Telehealth Breakthrough: Inside MUSC's Innovative Virtual Triage Program

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[00:00:33] Erin Spain, MS: Welcome to the Innovatively Speaking Podcast, a podcast brought to you by the Medical University of South Carolina.

My name is Erin Spain. I'm here in the MUSC podcast studio with my co-host, the Chief Innovation Officer here at MUSC, Dr. Jesse Goodwin.

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[00:00:56] Erin Spain, MS: COVID-19 transformed many facets of healthcare, and one that many of us have experienced firsthand is the rise in telehealth. From 2019 to 2021, the use of telemedicine technology in the US increased for office-based physicians from 15% to 86%. MUSC, long a leader in this field and home to the MUSC Center for Telehealth, is now taking this technology beyond nine to five appointments and into our emergency department.

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[00:01:50] Erin Spain, MS: Welcome to the show, Dr. Park.

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[00:01:53] Erin Spain, MS: Danny, as you know, innovation's sort of at the core and fabric of MUSC and we're always really excited to promote it. And you have innovation in your title, so can you talk a little bit about your journey as a physician and an innovator and how you came into the director role that you currently have?

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[00:03:11] Dr. Jesse Goodwin:

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[00:03:21] Dr. J. Danny Park: I have to go all the way back to my childhood. Actually, I was a Lego guy. I loved Legos and my dad, I remember this one year, he came home with this big Lego set, the biggest one I've ever seen of a pirate ship. We had so much fun like hours spent on building it and I would rebuild it, break it down, rebuild it, break it down. And at one point I got bored, right? I mean, you can't just do the same thing over again. So I started re-imagining how it could be better, and somehow it turned into a spaceship. That was my favorite thing of all things that I've ever made. It came from that. I think I learned how to be creative, learned how to make things better and just have that, that drive to sort of continually see things as they aren't, as they should be, you know? Innovation is about failing and it's about learning, and it's about getting back up and trying it again because that's part of the process. That's what's fun about it. It's really recreating something over and over and again just to get it right.

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[00:04:25] Dr. J. Danny Park: When I decided to go into emergency medicine, I ended up loving the chaos of the emergency department. Things are all over the place. There's craziness going on everywhere, there's so many patients. But you get to kind of make things happen and make sure that you're the calmest person in the room. That's what drove me towards my profession, actually. My early career I wanted to improve how the department ran its business and so I sort of was promoted pretty quickly within my first company and I became a clinical operations director for the company and I started re-imagining how we should do the front end, the back end, you know, how we interact with the EHR, you know, tinkering with stuff from early part of my career until now.

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[00:05:20] Dr. J. Danny Park: You know, in the ED, you gotta think about the different perspectives. If you look at the patient's perspective, there's different pain points for them. If you look at the provider perspective, there's pain points for them as well. And for ancillary staff, everybody has different pain points. But if you look at the big picture, some of them kind of, overlap each other. And some of those are overcrowding, staffing inefficiencies, and limited resources. By nature the ED is a limited resource. Waiting times become high. Door to doctor times become high. So patients get frustrated so they leave early without seeing a provider. So those things are crucial and it's something that we need to fix. And it affects the providers, the patients, ancillary staff, c-suite, everybody. That's something that I've always wanted to improve overall. So I had joined MUSC in 2022. And I was working a late Ash River Tower Ed shift. And it was just overflowing. There was patients everywhere. The ED lobby was blowing up. And there was this young mother who was a single mom. She had three kids with her. Two of them really young and she just didn't have anyone to watch them. So she brought them with her and she waited for hours before she got to see me. And so, you know, I noticed her out there with her kids and it was close to like 11 o'clock. It was a school night, and I just felt really bad. It was heartbreaking to see that she had nowhere else to go because she was hurting and she couldn't go back home and she felt guilty. She even thought about leaving, and so we knew we needed to change that, and that's when the ball started rolling.

If you look at the late nineties, early two thousands, we came up with this provider in triage concept, right? Where we focus on that left without treatment rates. We call it LWOTs, so I'll call it LWOTs from now on. And door to doctor times , right? So we wanted to improve those and provider and triage was a strategy that came about in the two thousands. And what we essentially did was place an advanced practice provider an APP out in the waiting room to see patients right away. It was not the most effective way to do things because a lot of times they just sit in the triage room. They kind of piggyback on what the nurse in triage is saying and asking questions and they're not actively engaging with the patients. That was one of the problems. But it really did get those numbers down. But did it impact patient satisfaction, did it impact their experience in the ED? I don't think it did. So that's something I wanted to change when I got here.

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[00:07:57] Dr. J. Danny Park: You know, we have these heat maps of when patients show up to the ED. It's not always correct, but it's, it's a good estimate on when we're gonna have surges, when we're gonna need extra providers, right? We looked at the number of patients waiting in the waiting room at certain times of the day and certain days of the week. We decided these days are where we can make the biggest difference. That's how we started this. We used to have a provider in triage seven days a week, but it still wasn't effective. Our left without triage times were still high. Not as high as it could have been probably, but it was still high. Our door to doctor times were still high. Patient satisfaction was still low. We wanted to do better. We wanted to change how we did that, and so this program came about.

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[00:08:43] Dr. J. Danny Park: It's actually fairly predictive of when we're gonna need extra people to work and cover the parts of the ED. It's not very helpful on the backside of the ED. You know how many people will get admitted 'cause that's really up to chance. But we call this big data, right? Fast food industries love big data. All these companies love big data. One of my passions, application of big data into patient care, is healthcare AI. So I wanna be able to do that in the ED.

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[00:09:29] Dr. J. Danny Park: Like I said, like a provider in triage was a concept that was out there before, but using telehealth for it was a little bit new. When we first started talking about this idea, there was a lot of naysayers. They said, you know, even with this PHE, this Covid Public Health Emergency Act, we could do whatever we needed to do to take care of patients. But even before that this idea of using telehealth for patient care, especially in the emergency department, wasn't new. It was talked about. It was just never done. And some of the legal challenges that came, you know, we were told that we couldn't do it. We went out and we interviewed people from all over the country that were experts in legal matters, in compliance matters, health insurance, payments, all the stuff, coding. They all told us, you know what, there's nothing that says you can't do it. So why not? You know, why don't we try it? That was the decision we made. We broke down those assumptions to try something, and that's how this came about. As far as the telehealth platform though, I mentioned jokingly, we were talking about the problem of the waiting room. The fact that we had a provider in triage at the main hospital, but not at Ash River Tower. And one day, Ash River Tower was blowing up and we were joking, should we just send the provider in triage over to ART and should we just have them run back and forth? And, we decided against that because that's a half mile walk. And so jokingly, I think one of us said, can we just FaceTime over there and just see patients that way? Why can't we do that? And so that's sort of how we came about. Fortunately, we MUSC had this partnership with Andor, and that was an opportunity for me to sort of get in there and try to see if we can apply their technology and their platform to get this done. So it just kind of worked out timing wise.

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[00:11:09] Dr. J. Danny Park: So we started the pilot January 17th of this year. And I don't know if you remember, but January was a tough month for the ED, for the whole hospital really. We had this boarding problem. This national boarding crisis actually. All the big hospitals were having problems with beds, and our ED was no exception. I think at one point we had 200% capacity in the ED. That means there were two or three times as many patients as there were beds available. And so because there were no beds available, we were going out into the waiting room. We were chasing patients down in the hallways, and some people would just disappear. And it was just a mess, you know? And we were afraid at that point that our LWOTS would go up. I mean, naturally it would, because if they're waiting longer than patients are just gonna leave and go somewhere else. But actually what we found is, by starting this VP program, our LWOTS were pretty flat for that month. And it didn't go up, didn't go down, obviously, but it didn't go up. We expected it to, so it shows the power of what we can do. We have updated metrics as well. I mean, now that our boarding problems is better. We've seen that our LWOTS rates have been reduced by almost 75%. Our door to provider times have gone down about 50%, and the most surprising thing that I've seen was because the provider in triage is able to cover both Ash River Tower and Charleston ED, their productivity went up 525%. That's crazy, right? We didn't expect that to happen.

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[00:12:38] Dr. J. Danny Park: You know, when we were first designing this, we were thinking about, should we get fancy tablets or big screen TVs in the triage rooms? And how do we do that? How do we make that happen? But we had these laptops. And we decided that's what we really need. We just need a camera and a microphone and a speaker. That's all it needs. So, we decided to use these basically little Dell laptops on a cart. They sort of roll around in between rooms and It's not very fancy, but it works.

You know, the providers love it. And one of the benefits I thought about was they get to work from home. They get to talk to the patients, they get to see how appreciative these patients are when they first arrive. And the feedback from patients has been great as well. They're very appreciative of the fact that as soon as they arrive, before they even talk to a nurse, they're actually talking to a provider. They're able to get their workups done early. They're able to get their blood tests, necessary blood tests, more pertinent blood tests, more pertinent imaging studies, all done while they're waiting. Because I think before in the traditional setting, I think,the waiting time was sort of a wasted time, right? They would come in, sign in, sit down and wait, wait for a triage nurse, and then wait again for a room before they see a provider. They would wait for a provider in the room. So all that time is wasted and that bothers me as an innovator. So we wanted to sort of improve the PIT program and that was just a natural flow of things, so we made it happen.

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[00:14:21] Dr. J. Danny Park: One of the things that we can improve on in all EDs that I've ever worked in is improving the communication between patients and making sure that they're informed throughout their stay. Even things like, you know, when am I going to the. X-ray machine. When am I going to get my medication? Little things like that. They just need answers. They don't need a person to come tell 'em necessarily. So, what our idea was that, you know, we could use secure messaging between patients and the providers and nursing staff or whoever's taking care of the patients to keep them updated throughout their stay, And that's something that platforms like Andor or, you know, even Epic can help us do. I think that's important to, to improve the whole patient experience of being in the ER because a lot of the frustration is they just don't feel well informed about their care, even if they're, getting great care, they just don't know about it, And so if we can improve that, I think that's a low hanging fruit there.

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[00:15:28] Erin Spain, MS: You talked about addressing some of these big concerns about patient privacy or cybersecurity, some things that scared other folks away from doing this. How were you able to address those concerns and overcome some of those challenges? How did you do it?

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[00:17:08] Dr. Jesse Goodwin: We are one of the only places that do this approach. And so have other sites been reaching out since the news came out on it to ask you how you've implemented it and how it's going?

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[00:17:50] Dr. Jesse Goodwin: I mean, we are one of two national centers of excellence in telehealth. And this is one of the examples of why, That we're pioneers in the space and are willing to take a big step and, and try it in different areas. And also have the benefit of having a good infrastructure in place, as you mentioned, with that team to help you pilot it in your area, 'cause it hadn't been done before. So I think it's a win across the board.

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[00:18:21] Dr. J. Danny Park: That's the exciting thing I wanted to sort of share. We are planning to expand the service to the rest of our health system. All of the 13 ERs that officially are under the MUSC umbrella. We're excited to be able to share this program with them. Just all the work that we've done as a team we can translate into a big difference in how those EDs perform and how those patients experience their ED over there. We wanna make sure that, when we try to expand the service, we want to sustain the fidelity of the program. That's been a concern for me as well. I wanted to make sure that what we put out there, this product is gonna produce the results that we want to produce. And so, all those things that we've learned, all the times that we've spent, all the conversations we've had with different people, I wanted to translate that and make sure that we have a good way to provide the service for the rest of the hospital system . And so I think, at the Department of Emergency Medicine, our division of EM Telehealth, we want to provide this service for the rest of the health system, and we're in process of getting that approved.

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[00:19:35] Dr. J. Danny Park: There's a lot of projects that, my division, the Division of EM Telehealth is working on, and one of those is, you know, in the realm of telehealth, we wanted to apply that in the EM experience with the pre-hospital stage as well. We look at the ED experience as pre-Hospital, hospital and post-hospital. And so we're looking at the pre-hospital stage at this point. There's a model called ET3 which stands for Emergency Triage, Treat and Transport that was started in Houston area, I believe. It was this radical idea that not all 9 1 1 calls need to go to the hospital, at least emergently. So they decided to use telehealth to see if that can change things. So what they did was they equipped the EMS units with telehealth capabilities so that they can call an ED doctor to try to talk to this patient to see if they actually need to go to the ER, if they have an emergency, or if they can, you know, see an urgent care doctor across the street or if they can wait and get an appointment next week. Things like that sort of save the system because that EMS unit can save another life five minutes after, but because they're being used for this patient that might not need ED, they can't go to that patient. That's another thing that we're looking at. We're looking to see if we can apply that concept to rural South Carolina, to a place where they don't have enough transport, they don't have enough EMS units. Patients call 9 1 1 for the basic things. And they don't need to call 9 1 1 for that, but they just need care. They don't have access to care. What if we could equip EMS units with ability to talk to an ER doctor, to get that virtual experience for the patient. Another project we're working on is, I talked about post-hospital. That post-hospital stay, you know, did you know our ED patients, they can't follow up with a provider for probably over 20 days or 35 days on average. And, just because they get discharged from the ED, that doesn't mean their disease process is over. And that their symptoms are just gone. You know, it doesn't happen that way. So symptoms change, they have more questions, they just don't have a place to go. So what do they do? They come back to the ED and that's just not a good use of resources there. So I think what we can imagine is if we equip the ED with telehealth capabilities, we can actually have people follow up with an ED doctor who would probably know if they need to come back to the ED or not. And if they can get that guidance, that reassurance from the provider, I think it would enhance their healing process that whole journey between, having a symptom first to being cured. So, that's another place we're looking at using telehealth to follow up with patients as well.

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[00:22:21] Dr. J. Danny Park: I think our patients deserve it, for sure.

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[00:22:29] Dr. J. Danny Park: Yeah, that's something we're talking about doing now. We actually have a research group within the ED that are going to help us publish this in a larger setting so that we can collaborate with other centers so that we can make things better to improve what we have and improve upon this idea.

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[00:22:53] Dr. Jesse Goodwin: Yeah, I'm really appreciative that you took the time to chat with us today.

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[00:23:04] Erin Spain, MS: You've been listening to the innovatively speaking podcast with Medical University of South Carolina. If you enjoyed this episode and would like to support the show, leave a rating and a review to hear more innovative ideas and to share your own, subscribe to the show or visit us on our website. Web dot MUSC.edu/ innovation.