An 11-member intervention team redesigns workflows, develops new EHR tools, and trains clinicians to use the EHR more efficiently.
An intense, two-week program to improve electronic health record systems at the clinic level improves clinician satisfaction with the EHR significantly, recent research shows.
EHR burden has been cited as a primary contributor to clinician burnout. Research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published in September found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
In a study published this month in Mayo Clinic Proceedings, researchers show the two-week "Sprint" EHR intervention developed at Aurora, Colorado-based UCHealth increased clinician EHR satisfaction. On a net promoter scale ranging from -100 (worst) to +100 (best), clinician satisfaction with the EHR was -15 before the Sprint intervention and rose to +12 after the intervention.
The Sprint intervention is led by an 11-member team that helps clinic staff improve the EHR to make the system more efficient and user-friendly. The Sprint team includes one project manager, one physician informaticist, one nurse informaticist, four EHR analysts, and four EHR trainers.
Sprint intervention components
The Sprint intervention has three primary components: training clinicians to use the EHR more efficiently, redesigning a clinic's multidisciplinary workflow, and developing new specialty-specific EHR tools.
1. Training clinicians: In a Sprint intervention, clinicians participate in a two-hour kickoff meeting, three 1-to-1 training sessions, and a two-hour wrap-up session. In the 1-to-1 sessions, clinicians meet with either a trainer or the physician informaticist to learn specific skills or address frustrations with the EHR. The training content for Sprint features 10 sets of efficiency tips such as chart review efficiency, medical ordering efficiency, and medication management.
2. Workflow redesign: To examine multidisciplinary workflow and patient flow, Sprint team members meet individually or in small groups with a clinic's non-clinician staff. After assessing strengths and weaknesses, trainers teach EHR best practices to the clinic staff, and the clinic manager redesigns common workflows to promote standardization. For example, a UCHealth clinic developed a pre-visit online patient questionnaire for neurological disorders that is used at every visit.
3. Specialty-specific EHR tools: Clinic leaders review all new EHR tool requests. Examples of popular new EHR tools are synopsis reports, flow sheets, patient-entered questionnaires, and customized note templates. New tools that receive approval are listed in a chart under five headings: backlog, to do, in process, done, and parking lot, with the last designation for tools that cannot be addressed during the Sprint intervention. The chart is available to the clinic staff and updated daily.
Sprint team strengths and ROI
Researchers found the Sprint intervention team model has several strengths:
The physician informaticist plays a crucial role, translating clinician requests for EHR changes into technical solutions and training opportunities
The nurse informaticist targets staff and team workflows
The project manager gives the team a dedicated leader
Having the Sprint team onsite boosts clinic staff engagement in the intervention and allows team members to confer easily and make decisions quickly
The researchers estimate that the Sprint intervention generates a significant positive return on investment.
For one Sprint team, the total annual cost of the invention program is about $1.7 million:
The annual cost of funding one Sprint team, which can engage 500 clinicians, is estimated at $1.2 million.
The annual cost of lost clinician productivity during Sprint interventions is about $500,000.
The researchers estimated that one Sprint team can reduce the number of annual burnout-related clinician departures by 2.5 staff members, which can generate annual cost avoidance as high as $2.5 million.
Research 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.
Since 2015, Providence St. Joseph's Own It program has been transforming how staff members interact with patients and each other.
"Number One, we focus on why people came into healthcare and help them reconnect with their purpose in healthcare. We talk and have training modules that are about compassion, empathy, accountability, and service cycle," says Kevin Manemann, executive vice president and chief executive of physician enterprise at the Renton, Washington-based health system.
The main component of the Own It program is a four-hour training session that emphasizes compassion and organizational values paired with communication standards, role playing, and storytelling.
About 35 people attend the training sessions, which group participants at tables of six to eight people. Facilitators lead the training sessions, with assistance from a peer facilitator seated at each table. "There's a leader at each table—someone who has been through the program and knows how to facilitate dialogue," Manemann says.
The emphasis on core healthcare values builds resistance to physician burnout, he says. "From a burnout standpoint, Own It reconnects people with why they came into healthcare in the first place. It also brings a reconnection with the organization and our purpose."
The training includes an introduction to "sacred encounters" among staff members and patients. Sacred encounters are caring and courteous conversations that establish connections between staff members and their patients and colleagues. "It's about connecting people with their daily interactions with each other," Manemann says.
As part of sustainment efforts for the Own It initiative, staff members share Own It Moments such as sacred encounters during routine employee huddles on inpatient floors and in other health system departments.
Own It by the numbers
So far, 12,000 Providence St. Joseph staff members have attended Own It training sessions and the initiative appears to be having a positive impact.
In staff surveys conducted immediately after Own It training sessions, 90% of session participants say the training better prepared them to improve the patient experience and interact with one another in a more positive way.
In Press Ganey scores, physician engagement rose from the 58th percentile in 2016 to the 71st percentile in 2017.
Physician engagement is currently trending above the 75th percentile.
Patient satisfaction scores have improved in three metrics: overall physician communication, overall caregiver helpfulness, and overall caregiver courtesy and respect.
"It’s really about behavior and attitude. The more that we understand how we treat each other, and the more that has an impact on our enjoyment in the work that we do, it impacts the patients' experience with us," Manemann says.
G.R.E.A.T. declarations and actions
Communication skills are an essential ingredient of Own It's G.R.E.A.T. principles:
Greet: Introducing yourself by name and role, greeting others in a manner appropriate to the situation, and using welcoming facial expressions and speech
Respect: Saying please, thank you, and you are welcome; facing the person you are speaking with for heart-to-heart conversation; respecting diversity, safety, and confidentiality; and working in an ethical manner
Engage: Providing opportunities for questions and engagement, listening with empathy, and validating needs
Assist: Explaining what you are doing and why you are doing it with good intent, working in partnership with patients, and conducting collaborative decision-making
Transition: Describing next steps and care coordination, escorting patients if necessary, and providing authentic departing remarks
Kenton Zehr wants DMC Heart Hospital to expand the for-profit health system's cardiovascular service line such as performing more open-heart surgeries.
An accomplished mechanic with an entrepreneurial spirit has his hands on the controls at Detroit Medical Center (DMC) Heart Hospital.
Kenton Zehr, MD, who earned his medical degree at Pennsylvania State University College of Medicine and completed a residency and fellowship in general surgery and cardiothoracic surgery at Johns Hopkins Hospital in Baltimore, was named executive director of DMC Heart Hospital in April.
The board-certified thoracic surgeon says a life-long interest in mechanics drew him to cardiac surgery as his field of interest.
"In sixth grade, we went to the grocery store to buy bottles and things, then I made a heart-lung machine out of bottles that pumped colored water with a syringe-type system. I won the science fair for that," Zehr told HealthLeaders.
"When I hit human anatomy at Penn State that became my favorite class with my mechanical background. My father and my brother and I built our house when I was a teenager. We pounded every nail. So, working in a mechanical healthcare subspecialty makes sense to me."
HealthLeaders recently spoke with Zehr about his vision for DMC Heart Hospital. Zehr wants DMC to perform more open-heart surgeries and expand the health system's cardiovascular service line.
Following is a lightly edited transcript of that conversation.
HL: Why do you find the mechanics of the heart and the vascular system appealing?
Zehr: First off, cardiac surgeons don't treat cancer, we treat something that is fixable. In large part, our patients do well; and once they are fixed, they are fixed with a durable result.
In some ways, it's like opening the hood of the car, fixing the car, and closing the hood. The cardiovascular system is very well circumscribed. You know your limitations—it's the pump and the vessels that come in and out of the pump.
HL: How has your medical background prepared you to lead DMC Heart Hospital?
Zehr: I've worked at several major institutions. I spent nine years training at Hopkins back in the day when we were on call every other night—before the resident work hours limited you to 80 hours a week. I did nine years working 100 to 120 hours per week. We were immersed in it very intensely.
After I finished my training at Hopkins, I went to the Mayo Clinic in Rochester, Minnesota. I spent eight years there. The mechanical portion of using the heart-lung machine started there as a tour de force.
I've worked at pioneering systems. The first successful pump support for heart surgery was done in Detroit in 1952. They made four of those machines. One is in the lobby here. One was given to the Smithsonian. I like to feel connected to the thread of history.
HL: How do you plan to strengthen the cardiovascular service line at DMC?
Zehr: For the past several years, the service line has been heavily oriented toward percutaneous interventions on coronary events, not so oriented to a balanced approach.
There has never been a study that has shown percutaneous interventions such as stenting are superior in terms of durability to open heart surgery. We need a balanced approach to cardiovascular care—more balanced than it has been here.
We need to expand into other areas like valvular work. We're not participating strongly in the surgical solutions for heart failure. We have durable pumps—ventricular assist devices—which are basically artificial hearts that are routinely used across the United States, but not in our program. These are the things I plan to bring to DMC.
HL: What are some of the key steps in that expansion effort?
Zehr: We'll start by expanding the surgical volume. I'm hiring another surgeon from Hopkins who will be starting in September and plan to hire another surgeon. So, I am expanding our surgical staff, and we will expand our internal staff at the Heart Hospital—we just hired two interventionalists for stents and percutaneous procedures.
We have hired an internationally known heart failure expert. With myself and the other surgeons we are recruiting, we will be able to put in artificial heart devices. Several years down the road, we hope to have a heart transplant program. Right now, some of those needs are being met by our competitors, which is fine, but it would be nice to offer that as part of being a comprehensive program.
We will have a full-on marketing strategy to market ourselves as available to our community.
HL: What is your vision for DMC Heart Hospital?
Zehr: I want to see us competitive with Beaumont, with Henry Ford, and with the University of Michigan. I would like to see somewhere between 500 to 1,000 open heart surgeries per year. We occupy a market in downtown Detroit that is not served by others in the area. It's a high-needs community, with high percentages of diabetics and high percentages of people with high blood pressure. The first system to be affected by those disease processes is the cardiovascular system.
One of the advantages we have at the Heart Hospital compared to other institutions is that we are in one building. We see patients in the same building. We drink coffee out of the same coffee pot. We have group meetings, where we have a team approach to discussing cardiac care, and we have cardiologists and cardiac surgeons sitting around the same table.
HL: You have a track record in medical entrepreneurism, including several mechanical device patents. Do you hope to involve DMC Heart Hospital in medical entrepreneurism?
Zehr: Historically in Detroit, there has been a lot of opportunity because we have the car companies here. The machine that did the world's first pump support for a heart operation in 1952 was called the Dodrill-General Motors Research pump. All of the engineers came out of General Motors. There are bioengineers who are still associated with those companies.
In Detroit, we have a history of being part of multi-institutional trials for devices like stents that open up clogged vessels and that will continue—one of our strengths is partnering with industrial companies.
The American College of Physicians is calling on policymakers to strengthen and expand the Patient Protection and Affordable Care Act.
The PPACA has achieved significant gains in access to healthcare, and policy makers should focus on nurturing and expanding the healthcare law, the American College of Physicians (ACP) says.
The healthcare law enacted by the Obama administration has notched several achievements, the ACP says in a recent article published by Annals of Internal Medicine. PPACA regulations such as barring coverage restrictions on pre-existing conditions have made health insurance more accessible. Premium tax credits and cost-sharing subsidies have made individual and family coverage more affordable. The essential health benefit package and preventive service coverage has made insurance more comprehensive. And Medicaid expansion has insured millions of previously uninsured adults.
The ACP, which represents internal medicine specialists and has more than 150,000 members worldwide, is making seven recommendations to improve the healthcare law:
1. Strengthen the PPACA: Efforts to undermine the PPACA such as decreased outreach and education funding should be reversed or eased. The PPACA should be redesigned to move closer to universal coverage. The current healthcare law falls short of universal coverage, with unaffordable premiums, coverage gaps, and weak insurer participation.
2. Individual insurance market affordability: Premium subsidies should be expanded and increased such as removing the 400% Federal Poverty Level cap for premium tax credits to boost enrollment and offset premium hikes. Incentivizing more healthy people to purchase insurance on the PPACA marketplace strengthens the individual insurance market.
3. Stabilize the marketplace: The federal government should take several steps to stabilize the PPACA marketplace, including adoption of a permanent reinsurance program and rollback of proposals to sell health plans that do not comply with PPACA regulations such as limited-duration plans. The reinsurance program provides financial protection to health plans with high-cost enrollees. Noncompliant health plans segment the risk pool and drive premiums for compliant marketplace plans higher.
4. Outreach, consumer assistance, and education funding: In 2017 and 2018, the federal government slashed funding for the PPACA's Navigator program and other efforts to provide education, outreach, and enrollment assistance. Federal, state and local agencies should fund initiatives to promote the PPACA's coverage options. These efforts should target people who are eligible for Medicaid or premium tax credits but are not enrolled in PPACA coverage.
5. Enrollment mechanisms: To increase patient participation in PPACA coverage, federal and state marketplace officials should strengthen enrollment mechanisms such as developing auto-enrollment programs, levying penalties for failure to enroll upon eligibility, and adopting an individual mandate.
6. Medicaid expansion: The expansion of Medicaid coverage to more adults in 36 states has increased access to care significantly, with more than 12 million newly eligible adults covered by Medicaid in September 2017. Medicaid should not be expanded with counterproductive conditions such as onerous work requirements that prompt patients to disenroll.
7. Public option: Congress should craft a public insurance plan to increase competition in the individual marketplace. For example, Sens. Tim Kaine (D-Virginia) and Michael Bennet (D-Colorado) have proposed "Medicare X," which would give PPACA marketplace enrollees a public insurance offering based on Medicare's provider network and reimbursement policies. Medicare X would have an expanded benefit package including services such as maternity and pediatric care.
PPACA by the numbers
The ACP says the health law has posted promising numbers:
With Medicaid expansion states leading the advance, the country's uninsured rate hit a historic low in 2016, dipping to 8.8%.
In 2017 and early 2018, the uninsured rate held steady at 8.8%.
With higher out-of-pocket costs, patients face significant financial side effects from their care.
With proactive communication and engagement, clinicians can ease the financial burden of their patients.
Out-of-pocket costs such as high-deductible health plans have expanded over the past decade. In 2018, 29% of patients with private insurance were enrolled in high-deductible health plans, up 25 percentage points from 2006. More than a quarter of Americans have trouble paying medical bills.
In this month's edition of Annals of Internal Medicine, researchers provide seven approaches to having effective cost-of-care conversations with patients:
1. Patient engagement: Most physicians take a passive approach to discussing patient finances. Months can be wasted before clinicians find out patients can't afford their medications. Patients should be screened for financial hardship.
2. Cost estimates: Clinicians make medical prognoses that allow patients to plan for their care, and they should make financial prognoses that help patients plan financially. Discussing costs early in care boosts awareness of available resources and increases patients' ability to plan for expensive treatments. Clinicians should consider financial burden as a side effect of medical treatment and try to prevent it.
3. Anticipate costs: Most patients are concerned about the indirect costs of their medical appointments such as lost income, transportation, and childcare. Through communication with patients, these costs should be anticipated.
4. Make exploring out-of-pocket costs routine: Hospitals and physician practices can give patients information about health insurance availability, local health-related resources, and tools for initiating cost-of-care conversations during clinic visits. Implementing a cost-conversation screening system should engage patients, ease shame patients feel about financial problems, and give patients options to speak with clinicians or ancillary staff.
5. Adjusting workflows: Clinicians should work cost-of-care conversations into their daily workflows. Effective strategies include assigning one staff member to serve as the out-of-pocket cost problem-solver to develop expertise and efficiency, using the electronic health record (EHR) to document patients' financial need, and mining the EHR for cost data and insurance coverage.
6. Ancillary staff play central role: Most practices involve ancillary staff—medical assistants, nurses, front desk staff, and financial counselors—in cost-of-care conversations. Ancillary staff generally have more flexibility in their workflows to accommodate financial conversations with patients, and their views on cost of care often align closely with patient views compared to clinician views.
7. Practice makes perfect: As clinicians conduct more cost-of-care conversations, the discussions become more effective and efficient. Clinicians who conduct cost-of-care conversations are more likely to consider cost in medical decisions.
Chronic conditions afflict more than 130 million Americans—more than 40% of the population. Costs for chronic illness and mental health account for about 90% of the country's $3.3 trillion annual healthcare expenditures.
Clinicians are not providing adequate lifestyle advice about chronic disease, the recent research indicates.
"Prevalence of lifestyle modification advised by healthcare providers is generally low among U.S. adults with chronic conditions, and worryingly low among those without chronic conditions, however overweight or obese. Prescribed lifestyle modification is a missing opportunity in implementing sustainable strategies to reduce chronic condition burden," the researchers wrote.
The study examined federal data collected from more 11,000 adults for weight status and five chronic conditions—high blood pressure, high blood cholesterol, osteoarthritis, coronary heart disease, and diabetes.
The study generated several key data points:
High blood pressure (32.7%) and cholesterol (29.3%) were the most common chronic conditions compared with osteoarthritis (7.4%), diabetes (5.7%), and coronary heart disease (3.7%).
Diabetes patients received considerably more frequent advice (56.5%) than patients with high blood pressure (31.4%) and cholesterol (27.0%).
A "remarkably low" number of overweight (21.4%) and obese (44.2%) adults free of chronic conditions reported receiving any lifestyle advice.
"Our analyses revealed that about 20% of overweight and about 40% of obese adults received any lifestyle modification advice when free of chronic disease, demonstrating that most healthcare providers are missing this crucial primary prevention opportunity recommended by numerous guidelines," the researchers wrote.
Lifestyle advice included in the study was increased physical activity, reduced dietary fat and calories, and weight control.
Chronic disease management
A co-author of the study told HealthLeaders earlier research indicated that physicians require more knowledge in lifestyle medicine and behavior modification.
"This would mean more emphasis on these issues during medical school but also during residency training, preferably across all medical specialties. This is very important given the high and still rising prevalence of overweight and obesity in the U.S. population," said Sinisa Stefanac, MSc, of the Institute for Outcomes Research at the Medical University of Vienna in Austria.
Clinicians need more time to dispense advice, he said.
"Physicians need more time per patient in order to discuss these issues and need to have structural support by hospital or health center management that allows them the extra time to work with their patients. These changes are more structural and would take more time and understanding from political stakeholders."
Encouraging physicians to follow evidence-based guidelines and best practices can drive improved patient outcomes.
The electronic health record can be more than a giant billing machine. A newly formed health system is using clinical software to manage order sets and tap current medical knowledge to promote evidence-based medicine.
LaGrangeville, New York–based Health Quest and Western Connecticut Health Network in Danbury, Connecticut, which merged as Nuvance Health in April, have been using clinical software to set alerts, to manage order sets called "power plans," and to give physicians access to the most recent guidelines, best practices, and journal articles.
Health Quest and Western Connecticut Health Network are not operating under the Nuvance Health brand yet.
"We're finding that our increased compliance scores with evidence-based practice are correlating with improved patient outcomes and financial outcomes, which is encouraging. It gives validity to the initiative," says Kelly Philiba, ND, physician informaticist at Health Quest.
Before an evidence-based alert was added to the EMR, compliance with VTE prophylaxis guidelines for heart failure patients was about 70%. After the alert was implemented, compliance increased to 92%.
"We're always attempting to perform at the top of the field, and we want to give our clinicians the resources they need to keep themselves well-apprised on the recommended best practices, emerging evidence, and guidelines," Philiba says.
Measuring adherence to evidence-based practice of medicine
Health Quest has more than 700 order sets, and recently reviewed all of them. "We went through every single one with our clinician experts and our software, and input evidence links and revamped any order sets that needed editing," she says.
Now, the health system tracks adherence to order set guidelines by individual physician and clinician cohorts such as cardiologists.
"We are asked to show whether cardiologists are adhering to evidence-based practice and who is not, who is using power plans and who is not, what is the length of stay for a provider who is using evidence-based practices and power plans and what is the length of stay for providers who are not," Philiba says.
Health Quest generates individual provider metrics, group-based metrics, adverse event metrics, and facility-based metrics on quality outcomes including length of stay, morbidity, mortality, and readmission.
Clinicians who do not follow order sets and fall short on clinical outcomes are held accountable for their performance through data presented to a hospital executive such as vice president of medical affairs or group lead, Philiba says. "Having the data and the best practices helps to facilitate the conversation regarding a physician's practice."
The emphasis on following a closely managed order set collection has encouraged physician engagement, she says. "Now that my clinicians have a better understanding of power plans and how they work, they feel more empowered to reach out to the IT department and ask about creating a power plan."
Managing medical knowledge
The pace of medical knowledge advancement has accelerated, with the doubling of knowledge estimated at 50 years in 1950 and projected at 73 days next year.
To keep pace, Health Quest is using software from Los Angeles–based Zynx Health to enter updated evidence-based information into the EHR workflows that physicians use daily. With the software, clinicians can click on links to access the latest guidelines, best practices, and peer-reviewed journal articles.
"The thing that I appreciate about the Zynx evidence links is that they are constantly updated when new articles or new guidelines are published. As a clinician, I find it difficult to know when new guidelines are published because they are on a haphazard schedule. You can't expect new guidelines every year—they come out when the evidence comes out," Philiba says.
The links also give clinicians crucial information at the point of care, she says. "Now that we have the evidence links at the point of care and they are constantly updated, guidance is delivered directly to the clinicians instead of making them search for information."
One of the goals of Health Quest's evidence-based medicine initiative is for the links to give physicians EHR-based decision support, Philiba says. The evidence links enable the review of evidence or guidelines with one click in the EHR. For example, cardiologists can get evidence-based information such as bleeding risk and oxygen utilization for heart failure patients.
"It makes information available in an easy and accessible way," she says.
Timely patient assessments and evaluation of symptoms are key care strategies to limit maternal mortality and morbidity.
Cardiovascular disease is a primary contributor to maternal mortality, particularly in the postpartum period.
Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions, congestive heart failure, and exacerbation of congenital heart defects. Recently released guidelines from the American College of Obstetricians and Gynecologists call for improved screening for cardiovascular disease during and after pregnancy as well as "pregnancy heart teams" for women at moderate to high risk for heart disease.
Jennifer Lewey, MD, is co-director of Penn Medicine's Pregnancy and Heart Disease Program, and director of the Penn Women's Cardiovascular Center in Philadelphia. Lewey earned her medical degree from Harvard Medical School and is board certified in cardiovascular disease and internal medicine.
The Penn Medicine cardiologist recently shared her approach to cardiovascular disease in pregnancy with HealthLeaders. A lightly edited version of that conversation follows.
HealthLeaders:Compare cardiovascular disease risk to other medical pregnancy risks.
Lewey: When looking at all deaths that occur during pregnancy, or in the year after delivery, one of the most common causes is cardiovascular, which includes deaths related to cardiomyopathies, congenital heart disease, valve disease, heart attacks, and stroke.
The risk varies according to the timing. We know that deaths that occur during pregnancy are more likely to be related to non-cardiovascular conditions. Deaths that occur on the day of delivery are due to obstetric causes. In the post-partum period, cardiovascular causes and cardiomyopathy in particular are much more common.
HL:When should pregnant women be assessed for cardiovascular disease?
Lewey: For assessment, there are three categories of women with cardiovascular disease.
There are women who have no cardiovascular disease who are at risk of worsening of their conditions during pregnancy given the hemodynamic changes that occur during pregnancy and delivery. These women may have congenital heart disease or acquire heart disease early in life, for example, valvular heart disease. For these women, they should be evaluated 6 to 12 weeks prior to pregnancy to evaluate their risk during pregnancy and to determine whether they need further testing to evaluate their risk.
Then there is a group of women who may have heart disease prior to pregnancy but were not diagnosed as such. A lot of these women have other risk factors for heart disease that could be diagnosed and optimized 6 to 12 months prior to getting pregnant. These are women who have obesity, severe uncontrolled hypertension, and severe diabetes.
The trickiest part are the women who don't have heart disease but develop it during pregnancy—we're not screening them before pregnancy because they don't have heart disease. This population highlights the importance of monitoring and evaluating new symptoms during pregnancy and the postpartum period.
HL:How do you coordinate care for pregnant women with cardiovascular disease?
Lewey: There needs to be communication between the primary care doctors and the cardiologists who see these women before they get pregnant, and the obstetricians and fetal medicine specialists who follow them during pregnancy.
I refer many of my patients for preconception counseling with an obstetrician prior to pregnancy—it's an opportunity for patients to learn more about their risks during pregnancy. It's also an opportunity for me to communicate with the obstetrician. The idea is we are following the patient together, before, during, and after pregnancy.
The biggest area for improvement is coordinating care after discharge, which is especially true for the women who are newly diagnosed with heart disease during pregnancy or the postpartum period.
HL:Should health systems and hospitals adopt heart care teams for pregnant women with cardiovascular disease?
Lewey: More and more large centers will be doing multidisciplinary heart care teams—it's something we certainly do at Penn. I serve as a point person for the obstetricians when questions arise. For our sickest patients, we discuss them at interdisciplinary meetings that occur at least once a month and more often if needed, so we can come up with a plan for monitoring during pregnancy and a delivery plan.
We're going to see more of these programs in response to the new guidelines and in response to the concerning rates of maternal mortality.
HL: What are the primary cardiovascular risks in the postpartum period?
Lewey: The leading cause of pregnancy-related death in the postpartum period is cardiomyopathy and the development of peripartum cardiomyopathy. Most women will present with this condition in the week after delivery. Oftentimes, it will develop after a woman has gone home from the hospital; however, they can present six months to a year after delivery.
Clinicians can avoid ethical and liability concerns by exercising good judgment and placing limits on provision of care.
When treating family members, friends, colleague, or themselves, ER physicians face ethical, professional, patient welfare, and liability concerns, a recent research article shows.
Similar to situations arising in the treatment of VIP patients, ER physicians treating loved ones or close associates may vary their customary medical care from the standard treatment and inadvertently produce harm rather than benefit.
"Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician," the authors of the recent article wrote in American Journal of Emergency Medicine.
There are several liability concerns for clinicians, the lead author of the article told HealthLeaders.
"Doctors would be held to the same standard of care as for other patients, and if care is violated and leads to damages, they could be liable. Intuitively, family and friends might be less likely to sue but that is not true of subordinates. In addition, as we state in the paper, for most ED physicians, practice outside of the home institution is not a covered event by the malpractice insurer," said Joel Geiderman, MD, professor and co-chairman of emergency medicine, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles.
Hospitals also have liability concerns, he said. "In California and some other states hospitals cannot directly employ doctors or control their practices. However, if they have policies in place and negligently allow rules to be violated, they could be liable."
Ethical entanglements
ER physicians who care for loved ones, colleagues, or themselves encounter a range of ethical concerns:
Autonomy: An ER patient seen by an ED physician loved one or colleague may feel reluctant to express a free choice regarding provider or treatment.
Beneficence: A clinician has a duty to provide benefit to patients and guide patients to the most qualified physician.
Nonmaleficence: In treating loved ones and colleagues, clinicians should not practice outside the limits of their training and abilities.
Objectivity: Loss of objectivity is often the most daunting problem when ER physicians treat seriously ill loved ones and colleagues, with not only risk of harm to the patient but also the clinician if there is a negative outcome.
Practice guidance
Geiderman and his co-authors offer nine recommendations to limit concerns when ER physicians treat themselves and patients with whom they have a close relationship:
Recognize the ethical, medical, and psychological considerations when treating loved ones and colleagues
In all emergency situations, provide care until another clinician is available
In general, risks are low when conditions are minor and episodic, and the possibility of failure is low
Know the legal requirements and limits in your state, local, and professional jurisdictions
If requested, give advice about other provider options
It is generally acceptable to honor requests for help reviewing laboratory and imaging reports as well as interpreting physician orders
Offer questions that the patient can ask the physician of record
Encourage second opinions when the patient is uncomfortable with care
ER physicians should lobby their professional associations to set policies for treatment of themselves, loved ones, and colleagues
It is challenging to set firm guidelines between minor and major conditions, particularly under emergency circumstances, Geiderman said.
"It is hard to be exhaustive. Ear aches, sore throats, simple wounds, and sprains are obviously minor. Long-term care and invasive procedures or life-threatening events like a rapid arrythmia or shock should be avoided. Physicians should exercise good judgment."
Artificial intelligence and natural language processing have the potential to boost patient safety.
A million-dollar partnership between University of California San Francisco and The Doctors Company is set to explore the intersections of digital health and patient safety.
The shift from paper-based information systems to digital formats has generated reams of information that has the potential to augment clinical judgment and improve patient safety with digital health tools.
"Artificial intelligence and algorithms can be used to help physicians and nurses select the right assessment information to gather and guide selection of medicine or therapy," Kerin Bashaw, senior vice president of patient safety and risk management at The Doctors Company, told HealthLeaders this week.
"The evidence indicates that—on the whole—we are practicing safer care because we have digital tools in place," Julia Adler-Milstein, PhD, an associate professor at UCSF School of Medicine, told Healthleaders.
The partners are well-matched, Bashaw said. "The Doctors Company is a leader in medical malpractice, so we have been a thought leader in patient safety, and UCSF is a leader in medicine and medical education."
"Malpractice claims are the ultimate data when things have gone wrong," Adler-Milstein said. "This allows us to try to help solve the problems that involve high patient risk, where there is actual harm. That is data that is very hard to come by."
Digital health safety opportunities
Bashaw and Adler-Milstein said artificial intelligence (AI) is presenting several opportunities to improve patient safety.
Using natural language processing (NLP) to review clinical charts from the previous day to check for omissions in patient assessments
Using AI to review notes and predict risk of harm
Using technology to boost clinical documentation with chart reviews, information integrity, and diagnosis support
Designing digital tools that accommodate the complexity of care but also support the ways teams communicate and interact with each other
Embedding AI algorithms into frontline clinical decision making
Limits of artificial intelligence
Technology is not going to replace physician judgment, Adler-Milstein said.
"We'll probably never get to a state where we would rely wholly on algorithms. There is always going to be a combination of algorithmic input and clinical judgment. We are not headed toward a healthcare system where we won't have doctors anymore."
It's crucial to strike the best balance between clinical judgment and incorporating an algorithm, she says. The key is weighing algorithmic evidence with all the other factors a clinician considers.
"If you think about the number of clinical decisions that are made today and how many have had input from artificial intelligence or an algorithm, we're probably at less than 1%. We are in the early days of finding ways clinical decision making can be supplemented or augmented with algorithms. Where you see it most often today is in image analysis; for example, detection of pulmonary embolism."
