How a 2017 snowstorm prepared an Oregon hospital system for the COVID-19 pandemic

When the growing pandemic and expected work-from-home orders became apparent by March 1, the health system put the lessons learned from that snowstorm into place.

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When a highly unusual 11.8-inch snowfall brought Portland, Ore., to a halt in January 2017, the seven hospitals and 13,000 employees of the Legacy Health systems hospitals and clinics were clobbered. About 4,000 administrative and clinical staff members couldn't get to work due to clogged roadways and a stalled public transportation network caused by the historically atypical storm.

For the officials in charge of the health system's seven area hospitals around metropolitan Portland, it was a mess. But in hindsight, it might have been a blessing because the lessons learned from that mammoth storm are today helping the health system cope with the latest and more dangerous disaster affecting everyone–the COVID-19 pandemic.

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At the time of the 2017 snowstorm, the hospital system, which has 3,000 physicians and serves about 1 million patients each year, quickly learned it was not ready to deal with 4,000 employees being unable to get to work simultaneously. Only 500 administrative managers and staff members had hospital-issued laptops so they could work remotely, which meant the other 3,500 administrative employees were stuck at home with no way to do their needed tasks. Even those numbers didn't tell the whole story, though, as IT officials soon learned that many of the 500 employees who had laptops couldn't log in due to limited access permissions.

"The city just shut down, and so did our technology," said John Kenagy, Legacy Health's CIO. "Effectively, all our clinics and administrative buildings were closed. Big snowstorms are unusual for Portland," and the city doesn't have the equipment needed to properly plow a heavy snowfall, he said.

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"The storm showed us how unscalable our remote access technology was," and taught that those problems needed to be fixed to prepare them for the future, Kenagy said.

Little did he know at the time that all those coming improvements would seamlessly help the hospital system deal with the coronavirus pandemic of 2020. But that's just what has been happening.

The paralyzing snow storm struck over two days, Jan. 10-11, 2017. On Jan. 12, a leadership team of about 10 workers on the system's IT staff gathered and began brainstorming to create a plan to prevent such a disruption in the future.

They began by listing the technology problems that arose in the previous 48 hours so they could determine what needed to be fixed. That included a Citrix deployment, which delivers medical records via Epic software to hospital workers. The software somehow didn't include remote access to all the administrative workers who needed it. The Citrix deployment also didn't allow enough simultaneous users on its VPN system, which limited many laptop-equipped workers from logging on. 

At the same time, though the hospital system had begun a rollout of Microsoft Office 365 and shared storage drives for workers, not everyone who needed them had those cloud-based capabilities yet. And for doctors who wanted to conduct remote video conferencing appointments with patients at the height of the snowstorm, there was no way to share video sessions that were HIPAA compliant and secure. Even the hospital system's billing system workers could not do their jobs remotely, which was a shortcoming. The inclusion of more cloud-based tools for administrative applications and users was on the to-do list.
 
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"It was all poised to be there, but it was not there at that time," Kenagy said of the shortcomings.

Jeff Olson, the health system's director of technology, said that until that snowfall, it had never really been an issue.

"We didn't have the demand previous to the storm" for work-from-home technologies, Olson said. "It was so unprecedented, so we didn't invest a lot of money to do it at that point."

After the snowstorm, as employees returned to work in the days that followed, many lamented the issues they discovered as they realized they couldn't perform their work remotely. In response, the IT team's strategy was to resolve the problems and limitations one by one.

"We wanted to build an infrastructure that for all intents and purposes was infinitely expandable and scalable," Kenagy said. "IT people hate when technology is blamed, and there was just this general feeling that we can never let that happen again. We knew that our technology was scalable and available, and that all this was on our road map. We just needed to speed up our road map."

To accomplish the expanded mission, another 1,500 laptops were acquired that would bring the total of laptop users to about 2,000 for managers and other critical users, while work began in earnest to boost Citrix capacity and Office 365 deployments to all the users who needed them. When Kenagy started his job in 2012, only about 100 administrative managers had hospital-issued laptops. By 2017, he and his team increased that number to the 500 that were being used when the snowstorm struck. "We were very conservative about laptops, not only their costs but that they might be stolen," which would be a threat to patient data security.

In addition, a valuable new web-based employee portal was created in 2018 for workers who didn't have hospital-issued laptops but needed the ability to work from home when needed. Built using Citrix, the MyPortal platform also includes needed multifactor authentication and regulatory compliance components to ensure patient privacy and safety. MyPortal is a customized virtual environment using Citrix where employees can view their workspace securely and remotely on their own home computers or laptops.

"Everybody has access to it if they have access to Epic medical records," Olson said. "Employees can sign in and do their work based on permissions needed for their jobs."

The Office 365 rollout started in April 2017 in the last fiscal budget quarter after the snowstorm, and was completed two years later as money was made available. By the end of 2017, the IT team had completed much of the fundamental work needed to expand the IT system's scalability and redundancy, followed by another year of completing needed datacenter and Azure expansions and tasks.
 
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But as the pandemic developed, the hospital system's IT transformation was accelerated to get the last few pieces completed before all hell broke loose.

"What happened with COVID-19 is that things that were 95% done got to 100% completed in a week," Kenagy said. That included finalizing virtual doctor's visit capabilities and finishing what had been a pilot deployment of the Microsoft Teams collaboration application.

"If this virus had hit three years ago, we as an organization would have been in a world of hurt," he said. "We would not have been ready" to ensure continuity of care, video conferencing for doctor's visits, providing access to email and other administrative tasks for workers, nor to adequately continue the organization's mission and operations.

On March 1, the call came in from the hospital system's emergency command center officials to let the IT team know that the command center was now in operation in preparation for system-wide steps to battle the pandemic. IT officials were told that they should immediately begin preparing to implement work from home capabilities for employees.

At that moment, all the IT team's projects had been completed and were ready, except one. Just before the COVID-19 pandemic struck, members of the IT staff were in the midst of a pilot project in mid-December 2019 that gave them access to Microsoft Teams collaboration tools. Teams was being tested out in the pilot before further users would be brought on. By the end of January, some 500 users were piloting Teams. By March 13, the Teams rollout was deployed remotely to the laptops of about 500 additional managers and administrative leaders who are coordinating the health system's COVID-19 response and recovery initiatives.

At first, the Teams use rate by employees was "mediocre to OK," Kenagy said, but it's now "impressive" after work-from-home orders were issued by Oregon's governor on March 23. After the work-from-home order, employees could now stay in touch and collaborate on needed tasks using Teams, which was a far cry from the days of the 2017 snowstorm.

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At the last minute, as workers were heading home to work, the IT staff realized that about 100 billing workers didn't have computers at home. For those employees, IT desktop support workers literally helped billing employees put their work desktop computers into their personal cars so they could take them home. The IT support staffers also explained how to set up the machines in their homes to get them up and running.

The final big task to ensure everything was ready for people working from home was the creation of a new help desk telephone line, where home-bound workers who were having technical questions or problems could call in to get support. The new telework support line was staffed by IT workers who were "deputized" and brought in to help out, Kenagy said.

From an IT perspective, this time the team knew it was ready to better handle a crisis, he said. Affected employees who have been working from home over the last few weeks have been appreciative of how the upgraded technology systems are now helping them do their jobs remotely, he said.

"It's been beautiful, an outpouring of thanks, that they were able to transfer to remote work without skipping a beat," Kenagy said. "None of those people remember yelling at us or how we felt bad at the time of the 2017 snowstorm. But we do," and that provided some motivation in making things work well today.

Some 9,500 doctors, nurses, housekeepers and other essential workers are now running the health system's hospitals in three shifts a day.

In all of 2019, doctors conducted 51 virtual visits with patients.

Since March 16 as the pandemic expanded, Legacy Health doctors have conducted 4,738 virtual visits with patients. On one day alone in March, 600 virtual visits were conducted.

The shift to working from home during the pandemic has so far been successful and will likely forever change the way the hospital system's employees do their jobs because working from home has now been technologically enabled for Legacy Health workers, Kenagy said.

"I think it's been a success such that we're likely not to go back to the old normal," he said. "We will have fundamentally changed the way we do work from now on. I think people will maybe come to work two or three days and then work from home the other two or three days."

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