Digitally transform the ambulatory environment

Bob Harrington, Mary Leonard and Catherine Krna on digitally transforming the ambulatory environment

As Bay Area case numbers jumped from dozens to hundreds in the initial days of the COVID-19 pandemic, it became clear that in-person visits to the clinic would soon need a new venue. In just weeks, Stanford’s ambulatory, or outpatient, environment underwent something of a digital-first overhaul, empowering clinicians and patients to connect virtually. The effort was led by Stanford’s Ambulatory Transformation Team, chaired by Bob Harrington, MD, professor and chair of the Department of Medicine; Mary Leonard, MD, MSCE, professor and chair of the Department of Pediatrics and physician-in-chief at Lucile Packard Children’s Hospital Stanford; and Catherine Krna, associate dean and president and CEO of the University HealthCare Alliance. Months into the pandemic, the trio have helped guide a transformation in outpatient care that prioritizes safety for both patients and clinical teams, maintains clinical excellence, and emphasizes digitization.

Although the transition toward digitizing ambulatory care was initially brought about by the necessity of crisis, the shift has also uncovered some unexpected advantages — some of which may likely persist even after the pandemic has subsided. Moving forward, Harrington, Leonard and Krna don’t see ambulatory care reverting to pre-COVID “norms” but instead see the opportunity to establish a new norm that hybridizes in-person and virtual care to continue to support what’s already working and to reach new communities that have been traditionally underserved through a digital-first approach.

Can you talk about the ambulatory care environment’s transition at the beginning of the COVID-19 outbreak and how it was powered digitally?

Harrington: For several years now, many of us have recognized that the increasing use of digital tools in the home environment was going to be important in the future of clinical medicine. That includes tools like heart rate and blood pressure monitors, as well as oxygen saturation monitoring devices. Some of our patients come from very far away, and virtual visits are a valuable way to offer convenient access without the need for travel. But for a long time, digital technology was underused in clinical medicine. Prior to COVID-19 we saw patients virtually around 2-3% of the time, but when the pandemic hit and we realized we couldn’t have patients coming to the clinics so frequently, we had to adapt — and quickly. Literally in a matter of weeks, we went from 2% digital visits to 80%.

Our success in responding so quickly at the beginning of the pandemic was, in part, due to the alignment between the School of Medicine and the clinical enterprises

Krna: Our success in responding so quickly at the beginning of the pandemic was, in part, due to the alignment between the School of Medicine and the clinical enterprises, Stanford Health Care and Stanford Children’s Health. We would not have been as successful if it weren’t for the joint accountability of our faculty and clinicians and the staff who work with them to care for our patients. Also, the digital foundation built by the teams of Natalie Pageler, MD, chief medical information officer for Stanford Children’s Health, and Topher Sharp, MD, chief medical information officer for Stanford Health Care, and implemented pre-COVID-19 enabled us to turbocharge our virtual efforts in the early stages of COVID. There were also already pockets of digital innovation on which we could build. For instance, I remember talking to a faculty member in rheumatology about how far some of his patients were driving to receive care. Pre-COVID, his team offered video visits and a broader care management approach for these patients, allowing them to avoid traveling to Palo Alto unnecessarily. 

Can you share some examples of how digitization was successfully adopted in ambulatory care?

Harrington: One of the examples I love comes from a colleague in the Department of Orthopaedic Surgery, Susan Bromley, the lead advanced practice practitioner (APP). And you might think "Orthopaedic surgeons using video? That seems odd." For post-operative care, patients who had surgery have to come back to have their wound examined and have their staples or stitches removed. During this shift toward virtual care, APPs and nurses have made a series of videos on how to take out your own sutures and staples that patients can use as a resource to train themselves. Then, on the day the patient is scheduled for their post-op visit, the APP or nurse join them on screen and walks them through an examination. They ask what the wound looks like, they ask to see it, and confirm that the patient has watched the tutorials. Then they walk the patient or a family member through the process of taking out the sutures or staples. Patients have overwhelmingly reported that they actually liked doing it, that it saves them time commuting to the clinic for what would amount to a 10-minute appointment.

Leonard: We’ve learned that virtual visits may offer advantages and can even be preferable to in-person visits for some patients and their families. For example, Heidi Feldman, MD, PhD, chief of Developmental and Behavioral Pediatric and a nationally renowned expert in language development, and her colleagues have discovered that seeing young children and their family interact at the kitchen table can provide important insights into the nature of the parent-child social interaction. It also provides a window into the child’s typical pattern of play, which may be less readily apparent in a medical setting. Children with complex medical conditions who show intense fears when they arrive at the hospital are often more relaxed in their homes. Likewise, children with autism or anxiety disorders who become confused or worried in a clinical context may show their typical behavior while playing with their own toys in a familiar setting. 

In a home setting, parents often demonstrate how they organize activities for the child and show how they engage their child in certain activities that provide insight into developmental levels. Thanks to these successes, our division is moving toward using virtual visits as the default for new school-aged patients. This provides an opportunity to determine the next best steps for care without requiring parents to take extra time to come to the clinic.

Virtual visits also provide advantages for fellowship education. Supervisors can see the entire fellow-patient interaction, rather than simply hearing a summary. Additionally, the supervisor can send messages to the fellow to make suggestions and the fellow can ask questions of the supervisor without pausing the visit. Finally, it’s easier to take notes about the patient during a visit without breaking eye contact and to manage the timing of the appointment compared with in-person visits.

Where are we today?

Harrington: We’re in a period where we’re seeing patients through a hybrid of in-person and virtual visits. It varies by individual subspecialty area — some specialties, such as primary care and preventive cardiology, are really amenable to virtual care, while others might benefit from the adoption of other digital tools. There’s no strict formula, and our clinicians have been able to be a little more creative with their schedules. Some of our physicians are at home with young children who are in virtual school, and now that virtual ambulatory care is more widely used, our clinicians can divide their day differently than they might have pre-COVID, which can be quite liberating. You don't have to be in clinic from 8 a.m. to noon or 1 p.m. to 5 p.m.; instead, you can choose to be “in clinic” from 4 p.m. to 8 p.m. That not only gives our physicians flexibility for things like child care, it offers our patients more options too.

Krna: Our tendencies to analyze and seek feedback as an organization have been critical to optimizing our operation. Since we started this effort, we’ve been receiving feedback about video visits from both clinicians and patients on a daily basis. Fast-forward to today: We have a ton of rich survey data that is giving us a head start in being able to dig deep into the provider and patient experience. Now, we have to figure out how to harness that information and bring it to bear as we ideate and iterate on our future digital ambulatory environment.

What are the future goals for the ambulatory care program, digital or otherwise, at Stanford?

Leonard: The big item we need to look at is health equity. First and foremost, we need to make sure that a digital-first approach isn’t actually making care worse for some patients. We need to make sure we’re not inadvertently widening disparities. If a family doesn’t have access to Wi-Fi or there’s only one smartphone in a large family, and it belongs to the dad who is an essential worker and doesn’t get home until 6 p.m., that doesn’t offer flexibility and it takes away access.

Harrington: I think there’s an opportunity to turn to our research, policy and advocacy work to make a difference and change federal law. Broadband should be treated like vital infrastructure, similar to an accessible service road. There shouldn’t be a community in the United States that doesn't have access to broadband. Unfortunately, in a lot of our rural communities, where many of our patients reside, they don’t have that access. So we need to use our health policy research and advocacy muscles to insist upon things like universal access to broadband.

Leonard: To really fuel that, we need longitudinal data to show that telehealth boosts the percent of visits patients actually attend, or the sheer number of appointments made by underserved communities. If you don't have to take a day off work, or borrow a car, or take multiple buses, or bring your kids with you, you're more likely to make the appointment. We need data that shows that adherence, follow-up and retention measures improve. This data will drive the policy.

How do you envision community and stakeholder involvement?

Krna: Often, when we set out to accomplish a new lofty goal, such as addressing medical disparities, our knee-jerk reaction is to do it ourselves. When I think about how we can best reach underserved communities, we have to think about partnerships with others — like local health organizations or community centers — because the most effective way to achieve outreach may well be through these entities that already have built trust with the patients in these communities who we hope to serve. Sometimes patients aren’t comfortable coming to Stanford for an appointment or to get tested for COVID-19, and it begs the question — why aren't we trying to figure out how to extend these services into communities outside of Palo Alto? Partnerships are a great way to make our resources go further and help us direct them in a way that really gets help to the people who need it.