A new computer-based decision support tool for sepsis at HCA Healthcare harnesses pivotal data in real time.
HCA Healthcare has developed an effective computer-based decision support tool for the early detection of sepsis.
Sepsis and the body's response to the infection is one of the deadliest medical syndromes in the United States, according to the Centers for Disease Control and Prevention. About 1.7 million adult Americans develop sepsis annually and the condition claims approximately 270,000 lives each year. About one-third of patients who die in hospitals succumb to sepsis.
The computer-based decision support tool is called Sepsis Prediction and Optimization of Therapy (SPOT), and it can detect sepsis 18 hours earlier than the best clinicians, says Jonathan Perlin, MD, PhD, president of clinical services and CMO at the Nashville-based health system.
"This is the future. Military fighter planes can't fly without decision support. Healthcare is equally complex. To think that we can manage all the variables without assistive technology is inconsistent with how we think about high-reliability endeavors like aviation and healthcare," he says.
HCA started adopting elements of the Surviving Sepsis Campaign in 2013. From 2013 to 2017, sepsis mortality at HCA's hospitals fell 39%.
The health system launched the SPOT initiative in 2018. From 2017 to 2018, sepsis mortality at HCA's hospitals dropped nearly 23%. "SPOT doubled our effectiveness in surviving sepsis," Perlin says.
The health system estimates that the combined effort of adopting the Surviving Sepsis Campaign and SPOT has saved about 7,800 lives.
How SPOT works
SPOT features an algorithm embedded in HCA's electronic health record that was built with Red Hat open source software. To indicate the onset of sepsis, the SPOT algorithm combines factors such as patient demographics data and medical history with continuous monitoring for signs and symptoms of sepsis as well as key elements of clinical care:
Body temperature
Blood pressure
Heart rate
Platelet count
Medications
Laboratory tests
Patient transfers such as moves to an ICU
"The SPOT algorithm surveils 24 hours a day, seven days a week to look for the signs and symptoms of sepsis. When those signs are found, they are teed up and presented to the caregivers," Perlin says.
When the algorithm detects a likely case of sepsis, SPOT initiates an alert similar to a heart attack or stroke code that prompts clinical care teams to take action. Caregivers who receive the alerts include telemetry units, nurse leaders, sepsis code teams, and rapid response teams.
An essential component of the SPOT initiative is the algorithm's diagnostic accuracy, Perlin says.
"We were able to train the algorithm to be more than 100% sensitive—we picked up cases of sepsis that the care providers did not see, and our rate of false positives was half that of care providers. So, the specificity was twice as good as clinicians. It not only improved care but also the efficiency of doctors and nurses," he says.
He continues: "On their own, clinicians can look piecemeal for sepsis signs and symptoms; but the computer can constantly look for those signs and symptoms, and when the computer has a hit, that information is immediately given to the caregivers at the bedside. That signal is not just an alert but also a representation of the sepsis criteria, so there is credibility and explainable data."
How the SPOT algorithm was developed and implemented
Three primary steps led to the development and implementation of SPOT.
1. Robust EHR and data management capabilities: The foundational step that made SPOT possible was the adoption of meaningful use and a data warehouse at HCA a decade ago, Perlin says.
"The past 10 years of building from meaningful use to become a learning health system created the platform for doing things like SPOT. We realized that we would have tremendous power through the data warehouse to learn at scale. Part of the rationale for the data warehouse was to be able to have a resource to be able to train computer algorithms through machine learning and other applications for artificial intelligence to support clinical workflow more effectively."
2. Pilot phase: Before SPOT could be implemented at more than 160 HCA hospitals, the algorithm had to be tested and proven effective, he says. "The computer algorithm was developed through our data warehouse. We piloted the algorithm at a couple of our facilities to test it against clinicians. At a certain point, the algorithm started to outperform the clinicians, and we began to implement SPOT."
3. Clinician engagement: During the launch of SPOT at HCA hospitals, the decision support tool was presented as a way to put critically important information into the hands of clinicians, Perlin says. "To gain acceptance at the bedside, we didn't just say, 'The computer sees sepsis, start treating it.' We said, 'This is what the computer sees; do you agree?' "
The SPOT algorithm's accuracy was vital to the clinician engagement effort, he says. "In addition to being able to show the clinicians what the computer saw, the fact that there were not burdensome false positives was incredibly important. We didn't waste people's time. There have been other sepsis algorithms at other institutions, but some of them have been turned off because there were so many false positives."
EHR payoff
An exciting benefit of the SPOT initiative is harnessing HCA's electronic health record and data warehouse to improve clinical care, Perlin says.
"All of us hear about the burdens of electronic health records, but without electronic health records we couldn't have done SPOT. We think this is one of the ways we can drive excellent care at scale. It's the payback for the challenge of using electronic health records. It's been received with a great deal of enthusiasm from clinicians because the caregivers at the bedside see this in real time saving lives," he says.
SPOT represents a significant step forward in the nationwide effort to develop computer-based decision support tools in healthcare, he says. "This is an extraordinarily exciting time to be in healthcare and at HCA because we can cast data at scale. Our data warehouse and computer algorithms like SPOT are bringing us closer than ever to our mission, which is a commitment to the care and improvement of human life."
A recent HealthLeaders Roundtable event explored the multiple benefits that can be garnered from establishing service lines.
Editor's note: This article is based on a roundtable discussion report sponsored by Vizient Inc. The full report is available as a free download.
Service lines allow health systems and hospital leaders to improve the performance of key clinical services such as cardiac and vascular care, orthopedics, and oncological care. The highlights of this recent HealthLeaders Roundtable included three key drivers of service lines gains.
1. Standardization: Service lines can play a pivotal role in reducing clinical care variation and boosting efficiency.
Roundtable panelist Gregory Kasper, MD, who is president of ProMedica's Jobst Vascular Institute in Toledo, Ohio, said the institute launched standardization processes initially as a cost management tool.
"We know that reduced variability improves quality and reduces costs. Surgical trays provide a surprisingly simple opportunity. By collaborating with the surgical staff and surgeons, we were able to reduce the number of our surgical trays for the vascular service by 30% and the number of instruments per tray by an additional 30%. This had a pretty dramatic impact on the efficiency of our central supply department," he said.
2. Scale: Service lines can help health systems and hospitals achieve economies of scale.
Roundtable panelist Jerome Granato, MD, who is system vice president for cardiology service lines at Englewood, Colorado-based Catholic Health Initiatives, said establishing economies of scale through service lines can foster vendor competition.
"We have developed a transparent process that enables physicians to evaluate vendors and products in an objective and numerically quantifiable manner. With this process, we have limited the vendors we use for high-price items, resulting in significant financial savings. You really can't go to a single vendor; you always need to have another vendor in case there's a back order. But we've gone to dual vendors, and that's been a huge savings," he said.
3. Alignment: Establishing effective and efficient service lines can improve alignment between health systems and their physicians, Granato said.
"Alignment comes from relationships and trust, and relationships and trust cannot be developed by email or by telephone. We try very hard to make sure that even though we're in multiple states, that we periodically bring our clinical stakeholders together for in-person meetings. When we have special projects like catheter bleeding, I will put together a taskforce, and we will fly into Chicago. Everyone will be there by 10 in the morning from almost any place in America. We will meet at an airport hotel until 4 in the afternoon, then everybody will be home by midnight. Having that personal connectivity is the key ingredient for building the confidence and trust that's essential to alignment."
The 26th annual review of clinician recruitment by Merritt Hawkins compiles data from more than 3,000 hiring search assignments.
A new physician recruitment report highlights recent trends in clinician compensation and incentives.
Ongoing clinician shortages across the country are impacting the recruitment and retention of these highly skilled medical professionals, including new physicians being inundated with job offers.
The new report from Dallas-based Merritt Hawkins features a range of clinician compensation and incentives that can be used as benchmarks in the recruitment of physicians and advanced practice providers.
The report features five key findings:
1. Primacy of primary care: For the 13th straight year, family physicians led the list of the 20 most requested recruiting assignments. Demand for primary care physicians is driven by common factors across multiple specialties such as the country's aging population, but new care models that emphasize prevention, quality payments, and care coordination also are pivotal drivers, the report says. "In the population health management model, for example, primary care-led teams coordinate care for defined populations, such as blocks of Medicare patients, under a global payment model where the health system—and, increasingly, its physicians—assume risk."
2. Rising demand for specialists: Recruitment activity is shifting toward medical specialists. Four years ago, 67% of search assignments were for medical specialists. Over the past year, 78% of search assignments were for medical specialists. "Despite the common perception that physician shortages are most acute in primary care, a growing percentage of Merritt Hawkins' search assignments are for surgical, internal medicine, and diagnostic specialists," the report says.
3. Psychiatrist shortage: For the fourth straight year, psychiatrists were second on the list of most requested recruiting assignments. "Today it is widely acknowledged that the shortage of mental health professionals, including psychiatrists, has developed into a public health crisis," the report says.
4. Pay leaders: Over the past year, invasive cardiologists earned the highest average starting salaries for physicians at $648,000. Orthopedic surgeons posted the second highest starting salaries at $536,000.
5. Employed physicians dominate: In a continuing trend for recent years, employment rather than independent practice was the dominant physician recruiting model over the past year. More than 90% of search assignments were in employed practice settings; less than 10% were in independent practice.
"The majority of the organizations recruiting physicians today—hospitals, medical groups, urgent care centers, federally qualified health centers, academic centers, and others—typically employ physicians rather than establishing them in private practices," the report says.
Physician shortage persists
The lead author of the report told HealthLeaders that there is little relief in sight for the physician shortage.
"We are stuck with the shortage for the foreseeable future given the time it takes to train physicians. If the federal government agreed to increase funding for physician training by 30% tomorrow, as some industry experts feel is necessary, we would not see the effects for 10 years," said Phillip Miller, vice president of communications at Merritt Hawkins.
However, there are three bright spots on the medical staffing horizon, he said:
The number of nurse practitioners (NPs) and physician assistants (PAs) has increased rapidly in recent years. NPs and PAs are addressing a significant amount of patient demand for medical services—often in convenient care settings such as urgent care centers and retail clinics.
Telehealth allows for the more efficient distribution of physician services. Through telehealth, healthcare organizations can transfer work from areas that have low physician capacity to areas that have higher capacity in specialties such as radiology, behavioral health, and primary care.
The healthcare sector is transforming the delivery of services from the volume-based fee-for-service model to the population health model, which puts a premium on prevention and patient outcomes. "The hope is this will lead to healthier patients and less need for interventions, hospitalizations, and readmissions, and therefore less need for physicians," Miller said.
A new proposal provides guidance for partnerships between primary care practices and community-based organizations to address social needs.
The United Hospital Fund has developed a four-part framework for healthcare organizations to address social determinants of health in the communities they serve.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
The New York–based United Hospital Fund has released a new report that features a four-part framework to address SDOHs with primary care practices at the frontline of the effort.
"Primary care practices are trusted sources in addressing the health needs of patients. They are uniquely positioned to screen for, and respond to, the social needs of their patients. Often, that entails referring the patient to community-based organizations (CBOs) that can provide services to meet the unique needs of that patient. In a perfect world, CBOs would report back to the primary care practice on the outcome of referrals, so the practice could be sure that documented problems are being addressed," the report says.
The four parts of the United Hospital Fund's proposed framework are as follows:
1. Screening for SDOHs
The first step in adopting the framework is deciding which SDOHs that a primary care practice will target for screening, a co-author of the United Hospital Fund report told HealthLeaders.
"Practices should consider the social determinants prevalent in the population they serve and whether those SDOH needs are issues that the practice can assess and refer for within their workflow constraints," Program Manager Kristina Ramos-Callan says.
Also, there are two primary considerations when matching a screening tool with a patient population, she says. "Screening tools need to be a good cultural fit—the questions and their phrasing need to be relevant and asked in culturally sensitive and acceptable ways. Practices also need to consider whether the questions they are asking require additional training of their staff or the development of training tools such as scripts or prompts for administering screens."
In choosing staff to conduct the screening, practices need to consider current job responsibilities, staff capacity to effectively screen and follow up, and the staff members' existing relationship with patients, Ramos-Callan says.
"Is the staff member a routine contact for that patient on the care team? Does that staff member have the time or inclination to help when it is immediately needed? Is that staff member trained in identifying issues that require a rapid response, or able to meet patients where they are in prioritizing among multiple needs?" she says.
2. Community organization referrals
Selecting community-based organizations for SDOH referrals can be a daunting task for primary care practices, according to the United Hospital Fund report. "There are myriad CBOs, ranging from large, citywide, well-developed, and multi-service organizations to small providers that focus on specific niche services in a specific community. Understanding that ecosystem and how to refer patients for specific services is a serious challenge for practices," the report says.
Two community health centers that helped develop the United Hospital Fund framework decided to pick large, multiservice organizations as their community partners. This approach allowed the health centers to work with familiar community organizations that had the scope and ability to tackle a wide range of social needs.
3. Getting patients needed services
Ideally, the report says making referrals and providing services to patients includes several key components:
Effective screening
Appropriate and efficient referrals
Patients follow through on referrals
Rendering of services
Fully addressing SDOHs
Primary care practices and community partners should be aware of how a case is resolved
4. Informing primary care practices about referral outcomes
Primary care practices and their community partners need to track the status of patients throughout the referral process and, hopefully, resolution of a patient's SDOH needs, the report says.
Social needs should be entered in a primary care practice's electronic medical record, the report says. If the EMR is incapable of collating and tracking social needs, the information should be entered into a designated registry or care management system so staff can track screening results and flag social needs for further action and follow-up during future patient visits.
It is essential for primary care practices and community organizations to bridge the gap between the practice's EMR and record systems at CBOs. "The referral and feedback loop must include the ability to flag and report … outcomes, so the CBO and/or practice can follow up as provided for in the workflow," the United Hospital Fund report says.
Beyond the framework
Changes in healthcare policy and health plans are needed to support the proposed SDOH framework, the report says.
Four essential components must be addressed to enable primary care practices and their community partners help meet the social needs of patients, according to the report:
Development of standardized and interoperable information platforms to coordinate the efforts of practices and their community partners
Expansion of the social service sector to accommodate increased demand for social-need resolution
A new capitated payment model in Hawaii shifts primary care physicians away from fee-for-service reimbursement.
A capitation-based primary care payment system in Hawaii improved quality of care, new research shows.
Healthcare providers across the country have been adopting alternatives to traditional fee-for-service payment models. Several alternative payment models have focused on primary care, including the Alternative Quality Contract (AQC) of Blue Cross Blue Shield of Massachusetts, the Medicare Shared Savings Program (MSSP), and the Medicare Comprehensive Primary Care (CPC) initiative.
In 2016, Hawaii's Blue Cross Blue Shield health plan—Hawaii Medical Service Association (HMSA)—launched a capitation model called Population-based Payments for Primary Care (3PC).
"In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in primary care provider visits but no significant difference in the total cost of care," researchers wrote in a journal article published today in the Journal of the American Medical Association.
The researchers found that 3PC increased quality measure scores by 2.3 percentage points and decreased primary care visits by 3.9 percentage points.
Hawaiian primary care physicians who helped craft the 3PC payment model had set decreasing office visits as one of their top objectives, the JAMA researchers wrote. "A particularly important goal for clinicians was reducing the pressure for a high number of office visits to generate revenue, to allow greater flexibility for PCPs to deliver care aimed at population health and quality, not numbers of visits."
How 3PC payment model works
The 3PC payment model includes two key components.
1. PMPM payments: For attributed members of 3PC, risk-adjusted per-member-per-month payments (PMPMs) replaced fee-for-service payments. PMPM payments ranged from $8 to $70 depending on patient resource utilization and health plan type. The PMPM payments also included money previously paid to primary care providers for patient-centered medical home status.
2. Shared savings: Physician organizations that participated in 3PC received shared savings as high as 40%. Shared savings were received if average risk-adjusted total member spending was below a benchmark calculated on historic spending. To earn shared savings, physician organizations had to maintain or improve quality.
In the first year of 3PC implementation, two out of the four physician organizations that participated in the program earned shared savings.
"Overall, the 3PC system was designed to incentivize shifts away from the prior fee-for-service system based on office visits toward payment emphasizing practice efficiency, PCP autonomy, and a focus on quality rather than volume of care," the JAMA researchers wrote.
Assessing capitation impact
The lead author and a co-author of the journal article told HealthLeaders that the quality improvement achieved through 3PC was modest but significant.
"First, it is significant by our usual statistical tests, so it was not a fluke. Second, if you look at comparison changes such as the Blue Cross and Blue Shield of Massachusetts AQC payment change, we were able to get more positive change in one year than it took them several years to achieve," said co-author Ezekiel Emanuel, MD, PhD, chair of the Department of Medical Ethics and Health Policy at the Perelman School of Medicine, University of Pennsylvania, Philadelphia.
The lead author of the journal article said 3PC made a difference in the lives of many patients.
"Thousands of patients received better end-of-life planning and better diabetes care, including management of their blood pressure. These are real people who benefited, and any time we do better for such individuals I think that is significant," said Amol Navathe, MD, PhD, an assistant professor of medicine and health policy at the Perelman School of Medicine.
The shift away from fee-for-service payments was likely a central reason for the improved quality scores, Navathe said. "The 3PC is a system that was designed with the patient and the clinician in mind. This afforded the clinicians the flexibility to practice medicine the way they thought best, while reducing barriers to accessing care for patients."
He said the capitated payments also contributed to the reduction in primary care office visits. "The 3PC system pays to take care of individual patients, not to do visits with them in the office. The reduction in primary care visits is a reflection of the flexibility that 3PC afforded primary care providers—and that they took advantage of the flexibility while improving the quality of care."
A cancer urgent care clinic in Texas reduced growth of emergency department utilization by more than half.
Cancer urgent care clinics can reduce emergency department (ED) utilization, new research indicates.
In the first six months after a cancer diagnosis, adult patients generate a high volume of unplanned visits to emergency rooms for commonly expected complaints such as nausea and pain. After ED visits, many cancer patients are hospitalized, which exposes them hospitalization risks, disrupts treatment schedules, and increases cancer care expenditures.
The new research, which was published in the Journal of Oncology Practice, found cancer urgent care clinics are a promising strategy to lower cost of care, the researchers wrote.
"Given the outsized role of unplanned hospital care in the early expenditures of cancer treatment, this delivery innovation was highly effective and may be a promising strategy for organizations participating in the Oncology Care Model demonstration project and other risk-bearing contracts, such as accountable care organizations."
Impact of cancer urgent care clinic on emergency department visits
The researchers examined the ED-visit impact of a cancer urgent care clinic opened at Dallas-based University of Texas Southwestern Medical Center in May 2012. The cancer urgent care clinic is available to patients during standard weekday business hours—8 a.m. to 4 p.m.
The study features an analysis of data collected from more than 33,000 adult patients. The research generated a key finding: the cancer urgent care clinic was associated with significantly reduced growth of ED service utilization.
Before the cancer urgent care clinic was opened, weekday ED visits were increasing at a rate of 0.43 visits per 1,000 patient-months. After the clinic was opened, the growth of ED visits was cut by more than half to 0.19 visits per 1,000 patient-months.
On weekends, when the cancer urgent care center was closed, there was no significant change in ED utilization.
"More than four years after implementation, the creation of a cancer urgent care clinic was associated with a significant reduction in ED visits made within the 180 days after a new cancer diagnosis. In contrast, the rate of ED visits made on weekends, when the UCC was closed, remained unchanged over the same period of time. This increases our confidence that the urgent care clinic was associated with a real reduction in ED visits when the clinic was open," the researchers wrote.
Innovative cancer care strategy
Cancer urgent care clinics are a relatively new and innovative approach to cancer care worthy of more widespread adoption and research, the lead author of the new study told HealthLeaders.
"What patients really want is a trusted resource and an alternative to the emergency department because—anywhere you go in the country—there are untold hours you could wait at an ED. Patients also may be worried about being exposed to the dangerous infections that people have in an emergency department. An urgent care center checks off a lot of boxes in terms of what cancer patients are looking for," said Arthur Hong, MD, an assistant professor of internal medicine and clinical sciences at UT Southwestern.
Only a handful of healthcare organizations have reported adoption of cancer urgent care centers, including Parkland Hospital in Dallas and Yale New Haven Health in Connecticut, he said.
Hong said there are common cancer-related symptoms that can be treated safely in the urgent care setting, including pain, headache, nausea, vomiting, diarrhea, and constipation. The UT Southwestern cancer urgent care clinic offers services that address these symptoms such as administering intravenous fluids and medications, obtaining basic laboratory tests with rapid results, and conducting common imaging tests such as chest X-ray.
Before launching a cancer urgent care clinic, healthcare organizations should assess their cancer patient population to determine which services would be most be most effective and useful for patients in an urgent care setting, he said. "Each institution has the ability to look at its line of business and find the common reasons patients would use a cancer urgent care clinic."
Researchers have adapted psychologist Abraham Maslow's Hierarchy to help healthcare organization leaders curb physician burnout.
A five-tier hierarchy has been proposed to help healthcare organizations prioritize interventions to address physician burnout.
Research published in September indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
In an article published recently by The American Journal of Medicine, researchers adapted psychologist Abraham Maslow's Hierarchy into a five-tier physician burnout and wellness hierarchy.
"Unlike long lists of variables, this hierarchical model is practical. Using an assessment strategy tailored to the hierarchy will identify the greatest need at whatever organizational scale measured: individual life, work unit, department, institution, or networked system. Put simply, this tells leaders where to start," the researchers wrote.
In priority order, the five-tiers of the physician burnout and wellness hierarchy are physical and mental health, safety and security, respect, appreciation and interpersonal connections, and healing patients and contributing to the fullest of a clinician's ability.
Tier 1: Physical and mental health
The potentially severe impact of nutrition on cognition is well documented, and many clinicians have poor nutrition such as skipping meals and eating too fast. Clinicians also are at high risk for dehydration—a United Kingdom study found that 45% of physicians and nurses ended their shifts clinically dehydrated. Sleep deprivation is also common among clinicians.
Beginning with research conducted in the 1800s, physicians have been found to suffer from depression at higher rates than other professionals. When present with other behavioral health disorders such as anxiety and hopelessness, depression is a suicide risk. A 2003 study found that about 350 U.S. physicians commit suicide annually.
The American Journal of Medicine researchers propose two interventions to address physical and mental health problems among physicians:
Assess the mental health of clinicians and their willingness to seek help such as employee assistance programs. If access to psychological care is deficient, healthcare organizations should bring behavioral health services on-site.
For clinicians and nurses, ease access to good nutrition, promote adequate sleep such as ensuring on-site sleeping quarters are comfortable and clean, make water and other beverages accessible, provide private bathrooms, and install breastfeeding stations.
Tier 2: Safety and security
The federal Occupational Safety and Health Administration has found that severe workplace violence that requires time off for recuperation occurs four times more frequently in the healthcare sector compared to private industry. Healthcare professionals are more likely to be injured in workplace settings with inadequate staffing, poor communication, subpar leadership, and insufficient attention to safety.
The American Journal of Medicine researchers propose three interventions to address safety and security concerns:
Violence de-escalation training for healthcare staff and deploying security to high-risk settings such as emergency rooms
Increasing total security staff
Maintaining adequate healthcare professional staffing
Tier 3: Respect
To limit burnout, clinicians need respect from supervisors and administrators, colleagues, patients, and technology such as electronic health records (EHRs), the researchers say.
A study of more than 20,000 workers found that employees who feel respected by immediate supervisors reported 89% greater enjoyment and satisfaction with their jobs. A recent study on incivility in operating rooms found that exposure of anesthesiology residents to even "run of the mill" rudeness was associated with diminished performance in four metrics: vigilance, diagnosis, communication, and patient management.
"There is growing attention on the impact of patient disrespect on health professionals and healthcare trainees. We don't yet have evidence that working repeatedly with rude, discriminatory, or abusive patients causes burnout. This model, however, predicts that patient disrespect is relevant and, where possible, policy and procedures should protect health professionals as much as is ethically reasonable," the researchers wrote.
Earlier research published in The American Journal of Medicine found that EHRs contribute to three primary elements of physician burnout—lack of enthusiasm, lack of accomplishment, and cynicism.
Actions to address lack of respect for clinicians include three interventions:
Supervisors and administrators should respond to physician requests, even when the answer is "no"
Adopt patient rights and responsibilities charters that include provisions to ban patient abuse of healthcare staff
Initiate improvements to EHRs such as easing information management and communication between healthcare professionals
Tier 4: Appreciation and interpersonal connections
The researchers say their model predicts that healthcare professionals desire and deserve appreciation much like other professionals. Studies indicate that healthcare worker satisfaction is improved when leaders express appreciation. A trial at Mayo Clinic curbed burnout by connecting physicians socially through sponsored after-hours dinners.
The American Journal of Medicine researchers propose four interventions to boost appreciation and interpersonal connections:
Provide fair compensation for physicians
Promote individualized, specific, and frequent communication of appreciation
Publicize successes such as effective clinician responses to complex medical cases
Foster interpersonal connections through establishment of shared spaces such as physician lounges
Tier 5: Healing patients and contributing to fullest of abilities
"For those drawn to medicine and healthcare, improving lives by ameliorating suffering and healing the ill is a need," the researchers wrote. Meeting this need includes conducting research and mentoring other clinicians, they say.
Actions to address self-actualization among clinicians include three interventions:
Reducing conflicts between business imperatives and the daily practice of medicine
Fostering opportunities to conduct clinical research
A new analysis of private healthcare claim records finds behavioral health disorders spiking among young people. Find out what one health system is doing to intervene.
Children and young adults are bearing the brunt of increased utilization of behavioral health services, a recent white paper published by New York–based FAIR Health says.
Over the past two decades, there has been a nationwide increase in behavioral health disorders. Suicide rates increased steadily from 1999 to 2014, according to the Centers for Disease Control and Prevention. A large-scale study found that the prevalence of major depression rose from 2005 to 2015. And the number of hospital stays for mental health and substance use disorders rose 12.2% from 2005 to 2014.
"To meet this growing demand for mental health services, we are seeing patients being treated in less traditional venues, such as in a telehealth setting. In some states, we also see behavioral health conditions represented among the top conditions presenting in hospital emergency rooms. By releasing the type of data we include in our recent study, stakeholders can better understand the prevalence of different types of mental health diagnoses and the demographic character of those statistics," she says.
Behavioral health by the numbers
The white paper features an analysis of data from 2007 to 2017 drawn from FAIR Health's database of 28 billion private healthcare claim records.
At the macro level, the FAIR Health data shows a 108% increase in behavioral health diagnoses, increasing from 1.3% to 2.7% of all medical claims. Generalized anxiety disorder claims spiked from 2007 to 2017, increasing from 12% to 22% of mental health claims.
The white paper includes behavioral health statistics for children and young adults that are particularly striking:
The pediatric share of claims for major depressive disorder rose from 15% to 23%.
Claims for generalized anxiety disorder (GAD) among high school- and college-aged people increased by greater percentages than any adult group. Claims for GAD rose 441% among college-aged people and 389% for high school-aged people.
In 2017, people 18 and under accounted for 32% of cannabis abuse claims, which was higher than any other age group.
Causes of increased behavioral health disorders in young people
Gelburd says there are likely three primary causes of the increase in behavioral health disorders among young people:
2. ACA: In 2010, the Patient Protection and Affordable Care Act made behavioral health an essential health benefit and enabled young people to remain as dependents on their parents' private insurance until age 26.
3. Social factors: The increased prevalence of depression and anxiety in young people may be associated with several social factors such as growing academic pressures, greater use of smartphones and social media, and school shootings.
Texas children's medical center rising to the challenge
Last year, Dell Children's Medical Center of Central Texas opened a new mental health unit at the Austin-based facility. The Grace Grego Maxwell Mental Health Unit has treated nearly 1,000 children over the past year, says Roshni Koli, MD, medical director of Pediatric Mental Health Services at Dell Children's.
"Being part of a children's hospital allows us to more holistically care for both the physical and mental health needs of our children and adolescents. Every child admitted to our MHU has an evaluation from our pediatric hospitalist team, which remains involved to help with any physical needs or questions that may arise," Koli says.
The new mental health unit features a multidisciplinary approach to care, including a dedicated art and music therapist as well as expanded nursing and social work teams. The new building also has an enclosed courtyard with a healing garden, so patients can get fresh air and play games such as basketball on a daily basis.
There are unique challenges when treating mental health disorders in children and young adults, Koli says.
"Children and adolescents with mental health disorders are among the most vulnerable individuals in our community. Understanding a child's mental health disorder means understanding their unique story and working closely with their family to understand all the aspects of their environment that are impacting their mental health," she says.
In supporting the construction and staffing of the Grace Grego Maxwell Mental Health Unit, the Austin metropolitan area is rising to the challenge of treating the growing number of young people who need mental health services, Koli says.
"The need for mental health treatment for our children and adolescents is large, and we often run into difficulties with shortages of providers and resources. However, our community recognizes the importance of mental health in our children and adolescents. With the continued collaboration with pediatricians, hospitals, and community partners, we can continue to reduce the stigma of mental health," she says.
The Dell Children's leadership team has played an important role in the new mental health unit's success, Koli says.
"We have been fortunate at Dell Children's to have the support of our leaders to expand our mental health program to meet these growing needs. Our vision is to provide excellent clinical care to every child who comes to our hospital and clinic, and to do so in a timely manner, reducing the barriers to accessing mental health care," she says.
There are a several areas where hospitals can manage ED malpractice risk, including medical condition diagnosis and opioid prescribing.
There are dozens of actions that health systems and hospitals can take to manage malpractice risk in their emergency departments, a new report published today says.
Emergency departments (EDs) are a crucial frontline healthcare setting, with more than 138 million visits to emergency rooms annually. EDs are the fourth most common healthcare setting for malpractice claims, according to Coverys, a medical liability firm that insures 42,000 medical professionals and 800 healthcare organizations.
A Coverys report published today on malpractice claims in EDs is based on an analysis of more than 1,300 medical liability claims from 2014 to 2018. The report features several key data points:
EDs accounted for about 13% of all medical liability claims. Surgery was the top target for medical liability claims, accounting for about 26% of claims.
Failure or delay in making a diagnosis accounted for 56% of ED claims.
Cardiac and vascular illnesses were the most common conditions identified on ED claims, accounting for 23% of the total, followed by infections (18%) and neurological conditions (8%).
More than one-third of ED claims involved the death of a patient.
The top risk management issues in EDs were clinical judgment (44%), clinical systems (10%), and documentation including electronic health records (10%).
The Coverys report provides risk management recommendations for 11 areas of ED operations and concerns:
Given that most ED malpractice claims involved failure or delay in making diagnoses, Coverys' Top 5 risk management recommendations are designed to improve diagnostic accuracy, Ann Burke, RN, director of risk management at the Boston-based company, told HealthLeaders.
1. Care transitions: EDs should commit to enhancing communication handoffs at all transitions of care based on a policy and structure for communication of patient information.
"Committing to improve communication is a first step to improving patient safety. Using standardized handoff processes to ensure crucial information is clearly communicated and transferred during care transitions is essential to safely moving the patient through the ED episode of care," Burke said.
2. Patient evaluation: EDs should ensure that patient evaluation occurs on an ongoing basis during the ED episode of care by requiring documentation of patient status at prescribed intervals, she said. "Concise and timely documentation cannot be understated as a critical communication component in patient safety."
3. Decision support: EDs should implement clinical decision support tools to assist clinicians in the diagnostic process, such as practice guidelines for high-risk presentation, clinical decision applications, and providing access to a dedicated radiologist and pharmacist to assist with diagnosis and treatment, Burke said.
"Because of the nature of the environment—fast paced, limited ability to elicit medical history, and high acuity—in which they work, ED providers should consider using additional resources that can help them arrive at an accurate and timely diagnosis."
4. Team effort: ED clinicians should communicate clearly and efficiently with laboratory and radiology professionals, as well as other relevant healthcare providers, she said. "Communication between diagnostic departments, other providers, and ED providers is an area where patient safety can be improved with the implementation and standardization of communication protocols."
5. Test results: EDs should develop a protocol to manage communication of outstanding test results for the patient, primary care provider, and consultants. The protocol should be hardwired into everyday routines such as customizing an electronic system that supports the protocol and its objectives, Burke said.
"Without a strong system in place, test results that are outstanding when a patient is discharged or transferred from the ED may place the patient at risk. It is important that a follow-up system is in place to ensure patients and providers receive timely notification."
Senior healthcare leaders from health systems and hospital across the country are set to share their technology adoption experiences and success stories.
Automation adoption and tapping the potential of technology to seize patient and clinician engagement opportunities are the dominant themes of next month's HealthLeaders Innovation Exchange in Ojai, California.
The event features four dozen top healthcare executives from health systems and hospitals across the country, including Intermountain Healthcare, OhioHealth, and Sutter Health. Here's a preview of the topics participants will address in roundtable discussions.
Automation
From clinical care, to workflow, to back-office operations, several automated technologies have taken hold in the healthcare sector, including artificial intelligence, predictive analytics, the Internet of Medical Things (IoMT), natural language processing, and robotic process automation.
Innovation Exchange participants are set to discuss a half-dozen automation adoption challenges and success stories:
Innovative approaches to automation as well as business and operational impacts
Processes for health systems in selecting innovation pilots, the role of information technology departments, and achieving scale
Automation partnerships and collaborations with third parties such as other health systems and nontraditional healthcare organizations
Executives who attend the Exchange plan to explore AI and predictive modeling that can help anticipate patient needs associated with social determinants of health, and understand how social determinants of health interact with chronic conditions and impact risk.
In addition, healthcare leaders will discuss how to scale innovation initiatives from pilots and prototypes.
Technological approaches to engagement
Patient engagement is a priority for health systems, not only in guiding patients to choose providers, but also in devising ways to involve patients in their own care. Examples of technology revolutionizing patient engagement include wearable sensor devices, online review platforms such as Google and Facebook, and chronic disease management apps.
Innovation Exchange participants are slated to explore technology solutions that can impact a wide range of engagement activity, including telemedicine, artificial intelligence, predictive modeling, and remote sensing:
Remote monitoring to serve vulnerable populations and address social determinants of health
Technology to manage population health initiatives
Generating and impacting online ratings on review websites such as Leapfrog
Technology that shapes the involvement of patients in their care such as navigating hospital services
AI and predictive analytics to allocate clinical resources and manage negative outcomes such as readmissions
Technology to boost clinician engagement such as monitoring adherence to evidence-based care
Technology that engages patients outside the hospital walls, including telehealth initiatives
Predictive tools to target high utilizers of healthcare services and help manage their care
Exchange participants also plan to discuss methods to elevate patient involvement in care with technology, navigators, educators, and motivational interviewing.
The Innovation Exchange is one of six healthcare thought-leadership and networking events that HealthLeaders holds annually. While the events are invitation-only, qualified healthcare executives, director-level and above, will be considered. To inquire about the HealthLeaders Exchange program, email us at exchange@healthleadersmedia.com.
