WellSpan Health is set to open three small-format hospitals by the end of 2025.
WellSpan Health is opening small-format hospitals to increase access to emergency care and inpatient care in three communities.
The small-format hospitals, which are being sited in New Freedom, Carlisle, and Newberry Township, Penn., feature emergency rooms with 10 beds and 10 inpatient rooms. The hospitals, which do not have operating rooms, will offer X-ray, CT scanners, and ultrasound as well as diagnostic laboratory studies. The hospitals will be open 24/7 year-round.
The three hospitals are expected to open by the end of 2025.
"We are locating the hospitals in convenient areas for our patients, particularly in areas that are underserved in relation to inpatient care," says David Vega, MD, MBA, senior vice president and CMO at WellSpan.
One of the big benefits of the small-format hospital model is that they tend to have short wait times compared to traditional hospitals and emergency departments, Vega says. "Typically, the wait time in the emergency department is 10 minutes to care, and for patients who are discharged from the emergency department, it takes about 90 minutes from the time patients check in to the time when patients go home."
The small-format hospitals are based on a streamlined model of care that allows caregivers to see patients faster and to expedite services without any reduction in the patient experience, Vega says. "In fact, it is a better patient experience than what most hospitals in the country can achieve."
The streamlined model of care includes use of standardized protocols and standardized ways of seeing patients that will help the small-format hospitals to gain efficiency, Vega says, adding the scope of care is more narrowly focused than at WellSpan's traditional hospitals.
"The scope of what is going to happen in the emergency departments at the small-format hospitals is not the same as we experience at York Hospital, which is a Level 1 trauma center," Vega says. "At York Hospital, there can be several trauma patients and stroke patients in the emergency department. At the small-format hospitals, the scope of care and the volume of patients is going to be lower than what you see at traditional hospitals, which will make us more efficient in the care that we provide."
The small-format hospitals will also be designed to provide efficient access to specialists through virtual connections, Vega says.
"This is a different model than traditional hospitals," Vega says. "Instead of having to wait for a specialist to become available and come physically to a location, a lot of our specialists will be available immediately at the bedside through a virtual connection. For example, if you need a cardiologist, they will work with the nursing team at the small-format hospital to be able to examine the patient remotely such as hearing the heartbeat."
From a CMO perspective, the small-format hospitals will allow WellSpan to have a more focused and efficient approach to care within the scope of services that will be offered, Vega says.
"The services that are offered are a little different than traditional hospitals," Vega says. "For example, there are no operating rooms or surgical procedures performed at small-format hospitals. However, the emergency department is fully licensed by the state and available 24/7. The inpatient side of the hospitals is also available to our patients."
As WellSpan's CMO, it also is important to have the small-format hospitals integrated into the health system's electronic medical record, Vega says. "If a patient needs a higher level of care than what the small-format hospital can offer, we will make it smooth and easy for patients to be transferred to a higher level of care at one of our traditional hospitals."
Providence is expanding the health system's Co-Caring Model at inpatient units and working to improve patient care progression in the inpatient setting.
The chief clinical officer of the Providence health system is shepherding a pair of inpatient care initiatives aimed at improving the patient's journey.
Hoda Asmar, MD, MBA, is supporting a quality improvement initiative called the Co-Caring Model. Under the Co-Caring Model, bedside teams in the inpatient setting are supported by a team of nurses, social workers, case managers, and other staff members who work in a virtual role 24/7.
The Co-Caring Model was launched as a pilot last year on one acute-care unit. By the end of 2024, Providence will have 33 acute-care units using the Co-Caring Model.
Staff satisfaction with the Co-Caring Model has been high and it has the potential to help address workforce shortages, Asmar says. In the first seven months of the pilot for the Co-Caring Model, there was 100% retention of staff on the inpatient unit that adopted the model.
Patients have also been receptive to the Co-Caring Model, says Asmar, who has been executive vice president and chief clinical officer of Providence since October 2021. Previously, she served as executive vice president and chief clinical officer of Adventist Health and chief medical officer of system clinical improvement at Baptist Memorial Health Care.
"We tell the patient there will be a virtual team supporting the bedside team that they interact with in-person," she says. "None of our patients have opted out of the Co-Caring Model. When we looked at patient satisfaction and experience scores for patients and their families who were engaged in the Co-Caring Model, there were great results."
The Co-Caring Model gives the patients and staff more choices, which supports growth, Asmar says.
"In healthcare right now, there is a challenge in having enough caregivers joining the workforce," she says. "By creating choices, efficiency, and a positive culture, the Co-Caring Model is helping us to recruit and retain staff members, which is helping us to serve more patients."
Providence considers the Co-Caring Model to be a learning opportunity, Asmar says.
"As we are implementing the model at acute-care units, we customize elements for the local context, and we keep refining the model as we go based on the results and what we are learning," she says.
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
Improving patient care progression
Asmar is also involved in efforts to improve patient care progression. Patient care progression is measured by operational efficiencies in the acute-care space and hospital length of stay, she says.
Providence started working on patient care progression about three years ago to address some of the challenges that occurred during the pandemic—long lengths of stay, difficulty in discharging patients, and lack of access to enough post-acute care.The work began with the goal that every patient deserves a safe and timely discharge from acute care, Asmar says.
"We created a multidisciplinary team from across the organization and implemented a back-to-basics approach," she says. "We adopted more than a dozen basics that hardwired and established critical processes and workflows. We also worked on the connection to post-acute care such as home care and skilled nursing facilities in addition to access to primary care after discharge."
The work is paying off. In the first quarter of 2024, the health system is seeing a trend in the right direction for length of stay in acute care.
What happens before and after an acute-care stay is part of the patient care progression work, Asmar says.
"We are looking at hard-wiring standardized workflows, promoting automation, having safe and timely discharge from an acute-care stay, and addressing some of the chronic and repetitive issues with access to primary care as well as access to post-acute care," she says.
As is the case with the Co-Caring Model, patient care progression work is supporting growth at the health system, Asmar says.
"The ability to create operational efficiencies, reduce length of stay, and improve access in primary care gives us more capacity to serve patients in our emergency departments and have the beds ready for patients who need acute care," she says.
The South Carolina-based health system's ACO is working in collaboration with CVS Accountable Care.
Prisma Health has established a collaboration between its accountable care organization, InVio Health Network, and CVS Accountable Care to participate in the ACO REACH model.
ACO Realizing Equity, Access, and Community Health (REACH) is an accountable care model developed by the Centers for Medicare & Medicaid Services that features upside and downside risk for healthcare providers serving traditional Medicare beneficiaries. Clinicians participating in ACO REACH include primary care physicians and specialists. ACO REACH participants must have a plan to meet the needs of people in underserved communities and to address health disparities.
The ACO REACH collaboration between InVio Health Network and CVS Accountable Care will have both organizations capitalizing on their strengths, says Drew Albano, DO, MBA, chief medical officer of population health management at Prisma Health.
"They can look at ways to provide additional clinical programs or expand on existing programs," he says. "They can also work together to harness data—there are increasing volumes of data in the healthcare space, and these partners will be able to manage data and use it in a meaningful way. This collaboration also will supplement InVio Health Network's population health programs."
InVio Health Network's strengths include robust connections locally with Prisma Health's employed physician practices and the health system's medical group, Albano says, adding InVio Health Network has strong relationships with independent physician practices in Prisma Health's geographic footprint in South Carolina. That local presence will be complemented by CVS Accountable Care's national presence and CVS Health's MinuteClinics in South Carolina, he says.
InVio Health Network also has staff tackling population health and value-based care initiatives from different angles, Albano says.
"Some of those angles include addressing care gaps such as cancer screening, scheduling of wellness visits, and getting patients in for chronic disease management for conditions such as diabetes and hypertension," he says.
CVS Accountable Care also has extensive experience with longitudinal care and care coordination, Albano says. "This will help us do well in managing populations of patients as they transition from acute care such as hospitalizations back into their communities."
Navigating upside and downside risk
Prisma Health has been serving Medicare beneficiaries since 2015, including downside risk arrangements such as Medicare Advantage health plans. Prisma Health is confident that InVio Health Network can achieve shared savings in the ACO REACH model, Albano says.
"We feel it is important to equip our clinicians with resources that are going to help them better address the holistic aspects of a patient's care," he says. "We think about not only medical management but also helping the patient to align with their optimal health trajectory and care pathways. So, we think about how we get patients in for preventative visits, chronic care management, and medication adherence."
Providing access
To be successful in ACO REACH, InVio Health Network is thinking beyond traditional methods of providing access such as getting patients into ambulatory settings for evaluation, Albano says.
"What we have seen since the coronavirus pandemic is that there are novel models for access that we can start to leverage," he says. "Virtual visits are certainly an opportunity, particularly in behavioral health. CVS Accountable Care has sought to provide access through their MinuteClinics. We are thinking about chronic disease management using remote patient monitoring for conditions such as hypertension and heart failure."
InVio Health Network and CVS Accountable Care want to provide access through the traditional model of providing in-person office visits for patients, but they also want to decentralize that model by taking care of patients in their homes, Albano says.
"So, there are many avenues to provide access," he says. "Partnerships such as this one help us to showcase which avenue is best to pursue with each patient. We know that the one-size-fits-all model is not going to work. We must take a tailored approach knowing that we are going to meet the patient where they are at and address the needs that they have using the right access pathway."
Promoting health equity
InVio Health Network's plan to boost health equity in ACO REACH includes addressing social determinants of health, Albano says.
"We have implemented a process to screen patients for social determinants risk factors," he says. "We have a tool that not only helps identify social determinants of health but also connects patients to community resources. We close the loop—it is not just providing an available resource for an identified social determinant but also making sure the patient is able to have their social determinant addressed."
CVS Accountable Care has a robust care management capability, which will also promote health equity, Albano says.
"We are going to be able to scale up what we have done historically from a care management standpoint," he says. "For example, we are looking at how the CVS Accountable Care transitional care management team can do more acute-care transitions such as patients who have a hospitalization for surgery then are transitioned back into the community."
David Battinelli says the health system must offer a range of approaches to boost the well-being of employees.
The top priority for the physician-in-chief of Northwell Health is the well-being of physicians and other staff members.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell. He is also dean and Betsey Whitney Cushing Professor of Medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Prior to taking on his current roles, Battinelli served as senior vice president and chief medical officer at Northwell.
1. Physician and staff member well-being
"I need my providers and staff members to be as well as possible," Battinelli says.
Addressing the well-being of a clinical staff requires "an entire menu of approaches," he says. "The concept of well-being is not a one-size-fits-all. We are going to have to engage a variety of different strategies for a variety of different people."
For some people, the adoption of a hybrid work environment at Northwell has been a big improvement, but for others, it does not work, Battinelli says. "You can't just say a hybrid work environment is going to solve well-being problems."
A crucial element of addressing workforce well-being is engaging staff members, he says. "If you are not aware of the things that people are struggling with regarding maintaining their well-being, then you are going to offer programs that have nothing to do with their real problems."
For clinicians, Northwell wants to work on reconstituting relationships that were formed in the past, Battinelli says.
"Years ago, ambulatory providers would round at the hospitals. They would congregate in a doctor's office or lounge, and they helped each other maintain their balance," he says. "Doctors used to support each other quite a bit, which helped them maintain balance. Now, ambulatory doctors don't go to the hospitals anymore."
The health system has two programs to foster physician get-together events. "The Doctors Lounge" is a regional dinner program initiated by practice leadership. "Connect the Docs" is a smaller local program initiated by individual physicians.
"These programs are a way for physicians to get together and relax," Battinelli says. "These programs have been remarkably successful—it is a way to ensure that doctors can support each other when they are feeling unbalanced."
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.
2. Patient access
Battinelli is also focused on an organizational goal to improve access for patients.
"There are many ways that our people are working at providing access," he says. "Getting in to see a provider for an appointment is important, but it is not the primary issue when people talk about access. The primary issue is that the only way to speak to a provider is with an appointment. Often, a provider cannot see a patient for two months."
Battinelli says Northwell has learned a lesson from the banking industry, which expanded access with online banking rather than hiring more tellers or expanding hours.
"We need to embrace 'connected care,' which is what they use in Great Britain, or embrace virtual care," he says. "Patients want to be connected first, then achieve access through an appointment later. They do not want to feel like they are being left 'out there' on their own."
To promote access, Northwell has two primary initiatives: offering a nurse navigation program and launching a virtual patient engagement program.
"Our nurse navigation program is centered on cancer services because of the emotional context of cancer and making sure that patients are connected immediately with anybody that they need," Battinelli says. "Our nurses can connect with patients 24/7 and make sure they understand everything that is going on with their care."
"The virtual patient engagement program is triggered the moment a patient calls in," he says. "The patient gets a virtual connection with a member of our staff, even if it is not the doctor with whom they get an appointment. This virtual connection assures the patient that waiting for an appointment for two weeks or two months is the best time if that is appropriate. The virtual connection also assures the patient that they are going to meet with the right doctor."
3. Technological transformation
Battinelli is also involved in efforts to establish the mindset at Northwell that artificial intelligence and other new technologies will help the staff to do work in the future.
"Many of these technologies are not mature yet, but it is clearly a good idea to be thinking about adopting these technologies," he says. "The number of things that can be done with AI is mindboggling."
For example, the patient-provider interface of the future will not involve a mouse and a keyboard, Battinelli says. At Northwell, the right interface is going to be new digital technology such as AI. The health system is looking at technology that will record the entire patient-physician interaction, then AI will generate the clinical note and documentation for the encounter.
"This will free up the physician, who can interact better with the patient," he says.
4. Becoming an age-friendly organization
Battinelli says he wants to be at the forefront of efforts at Northwell to better serve the health system's aging patient population.
"The healthcare industry has delayed addressing the aging population for as long as theoretically possible," he says. "If we do not start thinking about how to engage our aging population, the Silver Tsunami is going to hit us, and we are going to be overwhelmed."
Leaders and care teams at Northwell must think about all the things the health system should do beyond just giving expert medical care to be perceived as age friendly, Battinelli says.
"We must be able to provide things that aging patients might need," he says. "This does not necessarily commit us to something specific, but as things come along, we are thinking about how we can position ourselves to be age-friendly because we want our aging population to understand that we want to partner with them to learn how to take care of them."
Northwell is challenging care providers and other employees to identify potential programs that are going to be age friendly, Battinelli says. "For example, as an organization, we have more than 85,000 employees. We are considering creating a program that will allow employees to take time off to care for aging family members. We want to provide an employee environment that is age friendly."
The health system is also reaching out to older patients to find out about their needs, he says. "We are not going to solve the aging problem. But we can engage the aging population to find out what it is that they want from us."
Through automation, Ardent Health has increased inpatient vital sign collection from four times per day to 1,440 times per day.
Automating the collection of inpatient vital signs has improved the ability to identify patients who are deteriorating at Ardent Health.
Vital signs are critical indicators of a patient's condition in the inpatient setting. Manual collection of vital signs is conducted about four times per day, which is often insufficient to determine whether a patient is decompensating, says F.J. Campbell, MD, chief medical officer of Ardent Health.
The health system has adopted HealthCast, a technological solution that has increased the collection of vital signs to 1,440 times per day, Campbell says.
"We looked for technology that could automate the collection of vital signs. We felt that if we could improve the collection of vital signs, we would be in a better position to identify patients who were deteriorating," he says. "We were looking to improve workflow, take away workflow from the staff who were already overburdened with tasks, and identify the deteriorating patients better."
The data collected by HealthCast has been incorporated into the health system's deterioration index software, which has revolutionized the accuracy and efficacy of Ardent's deterioration index tools, Campbell says.
"We have deterioration index algorithms that look for rapid changes in vital signs, either up or down," he says. "These changes in vital signs can indicate whether a patient is going into respiratory failure, cardiac arrest, hypotension, or some other life-threatening condition."
Prior to adopting HealthCast, Ardent was using the deterioration index in the health system's electronic health record, Epic, to help identify patients who were deteriorating, Campbell says.
"We leaned in on the deterioration indexes that we had in Epic, which helped. But what we were not appreciative of was how limited that system could be without significantly increasing the amount of vital signs that we were collecting," he says. "The deterioration indexes in Epic helped, but there was not enough specificity. The sensitivity and specificity for all of our deterioration indexes went up with more vital signs coming in."
With essentially continuous collection of vital signs at inpatient units, Ardent has improved three key outcomes, Campbell says. The health system has reduced mortality, decreased length of stay, and increased transfers of patients to ICUs. The increase in patient transfers to ICUs shows that the health system is catching deteriorating patients before it is too late to provide them with critical care.
"It is a far better thing to capture someone who needs to go to the ICU than to not capture them in time," he says. "Patient satisfaction has increased because patients feel safer."
Reducing burnout
Automating the collection of vital signs and improving identification of deteriorating patients has reduced burnout among physicians, nurses, and technicians, Campbell says.
"We became aware of the untenable amount of work that we were asking bedside nurses and technicians to do," he says. "Their ability to identify deteriorating patients was their No. 1 source of stress. By extension, if nurses were not in a position to identify patients who could be deteriorating, that made the hospitalists and specialists working in the hospital uncomfortable."
A major source of burnout for anyone in the hospital working at the bedside is fear, Campbell says. "There is the fear that there could be a patient who is deteriorating that we can't identify. So, we tried to figure out what we could do tangibly to reduce this fear."
The emotional burden on clinicians seeing patients deteriorate that they were not expecting to deteriorate usually involves clinicians feeling that they made a mistake, he says. "The absence of identifying the patient who is deteriorating creates a situation that we call the second victim, which is specifically the clinicians. If a patient deteriorates on a clinician's watch, it has a tremendous impact on them. It is a catalyst for clinicians to leave the industry."
Advice for other health systems
Health systems and hospitals should not accept burnout as an inevitable consequence of the work that they perform, Campbell says.
"You do not want burnout to become a form of capitulation," he says. "We need to identify the elements that drive burnout. One example is patients declining on a clinician's watch, which makes the clinician feel they have failed the patient and they have failed themselves in their ability to execute care safely. Deterioration of patients cannot be viewed as, 'That's just the way it is.'"
Another example of a driver of burnout is the sheer number of tasks and burdensome workflows such as vital sign collection and interpretation that clinicians and nurses face, Campbell says.
"The best way to improve workflows is to take them away through automation," he says. "At Ardent, we are militant about workflow, which has gained the appreciation of our staff. Improving our workflows has an impact on our turnover and our recruitment, particularly for nurses and clinicians."
Anil Keswani is focused on organizational goals including promoting operational excellence and patient engagement.
Supporting efforts to bolster Scripps Health's financial standing is the top priority for the health system's chief medical and operations officer for ambulatory care.
Anil Keswani, MD, has been corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps since February 2020. He was previously corporate vice president of population health and president of Scripps Executive Health.
1. Financial health of Scripps
The top priority for Keswani this year is promoting the financial standing of Scripps. After the coronavirus pandemic public emergency, many not-for-profit health systems have been struggling financially, he says.
"We are looking at making sure we are fiscally responsible and financially strong to keep providing care," Keswani says. "This is a big issue in California because of the state Office of Healthcare Affordability. To meet this state agency's targets, we are going to have to manage our costs appropriately."
One area where Scripps is seeking to contain costs is the purchase of new equipment. For example, surgeons requested the purchase of new robots for operating rooms, but the health system conducted a robot utilization review and found that a surgery robot was not being used to its full potential at one of Scripps' hospitals, he says.
"With some operational changes and some clinician changes with how we schedule procedures, we were able to improve our robotic utilization across our health system to the point where we were optimizing that asset," Keswani says. "Had we not done that, we would be buying more robots and underutilizing them. Optimizing the use of our assets contains costs."
Scripps has also enlisted physician leaders in cost management efforts, he says. The health system has formed the Medical Equipment Capital Advisory Group, which includes physician leaders and operational leaders, to look at the purchase of capital equipment on both the ambulatory and acute-care sides of the organization.
"These experts are prioritizing our capital expenditures, which bubbles up to our C suite, and we make sure we are utilizing our assets appropriately," Keswani says. "It involves a lot of education and communication so our leadership can understand how to invest in the right equipment."
Anil Keswani, MD, corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps Health. Photo courtesy of Scripps Health.
2. Operational excellence
Keswani's second priority for 2024 is promoting operational excellence.
"When you talk about operational excellence, people typically think about staffing appropriately and using resources appropriately," he says. "What we need to figure out now is how artificial intelligence plays into operational excellence."
One of the things Scripps is doing this year to foster operational excellence is using ambient technology to produce AI-generated notes of clinical encounters that clinicians can review.
"Gone are the days when doctors were typing on the keyboard throughout a patient encounter," Keswani says. "We are moving to the next stage, where clinicians are able to talk face-to-face with patients, then generate a clinical note with AI."
Scripps is also using AI to help clinicians manage in-basket messages from patients, he says. Clinicians receive thousands of messages from patients, and the health system is using AI to help construct return messages.
"We have started to use AI to construct a first draft of a message back to the patient," Keswani says. "If a patient emails a doctor with a question, we are using AI to create a first draft of a message that tees it up for the doctor or nurse to review and edit, then they can send the message to the patient."
3. Care access and patient engagement
Keswani's third priority for this year is supporting a care access and patient engagement program that Scripps calls "Getting to Yes."
During the pandemic, barriers were erected in the interaction between healthcare providers and patients, Keswani says.
"There were literal barriers such as Plexiglas walls between us and the patients," he says. "Over the past few years, we have pulled back from the patient. When we had a patient surge during the pandemic, patients had to see us through telehealth."
Getting to Yes is a philosophical change and a change in care teams' attitudes so they embrace patients, Keswani says.
"Getting to Yes encompasses access and experience, but it is also creating personal accountability to connect with our patients the way we wanted to prior to the pandemic," he says. "This is more than a tag line. We want to make sure that we stay true to our organization's brand, which includes being a high-quality experience provider for our patients."
One Getting to Yes initiative has been replacing the health system's call center for patient phone calls with a hybrid contact center model, Keswani says. In some cases, patient phone calls are directed to clinical care offices, but in most cases, patient phone calls are directed to the health system's contact center.
"We have an on-site contact center, where we monitor metrics and how the staff is operating," he says. "At the contact center, we have highly skilled customer service representatives who check each other's work."
Health systems and hospitals have high turnover among customer service representatives, which affects the quality of patient engagement, Keswani says. Scripps has addressed this challenge by letting most customer service representatives work from home part-time.
"We have taken a percentage of the people in the contact center and let them work from home," he says. "Then they rotate into the contact center one week per month. We have found that the staff is excited to come into the contact center for one week, and they have an engaged attitude."
4. Engaging and developing staff
Keswani's fourth priority for this year is staff engagement and development.
Scripps has been named to Fortune magazine's 100 Best Companies to Work For list 16 times.
"The award is nice, but it reflects that we have a good relationship with our frontline people," he says.
The healthcare sector is going through a challenging time, and Keswani wants to make sure he is engaging staff members, he says.
"With an inordinate amount of change, we need to keep our clinicians with us," Keswani says. "We want to make sure they are part of the changes and understand the changes. We make sure that we keep our staff educated and informed as well as aware of the decisions that we are making."
One of the ways Keswani engages his staff is sending out a weekly "highlights" email to hundreds of people in his leadership structure.
"The email talks about what is happening locally, what is happening nationally, and what is on my mind," he says. "It is important to be connected with your staff."
A pair of chief physician executives talk trends with HealthLeaders at the recent AMGA Annual Conference.
The AMGA Annual Conference that concluded last week showed medical groups and health systems are rising to challenges and seizing opportunities, says John Kennedy, MD, AMGA chief medical officer and president of the AMGA Foundation.
Medical groups and health systems are facing a range of challenges, including workforce shortages, improving patient access, addressing health disparities, and adopting artificial intelligence solutions. All of these issues were front of mind during the AMGA Annual Conference.
Kennedy told HealthLeaders that he was impressed by the embrace of innovation shown at the annual conference.
"Medical groups are addressing key challenges such as physician engagement and physician resilience," he said. "I spend a lot of time with chief medical officers, and they have their workforces front-and-center. They are investing in new technology to help offload work from physicians. Chief medical officers are working to allow their physicians to spend more face-to-face time with their patients and less time in the electronic health record."
To address workforce shortages, medical groups and health systems are striving to improve the efficiency of clinicians and other healthcare workers, Kennedy said.
"There is a recognition that you cannot just continuously throw more people at the problem," he said. "Medical groups have physicians, advanced practice providers, case managers, pharmacists, dieticians, and other healthcare workers. There just are not enough healthcare workers to fill the entire need for staffing."
Kennedy said technology is at the heart of efficiency-gaining efforts at medical groups and health systems, and he gave two examples.
First, medical groups and health systems are adopting ambient transcription services in clinics to reduce clinician administrative burden and improve patient experience.
"The doctor can use their smartphone to capture all the elements of a clinic visit and immediately produce a medical note that requires only a short review for the physician," he said. "Ambient transcription services allow the clinician to engage the patient without working on a computer at the same time. The doctor is happier, and the patient has had a better experience."
Second, medical groups and health systems are adopting solutions to reduce the burden of in-box messages. "Doctors get all sorts of messages in their in-basket," Kennedy said. "It can come from a patient portal. It can come from phone messages. It can come from lab results or imaging. Those messages have gone up about 29% year-over-year since the coronavirus pandemic."
In-box solutions include artificial intelligence bots to help triage messages to the appropriate level of care and telehealth physicians who can provide remote care, he said. "What you are seeing is that messages are getting answered faster. Patients are more satisfied. And the huge volume of in-basket messages is starting to get under control."
Health equity is both a challenge and an opportunity, Kennedy said.
"The medical groups are all enabling their data systems to collect health equity data that is being required in accountable care programs," he said. "They must report on demographic information, race, gender, ethnicity, and insurance status. Medical groups' data systems are being set up to collect this data, and they are identifying underserved communities and developing programs to address underserved communities."
There are two primary areas related to patient access challenges, Kennedy said.
"One area is related to workforce. Medical groups need to strive to have fully staffed clinics—not just physicians but also nurses and the support staff. Medical groups are catching up on staffing after some difficult years during the coronavirus pandemic," he said. "Another area is related to technology. What we are finding is that patients are now able to self-schedule appointments from home. So, there can be openings in a doctor's schedule that have occurred in the previous 24 hours. Patients can fill those openings themselves, which improves access because there are fewer open visits in a doctor's schedule. In this way, clinics are getting more patients in sooner."
Chief physician executive perspectives
A pair of chief physician executives shared their views in separate interviews with HealthLeaders at the AMGA Annual Conference.
There are three keys to success in relationships between health systems and physician groups, said Bedri Yusuf, MD, MBA, chief physician executive of Northeast Georgia Physicians Group.
"The No. 1 key to success is trust," he said. "The second key to success is identifying the major challenges for the health system, then the medical group needs to consistently deliver on addressing those challenges. Third, physicians must buy-in to the health system's goals and what the health system is trying to achieve such as value-based care. When physicians are committed, you have accountability."
It can be a challenge to maximize the value of the interaction between a health system and a physician group, Yusuf said.
"There is a perception that medical groups lose money. But if you establish that a medical group is an investment in healthcare and the community, there are downstream benefits such as care efficiency, clinical outcomes, and meeting your mission," he said. "In our health system, we have pillars including safety, quality, healthcare stewardship, and healthcare delivery. If our medical group addresses those pillars point-by-point, we can generate revenue, achieve cost avoidance, make referrals to the hospitals, and attain improvements in service. By bringing new patients to the hospitals, we are adding to the bottomline and advancing the health system."
Matthew Mulder, MD, executive vice president and chief physician executive of UW Medicine's Valley Medical Center in Seattle, shared the keys to success for chief physician executives.
"First off, you must build your clinical credibility prior to taking the role," he said. "You also need to have a good relationship with the clinicians that you work with—you need to be a good listener and truly understand the needs of your clinicians. Likewise, you need to understand the needs of the administrative leaders you work with, who may not necessarily have a clinical background."
A chief physician executive must be intentional in bridging any gaps with administrative leaders, Mulder said. "Having common goals and common objectives helps," he said. "You need to understand their challenges, and they need to understand your challenges—very often, they are similar."
The physician-advanced practice provider primary care model can help address the doctor shortage.
Operating a primary care practice with one doctor and a handful of advanced practice providers was the focus of a session at the AMGA Annual Conference.
There is a shortage of primary care physicians nationwide, and the aging of the U.S. population is likely to make this shortage more acute in the years to come. Pairing primary care physicians with advanced practice providers such as physician assistants is one strategy to address this challenge.
"We have developed a successful interdependent team model consisting of one physician and multiple advanced practice providers (APPs), each with their own patient panel delivering high-quality and safe patient care," said Gretchen Velazquez, MD, a regional medical director at Atrium Wake Forest Baptist Health Network. She leads a primary care practice in collaboration with four physician assistants.
Valezquez said the model of her primary care practice is an effective strategy to address the physician shortage.
"There's a challenge—healthcare organizations do not have enough doctors," she said. "We need to have physicians practice at the top of their licenses while supervising and guiding advance practice providers in a way that we deliver safe and high-quality medical care."
Physicians must have qualities to be apt to successfully work with and supervise advanced practice providers, Valezquez said.
A doctor who supervises advanced practice providers should be experienced. In the first two or three years of being a primary care doctor, a physician is starting to grow their patient panel and learning how to navigate relationships with nurses and medical assistants. A more experienced physician can be a leader.
You want a physician who can be a team player. You want someone who is respected and able to bring a team together. You want someone who is available for consultation. You want someone who is available and willing to teach. There is a lot of mentoring with advanced practice providers.
You want a good communicator—someone who will tell it like it is when the time comes. When there is an issue with an APP, you want a physician who is not going to put people down and is not going to belittle people. You want the physician to be supportive. You want to have a physician who creates a relationship with APPs, so they feel comfortable coming to the physician.
There are many benefits from the physician-APP model, Valezquez said.
"You have greater access for your patients—that is really the bottomline. We must take care of a growing elderly population," she said "There is greater access for acute-care visits for patients. You have doctors working at the top of their license—you can have physician assistants handle the simpler cases such as urinary tract infections. This model is a leadership opportunity for physicians. At my practice, I am the captain of the ship. If the APPs run into a situation where they need me, they can call me any time and there is another doctor who has a similar model of practice who cross-covers for me and I cross-cover for her."
Another benefit of the physician-APP model is coverage of in-basket messages from patients, Velazquez said. "If I am out on vacation, the APPs can monitor my in-basket and respond patients."
For this model to be successful, the physician must be involved in the hiring of APPs, she said. "You can't have a physician who is disengaged. They must look through the resumes and sit down with the practice administrator to review candidates. If I cannot see a patient, I can tell the patient that it is OK to see one of the physician assistants because I hand-picked them. So, there is a level of trust there."
Interacting effectively with a multi-generational staff is foundational for retention.
Engaging and communicating with different generations of staff members is a key element of addressing the workforce challenges facing healthcare organizations, an AMGA Annual Conference speaker says.
With workforce shortages widespread in the healthcare sector, retention of staff members is crucial for organizational success. Interacting effectively with Baby Boomers, Generation X, Millennials, and Generation Z promotes retention.
A session during yesterday's AMGA Annual Conference focused on generations in the workforce. Different generations have different perspectives on job satisfaction, says panelist Elizabeth Buisker, DO, MBA, associate CMO of the Montana and Wyoming Medical Group of Intermountain Health.
"When I think about our Boomers at Intermountain Health, it is really about recognizing that they still want to have a place. They have worked hard to get to where they are at, and they want to go out on their own terms," she says. "Generation X wants to be given independence. They want to know what the goal of the organization is, but they want to get there on their own. Millennials really want to feel heard. They also need to be able to process change. You need to provide opportunities for them to have others hear their concerns."
To engage different generations of staff members effectively, it is important to recognize the different ways people like to be appreciated, Buisker says.
"Some people are mortified if you put them in front of a group and call out their good work. Other people want to be celebrated with a trophy in front of everyone," she says. "So, you need to determine whether recognition is private or public. Especially among Generation X and Millennials, they would like to get an extra day off as a form of recognition. Whereas, my Boomers are more likely to want a gift card or get a bump in salary."
Healthcare leaders need to understand what is important to their generational staff, then they must find ways to make that possible through recognition, Buisker says.
The biggest pitfall to avoid in engaging different generations of staff members is stereotyping, she says. For example, you shouldn't say, 'You're a Boomer, so you obviously do not know how to use a computer.' Or, you shouldn't say, 'You're a Millennial, so of course you are always on social media.' Putting people in buckets and not getting to know them as an individual can be detrimental.
Communicating effectively with different generations of staff members takes time and energy, Buisker says. "I wish I could just send an email, and everyone would get the message, but that is not going to happen."
Healthcare leaders should use multiple channels of communication to interact with their multi-generational staff, she says, adding these forms of communication include hard copies, email, and pop-up reminders.
From the CMO's perspective, managing different generations of staff members is pivotal for retention, Buisker says.
"You must recognize the experiences that individuals have had to get where they're at," she says. "For example, some of my older physicians consider themselves 'old school,' and they will work until they are bone tired because that's what was promoted early in their careers. But that way of working is not safe—it is not good for patient safety, and it is not good for physician well-being."
For some younger physicians, they have been tech-enabled and they can struggle to make human connections, Buisker says. "A CMO needs to be able to call this out and provide resources."
The Clinic by Cleveland Clinic provides virtual second opinions to patients, with access to more than 3,500 physicians at Cleveland Clinic.
Virtual second opinions offered by The Clinic by Cleveland Clinic are making a significant difference for patients and payers, data shows.
The Clinic by Cleveland Clinic is a joint venture of the Cleveland Clinic health system and telemedicine provider Amwell. The Clinic by Cleveland Clinic provides virtual second opinions to patients, with access to more than 3,500 expert physicians at Cleveland Clinic.
Case data from 2023 shows the health and financial impacts of The Clinic by Cleveland Clinic's virtual second opinions:
67% of virtual second opinions recommended a diagnosis or treatment plan change
In cases where the primary treatment plan included surgery, the virtual second opinion recommended an alternate treatment 85% of the time
Virtual second opinions recommended hospitalization 62% less often than the primary treatment plans
There was $100,911 average savings per patient for high-cost cases, where the primary treatment plan cost was above $10,000
There was $28,220 average savings per patient with a musculoskeletal condition
There was $8,036 average savings per patient with a cardiovascular condition
There was $4,306 average savings per patient with a cancer-related condition
"The kinds of recommendations that we make can have multiple benefits for the patient in terms of quality of life and a better chance of surviving disease-free or with less pain and disability. Our recommendations can also have benefits for employers and payers," says Peter Rasmussen, MD, chief clinical officer of The Clinic by Cleveland Clinic.
In general, patients request virtual second opinions directly or through their commercial insurance company. Patients who request virtual second opinions directly pay for the service out of pocket. Patients who request virtual second opinions through commercial insurance companies pay for the service through the payer.
There are several steps involved in a virtual second opinion at The Clinic by Cleveland Clinic, Rasmussen says:
Once a patient requests a virtual second opinion directly or through an insurance company, nurse care coordinators will talk with the patient to understand their clinical concerns and questions.
Within a week, The Clinic by Cleveland Clinic obtains all of the medical records of the patient that are relevant to their clinical condition including imaging. For patients facing a cancer diagnosis, pathology specimens are obtained for pathology interpretation.
A Cleveland Clinic specialty or subspecialty physician reviews the medical records.
The reviewing physician prepares a written report for the patient and their local physician. In most cases, there is a video consult with the patient and the Cleveland Clinic physician who reviewed the medical records.
"We take a fresh look at each patient," Rasmussen says.
Serving the patient's interest and lowering cost of care
Recommending a new diagnosis or change in treatment plan is "quite significant" for patients, Rasmussen says.
"For example, the local physicians could determine that a patient has rheumatoid arthritis causing joint pain and swelling. Our rheumatologists could differ and think it is a connective tissue disease," he says. "This would have a significant impact on the type of treatment that the patient receives. Obviously, if a patient gets a diagnosis that is wrong, they are going to get the wrong care."
Changes in treatment plans can benefit patients and payers, Rasmussen says.
"For example, for a patient with a prostate cancer diagnosis, we potentially would offer the patient three types of radiation treatment. Whereas, the local physicians may only recommend one type of radiation treatment," he says. "Choosing an option that takes less time benefits patients who are still working and minimizes the disruption of their lives; and from a payer's standpoint, it can be tremendously less expensive with no fall-off in cancer survival rates."
When a virtual second opinion recommends an alternative to surgery, the benefits for patients are substantial, Rasmussen says.
"Most people do not want to have surgery unless it is absolutely necessary. There can be alternatives such as physical therapy that lead to tremendous benefits for the patients. It decreases time away from work as well as avoids pain and potential disfigurement," he says. "If surgery is needed and it is the best thing for the patient, then that is what you need to do. But as our data shows, 85% of the time there are alternative treatment options available to patients."
Anything that can be done to avoid hospitalizations generally is going to be in the interest of the patient and lower the cost of care, Rasmussen says. "It reduces the patient's risk of hospital-acquired infections and other problems that can develop when a patient is in the hospital. Generally speaking, an alternative to hospitalization is going to be a lower-cost solution for the payer."
Tips for launching a virtual second opinion service
Rasmussen offered advice for other health systems that may be interested in having a virtual second opinion service.
"There definitely is a time and place for virtual second opinions, whether they are telephone visits or video visits," he says. "At a health system, a virtual second opinion program can fit into the portfolio of services they are offering. It certainly allows a health system to extend its reach beyond its standard geographic footprint."
With state regulations that do not allow physicians to practice medicine across state lines, it is important for physicians offering virtual second opinions to be licensed in multiple states, Rasmussen says.
"You need to pay careful attention to licensure and how the caregivers and physicians are delivering their opinions," he says. "We have chosen to move toward a model of broad licensure among our physicians in the vast number of U.S. states, so that we can create the most robust and meaningful interaction between the patients and our physicians."
The physicians who provide virtual second opinions at The Clinic by Cleveland Clinic each have licenses in about a dozen states, Rasmussen says.
"There is some administrative burden associated with maintaining these licenses. Over time, we have found that an individual physician with administrative assistance can maintain 12 to 15 licenses at a time," he says.
Another key to success in offering a virtual second opinion service is maintaining the "human aspect" of care delivery, Rasmussen says.
"We are using technology to assist with the care delivery for our virtual second opinion program, but there is no replacement for the human side of medicine," he says. "When patients are facing a significant diagnosis, change in their life expectancy, or treatments with side effects, they can be scared. So, we place a heavy emphasis on the human aspect of the virtual second opinion despite the fact that our interaction is delivered through technology."
To foster the human aspect of care delivery, a virtual second opinion service should rely heavily on video interactions with patients, Rasmussen says. "Clearly, over the past five to 10 years, we know that video can convey empathy and compassion as well as make a human connection as opposed to telephone visits or written communication," he says.
Communication training is crucial for virtual second opinion care teams, Rasmussen says.
"Our nurse care team and our patient liaison team all go through science-based communication training to assist in creating the right language for conversations with patients," he says. "We want to create a connection between the patient and our care team. All Cleveland Clinic physicians receive similar training to assist in creating a bond between the physician and the patient."
Hoda Asmar, MD, MBA, is executive vice president and chief clinical officer of Providence. Photo courtesy of Providence.
David Battinelli, MD, is executive vice president and physician-in-chief of Northwell Health. Photo courtesy of Northwell Health.
Anil Keswani, MD, corporate senior vice president and chief medical and operations officer for ambulatory care at Scripps Health. Photo courtesy of Scripps Health.
