Embracing the COVID-19 Disruption: Defining the Future of Dear Friends and Colleagues,

The late Thurgood Marshall once said, “The measure of a country’s greatness is its ability to retain compassion in time of crisis.” As I reflect on the COVID-19 pandemic and the way that healthcare workers across the country have responded, no other sentiment rings truer.

National shortages of personal protective equipment (PPE), test kits, ventilators, and treatment space have pushed our healthcare system to the limits. Physical exhaustion from long hours, the emotional toll of caring for acutely ill , and the fear of exposure to self and family members have tested clinicians in ways never before imagined. And yet, throughout this crisis, I continue to be inspired by the compassion on display. This is particularly true across the organization that I feel privileged to lead.

By cultivating a culture that empowers providers to champion new approaches to care delivery, clinical innovations can be more rapidly deployed to deliver Letter and expand care in new ways. Now more than ever, it’s vitally important that provider organizations meet from patients where they are to ensure everyone can gain Imamu access to needed care. Tomlinson, MD, MBA In this white paper, I’m pleased to share just a few of the strong advances in care delivery that have come CEO, Vituity out of the COVID-19 crisis.

We’ll explore: • The disruption facing hospitals and health systems nationwide. • Why the evolution of care requires adoption and development of technology-driven innovations and better-integrated provider teams. • Examples of acute care innovations that help patients access care where and when they need it. • How a culture of innovation and physician empowerment fosters advancement in care delivery.

I want to close by thanking all healthcare providers across the country—from the clinical front lines to the incredible management and support behind them. We truly are stronger together, thanks to all of you. Embracing the COVID-19 Disruption

The novel coronavirus that swept worldwide in 2020 has disrupted healthcare delivery like no other force in Here are just a few of living memory. As clinicians in New York City and other the issues health systems large metropolitan cities prepared for potential surges of must solve for in today’s COVID-19 patients, health systems around the country landscape: scrambled to expand inpatient and ICU capacity and implement stringent infection control measures.

Financial Viability Recouping financial losses, and boosting inpatient volumes and surgical cases.

Expanding Creating the workforce and infrastructure to manage patients while limiting face- to-face interactions.

Clinical Education Training clinicians across the Many hospitals took the unprecedented step of canceling to manage COVID-19 patients with elective surgeries and procedures and absorbing the up-to-the-minute best practices. inevitable financial hit. Some also established dedicated “COVID clinics” in tents or drive-up locations. As supplies of personal protective equipment (PPE) dwindled, technology emerged as a solution to reduce unnecessary face-to-face contact with patients. And with millions of Infection Control medical offices and clinics shuttered across the country, health systems began using telehealth to deliver primary Creating and maintaining protocols to and urgent care. protect patients, staff, and clinicians.

While the hope is the COVID-19 pandemic will have an end date in the not too distant future, its impact on the care delivery infrastructure of health systems is significant and long-lasting. Regaining Patient Trust With their missions on the line, health systems need to Convincing patients that it’s safe to bring creative solutions to market in a matter of weeks come to the hospital for emergency (if not days). That’s where solution partners like Vituity and elective care. can help, combining clinical excellence with business acumen to help healthcare organizations raise the standard of patient care and improve operational efficiency. Where is Healthcare Headed? 3 Predictions for the Near Future

A necessary and continued evolution is inevitable, as is the redefinition of the traditional hospital model through technology-driven holistic care and better- integrated provider teams.

In order to start this transformation, we must accept that there is no “post-COVID world.” The virus is likely to be with us for years to come, if not forever. This radical reorganization of our reality will touch every healthcare institution, starting with hospitals.

1. Shifting Beyond Hospital Walls

To continue to care effectively for patients, healthcare leaders must reimagine the idea of a “hospital.” Our challenge is to reconfigure our physical hospitals for the highest-acuity patients while shifting many other services beyond hospital walls.

This transformation has already begun in the (ED). Emergency department volumes have dropped in many parts of the country in response to the coronavirus threat. However, departments must remain poised for surges—either of COVID-19 from episodic to chronic care. And finally, virtual EDs patients or of those who have delayed care during the allow clinicians to treat and disposition many lower- pandemic. To respond effectively, we need to adopt acuity patients outside the ED itself via telehealth. a more encompassing and creative definition of an “emergency room.” 2. A Leap Forward for Healthcare Delivery Technology

The ED has traditionally been a first point of contact, Viewed through this lens, the hospital of the future the proverbial front door to the hospital. Thinking shifts from a four-walled physical location to a virtual ahead, this is evolving to a virtual front door that uses one that connects patients and providers in disparate technology (video conferencing, AI chat bots, etc.) to locations. Naturally, this new paradigm demands appropriately triage incoming patients—whether the advances in technology. complaint is chronic, acute, or an exacerbation due to deferred care. With this step, EDs shift from episodic As more health systems make the transition, we will providers to proactive navigators who help patients make likely see accelerated adoption of artificial intelligence informed care decisions. as well as remote care (e.g., hospital at home). Also, advances like longitudinal patient modeling may This virtual front door model solves several perennial help providers to proactively address health conditions problems that have plagued our nation’s EDs for decades. before a crisis like a stroke or heart attack develops. First, it connects patients quickly to the appropriate level of care—primary, urgent, or emergency—rather than The shift from physical to virtual hospitals will require leaving them to guess or fend for themselves. Virtual significant investments in information technology. care also provides pathways that help ED high utilizers Short term, this could be a tall order for cash-strapped (many of whom lack a medical home) to finally shift hospitals. New technologies will connect patients and providers in novel ways and drive a grassroots movement toward meeting However, over the long term, virtual care will likely cost less to deliver while allowing hospitals to reach new patients wherever they are. patients and expand market share. It could also lend itself to more cost-effective staffing models by allowing physicians to supervise advanced providers in urgent care centers and other remote locations. In addition, the ability to care for patients without putting their health and that of their families at risk is 3. New Provider-Patient Relationships an enormous relief to many clinicians. It is perhaps one of the best antidotes to the compassion fatigue and As we redefine hospitals, we also must rethink what trauma we see already in front-line providers that could it means to be a healthcare provider. Going forward, be inflamed by a second wave of COVID-19 outbreaks. expect to see an erosion of the physician and advanced provider-centric model, where patients visit offices Vituity: Here for Hospitals during set hours for care. Instead, new technologies will connect patients and providers in novel ways and Of course, hospitals as we know them won’t disappear. drive a grassroots movement toward meeting patients However, they will likely shift their focus to the highest- wherever they’re at. acuity patients who require face-to-face care. By leveraging multiple models of patient care from live to This shift in the way we care for patients, while no doubt virtual, health systems can more effectively care for jarring for some, may represent a blessing in disguise. all patients while controlling costs and stewarding the Many of our Vituity providers who signed on to provide health of their workforces. virtual care expected to feel more distant from their patients. To their surprise, these clinicians have received As shared owners in a physician-led organization, Vituity an outpouring of gratitude from patients that has Partners are committed to being part of this acute care brought great satisfaction to their work. Providers have evolution. We are excited to partner with like-minded also appreciated the greater scheduling flexibility that organizations to begin creating a more affordable, virtual care allows. accessible, and sustainable future for healthcare. VIRTUAL FRONT DOOR ED Visits that Begin at Home

Before COVID-19, EDs were the most commonly visited locations for patients to receive acute care for a wide variety of medical conditions. However, with the arrival of the pandemic, the pendulum has swung in the opposite direction. Patients are avoiding or significantly deferring in-person care, even for potentially life- threatening conditions. Fortunately, due to the recent expansion of guidelines by the Emergency Medical Treatment and Labor Act (EMTALA), patients have increased access to telehealth as an alternative. Virtual visits are proving popular with patients as a more convenient and increasingly effective way of receiving care.

To help patients access the right care in the right place, Vituity has launched a virtual ED care program. This new care model uses Vituity’s nationally recognized Rapid Medical Evaluation (RME)® framework as a blueprint. Traditional RME routes patients to different care processes in different parts of the ED based on rapid screening by a nurse-provider team and is a nationally recognized The virtual ED service is integrated with the hospital model used successfully for nearly twenty years. EHR. Since patients are already registered before their visit, an RME note can be documented and diagnostic testing and therapeutics ordered before arrival, creating a seamless experience for the patient. Physicians can chart the encounter using a user-friendly drag-and- A force-multiplier that drop interface. This frees clinicians—who may be working without scribes during the pandemic—to focus combats physician shortages more attention on their patients. Overall, this results and ED crowding and expands in improved front-end operational efficiency for the hospital and decreased reliance on staff. patient access to care. To enhance this virtual ED solution, Vituity is partnering with Decoded Health and developing an AI add-on to the The virtual front door to the ED follows a similar model. service. This “virtual medical resident” serves as patients’ Patients considering an ED visit can initiate the encounter first point of contact. Using natural language processing, from home simply by clicking a link on the hospital’s it assesses complaints, vital signs, and symptoms and website. They are then connected to an emergency routes the patient to the appropriate level of care. physician via videoconference. Working virtually, the The program is powered by “explainable AI,” meaning clinician performs a rapid medical screening exam and human supervisors can trace its decision-making. routes the patient to the correct level of care. Once hospital and system approval to implement is In the appropriate cases, the physician may treat and obtained, the virtual ED service can be incorporated into disposition the patient entirely via telehealth. However, operations within a matter of weeks. Vituity views this patients in need of emergent care are routed to the ED, innovation as a “force multiplier” that will help future- where the visit continues in person. Info from the call is minded hospitals combat physician shortages and ED shared with the ED team to expedite response, facilitate crowding. It could also help more patients, particularly an efficient patient intake process, and ensure timely those in rural and underserved areas, gain expanded care continuity. access to much-needed care. HOSPITAL@HOME Supports Patient Recovery

Fears over COVID-19 are keeping people away from visiting emergency departments across the country, which presents incredible risks of delayed treatments in cases of heart attacks, strokes, and other major medical conditions.

To avoid delays in care and expand inpatient and ICU capacity ahead of possible COVID-19 surges, virtual hospitals are being rapidly adopted by health systems nationwide. This cost-effective solution provides high- quality, hospital-level, patient-centered care in the comfort of the patient’s home and bed. Using telehealth, nurses and doctors are equipped to monitor patients from a command center at the hospital 24/7.

Hospital-at-home programs reduce costs while boosting outcomes and signs, pulse oximetry, and patient call lights, which are patient satisfaction. answered by a nurse in the command center located in a nearby Adventist Health hospital.

To this end, Gurvinder Kaur, MD, worked with Patients receive daily face-to-face visits from the Adventist Health in Hanford, California, as well as nursing team and have access to providers around the Medically Home® and Huron and other hospitalist clock. If at any time a patient experiences a crisis or and emergency physician groups in the state, to launch starts to deteriorate, the command center deploys a Adventist Health Hospital@Home, a 150-bed virtual rapid response team equipped to stabilize the patient hospital. The process for the virtual hospital is simple and transport them (if needed) to a higher level of care. but effective. Patients who present to the ED with an eligible diagnosis are screened to ensure they meet Virtual hospital programs are common in Canada and the program’s inclusion criteria. Eligible diagnoses for the United Kingdom but have never gained traction in Adventist Health Hospital@Home include congestive the United States due to cultural and reimbursement heart failure, COPD, pneumonia, UTI/kidney infections, barriers. However, research suggests that such programs gastroenteritis and cellulitis or wound infection. can reduce costs while boosting outcomes and patient satisfaction. In addition to freeing up inpatient resources Patients are then transported home, where Vituity and during the pandemic, the virtual hospital at Adventist other hospitalists manage them 24/7 via video visits and Health also reduces discharges to skilled nursing facilities, remote monitoring. Monitoring modalities include vital which are at increased risk for COVID-19 outbreaks. CLINICAL INFORMATION and Education in Real Time

With new evidence and best practices around COVID-19 emerging daily, front-line providers don’t have the luxury of attending conferences or perusing lengthy journal articles. They need fast access to the latest clinical guidance and operational best practices to make the most informed decisions for the safety and health of their patients. This paradigm shift in the way clinical knowledge and best practices are shared has created the opportunity for new models to emerge.

To meet this pressing need for real-time clinical education, Chief Medical Officer Gregg Miller, MD, pioneered new ways to keep up-to-the-minute knowledge at clinicians’ fingertips. A standout example is the Rapid Clinical Education Program. This webinar- based learning model delivers the knowledge clinicians need to treat patients, protect staff, comply with regulations, and control infection. Live and recorded sessions are led by Dr. Miller, and supplemented by case studies from medical directors across the country.

To prepare acute care teams for future surges, Vituity Topics covered to intensivists delivered training to internists, anesthesiologists, date have included: emergency physicians, and family physicians to care for intubated and otherwise critical patients. To accomplish this, our critical care clinicians created online training modules that can be completed for CME credit. Implementing new approaches to acute care delivery. In addition to training and webinars, Vituity clinicians connect and exchange best practices daily in our online • No-touch telehealth triage community. This has allowed our hardest-hit practice • Drive-up testing sites to share lessons learned and actionable insights • Tent-based COVID clinics with their colleagues across the country.

Finally, Vituity has established a learning collaborative to Clinical guidance on emerging drug help practice sites bring new telehealth solutions online therapies to combat COVID-19. in as little as three months. This rapid rollout positions hospitals to respond to future COVID-19 surges while preserving PPE and protecting their workforces. Safety checklists for providers, including tips for optimizing supply of PPE and equipment. These enhancements to traditional ways of disseminating clinical information demonstrate the importance of access to real-time knowledge sharing and are a key Cross-training on ICU best practices, part of the Vituity culture of physician empowerment such as intubation and life support. and resilience. It’s important for health systems to develop similar resources for their clinicians across a health system, not just at individual practice levels, Insights on cultivating personal and team- to foster widespread implementation of the latest best based provider resilience and wellness. practices in a rapidly changing care environment. Vituity Innovation in Action

The coronavirus pandemic has transformed healthcare overnight. Front-line healthcare providers have risen to the challenge across the nation, facing this crisis with courage and indomitable spirit. Now, as we move from the acute to the chronic phase of the pandemic, care delivery must embody this resilience on a hospital and health system level.

With a model driven by physician leadership and engagement, Vituity has been in a unique position to lead the transformation of care delivery in hospitals across the nation. Our nimble, innovative culture allows us to rapidly deploy clinical innovations that deliver and expand care in new ways.

Throughout this national crisis, Vituity has partnered with hospital leaders, government agencies, and other organizations to launch innovative solutions and equip teams with the tools needed to manage this epidemic. The opportunity has never been more significant to innovate care delivery for the lasting benefit of patients everywhere.

We’re excited to be part of that transformation, and we’re looking for like-minded health systems and industry partners to join us. To learn more about Vituity’s services and their benefits to hospitals and patients, please visit www.vituity.com.

Within the first two months of the national emergency being declared, Vituity launched: 50 clinicians serving public hospitals in New York City. 90 ED, inpatient, urgent care, and ICU telehealth programs.

1,000+ physicians delivering care nationally via telehealth. About Vituity

For nearly 50 years, Vituity has been a catalyst for positive change in healthcare. As a physician-led and -owned multispecialty partnership, our 4,200 doctors and clinicians care for 6.5 million patients each year across 400 practice locations and nine acute care specialties.

Through our commitment to excellent, patient-centered care, we are on a journey to impact and improve 10 million lives by 2023.

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