Effective clinical communication drives better outcomes. When clinicians coordinate patient care, the goal is getting the right information to the right person at the right time – with context. The University of Maryland Medical System sought to make communication more efficient for clinicians and provide better transparency of on-call schedules.
In this episode of The Connected Care Team, Tiffany Kuebler PA-C, MMS shares how UMMS implemented TigerConnect during the pandemic and the organization’s journey with communication technology.
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Will O'Connor: Today on the show we have with us, Tiffany Kuebler. She is from the University of Maryland Medical System. She is their medical director of Clinical Informatics. She's the director of their physician builders program and is a Senior Trauma Physician Assistant. And we are really excited to have her on the show today.
So welcome to the show, Tiffany.
Tiffany Kuebler: Hi. Well, thank you so much for having me.
Will O'Connor: Yeah, thank you for joining us and taking time out of your, your very busy schedule, just from your title alone. It sounds like you, you have a lot of responsibility for a lot of different things going on at Maryland.
Tiffany Kuebler: I have a few hats.
Will O'Connor: Well, tell us a little bit about, the University of Maryland and specifically Shock Trauma. Absolutely the number one place for trauma in the world and something I, a place I've been a huge fan of since, since I was a medical student. So tell us a little bit about, Shock Trauma and Maryland.
Tiffany Kuebler: Yeah, I will say we in Maryland are very lucky. I personally feel very lucky to work here. I was hired, uh, in 2007 as a PA, my first job out of school. I staff one of the three trauma teams that we have under the direction of Dr. Thomas Scalea, who is our Physician in Chief. He has been the Physician in Chief for going on 25 years, he got here in, in 1997. And we provide what I think is the highest level of care possible to patients with traumatic injuries, not just in the state of Maryland, but also all the surrounding areas.
We get patients from Delaware, West Virginia, Virginia, DC, Pennsylvania, transfers from, from out of state. And what's most impressive, I think is two things. One is that we have a, a 96% save rate, which we are really proud of. Um, we are also supported by the Maryland state police medevac system. And all of that is free to the patients.
They never get a bill. Tt is funded at least part by, fees that you are charged, when you register your car with the Maryland vehicle administration. This is the system that a lot of trauma centers around the country and, and, around the world, mimic, because of our commitment to, the golden hour and, getting the right patient to the right place within the right amount of time and that's really kind of a tenant that we apply in a lot of other areas. You know, when we talk more about our clinical communication, that's a, that's a trend that we follow with our clinical communication as well.
And so, the R Adams Cowley Shock Trauma Center is part of the University of Maryland Medical Center, which is a 700-bed Academic Medical Center. We're located in downtown Baltimore. Um, and we are part of the University of Maryland Medical System, which has 12 hospitals. We are in, almost every county in the state, including, outpatient centers.
And so we really have a huge footprint in providing care to folks all across the state of Maryland. And like I said, I've been here since 2007, clinically. And then when we went live on Epic in 2015 is when I started to done some IT hats. And as you mentioned, I'm now, one hat is I'm the Co-Medical Director of Clinical Informatics for our Academic Medical Center, where we focus on really trying to make our EMR as efficient and useful as possible for my fellow bedside clinicians.
Which really involves a lot of us being bilingual and translating IT to the bedside clinician and translating bedside care to our IT folks. And then my other hat, kind of expands on that. I now lead the Um, Physician Builders team, which was founded by my colleague and IT mentor Dr. Dan Lemkin.
We're a group of clinicians who really wanted to take the extra steps to be trained, almost like an analyst lite of sorts. We get trained at Epic and, and we learn how to do the build ourselves to build novel solutions to workflow challenges, and increase our ability to be subject matter experts so that we can better communicate and assist our, our clinical colleagues.
Will O'Connor: Got it. Well, you know, certainly, Maryland is, is, is lucky to have you. You, you are very unique in the fact that you are deep into the technology and have a great understanding of, of how it works, but then you're also at the bedside in the trenches with with the patients , all the time. I know when I try to connect with you, you're often, if you're working a clinical shift, you can be very hard to reach.
So having a lot of depth in both, I think gives you a, perspective, as a clinician that ends up being relatively rare these days. So I know, I know Maryland and, and the, the entire team is, is very lucky to have you.
Tiffany Kuebler: I appreciate that. It really, maintaining my presence at the bedside is what gives me street cred.
Right? So when I want to implement something new, with my clinical colleagues, I have to, I have to be willing to use it myself. I have to understand what those, I have to understand what those implications will be of having to use a new tool. And so if I'm not willing to use it myself, I'm certainly not going to try to sell it to my colleagues.
Will O'Connor: So talk to me a little bit about what you're doing with communication. You spoke earlier about the golden hour and making sure that you're getting the patient to the right place at the right time. Talk to me a little bit about your journey with communication technology, and now how you're leveraging that today.
Tiffany Kuebler: Yeah. One of our colleagues here has been sharing with us the goal should be getting the right communication to the right person at the right time. Right? It's a very similar process is when I need to communicate with someone, I don't want to have to spend time figuring out who the right person is when I need a stat cardiology consult, or a stat neurology consult.
I need to know that when I send that message or when I make that phone call, it's getting to the right person the first time. Because as we know in the clinical world, a lot of times, time is tissue. It's super important that we minimize the amount of time that it takes to affect that communication. Because otherwise it's taking time from the patient, getting the care that they need, or it's taking time from the clinicians continuing to care for other patients or that patient.
So the more efficient that we can be with our communication, the better it is for everybody. And that's something that we've really struggled with here for a long time. We have, uh, a paging system that is now quite aged, but it's not very robust.
It doesn't incorporate call schedules. So you have to trust that it's the right pager is being covered by the right person. And that that person didn't leave it on their desk in their office or that they didn't call out sick or, or maybe, they don't have a pager in and then the reliance is on a phone call.
And then you have to hope that they hear when the phone rings or you're calling a nurse, a nurse back. And, you're on hold for five minutes, or maybe we're relying on overhead paging, which is even more archaic but still done. None of these systems really helped to make sure that we were getting to the right person.
And on top of that, the communication is very rudimentary. We could send one-way communication and we could send a small amount of information. But there's character limits and really no way to give a ton of detail within that method of communication. And so with the fact that we have so much technology at our fingertips, now, the way that we were doing it just was no longer sufficient.
Will O'Connor: Yeah. And you know, I hear those types of stories a lot. And I, I don't know exactly what it is about healthcare that has made these changes so slow, but we are really the last industry that is, that is making widespread use of pagers and fax machines and our technology from the seventies and eighties. It's often very frustrating.
So tell me a little bit of how you, how you moved away from that and, and how you were able to make those changes to get to where you are today.
Tiffany Kuebler: It's been a work in progress for sure. We tried implementing another secure communication platform a few years ago, and that was successful to a point at one of our hospitals, not my site specifically. But really, ultimately was only partially adopted due to what I think is a combination of lack of buy-in because the software didn't meet all of our workflow needs and honestly, a lack of comprehensive implementation.
I was not part of that implementation process. So I can't speak in depth to what the particular fail points were. But it really was not well adopted and there was still overall a huge need for a fully implemented efficient two-way communication process. And additionally, we also needed something that was going to give us more transparency of our on-call schedules because of, as I was just describing, we spent too much time trying to track down the right person.
And so we launched, an RFP process and really compared a whole bunch of different vendors until we ultimately landed on TigerConnect in seeing the potential of giving us communication and scheduling and what we think is the long-term ability to really automate a lot of our communication processes and to make them more efficient.
Will O'Connor: Tiffany, tell me a little bit about some of the workflows now that you're, that you're using with TigerConnect. You said earlier time is tissue and it's, you know, that's spot on, correct. Right? You're you're really looking for speed and efficiency here. What, what types of workflows have you applied this to where you've, you've seen some impact?
Tiffany Kuebler: Yeah, we really dove head first with this. We did a huge go big or go home implementation. And so we really are working hard to make all of our communication workflows involve TigerConnect. We're not a hundred percent there yet. We do have some legacy workflows that we're working really hard to transfer.
But it's, it's not just as simple as messaging between individuals. We've really started to look for opportunities to automate notifications so that we're taking advantage of the technology, replacing what used to need to be a manual process that we realized no longer needs to be a manual process in a lot of cases.
Will O'Connor: What types of things have you been able to automate?
Tiffany Kuebler: Oh, gosh, we have a bunch that I'm really proud of. A few of these I just presented at HIMS last week. We're really, really excited about what we've been able to accomplish. And from our standpoint, these are just the beginnings.
So, when you place an order for a new consult in Epic, the consulting team receives a notification with all of the details of the consult order that was just placed.
And because Tiger allows us to create a group message thread, when that notification is sent out, it connects the requester with the consultant into a group message thread. So they can immediately be able to communicate with one another and not require anybody to consult an on-call schedule or track down a phone number, or even spend any time on the phone.
We notify social work when emergency department patients screen positive for homelessness. We send notifications to our neuro critical care consult team, whenever an ED patient that comes in and arrest achieves ROSC or return of spontaneous circulation so that the neuro critical care team knows that there's a patient that needs to be screened for targeted temperature monitor.
We notify the patient's primary team when their patient has left the operating room and needs to have their post-op orders reconciled because we have a lot of workflows where the primary team is not the operating team. And so therefore they didn't know when their operative case was completed and the nurse would have to manually message the primary team to request those post-op orders.
We have a notification now to let other, the trauma surgeon and the trauma OR staff know when a patient has met criteria for evaluation to see if they need to be taken to the OR due to three episodes of hypotension, which is an ACS guideline requirement.
And then I think the biggest one is our code blue notification process. Many of the units in the hospital have a button on the wall where you can press the button when a patients has a cardiac arrest or presumed cardiac arrest. And when that button is pressed, it results in an automatic notification being sent to the rapid response team. And that notification includes a customized template that gives you not only the patient's demographics, recent labs, recent vitals reason for admission, allergies, recent surgery, if they’re a difficult airway, a whole host of information.
And all of that goes immediately to the rapid response team. Previously, before this, the manual process was the button sent off a notification to our operators. The operators called back the unit to confirm that it was a code blue.
They sent out a text page through our paging system, that there was a code blue, but only with the location and no other information, and an overhead page. And we found that when we implemented this, it saved just under two and a half minutes from the time the button is pressed to the time of notification.
Between those two workflows, the manual workflow and the automated workflow, we saved two point, almost 2.5 minutes. And again, time is tissue. So 2.5 minutes is an eternity when someone is in cardiac arrest.
Will O'Connor: That's incredible results. And you know, not, I was thinking too, not only is it two and a half minutes, but now instead of getting there two and a half minutes later, and the people are arriving sort of blind, you've now given them situational awareness by linking and including with the message, some clinical and demographic data about the patients.
Tiffany Kuebler: That’s exactly right. We've given them the ability to now start to formulate a differential diagnosis as they are responding to the room and they have a better idea of what they're walking in on. Now, they don't have to wonder, is this a, a 20 year old or is this an 80 year old? Is this someone with a list of medical conditions, the length of my arm, or is this somebody who was otherwise healthy until they showed up?
It's, your differentials could be completely different. And now having that information ahead of time is crucial.
Will O'Connor: Yeah. I think that represents really good integration with your, with your EMR and the ability to supply clinical details within the message. The talk to me about why you don't just do this in your EMR? Epic has messaging in it. What led to your decision to decouple communication technology from your EMR?
Tiffany Kuebler: When we started our search for our secure communications vendor, at the time Epic secure chat, didn't have all of the functionality that we were looking for. And so we didn't continue to explore it beyond that. And so while I don't necessarily know all of the functionality that they may have added, since that point, we really felt like we needed more because we wanted a schedule platform that would allow our departments to upgrade from paper, Excel, spreadsheet, paper, napkin, whatever they were using.
And we wanted the ability to give everyone in the hospital system access to those schedules so that they could see who is on-call at any given time. And there are also a lot of clinical communications that are not necessarily patient-centric or involve communication with users who don't have Epic as part of their daily function, but they still need to be part of the conversation. And so to us, it seemed more intuitive to not have it rely upon being tethered within Epic.
Will O'Connor: Yeah, I think, I think, we're seeing more of that now. And you know, your point about having the EMR not include everyone is, is certainly one of the biggest reasons I think people are starting to adopt this, the strategy that you've taken. More and more where you're having this built out as a separate platform, but there are meaningful areas of automation and integration with the EMR. Tiffany, you mentioned earlier that you've now been using scheduling.
Talk to me about the transition from legacy technology that we're using, that you are using, sounds like including, Excel spreadsheets and disconnected schedules.
Talk to me about how that journey has been now to an enterprise-wide scheduling.
Tiffany Kuebler: Yeah, this has been an interesting transition. We have a ton of departments, just at our academic medical center alone, all of them really in their own silo of whether they were using Excel or paper or a scheduling application, like, Amion, Qgenda, Lightning Bolt, et cetera. And there was no consistency.
But everyone was very entrenched in what they were doing and the process that they had already been doing for so long. It frequently involved sending emails of their schedules, faxes of their schedules. Our access center has a binder that they carry of everybody's emailed or faxed and printed out schedules that they keep so that they know who's on call from every department.
It was long overdue for a makeover. And so being able to go to all of these departments and offer them another option, has been great. There's always a learning curve, but I think a lot of people have been really excited to see the functionality. I've had many schedulers or admins who've been very excited that this is going to make their life much easier.
It's going to make things much more efficient for them. And ultimately I think that it will finally allow us to go paperless so that we can stop the emails. The faxes, the printing, the binders, the, all of that stuff, because the TigerConnect scheduling platform allows us not only a place to input all of the schedules, but it allows us a one-stop-shop website where everybody can then see the schedules either in month form or in daily on-call form.
There's still some holdouts that haven't gotten used to not having a printed copy in their hand. And that is a challenge that we are working through to remind everybody the benefits, that their paper copy is probably outdated, as soon as they print it out and the website will never be outdated because it's updated automatically.
Overall the response has been great. I, a lot of folks have really appreciated the option to transition off of whatever platform that they are using so that they can take advantage of this enterprise software solution. Our requirement has been, at least at my site, our requirement has been that on-call schedules be placed into the Tiger scheduling system. But if they choose to keep their non on-call schedules, their clinic, their whatever in their legacy system, I certainly won't force them to change, but it's been interesting that as we've been going through this process and they see the functionality and see the benefits, how many people are talking about doing a, a full transition to Tiger.
Will O'Connor: Yeah. It's not uncommon that experience from what I've heard is as far as, just a little general resistance, right? I've been doing it for one way, for so long. It can be hard to, to change folks to the, to the new way. But it, it sounds like from what you said, you know, the feedback is good and people are seeing benefit.
Talk to me specifically about some of the feedback that you've received. Both on the physician side, I think the benefits there have, have been obvious, but then also from the perspective of, nursing and talk to some, talk to me about some of the feedback you've received from your nursing staff.
Tiffany Kuebler: Sure. I think the feedback from the providers overall has been very positive because while we haven't yet been able to necessarily decrease the number of notifications they're receiving, as we've switched from pager to secure messaging application, what they are noticing is the quality of the notification has improved.
And so it is decreasing their need to sit on hold on a phone call. It is giving them the ability to immediately respond back with an intervention or a response or a recommendation, or it just gives them more situational awareness than they had before that they can read as they are walking down the hall or, going from place to place.
And, and so I think overall, there is an efficiency benefit there that the providers have realized. From the nursing side, it's been very interesting because I haven't necessarily heard any specific verbal feedback other than I think actions speak louder than words. We initially thought that because we weren't mandating the nursing staff to use their own devices, that we were going to need to roll out unit based devices that would be available for the nurses to pick up at the start of their shift, used for their communication throughout their shift, and then give back at the end of their shift.
And before we ever rolled any of that, essentially the entire nursing staff was already using Tiger because they saw the benefit and the value of that two-way communication. So whether they're using it on their own device or they're logging in from a desktop, either at the nurses station or in their patient room, everybody's using it.
They have seen how efficient the communication can be with the providers. That was it. They just immediately started using it without even really needing to be invited.
And now I am getting routine requests for more functionality because everyone sees how beneficial this has been to our communication.
Will O'Connor: You're absolutely right that actions speak louder than words there. You have nurses independently downloading TigerConnect because they're seeing the benefit. That's that's really been our goal all along for the application is hoping that our clients get that much benefit out of it where people are voluntarily, volunteering to, to use it and, independently downloading it because they see the value.
Tiffany, this was a big project. And you mentioned earlier that you, you went big bang and rolled this out, broadly across the organization very quickly. Tell me about how that implementation went and how you ultimately drove the type of adoption you’re getting.
Tiffany Kuebler: The first thing that I will say, and to the people listening, my humble recommendation is to not do something like this in the middle of a pandemic. But if that can't be avoided, I will say that the collaboration and support from the Tiger team is really what helped ensure this to be successful.
And I also cannot speak highly enough of my colleagues at each of the hospitals in the, um, system. We identified a project team, there was one representative for each hospital. We met weekly, starting very early, and from the Tiger team was really an understanding of how comprehensive the planning and implementation strategy needed to be, especially because when you go live in the middle of a pandemic, not many people can be on site to help. And we had, unfortunately, no one from Tiger able to be on site to help us with this. And so the planning needed to be meticulous.
We ultimately ended up doing this in two stages. Uh, stage one was a like for like transition for anybody that was on the secure messaging application that we were transitioning off of, because we didn't want there to be any loss in functionality as we made that transition.
And then once that happened and was stable, we were then able to really expand anybody and everybody that wasn't already included. And it was definitely a big lift, but having that project team that was small and facile and full of subject matter experts was really helpful. Engaging marketing and communications to make sure that this was very well messaged and advertised in advance was also very helpful in making sure that we weren't just relying on people to read an email or two.
They were getting bombarded with this information because we wanted to make sure that everyone knew, Hey, you know what? This is happening and the train is moving forward, and this is how it's going to be from now on. Having that we having those weekly project team meetings was incredibly helpful.
We continue to have them and having the attention and support from our customer success manager, from our Tiger project manager, all of those components have really helped us feel like there is support so that when issues came up, which they did, I would've, I would've been shocked if issues didn't come up, but when we encountered issues along the way, we immediately knew who we needed to contact.
And then when the situation dictated it, resources were directed to address the needs as quickly as possible. So, It was very reassuring to us that when we encountered issues along the way that we had people that we were able to contact and they were able to direct resources as needed to address, and that continues to happen, the bigger and better we make our, our implementation, the more functionality we add, the more challenges come up, the more we come up with enhancements that we would like, or requests that we have, for future functionality.
And there's still a team of folks that is always willing to collaborate with us and support us and help ensure that we have the best functionality possible.
Will O'Connor: Absolutely. Tiffany, thank you so much. for, taking the time to join us today and congratulations on all the success that you are having at UMMS. And congratulations to the team as well. it sounds like, that you are making a real impact in the lives of patients, but also in the experience for the providers and for the nurses.
So, again, thank you for joining us today, and congratulations on all your success.
Tiffany Kuebler: Thank you so much. And thank you for having me.