Aesop tells us the story of the slender reeds and the mighty oak. Situated along a water bank, the oak tree mocks the reeds for bowing low every time the wind blows while the mighty oak stands strong. “We bend, we do not break,” the reeds whisper as a hurricane sets in. The slender reeds sway but do not break. The mighty oak stands strong until it is completely uprooted.
The hurricane that is hitting all of our shores is COVID-19. And organizations across the industry are learning to find strength like those slender reeds in building flexibility into their healthcare governance structures when responding to this global health emergency.
Using abstract terms like governance and process leads us away from the reality of what these terms embody in our daily lives. A group of people want to accomplish a task. They agree on a common method to get that task done. Some organizations may have shared methods for accomplishment, but haven’t written them down. Some organizations have documentation, but stop there. Some organization live their governance, actualizing policy in words and in deed by measuring its impact on operations.
The global experience that is the COVID-19 pandemic has forced all organizations everywhere, in all areas of industry, with mature or nascent governance and procedures, to reconsider what this looks like in reality as the high winds of fearful uncertainty blow over all of us. In responding to the speed and depth of the problem COVID-19 represents, many organizations have been making key decisions to build flexibility into their governance in order to effectively provide the same value its constituents seek in times less urgent.
Mary Greene, MD, director of the Office of Burden Reduction and Health Informatics at the Centers for Medicare and Medicaid Services (CMS), recently discussed with the Global Consortium for eHealth Interoperability how CMS saw the role of flexible healthcare governance as a lever to increase operational capacity responding to COVID-19. “Sometimes increasing capacity means reducing administrative requirements, where possible, to focus on resources and patient care so people are not working on the administrative reporting requirements, but actually taking care of patients. CMS has over this time really looked at the policy levers that we had to pull during the pandemic and is assessing the effectiveness of them, of any of the actions that we put in place. An example is our decision to provide flexibilities and coverage in things like prior authorization to expedite patients’ needs—like getting oxygen and respiratory-related durable medical equipment more quickly.”
Dr. Greene discussed how CMS’ flexibility was driven by the messages they were receiving from the healthcare stakeholders that they interact with regularly. “Some of these changes were informed by letters we have gotten from state governments, by conversations we had with governors. And—[this is] particularly important—they were informed by people in the medical community telling us what the challenges they had were in the field—so that we could then respond with potential flexibilities that we could create in our rules so they could expedite their processes and put them in place more quickly.”
Since our earliest days, shared enemies have always helped groups to forge new alliances. The speedy, pervasive and existential nature of COVID-19 has driven many provider organizations to incorporate flexibility in their regular partnership governance and processes to ensure they were able to respond effectively the many COVID-19 patients walking into their door.
For two-time Davies Award winner Ohio State University Wexner Medical Center, this meant the rapid ramp up of a partnership with an organization literally across the street from the hospital in order to improve their COVID-19 testing capabilities. Milisa Rizer, the hospital’s chief information officer, described the impact the partnership had on the hospital’s testing capacity to the Global Consortium for eHealth Interoperability back in April 2020, fresh from the initial experience of battling the virus. “For those of you who don't know what Battelle is, basically right across the street from Ohio State sits the Battelle Research Institute. It is an institution that started actually back in 1923, from a steel industrialist called Gordon Battelle, and his goal was to translate scientific discovery and technology into societal benefits. I don't know how he knew this almost 100 years ago—that we were going to need Battelle in such a real way. They really stepped up to the plate, and within a period of two days, we moved laboratory equipment from the Battelle site to one of our research towers and took over an entire floor of our research tower to start to be able to do COVID-19 testing with a very rapid turnaround.”
Milisa elaborated on what their rapid partnership looked like. “It was taking us up to almost two weeks with an outside lab to get COVID-19 results back. Once we had the Battelle partnership up and running, we were getting our results within six hours, which really helped with contact tracing and with helping people not spread this virus so quickly. Not only did our Battelle researchers help us with being able to report COVID-19 test results more rapidly, but when we had a need for viral media, we couldn't do any more tests; we rapidly ran out of swabs. We did that with 3D printing—we rapidly ran out of viral media for transport. Battelle was able to come up with the formula and get [Food and Drug Administration] approval for that viral media so that we were not stymied in our approach to do much more testing.”
Nimbleness in the approach to partnerships impacted the ability for Davies Award winner Atrium Health to respond to COVID-19 in their North Carolina community as well. With the goal to ensure the same quality of care, regardless of the patient’s entry point (virtual or face to face) into the system, the organization used a standard scoring tool to place COVID-19 patients into one of five risk strata to determine treatment strategies.
Their Tier III patients were individuals who had two or more morbidities, but were otherwise relatively healthy. Atrium Health asked these Tier III patients to home quarantine to minimize strain on healthcare resources and minimize exposure to higher acuity hospital patients and caregivers. But these Tier III patients are also at higher risk for negative outcomes associated with COVID-19.
To effectively remotely monitor Tier III patients, Atrium established an unlikely local partnership with a technology box store franchise to drop ship remote monitoring technologies to these Tier III patients. Using remote monitoring and virtual assessments, the Atrium team could identify any patient deterioration due to COVID-19. These processes allowed Atrium to monitor patients, without increasing risk of exposure to staff or other patients receiving inpatient care at hospitals.
So for almost 1,000 words, we have been arguing for flexibility in healthcare governance as a method for organizations to actualize resilience in the face of unprecedented threats. But for some organizations responding to the COVID-19 pandemic, it was actually a steadfast embrace of global standards, by their definition specific and tightly constructed, to operationalize the type of flexibility a resilient healthcare governance structure can provide.
As Andries Hamster, senior product manager, interoperability solutions at Philips shared with the Global Consortium for eHealth Interoperability in May 2020, it was their embrace of standard integration profiles developed by Integrating the Healthcare Enterprise (IHE) to provide the type of flexibility their customers and regional policymakers desperately needed to respond to COVID-19. “As the month of March progressed in the Netherlands, it was a month that we saw COVID-19 infections going up rapidly. As we came to the end of March, it became very clear that some of the Dutch hospitals were no longer able to treat COVID-19 patients with the quality and the attention that we would normally require. A bit of a chaotic patient transfer started to happen between hospitals with depleted capacity to hospitals that still had capacity. As a result, the Dutch hospitals turned to the Dutch government to say, ‘We need some help in coordinating these patient transfers.’
“And the Dutch Ministry of Health responded by setting up a nationwide Dutch Coordination Center that helped to basically spread the load of these COVID-19 patients across these hospitals. With that kind of coordinating effort there also was an emerging need for sharing the medical and healthcare data of those patients that were being transferred between hospitals. That was the moment that we as Philips could step in and actually use infrastructure that we already provide to many of the Dutch hospitals. We were able to build a safe and secure health information exchange, very much tuned to the specific needs of COVID-19 patient transfers between hospitals.”
Hamster discussed the impact leveraging IHE profiles had in responding to their local needs, and at a speed that this acute emergency called for. He and his colleagues utilized a number of key data transport IHE integration profiles, such as Cross Enterprise Document Sharing (XDS), which helps organizations share and discover EHR documents between healthcare enterprises, physician offices, clinics, acute care inpatient facilities and personal health records, as well as Mobile Access to Health Documents (MHD), a FHIR-based profile that provides a RESTful interface to document sharing including Cross Enterprise Document Sharing. By using IHE profile infrastructure, they were able to build a dedicated exchange portal in two weeks and get 95% of the hospitals connected to share clinical and medical data, shared Hamster. “Using IHE profiles, we were are able to support the Netherlands’ National Correlation Center and audit the use of the system to really check whether the transfers they were initiating were also happening between the hospitals.”
It is an undeniable truth around the world at this moment that we are all living through unprecedented times. Never has more been asked of individuals, of organizations, of nations and of the world collectively to respond to a threat at a scale very few of us living have ever faced.
The winds of this hurricane are strong, and there are times when all of us have felt the soil surrounding our roots begin to loosen, to give way to the gale force acting upon us. It is in these moments that the form of those roots, and the form of the structure those roots support are more important than ever to the sustainability of ourselves, our organizations, our nations, our shared world.
Now is the time to look to your organization’s governance and policies to make sure you understand if those structures allow you to bend but not break vs. brace unmovingly before being uprooted.
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