THE REAL TIME HEALTHCARE PODCAST · Mar 3 · 20:56 min

#31 - Dr. Matthias Merkel, Oregon Capacity System - The First Near-Time All-Hospital Bed Capacity System

In this Episode:

In this podcast, Jeff Terry, GE Healthcare welcomes Dr. Matthias Merkel of Oregon Health and Science University. They talk about both the Oregon Capacity System, which is a statewide effort, as well as the Mission Control program at Oregon Health and Science University. The statewide effort really grew out of OHSU Mission Control.

Jeff Terry
Hello and welcome. I'm Jeff Terry. Delighted to welcome Dr. Matthias Merkel of Oregon Health and Science University. Hello, Matthias.

Matthias Merkel
Hi, Jeff. Glad to be here.

Jeff Terry
Thank you. Today we're going to talk about both the Oregon Capacity System, which is a statewide effort, as well as the Mission Control program at Oregon Health and Science University. The statewide effort really grew out of OHSU Mission Control. Let's start there. If you don't mind, could you tell us the story of OHSU Mission Control?

Matthias Merkel
Yeah, absolutely. Thanks for having me. Our story started in 2016, where we recognized that the old fashioned way, how we managed our capacity, was just not meeting our needs and not the patients we wanted to care for. We actually did in 2016, we ran on paper and, when we had days where we felt we can't meet the demand on our inpatient admissions, we did crisis meetings which were starting with about two hours of searching, what is actually going on? How many patients do we have? How many do we need to accommodate? Who's waiting where? And then, we met with a group of people which every day were a little bit different group, so there wasn't a consistency there. And then, we talked about the solutions. The teams already kind of implemented a fair amount of the solutions we had available at that point, but we felt very stressed every day.

Matthias Merkel
Our interventions were largely limiting or closing admission portals, like the emergency department, inter-hospital transfers and really like limping by getting through it. Our most effective intervention which made everybody feel better is, ""Okay, let's see how this all plays out and meet again in the afternoon."" So then, everybody went their regular day job and a small group of people managed our capacity. In the afternoon, everybody was eager to hear that it worked out, and while some way it worked out, it didn't feel well and it didn't feel a very efficient way how an academic center should do it. So we looked around, we embraced in this journey, how should be transform capacity management?

Matthias Merkel
After a couple of iterations, we decided to move this, that one of the solution is a digital platform, so we founded our Mission Control. It was really a combination of putting the right team members and infrastructure together and using electronic, the tiles, which you guys developed for us, to really manage our capacity and our throughput much more efficiently. What used to be a white board is now a real-time data tracking capacity snapshot, where we can see all of our hospitals and our health systems, what their capacity is, what's coming in, what's going out, and has been really critically important. In our fifth, fourth year now, and through this COVID pandemic, it has been vitally important for us to have that.

Matthias Merkel
Critical pieces for us was really a very variable distributed team, to bring them together under one umbrella, which is our Mission Control. This includes our administrative and duty, often referred to as a house supervisor in areas, which is a nurse, our bed floor manager, which also a nurse. Then, we have our transfer center coordinators who act like dispatchers and are the multitasker par excellence to make this really happen. We brought in a new role for our health system, which is a transfer center and who is really helping following some triage protocols and doing some clinical screening. We also brought in a physician.

Matthias Merkel
Really, the mindset was running it like you run a unit like an ICU, where you have a nurse manager and a medical director. We wanted to have sort of the day and day operation, which is a physician and a nurse and all the other critically important team members to make Mission Control really function. Giving them technology who supports them, so that your decision-making is the key part you are doing, not the searching for the information. That has been really successful for us as a health system. We created about a 20 bed unit with 90% occupancy just by using our health system more effectively, being able to bring in more patients through all of our admission portals at any given time.

Jeff Terry
Incredible work. We can spend more time unpacking that, but it gives the audience a sense of just how sophisticated or far the journey had come. Of course, then COVID happened and obviously started to develop in February, and then, in March it occurred to you, we can apply the mission control toolkit to COVID. Can you share, where were you when you had that idea and what was the idea?

Matthias Merkel
Yeah, so it's already so long ago. It's really interesting. We are reaching almost the one year mark, unfortunately. In January, February around this time, we started having our emergency operation center meet and planning, what would we do if we get COVID patients? Then, end of February, the first detected patients showed up in one of our health systems, not our system, but in the Portland Metro area, so it became real. Then, the next 14 days, we sort of were waiting and went more in high gear of preparation about this, but we honestly didn't really know what really will happen. Little did we know what we will all see. The discussions, especially in the ICUs, were about, ""What are we going to do if we run out of ventilators? What is if we experience what we are seeing in Italy or what we saw in New York? And how would we manage that?""

Matthias Merkel
My biggest concern, what I heard from my peers was, ""How do I know that you guys still have a ventilator?"" Because we had communications across health system very rapidly, across the entire state, and it's like, we have to really rethink how we run this, because it's really about the patient, it's not about, Oh, this patient needs to go to this hospital, this hospital. It's like, where do we have the right team for this patient? And abandon that... Oregon, it's often referred to as a rural to urban state. We have 62 hospitals, 25 are critical access hospitals. There's a very one-way traffic into the Portland Metro area, which has all the big health systems really, including OHSU and our two Level one Trauma Centers.

Matthias Merkel
On Saturday, March 14, I actually, when I was in the shower in the morning, I thought, ""Would it be cool if we would have Mission Control for the state, if we would just have instant visibility of every single bed in the state?"" And I was just like, ""Okay, I'm going to send Jeff Terry on email."" Jeff, what did you do with this email?

Jeff Terry
Let's put it, you were in the shower. I was with the family getting ready to go to a little kid birthday party when I got your email and quickly gathered some people. Then I went to the birthday party and came back, and we got a couple of people together for a couple hours to really think through how could we get the data from all the hospitals in the state in a very easy way, because nobody's got time. It can't be complicated. We decided, of course we wouldn't take any PHI because if we share PHI between hospitals, that brings in massive complexity. And then, we started to design the UI, what the user would see. That night, at around 8:00 PM, I think, we sent back to you a design.

Jeff Terry
We iterated a course and it quickly went from, ""What? Okay. Is it just Portland? No, it's got to be statewide."" And then, boy, it all kind of runs together, but over, I think the next week, we had discussions with the OHSU team. Then, a group of intensivists for the Portland Metro area that had been formed, the Chief Medical Officers, of course OHSU CIO got involved. And then, within about 10 days, we had onboarded Kaiser, so we had your data, Kaiser's data. We had the thing hosted in OHSU's data center. Within about 14 days, we had all of the data for about 70% of the beds in the state live in the system, updated every five minutes with all the different types of beds, ICU, Med-Tele, Med-Surg, observation, psych, NICU, ventilators. And then, within about a month, we had 90% of the beds in the state, and it goes on from there.

Jeff Terry
Just a quick reflection is, I was inspired by how quickly everybody moved. We, GE, we're delighted to help find a way to help. Of course, OHSU, you had the idea. OHSU IT stood up a hosting environment in days. All the other health systems came together. Data started to flow. In something like 14 days from your email, we had 70% of the beds in Oregon live on a first in the world near-time tool. Yeah. It was cool to be a part of, and of course it's continued to go from there. One of the things that came relatively quickly, frankly, was then, we knew we were building a surge management tool for COVID. We knew it could be useful in the long run for many things, but I don't know that any of us saw summer 2020 in Oregon coming, when it started to prove useful.

Matthias Merkel
Yeah. After we stood this up, which was really an impressive collaborative work across all the hospitals in the state, we really grew closer together, tracking over 8,000 beds now on this tile, all major health system. From the bigger health system, we also have the ventilator data. This is super helpful. And yeah, as probably most of the listeners may remember, in September, suddenly Portland became famous for having the worst air quality in the world. I had no impression what this would really mean, but over a course of five days, the visibility and the air quality, you couldn't go outside without filtered air. All the hospital systems, while we are in the midst of COVID pandemic, we had to really shift gears quickly and activate our wildfire response.

Matthias Merkel
In the state, there were three hospitals needed evacuation because they were in immediate fire. In some hospitals in the state, the fire marshal, the local fire marshal, decided to defend in on site. We had to rapidly gear up as a state, how would we respond and evacuate. One of the hospitals... And part of that is that, [inaudible 00:15:07] use Mission Control is also what we call the Regional Resource Center. We manage mass casualties, and pretty quickly, during this pandemic, also got asked by the state to help in manage patient flow across multiple health systems, should this ever become necessary.

Matthias Merkel
During the wildfire, during this, at the end 10 day period, there were some of our suburban hospitals in the Portland Metro area who were on evacuation risk, and rightfully, the health system [inaudible 00:15:44] decided to bring the most vulnerable patients quickly out of it, which is ICU, neonatal ICU patients. Our Mission Control team helped them to... Because it was clear, if you need to do something like this, you need to be... It's not about calling around who can take it. It's just like, ""Okay. We have, I think it was somewhere around 14 or 15 neonatal ICU patients."" We knew which hospital has a neonatal ICU and which has kind of, ""Okay, you can take two. You can take one."" And then it became more the transparent logic.

Matthias Merkel
It was really interesting to see how this capacity tile A showed us, Wow, this hospital is now empty and suddenly having zero admission in certain hospitals, or how many ICU patients are still left. That was really important. Again, what we learned there, part is, there is a benefit of having supporting technology. The most important part is having a clear plan, and connecting the right people and partnering with the state and everything. Fortunately, the weather shifted, the fire calmed down. It made enough damage, but the combination of half of your staff sort of in evacuation zone for their own houses and the need of the hospital throwing down because of air quality and everything. It was certainly a stresser for the entire state, and it was glad for us to have Mission Control and have these tools at our fingertips so that we could actually incorporate them in our workflows.

Jeff Terry
I should mention, of course, we did that for Oregon. Necessity is the mother of invention, and others, it's expanded elsewhere. Other states learned about it. First Florida, and then the Canadian province of Saskatchewan. We're now live with a similar system in Florida and also in Saskatchewan. The scope there, it varies a bit in Florida. We also actually track some of the, how many COVID patients are in each ICU and how many are over and under 65. So the same concept has played out. I think what we've learned through that is, in virtually all over the world, the standard for regional, across all health system capacity management, has been manual systems that are updated once or twice a day. What we built for Oregon at your urging was a near-time system that's reliable, because there's no human in the loop, the data is extracted from the EMR, it's updated every few minutes, so those two things make it reliable.

Jeff Terry
It's also secure because there's no PHI. It's a simple website, anybody can use it and drill from the state down to the hospital level, the bed level. I know it's proven useful in the places that I mentioned, and I think, over time, we'll see more of that in the disaster preparedness agenda, because, for the reasons that you mentioned, when you're under pressure, people don't have time. You can't rely on fragile data and it takes too long to chase a bunch of phone calls to find the clinical resource. So I think what you and we together, with a lot of great partners and people pioneered in Oregon, I think has proven useful elsewhere and I think, over the next couple of years, I expect we'll expand a lot of places, so we're honored to have been a part of it.

Jeff Terry
My last question, Matthias, then, is, you spent almost a year, exactly. One final reflection or lesson learned from you on the Oregon Capacity System, specifically.

Matthias Merkel
I think one of the lessons learned was, if you... The cause, defining the why, why are we doing this? This was really driven out of clinicians wanting to have visibility and having a backup plan if their own ICU, and that was really started with the ICUs, would run out of beds. So before we go into the operating room, are we sure that other hospital and within reach still has capacity? I think this really drove that and removed all the common barriers you would normally have when competing health systems start talking about, are you willing to share your census data with us?

Matthias Merkel
That was the key part. The other one, what we learned, especially during the wildfire, that was the first time where we had a sudden drop in our staffing, because people had to take care of their own families or, in other areas of the state, they couldn't go to work because their spouses were firefighters, so somebody needs to stay home with the kids. All of this highlighted that, yes, we created an incredible capacity tracking tool, but it didn't help us to see which bed is staffed and not. And so we then started, ""Okay, how can we actually track staff beds in real time?""

Matthias Merkel
That was a really important kind of lessons learned. And again, it highlights that you have to be really thoughtful around that. Now, several of the health system have implemented, including ourselves, that, if we can't staff a bed, we block it in our EMR, and the technology and the design was in a way that as soon as you block a bed, it's not showing up as available. Similar like if you overflow in a search area, it immediately pops up as a bed. So you can really track this. That has been really helpful.

Matthias Merkel
It's the need for standardization, what your data means. I think your team has done an incredible job around that. When we started this idea on March 14, over a weekend, I think most thought, ""Yeah, this is kind of a great idea, but will it be able to pull it off?"" But jointly, with everyone involved, every single health system, we had a pretty robust plan within a couple days. We were very fortunate that we were able to secure philanthropic support so that we can actually finance it. And then, within four weeks, we had a pretty robust prototype. Even today, last week, we added the last component of health systems into this and are on track to have 60 of our 62 hospitals there. The two who are not there, that there's really a technical kind of barrier, not a willingness barrier.

Jeff Terry
I would also, just as my final reflection, give a lot of credit to you and the other clinical leaders and business leaders in the state of Oregon who pushed through that frenemy dynamic. You're all friendly competitors. That's just sort of the way it is in normal times, but very quickly, everyone agreed, ""Now we're going to share data. We're going to give transparency,"" and that it has inspired others that that can be done, that we can overcome the sort of inevitable politics of that dynamic. I think that's a big deal, so Dr. Merkel, thank you very much for coming on today and thanks. Obviously, we love working for you and with you.

Matthias Merkel
Thank you.

Jeff Terry
Yes, sir. And with that, I will close the podcast.

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