of the eHealth approach hinged on our ability to allow collaboration of multiple specialists to jointly system to provide the most comprehensive care,” Ball said.

During the pandemic stay-at-home order period, many specialties across Texas Children’s achied weeks of 100% eHealth utilization, including care coordination, clinical psychology, diabetes education, lactation consultation, psychiatry, speech therapy and more.

eHealth also enabled Texas Children’s to continue the commitment to research and education during the pandemic, with over tens of thousands of eHealth appointments that included fellows, medical students, research staff, residents and others.

Fig 2: eHealth utilization by outpatient departments

Future of eHealth
Since this summer, our hospital has safely and steadily increased in-person appointments across all departments, but it is clear eHealth is here to stay. Even those who may have initially resisted eHealth options are now realizing its usefulness, especially for routine follow-up and not-so urgent cases. Patients are excited about the new eHealth options and satisfaction surveys among those who participated in an eHealth visit have an overall score of 87% positive. In fact the provider related scores for eHealth have in many cases been higher than those for in person visits.

• “It was my first time doing a video visit and it went extremely well!” – Women’s Services Patient
• “I would recommend keeping video visits. It is very convenient considering I am a working mom with 2 other kids.” – Parent of an Orthopedics Patient
• “Very easy to set up and I appreciated not having to travel 5 hours to get there during the pandemic” – Parent of a Cardiology Patient

“Based on the glowing reviews and feedback we have received, we know many parents love the convenience of eHealth options, especially for routine or follow-up visits. They no longer need to travel long distances, plan for overnight stays, get stuck in the nightmare of Houston traffic for hours, or miss an entire day of work or school for their child’s appointments. In addition, with months of experience during this crisis, providers are now confident of the ability to provide the highest quality of care through virtual methods. This is why, even after this pandemic ends, we plan to continue offering virtual consultations for specific situations. Our physicians, clinical staff and the entire organization worked together and emerged stronger from this crisis. We are now equipped with new and valuable skills and knowledge about how to handle such emergencies in an expedient manner in the future,” Onugha concluded.