91 © Springer Nature Switzerland AG 2021 A. B. Bhatt (ed.), Healthcare Information Technology for Cardiovascular Medicine, Health Informatics, https://doi.org/10.1007/978-3-030-81030-6_7 Chapter 7 The Digital Transformation of Cardiovascular Clinic Workflows Srinath Adusumalli 7.1 Introduction Digital transformation is the process of using digital technologies to reimagine processes, culture, and in the case of healthcare, patient and provider experiences [1]. It is as much a cultural change as it is a change in the use of technology and involves a fundamental shift in the way technology is used to transform patient and provider experiences. As providers, practices, and health systems have gained familiarity with telehealth technology, digital transforming cardiovascular clinic workflows has become imperative to refining telemedical practice. From appointment scheduling, to intra-visit workflow, to checkout and follow-up care, the entire process of a cardiovascular patient-clinician visit has the potential to be transformed with the advent of broader utilization of telehealth. Rather than directly transfer in-person mechanisms of conducting a cardiovascular clinic visit to virtual formats, the transition to telehealth practice presents an opportunity to completely rethink the ways through which outpatient care is delivered. This chapter will explore how traditional cardiovascular clinic workflows can be re-engineered via the use of telehealth and related technologies, starting with a deeper dive into the process of digital transformation. 7.2 Digital Transformation The process of digital transformation is about much more than simply moving information from analog to digital format (known as digitization) or even using that information to make established ways of work simpler and easier (known as S. Adusumalli (*) University of Pennsylvania Health System, Philadelphia, PA, USA e-mail: srinath.adusumalli@pennmedicine.upenn.edu
92 digitalization) [1]. As opposed to digitization and digitalization, digital transformation is about fundamentally reworking processes, culture, and experiences (or creating new ones) using technology—in essence, taking advantage of technology to inform how an organization runs. The implementation of telehealth within cardiovascular clinics has presented an ideal opportunity to digitally transform those clinics. Organizations which have adopted principles from the process of digital transformation in telehealth efforts have found the following elements critical to success [2–4]: 1. Promote agility: Given the changing telehealth environment, teams need to be able to rapidly prototype, test, and iterate on workflows. This also means team members need to feel able to take risks in decision-making, not being afraid to fail (but fail fast and learn from failure). 2. Embed into the frontline: By having telehealth champions embedded in the frontline of care, those champions have been able to engage frontline stakeholders in change management around telehealth process and technology, bring back ideas for improvement in telehealth systems, and then close the loop with stakeholders once changes/improvements are made. This process allows for sustained engagement of frontline stakeholders in the process and culture change of digital transformation. 3. Develop digital competencies and fluency: Just as important as being embedded in the frontline is equipping both frontline operational and technical teams to know what is possible with, actively participate in, and advance digital transformation efforts. Digital competence “is a combination of knowledge, skills and attitudes with regards to the use of technology to perform tasks, solve problems, communicate, manage information, collaborate, as well as to create and share content effectively, appropriately, securely, critically, creatively, independently and ethically” [5]. Building digital competence for all members of the healthcare team is critically important to more not only telehealth efforts but digital transformation in general forward. 4. Build analytics infrastructure alongside telehealth tools: As the old adage goes, it is difficult to improve what can’t be measured. As such, as digital workflows are built or re-engineered, opportunities should be leveraged to embed measurement tools into workflow wherever possible. Examples of this will be given further in this text. One facet of cardiovascular telehealth practice which can directly promote and catalyze digital transformation is the selection of an appropriate telehealth platform, which we will discuss next. Telehealth Platform Selection: A Launching Pad for Equitable Cardiovascular Clinic Digital Transformation One of the most critical decisions in the digital transformation of the cardiovascular clinic is the selection of a telehealth platform. A foundational principle in this process should be that the platform enables providers and practices to reach all the patients they care for in an equitable, high-quality, and flexible yet highly reliable fashion. Given emerging evidence that variation in clinician and clinic practices S. Adusumalli
93 may contribute to differential access to telemedical care, it is critical for a telehealth platform to offer a range of tools which promote easy, seamless, and effective telehealth workflows [6]. Ideally, given known inequities among patient populations in access to EHR-based patient portals, the telehealth platform would have the ability to be both embedded in the portal but also be used outside of interacting with a portal. Based on this, there are several elements of platform which can help advance digital transformation: 1. No requirement for patient application downloads to utilize video telehealth services: Application downloads, whether they are onto a mobile or desktop device, present a barrier to engaging in care. This is because they require knowledge of installation processes as well as recall of pieces of information such as app store passwords. Rather than relying on the download of an application (or even multiple applications as some platforms currently require), a telehealth platform should be able to facilitate visits directly in modern desktop and mobile browsers using the popular WebRTC (real-time communications) protocol [7]. This minimizes the number of steps required to engage in a telehealth encounter. 2. Integrated accessibility services: Ease of access to video and audio interpretation services is critical to ensure all patients can participate in telehealth encounters [8–10]. Several interpretation vendors now offer integrations for telehealth platforms to facilitate joining of interpreters in the patient’s preferred language with 1–2 clicks. Furthermore, services such as closed captioning as well as encounter transcription should be offered directly through telehealth platforms 3. Bidirectional communication: Real-time textual communication in the peri- visit period between patients and care teams is critical to the success of the process of delivering telehealth. This can be achieved directly through telehealth platform chat functionality (ideally automated/using chatbots) or even through SMS text messaging tied into the platform. This type of communication is important because it allows care teams and patients not in the same locations to quickly communicate about issues such as the provider running behind or the patient having connection difficulties. Through available cloud services (such as Microsoft Azure), these messages can even be translated into other languages. 4. Multiparty connection: Multiparty connection is critical to the successful scaling of telehealth. Of course, the patient is the most important participant in a telehealth encounter; however, virtual exam rooms created by telehealth platforms should offer the ability for other relevant parties to participate in encounters such as patient family members or, importantly, interpreter services. When used, the platform should be able to directly integrate with interpreter services in order to make it easy to engage those services. 5. Electronic health record integration: Although there are several levels of EHR integration, at the least, the telehealth platform should be able to receive appointment/encounter and basic patient information data from the EHR in 7 The Digital Transformation of Cardiovascular Clinic Workflows
94 order to facilitate sending unique, secure, patient-specific virtual exam/meeting room links to patients. This should be able to be done inside of the patient portal (given integration with tools such as pre-check-in) but also outside of it via email and SMS text messaging given well documented inequities in patient portal access [11]. 6. Compatibility with multiple devices: Telehealth platforms should be able to be utilized to participate in video visits from a provider perspective on a diverse array of desktop or mobile devices to provide maximal flexibility, especially when hospital-issued computers are not available. The ability to be used across multiple devices also facilitates the utilization of another device as a second screen such that a telehealth encounter can be run on, for example, a mobile device while the EHR is running on an available computer. This flexibility, must, of course be balanced with appropriate consideration towards security. 7. Virtual waiting room: Given clinical visits often do not run on time, a telehealth platform should allow patients to wait for their encounter in a virtual waiting room. Ideally, this waiting room could be customized for an organization, offering branding as well as the opportunity to deliver customized educational material or even the opportunity to engage patients through completion of patient reported outcomes instruments. This waiting room should also make clear to patients they are in the correct spot (and should wait for their clinician to join) to prevent confusion regarding appropriate location of telehealth visit. 8. Screen/image sharing: Provider and patient screen/imaging sharing is an important aspect of telehealth. Providers should be able to share screens in order to review notes as well as testing/imaging results directly with patients during an encounter. A patient should also be able to share to synchronously or asynchronously send images or video (particularly important for fields such as dermatology). 9. Telehealth analytics: Given the practice of telehealth is rapidly developing, it is critical for care teams to be able to measure and improve on how care is being delivered. This means having access to analytics from telehealth platforms in addition to the EHR. Examples of useful analytics include video and audio bitrate, hiccup rate, frame rate, patient device and OS platform, and patient location 10. Provider usability enhancements: Given interactions with patients through telehealth platforms are completely digital, those interactions should make use of the full breadth of digital video tools through the platform, including employing virtual backgrounds, synchronizing telehealth appointments directly to clinician calendars, and automatically calculating the time each participant spent in a visit. These features greatly improve the ease with which clinicians conduct visits and keep them engaged in the process of delivering telemedical care. With a telehealth platform in place, care teams can turn to each phase of a visit to examine where workflows can be digitally transformed. S. Adusumalli
95 7.3 Appointment Scheduling Traditionally, appointment scheduling for ambulatory visits has occurred either via phone call to clinics or physically in clinic itself. Virtual workflows, particularly those associated with the already digital interactions of telehealth visits, offer the opportunity to revisit that process, particularly through utilizing features common in many patient portals. Patient visit self-scheduling can be enabled through portals and can be quickly implemented, especially for patients known to a particular provider. Most portals offer the opportunity to implement self-scheduling within the context of decision trees/branching tree logic, incorporating automated criteria to help guide a patient to appropriate types of visits and visit modalities. The process of developing a visit decision tree to embed within a portal is useful as it facilitates the structuring of clinic decisions around which clinical scenarios are best suited for in-person vs. virtual encounters [12, 13]. These visit decision trees match with provider clinic templates/schedules which have embedded in-person and telehealth slots and further facilitate the process of structuring. Finally, this process allows virtual visits to be as available as in-person visits to patients and reduces the amount of friction in engaging in both in-person and virtual care (such as waiting on hold to schedule via a call center). Moving forward, self-scheduling opportunities should be available inside and outside of patient portals, given limitations in equitable access previously noted. One way to operationalize this would be by using text messaging to connect to EHR-based schedules and offer the ability to see available appointment slots, modality, and ultimately a method through which to schedule into those slots. This is not dissimilar from the ways companies in other industries, such as OpenTable in the restaurant industry, have digitally transformed their interactions with customers. Finally, historically clinicians have not been able to directly schedule appointments with patients within the EHR. With the advent of flexible telehealth encounters, which can be conducted with a moment’s notice—in response to an on-call phone call for example—quick schedule workflows within the EHR should be enabled to allow patient and clinician flexibility in scheduling while maintaining downstream processes such as visit link generation, documentation, and billing. 7.4 Preparing for the Visit Once a visit is scheduled appropriately, both the patient and the care team can prepare for it. As above, it is important that communications occur via email, SMS text message, and the patient portal when available to ensure patients can access messaging, pre-visit activities, and virtual exam room links. As soon as a visit is scheduled, the telehealth platform or EHR should be able to send an email, SMS text message, or patient portal message containing a unique, patient/encounter specific visit link to the patient along with encounter specific messaging on how to prepare for that 7 The Digital Transformation of Cardiovascular Clinic Workflows
96 encounter—both from a technical and clinical perspective (such as have medications and home blood pressures readings available for the visit). This is like messages sent in other industries such as airlines where customers are prepared for upcoming flights. The advantage of having a visit link available from the time of scheduling to both the patient and clinical care team is that it can be used for pre-visit interactions such as medication or medical history reconciliation. The same link as the actual visit could also be used to confirm and assist the patient with ensuring they are technically ready for their appointment. This preparatory message could be repeated in the 24–48 h leading up to an appointment. As one final confirmation, only the visit link itself could be sent automatically—ideally via SMS text message—in the minutes prior to an encounter time. This will ensure the patient has this information readily available for this encounter. Many EHRs also offer “pre-check-in” functionality that is quite like tools offered by airlines used to obtain a boarding pass prior to a flight. These should be enabled for virtual as well as in-person visits—the questionnaires included within these workflows offer the opportunity to collect nonclinical information such as updated insurance but also important telehealth-adjacent clinical information such as past history, medications, and patient-reported outcomes measurements. One final advantage of “pre-check-in” is information collected through it can directly populate appropriate EHR fields without further care team intervention. 7.5 Conducting the Visit Once the patient arrives for their virtual visit, features of the telehealth platform discussed above can be utilized to ensure the patient and clinician conduct an effective encounter. If closed captioning or audio transcription is available via the platform and beneficial from a patient accessibility standpoint, this should be turned on at the beginning of the encounter, ideally in automated fashion as determined by accessibility preferences passed from the EHR. Bidirectional messaging is critical at this point. The patient and care team need to be able to stay in contact such that the patient is informed as to the status of their visit (i.e. is the provider running late, should they join the virtual exam room). This type of visit coordination ordinarily is expected during in-person visits but is more difficult to accomplish virtually. Especially when clinicians conduct mixed in-person and telehealth clinics, the synchronization of timing of virtual visits is key. Several organizations have found that although this communication can be carried out via a patient portal, patients are often delayed in seeing these messages. Borrowing from other industries, SMS text messaging can assist with quick, templated messages informing the patient, for example, a provider is running late and they should continue to wait in an exam room. This can also be accomplished via in-virtual room chat if offered by a telehealth platform. With regards to coordinating the activities of multiple care team members, S. Adusumalli
97 teams (nurses, medical assistants, providers) can utilize other virtual rooms on the telehealth platform or even on widely available collaboration platforms (Microsoft Teams, for example) to help coordinate and discuss patient cases prior to providers entering a room—a virtual visit “green room” of sorts. This type of “green room” is also effective as a precepting space for trainee encounters. Providers should also not neglect to fully utilize features of telehealth platforms such as screen/content sharing during a visit—this can be a good use of telehealth encounters for the purpose of patient education. One consideration to keep in mind is that content sharing can consume additional bandwidth in addition to video/audio and as such can degrade the quality of a connection. 7.6 After the Visit At the conclusion of the clinical encounter, it is critical that visit follow up tasks such as scheduling of downstream appointments and testing are not lost. One way to accomplish this is by having the patient remain in virtual exam room after a provider exits. An administrative staff member can then enter to guide the patient through scheduling tests and visits, like when a patient visits an in-person checkout desk. The EHR should also be able to discretely capture follow up information with regards to modality of follow up visit agreed upon through shared decision-making by the patient/clinician (i.e., in-person vs. telehealth) and expected timing of visits. This information can be queried later to ensure no follow-up activities are being lost. As mentioned above, collaboration platforms can be used to coordinate this activity among teams or alerting functionality can be built into telehealth platforms to inform other care team members when a provider has left the room. Moving into the future, this type of follow up scheduling could be done automatically via chatbot embedded in a portal or SMS text messaging if information regarding provider follow up intent is captured discretely in the EHR. Given telehealth is a relatively new vehicle for delivering care, automated mechanisms should be available either through a telehealth platform or outside of it to assess patient and provider satisfaction after a visit, immediately after a visit. This can be done with as little as one question (i.e., “How did we do today?”) along with space for a comment, all delivered via SMS text message, email, or patient portal; as with many of the workflows above, this is a technique borrowed from many other industries such as retail and restaurants. The advantage of capturing this information immediately adjacent to a visit is that it can be used for near-real-time continuous quality improvement using the voice of the patient (and provider/care team) for guidance. Finally, the fact a patient was able to successfully complete a virtual visit should be captured discretely in the EHR not only for billing reasons but also for quality improvement and future visit scheduling purposes. 7 The Digital Transformation of Cardiovascular Clinic Workflows
98 7.7 Conclusion This chapter has illustrated the power of digital transformation of cardiovascular clinic technology platforms and workflows in the context of the ongoing addition of virtual channels of care to our healthcare delivery system. Just as much as a technological shift, digital transformation is a cultural one, giving care teams the opportunity to fully reimagine the care they have delivered for years with digital tools in mind. Moving forward, all members of the care team should focus on developing digital competency and fluency to help advance virtual channels of care as a method of caring for and engaging our patients. Case A 66-year-old female with a past medical history of hypertension, hyperlipidemia, and coronary artery disease s/p STEMI and PCI to the proximal LAD contacts your cardiovascular clinic for a follow-up appointment to discuss her antihypertensive medications. Her preferred language is Spanish as expressed by her and documented in structured fields in the EHR. She has been taking her home blood pressures and has persistently found them to be greater than >140/90 and would like to discuss next steps in management. Your clinic has implemented and refined a set of digital workflows, so is able to offer a virtual visit the next day with an advanced practice provider (APP) in your practice. The clinic EHR has an indicator that this patient has successfully participated in virtual visits previously and therefore does not need a tutorial in setting up her devices appropriately. As soon as the visit is scheduled, the patient receives an email and SMS text message-based confirmation of scheduling— these messages also contain an active visit link and instructions regarding the visit, including a request of the patient to have her blood pressure cuff and medications available for review by the provider. They are translated into Spanish given her preferred language preference. Given the appointment is the next day, the messages also have a link to pre-check-in activities within the EHR patient portal through which the patient can confirm her insurance, history, and medications. 15 min prior to her visit, the patient receives a SMS text message with a reminder of the active visit link and nudges her to join the virtual exam room—the link takes the patient directly to the exam room in a phone browser without requiring an application download. Once in the room, the patient receives a chat message that her provider is running 5 min behind, so she remains in the room waiting for your APP. This message is also translated into Spanish. Your APP joins the patient in the virtual exam room and can quickly jump into the visit as the patient has her medications and blood pressure logs available for virtual/visual review—she had also uploaded these to the EHR during the pre-check-in process. Your APP also, with two clicks, requests a Spanish interpreter to join into the visit via video—the interpreter S. Adusumalli
99 joins within 1 min. Based on available information, your APP starts a new anti-hypertensive medication and requests the patient obtains labs as well as another visit in 2 weeks. At the conclusion of the visit, your APP messages your administrative assistant (AA) via your clinic collaboration platform to join the virtual exam room. Your AA joins the room and schedules the patient for labs as well as a follow up visit. At the conclusion of the encounter, the patient receives a text message asking her to rate the quality of the visit, which she thought was excellent. The APP also receives a similar message to rate the quality of the telemedical encounter. What does success look like in the digital transformation of cardiovascular care? • Every cardiovascular clinic team member is knowledgeable and fluent in the use of available technology to advance the care of the clinic patient population. • Virtual care is accessible to all patients in an equitable fashion. • Available digital tools are used to reimagine and create new workflows which were not possible in the analog world. • Information from digital encounters (including visit analytics as well as patient and provider satisfaction measures) is used to help improve the quality of future telemedical encounters. References 1. What is digital transformation? A definition by salesforce. Salesforce.com. https://www.salesforce.com/products/platform/what-is-digital-transformation/. Accessed 9 Jan 2021. 2. Choi K, Adusumalli S, Lee K, Rosin R, Asch DA. 5 Lessons from Penn Medicine’s crisis response. Harvard Business Review. Published online 22 Jun 2020. https://hbr.org/2020/06/5- lessons-from-penn-medicines-crisis-response. Accessed 9 Dec 2020 3. Digital transformation is not about technology. Harvard Business Review. Published online 13 Mar 2019. https://hbr.org/2019/03/digital-transformation-is-not-about-technology. Accessed 9 Jan 2021 4. Wechsler LR, Adusumalli S, Deleener ME, Huffenberger AM, Kruse G, Hanson CW III. Reflections on a health system’s telemedicine marathon. Telemedicine Reports. 2020;1(1):2–7. https://doi.org/10.1089/tmr.2020.0009. 5. Skov A.. The digital competence wheel. https://digital-competence.eu/front/what-is-digital- competence/. Accessed 10 Jan 2021. 6. Rodriguez JA, Betancourt JR, Sequist TD, Ganguli I. Differences in the use of telephone and video telemedicine visits during the COVID-19 pandemic.Am J Manag Care. 2021;27(1):21–6. https://doi.org/10.37765/ajmc.2021.88573. 7. WebRTC. WebRTC. https://webrtc.org/. Accessed 15 Jan 2021. 8. Eberly LA, Kallan MJ, Julien HM, et al. Patient characteristics associated with telemedicine access for primary and specialty ambulatory care during the COVID-19 pandemic. JAMA Netw Open. 2020;3(12):e2031640. https://doi.org/10.1001/jamanetworkopen.2020.31640. 7 The Digital Transformation of Cardiovascular Clinic Workflows
100 9. Eberly LA, Khatana SAM, Nathan AS, et al. Telemedicine outpatient cardiovascular care during the COVID-19 pandemic: bridging or opening the digital divide? Circulation. 2020;142(5):510–2. https://doi.org/10.1161/CIRCULATIONAHA.120.048185. 10. Julien HM, Eberly LA, Srinath A. Telemedicine and the forgotten America. Circulation. 2020;142(4):312–4. https://doi.org/10.1161/CIRCULATIONAHA.120.048535. 11. Digital health equity as a necessity in the 21st century cures act era | Health Care Delivery Models | JAMA | JAMA Network. https://jamanetwork.com/journals/jama/fullarticle/2766776 ?resultClick=1. Accessed 15 Jan 2021. 12. Croymans D, Hurst I, Han M. Telehealth: the right care, at the right time, via the right medium. NEJM Catalyst Innovations in Care Delivery. Published online 30 Dec 2020. https://catalyst. nejm.org/doi/full/10.1056/CAT.20.0564. Accessed 16 Jan 2021. 13. A hybrid model of in-person and telemedicine facilitates care delivery. MASS General advances in motion. https://advances.massgeneral.org/cardiovascular/article.aspx?id=1334. Accessed 24 Jan 2021. S. Adusumalli
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