In the early twentieth century, Austrian economist Joseph Schumpeter studied market disruption and the innovations that result from it, which he termed “creative destruction.” Schumpeter described the “process of industrial mutation that incessantly revolutionizes the economic structure from within, incessantly destroying the old one, incessantly creating a new one” (Schumpeter 1942, p. 79). In other words, organizations respond to disruption by destroying existing processes, or embracing the destruction of the present to encourage new alternatives.
The old proverb “necessity is the mother of invention” speaks further to creative destruction. With the COVID-19 pandemic changing assumptions in care delivery, Montefiore Health System has deployed many innovative strategies that exemplify creative destruction.
The Pandemic Comes to Montefiore
Montefiore serves the Bronx and Westchester County in New York. A bedrock of the Bronx for more than 135 years, the system today includes ten hospitals with nearly 3,000 acute care beds, 150 skilled nursing beds, and more than 200 ambulatory sites. The system also comprises the Albert Einstein College of Medicine, Montefiore School of Nursing, and Montefiore- Einstein Institute for Clinical and Translational Research. As Bronx County’s largest employer and provider of healthcare, Montefiore delivers care to approximately one third of the borough’s diverse population of 1.4 million residents.
Like other healthcare providers, we remained alert as the coronavirus spread through China, Iran, Japan, and the United States. The second case in New York was diagnosed on March 2, 2020, in New Rochelle, the heart of our region. Suddenly, COVID-19 was at our front door. By March 11, Montefiore saw its first COVID-19 patient.
Facing the Challenge
As an academic medical center, Montefiore values innovation. Nonetheless, change in academic medicine is slow. It takes a significant amount of time to implement discoveries into practice. With the pandemic’s approach, however, time was not on our side.
Forecasts and regression models indicated that we would soon be facing an exponential growth rate in the spread of COVID-19. We had to adjust our usual linear thinking—quickly. At that time, the news was alarming: The data made it clear that we would be out of both medical– surgical and intensive care unit (ICU) beds in a matter of a few days. The situation was grim.
Governor Andrew Cuomo laid out the challenge. In 30 days, he said, the state would need 110,000 hospital beds. In normal times, there were only about 53,000 across the state. He called on all New York hospitals to do their part and to work together. The cavalry, as he put it, was not coming. It was on us.
Doing Things Differently
Traditional assumptions about the number of beds, health of our employees, supply of resources, demand for care, and historical analytics were no longer constant. The situation called to mind Schumpeter’s creative destruction theory. In this state of uncertainty, the invisible hands of the changing market economy drove Montefiore to pursue creative destruction and accelerate innovation.
Implementing accelerated innovation enabled us to respond to the crisis and meet the needs of our community. Driven by the virus, we quickly put new ideas into practice. These innovations have changed the way we work, and they will continue to do so well after the virus is defeated.
Montefiore CEO Philip O. Ozuah, MD, PhD, established an incident command structure to give us the agility to make decisions and react to challenges as they arose. Each command has an assigned primary leader, along with a secondary leader to ensure continuity. A virtual war room allows leadership to assess patient volume and deploy resources as new capacity comes online and the number of patients rises. The room includes leaders from different areas of the medical center. Initially, they met twice a day, seven days a week. As the pandemic unfolded, the theme that resonated in the room echoed the words of Winston Churchill: “It is no use saying, ‘We are doing our best.’ You have got to succeed in doing what’s necessary.”
With the realization that this was not the time for silos, all egos had to dissolve. It was essential that everyone in the system think of all resources collectively, so Dr. Ozuah placed all resources in the healthcare system under central command. We also doubled our physical capacity throughout the health system. Facilities teams converted meeting spaces, operating rooms, gyms, ambulatory facilities, and cafeterias for inpatient use. Personal protective equipment (PPE), ventilators, staff, and even patients were moved across the system to facilitate a just-in-time model of resource utilization. Through these centralized efforts, each Montefiore hospital was able to manage patient loads and resource demands through the initial surge with resilience.
Implementing Rapid Digital Innovation
The virus disrupted normal care patterns, and many barriers had to be overcome. Most face-to-face visits in the early days of the pandemic were canceled, so staying connected to patients without direct contact required new alternatives. According to research conducted by McKinsey & Company in 2019, only 11 percent of consumers had used telehealth (Bestsennyy et al. 2020); in fact, Montefiore had no telehealth visits prior to the pandemic. Fortunately, system leadership was not risk averse; Montefiore was ready to experiment for a potential payoff. The COVID-19 crisis sparked transformative work—creative destruction. With the virus moving fast, we made innovation happen.
As our physicians’ offices faced an increasing volume of calls with questions about COVID-19 and worried patients came into emergency rooms and hospitals with possible symptoms, we saw the need for artificial intelligence (AI). The sudden increases led us to implement a coronavirus-specific chatbot, a virtual assistant powered by AI to provide 24/7 support for people via text messaging. The chatbot pops up when they visit the Montefiore website and addresses their most common questions about COVID-19. It also provides a self-assessment tool for evaluating risk for COVID-19 and then identifies appropriate Montefiore resources as needed. This technology provides accurate and prompt responses without taxing already-stretched resources across the organization.
After implementation of the COVID-19 chatbot, we saw an immediate uptick in patient engagement. Hundreds of patients conversed with it during the first week of deployment. Those conversations quickly spiked to more than 18,000 engagements in the first 30 days.
We soon realized that patients were also seeking medical services beyond COVID-19 through Montefiore’s website in the absence of face-to-face communication channels. The chatbot was then configured to direct users to other key areas on the website, including the system’s general FAQ document and patient portal application. Furthermore, the interactions have provided intelligence about the needs of our patient population. Data from the chatbot have prompted us to expand the symptom checker beyond a COVID-19 evaluation.
The pandemic has adversely affected ambulatory operations, prompting the need for enhanced outpatient engagement tools as well as a contactless visit experience. Many patients postponed preventive or elective care, which led to a significant pent-up demand. To meet that demand, we are finding ways to engage with patients across their entire care journey, not just by phone but also by text and e-mail. Digital innovations also enable online scheduling, preregistration, and thermal temperature-checking processes— all operationalized to alleviate fears of the in-office patient experience.
Additional strategies in development include kiosks for check-in and patient portal offerings such as asynchronous visits and electronic patient questionnaires to gather previsit information. Patients’ demands for services have changed in the pandemic’s wake; consequently, so have our operations.
Before the pandemic, when Montefiore did not have a direct-to-consumer telehealth solution, anyone who desired an ambulatory visit would need to come to an office. When the initial surge hit, in-person visits plummeted. Patients remained reluctant to schedule an office visit even after ambulatory services restarted; in addition, providers who normally worked in the ambulatory setting were reassigned to help with the surge of COVID-19 inpatients. Consequently, it was time for a drastic change.
Physicians called for a telehealth solution. So, Montefiore partnered with a software developer in late March to modify our Epic electronic health record infrastructure to accommodate the scheduling of telehealth visits, documenting the visits, and then dropping bills. On April 1, we launched the Montefiore FIRST telehealth platform with four video visit apps—one each for patients and practitioners and in both the Apple and Android mobile operating systems. By June, Montefiore FIRST was among the top 100 medical downloads in the Apple App Store.
While social distancing remains in effect, our creative destruction continues. Despite our assumptions, most patients remain reluctant to schedule in-person visits. In April, more than 80 percent of visits shifted to telehealth; in May and June, we saw only a small shift back to office-based visits. In that same time frame, however, we logged nearly 250,000 telehealth visits, even in new settings such as the research enterprise, inpatient consults, and urgent care. Extending healthcare access through telehealth services at home, where patients are more comfortable, has demonstrated improved clinical outcomes, greater patient satisfaction, reduced readmissions, and decreased costs at Montefiore.
Counting Losses—and the Victory
During the spring surge of COVID-19, our health system saw mortality levels that we had never experienced before. We lost more than 2,200 patients to the coronavirus, including 21 Montefiore employees. While our employees have shown tremendous dedication in battle, they also have felt great uncertainty and fear. They have watched patients die and have lost colleagues.
The wave of COVID-19-positive patients has not risen above capacity at Montefiore, and yet the struggles of social distancing, quarantines, economic shutdowns, and closed schools have been shared by all. Our teams have prevailed with innovative solutions tailored to this new environment. We changed how we work, how we innovate, and how quickly we respond to evolving needs. We accelerated disruptive innovation, and we did it while flying the plane. More than 25,000 New Yorkers have been lost to this virus, and that number is still growing, but many more lives have been saved. As the springtime census at Montefiore fell, we were able to reflect on and appreciate the amazing work, sacrifice, and bravery of so many.
The Road Ahead
Even as we face new COVID-19 waves, we also need to get back to normal, albeit a new normal. There is a significant reduction in volume across many of the service lines that drive most of our revenue. That being the case, we also have learned a lot through accelerated innovation and worked to redefine our new way forward. One key strategy to this mind-set has been the establishment of flexible settings to manage inpatient care.
Tele-ICU Command Center
Our early projections indicated that there was going to be a significant influx in March of critically ill COVID-19 patients requiring higher-acuity care, which demanded additional ICU bed capacity and critical care expertise. Michelle Gong, MD, our chief of critical care, worked with the information technology (IT) team to establish Montefiore’s 24/7 tele-ICU command center in a span of just a few days. As a result, medical staff anywhere in any facility can get on-demand critical care expertise from a critical care or pulmonary physician at the command center. The IT team installed servers to feed health records to the central location. Physicians in the command center can view many patients’ clinical data at once. The bioengineering team linked the command center to real-time vital signs, ultrasound results, and electrocardiograms from ICUs across the system. Now, providers in the command center manage the care of more patients across multiple hospital locations, with frontline staff in the various ICUs sending data back to the command center via iPads.
As mentioned, the implementation of the ICU command center fueled the adoption of telehealth in other inpatient settings. Physicians soon wanted to perform inpatient consults via video, too. Additional telehealth initiatives are now underway, including teleneurology, telepsychiatry, and remote patient monitoring. Spurred by COVID-19, telehealth creates an incredible opportunity for Montefiore physicians to deliver better care to patients wherever they are in the system. Geography is taken totally out of the equation. Inpatient telehealth is effectively extending expertise and promoting quality while ensuring cost-effective care across the system.
One of the major lessons learned during the initial COVID-19 surge is the value of real-time performance management, which supports the ability to react nimbly to situations as they arise. One application of this learning is the ability to flex (convert) regular medical–surgical beds into ICU beds with extra monitoring functionality. Another example is the real-time monitoring of PPE and other supplies. Similarly, through the real-time management of data, a command center can react with agility to other situations. For example, sensors can keep track of the humidity or temperature in operating rooms or alert staff if a patient falls out of bed. Whether it is monitoring bed census, parking lot capacity, equipment location, or phone volumes, a lot of information can be centrally observed and managed in real time.
AI has enabled Montefiore to swiftly react to COVID-19 and extend those learnings to other applications. Starting with the chatbot and predictive analytics, digital innovation via AI has become an essential tool for leaders. They now use cognitive computing technology platforms to improve their decision making. Although the organization had used some AI applications for natural language processing, machine learning, robotic process automation, and internet-tied sensors before the pandemic, digital innovation developed in response to the pandemic has helped all stakeholders recognize that AI allows the organization to reframe existing healthcare delivery models to meet changing needs.
We remain agile and focused. The virtual war room is still open, although we no longer meet twice a day; now, we meet once a week. We get together to solve problems, mainly about reopening. We work on upgrading and replacing equipment, refurbishing units, and improving processes. Problem solving continues at its newly accelerated pace because we know how quickly things can change.
Our analytics continue to evolve with the challenges. Even as we analyze potential recovery scenarios, we are watching for clusters in the community and positive spikes in employee testing. We are using data to help fuel our improved agility. We are adapting coronavirus testing and related services to meet patient demand in anticipation of spikes and exponential growth in the coming flu season. We are working to ensure that we have plenty of testing kits, testing locations, and laboratory capacity. Now that we have time to think about what we learned in the spring, we are prepared to evolve with greater flexibility than before.
As of July, we had only a few COVID-19-positive patients in-house. With infection rates in the US on the rise again, much of our expanded capacity remains in place. Ultimately, little of this is up to us; the virus calls the shots, and we remain vigilant.
The pandemic hit unlike anything anyone in healthcare had seen before. The world has been disrupted, and the status quo has been challenged. Amid this new sense of urgency, innovations that would typically have taken many years to operationalize at Montefiore have been completed in a matter of days. Through accelerated innovation, many lives have been saved from COVID-19, and more lives will be saved well beyond the pandemic.
This an opportunity for organizations to abandon old processes and rebuild with greater resilience and elasticity. As the barriers of the past come down, Montefiore is embracing creative destruction. As a result, the excitement of digital innovation permeates the entire organization.