Virtual Care in Population Health

The HCI Group was pleased to welcome Chief Population Health Officer of New York City Health & Hospitals (H+H), the largest health system in the U.S, Dr. Dave Chokshi. Dr. Chokshi was joined by Ed Marx, HCI’s Chief Digital Officer and former Cleveland Clinic Chief Information Officer, to take part in HCI’s live interactive webinar series, Leadership Insights.

During the 30-minute session, Dr. Chokshi provided audience members with emerging lessons from the COVID 19 crisis. This discussion included the impact of virtual care on population health during the crisis, and what the future state of health care will look like beyond COVID 19.

Emerging Lessons from the COVID 19 Crisis

“So much of how we organize healthcare delivery has been dependent upon who crosses our threshold and when. I think about the patients I care for in the primary care clinic at Bellevue. Too often people have other things going on in their lives that make it challenging to carve out time to seek care on physician’s terms rather than terms that make more sense for their busy lives. We have patients who are living in a cash economy—restaurant workers and cab drivers. Coming to see me in the clinic may be three or four hours out of their day which equates to wages lost. I think we must double down on some of what we had started before the pandemic, using telephonic visits and text messaging to give back our patients their most important commodity: time.”

Ed Marx:  Dr. Chokshi, recently you co-wrote a piece in the Janna Health Forum discussing emerging lessons from COVID 19 response in New York City. Can you tell us about some of the lessons you did learn?

Dave Chokshi: We wrote this in mid-April just as we were emerging from the peak of the crisis in New York City. Our aim was a simple one: to see if we could share some of the lessons that might help other cities around the world that were confronting the same suffering that we had seen among our patients, our neighbors, our family members. We highlighted four lessons. The first is that public health and healthcare are inherently intertwined. We saw that directly, particularly between the relationship between physical distancing and other public health measures and then what we saw cross the threshold in terms of ill patients in our Emergency Departments and ICUs.

The second lesson we learned was what we call the Primacy of clinician Moral. This alluded to the idea that while we have to count our ventilators and make sure that we have enough hospital beds, but the most valuable commodity was the moral of the clinical team itself, particularly as many of our clinical colleagues were facing peril for themselves.

The third lesson is that health equity is not a sideshow, it is the main event. It is of utmost importance that we keep health equity at the forefront, during times of crisis.

The fourth lesson we termed, “Moving beyond analytics to intelligence.” We found it was so important not just to have data at our fingertips, but with how things were rapidly evolving on the ground, to tie that together with what people were seeing with their own two eyes, with rapid, real-time communication and knit all those things together to enable sound decision-making in a time of crisis.

Virtual Healthcare and Population Health during COVID 19

“While we took care of thousands of patients with COVID 19, we serve over a million patients across New York City. We had to make sure not to forget about all those other patients who were experiencing foregone care and anxiety in their personal lives. To do so, we rapidly deployed our telehealth [infrastructure]; we went from doing about 500 telehealth visits in the month of February to just over 50,000 in the month of March.”

Ed Marx: Can you discuss some of the virtual health tools you deployed [during the crisis] and its impact on population health?

Dave Chokshi: It has been one of the most remarkable things to see how virtual care has grown by leaps and bounds, sometimes literally overnight in the context of our COVID-19 response. I divide this impact into two major categories.

First, how did we directly care for the thousands of patients who were affected by COVID 19 itself? My colleagues really led this work in terms of setting up a hotline for people who were exhibiting symptoms of COVID 19 to get triaged and routed to care. We coordinated with [New York City’s] 311 system to do that. We set up video-enabled isolation rooms to do screening in our emergency departments to preserve PPE for our clinicians. We used tablets to enable patient-family communications. One of the most heart-wrenching things to see is people who are going through the most difficult time of their life, but having to do it in a doubly difficult way because they didn’t have their loved ones next to them holding their hands and helping them manage.

Similarly, we had video-enabled palliative care where we connected over a hundred out-of-state volunteers with our sickest patients. [We also deployed] text-based post-discharge monitoring to keep a closer eye on at-risk patients.

While we took care of thousands of patients with COVID 19, we serve over a million patients across New York City. We had to make sure not to forget about all those other patients who were experiencing foregone care and anxiety in their personal lives. To do so, we rapidly deployed our telehealth [infrastructure]; we went from doing about 500 telehealth visits in the month of February to just over 50,000 in the month of March. We leveraged our e-consult system extend specialty care; and finally, we focused on behavioral health services given the mental health consequences associated with COVID 19 and that included a novel virtual buprenorphine clinic.

The Future State of Virtual Healthcare and Population Health: COVID 19 and Beyond

“It depends on how we think about population health. Our approach at H+H has been to consider population health with this definition: taking a more proactive approach to addressing avoidable human suffering. Our goal is to take that vision and make it very tangible and real for patients that we serve. We have a few strategies to help operationalize that vision. One idea is to get beyond the tyranny of the in-person visit.”

Ed Marx: Its impressive how you all responded so quickly and with so much creativity when it comes to virtual care. How much of that virtual care capability will become permanent in the future?

Dave Chokshi: I think we are all acclimating to this brave new world; back in April I was thinking in terms of a post-pandemic world, May has brought a shift in mindset: we are in a post-surge but pre-vaccine world. We are going to be in this situation for many months. One of the advantages of this is that it will help us develop and mature that virtual care infrastructure that we have discussed. I am an optimist with respect to how much of this will be durable and longer lasting for our patients. I think we will have to be even bolder with respect to investing and shifting to our virtual care infrastructure. What I worry about is making sure that policy and reimbursement follow suite. I think we have been able to demonstrate rapid changes on the delivery side, but that must be supported by investment and the right policies.

Ed Marx: The pandemic has influenced the technology to a great degree. How do you plan to further utilize that in population health?

Dave Chokshi: It depends on how we think about population health. Our approach at H+H has been to consider population health with this definition: taking a more proactive approach to addressing avoidable human suffering. Our goal is to take that vision and make it very tangible and real for patients that we serve. We have a few strategies to help operationalize that vision. One idea is to get beyond the tyranny of the in-person visit. So much of how we organize healthcare delivery has been dependent upon who crosses our threshold and when. I think about the patients I care for in the primary care clinic at Bellevue. Too often people have other things going on in their lives that make it challenging to carve out time to seek care on physician’s terms rather than terms that make more sense for their busy lives. We have patients who are living in a cash economy—restaurant workers and cab drivers. Coming to see me in the clinic may be three or four hours out of their day which equates to wages lost. I think we must double down on some of what we had started before the pandemic, using telephonic visits and text messaging to give back our patients their most important commodity: time.

Click here to watch the webinar recording