The key to getting doctors on board is to present them with the evidence, and then put it to a vote.

One of the biggest hurdles in supply chain is gaining physician support for clinical product procurement.

In this interview, Dan Hurry, president of Advantus Health Partners, the Cincinnati based supply chain mangement and group purchasing organization, says the key to getting doctors on board is to present them with the evidence, and then put it to a vote. Hurry spells out the process that he recommends in this, the first of a two-part interview with HealthLeaders. This transcript has been edited for clarity and brevity.

HL: How big of a factor is physician preference in supply chain?

Dan Hurry: From a quality of care, from an economic, and from an efficiency standpoint, it's probably 60% of what you should be talking about and working on at any given time. The activity is revolving around the ORs, the cath labs, because that’s the implant space, whether it's cardiac, whether orthopedic, those are the predominant spaces where the engagement between a physician and a manufacturing rep and your operational leaders interconnect.

Would hospitals always be looking for the lowest cost? No. They’re looking for what’s the best outcome for the patient at hand. Now with that, it's always debatable about what is the better product. So, we lean into clinical evidence in all those scenarios. The cost of goods, how much we're buying it for is only one part of the equation.

HL: Where is the potential for conflict?

DH: In many cases it may be relationships that a manufacturer's rep has with a physician. What is their role in the OR or the cath lab, and how does that impact choice? That space is always under scrutiny with the potential for conflict, but there's usually a superficial point that's brought forward, so we lean into most of the evidence and that all comes from the physicians’ side of the house.

We collect and organize data on the front end, and we put together a “fact pack.” Using cardiac rhythm devices as an example, we ask what the patient looks like, how the physicians use the devices, where do they use these devices, what does that look like from either a regional or a national market share utilization perspective, what do the outcomes look like with any particular devices, etc.

The fact pack yields data that allows some comparables between different scenarios, different companies, different products, whatever that looks like. Once you get that homework done, it's time to engage the physicians and see what the state of the union looks like.

Typically, there will be a very brief engagement with the physicians on the front end, before gathering the data, telling them we're going to review this. When we've got bigger, better and deeper data, we'll engage you on a deeper level.

Then when we engage them on all the facts, they're scientists, they want to see the data they want to see what this looks like, and we have some dialogue from there. Ultimately, we ask where do we want to go with the product based on its lead with that clinical evidence? Then we'll ask how do we negotiate for the best quality products.

HL: How important is volume in price negotiations?

DH: We’ll use the Costco model as an example. They usually don't put sub-quality products on their shelves. They negotiate for the best quality within a category or product mix and match what deserves shelf space. We do that at the front end. What are the products that deserve some shelf space, where we agree that this is a quality product made by a quality company with outstanding outcomes? How do we negotiate to come up with the economic package to support continuous use?

Once that's done, there is a perpetual review, with continuous improvement exercises constantly engaged with category management teams of cross-functional players in quality, clinical, economic and operations.

HL: To what degree is cost part of the equation?

DH: We do not chase low-cost goods. We chase the best quality goods and then drive the best economic outcome for those quality goods. Cost is always a factor, but it is a tertiary concern, behind outcomes and quality.

We contract with a few outside companies that are run by physicians who do independent assessments of outcomes, quality, the attributes associated with any given product. We’ll ask if these assessments align with our physicians’ experience. They may or may not agree with an analysis and that's where we want to gain their input.

HL: Who has the ultimate say in what product is purchased?

DH: We have a cross-function of folks, physicians, C-suite executives, quality, economics, finance. Supply chain is run by a certain group of folks that go through this process. There’s a vote and a proxy and what we land on and what's approved. It's no independent group in and of itself.

Once we've landed on the right product or product mix, like any other consumer, we negotiate based on attributes, our commitment to the products, the optimal logistics solution, what do our payment terms look like, everything that kind of supports the economic equation for the products that we've selected. There’s no rocket science out there.

What will it take? Rural health executives share their solutions to healthcare desert challenges.

Editor’s note: This article appears in the July-September 2023 edition of HealthLeaders magazine.

Virtually every problem that exists in healthcare today is exacerbated for rural providers due to lack of resources and funding, a smaller talent pool, and fewer points of access. What can be done? Can the problems facing rural healthcare be solved? Rural healthcare executives share ways that can help alleviate specialty care access, staffing issues, and financial challenges.

Telehealth can conquer rural access challenges for both patients and specialists

Access to primary care in rural and remote parts of the country is tough enough, but what about when someone needs to see a specialist?

According to the National Rural Health Association (NRHA), there are roughly 30 specialists available per 100,000 people in rural parts of the country, compared to 263 per 100,000 people in urban regions. Simply put, specialists tend to live and work in well-populated areas, where they can work near large health systems and have access to a large patient base. The only time you'll likely find a gastroenterologist or neurologist in rural America is if they've retired there.

Rural communities and health systems are addressing this challenge through telehealth and digital health tools and platforms. They're using platforms that enable rural residents to meet with specialists online, either from their homes or from telemedicine stations set up at local hospitals, health clinics, or doctor's offices. In addition, these platforms enable specialists to live in rural regions and build their own patient base.

Organizations like the MAVEN Project are contributing as well by forming virtual networks of specialists to help remote health clinics access specialists for mentoring and support. The MAVEN Project is a nonprofit organization that has built a network of retired and active providers and specialists to virtually mentor and support providers in rural areas and those who work with underserved populations.

"We want to be in an environment where everybody can have access to health services when they need them, and that includes specialists," says Suzan Bast, service excellence manager at Fairbanks Memorial Hospital in Fairbanks, Alaska, a city of roughly 100,000 that's closer to the Arctic Circle than the nearest major metropolitan center.

To facilitate access to specialty care, Fairbanks Memorial has a partnership with Troy Medical, a Texas-based telehealth company that provides virtual specialist services. Local residents who are referred to a hepatologist, rheumatologist, or gastroenterologist, or who need to see a neurologist or dermatologist and can't wait for the region's one specialist to clear time on the calendar, can visit the hospital's Tanana Valley Clinic to see a doctor located thousands of miles away.

"It's six hours to Anchorage," says Bast. "So if you need to see [a specialist], you're traveling a lot." That's time-consuming, costly, and exhausting to patients and their families, she says.

Standing up telehealth

Troy Medical was, in fact, launched by an Alaskan to meet that need for specialist services. Kara Hartl, MD, an ophthalmologist who'd spent roughly 15 years in Fairbanks, launched the company after struggling to find care for a patient who was living with a debilitating medical condition and needed to be seen by three specialists.

"I couldn't get them the access to care they needed," says Hartl, who named the company after that patient. "COVID made it a lot worse, but it also helped to validate telehealth as a way to provide that access."

Hartl says Troy Medical saw great success in its first year of operation in Alaska, at which point she decided to extend the company's reach to another state with similar rural health issues: Texas. She set up shop in Austin, began working with the Texas Organization of Rural and Community Hospitals, and launched a second site in Sulphur Springs, a city of 15,000 in the northeast corner of the state, about 80 miles east of Dallas.

Rural Texas faces many of the same healthcare access issues as Alaska. With smaller populations and a troubled economy, it's difficult to sustain a health system at all, never mind one with its own specialty services. Twenty-one hospitals in Texas have shut down over the last decade, more than any other state, and roughly a quarter of those still open are at risk of closure, notes the Texas Hospital Association on its website.

Hartl's business model is to establish relationships with local hospitals and communities, rather than just setting up a telemedicine platform and letting the chips fall where they may. As with Fairbanks, Troy Medical built a clinic in Sulphur Springs where residents can go for appointments. The hospitals have a role in selecting which specialists are needed, and the clinic is staffed with support personnel to handle administrative tasks and help patients with virtual visits.

"You need to have the presence on the ground," Hartl says. "Keeping it local is so important to those community hospitals."

That's because many specialist consults lead to more consults and care management, as well as treatments and other services that can be coordinated with local providers. The idea is to make sure care remains in the community.

"We're creating relationships and helping these patients navigate the healthcare system," she says. "The only thing we request of community hospitals is promotion."

State licensure rules often hinder telehealth expansion

Texas is proving an easier place to establish this platform, Hartl says, because the state has a lot of doctors. That means it's easy to find specialists in state and set up the virtual care network. Alaska doesn't have many doctors, so Hartl must expand her network into other states to fill the ranks.

That's one of the biggest challenges to this type of program. Each state licenses and regulates its own providers through state medical boards, and not everyone is comfortable treating a patient in another state through telehealth. The pandemic did make the healthcare industry aware that telehealth could be used to practice across state lines, and many states relaxed their rules during the public health emergency to allow certain telehealth services. But licensure is still a complex process, and doctors must apply for a license in every state in which they want to practice. This means telehealth platforms like Troy Medical must ensure the specialists they're providing can treat a patient in a certain state.

Hartl says she prefers to work with states that are part of the Interstate Medical Licensure Compact (IMLC), a network of states that have adopted a streamlined licensure process to allow providers to practice in other states (ironically, Alaska isn't in the IMLC).

That said, with successes in Alaska and Texas, Troy Medical is poised to expand to other states.

"The technology for this is straightforward," she says, referencing technology partners that include athenahealth and Logitech, among others. Troy Medical will spend roughly $100,000–$150,000 to stand up a clinic, then work with local hospitals and providers to bring in specialists virtually.

"Sometimes you feel like a rock star," she says, talking of providing access to a specialist in a rural area—which can save a patient and family thousands of dollars in travel costs, reduce stress, and uncover pathways to stronger care management, better clinical outcomes, and improved health and wellness. "It's what we want medicine to be like."

Back in Fairbanks, Suzan Bast says the platform can work both ways. While it gives residents access to the experts, it also gives her hope that the region can attract more providers.

"The benefits of Alaska don't necessarily appeal to everyone," the native Alaskan admits. But not everyone wants to live in a big city or densely populated state. Thanks to the technology now available, a doctor can think of moving to a rural area and develop a patient base that spans the country.

"The work-life balance isn't bad," she adds.

Why nurse practitioners are a solution to rural healthcare

With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NP) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.

NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.

"There are many people who don't see a doctor or get healthcare on a regular basis, and when they are really sick, they go to the emergency room for their care," says April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the American Association of Nurse Practitioners (AANP).

"It is definitely a need in rural health that we get providers out in every community," Kapu says.

Growing in number

The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.

The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.

"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."

Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.

A well-rounded approach to healthcare

NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.

"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."

NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.

"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.

Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.

"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So we try to prepare them in a way that it's global in that manner."

Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.

"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."

Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.

Breaking down barriers

Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.

For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.

The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep"and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.

States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.

Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.

"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."

Financial stability in rural health

According to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, 136 rural hospitals closed between 2010 and 2021. The Sheps Center says 19 rural hospitals closed in 2020, the most closures in a single year in the past decade.

A pair of top healthcare executives told HealthLeaders that four factors pose significant financial difficulties for rural hospitals:

1. Declining and stagnant populations in rural areas
2. An unattractive payer mix dominated by Medicare and Medicaid patients
3. Sicker patients in rural areas compared to urban areas
4. Financial challenges related to workforce shortages
    

"Declining and stagnant populations in rural areas are a challenge. About 80% of rural counties nationally have declining populations. Traditionally, rural hospitals had sufficient patient volumes, and they were able to provide care to most patients. That is just not the case anymore," says Brian Shockney, MHA, president of Indiana University (IU) Health South Central Region.

To address the impact that declining and stagnant populations are having on its rural hospitals, IU Health is careful about the kinds of services its facilities provide and it reviews the services relative to the population’s needs, he says. "Every three years, we do a community health needs assessment, and every year we reassess our services based upon that community health needs assessment."

Grants play a crucial role in providing services at rural hospitals with low patient volumes, Shockney says. For example, IU Health received a U.S. Health Resources and Services Administration grant to provide dementia and Alzheimer's disease care in Lawrence County, Indiana. "We are able to provide that care for patients through those grant dollars," he says.

The high percentage of Medicare and Medicaid patients at Lebanon, New Hampshire–based Dartmouth Health is a payer mix challenge, says Wendy Fielding, MBA, chief financial officer of Dartmouth Hitchcock and system vice president of finance of Dartmouth Health.

"For us, governmental payers are about 60% of our revenue mix. Medicare is about 46% and Medicaid is about 14%. Northern New England has an aging demographic, so we expect that percentage of Medicare to increase year over year. In our 2024 budget, we have a $15 million to $20 million expected erosion in our net patient revenue as a result of the ongoing growth of Medicare in our payer mix," she says.

New Hampshire has among the lowest-reimbursed Medicaid programs in the country. Dartmouth Health is dependent upon commercial payers to overcome the low reimbursement rates of Medicare and Medicaid, Fielding says. "We struggle to overcome the low payment rates. Ultimately, we are shifting the burden of these low governmental payment rates onto our commercial payers."

Other efforts to address the unattractive payer mix have generated limited results, she says. "We are always advocating for ourselves with our representatives in Washington, and though we work internally to become more efficient, we are still taking it on the chin."

IU Health sees sicker patients at its rural hospitals compared to the health system's urban hospitals, Shockney says. "Our rural citizens are not as healthy, and many are living in poverty. When we look at our rural populations and the death rates in rural areas, it outpaces urban areas in the top 10 causes of death, including heart disease, cancer, stroke, and Alzheimer's disease. They are expensive patients to care for. So, that raises the cost of care."

Medical home models of care have been effective in treating patients with high medical needs, he says. "At all of our practice sites, we have telemedicine for behavioral health, and we embed pharmacists, social workers, and dietitians where there is a need to address high diabetes rates and care for those patients. We provide a team of caregivers who surround the patient. In a rural clinic, we may not be able to provide a full-time pharmacist or a full-time dietitian, but we have the telemedicine capability to connect patients with behavioral health services, or a consultation with a dietitian, or something of that nature. That reduces the cost of having to have a physician, and it manages the care of the patient holistically."

Fielding says Dartmouth Health's biggest financial challenge is related to the health system's workforce. "Even though we are located in a rural environment, we are close enough to Boston that we do need to compete with that marketplace, so our workforce is more expensive than what you might think of for a rural setting. Like other healthcare organizations across the country, we have been dealing with an increased reliance on contract labor such as agency nurses. That is having a significant financial impact on us."

To make Dartmouth Health more competitive with the Boston labor market, the health system has been working with local real estate developers to boost affordable housing, she says. The health system has also been looking for ways to increase childcare options for its workforce, Fielding says. "We have explored investing in childcare centers and building up the workforce in those facilities."

She says keeping contract labor costs under control has been difficult. "In the short term, we have gone back to our payers to reopen contracts to negotiate higher payment rates for our health system members to reflect the labor cost inflation that we are experiencing. In the long term, the situation requires us to do things like work redesign to make sure if we are going to be using very expensive labor, we better be using those folks at the top of their license."

The purchasing power and economies of scale at health systems are pivotal in stabilizing the finances of their rural hospitals, Shockney says. "There is no doubt about it. That is why the hospitals in Bedford and Paoli came to IU Health. From a financial perspective, we knew we could improve those hospitals overnight. We could improve their purchasing power, reduce their costs, and spread those factors across the health system."

Healthcare remains a challenging commodity for both residents and care providers living in rural and remote parts of the country. Sparse populations, geographical challenges, and a dearth of financial resources all play a part in hindering access to care. But new ideas and technologies can change that paradigm, and in some places those innovative strategies are taking root and showing results. Telehealth and digital health tools and platforms, new collaborations, workforce initiatives, and innovative funding programs are all helping rural healthcare organizations provide access and improved health outcomes for their residents and communities.

Eric Wicklund is an associate managing editor and the innovation and technology editor at HealthLeaders. He can be contacted at ewicklund@healthleadersmedia.com. Carol Davis is the nursing and post-acute editor at HealthLeaders. She can be contacted at cdavis@healthleadersmedia.com. Christopher Cheney is the clinical care editor at HealthLeaders. He can be contacted at ccheney@healthleadersmedia.com.

Nashville General Hospital CEO Joseph Webb, DSc, FACHE, explains how health systems are addressing care gaps in the country's most underserved areas.

Editor's Note: Joseph Webb, DSc, FACHE, is the CEO of Nashville General Hospital.

It is no exaggeration to say that area codes determine as much about health and life expectancy as genetic predisposition, lifestyle, or daily habits. A community's built environment, including housing, parks, roads, and access to food and healthcare facilities, varies widely between rural, suburban, and urban communities, and it has a profound impact on the health of the people who live in them.

Gaping disparities exist, and on a wide scale. In fact, more than 80% of counties across the country lack access to services needed to maintain, much less improve, their health. That's approximately 30 million people in the continental United States who live in "healthcare deserts."

That sad fact has a real impact on all aspects of healthcare, including at its most basic level. Ongoing, regularly scheduled checkups with a primary care provider corresponds with better outcomes and reduced healthcare spending and the odds of a premature death. But that's for people fortunate enough to have access to that care. For those who live more than 30 miles from a provider and cannot reach one by foot or public transportation, lack of access to preventative services is more than just inaccessible. It is literally a matter of life or death.

People in rural areas are more likely to die from preventable or treatable diseases, such as heart disease, cancer, chronic respiratory ailments, and stroke than their urban and suburban counterparts. An analysis by the American Medical Association found that while overall mortality for Americans decreased between 1999 and 2019, mortality rates for rural residents between 25 and 64 years old rose by 12% in that same period.

The Growing Problem of Shrinking Access

The number of healthcare deserts in Tennessee makes it 15th in the nation. Twenty-three of its 95 counties, representing more than 36% of the state's population, or approximately 2.5 million residents, are designated as healthcare deserts, and slightly more than 27% of that population is rural. The healthcare services they lack include pharmacies, primary care providers, hospitals, emergency services, and community health centers.

Related, but no less impactful, factors include income, health literacy, and even internet access. Telehealth could help rural residents, but only a little more than 55% of Tennesseans have access to high-speed internet, compared to the nationwide average of 99.2%.

Changing demographics play a role, too. As urban Nashville gentrified, long-time residents were priced out, and so they moved out, which created new areas without sufficient access to healthcare.

This phenomenon is hardly contained to our region. The University of Texas reported that gentrification in Austin pushed low-income persons of color out of economically ascendant neighborhoods and into outlying areas that now have a rising population of disadvantaged residents. This "Great Inversion" has occurred in metro areas throughout the United States, and in Austin alone suburban poverty increased by 129% between 2000 and 2015.

Add to that an ongoing wave of rural hospital closures. More than 100 such facilities closed between 2013 and 2020, and 40% of all rural hospitals, already at risk of closing before the pandemic, were crippled further. Tennessee has seen the second-highest number of hospitals close since 2010.

Joining Forces to Bridge Healthcare Disparities

Low health literacy drives increased healthcare costs and poor outcomes, so elevating health literacy is obviously essential to creating healthier populations and communities. Collaboration with existing community organizations, such as churches, can be a powerful force in bringing education around health to people where they already live.

Local problems are driving local solutions. Tennessee Governor Bill Lee's recently proposed $52.6 billion budget includes $82 million to reimburse public hospitals for uncompensated care, primarily in rural areas, with more than $18 million dedicated to attracting 150 primary care residents to those regions.

Here at home, Nashville General Hospital is reaching beyond its service area through the Congregational Health & Education Network (CHEN), created in 2017 to address health disparities by training and providing resources that remove barriers to care in local communities. The CHEN framework is built upon four pillars: education starting in kindergarten, health literacy, access to care, and member support. And the soon-to-open Nashville Healthcare Center-Bordeaux in North Nashville will provide a comprehensive array of primary and specialty healthcare services in what once was a healthcare desert.

Eliminating healthcare deserts requires the combined efforts of fiercely dedicated individuals, proactive and imaginative community stalwarts, and deeply committed governmental entities and healthcare organizations. Only by working as a cohesive, goal-driven team can we address the wide-ranging disparities that create shortfalls in care among those who have been underserved for entirely too long.

Care to share your view? HealthLeaders accepts original thought leadership articles from healthcare industry leaders in active executive roles at payer and provider organizations. These may include case studies, research, and guest editorials. We neither accept payment nor offer compensation for contributed content. Send questions and submissions to Erika Randall, content manager, erandall@healthleadersmedia.com.

Northwell Health SVP and CIO Sophy Lu says health systems have to embrace consumerism—and the technology needed to support it—to establish personalized care experiences.

A health system's digital strategy won't work unless it's aligned with current trends and technologies, much like a car won't function at its best if its wheels aren't in alignment. And it's up to healthcare leadership to guide that transformation.

According to the HIMSS 2022 Future of Healthcare Report, roughly 90% of health systems surveyed expect to have a digital strategy in place within five years, and more than 60% say they're in the middle of that journey. But that strategy has to be planned carefully, focusing on how information is gathered from various locations, analyzed, and used to improve care pathways. Digital strategies won’t work unless there's a clear direction from leadership on value and ROI.

"We're in the business of delivering care," says Sophy Lu, senior vice president and chief information officer at New York's Northwell Health. And for that process to work best, she says, "We need to be in perfect synergy … with the patient experience."

And that begins with data.

"Data is the fuel for innovation," Lu said during a presentation at this year's ViVE conference in Nashville. This includes data from the health system's various platforms, like the EHR, as well as information from outside the network, culled from and about patients as well as payers. That data helps to create a plan to address a patient's healthcare needs and preferences and to work with payers to facilitate the patient's healthcare journey.

With so much data coming from outside the enterprise, health systems must invest in the technology to integrate and analyze that often-unstructured information. Lu says it's important for health system leaders to set the tone for that strategy by supporting digital health platforms that use data to improve the patient journey.

"Whatever we can do to enable that ease of experience will help us," she says.

[Listen to this Podcast: A HIMSS 2023 Chat With Northwell Health CIO Sophy Lu.]

It's a strategy that has been around long before the pandemic, Lu says, yet COVID-19 exposed just how slow the healthcare industry has been in effecting change. In many cases, she says, health systems are using legacy technology and antiquated processes for collecting, analyzing, and using data. Either they haven't committed the resources to upgrading that technology or they don’t feel they have the money to make those improvements.

"It takes a lot of energy technologically to integrate and validate" consumer-focused care with old tools and platforms, she says. "You have to invest in that change."

Many health systems are pulling in digital health partners to help execute that strategy. Northwell Health is working with b.well Connected Health, based in Baltimore. Company Founder and CEO Kristen Valdes says healthcare organizations often lack a background in understanding consumerism and need help on the intricacies of meeting patient needs, a concept she calls "shopability."

That includes learning how to work with partners to identify and implement consumer-friendly services, something the healthcare industry has traditionally avoided.

"The technology behind that is actually not a challenge," she says. "Change management is complex, [as is] learning how to collaborate. A lot of [health systems] need help as they make that transition toward consumerism."

Federal efforts to support interoperability and data transparency are helping to push healthcare organizations closer to sharing data, Lu and Valdes say. But the going isn't easy for an industry that has traditionally chosen to protect its own data in silos. Some are reluctant to share that data, especially with patients.

"They have to [come around to the idea] of how do I not just comply with a rule," Valdes says, but also invest in transformation that puts that data before both the patient and the provider and prompts them to collaborate.

In this era of shifting attitudes toward data, Lu says Northwell Health has to be "the harmonizer," leveraging data from multiple sources to create a longitudinal health record. Health systems that, as Valdes says, "own the process" will likely stand out among in an increasingly competitive field for care services.

"This is a journey toward personalized care," Valdes says. "How do we take a consumer and build an experience around them?"

The tool aims to predict a patient's chances of dying within 5-90 days of admission, helping care teams to decide when and how to integrate ACP into care management.

OSF Healthcare is using AI to help doctors and nurses integrate end-of-life discussions into care management plans.

A research team at the Illinois health system led by OSF Senior Fellow for Innovation Jonathan Handler, MD, tested an AI model that predicts the likelihood of a patient's death five to 90 days after admission. That information is then used by care teams to decide when to begin advanced care planning (ACP) for patients and their families.

The tool could help health systems improve care for a large number of patients. Surveys estimate only 22% of Americans have documented their end-of-life wishes. ACP can reduce the use of complex or intensive treatments at the end of life, thus reducing the cost and length of hospital stays and the amount of anguish placed on family members.

"Although experts agree on the importance of ACPs, clinicians cite time constraints and poor communication with other providers as barriers to having end-of-life discussions," Handler and his team wrote in a recently published study. Reduced access to healthcare in mixed-rurality populations may make ACP even more unlikely. Due to these barriers, many patients do not have documented preferences at the end-of-life and therefore do not achieve what has been termed an 'ideal death.'"

The researchers tested the tool on a dataset of more than 75,000 inpatient visits both before and during the pandemic, ensuring that the tool holds up over time and is equitable across genders, races and ethnicities, and against rural and socioeconomic factors. According to the study, the model helped to identify more than half of patients within the 5- to 90-day range.

Handler and his team also compared their model against one developed two years ago at NYU Langone Health, which was used to predict mortality rates within 60 days. Other health systems that have tested this type of tool include Penn Medicine, Stanford Medicine, and Duke Health.

"We sought a model to predict post-inpatient mortality to meet a different need – to help prioritize and encourage timely ACP conversations during an inpatient stay," the OSF team wrote. "The model’s intended use is to predict mortality soon after the length of an average inpatient stay. Therefore, the 5-to-90-day window was chosen to: 1) begin after the average 4-day length of an inpatient stay, 2) allow at least 4 days for an ACP if the inpatient stay is longer than average, and 3) create enough urgency to stimulate the ACP."

In their conclusion, Handler and his colleagues say their model holds up well over time and can help to "consistently and equitably help prioritize patients likely to benefit in the near-term from theses crucial conversations."

The Farm Family Resource Initiative offers telehealth access for mental health services to rural farming and ranching communities, where suicide rates are two to five times higher than other populations.

Rural health system executives looking to address the soaring mental health crisis may be interested in how Illinois is addressing the issue.

Illinois Governor JB Pritzker announced this week the state-wide expansion of the Farm Family Resource Initiative (FFRI), a program coordinated with the Southern Illinois University (SIU) School of Medicine to improve access to mental health services for rural communities, especially those in the agricultural industry.

"As governor, as a father, and as someone who has personally witnessed the mental health epidemic among family and friends, there is nothing more important than making sure every Illinoisan has access to the mental health services they need to lead happier and healthier lives," Pritchard said in announcing the program expansion at the 2023 Farm Progress Show in Decatur. "Our greatest problems require our most creative solutions — and I am confident that this grant program will simultaneously break down barriers and open up doors for our state's number one providers."

The program, supported by federal funding from the US Department of Agriculture's National Food and Agriculture (USDA NIFA) program, creates a statewide telehealth network for mental health services, along with a grant program to support Future Farmers of America (FFA) state chapters developing new projects aimed at encouraging and improving healthcare access through rural communities and their schools.

The effort addresses a particular pain point in rural healthcare. Farming and ranching communities are traditionally less open to talking about mental health issues, and as a result don’t access local hospitals or clinics when they need help. According to the Livestock Project, suicide rates among farmers are two to five times higher than the national average.

For health systems serving these communities, the challenge lies not only in providing resources, but reaching out to these populations and convincing them to access care. With that in mind, healthcare executives are looking at telehealth and digital health tools and platforms to bridge those gaps.

Illinois launched the FFRI several years ago as a pilot project in six counties, offering both telehealth services and a helpline. Officials say the program has worked so well, improving access and clinical outcomes, that it's being extended to all 102 counties in the state.

Through the program, rural families can access up to six free telehealth sessions with mental healthcare providers through the SIU School of Medicine.

The program could be a model for other states and health systems looking to address mental healthcare at a population health level, targeting groups such as forestry workers, fishermen, migrant workers, and Native American communities.

The health system is the latest to test the technology on administrative tasks to address stress and burnout, and will also explore opportunities to use it as a caregiver tool.

HCA Healthcare is collaborating with Google on a generative AI platform designed to handle time-consuming administrative tasks for clinicians, and has already seen success in an ED pilot.

The Nashville-based health system, comprising some 182 hospitals and 2,300 ambulatory sites of care, is the latest organization to test large language model (LLM) technology to improve workflows and reduce stress and burnout among clinicians and staff.

“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, the health system'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.”

[See also: AIMed Global Summit Puts Augmented Intelligence in the Spotlight.]

The collaboration with Google is the latest activity in a partnership launched in 2021, which initially focused on privacy and security issues. It signals a growing interest among healthcare's biggest networks to apply AI to address key pain points in business operations.

In a pilot program launched earlier this year, HCA Healthcare integrated AI technology with smartglasses developed by Augmedix to enable 75 emergency department physicians in four hospitals to document conversations with patients. The platform used natural language processing and Google's AI tech and multi-party speech-to-text processing to convert the conversations into notes, which the physician would then review before entering into the medical record.

[See also: OSF Healthcare Uses AI to Improve Nurse Navigator Workflows.]

The health system and Google are also working on applying AI to nursing operations. They're developing a platform that can generate handoff reports, with specific attention paid to medication, vital signs, labs, patient engagement, and response to treatment. The goal is to give nurses a tool that reduces the time and energy spent on documenting patient encounters and gives them more opportunities to interact with patients.

HCA Healthcare has been refining the platform after receiving nurse feedback and is now testing the technology at UCF Lake Nona Hospital in Orlando, Florida.

Beyond addressing workflows and administrative functions, healthcare organizations are interested in using AI as a clinical decision support (CDS) tool, enabling care providers to quickly and easily access the information they need at the point of care. Researchers at Boston's Mass General Brigham recently announced that a test of ChatGPT as a CDS tool found that the LLM platform was 72% effective in making clinical decisions and 77% effective in making a final diagnosis.

With that in mind, HCA Healthcare is first examining the value of AI for caregivers through Google Cloud's Med-PaLM 2 LLM platform. The idea there is to create a tool that caregivers can use to access resources and find answers to medical questions.

“Having an LLM tailored for medical questions and content could be beneficial for certain critical use cases,” Schlosser said in the press release. “We expect Med-PaLM 2 will be especially useful when we’re asking complex medical questions that are grounded on scientific and medical knowledge, while looking for insights in complicated and unstructured medical texts.”