“Those of you who think that I’m going to give you a technology talk, you might as well leave now,” said Roberta Schwartz, chief innovation officer at Houston Methodist at HIMSS22 this past month.
While technology is key to delivering virtual care at scale, the story of the sprawling Texas health system’s tele-ICU system, the tale of “getting from ground zero to where we are today,” is really “a story of change management,” said Schwartz.
Earlier this year we offered a sneak peek at how Houston Methodist went live with its virtual ICU in February 2020, just as the pandemic proved the value of having such a thing.
At HIMSS22, Schwartz gave an in-depth look at some of the challenging human factors that figured into such a momentous achievement – the cajoling and convincing and arguing and arm-twisting that it took to get the complex, paradigm-shifting telehealth program up and running.
Like most health systems, Houston Methodist was dealing with staff shortages and needed to provide support to its community hospitals, which didn’t always have round-the-clock intensivist coverage.
The decision to deploy a technology-enabled virtual care approach took place after years of deliberative discussion and preparation. The virtual ICU pilot launched in early 2020, just as COVID-19 shone its harsh spotlight on the need for critical care beds and staffing, and the need to minimize risk to providers.
It was a validation of lots of hard work – and more than a little disagreement – among C-suite, operations, IT and clinicians over the previous years. But it ultimately proved an adage from Seneca favored by Houston CIO Ken Letkeman, said Schwartz: “Luck happens when preparation meets opportunity.”
Houston Methodist is big. (“Our institution alone has done over 1.1 million vaccines – that’s more than many states have done,” said Schwartz.) And several years ago, she made the case for some big changes.
“I believe that the hospital needed to completely disrupt ourselves from the inside,” she said. “Disrupt or be disrupted.”
To help drive that change, the health system’s Center for Innovation convened a subcommittee called DIOP: Digital Innovation Obsessed People.
“We are 50% operators – from the physician organization, from the hospital, from our global operations, from our HR – and 50% IT,” Schwartz explained. “We sit at the table together, so when operations is ready, IT is telling us whether or not they can handle it. We go back and forth and choose things that can work in our organization.”
The goal, she said, is to foster a culture of innovation: “We believe that we have 28,000 innovators across the organization who need to continually help us change.”
That’s key. While much of the deliberation and decision about innovation will start with those innovative thinkers, “most of our work will never live in our Center for Innovation,” said Schwartz.
“It will live in the center for a year, and then it’s not ours anymore. I feel a little bit strange even standing up and talking about the Virtual ICU. It’s no longer in the center for Innovation. It’s a full-on graduate. It works. It’s out there. It has its own business unit with its own people.”
The path to getting there was not always an easy one.
“Virtual ICU was probably envisioned five to seven years before we went live with a virtual ICU,” said Schwartz. “We kind of played around with it. We weren’t really an outsourcing kind of shop, and it was just too expensive to jump into the world of virtual ICU. So we played around the fringes and never jumped.”
Earlier, more manageable successes occurred in areas such as virtual urgent care and tele-psychiatry, she said. Tele-stroke was another field where some substantial, if cautious, innovation took place. (“We had some very anxious physicians, and we helped spur them along.”)
Add in a tele-sitter program at Houston Methodist’s main hospital and a tele-rounding initiative that was “sped up for COVID-19 because of the great needs,” and the health system was already well-positioned in several diverse virtual care use cases.
But virtual ICU was a much bigger project, and one that took years of planning and prodding and pushback.
“We started this seven years before [because] you could already see that there was going to be an intensivist shortage,” said Schwartz.
“We actually had full intensivists, 24/7, in five separate ICUs. But I could see that they were constantly struggling to keep the talent.”
The value of tele-ICU is enormous, when it’s done right.
“You can vastly improve quality,” said Schwartz. “But it can be a very expensive endeavor if you already have intensivists. There is work to be done. You want to improve your ICU throughput. Reduce physicians’ burnout.”
The potential benefits are significant for quality and cost-effectiveness: improved severity-adjusted outcomes, reduced length of stay in the ICU, decreased hospital acquired conditions. The kind of goals all health systems are after in the era of accountable care.
“Everyone agreed on the outcome of what we wanted to achieve,” said Schwartz. “And then I will tell you, after that, there was almost no agreement on how to get there.”
According to many physicians, the “how to get there,” was to raise salaries and hire more intensivists, she said. Very few were onboard, at first, with launching a virtual ICU initiative – despite the fact that some were moonlighting with virtual ICU companies for extra cash.
It took a lot of political capital, plenty of cashed-in chips and, from time to time, some strategically-tightened purse strings to gain buy-in and build momentum on the project.
“They can tell you about some fine meetings where it was pretty dueling,” said Schwartz. “I can tell you, if you’re going to go down this road in an organization that’s not always ready for it, figure out who your person is with an iron stomach, who is willing to be a brick wall and take huge amounts of arrows, and sustain them. That support is what you need to go down this road and implement it in full.”
One fundamental fight will probably be over staffing, she warned.
“Our doctors, all they wanted to do was quote the statistics: ‘I can take care of 14 patients.’ ‘I can only take care of 14 patients.’ ‘We can only take care of 14 patients, day and night.’ The fights oftentimes come down to what is going to be left at coverage at the end of the day. They’re not going to be about the technology; they’re going to be very much about this implementation.”
Schwartz quoted some other common refrains from initially-resistant physicians:
- “That only works for rural hospitals.”
- “It’s for somebody else. It’s not for us.”
- “We will go last. We will go last after you prove it works. And by the way, it won’t work.”
The doctors, she said, “were absolutely convinced about this. And I was like, ‘If we fail, we fail. But it’s not going to be because we didn’t try.'”
Once the battle of hearts and minds was one, there was still plenty of other preparation and groundwork to lay, of course – both technologically and procedurally.
“The change management began years and years before the first camera was hung, and began with the fact of trying to get the staffing correct, trying to improve the operations, trying to improve the quality.”
Fast forward a few years. The virtual ICU pilot launched about 26 months ago.
“We put our last camera in the main hospital in February of 2020. COVID-19 came in March,” said Schwartz.
“I suddenly looked pretty smart. But luck happens when preparation meets opportunity.”