Russ Branzell talks with Daniel Barchi, CIO at New York-Presbyterian Hospital

[MUSIC] Hello and welcome to the Digital Health Leaders Podcast, where we bring the best of the best in digital health leadership to you. I'm Russ Branzell, President and CEO of the College of Healthcare Information Management Executive, or CHON, and the host of this podcast. These are truly unprecedented times for our industry and our healthcare leaders. These leaders are doing everything they can to support our frontline caregivers and guide their organizations through some of the most tumultuous times in modern history. Today, we have one of those special leaders with us. Terry Veteran, and most importantly right now, he is one of our healthcare leaders and heroes who's serving on the frontline in New York City, one of the city's impacted most by the coronavirus. He's the CIO at New York Presbyterian Health Delivery System. He's also a great friend of Chimes. Welcome, Dan, Bargey to our program. Great. Thanks for having me, Russ. Well, obviously, Dan, it is a trying time and a difficult time for our whole country, but I think appropriately so, almost all eyes in the country are in New York City. We've all seen the news, the press briefings from your governor for your mayor. Obviously, New York City, a place deared my heart because I teach at Columbia, and you've often been one of our guest faculty members over there, is impacted the most. So, it sounds like a simple question, but how are things going there and how's your team doing? Well, first of all, thanks for asking and thanks for having me on. I'm really proud of how New York Presbyterian, and quite frankly, all the hospitals of New York City and this region are responding. If you think about the way that the city, the state, the federal government, the military field hospitals have come together to battle this crisis, it is a heartwarming piece of what is otherwise a really significant crisis. Here at New York Presbyterian, the organization is doing really well for it being as hard a challenge as this is. We're a resilient group. We've got great leadership here, though. We're fighting an enemy that we have not seen before, but we've got amazing people. And the way that this organization has worked together for many, many years prepared us to surge into the roles that we're putting right now. But let me give you a sense of just how challenging it is. You know, at the time that we're talking, we have well over 2,000 COVID-positive patients in house across our 10 campuses. You know, four weeks ago, we had in the low 400s ICUs across our enterprise. So it's clear that what we had even a month ago would not have been enough to battle this crisis. And some of what we've had to do just in the past couple of weeks is build 7,800 new ICUs to meet this demand. And so the ability for our physicians or leadership or technology team or bio-med team to build this kind of capacity on the fly to respond is what's enabled us to get through this so far. So Dan, I worked in a large academic system, a large community health system. I can't even fathom the scale in which you up to your ICUs, especially when we hear about ventilator shortages and rooms that aren't necessarily set up. Or even physical locations. How did you all, how did you even approach this? Well, I'll tell you we're a physician-led organization, which is really important because it was clinicians and it's theologist, ED specialist surgeons, intensivists who know how to take care of patients, who knew what was within the realm of possibility. And so we were challenged to create capacity wherever we could. So across 10 campuses in New York Presbyterian, we've taken pack use and O-Rs and Med Surge beds and reconfigured them into being ICUs. I just came across from across the street where just last year we opened a brand new ambulatory surgery center. We took about 95 of these small rooms that were designed for patients to prepare for their surgery, then recover from their surgery and go home in that same day. We took every one of them and turned them into an ICU. So they already had a bad, they already had a monitor and pulse ox. We're adding ventilators in there and connecting them with central stations. And now those are 95 new ICUs. And we've taken some of our O-Rs in our larger campuses and taken a large O-R that has three oxygen and medical gas outlets and turned it into three ICUs. So everywhere that has the capability of being an ICU, we've surged and made it so. But it took a lot of coordination between technology, biomed, clinical leadership and our intensivist teams. I can't even imagine, I mean really what an orchestration this must be. All of the exact same time I assume because you're so innovative there that you were leading front of telemedicine, you were trying to connect to the communities. You now have had to send people home just like everybody else to work from at home. All those initiatives occurred at the same time. Well, you know, over a series of hours and days and weeks, we've gotten better at this. It's interesting. We're now at the peak intensity of what we're dealing with. And yet the team is focused and calm and carrying out what we need to because we've grown and developed our processes and our leadership structure, our incident command and virtual command center over the past couple of weeks. So it allowed us to do multiple initiatives simultaneously. So the piece that a lot of people would focus on sending our back office team a lot of our IT and finance and HR teams, you know, well over to 3000 people to work remotely. That's a small piece of this. It's something the leadership team has not even focused on. Our IT team just made itself by purchasing several thousand Chromebooks and laptops and iPads and doing what was necessary to make that entire team remote. But that's not even something we're focused on. The other initiatives are really the important ones. And you know, Russ, you and I talked in the past about starting things quickly. I'll give you an example of that are ED position leaders from across all of our campuses, meet on a call at 9 p.m. every night. And they talk about new initiatives and what they recognized was this is a this is a respiratory disease. And so a lot of it goes into knowing the pulse oxygen saturation of the patient. And if there are 95 or above percentage pulse oxygenation, they're probably going to be okay. In the 92 to 94 range, you really are concerned about the patient. And then below some range, they clearly need to be admitted as a patient. And if they're really in a bad spot because of their one condition, they need to be insulated. And what the ED leaders were saying is how do we give the care that our patients need and send them home at the same time. So that they're not in this environment so they can recover surrounded by their loved ones. And so they said, you know, using a pulse ox is great in the ED, but how do we recreate that at home? So just in a matter of hours last Sunday, we took a number of pulse ox sensors. We purchased several thousand of them for remote telemedicine anyway. And started distributing them to our different emergency departments. The ED physicians created really thoughtful protocol of when and how to use these. We worked with the Ames suppliers to make sure we had oxygen and oxygen concentrators lined up. And then we've created this program so we can send patients home safely and then have follow up telemedicine visits with them. That was something that started in a matter of hours before we were using the first patients and over a series of days, we codified the process and have improved it. But that's the kind of speed with which we've had to work to respond to this crisis. We're all in this together, including our foundation partners, our CIOs, CMIOs and every kind of leaders. There are special friends that have come alongside of us to support us during this time and this podcast. Now a message about those great supporters. Today's episode of Digital Health Leaders has been brought to you by LK, your healthcare data plumbers. Learn more at lk.com. That's E-L-L-K-A-Y.com. First of all, thank you for your service and you spent many years in the Navy and I spent quite a few in the Air Force. So it seemed like almost on a daily basis when we were in the military, you prepare for this because that's your job. But don't think about the same equivalency in a civilian healthcare setting. You know, we always thought that was the military's job, but the National Guard or some kind of first responders thing. And all of a sudden now it sounds like your entire organization, even the words you're using bring me flashbacks, military years of service and command centers and structures of command, all those type of things. How did your military time prepare you for this and what kind of parallels are you seeing and what you're having to do every day? Well, one of the things I think that we're seeing in every one of the leaders and the clinicians that are working on this is a is a column and a grace under fire. As challenging as this has been, one of the things that's most remarkable is the way that people are operating with grace and thought. So they're concerned about the patient. They're concerned about the patient's family. They need to do the right thing. They know it's a crisis and it's very stressful. But everyone is retaining a calm. They're thinking about the big picture. They're thinking about ways that we can help the greatest number of people. I'd say that's the closest thing that I've seen akin to crisis situations in the military where things get really hot under fire. The clinicians and the leaders of New York Presbyterian really just any health system to respond to this kind of crisis is that defining characteristic that allows you to get through it. I think what I found most interesting, and the most interesting parallel that I've heard was from our CEO, Dr. Steve Porwin, who himself as a cardiologist and worked through the AIDS crisis in the '80s and the '90s. And his comment was, "This feels like the AIDS crisis but compacted it into just a couple of months." So that was certainly gut-runching and life and death and we didn't know what we were dealing with in the health care industry. And yet, it wasn't this much magnitude packed into such a short period of time. But in every way, whether it's military or former medical experience in other areas, everybody's pulling on the experiences they have to allow them to serve as best they can to this. Again, thank you for your service. And everybody's there. All these health care heroes are at New York Presbyterian across all of the country in New York City, especially here for this call. I've had you come in and guess, like you're quite a few times. I think probably now over the last three years at Columbia's Executive Masters program. And I will tell you the students absolutely love hearing from you because you're so forward-thinking, digitally enabling, cutting-edge technology, thinking about the future of medicine. And yet, when a matter of three, four weeks, you had to take advantage of everything that you were planning for a really long period of time, somehow magically it all happened in three or four weeks. And I know it wasn't magic. But how was all A, how did all that preparation for these last few years enable you to do everything you just described? And now looking forward, how does all that enablement that you've actually actuated and put into practice give you forward momentum moving into the future? Yeah, thanks for asking. One of the things we're really proud of is we have an outstanding innovation team that's done really cutting-edge work in a lot of areas with artificial intelligence, robotic process automation. And certainly in telemedicine. And well before this, New York Presbyterian was a national leader in telemedicine in all of the different ways we were using it. And yet, what we were doing then is just really small. It's compared to how we were able to ramp it up. Now, have we not been doing this groundwork for three years? We wouldn't have been prepared for what we're doing right now. But in February, we were doing an average of 100, 150 telemedicine visits a day. We're now averaging greater than 4,000 and 5,000 telemedicine visits a day. And it was the years of preparation and this great team that worked with our clinicians to enhance and enable the capability that allowed us to add the additional resources, additional training and patients who were motivated to do all of their visits remotely that allowed us to ramp up that quickly. One of the other things that we're really proud of is in the summer of 2016, we started doing virtual ED visits via telemedicine. We call it NYP on demand. And that first time that we ever did a telemedicine visit, we were all watching as the first patient went through. And then we'd do briefs and make sure that it was safe and high quality. And we did 10 of them. Then we did 100 of them. And then we were doing on the order of several thousand every year where we would have one or two physicians available around the clock. Because of those years of experience, we were able to quickly ramp this up. And now we have as many as 15 to 20 physicians who are now providing the service at any one time, which is really important because a lot of this care is recognizing the condition of COVID early on. And then making sure that patients are following the appropriate care for them. So having that NYP on demand virtual ED service, which allows the patients to do it from home, is really a defining ability to care for more patients without having to physically come to us. I was talking to one of our good friends the other day, John Kravitz over at Geysinger on one of the podcasts. He talked about how on a Friday, it all started and by Monday, he had 1,800 physicians that weren't on telemedicine before, on telemedicine, 8 to 10,000 remote workers that had never worked remote. And now it's the new normal after two weeks. It's just what everybody knows. And the question I ask a great question for you, and obviously you're writing a little bit a fight part of this, but there's also the technology to such a hugely forward now in utilization. Can we ever go back now? Will we ever go back to the old way of doing business? That's a really good question. Certainly we want to use everything that we've learned to both provide outstanding care and think about what the next major crisis that might be upon us. I remember learning about the 1918 Spanish flu epidemic and more being fascinated from a historical perspective. Now we all need to think, what might happen later this year or next year and how might we respond? When it comes to the tools that we've adopted over the past several weeks to respond to this, certainly telemedicine took a major leap forward and I think we'll always be a major part of our toolkit. The way that we've had people work remotely, it'll cause us to question what jobs actually need to be done in a physical work environment versus what can be done remotely. And then thinking about where we go from here, how do we tie our systems together to make our physicians even more efficient? Crisis like this forces you to focus on what's very, very important and ignore everything else. I think it will be adopt some of that as we return to normal over the next weeks, months and perhaps even years, it will use this experience to question everything that we've done in the past and see if we can boil down to the absolute critical skills that are needed from everyone of our team members, from clinicians and nurses to our back office, finance, IT people and focus on those. - So Dan, you all are obviously, it may be it's not the peak, but it appears to be kind of at the peak of this in your general area of service, but there's a lot of places in the country that are just starting that ramp up. And some of our CIO members in China, but also just our healthcare leaders out there trying to get their head around of what's about to hit them, what's one or two nuggets you can give them preparing for this as they're probably where you were three or four weeks ago and some of these other locations in the country. - Sure, I'd be happy to share a couple of things. First, from the top level, we created a virtual command center that operates 24 by seven, that ties all of our campuses together. So we have one way of communicating and allows us to standardize our standard of care, standardize the way that we roll out PPE and update and communicate. So I think establishing that centralized command center with the expectation that it's a 24 by seven operation is really important. Another thing to think about this is, you hear national reports about how New York is doing and it begs the question if that New York state or New York city. And if you drill down to a city, you could say, well, here's the number of admissions or discharges in the city. What we're finding is this differs by zip code. So early on, we found that our hospital in Queens was a hotspot and we had high volumes. More recently, we were finding in our Columbia University Irving Medical Center on the upper northern Manhattan part of our catchment area is getting very, very busy. So I think that everybody prepares where they shouldn't just think about their town or their city or their state. They should think about specific areas and how it might surge from one area to another. One thing that I learned, and I'm not a clinician at all, but through the Biomed team and my organization, we've learned that there's a lot of renal failure and renal support necessary for patients. So there's been a lot of talk nationally about ventilators, but we've only learned over the past couple of weeks that kidney dialysis support at a low volume and continuous is necessary for the care of a lot of patients. So we're focused on CVVH and other machines that do renal support. And that's not something I heard, I heard of nationally, but it's something that I'm sharing with other CIOs. And then just the basics, a lot of places are surging into lots of areas that they had not created ICOs as ICOs. And the basics are the layout of the room and how you hear alarms down the hall in what used to be an OR. And so we're using a lot of the still video and broadcasting from one part of the floor to another so we can watch IVs or pumps or monitors or alarms remotely. So it's this kind of on-the-fly critical thinking and problem solving that really, I think, allows you to move quickly. - Yeah, I even heard you're taking on a few places that are not traditional sites of care. Sports facilities and tents and other things that have just not been a traditional environment for you. - Well, that's certainly something that the US military has done setting up a field hospital in our convention center here in New York, called the Javits Center. And certainly the US NS Comfort is here as well, but you're right, in addition to setting up a number of of ICUs, we're also setting up a number of step down units in your intermediate care where other patients can search to creating space on the fly in some of the lobbies of our hospitals and elsewhere in ways that we wouldn't have thought of just four weeks ago, but it's the right thing to do. So we're never caught in a spot where we don't have enough capabilities of our patients. One last quick question for you then, Daniel and that is, what can we as a country do to support you all on this frontline? You know, we've had outstanding outpouring of support nationally. There have been offers from around the world and around the country for PPE and equipment. We've had staff come in and join us. We've had clinicians join us via telemedicine to do ICUs support. So we couldn't be more thankful of the support we've gotten. I think the right thing for everybody to do is stay well informed about the progress of this disease and recognize how it's spreading across the nation and prepare locally. So it was kind of you to ask for us, well, you know, what others can do for us. I think the right thing for everybody to do is re-double your efforts locally to be prepared, get the capacity in place that you need. So no part of our country or quite frankly, the world is ever unprepared for what's coming. And if we over-prepare, that's a good thing. There's no choice that says it's right to under-prepare or just try to nail it perfectly because nobody can. So I think preparation in every way in our families and our health systems and hospitals and our physician practices and our medical schools is a right thing to do. Daniel, we're going to let you give back to the fight there and, uh, Naomi is God's speed and thank you all for everything you're doing there. Great, thanks so much for having me, Russ. Thank you. Well, ladies and gentlemen, we owe Daniel and all the other amazing heroes in New York Presbyterian and the other facilities across New York City. And our nation is a whole, a great deal of thanks for their service and sacrifice. We also thank you for joining us for this episode of Digital Health Leaders. You can use this broadcast again at chimescentral.org for slash media and for this and for many other broadcasts. Take care, stay home. Be safe. God bless.