How I Treat: COVID-19

Guest speaker Dr Carrie Nelson discusses her experience using technology-enabled care models, emphasizing the importance of health equity and personalized approaches to patient care, particularly in the context of COVID-19.

Read the full transcript: 

Please introduce yourself by sharing your name, title, organization, and experience. 

I'm Carrie Nelson. I am a family physician. I am currently the chief medical officer for KeyCare, which is a digital health platform on the epic electronic health record. And I've been working in leadership roles for healthcare transformation for more than 25 years. Most of my career has been spent on the inside of the walls of the traditional healthcare system. I have been leading on quality, patient safety, and population health for a lot of years. And before I got into the digital care model solutions, I most recently was the Senior VP for population health and health outcomes at a large midwestern healthcare system. I realized that we had a lot more work to do to accelerate the pace of change. And that's when I decided I would try to help influence that pace of change from the outside of health care. In a way that we can really focus on innovation in a way that is often not possible inside a traditional health care system, but we can focus on it in a way that augments the success of those changes that the health systems are trying to make.

Given your extensive experience in spearheading health care transformation and your shift towards technology-enabled care models, how do you believe your strategic vision and leadership have contributed to the advancement of health care systems, particularly in the context of achieving an accelerated pace of change when it comes to COVID-19?  

I've done a lot of work with health equity before coming to key care. That was something I made a priority in our response as a health care system to the COVID-19 epidemic and much of what we know is that people of color have much higher rates of hospitalization and death, and also have a lot of really valid reasons for not trusting the health care system based on the historical experiences that they've had. So one of the things I did was really focused on making sure that the vaccines were available in some of the most trusted locations where people would access them. And there certainly was a lot of work going on to try and make sure health care systems. We're using technology to try and bring people to get their vaccinations done. But there's there's a need to balance that. A lot of times the most trusted places are the places where they go for church, or they go to their own primary care physician. You have to really use a balance of making it easy for people to sign up and get an appointment for a vaccine through technology versus getting the right information that they need to make an informed decision through their trusted networks like churches and their primary care providers. And a lot of the work I did amid the COVID-19 pandemic was focused on that and leading that work at the health system I was at. And also after I left the health care system, I served on the ATA Presidents or CEOS Advisory Council for Health Equity. Recognizing that technology can be an enabler of access but there are risks. There's a digital divide out there that some communities don't have access to the broadband that could. That is a new source of care. With telemedicine now more so than it ever had been before the pandemic, we want to make sure that doesn't become another real barrier to access. So those are some of the things that I have been focused on in recent years to try and improve the ways health care can go wrong, especially in serving people in disadvantaged communities.

Can you provide specific examples or instances where your leadership had a significant impact on the implementation of quality and patient safety for patients with COVID-19? 

Actually, we developed a technology that enabled following people who were trying to recover from the illness at home and so as you recall, we had really scarce resources in terms of the beds, and you know there just wasn't enough capacity in our hospitals to be able to be able to meet the need of all the people that were coming down with the infection. And people were left to recover at home, and we use technology in a way that enabled better tracking of their symptoms, a nurse then could reach out to them if things were going south and get them access to the emergency room and whatnot to be able to keep them safe. So much was accomplished with that particular initiative, and not just making sure that clinically people were safe, but emotionally. We actually had patients say, I didn't feel so alone. So that was a real Aha! for my own experience in the ways that technology can create even higher touch health care systems. Sometimes you think of it as being lower touch but it actually can create a higher touch health care system. And so in my work in particular, with KeyCare, because we have close relationships with our clients who are on the epic platform we have fully integrated information because we're seeing patients on the epic platform as well as our clients. With those health systems that we're now working with, we have the ability to shore up challenges.

We just had a patient this morning that was seen by one of our doctors that had just a tremendous amount of barriers to keeping her safe for the long term. She had no food, she was sitting in her home with coats piled on because the electricity had been turned off, and she was on her phone trying to do a visit. We were able to quickly reach out to the health care system in the local community where she is to be able to get nursing and resources to help shore up some of those social, determinant challenges she was having. This is a person that I'm sure would have had trouble getting to a health care setting, in a brick-and-mortar setting, but that was able to access us on her phone in a way that really got her more help than she ever even anticipated. So that's just really gratifying to see. 

In managing patients with COVID-19, how do you prioritize patient-centric care? Can you elaborate on any specific strategies or initiatives you may have implemented to ensure a holistic and personalized approach to patients affected by the virus? 

The telemedicine solution is a way to keep people from going out into the community with their COVID-19, and they can stay home and get the care that they need and get and get it assessed, for their level of risk. And within that assessment, our doctors can use a lot of decision support. The EHR has great decision support available in a way that enhances diagnostics and treatment decisions. And we know that Paxlovic in particular, the medication that is recommended for decreasing high-risk Covid cases is grossly underutilized. And we can provide decision support that help our doctors to be able to assess a patient for their individual risk and customize the treatment plan accordingly. And knowing their life circumstances and some of the risks that they might have that might make them at higher risk for having a severe disease, plus having access to all the other medications that they're on through the epic environment. We can ensure that whether they're a candidate for Pexlovic, which has a lot of medication interactions, we can actually safely prescribe that knowing very clearly what medications they're on based on what we can see in the electronic health record versus just what might be self-reported, which sometimes misses some things. 

I think that's a really important way to be able to customize the care for people that are not sure what they should do. We can also assess them in a way that allows us to determine whether they need to go to brick and mortar right? We have all of the tools at our disposal to be able to do an assessment for shortness of breath and things like that in order to send them over to brick-and-mortar care if it's indicated.

Given your background in technology-enabled health care models, can you provide insights into how you use integrated technology to enhance patient care pre- and post-COVID-19 pandemic? Are there specific technologies or digital tools that you find particularly effective in managing and monitoring COVID-19 patients? 

Sure, so there's a couple of things that are working in progress in order to enhance how we're using all the different things that are at our disposal. So, we're a young company. And so we're very much in growth mode and expanding on all the ways that we can use this technology. Care companion is a solution that can be adapted. It's an epic solution that can be adapted for what I described. In terms of monitoring people at home to make sure that they're maintaining a safe approach to their care, and that they're recovering smoothly. There's more and more artificial intelligence coming out that will allow us to be able to even check blood pressure and a pulse through just observing capillary action on the screen. It's just how fast these things are progressing. 

Another thing that I do appreciate is that we have because we have a full electronic health record. We have full access to all the data tools that we can use through epic. So, we can actually look and see if our physicians are appropriately prescribing anti-covid medications, or what's the patient profile of the kinds of folks that we're seeing? What do we know about their demographics that can help us to continuously improve? The use of the data in the electronic health record is just a powerful tool to be able to continue to drive improvement and just get better at what we what we do every day. 

Can you provide insights into the specific treatment protocols or interventions you employ in the management of patients with COVID-19? Are there particular medications, therapies, or medical technologies that you find to be effective, and how are these integrated into the overall patient care strategy? 

So you know, we can take pictures. And we can actually take a picture of the COVID test and put it into the electronic record. We can also rule out other things. People that come in with respiratory symptoms might have another condition, right? And we can like do a picture of your throat. In a way that helps us to say, is there something going on with a bad sore throat? Those kinds of things are nice as a way to really get a comprehensive look at what is going on with a patient. So those are some of the ideas that we're employing. 

And then I mentioned how do you treat? How do you tailor? The treatment for an individual and so much of the treatment may just be supportive care, and you can provide it after the visit. The after-visit summary allows people to have all the instructions that they receive from the visit available at their disposal. It's all there in there my chart portal, and they can also potentially be prescribed the Pexlovic based on what we know about their particular risk and what other medications they're on. And there again all the instructions are very clearly put into the portal. Electronic prescribing is all completed. And then it's available to their primary care physician or their other members of the health care team in the local environment. They know exactly what happened and what transpired. 

In evaluating the outcomes of COVID-19 patient care under your guidance, what KPIs or metrics are used to assess the effectiveness of the treatment approach? How do you track patient recovery, manage complications, and ensure the overall well-being of individuals affected by COVID-19?  

Yeah. Well, one of the things we're very focused on is antibiotic stewardship. And people with respiratory conditions almost always have a viral condition, and we want to be very careful about not overprescribing antibiotics. And you know frankly, sometimes people want an antibiotic, they think they need an antibiotic, they might have gotten something in the past when they felt similarly. And yet we pay very close attention to the prescribing behavior of our doctors so that we're using antibiotics in a very focused way and appropriately. We're able to track that data and provide individual physician feedback as well as look at it at a population level, so that the clients and the health systems that we're working with can see exactly how we're performing on those kinds of metrics. Similarly, we use for pharyngitis a Centaur score. We have a variety of different ways of making sure that we're really targeting our therapies appropriately. And your other question about tracking patients, that's certainly something I've done in the past. We're still in the process of working through some of the ways that we would do that here at KeyCare. But there's definitely the technologies are out there and they're really effective. 

Are there any notable success stories or improvements in patient outcomes that highlight the impact of your treatment strategies? 

We're just getting underway with the COVID season, so I can't say I have a lot of current data as far as what we are seeing in the treatment of that and how people are recovering. But we have experience scores and we're at a 72 net promoter score, which really says a lot. I mean, that's a nice number in terms of the level of experience that people are having as they enter into this remote care model. 

I think that's what I would say about that now, other than some of the other metrics I've talked about. Antibiotic prescribing appropriateness as well as looking at individual physician decision-making. We need to make sure that the docs that we have brought on board are really being thoughtful about the diagnoses that they're making, and that their documentation reflects that. And when we don't when we see something that might be a little off, we will. We can circle back and coach that physician in a way that makes sure that they're learning from those experiences and continually improving. 

What strategies do you suggest for health care executives to implement that would enhance the well-being of patients with COVID-19? 

Well, I you know, one thing we know is that health systems are overburdened right? We don't have enough physicians or nurse practitioners. We don't have enough clinicians to see patients on-site, and I just read a study this morning that showed an enormous number of physicians and nurse practitioners are looking to cut back their hours in the coming year, if not leave the profession entirely. We've certainly seen that through all of the burden of recent years and the Burnout Associated. But we've we're now seeing that they're looking to cut back their hours at a time when you really can't afford to do that. I mean, we've talked to some health systems in different parts of the country that are a hundred doctors short of what they really need to meet the needs of their communities. And so that creates a tremendous barrier for patients to get the care that they need right. And the ability to have alternative resource points. You know, we have doctors that are that are licensed in multiple states. 

And we can bring those resources on nationally when they're not available locally and right then right there, that just enhances the patient's experience of and their level of confidence in being able to get the care that they need. It's never fun to call the doctor and sit on hold for a long time, and then find out that you can't get in for a couple weeks when you're sick. 

We've seen that many of us learned how to deliver virtual care during the pandemic by necessity. A lot of physicians and nurse practitioners in brick-and-mortar settings really have struggled to integrate a hybrid care model. Flipping between brick-and-mortar and in-person care versus virtual care has proven to be a challenge for clinicians. And we're starting to think that perhaps there's a specialist that is in the brick-and-mortar setting. They're the in-personologists. And for those of us who have decided to work in a virtual environment, we're virtuologists. Those are the distinctions that we're seeing. We think over time it can create a care model that solves some of the local access problems and also enhances providers' experience. We know burnout is a significant issue, and if it's more of a burden to flip between in-person care and virtual care, maybe we can relieve them of that burden, and they can focus on the in-person care while we focus on the virtual in a way that is tightly tied to that brick and mortar setting, and allows for good handoffs and really good collaboration for caring for individual patients.

Is there anything else you’d like to add?  

You know, I'm still a believer in vaccination. So anybody you know who's watching I would recommend strongly considering getting vaccinated. And then also, patients should ask questions about whether they're an eligible person for Paxlovid in particular, to help decrease the risk of severe disease. Be informed and have a conversation with providers about your level of eligibility for that.