Pandemic Prep and Progression: Using Business Analytics & Geospatial Data

Podcast Transcript

Will Morris, MD:

Hi, this is Will Morris with another Health Amplified, a Cleveland Clinic podcast. And with us, as always, is my co-host Akhil Saklecha, Managing Partner of Cleveland Clinic Ventures.

Will Morris, MD:

Today we have a special treat. We have Dr. Robert Wyllie, who is the Chief of Medical Operations at Cleveland Clinic, a very, very interesting role at the cornerstone of business intelligence and analytics, pharmacy, continuous improvement, hospital throughput, surgical operations, and critical care transport. Under his stewardship, he is also responsible for Ohio's state response for the COVID pandemic. So, it's an absolute pleasure to have you, Dr. Wyllie. Thank you for joining us.

Robert Wyllie, MD:

It's a pleasure to be here, Will.

Will Morris, MD:

So, I think it's important to explain to the audience, as the Chief of Medical Operations and focusing on managing a very, very complex system, all of a sudden the pandemic hits. What is the role of the hospital system or someone in your role in informing and guiding the legislation and the Governor of the state of Ohio?

Robert Wyllie, MD:

So, it really starts with incident command, which is our emergency operations center at the Cleveland Clinic. That has been running for several years. It started... One of the last big things was Ebola, in terms of an outbreak we were significantly worried about. As you remember, we had somebody who went to Akron, looked at a bridal dress, and then went back down south. So, we were very concerned immediately with the Ebola outbreak about what it might mean to Ohio. With that, we set up a freestanding Ebola unit within three weeks that we built, including we trained over 600 people in the proper use of personal protective equipment, and as well, developed a transport capability, not only ground but helicopter and even air transport, which we got asked to use by the Federal Government during that time.

Robert Wyllie, MD:

So, we respond to all kinds of emergencies: Ebola, the coronavirus infection, but also gas leaks, loss of electricity. Anything that happens on an emergency basis that must be managed comes through the incident command center, so that was really where we started.

Will Morris, MD:

And I imagine no good deed goes unpunished. You're a leader in that space, and then obviously a global pandemic hits. How does that actually work? Did Governor DeWine reach out and say, "We need help. We need the input of those who are administrating hospitals to help guide us"? Tell us a little bit about that orchestration, and where has it evolved in the past nine months?

Robert Wyllie, MD:

It evolved very rapidly, on March 9th of last year was the first Ebola patient. I know it seems like several years ago but it was just March of last year. By March 12th, the Governor closed the schools. Three days later, he closed the bars and restaurants, and by March the 23rd he had issued a stay-at-home order. And the other thing he did was he told all hospitals to stand down any unnecessary medical care, and really the point of that was to preserve personal protective equipment because we knew we were going to be short. China produced a lot of the PPE that was going to be available, over half around the world. We got major supplies and shipments from China, so we recognized actually way back in January when we began to hear rumbles of a pandemic in Wuhan in China that maybe we ought to look at expiring product and maybe we should keep it instead of sending it back.

Robert Wyllie, MD:

So, it actually started in January in terms of ramping up our capabilities, because we looked at a virus, many scary pictures coming out from China, and we were pretty convinced it wasn't going to stay in China or in Asia with world travel being what it is.

Akhil Saklecha, MD:

So, I'm curious. When this first started, as you described, you're getting a handle on things. We're starting to see the early signs of the disease in China, we're starting to see preparation here, and you've got the incident command center here. So, can you walk us through a little bit as to how you started thinking that, first of all, this may be different than Ebola, which was a limited number of cases versus a pandemic with potential for huge spikes? So, the way you're thinking and approaching this would be probably very different. Can you walk us though a little bit as to how you were thinking of setting up the command center and then, I think, interacting with internal operations and then externally to the community and state?

Robert Wyllie, MD:

Will do, Akhil. We set up the background of the timing of events with the Governor, so as soon as the first case hit Ohio March 9th, we activated incident command. Dr. Morris was part of that group that got activated. And we really looked at doing three things. One was increasing our immediate capacity, and we tried to get a handle on, "Well, what does that mean? How much capacity do we actually need?" So, we have 2,500 to 3,000 beds in Ohio. How many were we going to need for our part of the market in the 21-county area?

Robert Wyllie, MD:

The University of Pennsylvania developed a model and we ran the model assuming about a 3% admission rate, and it showed some scary numbers. It showed that if nothing changed, we were going to have to be able to handle at one time up to 8,000 patients with under 3,000 beds. So, the first job was increasing capacity of the hospitals. The second one I mentioned, which was increasing personal protective equipment. And the other one was going to be, "How do we coordinate with the state, and what does that look like?" The first part of it, we started looking at all our PPE. We put up PPE dashboards in business intelligence so we knew how many days supply we had. For every PPE different type of thing, from masks to gloves to gowns et cetera, small masks, large masks, N95s, regular surgical masks, the whole gambit, including medications that we might need. As time went on, we added dexamethasone and remdesivir to that, and then regeneron and imdevimab in terms of the monoclonal antibodies, and those have been added to the list more recently.

Robert Wyllie, MD:

So, keep the list, order, develop the amount of PPE that you need, we were looking at greater than 90 days, and then we looked at the burn rate. Okay, if you've got 8,000 patients, boy, you're going to go through a lot of PPE. So, we really expanded very rapidly in terms of looking at what our capabilities would be.

Robert Wyllie, MD:

We did find something with which we could tweak in the University of Pennsylvania model though that looked like 8,000 was probably going to be, and this was open-source, but that 8,000 was going to be an overestimation of what we actually really needed. And it began to round into a number more like 2,500. Well, 2,500 is almost every bed that we have in Northeast Ohio. That's still way too many for the other emergencies that we have to handle.

Robert Wyllie, MD:

So, as we looked at what the Governor did, he called a small group of us down to Columbus to meet with him. No masks, no spacing. We didn't know about that at the time. And he suggested, "How shall we manage this?" And what we actually suggested from the Cleveland Clinic point of view is we take the eight emergency regions, which seemed too big and too awkward to manage, and just divide it into three zones. It's more representative of the healthcare delivery system. So, a northern zone, which included anywhere from Toledo, Cleveland, Akron, Youngstown, Canton, and then you had the mid-Ohio centered on Columbus, and then you've got Southern Ohio, zone three, centered on Cincinnati.

Robert Wyllie, MD:

And the National Guard, General Harris agreed with us that that made a lot more sense in terms of his delivering product and supplies, as well as potentially people, if he was only trying to manage to three zones. So, that got set up, and I was assigned the zone lead of region one, which of Ohio's 11.7 million people, is over 5 million. That's by far the dominant zone. And then the job within the zone became... Well, there are some things which are not very well-connected traditionally, so local departments of health are not connected actually with local hospitals, or local healthcare providers, or the congregate facilities.

Robert Wyllie, MD:

What do we mean by congregate facilities? Ohio is a relatively old state, not in terms of when it was founded but in terms of its population. In fact, we're the oldest largest state. The other ones are quite small in front of us, like Delaware. So, we have an aging population which is older than average, and we have more people in extended care facilities. Ohio has in excess of 900 private extended care facilities, housing about 50,000, 60,000, 70,000 people. The state also houses people. Now, part of these are prisoners, but part of those are veterans, and people with developmental disabilities, and disadvantaged youth and other things in homes. So, it's not all prisoners. It's quite a big mixture.

Robert Wyllie, MD:

But they have about 50,000 people, and these people in the extended care facilities, whether it's state-run or privately run, really don't have any way of getting away from each other. And the threat really is the people who work in these homes and come in and out, or in these facilities if they're government facilities, and they work at several. There was a potential threat of spread there, so what we did is we cataloged every privately owned nursing home in zone one, over 400. We put the number of residents in. We put all the employees in. We looked it up with the local county department of health and with the local hospital, and we made that triad in terms of healthcare delivery.

Robert Wyllie, MD:

The other thing we realized is if we were going to have outbreaks, and it turns out that we did, how do we balance load the system? What happened early on was Elkton Federal Penitentiary in Columbiana County on the far eastern edge of the state of Ohio had an outbreak. It's still one of the largest outbreaks, over 1,200 prisoners and employees. Quickly it crashed the east Liverpool and the Salem hospitals, which are very small hospitals with a handful of ICU beds. So, what we did immediately was set up a cascading system and told them not to worry. You start to get overwhelmed, we're going to transform to Akron. Akron starts to get overwhelmed, we're going to transfer to Cleveland.

Robert Wyllie, MD:

And it's that balanced load which was the other part of it, so how do we balance load across zone one and even between zone one, two, and three? Although we've not had to do that very often. So, it's balance load and get rid of the nervousness about hospitals afraid that they were going to get overwhelmed, like pictures that we saw in China but also pictures we saw in Italy.

Robert Wyllie, MD:

We actually spoke over the phone three weeks into the pandemic in Italy when the hospitals were overwhelmed. We talked with the director of the busiest hospital there, and he gave us some good advice. He said, "If you're thinking two or three days ahead, you're three weeks behind. The virus is going to move that quickly." And we took that advice to heart and we started thinking several weeks out, not just managing the next 72 hours but what's going to happen in the next two or three weeks that we need to be on now while somebody's trying to manage the immediate threat. So, those were some of our initial thoughts about how to manage this.

Will Morris, MD:

I don't imagine you even have a moment to pause and reflect, by hypothetically if you did, what are the lessons learned out of this that you think, "Gosh," from an analytics standpoint, from an awareness standpoint, from a care coordination standpoint? We have riches of resources, but yet they don't talk to each other. Are there innovations or just ideas that you think could surface, whether it be for the next pandemic or disaster, or things that actually might help facilitate better care? I'm just curious, any of those thoughts?

Robert Wyllie, MD:

Probably the most exciting thing we've done is set up a geospatial analytics system with university hospitals, and we've just drawn metro into it. And we used combined data. So, what this allows us to do, and let's just use COVID as an example since that's the top of mine currently... We can detect clusters and we can detect micro clusters, that's a couple people within a 100 meters of each other, and we detect positive tests not in a zip code but to actual address locations. We can put Google Maps on top of that, so we can show the local county departments of health where people are being infected and where clusters are starting to develop so they can put appropriate resources there in order to manage. So, give people masks, tell them about hand washing, give them gloves if necessary, gowns if necessary. And moving into the back scenes stage, let's vaccinate everybody around those. And this turns out to be high-density housing areas.

Robert Wyllie, MD:

We can also put the social deprivation index over that to show where people are most vulnerable. We've done all of this, and I'm delighted to report within the last week we used the Ohio Hospital Association with all our legal agreements to share data. Now this is state-wide. We're the first state in the United States which will have a geospatial analytic capability. We're doing it for COVID, and that's going to be very useful. We're wrapping in vaccines now on top of that so we can look at the map of vaccines and the map of who has been identified as a patient and is infected and then everybody else living in that area.

Robert Wyllie, MD:

But what about infant mortality after we're over COVID? And maybe with drug abuse. What about new drugs coming in which are more lethal, like we've seen in the last couple years, than other drugs? We can detect fatalities as well as overdoses, and we can start to intervene in these areas.

Will Morris, MD:

It reminds me of the reaction of the one pediatrician in Flint who basically was the whistleblower of the lead poisoning in the water situation. But I can imagine with this data at such a granular but aggregate level, you could start understanding tremendous health disparities, inequity, or other public health issues.

Robert Wyllie, MD:

Yeah. I think we're very excited about it. The Governor is very excited about it. We've shown the Governor, in terms of the capabilities, and we're using it. So, we pulled in Ohio State, which has a great analytics partner. We pulled in the University of Cincinnati as well. And we're pulling in all the resources for everybody to use this in a transparent way, on an open platform essentially, so we can all look at the data and we can help each other.

Akhil Saklecha, MD:

The con around data though is important. I think the concern or issue is it's really only as good as the data going in, and it's only as good as the data sharing agreements between institutions. And going back to a comment you made earlier around the fact that when this first came out a lot of the local county health departments weren't really in sync with each other. They weren't in sync with the hospitals or the primary care doctors. So, when you think about that and you think about that communication gap, how has that evolved? Or has it evolved? Will we be in a situation like this in the future, or are there systems now in place that you think will carry on and maybe give us more insight and prevention around that?

Robert Wyllie, MD:

Yeah. I think with the triad that we've formed now, so you've got congregate facilities with the local hospitals for the county health departments, I think we see that holding and being sustained. We also have calls, and we just changed it. We had calls three times a week for all the hospitals in zone one to report out. So, it was not only how many COVID patients they have. It's their percentage of positivity, their PPE needs, where did they need PPE, as well as the local departments of health to rope them in to make sure that everybody is on the same page.

Robert Wyllie, MD:

In the state of Ohio, the departments of health are actually appointed in each individual county, and they have a dotted line to the state department of health. So, the state department of health has oversight but it's really no hiring or firing capability, so they could suggest direction. So, we've tried to put that together in a stronger framework to make sure everybody is on the same page, because to your point, it's all about communication at that level.

Robert Wyllie, MD:

We had to know and we had to figure out, because typically we had the department of health in Cuyahoga County with Terry Allan, who had been head of it and I've known for quite some time. But they did their bit of work, and as hospitals, we did our bit of work. We also had to pull together the hospital systems in Cleveland and Cuyahoga County and work with the County Commissioner, Armond Budish, and work with Terry Allan in terms of the Cuyahoga County department of health as well as the city's department of health. So, pulling those people together to make sure that everybody was on the same page. So, we put together CEO calls, and I talk with my counterparts at metro and at university and St. Vincent's at least three times a week, if not daily, about it.

Robert Wyllie, MD:

We set up common testing platforms, and we also set up SWAT teams. So, university set up a SWAT team to test so if there's a nursing home outbreak, they could swab everybody in the nursing home. We set up a SWAT team and metro set up a SWAT team to make sure we could cover the county and that our citizens were relatively protected. Now that we're vaccinating, we're all vaccinating as well. The control of the vaccine is really at the state level and from there the Federal level, and there have been many issues with that, which we can discuss if you like.

Will Morris, MD:

We won't touch the Federal level. We don't have a three-hour podcast. But I'm curious also... What's amazing is how we can all come together regardless of what color badge you wear and what role and really knock it out of the park in terms of service of a crisis. Out of this, you also are over our pharmacy and drug shortages, and drug pricing cost transparency is always an issue. Do you see a degree of statewide or even Federal-wide collaborations in which either the manufacturing of limited cheaper versions of generics or a group purchase organization? How well do you think these collaborations will yield other benefits?

Robert Wyllie, MD:

I think moving forward there are certainly collaborations that healthcare providers can do on the backend, not necessarily the direct patient interaction end, so to some extent pharmacy, laboratory services. You could imagine a number of other things to make healthcare delivery more efficient across different providers. Now, what that's going to look like in the future, I'm not sure. Obviously, the clinic just added its 12th hospital in northeast Ohio, Mercy Canton, into the fold. The bigger we get, the more efficient we get in terms of spreading the backend costs. And we get more patients to serve in our local area, and we can become more efficient over time. But where the healthcare industry is going to end up, I think it's a little premature to know right now.

Akhil Saklecha, MD:

We just touched on the vaccine briefly, but I don't want to click on that. We knew the vaccine is coming at some point, and we knew that there would be challenges on the supply chain and the distribution. What are the steps that we took at the Cleveland Clinic and that you took at the incident command center to prepare and handle the logistical issues that we knew would be coming up? And not just the supply from the Federal side but the part that we can control.

Robert Wyllie, MD:

Yeah. There's a thing called CORT, which is the coronavirus operations and recovery task force that we transitioned into incident command. So, incident command is a relatively short stand up. Typically, in terms of days, we ran day after day for several months seven days a week. Will was in on all those meetings, Saturdays, Sundays, a lot of time. But eventually we had to change it over into a regular operating system, a system of operations, so that got done.

Robert Wyllie, MD:

In terms of the vaccine, we began to think about vaccines early last fall, and then we learned about the Pfizer and we learned about the cold storage and the temperatures required. We looked at the Moderna as well. So, we began to look at our freezer capabilities. We have a freezer farm built just for coronavirus, and we can actually store within the Cleveland Clinic main campus several hundred thousand doses of vaccine at minus 70 or at minus 20 degrees centigrade, either one. We have offered to help the state store their vaccine if they're getting overwhelmed. We've volunteered to be a distribution center for the entire northern part of the state. We could probably take on almost the whole state with our capabilities. So, we looked at that proactively.

Robert Wyllie, MD:

A guy named Jeff Rosner from a pharmacy and supply chain was working with our operations group in terms of providing all the freezers. We also did the same thing. We roped in Florida, so there are the same freezer capacities at Indian River, Martin's, and obviously at Weston. So, we began to think of that early in terms of what we would need just to store the vaccine, and we began to think of where we were going to give the vaccine and how we were going to give the vaccine.

Robert Wyllie, MD:

As you know, the Federal Government, and adopted by the state, said, "The people most at risk are the eldest," and it's true. If you look at people over the age of 65 in the state of Ohio, there are 2.2 million people, about 20% of the population, but it's about 87% of the fatalities from COVID in the state of Ohio is in that age group. And if you looked at those who live in extended care, it's only about 7% of those infected but it's 40% of the fatalities in the state of Ohio. So, the idea at first was let's get the people in extended care facilities. Let's get them injected with the vaccine first, and that happened, and then let's take the oldest. And the Governor had a plan where he went down from 80 to 75, 70 to 65 at weekly intervals and gradually ramping up to those 2.2 million people that I talked about.

Robert Wyllie, MD:

We were a little bit concerned about healthcare inequities in just saying it's open to everybody over a certain age. We were also worried about the perception of our patients, just trying to get in and calling and calling, like we've heard. So, we've told our patients, "Don't call us. We'll call you." So, we started with the most vulnerable, and then we started just going down and adding more and more patients in to match our vaccine supply capabilities. And in doing that... We actually looked last Friday and I just presented this data yesterday to the Governor's office about health inequities.

Robert Wyllie, MD:

In terms of the African American population who we take care of above the age of 80, they get relatively more vaccine than any other specific group. So, that just shows you, by us reaching out, by us being proactive to everybody... We use my chart if they're on my chart. We activated nearly 100,000 people on my chart this January alone, to tell you how far we've come. We text message them if they've got a phone which will handle that, but if not, we call them and we offer them the vaccine. And if they don't have a ride, we give them a ride. I think that's the type of health equity that the state really wants, that the Governor has put out there, but I think you have to do it in a certain way if you're actually going to achieve that goal. So, we've been able to achieve it. I'm very proud of how the Cleveland Clinic has done it.

Will Morris, MD:

Yeah. The messaging I think has been really, really, really profound in ensuring that we have multiple channels of getting access, that it's not just electronic, a good old phone and actually leveraging other community sites like pharmacies I think is absolutely ingenious and strategic. I guess the last word for you, you wear many hats, one of which is obviously surgical operations and the other world of patients who perhaps are deferring care and avoiding going to the health system for a myriad of reasons. I'm curious, what are your observations around that and how do we ensure that patients who are nervous about achieving the care they need? I'm curious, from your colleagues in other health institutions, I'm sure that's a common refrain.

Will Morris, MD:

What do you think the state's role is to create that, that it's so important that we don't defer care for cancer screening, health maintenance, blood pressure, diabetes care, because these are also the other pandemics? How are you wrestling the messaging on, "Yes, COVID is important, new variant, vaccine is coming, but we also have this entire other piece"?

Robert Wyllie, MD:

First of all I should mention surgical operations is being run by Mark Taylor. Mark was at medical operations and now he's reporting directly to Don Malone as the president of the main hospital and the regional hospitals, and he's doing a great job doing it. But you're correct in terms of... So, the first thing we did way back in March in terms of deferring all non-emergent medical care was... And that, again, was because of PPE. And we had our peak about April 22nd, then we began to relax a little bit and let people come back in. We had another peak 90 days later, July 22nd. Both of these peaks were about 1,100. Our third peak, in terms of the number of hospitalized, was on December 15th. That was 5,300. We went from 1,100 to 5,300, and today we're sitting at about just over 2,500 as of this morning. So, well above the other two peaks.

Robert Wyllie, MD:

At first people, because we were deferring surgery, the messaging in terms of what was messaged by the governors and the various hospitals and what we were going, I think people got nervous. And then they got nervous about COVID as they saw the news, and then they thought, "Well, the hospitals might be a dangerous place." So, what we've tried to message, and Will and Akhil you're both very familiar with this, is the hospital is one of the safest places in terms of COVID exposure because everybody around in the hospitals is wearing a mask. So, because we're all masked, transmission within a hospital, it's not zero but it's very unusual. In fact, when we see it it's almost always within a break room, where people are eating and they've got their mask down. So, we have had some transmission. It's been very unusual. But in general, the hospital is significantly safer than the community.

Robert Wyllie, MD:

In fact, we were able to prove that by looking at where hospital workers got COVID. For the most part, they didn't get it at work. The vast majority, over 90%, got it in their community at the same rate as the people that they lived adjacent to wherever they live. With that, we've tried to message now, particularly since we saw decreased people coming to emergency rooms for strokes and for heart attacks, that we've tried to message them, "No, if you're sick, come in and get seen," because we can intervene early. And what we did was we saw people not only in Ohio but around the nation starting to come in late after they'd had a heart attack, significant cardiac failure, no chance for revascularization. The same thing with stroke. If you had a clot, no chance to revascularize, and they had permanent deficits. So, trying to message them, "Don't wait. For these type of symptoms particularly, come in." And the same is true for cancer and cancer follow-up in terms of screening. If you've had a bad polyp, you need to be screened. Putting it off puts you at risk.

Robert Wyllie, MD:

Certainly around the United States, and you're familiar with this, there have been excess deaths beyond that simply attributed to COVID infections. So, there's the COVID excess, and above that is people who didn't receive their normal healthcare or the emergency healthcare they needed and they stayed home. We've seen excess deaths in that category around the United States. Fortunately, it's been relatively low in Ohio, but it's not zero.

Will Morris, MD:

I think those are somber but important points to end our podcast on. Because at the end of the day, it's not just us getting through this crisis, and we will. And certainly attributed to your leadership and your team's leadership, absolutely impressive. But also the messaging that this is a continuous marathon and health inequities, health disparities in creating affordable, accessible healthcare, is continuous work that never ends.

Will Morris, MD:

So, on my behalf, Dr. Saklecha, Dr. Wyllie, thank you so much for joining Health Amplified, a Cleveland Clinic podcast.

Robert Wyllie, MD:

Well, thank you both. It was a pleasure.