The nonprofit's expanded Never Event Policy is designed to hold hospitals accountable to their patients and attain high reliability in healthcare.
Hospitals need to hold themselves accountable when errors lead to catastrophic consequences for patients, the leader of a national quality and safety organization says.
Preventable adverse events in hospitals are one of the leading causes of death in the United States, with estimates of lives lost ranging from 210,000 to 440,000 annually. Serious harm is as high as 20 times more common than fatal harm.
"This is really about the hospital industry declaring itself as accountable as any other industry in the country," Leah Binder, MA, MGA, president and CEO of The Leapfrog Group in Washington, D.C., tells HealthLeaders.
Leapfrog is promoting a nine-point Never Event Policy to help health systems and hospitals address catastrophic medical errors. The nonprofit group defines a never event as egregious mistakes such as surgery performed on the wrong patient or foreign objects left inside a patient after surgery.
The Never Event Policy includes apologizing to patients, reporting adverse events internally when they occur, performing root cause analyses, waiving costs directly related to an adverse event, and providing a hospital's adverse event policy to patients and payers upon request.
"If an airline did not adhere to a policy like this in the event of a crash, they would be out of business. No one would tolerate it," Binder says.
Never Event Policy adoption
Leapfrog recently published a survey report on adoption and adherence to the group's Never Event Policy, which was expanded from five points to nine points in 2018. The report features several key recommendations and data points:
100% of U.S. hospitals should adopt the Never Event Policy.
In 2018, 74.6% of hospitals met all nine elements of the Never Event Policy.
After the Never Events Policy was expanded to nine points, performance on the policy dropped at both rural and urban hospitals. Performance dropped more significantly at rural hospitals (9.9%) than at urban hospitals (5.1%).
Human nature is the most daunting barrier to hospital adoption of the Never Event Policy, Binder says. "As human beings, when we make mistakes, we are loath to admit it. We certainly don't want to have to apologize to someone or admit a mistake when we have made a catastrophic error."
Establishing protocols to respond to never events is essential, she says. "You need to move beyond human nature—that's why you need to have a policy. The policy must be enforced and monitored carefully by leadership because it is a critical part of running a hospital that is committed to what is best for patients."
Never Event Policy serves interests of hospitals and patients
Adoption of the Never Event Policy is good for hospitals and their patients, Binder says. "It's in the interest of hospital patients because it is the right thing to do. It treats patients with the dignity and the respect that they deserve. It's in the interest of hospitals because it has been tested; and where the nine elements have been used, they reduce overall risk for the hospital."
The Never Event Policy is based on the Communication and Optimal Resolution (CANDOR) program developed at the federal Agency for Healthcare Research and Quality. AHRQ initially tested and applied CANDOR at three health systems. "They have seen a reduction in malpractice claims. We know from literature that people who get an apology and get treated with respect are less litigious in the long run," Binder says.
When the Never Event Policy was expanded to nine points, calling on hospitals to care for medical staff was a pivotal addition, she says.
"Hospitals need to recognize how difficult and sometimes devastating never events can be to the individuals who lead to a catastrophe for a patient. It's difficult for them to move on after an error, and they need help and protocols. The protocols need to be public, so everybody who works in a hospital knows the hospital will take care of you if you make an error."
Caring for healthcare workers when never events occur sends an important message to staff members and patients that medical errors will be addressed, Binder says. "The hospital owns up to the error, stands up for its people, and does what is right."
Quest for high reliability
Leapfrog's Never Event Policy is part of a national effort to achieve the same level of high reliability in healthcare that has been achieved in other high-risk industries such as aviation, Binder says. "I expect hospitals to achieve that level of high reliability. People place their lives in the hands of healthcare providers every day, and our lives are worth the same when we walk into a hospital as when we board a plane."
The healthcare sector has completed about 20% of its high-reliability journey, she says. "We are not at the very beginning—a lot of hospitals have embarked on the journey. But we have a very long way to go. The data and statistics on errors in hospitals are extremely disturbing."
The next big step is for the healthcare sector to commit to attaining the highest possible standards for transparency, Binder says.
Boosting transparency features two components, she says:
Hospitals must hold themselves accountable to their patients.
Hospitals must fully accept the shift from fee-for-service medicine to value-based medicine. "They can embrace transparency, hold themselves accountable for results, and demand payment for results. They can sit down at the table with payers and ask for rewards when they achieve better outcomes," Binder says.
Leadership will play a decisive role in the quest for high reliability in healthcare, she says. "If hospitals can reach a new level of leadership, we would see major transformation in our healthcare system. The pathway to get there is through high reliability—it's with leaders who undertake the journey to high reliability and with leaders who are willing to hold themselves accountable."
Advice for effective quality improvement includes devoting time and resources, gauging patient experience, and taking a persistent approach.
At primary care practices, clinician-led quality improvement efforts not only boost the value of patient care but also elevate meaning in providing care, according to a recent journal article.
Primary care quality in the United States compares poorly to other industrialized countries on several measures, including timeliness of appointments when patients are sick as well as access to care on weekends and holidays. In addition, nearly half of physicians are experiencing symptoms of burnout, which can be eased through quality improvement (QI).
Quality improvement benefits primary care practices and their patients, Canadian clinicians wrote this month in the journal BMJ Quality and Safety. "Primary care professionals in North America are trained to provide excellent care to the patient in front of them. Few have been trained to measure and improve the care they provide to a population of patients. Fewer still are familiar with improvement science or QI tools."
The clinicians generated 10 tips to help guide QI efforts at primary care practices:
1. Time and resources: Enlist a dedicated cadre of clinicians and other staff members to lead QI work, including redistribution of clinical income to pay for physicians to lead the effort. Training should also be provided to QI team members.
2. Intrinsic motivation: QI efforts should capitalize on the natural desire among caregivers to improve clinical care such as clinician passion for teaching and developing expertise.
3. Patient experience: A patient experience survey can play a pivotal role in driving QI efforts. At their primary care practice, the BMJ Quality and Safety clinicians garnered a 20% response rate to the patient experience survey administered at their Toronto, Canada-based primary care practice. "Patient feedback has helped us identify and prioritize improvement opportunities," they wrote.
4. Early win: One way to promote QI success is to identify an early win. The BMJ Quality and Safety clinicians initially focused on boosting cancer screening rates for cervical, breast, and colorectal cancer.
5. Flexibility: Leaders of a successful QI effort are open to learning and adjusting course when necessary. In addition to ramping up cancer screening at the start of their QI initiative, the Toronto-based primary care practice also sought to improve influenza immunization among patients over 65, but positive results were difficult to achieve. Interventions to increase flu shots at clinics such as mass media campaigns were eventually dropped so resources could be diverted to more promising areas.
6. Persistence: Some priorities such as timely access to care require sustained commitment even if there are daunting obstacles such as resistance from some staff members.
7. Patient engagement: The Toronto QI team generated several gains based on involvement of patients in the improvement work, including increased access on evenings, weekends, and holidays. For example, patient surveys revealed the need to promote awareness about the availability of urgent care.
8. Openness to criticism and imperfection: QI teams should be transparent about their efforts and open to critiques. "Our QI leaders have tried to welcome criticism, suppress our own defensive reactions, and have made changes to how we collect, analyze or present data based on staff feedback," the clinicians wrote.
9. Ongoing improvement: Successful QI initiatives feature a strategy aimed at ongoing improvement rather than time-limited projects. "Concerted efforts to enable change may be time-limited, but the commitment to monitor and sustain improvement in a core set of performance indicators should be ongoing," the clinicians wrote.
10. Embed QI organizationally: To help ensure success, a primary care practice's leadership team should be heavily invested in QI efforts. The chief of the Toronto-based practice made sure QI was consistently included on the medical staff's meeting agenda and featured in the organization's strategic plan.
Applying quality improvement tips
Although these QI tips were developed at a Canadian-based primary care practice, they are widely applicable to practices in the United States, the lead author of the BMJ Quality and Safety article told HealthLeaders.
"All of the tips are suited to U.S. primary care. I think the payment and measurement context are different, so galvanizing intrinsic motivation and measures that are meaningful to the local practice may be more challenging," said Tara Kiran, MD, MSc, a physician in the Department of Family and Community Medicine at St. Michael's Hospital, Toronto, Canada.
Involving patients in QI efforts is crucial, she said. "This was a turning point for us. Clinicians want to improve the health and lives of our patients—we want to provide them with excellent care. Sometimes though, we aren't aware that what we are doing is not meeting patient needs. Hearing praise, concerns, and potential solutions directly from patients is helpful to motivate care teams to improve."
Opportunities and risks abound as healthcare organizations adopt new digital technologies and seek to manage disruption.
The digital future of healthcare is now.
More than 40 top executives from healthcare organizations across the country attended last week's HealthLeaders Innovation Exchange in Ojai, California, to share success stories and cautionary tales from the frontlines of digital invention and population health initiatives.
1. Clinical decision support adoption
An informal poll of Exchange participants found that 94% of the healthcare organizations present at the event were either actively using or developing computer-based clinical decision support tools.
Diana Rhyne, MHA, executive director of research and innovation at WakeMed Health & Hospitals in Raleigh, North Carolina, said clinical decision support tools are harnessing a wealth of digital data in clinical settings.
"Ultimately, all the tools, tech, and innovations we use in healthcare are embraced for their ability to impact the care we provide to our patients and families. We're in an era now where we have a tremendous amount of data: clinical data, social determinants of health data, evidence-based care guideline data, never ending data! Impactful clinical decision support tools enable clinicians to translate this data into actionable results," Rhyne said.
Clinical decision support has a wide range of applications, she said. "We see these tools across the spectrum in healthcare: from managing a patient's pain while avoiding harmful addictions, to intervening before a patient decompensates in the ICU."
2. 'Re-humanizing healthcare'
Digital technology has the potential to elevate healthcare to a higher plain, said Chris DeRienzo, MD, CMO at Palo Alto, California-based Cardinal Analytx Solutions and an adjunct professor at Stanford University.
"It's incumbent upon us as leaders to ensure our people spend as much of their professional time as possible doing work that brings them joy. And whenever I ask clinicians, 'What brings you professional joy?' the answer is inevitably 'spending time with my patients.' As a result, when we point the incredibly powerful engine of artificial intelligence and machine learning toward solutions that maximize the time clinicians spend with the patients who need them most, we not only help reduce burnout, but also simultaneously and systematically begin re-humanizing healthcare."
3. Leading disruption from the top
In managing disruption, healthcare leaders can learn a valuable lesson from Facebook's acquisition of Instagram, said Neil Carpenter, vice president of strategic planning at Array Advisors.
Facebook CEO Mark Zuckerberg orchestrated the billion-dollar acquisition of Instagram mainly to ensure that Facebook would not be disrupted by the upstart social media platform, which at the time was generating no revenue.
"Today in healthcare, a lot of the disruption has been delegated from the CEO down. In other industries, the CEO owns disruption. That's part of their bread and butter. So, Mark Zuckerberg is out there looking for the next Instagram—how to buy them, how to build them into his business model, and how to avoid becoming obsolete," Carpenter said.
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Chris DeRienzo, MD, CMO at Palo Alto, California-based Cardinal Analytx Solutions and an adjunct professor at Stanford University, makes a point at last week's HealthLeaders Innovation Exchange. (Photo: David Hartig)
Amazon Web Services is focusing on services that are not at the core of healthcare organization operations such as data centers.
The biggest impact that Seattle-based Amazon Web Services makes in healthcare may receive little notice.
AWS is a separate business inside Amazon that focuses on cloud computing. AWS has more than 165 featured services including Amazon Comprehend Medical that are used by healthcare companies.
At this week's HealthLeaders Innovation Exchange, a top AWS executive said the company is primarily focused on providing services to healthcare organizations in areas outside of their core operations.
"For many healthcare organizations, you are doing things that you probably shouldn't be doing that do not help to differentiate you in the market. If you are running a data center in healthcare, a data center is probably not a core part of your business. AWS can do the undifferentiated heavy-lifting in healthcare so our customers can focus on differentiators," said Shez Partovi, MD, senior leader of global business development for healthcare, life sciences, and genomics at AWS.
Partovi gave three examples of operational areas in healthcare where AWS has supported customers:
1. Access: AWS has developed machine learning services that help its customers remove the "friction" in making a medical appointment online. For example, Zocdoc uses Amazon Rekognition to simplify insurance eligibility verification. Patients can hold up an insurance card to an iPhone, which determines health plan coverage and matches the patient to appropriate clinicians.
2. Patient activation: AWS has services that allow companies to stream IoT data on the cloud. For example, digital health companies are using services to help remotely monitor patients with asthma. Every time a patient presses the button on the inhaler, it sends a signal to the cloud.
The technology has three primary benefits: helping to boost medication adherence, alerting clinicians when patients are using their rescue inhaler at an increasing frequency and are at risk of hospital admission, and providing the capability to build personal prediction models for patients. If a patient consents to it, the prediction model is built based on GPS location, with includes features such as air pollution index and temperature that can be used to predict asthma-attack risk.
3. Automation: AWS is working with customers to develop predictive analytics to forecast medical-related events. For example, Beth Israel Deaconess Medical Center is using AWS machine learning services to develop technology that can predict operating room cancellations and no-show rates at medical clinics.
Making a splash
While most of AWS' healthcare team is focused on undifferentiated services, the company also is resolving vexing problems, Partovi said. "About 90% to 95% of what we build is driven by what customers tell us matters. The other 5% to 10% of the time, we invent solutions on our customers' behalf."
For example, a cancer research center approached AWS with a challenge—finding a way to quickly read through patient charts to see who was eligible to participate in clinical trials.
"AWS invented on their behalf," Partovi said.
"We created a service called Amazon Comprehend Medical . It's like when you would read a book in high school and highlight key words. Amazon Comprehend Medical can read medical notes and extract key concepts, entities, and relationships, and it is HIPAA compliant. This means that it can quickly identify protected health information (PHI), such as name, age, and medical record number, and can be used to create applications that securely process, maintain, and transmit PHI. So, it can help providers better determine whether you have a condition, or whether you are taking a medication at a particular dosage, or some other key information. It generates discrete data that can be matched to inclusion or exclusion criteria."
Amazon Comprehend Medical also generated front-page media coverage, he said. "That was a groundbreaking machine learning service. But we didn't do it to be splashy. We did it because a customer came to us and needed to solve a problem."
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
Photo credit: Pictured above: Shez Partovi, MD, senior leader of global business development for healthcare, life sciences, and genomics at AWS. (Photo: David Hartig)
Compared to other Western democracies, Americans pay significantly more for medical services without garnering higher quality.
Several factors are contributing to the low value of services in U.S. healthcare, with high pricing among the strongest drivers, a Harvard Medical School professor says.
Americans spend significantly more on healthcare services than other industrialized countries—healthcare spending in most Organization for Economic Co-operation and Development nations ranges from 10% to 11% of gross domestic product, but U.S. spending is about 18% of GDP and rising. Despite spending more on healthcare than its peers, the United States is lagging in many health-related measures, including life expectancy and risk of death among infants and children.
In the recently published first installment of a series of articles on the broken economics of U.S. medicine, Edward Hoffer, MD, an associate professor of medicine at Harvard Medical School in Boston, says American patients are getting an awful deal on their healthcare.
"The one area in which the United States does lead the world is in healthcare causing enormous financial hardship to many of its citizens. Unlike in most developed countries, where adequate healthcare for all is routinely available and rarely causes financial hardship, medical debt is a huge problem in the United States," Hoffer wrote in the American Journal of Medicine.
The series of articles Hoffer is publishing in the American Journal of Medicine is based largely on his 2018 book, "Prescription for Bankruptcy."
'It's the prices, stupid'
Pricing for U.S. healthcare services is the largest contributing factor to the country's high medical costs, Hoffer recently told HealthLeaders.
"As the late Princeton economist Uwe Reinhardt put it so well, 'It's the prices, stupid.' We in the United States see doctors less often and spend fewer days in the hospital, yet we spend about twice per capita as do the citizens of peer Western democracies," he said.
Payers account for a major portion of the pricing problem, Hoffer said. "It is estimated that about 25% of U.S. healthcare spending goes to administrative overhead, both directly to the insurers and on the costs of billing, pre-authorization, and other expenses to the providers."
But he said there are "ample villains to go around," including physicians and hospitals:
Physicians: The high cost of medical school and crushing debt leads physicians to try to maximize their revenues. Malpractice insurance costs are much higher in the United States than anywhere else, and defensive medicine adds to costs. The country has too many specialists and not enough primary care physicians. The fee-for-service payment system encourages doing rather than thinking, and it adds to low-value care utilization.
Hospitals: There is grossly excessive administrative personnel. In many cases, the prestige of large hospitals or health systems allows them to essentially charge whatever they want—they know insurers need them in-network. Hospitals are increasingly employing physicians, which increases overhead and boosts charges for the same service. Many high-tech services are needlessly duplicated in the same geographic area because each hospital wants to be viewed as full-service. There is no incentive to drop prices even when costs go down.
Prescription to heal healthcare's broken pricing of services
Three strategies would help address the high pricing of U.S. medical services, Hoffer said:
1. Site neutral payment: "If a private cardiology group can make a living charging about $800 for an echocardiogram, why should a hospital get paid $1,500?"
2. Bundled payments: "Most surgical procedures should be paid on a bundled basis, and patients should be directed to the hospitals and doctors who provide quality results at low cost."
3. Transparency: "Insist that true informed consent, using proven teaching aids, be used before any elective procedure."
A worsening shortage of palliative care physicians is predicted over the next 14 years. One healthcare leader suggests ways to address the crisis.
A research article recently published in Health Affairs warns of a looming "workforce valley" in the palliative care field. Unless new policies are adopted, a surge of retirements combined with early departures from the field linked to burnout will result in a steady decline of palliative care physicians over the next 14 years, the Health Affairs researchers found.
Diane Meier, MD, director of the Center to Advance Palliative Care (CAPC) at the Icahn School of Medicine at Mount Sinai in New York City, says, "We know palliative care works. We have a massive increase of Americans who are going to need palliative care. And we don't have a workforce pipeline that will make that care accessible to those who are in need."
She says there is a pressing need to bolster the ranks of palliative care professionals, and that innovative policy changes are needed to address the shortage in the palliative care workforce.
Following is a lightly edited transcript of HealthLeaders' conversation with Meier about what she thinks is needed to address the shortage.
HealthLeaders: Why is the predicted palliative care workforce shortage a concern for health systems, hospitals, and physician practices?
Meier: The first and most obvious reason is the rapid growth in the population living with serious and complex illness, particularly as 10,000 baby boomers are turning 65 every day. We are going to see a huge increase in the number of older adults living with not just one chronic illness but multiple chronic illnesses. Those illnesses are associated with substantial burdens—physical symptom burden, emotional burden, and financial burden on patients and their families. There's also social burden—patients might say, "If I can't afford food, I'm not going to be able to do what my doctor tells me to do to be healthy."
Multiple studies have shown palliative care markedly improves quality of life, increases quality of care, and reduces crises. Palliative care reduces patient need to call 911 or go to the ER.
HL: What are the most urgent issues raised in the recent Health Affairs article about the palliative care workforce shortage?
Meier: There are two pressing issues. The first is burnout.
Just as with other specialties, the overwork, the overextension, and the typical 12-to-14-hour day that people work in palliative care is not sustainable. It's not just the physical labor of taking care of patients over many hours—it's the emotional labor of taking care of patients and their families who are going through the most difficult experiences of their lives.
There is failure to recognize that we need to give clinicians enough time to recover between days at work. Right now, they don't have that recovery time.
The level of need and suffering in the patient population could fairly be said to be infinite, but the workforce capacity is not infinite. We must be careful to protect this scarce and precious resource.
The second issue is that palliative care is a team sport—it's not just physicians. It's physicians with a team of nurses, nurse practitioners, physician assistants, social workers, chaplains, and, often, many others such as physical and occupational therapists. In every discipline, the same challenges exist. There is not an adequate workforce—there are jobs that go unfilled because we can't find people to recruit. Many palliative care professionals are working in programs that are understaffed and totally overextended. So, I'm worried about the sustainability and retention of the existing workforce.
HL: CAPC recently received a $2 million grant from the Hartford Foundation. How is that grant going to help address the palliative care workforce shortage?
Meier: Several years ago, we looked at what it would take to meet the palliative care needs of an enlarging population of older adults with serious and complex illness. It became clear very quickly that there would never be enough trained palliative care specialists—either doctors or nurses—to meet the need. Even if we multiplied by 10 the current training pipeline, we would still fall far short of an adequate workforce.
We decided the only rational solution was to do a better job of training the frontline clinicians already taking care of these patients. We built a comprehensive online training curriculum, which is not aimed at palliative care specialists. It is aimed at all clinicians—oncologists, nursing home nurses, social workers, doctors, and other professionals who take care of people with serious illness.
There are now about 46 separate courses. Each one is linked to continuing medical education credit for physicians and continuing education units for nurses, social workers, case managers, and licensed professional counselors. We have given out upward of 300,000 continuing education credits since 2015.
The Hartford Foundation grant is helping to fund course administration as well as marketing and communications. For example, the foundation is supporting the John A. Hartford Foundation Tipping Point Challenge. The challenge is an attempt to get palliative care training for at least 20% of the clinicians in every major health system. The research on reaching tipping points suggests that once 20% of a population has been influenced, their activities start to influence everybody else in their field.
HL: Beyond the online courses, what are the primary strategies to address the palliative care workforce shortage?
Meier: There are multiple levers that need to be pushed to solve this problem.
It starts with undergraduate and graduate medical and nursing education—changing the requirements that medical and nursing schools must meet to retain their accreditation. Right now, a newly minted physician or nurse can graduate from school without having any palliative care training.
A second approach would require policy change—increasing the funding for graduate medical education and specialty training in palliative care. Right now, many professionals pursuing advanced training in palliative care receive funding from either philanthropy, grants, or operational dollars from the health system in which they work. That is not a sustainable model for training the workforce of the future.
The third issue is changing how health insurance plans decide who is eligible to be in their network—hospitals as well as physicians and nurse practitioners. If health insurance plans required hospitals and clinicians in-network to demonstrate completion of palliative care training, our problem would be solved. If health insurance plans required hospitals to have specialty-level palliative care teams to remain in-network, then every hospital would have a palliative care team.
Lastly, hospitals can't get paid by Medicare unless they are accredited, either by The Joint Commission or other accrediting bodies. Right now, those accrediting bodies do not require the presence of a high-quality palliative care service as a condition of accreditation. We would like to see that changed.
As the telemedicine market expands, an increasing number of physicians are seeking telemedicine employment.
A new survey shows several of the primary characteristics of physicians who are interested in pursuing telemedicine opportunities.
Telemedicine is one of the most significant growth areas in healthcare around the world. Last year, the value of the global telemedicine market was estimated at more than $38 billion, and the market is expected to be valued at $130 billion by 2025.
The lead author of a new survey published this week by San Francisco-based Doximity says the data sheds light on the kinds of physicians who are interested in practicing telemedicine.
"The main takeaway is there has been a focus on the patient side of telemedicine and not much on the other side of the screen. So, it's interesting in our survey to see there is variation in the types of doctors who are engaged with telemedicine, and as more patients turn to telemedicine there are more telemedicine opportunities for doctors," Christopher Whaley, PhD, an assistant adjunct professor at University of California-Berkeley's School of Public Health, told HealthLeaders.
Survey findings
The Doximity survey is based on data gathered from about 22,000 physicians who expressed interest in telemedicine job postings. The survey generated six key findings:
1. Job growth: From 2015 to 2018, the number of physicians reporting telemedicine as a skill doubled. "There has been steady growth every year. There is no reason to think that this trend will not continue to increase," Whaley told HealthLeaders.
2. Age distribution: The age of physicians interested in pursuing telemedicine was evenly distributed. Physicians aged 31 to 40 showed the highest level of interest at 28.4% of the total; but older physicians showed comparable interest, accounting for 23.5% of the total.
"We could have more young doctors interested in telemedicine because they are more tech savvy; at the same time, young doctors who are just starting out could have less employment flexibility. Older doctors who are more established could have more flexibility to do telemedicine," Whaley said.
3. Job status: About three-quarters of physicians who showed interest in telemedicine opportunities were working full-time in private practice or at larger healthcare organizations.
4. Gender: Compared to their male counterparts, female physicians were 10% more interested in pursuing telemedicine opportunities.
5. Geography: Physicians living in highly populated metropolitan areas showed the highest interest in telemedicine jobs.
"From our other work, we have found that doctors tend to concentrate in large metropolitan areas. In fact, the lowest compensation is often in the largest cities because there is an over-supply of doctors. At the same time, we know many rural areas have trouble finding doctors to practice in their communities. So, potentially, we could be seeing doctors living in a city like San Diego but practicing in more rural markets through telemedicine," Whaley said.
6. Specialty trends: The Top 5 physician specialties showing interest in telemedicine opportunities were radiology, psychiatry, internal medicine, neurology, and family medicine. The Bottom 5 specialties showing interest in telemedicine were anesthesiology, general surgery, orthopedic surgery, obstetrics/gynecology, and oncology.
"It is intuitive when you think about it. If you are having a telemedicine appointment, it is by nature done remotely. So, the physicians who are most interested in telemedicine are those whose training and specialty allows them to provide care remotely. Radiologists can read an MRI remotely and discuss the findings remotely," Whaley said.
New research shows an increasing number of hospitals are relying on pharmacists to monitor drug therapy and prevent opioid abuse.
More hospitals are routinely assigning pharmacists to conduct drug therapy management, according to a recent national survey.
The survey, which was conducted by the American Society of Health-System Pharmacists (ASHP), focused on medication management activities, which have a major impact on patient safety and clinical care such as medication monitoring, reporting and monitoring of adverse drug events, and patient counseling.
"Pharmacists continue to improve drug therapy monitoring for patients in U.S. hospitals. They are also responding to public health issues related to medication use. These advancements include taking an active role in opioid stewardship programs," the survey report says.
The 2018 survey, which features responses from pharmacy directors at more than 800 hospitals, generated several key data points:
The percentage of hospitals that have pharmacists monitoring at least 75% of patients has increased from 20.3% in 2000 to 60.9% in 2018.
Pharmacists monitored all patients at 33.0% of hospitals in 2018.
Abnormal laboratory results that prompted dosage adjustments were the most common factor spurring patient monitoring by pharmacists (80.0% of hospitals).
Other factors that led to pharmacist monitoring of patients included formalized lists that required patient monitoring (74.8% of hospitals), disease state (54.1%), surgical services (51.1%), patients taking medications that were in shortage (40.1%), and high-cost medications (38.1%).
There was an active opioid stewardship program at 40.9% of hospitals.
At 97.4% of hospitals with an opioid stewardship program, pharmacists played an active role in the programs such as prescribing support.
A co-author of the survey report told HealthLeaders that pharmacists are playing a crucial role in medication management in the hospital setting. "Pharmacists are increasingly managing medication therapy, including selecting appropriate drug therapies, monitoring patients and assessing outcomes, and educating patients and other providers," said Michael Ganio, PharmD, MS, director of pharmacy practice and quality at ASHP.
Hospital pharmacists helping to tackle opioid abuse epidemic
Hospital pharmacists have helped manage antibiotics stewardship programs for years, and they are increasingly being called upon to help manage opioid stewardship programs, Ganio said. "This survey shows that pharmacists are also being looked to as leaders in addressing the opioid crisis by implementing similar stewardship programs designed to ensure the appropriate use of opioids and to prevent and detect opioid diversion."
Hospital pharmacists are uniquely qualified to curb opioid diversion, he said. "Through diversion prevention and detection programs, pharmacists can ensure the supply of opioids are used appropriately and prevent misuse through diversion."
Opioid stewardship programs benefit from hospital-pharmacist leadership, Ganio said. "Pharmacists are the medication experts and can ensure that opioid use in hospitals is optimal, safe, and effective. By engaging the interprofessional team, pharmacists can educate providers and establish guidelines for opioid use. Pharmacists can also use data from prescription drug monitoring databases to track prescribing practices and patient behaviors that can lead to abuse."
When there are disagreements about ICU care, methods to achieve resolution include communicating prognosis and offering treatment options.
For patients in intensive care units (ICUs), there is disagreement between clinicians and patients and their surrogates in about one-third of cases, recent research indicates.
Among patients and their surrogates, perceptions of inappropriate treatment are linked with lower satisfaction and decreased trust in the care team, the research found. For ICU clinicians and nurses, earlier research found delivery of treatment that caregivers perceived as inappropriate increased the likelihood of burnout.
Examining disagreements between clinicians and patients and their surrogates is crucial to addressing the decision-making challenge, researchers wrote last month in the journal CHEST. "It is important to understand the nature of perceived inappropriate treatment in order to be able to implement measures to ameliorate disagreements about treatment intensity in critically ill patients."
The recent research—which is based on surveys of more than 1,300 patients, surrogates, physicians, and nurses—features several key findings:
For 26% of ICU patients, there was disagreement between clinicians and patients and surrogates over provision of too much care
For 10% of ICU patients, there was disagreement between clinicians and patients and surrogates over provision of too little care
For 55% of patients and surrogates, a perception of inappropriate treatment was associated with moderate or high distress
For 35% of clinicians and nurses, a perception of inappropriate treatment was associated with moderate or high distress
The study data also indicated that some of the discordant perceptions about the appropriateness of care were based on prognostic factors, the researchers wrote. "Since patients and surrogates are often unaware that their prognostic estimates differ from those of physicians, these findings highlight the importance of improving prognostic communication and understanding."
Bridging the perception gap
While some level of disagreement over ICU care is unavoidable, the magnitude of disagreement found in the recent research can be reduced, the lead author of the study told HealthLeaders.
"For there to be more agreement about whether a trial of life support is the right thing to do for a particular patient, we need to help families accurately understand the available treatment pathways and their outcomes. And we need to help physicians be able to accurately understand the values and preferences of the patients," said Michael Wilson, MD, a critical care specialist in the Department of Pulmonary Medicine at Mayo Clinic in Rochester, Minnesota.
There are two primary steps to improve prognostic communication and understanding, he said.
"The first way to improve communication of prognosis is to actually do it. A majority of patients and families desire prognostic information; but for a significant proportion of patients, doctors don't discuss prognosis."
Second, uncertainty regarding prognostic information should be acknowledged, Wilson said.
"In large studies, doctors are no better than a coin toss at predicting whether or not patients will survive and leave the hospital. In addition, there is high variability in physician predictions—two doctors with the exact same patient and circumstances may come up with vastly different conclusions about whether the patient will survive and what their life will be like if they do survive. When I talk about prognosis with families, I talk about the best case scenario, the worst case scenario, and the most likely scenario. This is a way that acknowledges a range of possible outcomes, but still allows me to give my professional opinion about what I think will happen."
Reaching agreement
There are four ways to improve collaborative decision making between clinicians and patients and their surrogates, Wilson said.
More effort should be devoted to preparing families before they have decision-making conversations with their medical teams.
Clinicians should clearly distinguish decision pathways and present those options to patients and their surrogates. Options focused solely on comfort should be discussed.
Clinicians should make a recommendation about what treatment pathway is best for the patient. This recommendation should be based on the clinician's understanding of both the medical facts as well as the clinician's understanding of who the patient is as a human being—his or her values, preferences, quality of life, and goals. "We cannot abandon patients and families to make these decisions alone," he said.
Decision making should be tailored to the individual patient, family, and situation. Some families want every detail. Other families only want the big picture. Some families want to participate in decision making. Other families want to follow the physician's lead. Sometimes, families are so completely exhausted and stressed that they do not know what to do, and they just need more time and space.
A new computer-based decision support tool for sepsis at HCA Healthcare harnesses pivotal data in real time.
HCA Healthcare has developed an effective computer-based decision support tool for the early detection of sepsis.
Sepsis and the body's response to the infection is one of the deadliest medical syndromes in the United States, according to the Centers for Disease Control and Prevention. About 1.7 million adult Americans develop sepsis annually and the condition claims approximately 270,000 lives each year. About one-third of patients who die in hospitals succumb to sepsis.
The computer-based decision support tool is called Sepsis Prediction and Optimization of Therapy (SPOT), and it can detect sepsis 18 hours earlier than the best clinicians, says Jonathan Perlin, MD, PhD, president of clinical services and CMO at the Nashville-based health system.
"This is the future. Military fighter planes can't fly without decision support. Healthcare is equally complex. To think that we can manage all the variables without assistive technology is inconsistent with how we think about high-reliability endeavors like aviation and healthcare," he says.
HCA started adopting elements of the Surviving Sepsis Campaign in 2013. From 2013 to 2017, sepsis mortality at HCA's hospitals fell 39%.
The health system launched the SPOT initiative in 2018. From 2017 to 2018, sepsis mortality at HCA's hospitals dropped nearly 23%. "SPOT doubled our effectiveness in surviving sepsis," Perlin says.
The health system estimates that the combined effort of adopting the Surviving Sepsis Campaign and SPOT has saved about 7,800 lives.
How SPOT works
SPOT features an algorithm embedded in HCA's electronic health record that was built with Red Hat open source software. To indicate the onset of sepsis, the SPOT algorithm combines factors such as patient demographics data and medical history with continuous monitoring for signs and symptoms of sepsis as well as key elements of clinical care:
Body temperature
Blood pressure
Heart rate
Platelet count
Medications
Laboratory tests
Patient transfers such as moves to an ICU
"The SPOT algorithm surveils 24 hours a day, seven days a week to look for the signs and symptoms of sepsis. When those signs are found, they are teed up and presented to the caregivers," Perlin says.
When the algorithm detects a likely case of sepsis, SPOT initiates an alert similar to a heart attack or stroke code that prompts clinical care teams to take action. Caregivers who receive the alerts include telemetry units, nurse leaders, sepsis code teams, and rapid response teams.
An essential component of the SPOT initiative is the algorithm's diagnostic accuracy, Perlin says.
"We were able to train the algorithm to be more than 100% sensitive—we picked up cases of sepsis that the care providers did not see, and our rate of false positives was half that of care providers. So, the specificity was twice as good as clinicians. It not only improved care but also the efficiency of doctors and nurses," he says.
He continues: "On their own, clinicians can look piecemeal for sepsis signs and symptoms; but the computer can constantly look for those signs and symptoms, and when the computer has a hit, that information is immediately given to the caregivers at the bedside. That signal is not just an alert but also a representation of the sepsis criteria, so there is credibility and explainable data."
How the SPOT algorithm was developed and implemented
Three primary steps led to the development and implementation of SPOT.
1. Robust EHR and data management capabilities: The foundational step that made SPOT possible was the adoption of meaningful use and a data warehouse at HCA a decade ago, Perlin says.
"The past 10 years of building from meaningful use to become a learning health system created the platform for doing things like SPOT. We realized that we would have tremendous power through the data warehouse to learn at scale. Part of the rationale for the data warehouse was to be able to have a resource to be able to train computer algorithms through machine learning and other applications for artificial intelligence to support clinical workflow more effectively."
2. Pilot phase: Before SPOT could be implemented at more than 160 HCA hospitals, the algorithm had to be tested and proven effective, he says. "The computer algorithm was developed through our data warehouse. We piloted the algorithm at a couple of our facilities to test it against clinicians. At a certain point, the algorithm started to outperform the clinicians, and we began to implement SPOT."
3. Clinician engagement: During the launch of SPOT at HCA hospitals, the decision support tool was presented as a way to put critically important information into the hands of clinicians, Perlin says. "To gain acceptance at the bedside, we didn't just say, 'The computer sees sepsis, start treating it.' We said, 'This is what the computer sees; do you agree?' "
The SPOT algorithm's accuracy was vital to the clinician engagement effort, he says. "In addition to being able to show the clinicians what the computer saw, the fact that there were not burdensome false positives was incredibly important. We didn't waste people's time. There have been other sepsis algorithms at other institutions, but some of them have been turned off because there were so many false positives."
EHR payoff
An exciting benefit of the SPOT initiative is harnessing HCA's electronic health record and data warehouse to improve clinical care, Perlin says.
"All of us hear about the burdens of electronic health records, but without electronic health records we couldn't have done SPOT. We think this is one of the ways we can drive excellent care at scale. It's the payback for the challenge of using electronic health records. It's been received with a great deal of enthusiasm from clinicians because the caregivers at the bedside see this in real time saving lives," he says.
SPOT represents a significant step forward in the nationwide effort to develop computer-based decision support tools in healthcare, he says. "This is an extraordinarily exciting time to be in healthcare and at HCA because we can cast data at scale. Our data warehouse and computer algorithms like SPOT are bringing us closer than ever to our mission, which is a commitment to the care and improvement of human life."