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PSQH: Patient Safety & Quality Healthcare, September 11, 2020
Via existing standards for developing and selecting individual measures, NQF collaborated to establish a method of assessing how measures can best work together.
This article was originally published September 10, 2020 on PSQH by John Palmer
With value-based healthcare models becoming more popular, it’s more important than ever for healthcare organizations to be able to measure the care they provide.
Measurements help serve many purposes, including quality improvement, pay for performance, accreditation, and public reporting.
Yet, for some reason, organizations still lack an overarching process for assessing how individual quality measures work together.
That’s about to change, thanks to a recent report from the Washington, D.C.–based patient safety advocate group National Quality Forum (NQF).
“This is how we drive the next generation of quality improvement,” said Shantanu Agrawal, MD, MPhil, NQF’s president and CEO. “If we want to empower patients and other healthcare users to make informed decisions, measure sets and measurement systems must ensure valid assessments of quality and reliable results. This report draws on our collective expertise to define the components of sets and systems that must be transparent and also proposes standardized approaches to assess their design. With clarity on evaluation and impact, we can work together to improve the quality of healthcare for all.”
Using feedback from patients, patient advocates, purchasers, public and private payers, clinicians, provider groups, measure developers and implementers, statisticians, and health services researchers, the group looked at how standard measures used in healthcare assessment can be combined in a system to improve health outcomes and drive high-value care.
Via existing standards for developing and selecting individual measures, NQF collaborated to establish a method of assessing how measures can best work together.
“Measure sets and measurement systems can improve patient safety by working together, providing more accurate measures, assessing multiple components, and painting a more complete picture of quality,” said Agrawal. “This is how we drive the next generation of quality improvement.”
The NQF effort tasked a panel of 25 diverse healthcare experts with the goal of ensuring that measure sets and measurement systems produce accurate and measurable impact.
The group’s July 2020 report, entitled Measure Sets and Measurement Systems: Multistakeholder Guidance for Design and Evaluation, builds upon the tradition of taking on emerging national health needs that demand comprehensive approaches across sectors.
Many of the measure reporting requirements are based on federal programs, private health insurance providers, and accreditation entities, said Agrawal. Examples of a measure set and how it would be utilized in a typical healthcare setting or environment include the following:
The Medicaid Core Sets are measure sets reported at the state level.
HEDIS® measures are a set of measures reported by health plans that determine accreditation, compare health plan performance, and serve as a performance improvement tool.
The CQMC core sets were developed through a public-private partnership to align measures, using a multistakeholder process across payers in their value-based contracts.
Several regional collaboratives and states have also created measure sets in an effort to track and drive progress toward specific goals and/or to be used in payment and service delivery models.
Composite measures can also be thought of as measure sets, Agrawal said. For example, PSI-90 is considered a measure set as it combines multiple preventable hospital-related events associated with harmful outcomes and is used in several public reporting and pay-for-performance initiatives to compare hospital performance. It can assist hospitals in assessing, tracking, and improving the safety of inpatient care.
“There exists an opportunity in the healthcare quality measurement field for greater access to comprehensive, actionable, and scientifically sound data to compare healthcare quality,” according to the report.
“Understanding the importance of the relationship between observed performance outcomes and the design of measurement systems is essential to the evolution of healthcare quality measurement and value-based models.”
According to Agrawal, agreement on the terminology and differentiating factors between sets and systems required a lot of discussion by the expert panel. Even though the use of measure sets is increasing and measurement systems play prominent roles in the healthcare industry, there were not agreed-upon definitions for these concepts.
“This work can help the quality field unite around a common understanding, which is crucial to advancing set and system design and evaluation,” Agrawal said.
Another interesting point was that even though stakeholders generally agreed that cohesive measure sets (e.g., sets implemented as a whole) are desirable, most measure sets are apparently not treated this way.
“Quite often, providers or those establishing value-based models select which measures from the set they would prefer to use, which can lead to a lack of alignment and less ability to understand performance more broadly or to establish benchmarks,” noted Agrawal. “We have a lot of opportunity for greater alignment in the design of sets and systems and the measures that are used within them. We look forward to advancing the transparency, actionability, and stakeholder understanding of sets and systems as we continue this work.”
The proposed methodology builds on the use of individual measures to assess quality, safety, and person-centered care; emphasizes goals at the outset; ensures the set and system is sound and aligned; and engages diverse stakeholders in the discussion to make sure that measurement systems provide accurate data about quality of care.
NQF intends to field test the approaches with developers and stakeholders to ensure that the guidance can be used to design valid assessments and produce better outcomes.
“Serving all patients with quality care is even more essential as our healthcare system contends with complex challenges, such as COVID-19 and its lasting impact,” said Agrawal. “We are indebted to our members, partners, and Technical Expert Panel for supporting this work and for demonstrating yet again that NQF is the forum for tackling emerging national health needs that demand comprehensive approaches across sectors.”
But how to get leadership buy-in to develop some of the recommendations from the report? Adopting measure systems throughout a healthcare facility must be a systematic process.
“Getting commitments and declarations of a shared vision from a facility’s leadership team is key in developing recommendations for aligning and improving systems,” Agrawal said.
Facilities should start small, commit to implementing something simple and doable, and be strategic about how new measure systems would fit in with existing quality measurement programs, he added. They should spur on teams already excited about quality improvement, or partner with groups that have demonstrated success to adopt measurement systems.
“Leaders should understand what measures are already in use and what available sources of data can be leveraged to build a culture of innovation to improve patient safety,” Agrawal said. “We are taking similar steps internally at NQF. We are evaluating changes to our core programs, such as endorsement, to better integrate this thinking and work.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, September 2, 2020
AI-based remote monitoring helps providers manage care for COVID-19 patients.
This article was originally published September 1, 2020 on PSQH by Megan Headley
While there has been much discussion on the dramatic increase in telemedicine usage due to the COVID-19 pandemic—usage is up 22% even in U.S. states with the lowest telehealth adoption—video and phone calls are just one small piece of the telemedicine puzzle. The other, more critical piece is the monitoring equipment that arms physicians with the clinical data to determine if and when an intervention is necessary.
“With video calls alone, they would not have enough information to provide proper care to the patient,” points out Kuldeep Singh Rajput, CEO of Biofourmis, a provider of AI-powered digital therapeutics technology. “Hospital [systems] in the U.S. and internationally are now moving towards equipping patients with the right tools to [provide monitoring and management], have the data collected, and process that data using an analytics platform so that clinicians are not overburdened.”
Biofourmis’ Biovitals® Sentinel, powered by the FDA-cleared Biovitals AI platform, is one such solution being used to provide that insight. The platform provides continuous remote monitoring through a biosensor, worn on the patient’s upper arm, that collects data from more than 20 physiological signals. Combined with a patient-facing app that gathers additional information on symptoms and enables text and video visits, care providers can get a fairly complete picture of a patient’s health via a dashboard app on their smartphone.
Like many such remote monitoring platform providers, Biofourmis pivoted at the beginning of the year to customize the platform for COVID-19.
The platform has been adapted both to track viral load (in order to predict, with approximately 93% accuracy, when a person should pursue a PCR swab test to confirm COVID-19) and to alert a provider of the need for interventions around 21 hours in advance of a critical complication due to COVID-19. Each of those applications was tested in a Hong Kong rollout earlier this year.
“In some of the rollouts that we have done in Australia, the U.K., and the United States, we also have monitored hospital staff, because the frontline workers are at a significant risk of getting COVID-19,” Rajput adds.
There’s a third instance where remote monitoring has helped healthcare systems better allocate resources. Using the continuous flow of patient data, providers can predict the length of stay for a patient and maintain a more accurate projection of bed availability.
While patient safety is driving the use of wearables, the efficient allocation of resources is partially why many health systems are turning to remote monitoring. “The entire idea of the platform and program was around how to improve nurse efficiency,” Rajput explains. “The challenge really was [the] shortage of nurses everywhere … one-at-a-time monitoring just isn’t a feasible option. So how do you leverage continuous monitoring to pick up complications so that clinicians and nurses can intervene earlier?”
In April, the Biofourmis platform was rolled out across Singapore’s state-run health system to support nurses dealing with a COVID-19 surge that has grown in recent months, largely impacting foreign workers.
Singapore’s Ministry of Health set up community care facilities around the nation to care for COVID-19 patients who do not require acute care.
“Having this massive isolation facility with 15,000 beds and limited nurses, you need an ability to passively monitor these patients and be able to triage them so that we can improve safety of these patients,” Rajput explains. “So, all of these patients are monitored using the platform.”
If there’s a learning curve for the clinical care team adopting this solution, that curve can seem infinitely steeper for patients. It’s one reason Biofourmis set up a supporting 24/7 call center that answers patient questions about the platform.
In many ways, the use of wearable sensors to track COVID-19 upends many healthcare providers’ formulas for managing the surge.
During the early days of the pandemic, health systems focused on containing COVID-19 patients, sending patients who did not have COVID-19 to alternate sites for care. With wearable sensors now able to monitor patients for potential complications due to coronavirus, those infected patients can be more safely quarantined remotely.
The Biofourmis solution is but one of the sensor-based solutions being considered. The Stanford Healthcare Innovation Lab is gathering data on the possible use of devices including FitBit® and Apple Watch® to pick up abnormal patterns that could predict possible infections.
The goal is to build an algorithm that can apply this data to detect COVID-19 infection before symptom onset to improve rates of self-isolation. With more than 5,500 participants to date, the Stanford project has become one of the world’s largest studies on infectious disease using data from wearable health monitoring devices.
Of course, this tremendous amount of available data could also provide big-picture insight into how COVID-19 operates. “We are working with a couple of pharma companies that are leveraging some of the data we are collecting to learn more about the disease, and are also involved in a couple of clinical trials for COVID-19 drugs and vaccines,” Rajput says.
Rajput points out that existing EMR data already enables this type of analysis. The wearables simply deepen the understanding of the patterns in the data. “We have structured partnerships in such a way that we are computing continuous data from the patients, but we also have patient-reported data on top of that. We also have [a] clinical data layer, which includes comorbidities, medications patients are taking, and x-rays, as well as lab results, plus any swab tests that patients have taken. The data that we have collected is very comprehensive.”
PSQH: Patient Safety & Quality Healthcare, August 26, 2020
"The first hurdle is knowledge-based: knowing a patient experienced a recent sepsis diagnosis and sepsis hospitalization," says Benjamin A. Zaniello, MD, MPH.
This article was originally published August 26, 2020 on PSQH by John Palmer
Editor’s note: The following Q&A resulted from a conversation with Benjamin A. Zaniello, MD, MPH, chief medical officer at Salt Lake City–based Collective Medical. The company recently rolled out an event notification and care collaboration platform that identifies patients with a history of sepsis so that care teams may more quickly intervene to address these patients’ unique needs.
Sepsis is the number one driver of hospital costs in the United States and—according to the CDC—accounts for more than one-third of hospital deaths and more than $24 billion in hospital expenses. Sepsis is the most expensive all-payer condition in the United States.
PSQH: Why is sepsis such a prevalent problem in U.S. hospitals? Why are survivors rehospitalized so often? What are the factors that put them at such high risk?
Benjamin Zaniello: Sepsis is prevalent in U.S. hospitals for a variety of reasons—from the fact that it’s not always easy to identify sepsis before it becomes life-threatening to the high number of seniors living in the U.S. with multiple comorbidities such as heart disease and kidney failure. One recent study indicated that sepsis is associated with one in five deaths globally, twice the amount that some previous estimates indicated. That’s not surprising, considering how insidious it is.
The main problem is that sepsis is hard to identify because it has multiple signs. In an elderly patient, sepsis could originate from an untreated or undertreated UTI. In a pregnant woman, it could manifest from the flu. In a child, it could escalate from a skin infection.
It is a problem of sensitivity versus specificity. It’s very easy to be specific—to know a patient has sepsis when it’s too late. It’s hard to be sensitive in sepsis identification when the potential at-risk population is so large.
PSQH: What do you think is the biggest hurdle to overcome when it comes to preventing the rehospitalization of a sepsis patient?
Zaniello: The first hurdle is knowledge-based: knowing a patient experienced a recent sepsis diagnosis and sepsis hospitalization. Often physicians have no idea that someone who arrives in their ED or clinic had a recent history of sepsis. We know from the statistics that only half of all patients fully recover post-sepsis and the other half needs very, very close follow-up—but they aren’t usually getting the level of close follow-up care that they need.
With sepsis you often see comorbidities like congestive heart failure, which requires close follow-up to monitor weight and manage edema and medication. Another common side effect of sepsis is acute renal failure, which, if not addressed by a specialist post-discharge, can turn into chronic renal failure (and a higher risk of rehospitalization).
The second biggest hurdle is the fragmentation of our healthcare system. Sepsis patients are often managed in one hospital, but their follow-up is in another—we frequently see the patient transferred from their community hospital to a Level I trauma center or an academic hospital, but when they’re transferred back to their community hospital, information isn’t shared between facilities and providers.
Until recently, sharing that kind of information across a network—between disparate health systems, even in the same state—was next to impossible.
PSQH: What is the intent of rolling out the sepsis history alerting functionality on the Collective platform, and how does it work?
Zaniello: A study published by JAMA found 42.6% of severe sepsis survivors were rehospitalized within 90 days—so it’s absolutely essential for care teams to know these patients are at high risk. To do this, hospitals and healthcare systems need to be able to address the gaps in care coordination that affect the outcomes of their patients. Sepsis patients or those with history of sepsis are high-risk and high-needs patients that benefit from careful, close collaboration post-discharge.
The highest-risk patients are geriatric patients, discharged from postacute facilities, who require more intensive care collaboration and monitoring. By flagging patients with history of sepsis in our system, care providers on the Collective Medical network can intervene much more quickly. Health plans, ACOs, and relevant healthcare providers are notified as soon as their patients are discharged with a recent history of sepsis, allowing them to collaborate with critical providers notified at point of care. Likewise, when a sepsis survivor presents at an ED, physicians and nurses are notified in real time of the patient’s history with sepsis, allowing them to act more quickly and with better context.
PSQH: Is there an area of the country where sepsis rehospitalization seems to be a bigger problem than others? Why?
Zaniello: From what I’ve seen, states that have a stronger managed care network tend to have a slightly lower risk of sepsis, while more urban areas with higher concentrations of patients will have a higher rate of sepsis per capita. The states with an older population like Florida are going to have a higher rate because they have a larger geriatric population.
But it is a risk everywhere—even in the most highly-rated hospitals staffed with the best care providers in the world. The best way to effectively lower our risk of rehospitalization is to address sepsis before it exacerbates by identifying risk factors early, intervening on a timely basis, and using the technology and resources at our disposal to coordinate care.
PSQH: What results have you seen in the short time the alert system has been rolled out?
Zaniello: Prior to the national rollout, the states that used the Collective Medical platform saw significant reduction in various outcomes, including avoidable ED visits. In Oregon, for example, use of the Collective platform contributed to a statewide reduction in potentially avoidable ED visits from patients with patterns of high utilization by 11.2% across 2018. As an example of another outcome supported by our platform, during that same time period, comorbid substance use disorder–related visits fell by 4%, while visits within 90 days following development of an initial care guideline fell 31%.
We’re really encouraged by these figures. With sepsis, ultimately, you’re dealing with something that is hard to identify [until] it arrives and presents an emergency that is frequently fatal.
By improving our identification of patients with high risk factors (e.g., those with previous incidents of sepsis) and notification process, it’s possible to change the scope of care and potential outcomes for those patients.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, August 25, 2020
The NSC reiterated its position that employers reopening their facilities must ensure their employees are returning safely.
This article was originally published August 25, 2020 on PSQH by Guy Burdick
On August 18, the National Safety Council (NSC) predicted that coronavirus disease 2019 (COVID-19) may become the third leading cause of death in the United States for 2020, behind only heart disease and cancer. In 2018, the most recent year of final fatality data, the third leading cause of death was preventable deaths from drug overdoses, motor vehicle crashes, and falls.
The number of deaths from COVID-19 this year already has surpassed the number of preventable deaths in calendar year 2018. COVID-19 is a respiratory illness caused by the SARS-CoV-2 virus. COVID-19 currently is widespread in most U.S. communities and considered a workplace hazard.
The number of deaths in the U.S. from confirmed and probable cases of COVID-19 now exceeds 170,000. There were 167,127 deaths from preventable causes in 2018.
An indirect consequence of the COVID-19 pandemic may be increases in opioid overdoses and the rate of motor vehicle fatality, according to the NSC. The American Medical Association has reported increases in opioid-related mortality in more than 40 states during the COVID-19 pandemic.
Overdose deaths already were increasing. The NSC noted that preliminary data out of the Centers for Disease Control and Prevention (CDC) show that overdose deaths set records in 2019, rising by 4.8% to a total of 70,980, with 50,042 of those deaths due to opioid overdoses.
Despite a decrease in driving during the pandemic and an 8% decrease in deaths from motor vehicle crashes, the mileage death rate per 100 million vehicle miles driven for May 2020 was 1.47 compared with 1.19 in 2019, according to the NSC.
The NSC reiterated its position that employers reopening their facilities must ensure their employees are returning safely.
The NSC established a reopening framework based on recommendations of its Safe Actions for Employee Returns (SAFER) task force, a group that included the American Industrial Hygiene Association (AIHA) and American Society of Safety Professionals (ASSP).
The NSC’s recommendations for employers included screening employees for symptoms at the start of work shifts, testing for COVID-19 infections, and cooperating with public health authorities performing contact tracing.
The group even suggested that employers encourage their employees to use contact tracing apps like COVID-19 Watch, CoEpi, and Private Kit: Safe Paths on their mobile devices.
Employers should be especially mindful of risks to older employees and employees with chronic health conditions, who may have severe illnesses due to COVID-19 infection, the NSC said.
The group also warned employers they may need to adapt to future restrictions, including cities, counties, and states that reimpose stay-at-home orders or issue other restrictions on operations if the spread of COVID-19 remains uncontrolled.
The NSC also urged states’ governors to develop consistent testing and contact tracing protocols.
A letter from the NSC and a coalition that included several state safety councils called on the governors of all 50 states to make effective testing and contact tracing protocols a top focus as state stay-at-home orders expire and workplaces reopen.
The NSC emphasized the importance of testing and contact tracing because 80% of individuals infected with COVID-19 are asymptomatic or have mild symptoms.
PSQH: Patient Safety & Quality Healthcare, August 6, 2020
Patient deterioration, which refers to the worsening of a patient’s condition during a hospital stay, has become a growing concern and affects as many as one in six inpatient admissions.
This article was originally published August 5, 2020 on PSQH by John Palmer
Editor’s note: The following Q&A resulted from a conversation PSQH had with Nancy Riffel, MSA, BSN, RN, the patient services manager for Covenant HealthCare, a 643-bed hospital in Saginaw, Michigan, that is the largest healthcare provider in the Great Lakes Bay Region. Riffel has been a nurse for more than 40 years.
The hospital recently installed Centrella® smart beds from Chicago-based Hill-Rom with contact-free, continuous monitoring powered by EarlySense in its 24-bed medical pulmonary unit to continuously monitor patients’ respiratory and heart rates, the most common and problematic signs of patient deterioration.
Patient deterioration, which refers to the worsening of a patient’s condition during a hospital stay, has become a growing concern and affects as many as one in six inpatient admissions.
PSQH: Why is it important to identify if a patient is deteriorating, and how can a smart bed help those with COVID-19?
Nancy Riffel: One of the best ways to protect patients from this problem is to recognize changes in their vital signs, which can accurately predict clinical deterioration. One study found that 60% of patients had a documented physiological indication before a cardiac arrest, unplanned ICU admission, and/or death.
Though much about COVID-19 remains a mystery, one thing is certain: It can turn deadly in a heartbeat, and the smart beds turned out to be a lifesaver in many cases where the hospital was able to identify deteriorating cases faster using the beds.
A Reuters story I read reports that “the speed with which patients are declining and dying from the novel coronavirus is shocking even to veteran doctors and nurses.” A recent study shows that early identification systems for COVID patients using triggers based on vital signs to escalate care have resulted in lower mortality rates.
PSQH: What are some of the biggest challenges facing nurses (besides their usual daily duties) when it comes to monitoring the conditions of COVID-19 patients? How can smart beds help them do their jobs more efficiently?
Riffel: One of the biggest challenges for our nurses is identifying the first signs of deterioration, since the virus can overwhelm patients in a matter of minutes. When this was a pulmonary unit, nurses would do hourly rounds. But to protect nurses from infection and preserve our PPE supplies, they now go into COVID patients’ rooms only every four hours or when necessary.
The smart beds with continuous monitoring have become an essential tool in our toolbox. When a patient’s heart or respiratory rate moves higher or lower than preset parameters, the beds alert the nursing staff using nurse call as well as visual and audible alarms outside the room. A nurse who enters the room can glance at the bed monitor to immediately see the abnormal rate. Nurses also can access trending data to guide decisions about initiating a call to action to response teams, which can decide if the patient needs to be transferred to a higher level of care such as the ICU.
This monitoring method gives our staff the reassurance of knowing they can track a patient’s condition without having to put on PPE and step into the room. Also, high respiratory rates are the No. 1 concern for COVID patients, and it’s impossible for nurses to “eyeball” shallow but rapid rate changes as well as the monitors.
We have had about 120 patients on the COVID unit, and five of them were intubated within an hour after their bed alarms went off. Since installing the monitoring system, the unit has not had any code blue alarms, and not one patient has had a cardiac arrest.
PSQH: Are smart beds connected to the internet or other networks that could be susceptible to hackers? Is there a concern that sensitive patient information could be compromised, and how is that mitigated?
Riffel: The smart beds are not connected to the internet or any networks and monitor only respiratory and heart rates, so there is no risk that sensitive patient information could be compromised.
PSQH: While alarms on a bed are important to make sure that nurses are alerted when a patient needs help, a recent trend in healthcare is to reduce the number of alarms in patient care units. How will the smart beds help continue this trend, while improving the outcome of patients with COVID-19?
Riffel: Alarms are absolutely essential, but the problem with them is that too many are false or non-actionable. In fact, The Joint Commission estimates that 85% to 99% of alarm signals do not require clinical intervention.
That’s not the case with our contact-free, continuous monitoring alerts. First of all, we are not concerned with their accuracy because we have not had any false alarms. When the alarms go off, all our nurses know they need to check the patient for signs of distress.
Unlike telemetry device alarms, which can be triggered when the monitoring leads become detached from the patient, the smart bed sensors under the mattress do not touch the patient. When patients lie down, these sensors continuously record their respiratory and heart rates and send alarms only when these rates are outside preset measures. Nurses also can easily change the alarm parameters as needed to make them appropriate for each patient.
The smart beds are a wonderful complement to the telemetry equipment we use for some of our unit’s COVID patients. Being able to continuously monitor patients without attaching anything to them not only eases our staff’s workload, but also improves patient experiences.
PSQH: What kinds of technology do smart beds use to monitor patients? AI and machine learning are both new technologies that are making their way into healthcare. How will these technologies replace the healthcare worker—and in what ways shouldn’t they?
Riffel: The monitoring system uses patented sensing and signal processing technology sensitive enough to detect subtle vibration and motion signals in the chest, hands, legs, or torso as often as twice a second. Based on this information, proprietary analytic software can determine heart pulse and respiratory rate patterns and alert nurses when significant changes occur.
This technology will never replace healthcare workers—it just lets them know that a patient urgently needs their attention. Our nurses have so much to do when caring for COVID patients and have enthusiastically welcomed the smart bed monitoring solutions as a complement to their responsibilities.
PSQH: Are there any dangers to relying on the technology of smart beds too much? While certainly lifesaving and a breakthrough, how can healthcare workers ensure that the information they are getting is accurate? What mitigation factors (such as human monitoring) need to be in place as a safeguard? Is that even possible on a busy COVID-19 unit with so many other things going on?
Riffel: As I have mentioned, we trust the accuracy of this technology in the same way we trust a thermometer to give us a patient’s accurate temperature. But, again, smart beds are only tools. Nurses and managers still need to regularly listen to COVID patients’ lungs, assess their overall health, and provide support that can come only from human contact. We must always remember: COVID patients can deteriorate very quickly, so we can never let our guard down.
For Covenant HealthCare to fulfill our mission of providing extraordinary care for every generation, we need to continue investing in state-of-the-art equipment. I have been a nurse for more than 40 years, and I believe these smart beds are amazing and will save lives. I often tell my staff, “You don’t know how lucky you are to have them.”
PSQH: Patient Safety & Quality Healthcare, July 21, 2020
Clinical experts in maternal and fetal medicine have been unable to agree on the physiological parameter thresholds for various conditions, leading to a variety of treatment protocols across the country.
This article was originally published July 20, 2020 on PSQH by Alana McGolrick, DNP, RNC-OB, C-EFM
The steadily climbing maternal mortality rate in the U.S. has (appropriately) attracted a great deal of media attention over the last few years.
Figures from the Centers for Disease Control and Prevention (CDC) show that the rate has more than doubled since 1987, reaching an alarming high of 17.3 maternal deaths per 100,000 live births. That is well above the Healthy People 2020 goal of 11.4.
Worse, the CDC estimates that 60% of maternal deaths reviewed in a study were preventable. Stopping those would result in easily meeting and surpassing the Healthy People 2020 goal.
Many factors have contributed to the rise in maternal mortality, including the increase in complex comorbidities in expecting mothers such as diabetes, obesity, hypertension, and cardiac disease. There has also been disagreement on the best approach to manage maternal patients, from creating a single oxytocin checklist to detailing more complex processes for managing preeclampsia.
Clinical experts in maternal and fetal medicine have been unable to agree on the physiological parameter thresholds for various conditions, leading to a variety of treatment protocols across the country. Exacerbating it all is the limited success of research into maternal early warning systems that could overcome the common occurrence of clinicians failing to recognize or respond to clinical warning signs in a timely manner.
Fortunately, these issues have also captured the attention of The Joint Commission (TJC), which has added 13 new elements of performance (EP) for hospitals to be surveyed on, effective July 2020. All accredited hospitals providing obstetric (OB) services will be required to show evidence of compliance with these new standards, which cover two of the most common causes of maternal morbidity and mortality.
While TJC has suspended all regular on-site surveys until further notice due to COVID-19, hospitals should review the new EPs to determine elements that could be easily implemented. Especially during a pandemic, following evidence-based and recommended protocols can greatly improve clinical outcomes for patients while ensuring staff have access to necessary resources and are trained appropriately.
The first set of EPs focuses on maternal hemorrhage, which is the leading cause of maternal deaths worldwide. CDC data shows it also accounts for 11.2% of pregnancy-related deaths in the U.S., and that Black women are two to three times more likely to experience issues with hemorrhaging than white women despite not being considered at higher risk for blood loss during delivery. Typical causes include missed or inaccurately communicated signs and symptoms of active blood loss, underestimating the amount of blood loss, and the lack of a standardized response.
The second set of EPs focuses on maternal deaths from hypertensive crisis/preeclampsia, which accounts for 6.8% of pregnancy-related deaths in the U.S. It is estimated that preeclampsia can occur in 5%–8% of all pregnancies, and is responsible for 76,000 maternal and 500,000 infant deaths globally each year.
Following is a more detailed look at the new EPs TJC has implemented to reverse these trends and improve the safety and lives of both maternal and fetal patients.
Maternal hemorrhage
TJC has issued seven EPs related to maternal hemorrhage, requiring:
Performing a hemorrhage risk assessment using an evidence-based tool upon admission to labor and delivery (L&D) and postpartum care. This risk assessment can be performed on paper or (preferably) in the mother’s electronic medical record. Taking this initial step will allow the care team to prepare for those patients who may be at higher risk. The California Maternal Quality Care Collaborative (CMQCC) offers an excellent starting point in its OB Hemorrhage Toolkit V2.0.
Development of written procedures for hemorrhage management. This is the EP that is likely to require the most work at the hospital. Fortunately, most of what is needed should already exist in an organization’s massive transfusion protocol or OB hemorrhage protocol. The goal is to standardize on an evidence-based approach to minimize delays and foster effective communication among team members. To comply, hospitals need to describe the med kit in detail, establish team members’ roles and responsibilities, and describe how to call the blood bank. Hospitals will also need to develop procedures to confirm how much blood is required and should be on-site, when to call for a consult, and when to transfer a hemorrhaging mother to a higher level of care if the facility is a critical access hospital or is unable to provide the higher level of care itself. Hospitals must also demonstrate that they have scripted how to communicate with patients and their families during an active blood loss event.
Standardization of a hemorrhage supply kit. Here again, the CMQCC OB Hemorrhage Toolkit offers a great starting point as it lists all the required elements. Hospitals should have a crash cart dedicated to maternal hemorrhage that has all these elements on board, along with anything else the hospital and delivering clinicians prefer. This cart should be checked with the same frequency as regular crash carts and locked in a secure area. The number of carts/kits required depends on the patient population and the layout of the hospital. For example, if postpartum is on a different floor than L&D, there should be at least one cart on each floor. If a large number of L&D patients are admitted through the emergency department (ED), there should be a cart in the ED as well. Organizations with a high percentage of high-risk mothers might want to consider having more than one cart/kit available in these areas.
Delivery of role-specific staff and provider education about the organization’s OB hemorrhage procedures. For the care team to function optimally in an emergency, everyone must know the procedures to follow in the event of a hemorrhage. This education should be delivered during orientation, when there are changes in procedures, and every two years. Ensuring readiness in this way will make an impressionable impact on maternal outcomes.
Conducting hemorrhage drills. Just as in the military, multidisciplinary simulation of emergency events is essential to uncovering gaps in education or procedures as well as improving staff response time and recognition of a worsening condition. Drills should be conducted annually at a minimum.
Performing OB hemorrhage case reviews. A standardized approach to assessment of the response team and effectiveness of treatment in actual situations is an invaluable tool for gathering key information that can improve future patient experiences. With this information, hospitals can address process gaps and confirm optimal best practices that will help reduce maternal morbidity and mortality rates.
Providing patient and family education. Patients and their families are often forgotten elements of the care team, yet their understanding of issues is vital. At a minimum, education should include the signs and symptoms of postpartum hemorrhage during hospitalization and instructions on when to seek care as well as signs and symptoms for when to seek immediate care. Research shows that discharge education suffers from alarming inconsistencies, misinformation, and healthcare provider subjective bias. As a result, patients often leave the hospital misinformed, undereducated, and unappreciative of the high-risk nature of their medical condition. A checklist tool greatly reduces these inconsistencies so clinicians can provide better patient education.
Hypertension/preeclampsia
It is not uncommon for maternal patients to present without the common signs and symptoms of hypertension or preeclampsia, such as sudden edema or weight gain, headaches, and visual disturbances. To combat this and improve patient assessment, TJC has issued six EPs for this condition, requiring:
Detailing within the policy and procedure steps for accurately measuring and remeasuring maternal blood pressure. Taking blood pressure properly is usually learned in the first weeks of nursing school, but in the clinical setting, it’s often done incorrectly. Following the proper, written procedure will lead to more accurate blood pressure assessments and data interpretation, which is extremely valuable for diagnosing a patient who is suffering from severely elevated blood pressure or preeclampsia. Conversely, inaccurate measurement can lead to a mother not receiving proper treatment and being discharged unknowingly with elevated blood pressure that is potentially fatal. The recommended procedure can be found in the CMQCC preeclampsia toolkit.
Development of a policy and procedure for managing maternal patients with severe hypertension/preeclampsia. This may be the most difficult and time-consuming EP to implement because several factors must be addressed, including:
Creation of an evidence-based set of emergency response medications that are stocked and immediately available on the OB unit
Use of seizure prophylaxis
Guidance on when to use continuous fetal monitoring
Guidance on when to consider emergent delivery
Criteria for when a team debrief is required
Delivery of staff and provider education on maternal severe hypertension/preeclampsia. This carries the same rationale and requirements as #4 in the OB hemorrhaging discussion. Special attention should be paid to staff education surrounding magnesium sulfate due to its high-risk medication label. Understanding the pathophysiology of eclampsia, the rationale for magnesium sulfate as seizure prevention, and the risk of maternal cerebral events is critical to the care of at-risk patients.
Conducting OB severe hypertension/preeclampsia drills. This carries the same rationale and requirements as #5 in the OB hemorrhaging discussion.
Performing OB severe hypertension/preeclampsia case reviews. This carries the same rationale and requirements as #6 in the OB hemorrhaging discussion.
Delivery of patient and family education. This is similar to #7 in the OB hemorrhaging discussion, but also offers an opportunity to get creative. For example, staff can wear t-shirts that say, “Got headaches?” as a reminder to patients to report them. Magnets in the discharge package that look like drops of blood can be a reminder to look for active, bright red bleeding. Anything hospitals can do to draw the attention of patients and families to these high-risk situations is an added benefit.
Reversing the trend
Maternal hemorrhage and severe hypertension/preeclampsia are pervasive issues in America today, leading to far too many maternal morbidity and mortality events. But both are eminently fixable. Following TJC’s new EPs isn’t just a requirement for accreditation—it’s also the right thing to do. Together, we won’t just meet the Healthy People 2020 goals, we can greatly exceed them.
Alana McGolrick is chief nursing officer of PeriGen, a company delivering innovative perinatal software solutions.
PSQH: Patient Safety & Quality Healthcare, July 21, 2020
The pandemic also highlighted how technology and communication gaps can jeopardize patient care and staff safety.
This article was originally published July 20, 2020 on PSQH by John Palmer
Editor’s note: The following Q&A resulted from a conversation PSQH had with Stacy Pur, vice president of product development at Minneapolis-based VigiLanz, a company that provides real-time clinical surveillance systems for hospitals.
With a potential second wave of COVID-19 on the horizon for the fall, combined with the regular flu season, real-time surveillance alerts may be the key to infection prevention as well as mitigating and controlling future on-premises infections.
PSQH: If clinical surveillance is so important, why do only 29% of surveyed hospitals use it? What would improve the rate of surveillance usage?
Stacy Pur: Clinical surveillance is a fairly new technology, developed about 10 years after EHRs [electronic health records]. Unfortunately, some of the early clinical surveillance solutions were fraught with issues, such as issuing alerts that weren’t relevant, meaningful, or appropriate, as well as tedious, inefficient workflows. These factors contributed to a slow initial adoption rate.
Over the past few years, clinical surveillance has significantly improved, and hospitals are taking notice. While the survey found that currently only one-third of hospitals are using clinical surveillance, about half of those who aren’t using it yet plan to do so by 2022. Hospitals are increasingly recognizing its value, particularly as the technology continues to grow in sophistication and efficiency.
PSQH: What will COVID-19 tell us about the status of patient safety in healthcare facilities? Will it improve some things? Make some things worse?
Pur: While hospitals have made significant patient safety gains over the past few years, and while they have responded to the pandemic with heroic efforts, COVID has exposed some critical patient safety challenges at hospitals across the country. For example, many hospitals struggled with delayed COVID-positive patient identification, PPE shortages, ventilator shortages, and lack of adequate capacity during the first surge of COVID patients.
The pandemic also highlighted how technology and communication gaps can jeopardize patient care and staff safety. For example, from an infection prevention standpoint, the faster that healthcare providers have information about a patient’s risk of currently being infected with a contagious illness like COVID, the sooner they can isolate that patient and contain the spread, initiate contact tracing, equip staff with PPE, and begin treating the patient appropriately.
In the early stages of the pandemic, positive test results took days to come back. Hospitals needed technology that looked beyond test results to identify probable infectious patients who not only needed to be isolated, but also needed to have their contacts assessed. Many hospitals were able to do this, as well as respond more proactively to the threat of drug shortages, by deploying clinical surveillance. For example, Sharp HealthCare in San Diego set up rules in its clinical surveillance platform to alert relevant providers in real time when patients have symptoms consistent with COVID, when COVID test results are ordered, what the results are, and when select medications are ordered inappropriately.
COVID has taught us that when healthcare systems are stressed, patient safety is vulnerable. It has also shown that tools that improve efficiency for healthcare workers and that improve the quality and timeliness of information provided to healthcare workers have immediate positive impacts to the safety of all concerned.
PSQH: COVID-19 has made it so only about 40% feel comfortable going to a hospital, the place everybody should feel comfortable about going to for help. Why is this, and what are some of the things that need to be done to improve customer confidence?
Pur: At the height of the first wave, many hospitals faced unprecedented patient demand that strained EDs and ICUs, and created critical supply shortages. Customers felt unsafe because many hospitals were not safe. Crowded EDs filled with infectious patients, and hospitals lacked basic protective measures, such as PPE. This was a recipe for disaster and resulted in the deaths of several healthcare workers.
Hospitals learned a lot from the first wave. They are acquiring additional PPE, increasing training on infection prevention protocols and procedures, implementing new technology such as clinical surveillance that can help them more rapidly identify and isolate COVID patients, and modifying their contingency plans to include overflow areas when cases increase.
The key for hospitals moving forward is effective communication with customers regarding how they will keep them safe. Then, hospitals must actively model the steps they are communicating. A sign in the ED that says everyone must wear a mask is meaningless unless healthcare workers wear masks at all times. If patients are still waiting in communal areas, hospitals should consider having them wait in their cars.
Hospitals are taking extraordinary measures to improve safety and have learned some valuable lessons. They should continue to apply these lessons even after the pandemic begins to wane.
PSQH: What types of clinical surveillance tools would work best for most hospitals looking to improve patient safety in general? With less than 40% using technology to detect problems such as opioid problems and viral outbreaks, it seems there is a lot of work to do.
Pur: When hospitals first began implementing EHRs, many healthcare workers hoped the technology would make providing patient care much easier. Instead, in many cases, they are tied to screens responding to large numbers of alerts that are little more than white noise, performing redundant documentation, and struggling to find answers to the most basic questions. For new technologies to be successfully adopted and implemented, they must introduce meaningful efficiencies and naturally fit into providers’ everyday workflows. If it’s not easy for healthcare providers to use, and if it doesn’t communicate with established tools such as EHRs, meaningful data won’t be extracted, and providers won’t have the time to use it. Hospitals looking to implement clinical surveillance must prioritize solutions that have the sophistication to provide highly targeted alerts and offer seamless integration and easy implementation.
In addition, as we have seen with recent events, healthcare needs can change on a dime. Clinical surveillance technology needs to be nimble and responsive; able to adapt to the new needs of practitioners within hours, not weeks. For example, if a hospital’s top priority is reducing acute kidney injury, the clinical surveillance provider should be able to provide support that aligns with current industry gold standards, but that also can address the unique challenges specific to that institution’s patient population.
Key clinical surveillance attributes that hospitals should look for in a solution platform include the ability to do the following:
Provide targeted real-time identification of patients requiring active interventions
Identify and manage safety events in patients, employees, and visitors
Provide ongoing, behind-the-scenes analytics detecting disease clustering, medication usage patterns, outbreaks, and other unusual trends of value to safety-driven cultures
Identify complex medication errors or adverse events
Identify opportunities to optimize care
Identify opportunities to mitigate risk, such as opioid use
PSQH: With a possible second wave of COVID on the horizon, what are some of the biggest things that hospitals and healthcare workers need to be vigilant about? How will we know if a second wave is here?
Pur: The “second wave” is irrelevant, in my opinion. The reality is that COVID is here. Cases will wax and wane until an effective vaccine is developed and a large percent of the world population has been immunized or developed immunity. This will likely take years. Healthcare organizations must implement new strategies to rapidly recognize infectious individuals, screen employees, communicate shortages, assist stressed and/or infected healthcare workers, adapt to disease surges, implement telemedicine more broadly, and assure active and effective employee and public communication. These strategies should also remain in place permanently.
Most importantly, the science must continue to be actively monitored. Just recently, a new strain of influenza was detected, the G4 EA H1N1 influenza virus, which has acquired increased human infectivity. This is certainly not an immediate concern. However, COVID was “not an immediate concern” for months—until it was.
As healthcare organizations monitor the scientific findings that are helping improve COVID outcomes, vigilance around the next new concerns—whether they be infectious, economic, supply chain, environmental, or worker related—must be ongoing. Clinical surveillance tools that quietly monitor while supporting the science, and that alert healthcare providers when action is indicated, will be invaluable as we move into the new norms around the pandemic and challenges to healthcare in general.
PSQH: What should hospitals be doing right now to be ready for a second wave?
Pur: They should debrief on what has gone well and what hasn’t. They should consider not only implementing their best ideas permanently, but also sharing them more broadly with their peers. For areas where they were challenged, they should analyze and, if possible, test and implement new approaches.
If not yet in place, they should explore new technologies and solutions, such as clinical surveillance, cleaning solutions, and telehealth.
They should also assess their surge plans to ensure they have adequate PPE and other supplies and evaluate their overflow plans.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, July 20, 2020
As part of World Patient Safety Day on Sept. 17, NAHQ Next will include a collaboration with the Patient Safety Movement Foundation (PSMF).
This article was originally published July 15, 2020 on PSQH by Jay Kumar
Four months into the COVID-19 lockdown, we’re seeing some states gradually open up and others frantically put restrictions back in place because of new surges in coronavirus cases.
Meanwhile, healthcare conferences of all kinds have been cancelled or postponed, or in some cases, turned into virtual events. The National Association of Healthcare Quality (NAHQ) is going with the latter option, with plans to hold its first virtual conference in September.
NAHQ Next 2020 is scheduled for September 14-16, featuring speakers from quality or leadership positions at healthcare organizations including Cedars-Sinai, Cleveland Clinic, Kaiser Permanente, Lifespan, and SSM Health. Initial plans were to have the conference take place in Indianapolis.
“NAHQ has been working to reduce variability in healthcare quality competencies, and the COVID-19 pandemic further highlighted the shortcomings of working on-the-fly at a local level to solve national and global healthcare quality issues. NAHQ is convening leaders at NAHQ NEXT to focus on the healthcare quality imperatives in a post-COVID-19 environment and to discuss the requirements to prepare the workforce to become more high-functioning in the future,” said NAHQ CEO and Executive Director Stephanie Mercado, CAE, in a release. “Before the pandemic, healthcare waste was estimated to be upwards of $900 billion annually and was the third leading cause of death. The pandemic was the crisis that shined a bright light on existing challenges, and NAHQ’s competency framework will be a foundational solution to addressing these issues in the long term.”
As part of World Patient Safety Day on Sept. 17, NAHQ Next will include a collaboration with the Patient Safety Movement Foundation (PSMF), which will provide content for the final day of the conference and continuing medical education credit for select sessions (pending approval).
Similarly, the American Society for Health Care Engineering (ASHE) had planned to hold its annual conference and technical exhibition in Chicago next month, but has converted the event into a virtual conference that will run from Oct. 5-7.
The conference will include a keynote speaker, presentations, breakouts, interactive chatrooms, and an online exhibit hall. Attendees will have on-demand access to the presentations through Dec. 31.
Networking opportunities will be available via the ASHE Lounge, where attendees can chat publicly with other attendees and sponsors.
The chat will show the profiles of everyone in the lounge; attendees can click on profiles and send an email, request a private chat, or send them a virtual business card.
PSQH: Patient Safety & Quality Healthcare, July 19, 2020
During the pandemic, the spotlight has turned to telehealth and its power to deliver healthcare while maintaining social distancing.
This article was originally published July 15, 2020 on PSQH by Peter Antall, MD
“We have the technology.” It’s a catchphrase from “The Six Million Dollar Man,” a TV show that filled children of the 1970s with the hope that they would one day live in a world where bionic humans weren’t just the stuff of science fiction. And while bionic implants are still an emerging but competitive market, we’re entering a time when the digital health advancements many of us once dreamed of, like virtual care, are transforming healthcare as we know it.
Now, those advancements are not only critical to our country’s defense against the coronavirus pandemic—both the current wave and the subsequent waves—but they’re also allowing us to reimagine how all healthcare is delivered.
During the pandemic, the spotlight has turned to telehealth and its power to deliver healthcare while maintaining social distancing. But as the World Health Organization warns of a second peak of coronavirus cases in the United States and a second wave of COVID-19 later this year, healthcare leaders must consider: How do we apply the rear-view mirror lessons from the first wave of the pandemic to our virtual response to consumers’ healthcare needs during the second wave?
Further, as many providers adopted telehealth for the first time during the COVID-19 outbreak, they experienced how telehealth could benefit their practice even outside of a pandemic.
Here are three key insights gained during the initial trajectory of COVID-19 around incorporating telehealth as a first response.
1. Strengthen the infrastructure for telehealth.
As we saw during the first wave of the coronavirus, even health systems that had invested in telehealth found they needed to dramatically ramp up their capabilities to meet swelling demand.
Forrester Research projects that virtual visits will reach 1 billion in the United States this year, with 900 million resulting from COVID-19 alone. “This is going to become medicine, moving forward,” one health system leader shared with me recently. “The pandemic has pushed virtual care ahead 10 years.”
For example, at Augusta University (AU) Health System in Georgia, the organization had a relatively new home-based telehealth program when COVID-19 hit. Health system leaders quickly realized that this program would play a big role in their response to the pandemic; however, the ability to rapidly scale would be a challenge. They also found, like many other organizations, that the process of shifting most of their ambulatory care visits to an all-digital format was challenging.
Once the coronavirus began to spread, AU Health quickly bolstered its telehealth capabilities, training 400 providers on virtual COVID-19 screenings and collaborating with the Georgia Department of Health and the Georgia National Guard to open testing sites.
From March 10–20, AU Health performed 1,500 virtual COVID-19 screenings; by April 20, it had conducted 3,500 virtual screenings. Those who qualified for testing based on a virtual screening were directed to an emergency department (ED) testing center established by AU Health.
Today, AU Health is expanding its telehealth footprint and creating virtual services in the ambulatory space, such as postoperative visits and geriatric care. So far, 22% of ambulatory visits have been converted to telehealth, primarily in areas such as behavioral health, neurology, family medicine, and pediatrics. The system’s goal is to convert 50% of ambulatory visits to telehealth.
The onus isn’t just on providers to support a more robust telehealth response. For the U.S. healthcare system to fully leverage telehealth throughout the coronavirus pandemic, stakeholders such as government, health plans, and health systems must partner to:
Ensure equitable access to broadband technologies for patients
Limit regulatory barriers to telehealth adoption, such as licensure portability and reimbursement reform
Incentivize programs that encourage innovation, particularly for vulnerable populations in skilled nursing and long-term care facilities
2. Position telehealth as the “great load balancer” in healthcare.
Using telehealth to leverage clinicians from areas that are less affected by the coronavirus can replenish vital healthcare services in areas that are overwhelmed. This puts trained resources where they are most needed, saving lives while shielding those who have not been infected. It’s an approach that also helps to prevent harm, such as when local workers become overtaxed in keeping up with demands for care.
Our own Amwell Medical group ensures we can provide this assistance by obtaining multiple state licenses for our providers. This notion was also extremely helpful during the initial COVID-19 wave. For instance, the New York medical license reciprocity allowed us to project our entire national network of providers to help the New York City outbreak.
Another example is Ochsner Health in Louisiana, which enables providers from outside their system to “Uber into the telehealth app.” More than 2,400 providers—both within and outside the health system—are trained to deliver virtual care through Ochsner Health’s telehealth platform. Currently, about 230 on-demand urgent care visits take place each day, with an average wait time of just eight minutes. The organization far surpassed its goal of 6,000 telehealth visits in 2020, with more than 80,000 virtual visits conducted since March alone.
Even within a state, any provider who is duly licensed can provide telehealth services throughout that state. This is useful for specialty consults, on-call coverage, and projecting care to rural regions. But, as mentioned above, national licensure or a national compact allows for much greater load-balancing potential.
The Federation of State Medical Boards’ Interstate Medical Licensure Compact has helped some, but it is fraught with challenges and only available in some states. The coronavirus pandemic has demonstrated what can be achieved when state licensure barriers are removed; hopefully the future will involve more licensure portability.
3. Establish the right incentives for virtual care.
The use of telehealth to replace in-person, routine care ensures continuity in care without exposing individuals to other illnesses—including the coronavirus—in the waiting areas of physician practices or EDs. Leading health plans are already offering telehealth to their members, but with caveats, and the offerings are disproportionately in states with reimbursement mandates.
In the federal space, reimbursement for telehealth is still spotty—permissible in Medicare Advantage (MA) but hamstrung in fee-for-service (FFS) Medicare by the site restriction. Medicaid coverage for telehealth exists, though it varies dramatically by state.
But expanding access to telehealth will require commercial payers and the federal government to incentivize providers and patients to use virtual care, and to offer payment parity for in-person and virtual services. It also necessitates regulatory flexibility, including greater flexibility around modality and model.
Prior to COVID-19, CMS took steps to increase access to telehealth for seniors by allowing MA plans to make telehealth a core benefit. After the arrival of the pandemic, the U.S. Department of Health and Human Services also took steps that resulted in a waiving of the Medicare site restriction for FFS Medicare. This has increased utilization and, importantly, encouraged providers to adopt telehealth for their entire patient panels.
The technology to combat the pandemic is here
The use of telehealth to transform our response to the coronavirus pandemic isn’t some futuristic idea. Telehealth was already establishing itself as a standard point of care prior to COVID-19. But during the pandemic, telehealth has become a necessity—and a vital part of most systems’ strategies.
Telehealth has played a key role in triage and gatekeeping overloaded EDs. It’s allowed providers to care for their patients while their offices are closed or restricted, and it has given patients much-needed access to care. In short, telehealth has saved lives and helped keep our healthcare system going. As we move forward, telehealth will simply be a part of how routine healthcare is delivered.
Peter Antall, MD, is chief medical officer for Amwell, a telemedicine provider.
PSQH: Patient Safety & Quality Healthcare, July 18, 2020
"EHRs by their nature are designed to protect and keep patient data private and confidential," says Doug Cusick, CEO of TransformativeMed.
This article was originally published July 15, 2020 on PSQH by John Palmer
Editor’s note: The following Q&A resulted from a conversation PSQH had with Doug Cusick, CEO of TransformativeMed, a Seattle-based electronic health record (EHR) provider and consultancy.
In this discussion, Cusick talks about why it has taken EHRs so long to roll out their technology virtually and why it took a pandemic to make EHRs—and health systems that use them—more accessible and easier to use.
PSQH: What do you think are the greatest benefits to implementing an EHR system virtually? What exactly would a virtual system look like, and what are some of the biggest infrastructure upgrades that would be needed?
Doug Cusick: The greatest benefit to a virtual EHR implementation is the cost savings to an organization.
Consider a scenario where an organization can sign up for an EHR service via a website, provide some basic information about the organization and its users, and then immediately begin using the software after some basic tutorials. This is a low-impact, low-cost alternative to traditional “go-lives” that, at most, might require some local computer upgrades to have increased memory capacity. A virtual or cloud-based EHR should require no significant infrastructure upgrades for the purchasing organization due to the very nature of the EHR being virtual. Likewise, “plug-and-play” or app-based technologies are also now available to make EHRs function more efficiently, and many allow for quick installation, configuration, and deployment.
From a software company’s perspective, the biggest challenge in providing virtual or cloud-based EHR solutions is the ability to make configurations quick and easy through the design and implementation of clinical best practice workflows, reducing the complexity of system functionality and designing a system that is so intuitive that it requires minimal user training. The infrastructure and experience needed to accomplish this is immense, as a virtual EHR requires substantial data storage capacity, security to protect protected health information (PHI), and outside connectivity technologies to share information with other EHR systems (e.g., with departments of health).
PSQH: In this world of COVID-19, what can a virtual EHR do to improve patient safety and potentially save lives?
Cusick: A virtual EHR removes physical location as a barrier to providing care and information-sharing—making it safer for providers to deliver care and supporting technologies such as telehealth that reduce patients’ potential exposure to COVID-19. It enables provider groups and hospitals to bring more minds to the table for deliberation, decision-making, and information-sharing, and also minimizes the care team’s exposure to COVID-19.
As we’ve seen during the pandemic, keeping frontline workers safe and healthy has never been more paramount. Enabling remote medical consultations between the provider and an ambulatory patient, as well as practicing telemedicine from home, minimizes exposure to COVID-19 and other infectious diseases, reducing the chances of exposing and infecting otherwise healthy patients.
Virtual information sharing can be critical in the context of patient safety in the face of new viruses. For example, remote medical consultations and real-time information sharing between providers in a health system with a shared EHR—or between departments such as the MICU and Infectious Disease—can cut down on safety misses and adverse events that could potentially harm patients.
Specific to the hospital workforce, with the right technology integrations, care teams can work remotely or semi-remotely and maintain a physical distance, helping to prevent the potential spread of COVID-19.
PSQH: Many hospitals have already invested lots of capital into EHR systems. What are some incentives for getting them to go virtual, and how do existing systems integrate with a new virtual system?
Cusick: Extensive adoption of electronic communication options (virtual meetings, remote systems access, high-speed internet) makes moving to a virtual system more logical than ever and reduces barriers to getting support when needed. With virtual implementations, design and training sessions can take place with end users without needing to schedule a physical space. And there are options for information dissemination, such as electronically delivering premade videos, live webcasts, and social media.
Other incentives for the organization to use virtual implementations to upgrade their existing systems are the overall reduced costs. There is less physical space needed for on-site employees, and reduced implementation and support time as the virtual work provides for more flexibility for getting work done outside of the traditional workday.
With virtual systems, there can be increased clinician satisfaction because there’s an increased flexibility to meet with clinical users on their schedule without interrupting workflow. And there are other aspects that increase satisfaction, such as 24/7/365 technical and clinical support without delay for travel to and from different physical locations.
Keeping clinician satisfaction in mind—and helping them with their workflows rather than impeding them—results in more productive physicians who are more satisfied. With that comes greater—and safer—patient throughput. There is also a significant opportunity to reduce the burden on the health systems’ IT support centers and the CIO [chief information officer] because the vendor partner takes on more of the traditional roles that link the IT department with the clinical users. This reduces the frustration and need for the CIO and IT support to juggle and manage so many requests coming from the users and enables “wins” to be delivered quickly and with more success.
PSQH: What are some examples of healthcare organizations that have used a virtual EHR, and what outcomes have they seen?
Cusick: It’s only recently that any health system has implemented a full EHR virtually, with the most recent being a Cerner implementation at Macon Community Hospital in Lafayette, Tennessee. The healthcare industry typically has not implemented EHRs remotely due to the vast undertaking needed. However, a small number of software companies recognized years ago that available technology could enable remote implementation of “out-of-the-box,” already customized clinical workflow solutions, such as those that enhance EHRs, with little to no training required as long as the solutions are designed to be naturally adopted at “go-live.” It is also critical that these application vendors not be an IT burden on the organization, especially for the IT decision-makers responsible for the vendor selection. The value expected from the health system should be realized right away, with quick wins that increase clinical quality and provider satisfaction.
PSQH: What do you foresee as the future of virtual EHR? Will patient information, for example, live in the cloud instead of in file cabinets in the future? How will a virtual EHR protect sensitive patient information?
Cusick: The future is already here as very few healthcare providers in the United States use paper medical records. Medicare reduces reimbursements to providers who do not use EHRs, so many have converted to EHRs either by purchasing and implementing large, expensive systems or by joining larger healthcare organizations and adopting their EHR systems—or by using one of the many smaller, cloud-based systems that provide end-to-end patient-provider engagement through portals to access records, schedule appointments with providers, and perform medical billing.
EHRs by their nature are designed to protect and keep patient data private and confidential. Because technologies such as APIs communicate back and forth with the EHR where the data resides, it remains protected.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.