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Leading in the Time of Crisis

By Kevin O. Stinnett

Dr. Mark F. Newman joined the University of Kentucky in 2017 as executive vice president for health affairs.

Mark Green: Kentucky has kept its COVID-19 infection rates relatively low and its treatment capacity comfortably ahead of demand. How much of this is due to Kentucky being a rural state away from the coast, and how much can be credited to proactive management by medical and public officials?

Dr. Mark Newman: I would say both. We ran models looking at the probability and number of cases we were likely to see in the state or in our hospital. Early on, that model looked overwhelming. It’s part of the reason we put in the field hospital—to have that capability. But as the data started to come in, it was substantially flatter than our models initially and as we continue to run new models, even flatter still. We’re a rural state with a few smaller, urban hubs, so that gives us a natural spacing. But the sheltering-in-place, the understanding of distancing (and) masking—if you look at how flat our case numbers were compared to the models and the projections, we have to assume both played an important role. The active management was very, very important.

MG: What has the medical sector learned from responding to this crisis? Do you expect permanent changes as a result of this?

MN: We’ve learned we depended upon a supply chain that may not be able to meet pandemic needs. That’s an important lesson. Pharmacy is the same way. We had gotten used to doing supply chains and pharmacy on a ‘just-in-time’ model and that’s burned us. When you have a pandemic, everybody has the same need and your purchasing organization can’t meet the need. We’ve learned having more duplicative sources and more local sources is something we need and not so much outsourcing and coming from broader sources.

If you were to come up with the ‘silver lining’ of this, it would be things like telemedicine and drive-thru testing. The reductions or relaxations in regulations that have allowed us to do more telehealth have been a boon for our patients and for health care. We had an 18-month plan to update and expand our telehealth, and we did that in about 10 days.

This pushed us, and now we’ve done 25,000 telehealth visits, where we were doing a very small number before. That’s a plus. It will push us to continue to be as consumer-friendly as we can and think about the lowest-cost way to provide a good consumer process. Our younger patients especially like telemedicine and pharmacy delivery—things that make medicine start to catch up with the rest of the consumer world. It was where we wanted to go, but there was a natural lag because people are used to an older system. Our physicians felt if we’ve done it the same way for a long time, why do we need to change? This (COVID-19) was the reason; we had to change. They’re seeing half of their patients now by telehealth, and most see that as a good thing because we’ve been able to do it efficiently and effectively—and the patients like it.

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MG: Will the pandemic restructure medical priorities and is it going to have a significant effect on revenue streams in health care?

MN: It’s important that we reiterate safety as we go forward toward a new normal. People, especially our elderly population, are scared. They’re concerned about the safety of coming to a health care facility. We will still use telemedicine when we can to achieve that (level of safety).

As we open up, it could be nine months, a year or longer before we get back to the same volume and/or level of revenue we had before. It’s going to take an adjustment to how we manage and staff to be aligned with that. We’ll get back there, but my concern is in rural health care because they were already on a tight (financial) margin—not that we aren’t, but they especially are. This is going to create an even tighter component in rural health.

Hopefully UK HealthCare can do telemedicine to help them keep as many patients there as they can and manage that effectively. That’s some of our role in being that resource for the state. We can use what we’ve learned in this interim to have them keep those patients close to home, so they can manage a strong financial picture that probably is going to be challenging until people and volumes come back.

MG: There was significant discussion before the pandemic that some smaller community hospitals were teetering on financial viability. Might this force some financial efficiencies through the system?

MN: I hope. Things that happened around the regulatory side have been very helpful. I hope we look at those in the next phase and see which ones can we continue to relax because they benefit patients. Ones around telehealth are key as are other ways we can provide service at a distance. Electronic ICU is one. E-Acute is another, where we can provide a distance service. If the patient continues not to do well we can transfer the patient here, but try to keep the patient there as much as we can.

We have EICU in place now; we use it mostly internally. It gives another set of both nursing and physician eyes into the rooms where the patients are. They can see the patient monitors as well as look directly at the patient. When we turn that externally (to a community hospital), it allows (our specialty intensive care) input to have the more acute patients not have to be transferred as early as when they don’t have that backup as a part of their care.

MG: How prepared for this pandemic medical crisis were we? What did we do well and what do we need to improve on?

MN: UK HealthCare had a good disaster plan, and when we built Pavilion A (of UK Albert B. Chandler Hospital), which opened in 2009 or so, it was designed so every room in that part of the hospital could convert to a negative-pressure room, where we can take care of people who are potentially infectious. Every room in that hospital also can convert to intensive care and every room in the hospital was set up so we could run, if we needed, two patients on ventilators. The design was forward-thinking and fortuitous because it allowed us surge capacity as well as capacity to be able to manage big groups of these COVID patients who would need negative-pressure isolation and other things.

We have a strong disaster plan and added the field house to that very quickly. The field hospital was up and running in six or seven days using external resources. We set that up negative-pressure also so we could put COVID-19 patients there as well as have throughput for patients who are getting better because they may still be infectious for some period of time. From a UK HealthCare standpoint, we had a good disaster plan, a good team, and were big enough that we could take the resources that usually would be for ambulatory care and move them to the more acute setting to run a hospital and to run a field hospital.

On a state basis, the good things are it showed the need for a higher degree of collaboration between our hospitals, and it came together quickly. We took leadership, together with some of the hospitals in town, to create what we called the Regional Operation Center for Kentucky (ROCK). We got information from all the hospitals in the region on their bed census, their ICU census, their ventilators. We got it in a real-time basis so that when these patients were going to need to escalate their care we could work with Baptist Health, with CHI Saint Joseph, with St. Claire or King’s Daughters or whoever to say, ‘If this patient needs to escalate, where is their bed? Where can we move them?’ And as patients get better, how can we move them back out into the community to their local hospital to create more capacity for the sicker patients?

It showed a high degree of coordination and collaboration. We’ve set that up and it can be there for the future. It’s an opportunity for collaboration going forward about how we better manage beds to keep people where they need to be. Competition and regulation make that harder on a normal basis, but I think it’s something we can look at more. We can definitely look at it in situations where we have an emergency.

MG: How does UK HealthCare, with its tremendous assets—the medical school and a major academic medical center—currently see its role in the Kentucky medical community?

MN: If you look at us compared to every other medical center in the country, for the six months around the beginning of this year we had more transfers than any other medical center in the whole United States. That tells you we are that resource for transfers from other hospitals, for the escalation of the acute care, to facilitate and be that resource for high-level care within the state. Even when you compare us to the Cleveland Clinics and the other places of the world, we get more transfers in, hospital to hospital, than any place in the country right now.

We were essential to getting the testing up very quickly and increasing the volume of testing. In addition to our own, we provide a lot of testing for people in the region: Baptist Health Lexington and Saint Joseph Health and others in the city. Now we have the (coronavirus) antibody test up and running.

Another piece we worked on with the state was how to create models and understand the probability. Using epidemiology and public health, what is the potential risk for higher levels of need, of care, as we do this? And then how do we adjust the relative need (expectations) as we see the data change over time? We were a good resource for the state along those lines. And we made others feel comfortable that they have a tertiary, quaternary care (resource available) if they couldn’t manage it overall. The Regional Operation Center for Kentucky I talked about before—people look to UK to be that coordinating resource for the state. That’s something that’s developed these past 10 years. People have that trust, and that’s been a key component we want to build on as we ramp back up.

MG: The 2019 annual report states UK Healthcare had more than 100 telehealth programs before the pandemic shutdown furthered their use. What types of medical care or parts of the process are candidates for increasing use of telehealth going forward?

MN: All of our more than 130 clinics now have telehealth as a component, which is a good thing when you think about things like care management, the ability to follow up on patients and giving them easier access to care. It’s about not only health care but the improvement of health in the state.

One of our challenges in Kentucky overall is that our utilization of hospitals is high. Some of that is because we don’t do the preventative care and other things as well as we could. The more we take advantage of telemedicine to do that is good. Hopefully some of what they need can be done locally. But if it can’t, can we do some of it by telehealth? Labs and X-rays can be done there, and we can see and talk to them and make it easier to get high-level subspecialty care with less travel. That is a real consumer-side benefit.

The EICU and E-Acute are both real opportunities for us to expand our expertise out into the state, raise the level of care at all the hospitals, and make it easier to keep more people close to home. Also, the idea of our physicians driving three or four hours to have a two- or three-hour clinic then driving back doesn’t make a lot of fiscal sense and doesn’t make a lot of patient sense.

Rural hospitals are going to be challenged coming out of this; the more we can help them, the more we can provide subspecialty level care, the better. The more we can use technology to expand our capability is going to be a key component of what we do in the future.

MG: What are the top goals for UK HealthCare in the current strategic plan?

MN: When we started into COVID we were in the process of updating our strategic plan for 2020 to 2025, and a key part of that is we want to continue to be that resource for Kentucky: How do we help our partners, help rural hospitals? How do we use new technology, new advancements, to not only work on health care but improve health overall? Enhance education, preventative care and those things?

People see us as an important resource, but sometimes it’s hard to get to us. A goal is using telehealth and other things to drive a continued improvement in our ability to be consumer-friendly and make it easier for people to get to us. We need to build out more ambulatory capability and reach out into the community more. That’ll be part of our strategic plan. But some of that doesn’t have to be as much bricks and mortar as it used to be, right? We should be able to do more with technology to make it easier for people to get to us.

We should keep planning for the future to keep our patients and our people as healthy as possible. We’re going to be coming off a very stressful period for our health care workers and our patients. They’ve been coming in to work knowing that they’re at risk, so what can we do to make them feel supported? This has created a lot of uncertainty when you have workers furloughed or working in platoons, working one week and not working the next. Health care over the last 50 years has been a very stable environment where things don’t typically change too much. Now they’re seeing change. We’ve always had so much volume we couldn’t take care of it all, and now we’re not in that same boat.

MG: How do people who do business with the health care sector keep up with what’s going on in this complex, ever-changing sector?

MN: We want to be a resource to the business side of the equation. We want to help them think about what a smart reopening looks like, how they can interact in a safe way. I got calls last night from two different businesses: ‘We’re getting an OK to reopen, but how do we do this in a way where we don’t create new problems for ourselves and don’t end up having a new spike that shuts us back down?’

MG: Does UK HealthCare have a resource yet for the business community to get some of this information?

MN: We’re working across multiple colleges to develop those resources. We’ve just put together a group led by our College of Medicine Dean Robert DiPaola and our College of Public Health Dean Donna Arnett to think about and create how we use testing. How do we create the environment and do electronic tracing?

After we get through this initial phase, I think we’re going to have small outbreaks to manage. So how do you do the testing you need, assess what’s going on, contain that in a small area, and then do the tracing that’s needed? The old epidemiological approach is good, but can we use technology like cell phone tracing, GPS and other components to look at where people have been? It sounds a little Big Brother-ish, I realize, but on the other hand, when we’re in unusual situations we have to use every tool we can. We intend for it to be a resource for other universities and for businesses.

MG: What is highest on the UK Healthcare wish list? Is it to grow your staff and expertise, acquire more technology and equipment?

MN: No. 1 is access and making ourselves more consumer-friendly, making it easier to get care. Second is continuing to drive technology through the research and other things we do. A third component is being the education resource to put doctors out in the state through the Bowling Green campus, the Northern Kentucky campus, the Morehead campus, together with the Lexington campus. We’re going to be putting out about 200 physicians a year, and hopefully most of them will stay in Kentucky. Ninety percent of the class from last year were people from Kentucky.

The last piece is probably going to be a little different post-COVID. We’re going to have to look how we can help some of these smaller hospitals sustain and maintain, because if we’re about the health of Kentucky, we have to help that happen.