Bon Secours’ new Richmond market CNO is excited to take on her new role after holding many leadership positions within the system already.
Cassie Lewis has held a variety of leadership positions since joining Bon Secours in 2012. During the last 11 years, she has served as the chief nursing and quality officer for the Providence Group within Bon Secours Mercy Health, regional director of Advanced Practice, and lead nurse practitioner and co-director of St. Mary’s Hospital in Bon Secours’ Richmond market.
Lewis now serves as the new chief nursing officer for the Bon Secours Richmond market. She says she has a passion for blending the perspectives of providers and nurses together and uses that knowledge to lead, and she has a vision for building a sustainable workplace culture where nurses feel safe, seen, and heard.
For our latest edition of The Exec, we sat down with Lewis to discuss her thoughts on advancing nurses’ careers, reflecting the community in your staff, and the messaging of virtual nursing. Tune in to hear her insights.
A Kaiser Permanente study of ambient AI scribes used to capture doctor’s notes and enter data into the EHR finds that they are improving the doctor-patient experience, but doctors still need to edit their notes
Ambient AI scribes designed to transcribe patient-physician encounters into the EHR may hold promise in reducing clinician workloads, but they aren’t there yet.
That’s the conclusion drawn from a recent study of more than 3,000 clinicians at the northern California-based Permanente Medical Group (TPMG) who used the technology in late 2023. The study, appearing online today in NEJM Catalyst Innovations in Care Delivery, finds that the AI tool did accurately represent the conversation between doctor and patient, but there was still a significant amount of editing that had to be done.
“Ongoing enhancements of the technology are needed and are focused on direct EHR integration, improved capabilities for incorporating medical interpretation, and enhanced workflow personalization options for individual users,” the study team, comprised of eight Kaiser Permanente researchers and executives, concluded. “Despite this technology’s early promise, careful and ongoing attention must be paid to ensure that the technology supports clinicians while also optimizing ambient AI scribe output for accuracy, relevance, and alignment in the physician–patient relationship.”
While automation and AI technology have been around for several years, the rapid advances of new forms of the technology have created a stir in several industries, including healthcare. AI and large language model (LLM) tools have the potential to not only handle administrative and back-office processes, but reduce workloads and stress for clinicians and staff by handling time-consuming and computer-driven tasks. Ambient AI scribes, for example, are designed to capture conversations and input data into the EHR, giving clinicians and staff the opportunity to interact with patients more freely instead of typing words into a laptop or trying to recall the gist of the conversation later.
While not the first study, the Kaiser Permanente study is one of the largest to test the technology in a clinical setting. It gives healthcare executives valuable insight into where the technology stands now, and what needs to be done to make it more effective.
According to the study, some 6,000 Kaiser Permanente clinicians have been using software-based medical dictation technology for at least two years. In August 2023, TPMG launched a two-week pilot with 47 physicians using an AI scribe; based on positive reactions from the physicians, the organization then secured licenses for 10,000 physicians and staff across several settings.
According to researchers, 3,442 physicians used that tool in the first 10 weeks of implementation for 303,266 encounters, with almost 100 physicians using the tool more than 100 times and one doctor using the tool for 1,210 encounters. Overall, the tool was used more than 19,000 times a week in seven of the 10 weeks studied.
In studying how clinicians and their staff used the technology, the research team identified four aspects of ambient AI scribes that would facilitate effective use:
Facilitate engagement by demonstrating growing and sustained adoption of ambient AI by number of clinicians and percentage of patient encounters across diverse specialties and settings.
Aim for effectiveness by reducing the burden of documentation within and outside of direct patient encounters.
Enhance the physician–patient relationship by increasing the amount of time physicians spend interacting with patients by improving engagement and reducing time spent interacting with a computer.
Maintain documentation quality by developing approaches to assess and safely use ambient AI technology capabilities in transcription and summarization.
And at the end of the study, the team listed four takeaways:
Ambient AI scribes “show early promise” in reducing the burden on clinicians to take notes and spend extra time entering that data into the EHR.
Both clinicians and patients said the technology improved the care experience, and some clinicians called the technology “transformational.”
While a review of AI-generated transcripts resulted in an average score of 48 out of 50 in 10 key factors, that doesn’t mean they can replace clinicians. There were inconsistencies, and clinicians still had to review the notes and make corrections “to ensure that they remain aligned with the physician-patient relationship.”
“Given the incredible pace of change, building a dynamic evaluation framework is essential to assess the performance of AI scribes across domains including engagement, effectiveness, quality, and safety.”
The research team also noted that AI technology is evolving quickly.
“The approaches to robustly evaluate the quality and safety of AI technologies, including tools such as large language models, remain incompletely defined,” they said. “The underlying algorithms and relevant regulations are also continuing to evolve rapidly, which will necessitate ongoing benchmarking, evaluation, and monitoring as the technology improves and vendors bring new software to market. Adoption rates and usage patterns are also expected to change as new user groups and application domains are identified and tested.”
With that in mind, the study offered advice for other healthcare organizations aiming to evaluate ambient AI scribes.
Find clinical champions to overcome barriers to adoption and create a culture that embraces innovative ideas.
Starte with a limited pilot involving a small number of clinicians, then scale up to a regional or larger-scale pilot with “opportunities for clinician and patient feedback that result in ongoing improvement that is tangible to stakeholders.”
Develop monitoring and benchmarking processes “that offer proactive assessment of the tools and their impact on meaningful goals.”
The Tennessee-based health system has migrated its data to a FHIR-based platform and now plans to use AI to address administrative and clinical efficiencies.
Community Health Systems has announced a collaboration to develop generative AI programs on Google Cloud.
The Tennessee-based health system, comprising 71 hospitals and more than 1,000 healthcare sites across 15 states, announced today that it has completed migration to a FHIR-based clinical data platform on Google Cloud.
“The goal of this migration extends well beyond modernizing our data infrastructure,“ Miguel Benet, MD, MPH, FACHE, CHS’ senior vice president of clinical operations, said in a press release. “By building a secure foundation to take advantage of new innovations in AI, we’re able to streamline our clinical providers’ workflow and advance the way we deliver patient care.”
Tech giants like Google, Microsoft, and Amazon are partnering with health systems and hospitals to develop enterprise-level AI programs, combining the data storage and analysis capabilities of the former with the clinical and administrative expertise of the latter. In December, Google unveiled a new suite of healthcare AI models called MedLM, built off the Med-PaLM 2 large language model introduced earlier in the year, as well as an early iteration of its next-gen generative AI model called Gemini.
One of Google’s biggest partners is HCA Healthcare, also based in Tennessee, which has been piloting Ai technology in Emergency Departments (through smartglasses) and to help nurses with documenting patient encounters.
“We’re on a mission to redesign the way care is delivered, letting clinicians focus on patient care and using technology where it can best support doctors and nurses,” Michael J. Schlosser, MD, MBA, FAANS, HCA’s senior vice president of care transformation and innovation, said in a press release. “Generative AI and other new technologies are helping us transform the ways teams interact, create better workflows, and have the right team, at the right time, empowered with the information they need for our patients.”
CHS is looking to build off its centralized data depository on Google Cloud’s health data platform to improve interoperability and drive real-time data analysis. The health system also plans on using Vertex AI and other large language models to target both administrative and clinical efficiencies, even pairing AI with Google Maps to give patients personalized resources in their communities.
Supporting nurses' education might be key to solving the staffing crisis.
Recruitment and retention are particularly difficult right now in healthcare, especially in nursing.
Health systems are struggling to find new nurses who will stay at their hospitals permanently. Many veteran nurses are retiring and taking their knowledge and experience with them. This combined with the overall shortage of staff leaves new nurses feeling overworked and without the guidance and mentorship of their predecessors.
Here's what you need to know about building academic partnerships to improve recruitment and retention, according to Maribeth McLaughlin, VP and CNE at UPMC.
This leader outlines the dissatisfaction of nurses across the industry.
On this week’s episode of HL Shorts, we hear from Katie Boston-Leary, Director of Nursing Programs at the American Nurses Association, about the factors leading to nurse dissatisfaction and the increase in union and strike activity across the country.
What are the underlying causes of the recent union and strike activity happening in the U.S?
There's a generalized dissatisfaction of the current state of [nursing] from nurses. There are a number of things that nurses that have historically [and] traditionally struggled with, and I think that the phenomenon that's happening right now is nurses are really saying “no more.” There was dissatisfaction, but it was a dull roar, and now a lot of what's bubbling is manifesting in a lot of this organized activity. That is a big concern for a lot of administrators and hospital executives, but in some respects, nurses are using this as a last resort. [Some are having a] “tried everything and this is where we are” kind of approach to this, and then there's some that are saying, “you know, maybe this is the way for us to have a voice, so getting unionized is probably the way to go.”
There is a lot under the surface that's causing this, starting with the staffing and the crisis that we're in. Then you have the well-being piece where [the] nurses’ overall health and well-being is compromised because of everything that's happening, and we have data that actually links those two, staffing and well-being, together for nurses. Then there's everything else after that, that's a close second, third and 4th and 5th. There's workplace violence, there's unmanageable workloads, there's [the] hierarchical structure of healthcare systems. There's the feeling of not being heard, the feeling of exhaustion and not being able to do what you figure patients deserve, and leaving everyday feeling that moral distress. All those things have brought us to this point, unfortunately.
With version 2.0 now supporting FHIR-based exchange, Mariann Yeager of the Sequoia Project says the final draft of standards for nationwide interoperability should be unveiled by the end of March.
Healthcare organizations with a vested interest in interoperability should be taking a close look at version 2.0 of the Trusted Exchange Framework and Common Agreement (TEFCA), which now supports FHIR-based exchange.
The government-supported effort to create nationwide interoperability standards has been more than two years in the making, coming out of the 21st Century Cures Act. This past December, five healthcare organizations were the first to be certified as Qualified Health Information Networks (QHINs), giving them the standing to support data exchange.
Yeager says the biggest take-away from version 2.0 is federal recognition of FHIR (Fast Healthcare Interoperability Resources), the HL7 standard that defines how healthcare information can be moved between disparate platforms.
“The most important thing for people to understand is that version 2.0 was revised to support FHIR-based exchange,” she told HealthLeaders. “There are new use cases to support healthcare operations and public health. The other thing is it does permit health systems that participate in TEFCA-based exchange to connect to multiple QHINS, to the extent that they support multiple data sources.”
Yeager also said she expects more conversation around health systems that appoint another entity to exchange healthcare data.
Writing in the HealthITbuzz blog earlier this month, Chris Muir and Alan Swenson of the Health and Human Services Department’s Office of the National Coordinator for Health IT (ONC) said the unveiling of five QHINs and the release of TEFCA version 2.0 “continue the momentum” toward a nationwide interoperability platform this year.
“In the short-term, ONC and the TEFCA RCE anticipate ‘facilitated FHIR’ exchange beginning to be implemented as part of TEFCA exchange as early as the first quarter of calendar year 2024 connected to the release of Common Agreement Version 2,” they said. “As in Version 1, Version 2 of the Roadmap describes facilitated FHIR exchange in which Qualified Health Information Networks (QHINs) provide the network infrastructure to support FHIR API-based exchange between TEFCA Participants and Subparticipants from different QHINs.”
“Specifically, if a TEFCA Participant or Subparticipant wants to obtain a patient’s data using FHIR, they will go to their QHINs to determine who has the patient information,” Muir and Swenson continued. “Patient discovery will take place through the QHIN-to-QHIN interaction, including discovery of the FHIR endpoints for those that have the patient data. The initiating Participant or Subparticipant will then directly (i.e., without going through the QHIN) and securely query each of those endpoints.”
Yeager says she’s excited to see data exchange scaled up to a national level.
“There are different ways in which FHIR is being used,” she said, noting that TEFA had support content exchange and is now embracing native FHIR. “We’re talking about … facilitating FHIR-based exchange with each other. What that enables is nationwide scale. This is an unprecedented opportunity in the US to support FHIR-based exchange at such scale.”
The five QHINs, MedAllies, the eHealth Exchange, Epic Nexus, Health Gorilla, and the KONZA National Network, have been exchanging data since TEFCA officially went live in December. Yeager says “several others” are going through the process to become designated QHINs and other healthcare organizations are preparing to take that route as well.
“They really see FHIR as an important functionality,” she said of the first QHINS.
Aside from gathering information through the public comment period, Yeager says the Sequoia Project will be scheduling public information webinars as well as targeted feedback sessions over the next several weeks to prepare the final version.
Muri and Swenson of the ONC said there are more goals ahead.
“Looking forward, the updated Roadmap describes two more phases of FHIR implementation beyond facilitated FHIR exchange,” they wrote in the blog. “The next phase, QHIN-to-QHIN FHIR Exchange, [will] enable QHINs to leverage FHIR-based exchange for exchange between QHINs while continuing to support non-FHIR approaches within the QHINs’ internal networks.”
“The last phase, End-to-End exchange, would permit a Participant/Subparticipant to seamlessly exchange FHIR data between themselves and other network members through the QHINs and multiple other intermediaries both within a QHINs’ network and through the TEFCA-governed network,” they added.
Yeager expects interoperability to be an ever-evolving process.
“TEFCA is really going to be evolutionary,” she said. “We will definitely be learning as we go, learning and adjusting. … You learn by putting things into practice.”
Recruitment and retention are particularly difficult right now in healthcare, especially in nursing.
Health systems are struggling to find new nurses who will stay at their hospitals permanently. Many veteran nurses are retiring and taking their knowledge and experience with them. This combined with the overall shortage of staff leaves new nurses feeling overworked and without the guidance and mentorship of their predecessors.
Maribeth McLaughlin, vice president and chief nurse executive at UPMC, says the COVID-19 pandemic also contributed to this issue.
“During the pandemic, if you think about back in the beginning in 2020,” McLaughlin says, “for many of us, our pipelines with the schools of nursing, our academic partners…really kind of fell apart.”
Students moved to remote settings, relationships were strained, and curriculums changed, she says. And it affected academic partnerships all across the healthcare industry.
Establishing partnerships
A crucial first step for CNOs dealing with this issue is to reestablish academic partnerships with nursing schools to help create clear pathways into the industry for students who are working to become nurses.
McLaughlin says UPMC partners with about 140 different schools, and a senior nurse leader runs point with each of those relationships. UPMC also created an academic affairs office, with oversight from a CNO, that helps with finding placements for students, building relationships, and partnering on new and innovative programs.
Additionally, health systems can take certain measures to support their own employees going back to school.
McLaughlin says UPMC expanded the diploma at its schools of nursing, and partnered with other universities so their students can become nurses and continue to work towards bachelor’s degrees. UPMC also has a tuition reimbursement program, in which many of the participating students are UPMC employees who are in entry level positions and want to become nurses.
“There are an overwhelming number of people who want to still become nurses,” McLaughlin says. “The challenge is helping them, not just with tuition, [but also with] going back to school, and with trying to work and go to nursing school.”
CNOs should focus on pipelines and targeted recruitment, and ensure that there are good student experiences in the health system. McLaughlin says UPMC created student ambassadors in all of the units across all the hospitals, as well as the student nurse internship program. Both programs allow students to get clinical experience before they graduate, making them better candidates for recruitment.
The education of future nurses can go far beyond university and collegiate experience as well.
“[We have started] to think about how to get into the middle schools and high schools,” McLaughlin says. “Not just for nursing, but for all of our patient care roles in a hospital, to be able to really grow our professions for the future.”
Support from outside agencies can also make these pipelines possible. For instance, the Vanderbilt School of Nursing was recently granted funds from the Health Resources and Services Administration’s (HRSA) Bureau of Health Workforce to help build the new Nurse Education, Practice, Quality, and Retention Simulation Education Training Program. The $1.5 million grant is intended to help expand offerings for students, faculty, and other health professionals and to provide them with more learning and career-building opportunities.
The grant is funded by the Department of Health and Human Services and is part of the HRSA’s Nurse Education, Practice, Quality and Retention (NEPQR) grant program. The goal behind the grant program, according to the HRSA, is to forge a pathway for students to enter the clinical environment by creating and implementing Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) to Registered Nurse (RN) bridge programs, and the employment of clinical nurse faculty. The funds can be used for program development, direct LPN/LVN to RN student support, curriculum and partnership development, and for recruiting faculty and clinical preceptors.
Support after recruitment
How can CNOs build upon this progress?
Creating the pipelines is only half the battle. CNOs must provide support for incoming nurses and make sure they feel valued and have opportunities for advancement in their careers.
“Rotating shifts is not easy,” McLaughlin says. “Being a nurse in a hospital, you’re going to work off shifts, you’re going to work weekends, [and] you’re going to work holidays.”
The support needs to go beyond just the clinical.
McLaughlin says UPMC is restructuring the onboarding and education processes to be more supportive at the bedside, and to consider what nurses need in a residency beyond the support that is typically provided. New nurses need help learning how to rotate shifts and how to take care of themselves throughout their shifts. They should be given advice on how to sleep in different patterns, eat properly, wear the right shoes and clothing, look at their schedules, and know how many shifts they should be working.
“We have a wellbeing committee of frontline staff and we’ve been working with our own health plan to develop a tool kit,” McLaughlin says. “That’s where we’re now very focused, trying to support those nurses.”
There are other kinds of support as well that must be made available to new nurses. Nurses need to have the right teaching skills and know how to deescalate situations, delegate, work in teams, and process what they are going through on an emotional level, McLaughlin states.
She says UPMC created “condition support,” which is a resource that nurses can use to get help with deescalating situations.
“Those are all things that are really important for all our staff,” McLauglin says, “so that we can help them as they transition to the workforce, [and] learn the skills they need. …We’re trying to give them as many of those tools and support as we can.”
CNOs should focus on academic partners and making sure student experiences are positive, and then focus on first year turnover. McLaughin recommends checking in with employees and asking more targeted questions to find out how they are doing.
“Try to create mechanisms for identifying people who are beginning to be at risk or are struggling [with] anything from the work to emotions or situations,” McLaughlin says. “And then [look] at scheduling, and [look] at the ability to be as flexible as you possibly can be, so that people feel like they have that work-life harmony.”
A new law allows Garden State health systems to expand their Hospital at Home programs to include Medicaid patients and those on private insurance
Health systems in New Jersey are now able to expand their Hospital at Home programs to patients in Medicaid and private insurance, thanks to a new state law.
The Hospital at Home Act, which was passed by the state Legislature and signed by Governor Phil Murphy in September 2023 and enacted into law on January 23, establishes a state Hospital at Home permitting process through the New Jersey Department of Health that is consistent with the Centers for Medicare & Medicaid Services’ Acute Hospital Care at Home Program.
Executives at Virtua Health, which launched its Hospital at Home program two years ago and now offers services through five of its hospitals in the southern part of the state, hailed the new law. Aside from introducing patients in the state’s NJ Family Care and Medicaid programs to the service, the law enables the health system to work with private payers to cover the program.
“We are excited to see Hospital at Home expand in New Jersey through this legislation, and we believe our state can serve as a template for the rest of the country,” Michael Capriotti, MBA, senior vice president of integration and strategic operations for Virtua Health, told the Gloucester City News earlier this week. “It is important that we continually innovate to create the best possible experiences and outcomes for our patients.”
More than 300 health systems and hospitals across the country are following the guidelines set by the CMS program, which includes a waiver, put in place during the pandemic in 2020, that allows the healthcare organization to qualify for Medicare reimbursement. That waiver is due to expire at the end of this year, and supporters are lobbying both Congress and CMS to make that waiver permanent.
The program targets patients who would otherwise be admitted to the hospital, creating a home-based care management plan that includes often-multiple daily visits by care teams, virtual care services and remote patient monitoring. Some programs have added ancillary services to address social determinants of health, imaging and tests, and pharmacy and rehab needs.
New Jersey is one of the first state to establish specific state guidelines for the program.
According to Virtua Health, the health system has enrolled more than 900 patients, representing more than 60 different medical conditions, in the program.
According to a recent national study of the program by researchers at Mass General Brigham—one of the first health systems to launch the program—the Hospital at Home concept has reduced the mortality rate for patient who would otherwise be hospitalized; it has also reduced the escalation rate (returning to the hospital for at least 24 hours) and rehospitalization rate within 30 days of discharge.
“Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.” David Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home, said in a press release. “If people had the opportunity to give this to their mom, their dad, their brother, their sister, they should.”
Here’s how CNOs should be preparing for nursing strikes, according to this CNO.
Nurses have been going on strike all throughout the United States.
The recent union activity is indicative of large, widespread problems in the nursing industry with staffing, work environment, and nurse wellbeing. While it is the CNO’s responsibility to address those issues and to facilitate those conversations, it can be quite difficult.
To learn how CNOs should handle these situations, we sat down with Dr. Chaudron Carter, Executive Vice President and Chief Nurse Executive at Temple Health, to hear how her health system avoided a strike, and how to build a plan for continuing operations during a strike.
Federally qualified health centers (FQHCs) are using telehealth and digital health tools to improve access and erase care siloes for millions of underserved Americans
Federally Qualified Health Centers (FQHCs) are often the first point of contact for underserved populations seeking access to care. And often that first impression can make all the difference in accessing care that improves outcomes.
At Kenosha Community Health Center, that first contact is now handled by a nurse who can quickly and efficiently funnel the patient to the right care provider.
“We’re seeing a higher volume of patients with more complex needs, so it’s important that we make this as efficient as possible,” says Mary Ouimet, the Wisconsin-based health center’s CEO. “When you have more than 450 calls a day, that can be a bottleneck.”
Kenosha, part of the Pillar Health network, is one of several FQHCs to collaborate with Conduit Health Partners on nurse triage services. And that’s part of an even larger trend of FQHCs, rural health centers (RHCs), and assorted community health clinics outsourcing some services and using telehealth and digital health technology to alleviate those bottlenecks that keep patients from accessing the care they need.
There are an estimated 1,400 FQHCs and more than 4,400 RHCs in the US, according to the Health and Human Services Department’s Health Resources and Services Administration (HRSA), which supervises funding for those providers. They, along with look-alike (LAL) organizations, provide care and resources for more than 30 million Americans, many of whom can’t afford or access care at a hospital, health systems, or primary care provider.
With the Centers for Medicare & Medicaid Services (CMS) loosening the purse strings on Medicare and Medicaid coverage, these providers are embracing new technologies to improve access to care and resources. At Kenosha, that means instituting a digital nurse triage service that channels the right patients to the right care.
“This is an essential function of the health center,” says Ouimet, who estimates that 100-150 incoming calls a day are now connected to Conduit Health nurses. “These are nurses at the other end who can work with [patients] to coordinate care. The average call time is reduced, and we’re improving time to treatment and bed scheduling. It’s just better care.”
In Massachusetts, meanwhile, an organization serving the commonwealth’s 52 community health centers covering more than 300 sites and 1 million patients is using HRSA grant funding to maintain a technology platform that keeps track of when and where patients receive care. The platform, developed by Bamboo Health, sends real-time notifications to care teams when a patient visits another care provider outside the system, enabling the care team to access admission, discharge and transfer data.
Susan Adams, vice president of health informatics for the Massachusetts League of Community Health Centers, says the technology gives care teams instant digital access to information that would otherwise be siloed away, creating gaps in care that could affect outcomes. She said those care teams had to ask for paper printouts of those visits, then manually enter the data into the patient’s medical record.
“We could be at the printer all day long,” she says.
Thirteen of the Mass League’s CHCs were originally put on Bamboo Health’s platform to monitor some 400,000 patients. According to the organizations, those CHCs saw a 47% reduction in 30-day readmissions among ED patients, a 20% reduction in 30-day readmission among hospitalized patients, and a 33% increase in follow-ups within 30 days of discharge.
The Mass League is now expanding that platform to more CHCs.
“We aren’t getting all the data we need to manage these patients,” Adams says, noting care teams sometimes never learn that a patient has been hospitalized or visited an ED somewhere else unless it comes up in conversation with the patient. The more data we can put into [the patient record] the better chance we have of providing care.”
Having a complete patient record, she says, also helps with chronic care management and strategies to address social determinants of health (SDOH), key care programs that CHCs, FQHCs and other health clinics are being asked to take on.
“I think the challenge will come with managing all of these alerts,” Adams says. “But that’s a good challenge. This gives us a chance to address more care [management and] coordination goals. It’s something that we’ve been waiting a long time to do.”
