A hospital without patients


https://www.politico.com/agenda/story/2017/11/08/virtual-hospital-mercy-st-louis-000573

Nurse Veronica Jones speaks with patient Richard Alfermann, who suffers from Chronic Obstructive Pulmonary Disease, during a video call on Thursday, Nov. 2, 2017, at the Mercy Virtual Care Center in Chesterfield, Mo. Jones says that she and other nurses who work with homebound patients like Alfermann feel like they have “50 grandparents.”

 

Located off a superhighway exit in suburban St. Louis, nestled among locust, elm and sweetgum trees, the Mercy Virtual Care Center has a lot in common with other hospitals. It has nurses and doctors and a cafeteria, and the staff spend their days looking after the very sick―checking their vital signs, recording notes, responding to orders and alarms, doing examinations and chatting with them.

There’s one thing Mercy Virtual doesn’t have: beds.

Instead, doctors and nurses sit at carrels in front of monitors that include camera-eye views of the patients and their rooms, graphs of their blood chemicals and images of their lungs and limbs, and lists of problems that computer programs tell them to look out for. The nurses wear scrubs, but the scrubs are very, very clean. The patients are elsewhere.

Mercy Virtual is arguably the world’s most advanced example of something gaining momentum in the health care world: A virtual hospital, where specialists remotely care for patients at a distance. It’s the product of converging trends in health care, including hospital consolidation, advances in remote-monitoring technology and changes in the way medicine is paid for. The result is a strange mix of hospital and office: Instead of bright fluorescent lighting, beeping alarms and the smell of chlorine, Mercy Virtual Care has striped soft rugs, muted conversation and a fountain that spills out one drop a minute. The mess and the noise are on screens, visible in the hospital rooms the staffers peer into by video—in intensive care units far away, where patients are struggling for their lives, or in the bedrooms of homebound patients, whose often-tenuous existence they track with wireless devices.

The virtual care center started as an office in Mercy’s flagship St. Louis hospital in 2006, but got its own building and separate existence two years ago. It is built on many of the new ideas gaining traction in U.S. health care, such as using virtual communication to keep chronically ill patients at home as much as possible, and avoiding expensive hospitalizations that expose patients to more stress, infections and other dangers.

But perhaps the most important factor driving Mercy Virtual isn’t technology or new thinking but new payment systems. In the near future, the hospital’s administrators believe, instead of earning fees for each treatment administered, insurers and the government will pay Mercy Virtual to keep patients well. A visit to the hushed carrels and blinking monitors is a glimpse into a future in which hospital systems are paid more when their patients are healthy, not sick.

Even now, Mercy Virtual is in the black, because of existing Medicare payment reforms that have already converted some of the agency’s payments into lump sums for treating specific illnesses. Mercy can get its patients out of the hospital much faster than average, so it pockets the money it doesn’t need for longer stays, says Mercy Virtual President Randy Moore.

The hospital is well placed, he adds, for the full transition to a payment system based on efficiency and preserving wellness. “Our idea is to deliver better patient care and outcomes at lower cost, so we can say to an insurer, ‘You expect to spend $100 million on this population this year. We can do it for $98 million with fewer hospitalizations, fewer deaths and everyone’s happy,’” says Moore. “It’s a very strong future business model.”

One weird thing about thinking this way is that it radically reimagines traditional notions of medical care—not just how it’s delivered, but when. Most hospitals wait for a sick person to walk through the doors or come into the ER. Mercy Virtual reaches out to patients before they’re even aware of symptoms. It uses technology to sense changes in hospitalized patients so subtle that bedside nurses often haven’t picked up on them. When the computer notes irregularities, nurses can turn a series of knobs that allow them to “camera in” on the patient; they can get close enough to check the label on an IV bag, or to observe a patient struggling for breath or whose skin is turning gray.

There are those who say that even an intensive care unit could, in principle, be brought to a patient’s home. But for now, the future looks like this: Hospitals will keep doing things like deliveries, appendectomies and sewing up the victims of shootings and car wrecks. They’ll also have to care for people with diseases like diabetes, heart failure and cancer when they take bad turns. But in the future, the mission of the hospital will be to keep patients from coming through their doors in the first place.

Racing the Symptoms

On a recent Monday morning, nurse Veronica Jones touched a button on a screen in front of her to make a video call with Richard Alfermann, a retired 75-year-old banker living on a wooded acre outside Washington, Missouri, 50 miles west of the center. A lifelong smoker until 10 years ago, Alfermann suffers from chronic obstructive pulmonary disease, or COPD. He has trouble breathing and even slight exertion can floor him. The most minor illness, in the past, was enough to force him into the hospital.

Seated on a couch in his home, Alfermann happily greets Jones, with whom he has spoken through video at least twice a week since entering the virtual care program in August 2016. The previous year, he was hospitalized three times. Since then, Alfermann has managed to stay in his home.

One paradox of care at home is this: Monitoring patients from afar with regularity can create more intimacy between patient and his caregivers than a sporadic, once-every-three-months visit in person. Jones and the other nurses on the virtual ward say they feel like “we have 50 grandparents now,” she says. In addition to the touchless warmth, regular interactions enable more individualized care. For example, many COPD patients have such high pulse rates on a good day that an unsuspecting doctor might immediately send them to an ICU. A tele-doctor in regular contact, however, can distinguish a true crisis from a baseline reading that might seem alarming but is normal for that patient.

In Alfermann’s case, if he shows signs of failing health, his physician―Carter Fenton, an emergency medicine doctor with 450 patients under his care—can call in home health care nurses, who can examine Alfermann more closely, take X-rays and EKGs and blood samples if necessary. In a sense, Mercy has given Alfermann his own hospital, a home hospital.

And that’s the main purpose of the “engagement at home” program—to keep very sick patients out of the hospital, where their care runs up enormous bills and is laced with dangers to the patient, ranging from nasty bacterial infections to misplaced drug orders to the disorientation of constant alarms, tests and injections. “A telemedicine visit is never going to be as good as having a doctor and his or her team at your bedside,” says Moore. “But 99 percent of the time we can’t make that happen. With virtual we can at least see any patient just like that―rather than tomorrow or next week. And that can be a life or death thing.”

One major aspect of the hospital of the future, it seems, is “less hospital, more future,” says Robin Cook, a former ophthalmologist and the best-selling author of medical thrillers that feature things like roboticized hospitals and killer apps that actually kill their patients. People will continue to go to hospitals—or, increasingly, outpatient surgical centers―to get operations, but their stays will be shorter. “It’s going to be progressively more procedure-oriented, with a lot less parking people to monitor them,” says Cook.

As Alfermann, his nose fitted with a cannula bringing him 100 percent oxygen, pops up on the monitor in front of her, Jones is examining his vital signs, which include blood pressure, pulse, temperature and blood oxygen readings that feed wirelessly into the system from devices that Alfermann attaches to himself at home.

Most medical interventions take place when a patient presents himself at a doctor’s office or an emergency room. Because “frequent flyers” hate going to the hospital—often a traumatic place for the old and infirm–they’re often in denial about any symptoms they may have, which, ironically, raises the risk that things will get to a critical point if no medical staff are watching.

“A lot of times they’ll say, ‘I feel fine,’ but I can see on the monitor that they are struggling to breathe,” says Fenton. “I remind them that this is how things got started the last time they were hospitalized. There’s a trust factor at first. Sometimes it takes a trip to the ER to vindicate us.”

Today, the concern is Alfermann’s pulse. It’s been above 100 beats per minute twice the last three mornings, from its usual level around 85. Pulse is “a big clue that he may not know what’s happening but something may be about to happen,” Fenton says. He and Jones worry that with cooler weather and drier air, Alfermann might be developing a cold that could exacerbate his COPD.

“Any shortness of breath or changes in your cough?” Jones asks. “Any fever or chills?”

“I don’t think so,” responds Alfermann, a fan of bowling, fishing, and the St. Louis Cardinals. “Yeah. Nothing better, nothing worse. Same old shit.”

“If anything changes with that you know you got to call me right way.”

Jones and Fenton monitor Alfermann carefully over the next several days to make sure there’s no incipient problem. But by Wednesday his pulse is back to normal. Until the next time. “I don’t feel super, but I’m OK,” he tells Fenton. “I haven’t felt good in so long I don’t know what good is.”

Reassured for the moment, Fenton knows there’s always an escape valve. “We always tell the patients, if you feel like you’re getting worse, you need to just go to the hospital,” he said.

Virtual ICU
On the other end of the second floor at Mercy Virtual Care, which is a maze of desks and computer screens, nurses and doctors have their fingers deep in the business of colleagues at hospitals across the country, from North Carolina to Oklahoma. They run a series of programs —TeleICU, TeleStroke, TeleSepsis and TeleHospitalist — all aimed at keeping hospitalized patients from growing sicker and at getting them home faster.

In part, the virtual ICU is dealing with a problem that technology created. All the beeping monitors in the patient’s hospital room crank out massive amounts of information, presented in too cumbersome a way for nurses and doctors on site—at least in typically understaffed hospitals―to deal with quickly. So Mercy Virtual provides nurses and doctors who can focus on monitoring and digesting these data streams, looking for signs of trouble. That way the nurses and doctors on site can pay more attention to the patients and less to the machines.

Electronic health records, which most hospitals started using over the past decade, “inundated us with data,” says Chris Veremakis, who runs Mercy’s TeleICU program. “The EHR has become a thing of its own, and you find people spending so much time in front of the EHR instead of spending time with the patient.”

A layer of backstopping colleagues, watching the data roll in in real time, can improve the quality of treatment by making sure good care standards are being met and catching signs that a patient is going downhill, Veremakis says: “We let the nurses on the floor do their regular work and not be pulled in a million different directions.”

One of the intense professionals doing this is Tris Wegener, who was an ICU nurse for 22 years before a snowmobiling accident wrecked her arm and led her to virtual nursing. Now she spends most of her days at Mercy seated in front of a bank of computer screens. She’s waiting for the appearance of a little red flower icon, which means that a computer program, after taking in data from the monitors in the patient’s room, is warning of a danger of sepsis, an immune response to a bacterial bloodstream infection that is the No. 1 hospital killer.

Sepsis can be hard to spot, manifesting itself in irregular symptoms. It’s on the increase among chronically ill patients who are living longer than before―about 1.5 million people get sepsis in the U.S. every year, and 1 in 6 die. When one of the red sepsis flowers pops up, Wegener makes a series of inquiries to rule out false positives. If the patient meets all the criteria—typically very low blood pressure, high fever, infection and high levels of lactic acid—she calls the nurse or doctor on duty. The hospital might be in High Point, North Carolina, Joplin, Missouri, or a dozen other places.

“I get the data as soon as it enters the system,” she says. “The nurse on duty might have three other patients. Is she aware of the problem? Sometimes, sometimes not. She might have another patient who’s coding in the emergency room. They don’t have time to check out this patient whose X-ray looks clear, but we know that tomorrow, if this isn’t taken care of, he’s going to code with pneumonia.”

It’s not unusual for the entire staff of a small ICU to rush into a patient’s room when a patient crashes. When that happens and Mercy is watching, its remote nurses can keep an eye on the other patients while those at the scene take care of the most critical case.

Working on a single shift not long ago, Wegener and two other virtual nurses had to sort through 136 sepsis alerts from hospitals around the country. Each one takes as long as 40 minutes to resolve. “It keeps your mind going,” she said.

“The job isn’t physically demanding but mentally, oh gosh,” says Lindsey Langley, whose expertise is in diagnosing and ordering treatment for stroke—a condition in which speedy diagnosis and treatment can be the difference between a minor tic and death, or a grave, lifelong disability. “You go home every day exhausted. You are tapped out.”

Most of Mercy’s telehealth and remote monitoring covers patients and hospitals inside the small Catholic hospital system, which has facilities in Missouri, Arkansas, Oklahoma and Kansas. But it also partnered with hospital systems at the University of North Carolina and Penn State. Part of the attraction is the backup Mercy provides to hospitals that serve uninsured or low income patients and can’t afford to staff up to levels that might be desirable.

“Mercy runs 24/7 in the background collecting analytics on our patient population,” said Dale Williams, chief medical officer at 351-bed High Point Regional hospital in North Carolina, which is part of the UNC system. As they gather vital signs, EKG data and so on, the Mercy staff can alert brick-and-mortar staff to any significant changes. If there isn’t a nurse or doctor in the room, they intervene.

Of course, a nurse in St. Louis can’t fill an IV fluid bag in North Carolina, but she can use a camera in the room to see that an IV bag is almost empty—then call and instruct a nurse on the floor to refill it. The telemedicine cameras are powerful enough to detect a patient’s skin color; microphones can pick up coughs and gasps and groans.

Making that order from far-off St. Louis can be a delicate matter until the virtual nurses and doctors establish good working relationships with their partners in the flesh-and-blood world. Unsurprisingly, when Mercy starts its virtual relationships with these hospitals, the professionals on site often aren’t exactly enthused to be getting instructions from afar.

“People just think that they can put the technology in place and get amazing results,” said Moore, who estimated that Mercy had spent $300 million to create the virtual care center. But acculturation is key to the process. At most ICUs and other hospital services, physicians and nurses already think they are operating at top capability. It takes work to convince them that their services would be better with help from outside.

“We’ll spend time with them and say, ‘This isn’t Big Brother looking over your shoulders: We’re partners,’” he said. “But doctors don’t necessarily want other doctors writing their orders, and if they won’t accept it, it doesn’t work. If a nurse ignores our team because she’s too busy and not used to TeleICU, nothing happens.”

Sometimes the cultural shifts required may be a bit too much to work. Tampa General Hospital piloted a TeleICU relationship with Mercy Virtual for six months, but ended the agreement Nov. 15. The hospital gave no explanation for the decision.

Longer term partners, however, seem to have converted to the concept. “A decade ago I would have said, ‘I don’t know that that can work,’” said Williams, who has been working with Mercy Virtual for about two years. “I’ve been convinced. It would be ideal to have a doctor in each unit 24/7, but even then they can’t be looking at the analytics the way these people do. They have critical care-trained nurses and doctors looking at this stuff all the time. They can camera in and count the pores on someone’s nose.”

Williams’ hospital has two critical care doctors who take care of the 28-bed intensive care unit from 7 a.m. to 6 p.m. each day, with “Mercy running in the background,” he said. After 6 p.m., nurses on the ward continue to do their thing, but Mercy is in charge.

“This allows our guys to go home on backup call,” he said. If needed, the doctor can always drive back to the hospital, but most nights Mercy’s intensivists take care of problems. “This allows us the best of both worlds. We have constant analytics and if something is changing that’s not seen by nursing staff, they’re right there monitoring it in St. Louis.”

The relationship has improved outcomes at High Point, Williams said. Doctors who used to get burned out and quit after a year or two tend to leave less often. And the hospital’s care has improved year after year—fewer hospital infections, fewer patient days on ventilators, fewer readmissions and better patient survival, he said.

For now, Mercy and its partners have one foot in the old payment system and the other in the new world, where best outcomes and money align. But there are still administrators at Mercy hospitals who see fewer admissions and days in the hospital and “aren’t particularly happy about it,” Veremakis said. “There is an awkwardness in this time. But enough people with vision recognize this is the right way to go.”

Mercy Virtual’s ICU nurses, most of whom had years of experience before coming here, are sometimes a bit nostalgic for the bedside, with its immediacy and adrenaline. “You’re used to being in charge. Here you’re part of a team,” said Wegener. “If you think something is not being done you have to be polite.

“And there’s no way I can put a price on being able to put my hand on a patient and say, ‘My name is Tris.’”

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