In this episode of Fireside Chat, we sit down with Dr. Joanne Conroy, President and CEO, Dartmouth-Hitchcock Health System to talk about the COVID-19 pandemic and how the crisis has changed several aspects of healthcare for the future.
Please note: The number of COVID-19 cases and the situation referenced in this episode were based on reported data at the time of the interview and are subject to change.
Joanne Conroy 0:04
If we continue to have a significant portion of our workforce working from home, then I have an opportunity to repurpose some of our space for activities that actually are growing and need more space. We were thinking about building an extra administrative building. And now that’s totally off the table. I wouldn’t even consider that.
Gary Bisbee 0:27
That was Dr. Joanne Conroy, President, and CEO Dartmouth-Hitchcock health system, noting that lessons learned from treating COVID patients has led to the development of an approach that allows COVID and non-COVID patients to be treated at the same time. I’m Gary Bisbee. And this is Fireside Chat. Dr. Conroy has seen telemedicine visits grow from three visits a week pre-COVID to 2,000 visits a day post-COVID. Concern overexposure to Coronavirus drove the increase but Dartmouth Hitchcock found that many users embraced it and will continue to use it going forward. The caregivers quickly became facile with it, and Dr. Conway believes that they will become increasingly innovative in how to best work with patients.
Joanne Conroy 0:44
COVID patients when they are admitted, actually Gary are quite sick. If you look at the CMI of most of their admissions are pretty high, and they’re very resource-intensive to care for them. But you don’t have to shut down the entire institution in order to provide that care. You just have to make sure it’s appropriately cohorted.
Gary Bisbee 1:02
Dr. Conroy has concluded that Dartmouth-Hitchcock’s approach to the future will be substantially different. The new normal will include reconsideration of facilities incorporation of remote working and Dartmouth-Hitchcock’s human resources, strategy, and restructuring ambulatory care waiting rooms and patient flow. I’m delighted to welcome Dr. Joanne Conroy to the microphone.
Well good morning, Joanne, and welcome.
Joanne Conroy 2:02
Thanks, Gary. Glad to be here.
Gary Bisbee 2:03
We’re pleased to have you at this microphone. We’ve learned that the surge is highly variable by region. What’s the status of the surgeon Dartmouth-Hitchcock’s primary service areas?
Joanne Conroy 2:13
Well, it really depends on what model you look at. I would say that the Washington model had indicated that our surge occurred early in April. Our epidemiologists, however, are looking at the data, and they are actually predicting that we may have a more meaningful increase in volume in September. But nothing that would exceed the ability of our health system to manage those patients from an ICU. That perspective or ventilator perspective.
Gary Bisbee 2:45
Well, as a chronic disease epidemiologist, I’m delighted to see that we’re all now including epidemiologists in our planning going forward. But the fall surge has been under discussion for some time and it sounds like your epidemiologists are thinking that that might be the case.
Joanne Conroy 3:02
We had one of the first cases in New England up here. We had an employee that had traveled to Italy and came back at the end of February and was probably the first patient tested for COVID-19 in the state of New Hampshire. And that activated the entire state, we were on the front page of every single newspaper. And I also believe the globe and the New York Times covered it as well because the employee chose not to strictly adhere to quarantine and they went to a party. And that activated the entire community to be aware of the implications of COVID-19. And I would say that we had a diminished surge because people were social distancing, and staying at home from the first weekend in March, which was in advance of any order from the governor or in a blanket expectation across the state. But you could see that across the state. We canceled a very large fundraiser on the 14th of March. And we did that a week in advance. People weren’t happy with us. But when we look back, we can see that probably had a big impact on communities spread a virus.
Gary Bisbee 4:13
Yeah, for sure. You definitely were early. What’s been the morale of the population? If I could ask it that way. Are people sticking with social distancing and staying at home and so on?
Joanne Conroy 4:25
I would say shifting initially in early March, people were actually a little frightened and angry at the employee that had not adhered to quarantine. Then they moved into appreciating the impact of the virus and were very supportive of healthcare personnel in the hospital and you could just see the surge of support moved through the community. I would say now people are having a little bit of quarantine fatigue. And now that the days are warmer people are out. But most people up here are wearing masks, voluntarily any time they’re outside their homes, and are trying to adhere to social distancing. We have a pretty obedient population in the upper valley.
Gary Bisbee 5:16
Well, I live in the New York area and there, you would not describe this group as obedient at all, but why don’t we go on to Dartmouth-Hitchcock Health System for those of us that may not be familiar or up to date. Joanne, could you please describe Dartmouth-Hitchcock health system for us?
Joanne Conroy 5:35
Dartmouth Hitchcock is a health system that is about 2.8 billion a year consists of the academic medical center here in Lebanon, as well as a PPS Hospital in Keene, New Hampshire. We also have three critical access hospitals, and we have a nurse and hospice association that serves the upper valley of New Hampshire and Vermont. We also have 24 ambulatory practice sites and actually three very large multi-specialty group practices in Concord, Manchester, and Nashua. They serve anywhere between 20% to 35% of the people in those communities. So a robust ambulatory enterprise. Those ambulatory facilities actually are responsible for a lot of the inpatient volume at hospitals that we are not affiliated with in Manchester and Nashua and Concord.
Gary Bisbee 6:41
So before COVID here, what were your top priorities?
Joanne Conroy 6:45
Our top priority before COVID was consummating a combination agreement with Grant at One which is a Catholic Medical Center. And we have continued to work on consummating the combination agreement. But how we look at it and how we look at assets and how we look at our future has changed dramatically. And I don’t think things are going to go back to the way they were pre COVID. So we are moving through an evaluation of kind of what’s possible from a capital perspective as, as well as thinking about how the markets going to change in the future.
Gary Bisbee 7:27
Are you thinking differently about scale? Now, you must be but is size more important? Do you think about going forward?
Joanne Conroy 7:33
I think the size is much more important. In fact, our system members would say that they have seen the benefits of being part of a system through COVID-19. And I’ve actually received letters from a number of physicians that work at the other smaller facilities that they felt much better prepared, much more coordinated, and how we approached managing this surge. Much better supported from PPE and information perspective than they think they would have been if they had remained a standalone facility. So I actually think people will see the benefits of being a system. The things I think are going to change, though, will be certainly the ambulatory enterprise. Because there are things that we learned about telehealth, our ability to provide it, and the community’s willingness to embrace it through COVID-19.
Gary Bisbee 8:32
Most of the health systems have seen a dramatic increase in tele-visits. That sounds like you have as well?
Joanne Conroy 8:38
We went from about three telehealth visits a week to over 2000 a day in less than 10 days. So it was a dramatic increase. And it’s the fascinating part of that is that we really wanted to continue to care for our patients, but the insurance also paid for us and that removed one of the major obstacles to really expanding telehealth is that many payers didn’t acknowledge it. And it’s both commercial and government payers. I don’t think you could put that genie back in the bottle now.
Gary Bisbee 9:13
Any lessons learned as you’ve gone to 2,000 visits a day that will allow you to adjust how you’re approaching tele-visits.
Joanne Conroy 9:21
We have done a combination of video, when available, and telephone visits when a video is not available. So a couple lessons learned are in rural health care. A lot of the broadband access is inadequate to do really robust telehealth and I have to say that the governor of Vermont is investing a lot of money in increasing broadband capabilities across the state which will be really great for telehealth number one. Number two, I would say that patients do like it. It is convenient especially if they are afraid to leave their home are concerned about community transmission of the virus however it most of the older patients do say I am looking forward to seeing you to all of their primary care providers. So I don’t think our patients will go totally telehealth, but they will probably incorporate it as part of their relationship with us in the future.
Gary Bisbee 10:23
Seems likely that as the physicians become more familiar with it, they might figure out ways to make the patients more comfortable with it. Do you see that happening?
Joanne Conroy 10:33
Some of our providers are better than others in navigating through a telehealth visit. There are a couple things that we’ve started to look at. Number one, let’s understand really the infrastructure needs of telehealth. We have an MA, who actually calls the patients a day before starts to populate the record. Make sure that the technical capability of the patient allows for the video ad or telephone visit. So they actually do some work ahead of time so the provider can move through their list of visits, without a lot of technical things getting in the way of taking care of patients. So we need to really figure out what the cost is the infrastructure costs of telehealth, which will be less than face to face. But it is not just the cost of a provider on a computer. There is other costs that we’ve got to quantify and then figure out how we can actually create that type of infrastructure for everybody that is doing a data telehealth visit.
Gary Bisbee 11:36
Well, that makes good sense. But as you say, it seems unlikely that at least around the country will put the genie back in the bottle on these tele-visits. So what’s been your policy for working remotely, how many of your staff are working remotely?
Joanne Conroy 11:52
When we did an analysis of how many people were actually logging in remotely the vast majority before COVID-19, were providers or people working after hours after they got home. So logging in through VPN, or through our remote access. Within a week, however, when we decided to move all non-essential people off-campus, we went from basically a handful of people that were remote working to over 4,000. And I actually think that’s something else that’s gonna stay. I think there are some leaders institutions that are resistant to remote work, which I don’t agree with. I think remote work is something that allows you access to a national talent pool instead of just a local talent pool. Number one. I think that we have demonstrated that people are actually very productive when they work remotely, but we do have to train our leaders to actually lead remote workforces which is different then, sometimes leading a workforce that you’re face to face with a team, five days a week. I would say that a lot of our employees like it, and they feel that they save time on the commute. Some of our employees are commuting an hour and a half to get here. And they also are probably juggling some of their childcare and homeschooling issues now, as we have stay-at-home orders for all the schools, and they’re all online. And that actually helps those employees accommodate all those different demands on their daily working hours. It remains to be seen though, how many employees will say yes, I want to continue to work from home when their kids go back to school and the younger children maybe go to a local daycare. Now, I would say that it creates an opportunity for us to look at our space needs here. If we continue to have a significant portion of our workforce working from home, then I have an opportunity to repurpose some of our space for activities that actually are growing and need more space, we were thinking about building an extra administrative building. And now that’s totally off the table, I wouldn’t even consider that. The second thing is the parking. I have to say that there’s no problem with parking anymore here. And for most hospital CEOs, that is something they get an incredible number of complaints about, but when you don’t allow visitors in the institution, and your employees are remote working, all of a sudden, we have just scads of parking. And you know what, that’s a real investment. We were even thinking about building a parking garage and we’re not going to do that now. So I think there are a lot of advantages to leveraging a remote workforce.
Gary Bisbee 14:53
We have a question later about the new normal, but you’ve just covered two points. One would be the tele-visits and the other is working remotely and what that means to the administrative expenses. Well, if we could go back to COVID communication with your community and with your caregivers is all-important. How have you thought about communicating with the community, Joanne?
Joanne Conroy 15:17
Our communications team isn’t really a fabulous job. They have communications that come out from me every single day. And we have a flash report that identifies where we are in the surge and also key points for leaders to share with their teams. They also very early on created town halls and webinars for the community. So we could put our epidemiologists on camera, put our Chief Clinical Officer on camera and talk about what we were learning about the virus, what was available in terms of testing, whether or not people had questions. We do have a studio here in the hospital. And that’s been invaluable for really creating these 15-20 minute webinars that go out broadly on the community. We use Facebook, but I would say that the uptake in the community has really been tremendous. And people were actually waiting to see the webinars to get an update on our best understanding of what the community could expect. They had a lot of questions about testing, about symptoms, about quarantining, and we were able to address all of those. So I would say communication was critical for actually managing the concerns of the community number one, and it’s even going to be more critical as we try to get people to start to think about coming back to the facility for the appropriate care of their chronic diseases and or necessary procedures.
Gary Bisbee 16:59
What about the community with your caregivers?
Joanne Conroy 17:01
So we send out an email every single day to all of the caregivers. I would say, I receive lots of feedback that people feel very well informed about everything that’s going on. In terms of the adequacy of PPE, the understanding of the virus, the status of people in the hospital. Can we share with them the number of people that are in quarantine, answer questions about any employees that have turned positive. We’ve been very fortunate; we have had no employee turn positive. While there were using appropriate PPE with a COVID 19 patient. So our employees actually moved from being super anxious about dealing with this patient population to feel supported and protected.
Gary Bisbee 17:49
How’s the morale been among the caregivers?
Joanne Conroy 17:52
Pretty good. I toured in the COVID-19 ICU about 10 days ago. And there is a sense of confidence and definite competence, there is no panic. You know, they’re taking care of incredibly sick patients that have to be proned for 6 to 12 hours a day. And it’s just kind of part of their work and how they care for these patients. And at the same time, they’re training other providers throughout the institution. So if we have a surge and have to expand our COVID ICUs, that we have enough people that have that level of experience with COVID-19 patients so they know how to care for them with confidence.
Gary Bisbee 18:37
What about testing? Have you had enough supplies to conduct the right level of tests?
Joanne Conroy 18:44
Our lab has been fabulous. When we first started on this journey. there weren’t tests or reagents, etc. They very quickly got some virus to actually use as their quality control and then developed their own internal tests. You know, we have two of the Abbott machines here. So we can do 1000 tests a day. And they struggled a little bit with reagents and viral media, as everybody did across the country. They created their own viral media and validated it and used that. Then they also just figured out how to do dry nasal pharyngeal swab testing where you don’t need media and validated that. And now they’re working on a 90-minute bass test. So they’ve really been ahead of the curve. In fact, we did most of the tests for the state, because they were overwhelmed after about two to three weeks. And there was an incredible backlog it was like eight days to get a test back. So we work the backlog for the state so they could actually get to some level of testing that they could actually manage. We continue to be challenged in getting reagents and I think just like everybody else, that’s one of the limiting factors. We did actually contract with a supplier that did not make nasal pharyngeal swabs but created some nasal pharyngeal swabs that again that we validated so we have plenty of nasal pharyngeal swabs to actually test any patients that require it. You know, we’re testing symptomatic patients. We’re testing people in nursing homes, we’ll test first responders and healthcare workers that feel like they have been exposed. We are talking about testing patients that come in for elective procedures or semi-urgent procedures, and people that are coming in for bronchoscopies, endoscopies, and cardiac procedures. We’re also talking about testing patients that are admitted to the hospital, but we all know that the specificity of that test decreases if people don’t have any symptoms, so remains to be seen. It just has not been validated in people that don’t have any symptoms. Well thinking about the possibility of a September increase in a surge, what’s happening to try to find the right reagents and solve this testing capacity issue? Well, we expect to have a validated accurate serology test number one, so you can actually see if somebody has anybody, which will be helpful, I would say our supply chain and this is a benefit of being a health system has just been phenomenal in sourcing both reagents and PPE, you know, the search for PPE, you feel almost like a drug dealer sometime. You know, you’re wiring money to China, not sure you’re going to get the supplies but we’ve worked with the University of Vermont and as a large purchaser has been able to secure large shipments of level two masks for our institutions. And the same people that are sourcing PPE are working really hard to source reagents, I would say that the manufacturers are starting to ramp up. And that probably will be an issue that solved by September. I would expect people who will have appropriate PPE will have appropriate reagents will have accurate tests will be able to do the test more quickly. And we should have a reliable antibody blood tests by then; those are all good things. I think we’ll be in a much better position in September.
Gary Bisbee 22:33
Have you begun to treat elective non-emergency surgeries at this point?
Joanne Conroy 22:38
We’re starting with time-sensitive surgeries and we started on Monday with that. And we feel that after a couple weeks of work in that backlog of people that actually were asked to delay their procedures, then we’ll move into more elective procedures that I call that more preference-sensitive. That means the patient could have it now, or they could have it three months from now. And patients do want to have their procedures. There are a subset of patients that are nervous about leaving their homes. And those patients may elect to wait two or three more months, but they’ll eventually want to have their procedure. So we’re trying to figure out how do we accommodate time-sensitive first and then roll into elective?
Gary Bisbee 23:25
That’s a good transition into Dartmouth Hitchcock’s economics, which of course, has not been a pretty picture of any place in the country for our health systems. How does the economics in 2020 look for Dartmouth Hitchcock?
Joanne Conroy 23:40
So like every health system, we tried to figure out how much we could lose. But yeah, with the backstop it and we had positioned ourselves well. We actually had finance two of our major construction projects before January of 2020 and we actually secured line of credit with our banks that give us more cash should we need that. And we started out in a pretty strong cash position. But having said that the revenue losses are breathtaking. We know how to shut down a facility and we were able to decrease all of our semi elective procedures very quickly. And I think over a week, we probably shut down almost 80% of our operations to prepare for the surge. It doesn’t take a lot of math expertise to figure out what that does to revenue. We think we’re going to be 10% off at the end of the year and our year does end June 30. And right now we’re thinking about how do we create a budget for ’21. We have gone back and forth whether or not we are going to really try to do a budget or are we just going to do a roll forward budget from ’20. And just constantly adjust it. We’re debating that right now.
Gary Bisbee 25:08
Well, if there’s another surge or at least partial surge in September, then it sounds like the first quarter to 2021 will be under attack as well.
Joanne Conroy 25:18
It could be. Not necessarily though I think that we know how to manage COVID and non-COVID patients together. What it will do will probably displace some non-COVID cases, but we’re not going to shut down the institution as we did before. We will just create COVID and non-COVID units and train people appropriately and use the appropriate mechanisms to actually route patients. So they’ve asked us to do to have kind of separate patient flow areas for COVID versus non-COVID patients. COVID patients when they are admitted, actually Gary are quite sick. If you look at the CMI most of their admissions are pretty high. And they’re very resource-intensive to care for them. But you don’t have to shut down the entire institution in order to provide that care. You just have to make sure it’s appropriately cohorted.
Gary Bisbee 26:19
Well, that’s good news, and that’s clearly learning from what we’ve gone through, which is also good news. Could we transition to governance for a moment? How did you communicate with your board of directors?
Joanne Conroy 26:31
We have been communicating a very lengthy update about every 10 days that addresses COVID-19. The search the best things we know about the transmission, the impact on the community, as well as the financial challenges that it creates for the organization and we’ve been very transparent with our board. Our March board meeting was virtual. And I would say our board members were unified and encouraging us to focus on taking care of what was most important, which was preparing for the surge and taking care of patients and taking care of the community at that time. Our June board meeting will probably be a hybrid of both people that are present and people that choose not to travel because many of our board members travel from up and down the eastern seaboard. But it will be probably a little bit more streamlined because we have kept them so well informed during this period of time.
Gary Bisbee 27:30
I’m asking everybody this question any tips for a smooth virtual board meeting?
Joanne Conroy 27:35
You need to spend a lot of time training your trustees that don’t spend a lot of time online. How to position their technology. I would say even with our staff, I encourage people to put their laptop on three or four books, so their camera points at them rather than up their nose, number one. Number two, we encourage people to use a headset, if their connections are questionable at all because audio sometimes is the most difficult aspect of this. We do use WebEx from a security perspective. But that requires an active manager to highlight people who are speaking on the screen. I would say that we are very careful to make sure that people actually do a run through. I can’t tell you how many minutes are spent sometimes dealing with echo audio because somebody has their computer audio on as well as their phone. So those are the things that it’s just it’s worth it to spend a half an hour 45 minutes with your board members ahead of time to make sure they’re good to go and it’s a better experience for them. Nothing is more frustrating than running into technical issues when you’re really trying to have an important conversation.
On a completely different note, it’s becoming clear that public health is part of the national security. I think there’s a growing view of that. How do you think about that, Joanne?
Public health has been the stepchild of Western medicine for a long time. And I think this is really emphasized to people the value of public health. I would say we’re going to see a couple things happen. Number one, I think medical students will really be interested in public health. And there are so many important aspects of medical education that will change because of this experience. People will spend a lot more time thinking about public health. I would say the whole telehealth experience we’re doing a medical student elective on telehealth because it’s a new skill for the future. I would say that our epidemiologists are embedded as members of our incident command and are really important members of that and I’m not sure that’s going to go away. I think this is kind of the heyday for infectious disease and epidemiology, probably like it was back in the 80s when we were dealing with AIDS when it first came out, and we didn’t completely understand it. So this is kind of another resurgence and awareness of the importance of that discipline.
Gary Bisbee 30:19
Well, if you could say this, back to the public health issue, how do your fellow AHA board members think about that?
Joanne Conroy 30:27
I think they’re integrating it into what they think how they can intervene on the things that we’ve discovered, through the COVID-19 experience, for example, disparities, all of a sudden, it’s become real. The impact of your economic situation and access to healthcare during this crisis. So I would say instead of generally saying we believe everybody deserves the same access to health care. This is a real example for many of the AHA board members, many of whom are from urban areas, but a lot also from rural areas. But there’s seen the impact of socio-economic disparities in the care and outcomes that people in their communities. So I think it moves it from something that’s good to be supportive to something that actually impacts the people you care for.
Gary Bisbee 31:26
Let’s come back to that new normal question that we were talking about earlier. Both Dr. Marc McClellan and Governor Bob Kerrey, sitting at this microphone made the point that there will be a new normal one, how do you think about that? And you’ve basically already said that you agree with that. What do you think is going to change going forward?
Joanne Conroy 31:49
A couple of things that we have already talked about. So telehealth, you can’t put that genie back in the bottle. Remote work. I think that’s going to be a really important part of our workforce in the future. I also think that our ambulatory care enterprise will change. Well, you may say what doesn’t change? I don’t think our in-patient enterprise changes. In fact, I think there’s a greater focus on moving to private rooms. I think the issue of a semi-private room is going to be a standard that’s going to be hard to support probably in the future. I would say that all of us will be looking at our ambulatory enterprise and trying to consider how much of that business will stay in the telehealth space and how much we’ll come back with face to face visits. And then it’s also how do we actually space out the patient flow in the ambulatory enterprise we see 4000 people a day here in Lebanon, and some of the waiting rooms are actually very busy, that’s not going to be acceptable anymore. So we actually have to look at our physical plant as well as our patient flow to figure out how can we make sure that people have appropriate social distancing, but we actually move them through the facility in an effective and efficient way. I would say waiting rooms may even disappear, and we’ll have different patient flow. So people go right into a room. When it is an appropriate time for them to see their provider. So it’s going to change that dramatically. I believe,
Gary Bisbee 33:28
Joanne, this has been a terrific interview as expected, always great chatting with you. So thank you very much for your time today.
Joanne Conroy 33:34
Thank you, Gary.
Gary Bisbee 33:37
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Transcribed by Otter