Johns Hopkins Department of Medicine shares successful managerial and organizational strategies.
Academic Departments of Medicine are most effective with a mission-focused leadership structure, a thoroughly engaged workforce including nurses and administrators, and supporting faculty in scholarship achievements, recent research shows.
There are inherent leadership challenges at academic Departments of Medicine such as managing a diverse workforce and balancing the clinical and scholarly responsibilities of faculty.
Research published last month in The American Journal of Medicine shares how Johns Hopkins University School of Medicine has risen to these challenges.
The lead author of the research, who serves in a top role at Johns Hopkins, told HealthLeaders that the leadership recruitment process is crucial.
"Have a transparent process for leadership selection to develop a team with diverse experience and expertise. It is often easy to select individuals for leadership roles with whom we have a comfortable, pre-existing relationship; however, that may or may not be the best individual for the job," said Sherita Hill Golden, MD, MHS, professor of endocrinology and metabolism; executive vice-chair, Department of Medicine; at Johns Hopkins University School of Medicine.
At Johns Hopkins, all faculty members can vie for open leadership positions, she said. "A request for applications process that is disseminated to the entire faculty allows individuals with leadership aspirations and unique skills who may not be as well known to departmental leaders to be considered for important opportunities."
The Johns Hopkins Department of Medicine has more than 1,800 faculty, 900 nurses, about 900 trainees, and more than 1,000 non-clinical staff members.
The department's leadership structure features a vice-chair hierarchy. As executive vice-chair, Golden serves directly subordinate to the director of the department. There are four primary vice-chair leaders, who manage education, clinical care, research, and human resources.
Golden said there are three elements to attaining the best performance from a vice-chair leadership team.
Develop clear job descriptions for each role so that the scope of responsibility is clear.
To foster innovative programming across the academic mission, require vice-chairs to develop annual metrics and goals that are reported to the top leadership.
Empower vice-chairs to lead within their mission area by entrusting them with responsibility. If the right leaders are in place, they should be given latitude to innovate without being micromanaged.
The Johns Hopkins Department of Medicine has developed sophisticated approaches to all four primary vice-chair mission areas, Golden and her coauthors wrote.
1. Managing human resources
The Faculty Development and Promotions Office supports all faculty in the pursuit of academic achievements in several fields such as biomedical research, medical education, clinical care, program building, innovation, quality, and safety.
There are several recognitions for clinical excellence, including enrollment in the Miller-Coulson Academy for Clinical Excellence at Johns Hopkins Bayview Medical Center in Baltimore.
Two associate vice-chairs promote retention and advancement of women and faculty who are underrepresented in medicine. Services offered include enhanced mentorship, access to career development opportunities specific to women and minorities, and leadership training.
2. Excelling at clinical care
The Clinical Affairs Office is split into two main divisions—overall clinical affairs and quality, safety, and service. Inpatient and ambulatory operations groups are also part of the leadership structure.
The quality team focuses on four areas: patient safety; externally reported quality metrics such as hospital acquired condition rates; patient experience; and value-based initiatives that cut costs without compromising quality.
The inpatient team monitors and manages hospital throughput, inter-hospital transfer processes, length of stay, readmissions, and inpatient care policies. The ambulatory team has responsibility for clinical practices on both of Johns Hopkins' academic campuses and more than 30 satellite locations.
3. Driving research and innovation
A key feature of the Research Office is an innovation-to-market program called Innovation and Commercialization in Medicine (InCMed). The program is led by two Department of Medicine vice chairs in collaboration with the Johns Hopkins Carey School of Business.
The main goal of InCMed is to generate marketable healthcare products from discoveries in biomedical science and clinical care delivery. The program provides innovation networking opportunities across the medical campus and the applied physics laboratory.
4. Embracing education
The Education Office currently has four primary goals.
All learners such as medical students and house staff have excellent clinical skills. Clinical learning experiences are encouraged—particularly bedside rounding.
Multiple educational pathways and accelerated training foster careers in a wide range of healthcare fields.
Faculty are incentivized to teach such as a compensation model incentive.
Ambulatory medicine leaders are developed through measures such as enhanced curriculum and engagement of ambulatory subspecialists.
Learn how one health system launched systematic initiatives to improve its quality and safety rankings and is pursuing a zero-harm environment.
Nearly two decades after the Institute of Medicine published its groundbreaking healthcare safety report "To Err Is Human," medical errors remain a leading cause of death in this country.
To rise to this challenge, hospitals from coast to coast are engaged in efforts to boost quality and safety such as initiatives aimed at hospital-acquired infections.
For one hospital in particular, a poor Leapfrog Hospital Safety Grade rating in 2014 became a launching pad for improved quality and safety.
"When we got a 'D' from Leapfrog, that was our wake-up call. We had done good patient safety work before, but it wasn't the fanatic level that we have now," says Leigh Hamby, MD, MHA, executive vice president and chief medical officer at Piedmont Healthcare, an integrated healthcare system with 11 hospitals and almost 100 physician and specialist offices throughout Atlanta and North Georgia.
Since launching systematic initiatives to improve quality and safety in 2014, the health system has posted gains.
In November 2018, six of Piedmont's 11 hospitals received "A" grades in The Leapfrog Group's Fall 2018 Hospital Safety Grade ratings
From July 2016 to June 2018, Piedmont reduced hospital-acquired infections 40%
One Piedmont hospital has not reported a hospital-acquired infection for more than a year
Hamby says there are four ways Piedmont implemented better quality and safety at the healthcare organization and boosted its rankings.
1. Reallocate staff’s time and focus
One of the first quality and safety initiatives that Piedmont started was reforming quality and safety staff allocation. Hamby says about 80% of the staff's time was dedicated to surveillance such as chart reviews, rather than improvement projects.
He says the department, which has a staff of about 75, had to change.
"When I started looking at our hospitals and who was charged with quality and safety, they were not working on infections and other elements of the Leapfrog grades. When Leapfrog says hospital-acquired infections are important and people are working on something else, that told me we were working on the wrong things."
The department's functions were split into three branches: surveillance, analysis, and improvement. The improvement branch was divided into design and implementation segments.
"We took most of the folks doing the work—most of whom were clinicians reviewing charts—and put people on the design and implementation sides.
Our original resource allocation was about 80% looking for problems and maybe 20% trying to fix problems. We [have now] put it at 50-50," Hamby says.
2. Commit to a scientific approach
Piedmont's approach to clinical care is rooted in best scientific practices, Hamby says. "What we have done is to be fanatical about making sure every patient gets every component of the things we know scientifically they should be getting."
Central lines and other implantable devices are infection risks and hospitals can lower risk through a science-based approach to care, he says.
Hamby says the clinical team only inserts devices when needed and then removes them as soon as it is safe to do so. "You follow all of the procedures that science calls for while the devices are in to prevent an infection, and we measure performance on a patient-by-patient and hour-by-hour basis."
To prompt clinicians and nurses about care steps, reminders have been built into Piedmont's EMR, Hamby says. "We are giving frontline caregivers real-time tools that help them remember the things they are supposed to do for the patient."
3. Standardize care into'promise packages'
Piedmont has adopted an expanded approach to clinical care order sets that the health system calls promise packages. Catheter-associated urinary tract infection (CAUTI) is a prime example, Hamby says.
"The promise package is literally everything that you would do. For CAUTI, it's a policy, it's a training program, it's a documentation element in the EMR, and it's all the dashboards and reporting. You take all that up and call it a promise package," he says.
When new expanded order sets are rolled out, many members of the quality and safety staff are enlisted to assist in implementation, Hamby says. "We provide elbow-to-elbow support anywhere from seven to 14 days, depending on the complexity of the promise package. We get in the field and sort through the bugs in software or questions the nurses have."
After a 60-day trial period, effective promise packages become order sets for the entire health system and responsibility for order set compliance is shifted to hospital CEOs.
Compliance to promise packages and other order sets is crucial to quality and safety, Hamby says. "In the old days, we would be happy with 80% compliance," he says, but Piedmont found it needed to be within the 95%–99% compliance range, especially because of medical departments such as the ICU with significant utilization of implanted devices.
Regular reporting of compliance rates can avert safety events, he says. "It gives you the ability to identify problems in the process measure before it becomes an outcome problem. If I've got 10 doctors doing colon surgery and I know who is not compliant to the order set, I can intervene before it leads to an infection."
4. Reach for zero harm
Piedmont embraced a zero-harm strategy as part of the fallout from the "D" Leapfrog grade in 2014, Hamby says.
"We look at our harm count every month. Our harm count is comprised of four components: hospital-acquired infections, serious safety events, hospital-acquired conditions, and patient safety indicators as described by AHRQ. Every month, we know how many harms we have, and we have programs to address them," he says.
Benchmarking has no value in the pursuit of zero harm, Hamby says.
"I don't care if we are the best in the country. If we're not at zero, we're not done. I think benchmarking is an excuse for when you can stop working on something. We're going to keep on working until we get to zero harm," he says.
Piedmont's goal is to attain zero harm by 2024, and Hamby says the 10-year time frame is realistic.
"Ten years is a long time, but this is a pretty complicated business. Sick patients, by their very nature, require lots of complicated treatment. Since the IOM report in 1999, as a nation, we have not gotten all that much better."
If health systems and hospitals can create high-reliability organizations, there should be significant economic and operational gains, he says.
"Let's just say we woke up tomorrow and no more harm ever happened. One of the things we would realize almost immediately is an increased capacity of the healthcare system to accommodate more people. We would reduce wait times for service," Hamby says.
In adults, shortened length of stay has been linked to higher readmission rates for some conditions.
Shortening hospital length of stay does not increase readmission rates for pediatric patients, recent research shows.
For adults, length of stay has become a key metric for hospital readmissions, with concerns about the quality of discharge care such as patients discharged before they are ready to leave the hospital. Shortening hospitalization length of stay for adults is associated with a higher risk of readmission for some conditions.
The authors of the recent research, which was published in JAMA Pediatrics, say their finding likely reflects well-managed length of stay for pediatric patients.
"In children's hospitals, the majority of children may already be staying in the hospital for the appropriate amount of time. As a result, efforts to avoid readmissions should focus on other aspects of hospital discharge care," the researchers wrote.
The lead author of the research told HealthLeaders that most adults and children have fundamentally different length of stay experiences.
"When compared with adults, more pediatric hospitalizations are due to acute illnesses that are either self-limited or require interventions that can improve health with a short LOS. Adults with more chronic conditions may get more benefit from some additional time for improvement as well as discharge planning," said James Gay, MD, professor of pediatrics and medical director for utilization and case management, Monroe Carell Jr. Children's Hospital at Vanderbilt in Tennessee.
Gay and his team found little benefit from extending length of stay for pediatric patients.
"Keeping all children in the hospital longer may prevent some readmissions—as our study showed—but the cost is just too great for the relatively few readmissions prevented," Gay said.
Evaluating length of stay impact
Gay and his colleagues examined data from the Children's Hospital Association, including clinical and billing information from 49 children's hospitals.
The research team reviewed more than 950,000 pediatric hospitalizations.
There were 314 potential reasons for an admission and only six (1.9%) conditions had higher readmission rates with a shortened length of stay
The outlier conditions included asthma, cellulitis, and nephritis and nephrosis
The time estimated to prevent a single readmission ranged from 18 hospital-bed days for nephritis and nephrosis, to 148 days for newborns
The cost of preventing a single readmission through length of stay was prohibitive, ranging from $41,000 for nephritis and nephrosis to $1.4 million for dorsal and lumbar spinal fusion.
Rising to readmissions challenge
As they seek effective strategies to reduce readmissions, children's hospitals should be able to adopt some approaches from acute care hospitals, Gay said.
"In adults, improved discharge planning, follow-up telephone calls, and home visits have been shown to reduce readmissions for some patient populations. So, it seems logical that improved discharge planning and follow-up are potential targets for reducing preventable pediatric readmissions, too," he said.
Children's Hospitals will have to move cautiously, Gay said.
"Mounting evidence suggests that some post-discharge interventions such as follow-up home or office visits may actually be associated with more frequent readmissions in children. Is it just that the sicker patients—who are more likely to need readmission in the first place—are more likely to seek post-discharge care? Perhaps, but at this point, it's not clear and we continue to seek effective means of reducing pediatric readmissions."
Following length of stay best practices
Length of stay for individual patients should not be set rigidly, and providing efficient treatment in the hospital and effective discharge planning with the patient can safely shorten hospital stays, Gay said.
"We can shorten the LOS to the greatest extent possible while providing the patient with the best means to return to their previous health baseline," he said.
Some patients can go home earlier than others, Gay said. "We must remember that patients often do not require complete return to baseline while in the hospital and it may be appropriate for the recovery period to extend beyond the discharge date."
Federal and state rules have enabled spending on nonmedical services that have health benefits such as food security.
Managed care organizations (MCOs) are on the leading edge of efforts to strike a better balance between health and social service expenditures, a recent article in JAMA says.
Evidence is mounting that countries with higher social services spending such as disability, unemployment, and housing have better population health outcomes. Among Organization for Economic Co-Operation and Development (OECD) countries, higher social services spending is associated with higher life expectancy, lower infant mortality, lower prevalence of chronic diseases, and lower all-cause mortality.
MCOs are taking a leading role in addressing social determinants of health, the JAMA article authors wrote.
"By expanding the scope of service delivery as part of managing population health risk, managed care companies can invest in services and supports that meet their members' health-related needs, benefit from reduced spending on medical care, and leverage business principles to justify resource reallocation," they wrote.
The Centers for Medicare & Medicaid Services (CMS) have enabled MCO expenditures for social services.
In 2016, CMS amended the Medicaid managed care rule to prompt Medicaid MCOs to help patients with nonmedical expenses that were considered crucial to achieving health outcomes and cutting costs.
Under the CMS Accountable Health Communities Initiative, many Medicaid MCOs assess patients' unmet social needs, including housing instability, food insecurity, utility needs, interpersonal violence, and transportation requirements.
An increasing number of states are requiring Medicaid MCOs to address social determinants of health as part of contractual agreements. In New York, The Empire State's Value Based Payment Roadmap requires MCOs to offer startup funds for partners in Value Based Payment agreements who are conducting social determinant of health interventions.
Berwick's perspective
MCOs cannot take on social determinants of health single-handedly.
"Even if all MCOs were appropriately incentivized to invest in upstream social services for their members, the sum of these investments would be insufficient to create the system for providing social services and blending them with medical services to optimally serve all U.S. residents," the JAMA article authors wrote.
Healthcare organizations must build partnerships to address social determinants of health in the communities they serve, Don Berwick, MD, former CMS administrator, told HealthLeaders at last month's IHI Forum.
"Cincinnati Children's Hospital Medical Center is working with dozens of organizations in the city with the shared goal of improving outcomes for 60,000 disadvantaged kids in Cincinnati. They are not trying to do it alone," he said.
Hospitals can also look for economic opportunities to engage distressed communities, Berwick said. "Hospitals account for about $750 billion of economic activity—employment, construction activity, and supply chain."
Opportunities to generate partners through economic activity include hiring from those communities, using construction firms from those communities, purchasing products in those communities, and investing in community infrastructure such as housing.
"We're going to spend the money anyway. Why don’t we spend it where we can work on progressive income redistribution and opportunities?" he said.
This approach features a collaboration between the clinical team and a nurse practitioner specialized in palliative care.
In oncology outpatient clinics, a structured, scheduled, and systematic approach can deliver palliative care to cancer patients at any stage of their illness, recent research shows.
Previous research has shown that combining palliative care with oncologic care generates several benefits, including increased survival and improved symptoms, quality of life, and satisfaction with care. In cost savings, providing palliative care to cancer patients reduces utilization of emergency and intensive care.
"Rapid growth over the past two decades has increased the availability of palliative care specialists from 25% to 75% in U.S. hospitals with more than 50 beds. However, access to such specialists in the outpatient setting remains limited, and in all care settings, workforce shortages and other factors constrain the role of these specialists in meeting the palliative care needs of patients," researchers wrote recently in the Journal of Oncology Practice.
The researchers found that a systematic assessment of palliative care needs from the time of diagnosis reveals actionable information and opportunities to utilize palliative care, the lead author of the study told HealthLeaders this week.
Nurses play a crucial role in the palliative care model featured in the study, said Anjali Varma Desai, MD, assistant attending, Supportive Care Service & Hospital Medicine Service, Memorial Sloan Kettering Cancer Center in New York.
"Oncology nurses and teams can excel in their role as providers of primary palliative care, which is then augmented by access to palliative care specialists," she said.
The oncologic palliative care model at Memorial Sloan Kettering has four primary elements.
1. Adopting collaborative approach
Offering palliative care to all newly diagnosed patients with cancer was a collaborative effort between oncology clinic teams and palliative care specialists. With nursing staff carrying the heaviest workload, the oncology clinic teams focused on primary/nonspecialist palliative care and enlisted specialists for clinician support and direct patient consultation.
2. Systematic assessments
On a visit-based schedule, patients reported symptoms, decision-making preferences, illness understanding, and core values.
During every clinic visit, patients rated 10 physical, psychological, and spiritual symptoms using a scale from 0 to 10.
During visit 1 (first follow-up visit after cancer diagnosis) patients were asked about preferences for receiving medical information and designation of a healthcare proxy.
During visit 2, patients reported their understanding of the expected course of their illness and treatment.
During visits 3 and 4, an intervention led by the oncology nurse featured discussions of the patient's core values. These discussions are an opportunity for the patient to express preferences about specific care goals.
During visit 4, caregivers provided an assessment of their well-being.
3. Implementing palliative care
Palliative care services were offered in two Memorial Sloan Kettering outpatient clinics, with an attending oncologist and oncology registered nurse on staff. Palliative care assessments including symptoms, information preferences, treatment understanding, and patient values were pretested then implemented incrementally.
4. Engaging patients
During visit 1, the oncologist and registered nurse told patients that palliative care would be a part of their cancer care such as attention to symptoms.
The outpatient clinics adopted a Care, Coach, Consult model. The oncologist and registered nurse provided primary palliative care, with the nurse on the frontline. The nurse practitioner specializing in palliative care coached multiple oncology teams and was a resource for direct care and advice on symptom management, communication, and care planning.
This year's expected developments include a new electronic recertification process for physician assistants.
This year will feature several significant trends and developments for physician assistants, says Dawn Morton-Rias, EdD, PA-C, president and CEO of the National Commission on Certification of Physician Assistants (NCCPA).
Physician assistants (PA) are widely viewed as part of the solution to the country's physician shortage. By 2030, the physician shortage is expected to grow to as many as 120,000 doctors, according to the Association of American Medical Colleges.
Physician assistants are a dynamic segment of the healthcare sector workforce, according to NCCPAstatisticsreleased in July 2018.
From 2015 to 2017, the number of PAs grew more than 13%.
The number of PAs per physician rose 23% from 2015 to 2017, increasing to 128 PAs per 1,000 physicians. Two of the highest PA-per-physician ratios were occupational medicine at 621 PAs per 1,000 physicians and orthopedic surgery at 537 PAs per 1,000 physicians.
In 2017, the average salary of PAs was nearly $108,000.
The ranks of PAs are filled with relatively young professionals. In 2017, 78.5% of physician assistants were under the age of 49.
The family medicine and general practice area had the highest concentration of physician assistants (19.9%), followed by surgical subspecialties (18.5%).
Morton-Rias expects four trends and developments will significantly influence the physician assistant profession this year.
1. Easing physician shortage
Physician assistants will continue to play a key role in easing the country's physician shortage, Morton-Rias says.
"Given the youth of the profession, the broad-based knowledge and skills of PAs, and the ability to provide services across all disciplines, PAs can ease physician shortages and improve access to care," she says.
The relatively young age of PAs—which averages about 38—and their propensity to stay in the profession is a bright spot in the healthcare workforce.
"The attrition rate is very low, and when we compare the PA profession to some of the other healthcare professions where the average age is in the 40s or 50s, there's a concern because you have a bolus that will be retiring out," Morton-Rias says.
The relative youth of PAs helps address the physician shortage in ways beyond actuarial considerations, she says. "The youth of the PA profession will help in increasing access to care. These are young, energetic folks who are entering the profession."
2. Modernizing certification exams
Starting this month, NCCPA will start offering electronic administration of the 10-year recertification exam for PAs, allowing PAs to take the exam on their phone, laptop, tablet, and desktop computers.
"This assessment that we are piloting is in keeping with the emerging trends in assessment and utilizing technology. In the PA profession, we have always relied on the testing methods where you sat in a test center after memorizing a lot of information," Morton-Rias says.
The electronic platform NCCPA has developed is the first major step toward modernizing certification exams at the accrediting organization, she says.
"In this assessment method, PAs can answer questions in real time, with about a minute to respond to a question. If they get the question right, they know right away, so it reaffirms their knowledge. If they get a question wrong, they are corrected right away, and they are given resources to improve their knowledge base."
Other primary facets of the new assessment method include completing 25 questions each quarter (there are a total of 100 questions and PAs have 11 weeks to complete each 25-question set). The questions cover a broad swath of core medical knowledge, and the assessment tool has the ability to allow test takers to delay answering questions that display images by switching from their phone or tablet to a device with a larger screen.
"This assessment utilizes technology and it provides real-time information in the same way people practice medicine today. Physicians are also starting to pilot this approach," Morton-Rias says.
3. Updating state PA legislation
Changes in the practice of medicine are prompting state lawmakers to reform the way PAs are regulated, Morton-Rias says.
"States are modernizing their legislation as it relates to PA practice because the healthcare industry has changed from PAs working for one doctor to more providers working in health systems. As this change has occurred, some of the states still have laws that are outdated and don't reflect the new flexibility."
She says the legislative changes include reforming scope of practice, supervision, and delegation of authority.
4. Expanding specialty care roles
PAs are shifting away from their roots in primary care to specialty care, Morton-Rias says. "Although the profession began with primary care and general medicine mostly in underserved areas, medicine has become highly specialized and the PA profession is becoming specialized as well."
She says as many as 70% of PAs are working in specialty practice, including surgical specialties such as orthopedics, neurosurgery, and cardiothoracic surgery.
The transition to specialty care presents a challenge to PAs, she says. "PAs are carrying two responsibilities. One is to maintain expertise in their current practice discipline; the other is maintaining core medical knowledge that is useful across all disciplines."
PAs are well-prepared to rise to the challenge, Morton-Rias says. "PAs have a very solid educational process and fount of knowledge that they develop through a rigorous educational training. It's a full-time immersion type of training, so PAs enter medicine with a deep knowledge base."
Healthcare organizations have an opportunity to benefit from providing high-quality care that generates positive patient experience.
Patient experience is the primary driver of patients' consumer loyalty at health systems, hospitals, and physician practices, according to a recent Press Ganey report.
Consumer loyalty not only impacts finance but also enables population health efforts and care coordination such as long-term care of patients with multiple chronic illnesses.
is five times more likely to influence brand loyalty than conventional marketing tools such as billboards, or television, print, or radio ads, the report says.
More than 1,000 adults were surveyed for the report.
Healthcare organizations can tap the power of patient experience, the report says.
"To harness that influence, providers should capitalize on the power of word-of-mouth marketing by viewing the patient experience as an essential part of their acquisition strategy. By gaining a deep understanding of what gets people talking about positive patient experiences, identifying opportunities to advance the conversation and disseminating key information, healthcare systems can naturally align the mission of delivering safe, high-quality, patient-centered care with the business of acquiring and retaining consumers."
Cultivate consumer loyalty
There are four activities that should be a part of a healthcare organization's patient acquisition and retention strategy, Chrissy Daniels, MS, a partner in the Medical Practice/Consumerism & Transparency at Press Ganey, told HealthLeaders recently.
Give every patient a voice. Maximize the volume and timeliness of feedback by leveraging delivery of surveys via text and email in addition to standard outreach.
Identify factors that drive and erode loyalty. In order to enable targeted improvement strategies, it is important to be able to identify positive loyalty metrics such as likelihood to recommend.
Use natural language (NLP) processing to analyze comments. NLP ensures that every opportunity for service recovery is identified. NLP also allows aggregation of comments into clear brand equities and liabilities, allowing for proactive management of both experience and brand.
Post ratings and reviews in physician profiles. Ensure that future patients have the most convenient access to all the information they seek by including comments—both positive and negative—and ratings of current patients.
Elevate search engine optimization and online user experience
There are two primary ways for healthcare organizations to maximize their presence in search engine results and to boost online patient experience, Daniels said.
Build a great website: Your website is your brand. Make sure it represents your practice. Build a site that is mobile friendly, loads fast, and utilizes proper quality design standards to ensure a great user experience.
Earn quality reviews: When patients are looking for a healthcare provider, they are looking for quality and volume of reviews—so are search engines. Paying attention to the volume and quality of your reviews online is extremely important, and it is also a huge part of local SEO for doctors.
Address negative reviews
Negative reviews online from patients can be an opportunity to improve patient experience, the Press Ganey report says.
"Although no physician likes to be the subject of negative reviews, these findings should reassure physicians that a single negative comment—particularly if it is an outlier among favorable comments—is not going to keep patients from selecting that provider. The real opportunity is to focus on any emerging patterns from negative comments and to target those areas for improvement."
Physicians can help their cancer patients benefit from social media while avoiding drawbacks.
Oncologists should help cancer patients be savvy about social media, recent research shows.
Earlier research has shown that judicious patient use of social media can improve health outcomes. However, benefits of social media for cancer patients such as psychosocial support and patient engagement can be offset by drawbacks including misinformation and privacy violations.
With social media's potential for both benefits and harms for cancer patients, oncologists and other healthcare providers have an obligation to help patients use social media wisely, researchers wrote this month in Journal of Oncology Practice.
"Oncology professionals are encouraged to speak with their patients about social media and to suggest best practices to enjoy the positive and circumvent the negative aspects of social media. As social media platforms continue to modify the social landscape, the oncology community must recognize and act on their influence on patients with cancer," the researchers wrote.
The researchers highlighted five benefits for cancer patients from social media.
1. Promotes patient engagement and empowerment
The researchers reviewed 170 studies of patients using information technology, which showed 89% of the studies found positives impacts on health such as weight loss. In addition, 83% of the studies found enhanced patient engagement such as text messaging for diabetes patients to access clinical data.
The researchers also found social media can help empower patients by giving them an opportunity to mentally process their cancer experience. Earlier research has shown empowered patients are more likely to attend checkups and screenings.
2. Provides psychosocial support
Earlier research has associated social support with better physical and mental health. Social media communities can help cancer patients who do not have in-person social support by reducing social isolation. Social media can also help cancer patients have conversations about emotional, spiritual, and physical treatment barriers.
3. Offers informational support
Social media can help cancer patients find oncology information. Social media can also spark incidental learning such as hashtag searches on Twitter that inadvertently connect cancer patients with online support communities. Video platforms such as YouTube can overcome healthcare literacy barriers.
4. Enhances the physician-patient relationship
Cancer patients should not use social media to interact with their physicians, but accessing oncology information through social media can increase confidence in relationships with physicians. Experiencing physicians sharing oncology information on social media can improve patients' perceptions of medical professionals in general and improve relationships with their healthcare providers.
5. Finds clinical trials and cancer research education
Social media can help cancer patients find clinical trials for particularly isolated populations who can be reached through social media advertising. Patients with rare forms of cancer can join social media groups targeted at their diagnosis, where they can connect with trial recruiters and other research opportunities.
The Journal of Oncology Practice researchers also highlighted five social media drawbacks for cancer patients.
1. Substitute for in-person support
"Social support from social media ranges from infrequent and unstructured to regularly scheduled formal online support groups," the researchers wrote.
Behavior on social media can interfere with in-person assessment and treatment. Social media use can become impulsive, which could impede in-person interactions.
2. Misinformation
Online health information is often unreliable compared to information from healthcare providers. Online research should form building blocks for conversations with caregivers. Cancer patients should also keep a vigilant eye on conflicts of interests such as healthcare professionals not disclosing their ties to medical supply and pharmaceutical companies, then promoting them on social media.
With the untrustworthy nature of information online, cancer patients should be skeptical of information gathered through social media and fact check with healthcare providers.
3. Financial exploitation
For cancer patients, financial perils on social media include unproven cancer cure claims such as vitamins and special diets. Another risk is medical ads on social media that promote unnecessary procedures and treatments.
4. Information overload
Cancer patients who have Internet access can be overwhelmed with medical information. Earlier research has linked information overload with anxiety over the inability to comprehend the avalanche of information and harness it for decision-making.
5. Compromised privacy
Social media users face privacy risks. Social media are public forums, so cancer patients should avoid posting private information. Patients should avoid sharing information that could be identifiable such as age, disease type, sex, and location.
How physicians can help
There are three primary ways healthcare providers can help cancer patients navigate social media safely and effectively, according to The Journal of Oncology Practice researchers.
Experience cancer-related social media, including exposure to content that patients are viewing.
Help patients navigate the benefits and drawbacks of social media such as gauging the social media sophistication of a patient or cautioning patients to be skeptical about information found through social media.
To limit privacy risks, physicians should not offer medical advice via social media or interact with their own patients via social media.
Avoiding air medical transfers of newborns from community hospitals to tertiary hospitals saves an average of $18,000 per flight.
Intermountain Healthcare's neonatal telehealth service has improved quality of care at community hospitals and reduced risky transfers of critically ill newborns, recent research published in Health Affairs shows.
Earlier studies have shown that 10% of newborns require breathing assistance, and 1% need resuscitation. Although hospital-based clinicians who care for newborns attend biannual newborn resuscitation programs, researchers have found key skills decline within months of course attendance.
Intermountain's neonatal telehealth service provides clinical and educational support at 17 Intermountain facilities and four partner hospitals that do not have neonatologists on staff. The telehealth service provides access to neonatologists based at four Intermountain tertiary hospitals with neonatal intensive care units (NICUs).
This week, a co-author of the Health Affairs research told HealthLeaders that the neonatal telehealth service is a valuable capability at community hospitals.
"We use a synchronous, video connection with bedside teams. These teams provide hands on care for the newborn and may be guided through procedures by the neonatologists. These specialists provide their expertise for newborns that are delivered at rural or community hospitals that were previously not typically managed at these hospitals, but often transported to larger facilities," said Stephen Minton, MD, neonatology medical director at Intermountain's Utah Valley Hospital in Provo.
Minton's research team examined newborn transfer data over a yearlong period at eight hospitals participating in the neonatal telehealth program. The researchers found that the program reduced the odds of a neonatal transfer 29.4%. This figure was associated with an estimated 67 fewer transfers annually and cost savings of $1.2 million.
Avoiding transfer of critically ill babies helps support the financial viability of community hospitals and has clinical benefits such as averting the risk handoff communication errors and high-altitude flights.
The neonatal telehealth program features several services and benefits.
For newborns such as premature infants who require transfer to a NICU, neonatologists are available to guide pre-transport stabilization until the specialized neonatal transport team arrives
Neonatologists, who are familiar with unique newborn physiology and emergency procedures, act as subject matter experts and coach bedside teams for infants who have serious conditions such as infections
When a need for neonatologist assistance is identified prior to delivery, a consultation can be scheduled prior to birth
Synchronous resuscitation support at the bedside creates educational opportunities for hospital staff to learn from neonatologists
The costs to implement the neonatal telehealth service were limited, Minton said. "No additional FTE were added for the newborn critical care program, only the dedicated efforts of physician champions. The service was implemented with technology and implementation support from telehealth team."
The American College of Physicians is promoting principles that are designed to support authentic participation of patients and family members in clinical care.
Patient- and family-centered care is an approach to healthcare featuring partnerships between healthcare providers, patients, and family members, according to an American College of Physicians position paper published this month in Annals of Internal Medicine.
Research has shown that patient-centered care is essential to achieve the Triple Aim—improving patient experience and health outcomes while simultaneously reducing costs. Patient-centered care also generates other benefits such as reducing hospital admissions and surgical procedures.
"Increasing evidence shows that patient and family partnership in care can improve health outcomes, practice efficiency, and patient and professional satisfaction. Patient- and family-centered strategies have been shown to reduce use of healthcare resources, result in fewer referrals and diagnostic tests, and lower healthcare costs," the ACP position paper says.
The four ACP principles for patient- and family-centered care include enacting strategies.
Principle 1: Treat patients and families with dignity and respect
The unique nature of every patient and family should be respected, and their preferences and values should be incorporated into delivery of healthcare. Research has shown that patients consider dignity and respect in behaviors such as recognizing the patient as an individual and paying attention to the patient's needs.
Communicating respectfully with the patient as a whole person during interviews and office visits
Listening to patients without interrupting
Asking patients whether they want family members and caregivers involved in healthcare discussions
Inquiring about whether patients have religious or cultural beliefs that should be accounted for in treatment
Principle 2: Include patients and families as active partners in care
Patients and families should participate in care to a degree of their choosing, and their perspectives should be recognized. Patients should be engaged in their care through shared decision making and collaborative goal setting.
Include patients and family members during bedside-rounds discussions
Honor patient preferences on following recommendations
Provide educational material such as after-visit summaries to increase patient knowledge
Principle 3: Give patients and families chances to impact health systems
Patients and families should help design, improve, and evaluate health systems and hospitals. Patients and families can contribute in ways that augment the perspectives of healthcare professionals. For example, patients and families have helped redesign waiting rooms, evaluate educational materials, as assess patient portal functionality.
Seek patient and family perspectives through surveys or focus groups
Include patients on committees for performance measurement and clinical guidelines
Request patient comments on purchases of capital equipment
Principle 4: Enlist patients and families in educating healthcare professionals
As the healthcare sector shifts toward team-based care, patients and families can play a key role in educating clinicians and other staff members. As opposed to a focus on diagnosis and treatment of disease, medical education is increasingly directed at teamwork and patient partnership, which are well-suited for involvement of patients and families.
Include patients and family members in teaching rounds
Pair medical students and residents with chronic-illness patients to help them navigate their care
Invite patients and families to serve on curriculum committees
