NYU Langone Health recently launched a molecular oncology program with clinical, research, and educational elements.
NYU Langone Health has launched an innovative molecular oncology program.
Molecular oncology focuses on the molecular classification of tumors. By determining the molecular makeup of a tumor, molecular oncology can determine the best therapies that match the patient, target patients for appropriate clinical trials, and monitor the response to therapy.
NYU Langone Health launched the Center for Molecular Oncology at the Laura and Isaac Perlmutter Cancer Center in October.
"A big part of what makes our program special is the scale, the scope, and the integration," says Alec Kimmelman, MD, PhD, director of the Perlmutter Cancer Center. "Patients can have access to interpretation of molecular testing wherever they come into our health system. They can go to any of our practices and have the same access."
Molecular oncology testing is available commercially, but the new Center for Molecular Oncology offers a comprehensive level of services and capabilities, according to Kimmelman.
"We have a centralized integrated infrastructure," Kimmelman says, "all of the tests are done on the same platform, the results are analyzed by a central team of experts, and a dedicated group of clinicians is making the treatment decisions and are expert in making analyses."
There are also research and educational components at the Center for Molecular Oncology, Kimmelman explains. The goal is to train the next generation of people who are going to lead in molecular oncology.
"With consent, the data from patients is going to be used for research to understand which patients respond to which therapies." Kimmelman says. "We are going to be continuously learning while we are treating patients."
Alec Kimmelman, MD, PhD, is director of the Laura and Isaac Perlmutter Cancer Center at NYU Langone Health. Photo courtesy of NYU Langone Health.
Advanced diagnostics
The Center for Molecular Oncology offers a range of advanced diagnostic techniques, including liquid biopsies, according to Kimmelman.
"You get a tube of blood from a peripheral vein, just as you would for standard blood tests at a primary care practice," Kimmelman says. "We can take that tube of blood and use deep sequencing technology to detect the presence of DNA that tumors shed."
Liquid biopsies enable several benefits for patients, Kimmelman explains, including quantifying whether there is tumor present in a patient. They can give a quantitative analysis of how much cancer is present, and characterize tumors to determine the genetic alterations in tumors. They also allow the Center for Molecular Oncology to pick the best therapies for patients.
Liquid biopsies also have the potential to screen patients for cancer, Kimmelman says.
"You can use liquid biopsies to help with diagnosis," Kimmelman says. "You can use them to guide therapies. You can use them to change therapies much quicker than you could before. And you can use them to follow patients for the presence of disease."
Part of the Perlmutter Cancer Centers molecular oncology program is following patients with molecular testing, according to Kimmelman.
"They will get liquid biopsies whenever they come in for a visit," Kimmelman says. "Then we have a centralized molecular oncology tumor board that is going to review the cases with the referring oncologist to make sure that all patients have access to our expertise."
What CMOs should know
Establishing a molecular oncology program should be a consideration for all health system CMOs because molecular oncology is destined to become the state of the art in oncology, Kimmelman explains.
"For a CMO, having a molecular oncology program is a way of ensuring that patients are getting the most advanced testing and therapies," Kimmelman says. "Eventually, all oncology is going to be molecular oncology—this is the way we are going to diagnose and treat patients."
Kimmelman recommends that CMOs weigh the decision to launch a molecular oncology program, depending in part on the level of infrastructure.
"We have been able to put a central umbrella program in place for our program, which is one of the unique features about the Center for Molecular Oncology," Kimmelman says. "We also have a fully integrated health system with the same electronic health record at all of our facilities."
Kimmelman emphasizes that almost every health system would benefit from a centralized approach to molecular oncology.
"Instead of having clinicians send tests out for certain cases to a particular company and the results come back in a PDF that is scanned into the electronic health record," Kimmelman says, "a more centralized approach generally to molecular diagnostics would benefit most health systems."
Sleep and rest are crucial to achieve positive clinical outcomes in the inpatient setting.
Hospitals can be a poor environment for patient sleep and rest.
Hospital wards are often noisy, and patients can have their sleep and rest interrupted by medical care such as collection of vital signs and blood draws during sleep and rest time.
However, hospitals can launch interventions to promote patient restfulness, according to a new journal article published by JAMA Network Open. The researchers studied restfulness interventions conducted at Barnes-Jewish Hospital in St. Louis. Data was collected from nearly 700 patients.
"Inpatient wards are notoriously disruptive environments for patients," the journal article's co-authors wrote. "Nighttime disturbances are particularly common, reducing sleep by more than an hour per night for most patients. Overnight disturbances are often caused by pain, excessive light and noise, nursing assessments, and awakenings for blood draws and medication administration."
Four primary interventions were examined. First, a one-page educational document on the benefits of restfulness and ways to promote restfulness was distributed at nursing stations.
Then, care teams reduced unnecessary nighttime interruptions by clustering care as well as limiting light and noise, including the use of red-wavelength flashlights by nurses instead of overhead lights in patient rooms.
Third, staff were encouraged to limit nighttime interruptions for patients who were stable.
Finally, an intervention emphasized personalization of the patient rest environment, including distribution of sleep kits and white noise machines to all patients.
"Sleep opportunity increased significantly during the project," the journal article's co-authors wrote.
Donald Whiting, MD, is CMO of Allegheny Health Network and president of Allegheny Clinic. Photo courtesy of Allegheny Health Network.
Patient restfulness at Allegheny Health Network
Promoting sleep and rest in the hospital setting is crucial for patient experience, according to Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic.
"If patients feel rested and feel they are in an environment where staff care about their time and rest, they have a better experience," Whiting says. "A better patient experience helps to determine the patient's outcome. If patients have a better experience, they tend to do better clinically."
Research has shown that restfulness has several benefits for hospitalized patients, Whiting explains.
"There is a lot of evidence that shows that restfulness improves healing, improves anxiety, helps with concentration and orientation, and helps with participation in therapies," Whiting says.
In the hospital setting, the patient's body is working hard to recover from whatever injury it is experiencing, which can be a surgery or an infection, says Eugene Scioscia, MD, chief experience officer at Allegheny Health Network.
"The body is working overtime in terms of its metabolism and healing process," Scioscia says, "so it is critical to allow the body to rest."
Allegheny Health Network's hospitals have taken several steps to promote patient sleep and rest, Whiting and Scioscia say.
"There are some easy things to do such as eliminating hallway conversations during rest hours," Whiting says. "We have a certain period of time at our hospitals that is quiet time, where staff are educated and encouraged to limit loud conversations."
Allegheny Health Network's hospitals have also looked at intervening in patient care during the rest time, when patients should be resting or sleeping, according to Whiting.
"There are certain things that we must do for medical care such as collecting vital signs, but we can bundle these things together at one time to allow for patients to have time to get some rest and sleep," Whiting says. "There can be periodic blood draws, periodic collection of vital signs, and periodic times where dietary staff or environmental staff do things. We try to coordinate those events to minimize interruptions in the patients' rooms."
A restfulness focal point for Allegheny Health Network hospitals is blood draws, according to Scioscia.
"We are trying to limit the drawing of bloodwork very early in the morning," Scioscia says. "Most patients are sleeping at that time in the morning, when the phlebotomist comes into the room. We ask whether we need that bloodwork—is it really going to be critical for the day?"
Limiting disruptions from patient rounding is a priority at Allegheny Health Network hospitals, Scioscia explains.
"There can be more than one clinician rounding on patients," Scioscia says. "There can be attending physicians, medical students, and residents. We ask these clinicians to try to avoid talking outside of the patient's room to limit awakening the patient."
Allegheny Health Network hospitals provide patients with white noise machines to promote a quiet environment in the inpatient setting, Scioscia says.
Why should CMOs care?
Patient restfulness should be among the priorities of CMOs, according to Whiting.
"First and foremost, the CMO cares about everything patient-related and hospital-related," Whiting says. "We help bring all of the components together to boost the ultimate outcome and ultimate experience."
Promoting patient restfulness is part of a CMO's responsibility to pursue the Quintuple Aim of healthcare, Whiting explains.
"It is the CMO's job to ensure that we are doing our best to deliver on the Quintuple Aim, which is best patient experience, best clinician experience, equitable delivery of care, best clinical outcomes, and lowest cost per outcome," Whiting says. "Restfulness and patients doing well in terms of healing as quickly and efficiently as possible is squarely in the CMO's bailiwick."
Managing patients with Parkinson's disease should be viewed as part of a hospital CMO's responsibility for patient safety and quality.
Hospital CMOs and their care teams need to take steps to avoid preventable complication risks among Parkinson's disease patients in the inpatient setting, the lead author of a recently published journal article says.
Parkinson's patients face three primary preventable complication risks in the hospital setting. These risks are medication mismanagement such as nonadherence to time-sensitive medication administration; failure to ambulate Parkinson's patients; and failure to screen for dysphasia, which is associated with aspiration and aspiration pneumonia.
The data on medication management missteps for Parkinson's disease patients in the inpatient setting is "stunning," according to the lead author of the recent journal article, Peter Pronovost, MD, PhD, chief quality and transformation officer at University Hospitals Cleveland Medical Center.
"Of the 300,000 patients with Parkinson's disease admitted to hospitals each year, about 75% of them will have some medication mismanagement," Pronovost says. "One-in-10 receive contraindicated medications that can make their symptoms worse."
Click here to read the accompanying HealthLeaders story.
Clinical AI is top of mind for CMOs and clinical leaders. Here are eight insights they shared that you need to know.
The HealthLeaders AI in Clinical Care Mastermind program reached a milestone today, with healthcare provider executives discussing key opportunities and challenges in Atlanta.
In the months leading up to today's in-person meeting in Atlanta, executives from 10 health systems and hospitals held several virtual calls and collaborated with HealthLeaders editors on stories about how their organizations are adopting and managing AI tools. The program will conclude by the end of the year, with publication of a final report.
Determining return on investment from AI tools was a pressing issue discussed during today's event.
"There are a couple of areas where there is 100% clear ROI from AI, said James Blum, MD, chief health information officer at University of Iowa Health Care. "In coding, there is clearly an ROI. With AI-based coding, I can decrease my claims denial rate. There is also an ROI with clinical documentation improvement."
Thinking about AI as infrastructure is the right play for health systems to determine ROI, according to William Sheahan, senior vice president and chief innovation officer at MedStar Health.
"For things like coding, you can find a third party and plug their tool into your data infrastructure and generate ROI," Sheahan said.
Generating an ROI from AI tools involves preparing staff members and leaders to benefit from the technology, Sheahan explained.
"There is a whole separate body of work for us that is about people and process to train clinicians, back-office staff, administrators, and leaders on how to use AI to make themselves more efficient," Sheahan said. "Ultimately, that is what is going to deliver ROI over time. We can make our business more efficient."
The impact of AI on clinicians and the role of clinicians in hospitals and health systems was a hot topic at today's event. Participants said it is highly unlikely that AI will replace clinicians.
"You are always going to need clinicians," said Hoda Asmar, MD, MBA, executive vice president and chief clinical officer at Providence. "AI will never replace clinicians, but it will affect what clinicians do and not do. AI can provide simplification and ease the way for the people who are delivering care."
The AI in Clinical Care Mastermind program was a golden opportunity for participating health systems and hospitals, executives said.
"We talked about how fast AI is changing and there is a lot of information coming out," said Roopa Foulger, vice president of digital innovation development at OSF HealthCare, "When you are collaborating with practitioners who are dealing with the same issues, you can share ideas and avoid potential pitfalls."
In addition to the difficulty of determining the ROI of AI tools, the Mastermind program focused on several other daunting challenges, including applying AI in the right clinical areas and addressing the cost, Asmar said.
"The other part is making AI benefit the people it is supposed to benefit the most," Asmar said. "We need to understand that the clinicians and the care teams on the frontline need to see some benefit from AI. They need to feel that things are changing for the better—not like the example of the struggles with the EHR."
Insights from virtual calls and HealthLeaders stories
As part of the AI in Clinical Care Mastermind program, HealthLeaders held several virtual calls with participating executives and featured each executive in a HealthLeaders online story. The following are the primary themes and findings from these virtual calls and stories:
ROI is elusive: Many small projects are showing early success, but that doesn’t translate into scalability or sustainability. There is a challenge in balancing financial ROI with clinical ROI, which can take longer to develop.
Early wins in ambient listening: Many health systems and hospitals are launching ambient listening tools to capture the clinician-patient encounter. Often these tools also capture coding opportunities. These tools are reducing clinician stress and "pajama time" conducting documentation after work hours.
Bots are becoming popular: Many health systems and hospitals are experimenting with AI agents in population health and public health programs, garnering success in engagement and increased appointments. They are exploring where else bots can be used to help doctors with clinical care.
Governance is an issue: Many health systems and hospitals are handling AI governance on their own, with dedicated committees, but they worry about stunting innovation. Challenges include determining who sits on these committees and making sure all bases are covered.
Outsourcing versus in-house: Many health systems and hospitals are outsourcing AI development because they do not have the knowledge or analysis capabilities to do the work on their own. Some are waiting on their EHR provider to develop tools for them, while others are looking at startups for innovative ideas. Those with in-house capabilities are doing what they can and partnering with vendors for the rest.
Cost concerns: AI is expensive, and it requires a lot of data and data storage, which can also be expensive. Costs are limiting innovation and AI development, particularly for small and rural health systems and hospitals.
Pressure on vendors: Many health systems and hospitals are taking extra precautions in negotiating with AI vendors. They are requiring proof of concept and ROI up front, shortening contracts to three years or less, and asking for details about how data is collected and used.
Generative and predictive AI: As AI evolves, healthcare executives will ask the technology to do more, such as predicting treatment plans and clinical outcomes. A key factor will be building clinician trust in AI tools. A pressing question is how AI will be measured against a doctor's observations and experience?
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Lifepoint Health's top clinical officer says technology and health equity will be dominant themes next year.
AI, health equity, and telehealth will be healthcare hotbeds in 2025, according to Chris Frost, MD, senior vice president, chief medical officer, and chief quality officer at Lifepoint Health.
Frost was named to his current position at Lifepoint in July. He has served in two other leadership roles at the Brentwood, Tennessee-based health system: chief medical officer of Lifepoint Communities and national medical director of hospital-based services. He is a member of the HealthLeaders CMO Exchange.
Prediction 1: Healthcare AI developments will accelerate
First and foremost, Frost believes adoption of AI tools in healthcare will proliferate in 2025, adding ambient listening technology for clinician-patient encounters will become ubiquitous next year.
"The AI works parallel to the clinician and the patient, capturing all of the information then dropping that information into the medical record," Frost says. "It takes unstructured data—the conversation—and organizes it in a structured format that is consistent with the architecture of the medical record."
In addition to generating documentation, ambient listening technology separates the signal from the noise, Frost explains.
"If the physician and the patient are talking, and the physician takes the conversation off to a tangent that has little or nothing to do with the patient's symptoms or complaints," Frost says, "the AI will parse that out and discard that extraneous information."
In 2025, ambient listening technology will include prompts for clinicians, according to Frost.
"For example, AI is going to listen to a conversation between a clinician and a patient," Frost says, "and if the patient tells the clinician something interesting about travel history or an exotic pet that they own, the AI is going to prompt the clinician to ask the patient about environmental exposure or zoonotic infection from the pet."
Virtual sitting in the hospital setting is another AI technology that will take off in 2025, according to Frost.
"As we grapple with workforce challenges," Frost says, "any technology that we can leverage that allows our clinicians and our nursing staff to practice at the top of their licenses rather than be distracted with other tasks is going to be helpful."
AI tools that provide a virtual sitting function are most helpful in reducing fall risk, Frost explains, and if a patient is considered a fall risk, a virtual sitting AI tool can alert the nursing staff to rush to the patient's room.
"It has an algorithm that can distinguish between a patient shifting in bed to get comfortable versus movements that may signify that the patient is about to get out of bed," Frost says. "We can get a person in the room to help the patient to the restroom or to get something for the patient."
In 2025, there will be an emphasis on AI development to have tools that complement rather than conflict with clinical work streams, according to Frost.
"We have learned from the electronic health record experience what not to do," Frost says. "We learned that introducing an EHR does not win the day if you do not take the time to work with the clinicians and nurses to integrate the EHR with the clinical workflow."
Additionally, AI engineers will listen, watch, and learn before they deploy AI tools, Frost explains.
"The technology will adapt to the person rather than the person adapting to the technology," Frost says.
Chris Frost, MD, is senior vice president, chief medical officer, and chief quality officer at Lifepoint Health.
Prediction 2: Health equity reaches crossroad
In 2025, there will be a reckoning for health equity efforts, according to Frost.
"Health equity has already grabbed a foothold in healthcare, but in 2025, we will find where health equity shakes out," Frost says. "Does it stay a central focus of the Centers for Medicare & Medicaid Services as well as The Joint Commission around health disparities and social determinants of health? Or does health equity get swept up in some of the culture wars that we see in diversity, equity, and inclusion (DEI)."
Next year, Frost believes health equity is going to be caught between two competing forces.
"There is the DEI side of the tug of war on one side and anti-wokeness on the other side," Frost says. "CMS and The Joint Commission have done a thoughtful and deliberate job around using data to identify patients who may be at greatest risk for adverse health outcomes because of health disparities or social determinants of health that are not being met."
Frost explains that the industry is moving in the right direction by addressing health equity.
"For clinicians and the healthcare arena, health equity allows us to address things that we have not paid much attention to historically," Frost says. "We are moving in the right direction by focusing on health equity, and I hope it does not get caught up in culture wars. That will be a focus for 2025, and I do not know how it is going to shake out."
Prediction 3: Telehealth revolution continues
Telehealth will continue to gain momentum in 2025, whether it is telemedicine, remote patient monitoring, remote therapeutic monitoring, or expansion of wearables, according to Frost.
Frost is bullish on telehealth because there is an estimated shortfall of nearly 90,000 physicians by 2036.
"We are going to see fewer specialists in nonurban and rural communities—fewer rheumatologists, neurologists, infectious disease doctors, and endocrinologists," Frost says. "We are going to be dependent on providing access to care through telemedicine, remote patient monitoring, and remote therapeutic monitoring."
Remote patient monitoring will be supplemented by remote therapeutic monitoring in 2025, Frost explains.
Remote patient monitoring allows clinicians to gather information about a disease process to get updates on indicators of the disease. For congestive heart failure, it largely involves daily monitoring of a patient's weight. For hypertension, it involves gathering blood pressure readings multiple times per day. Based on that information, care teams can adjust diuretic doses or blood pressure medication.
Remote therapeutic monitoring takes remote care to the next level, according to Frost.
"There is a component of monitoring but there is also a component of therapeutic guidance from algorithms," Frost says. "The clinical algorithms are embedded within the monitoring process. It provides clinical decision support for clinicians and patients."
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Sepsis is the body's extreme reaction to an infection that can result in tissue damage and organ failure. Annually in the United States, there are at least 1.7 million adult hospitalizations for sepsis and at least 350,000 deaths from the condition, according to the Centers for Disease Control and Prevention.
Providence reduces sepsis deaths three years in a row
A HealthLeaders story published in July details how Providence has decreased sepsis mortality at the health system's hospitals.
"Sepsis care is a key focus for us," says Hoda Asmar, MD, MBA, executive vice president and chief clinical officer at Providence. "We have made significant strides, and we will continue to make strides. This is something we are going to be working on for years to come, and we are saving lives."
Asmar says Providence focused on two sepsis care processes in 2021 and 2022. The health system more than doubled use of a standardized order set for sepsis patients. The primary elements are blood work and tests used to diagnose sepsis, administration of antibiotics, intravenous fluid resuscitation, and management of hypotension. Providence now uses the order set for 76% of patients presenting with sepsis and hopes to raise that rate to 80%.
Additionally, the health system set a goal to have the first antibiotic administered within one hour of identifying a patient with sepsis. It’s currently meeting this goal for 77% of patients, with a target of 80%. Asmar says those efforts helped reduce sepsis deaths from 2021 through 2023.’
Providence’s end goal is to be at a rate better than expected mortality, Asmar explains. The health system measures sepsis mortality using the ratio between observed mortality and expected mortality.
"The expected mortality comes from a benchmark based on the acuity of the patients we see," Asmar says. "We want to be better than 1.0 on the sepsis mortality ratio of observed mortality and expected mortality."
In 2021, Providence ended the year with a sepsis mortality observed-to-expected ratio of 1.11. In 2022, that ratio was 1.04, and in 2023 the ratio was 0.90. Last year, the health system saved an estimated 1,250 lives of sepsis patients, according to Asmar.
Asmar says Providence is now focusing on four more areas to improve sepsis care.
First, the health system is looking at gaps between its care performance and the Centers for Medicare & Medicaid Services' sepsis bundle expectations, which include early antibiotic use, timing of blood cultures, fluid resuscitation, and management of hypotension.
Second, Providence is looking at sepsis care through a health equity lens. Nationally, several patient populations experience worse sepsis outcomes than white patients, including Black patients and Hispanic patients. The health system wants to solve the unique challenges of vulnerable populations and is working on educational tools in languages other than English.
Third, the health system is also focusing on early intervention. The earlier that clinicians can identify sepsis and intervene, the fewer complications and deaths. Providence is focusing on key settings such as emergency departments and urgent care centers. One strategy involves using the EHR to monitor vital signs such as blood pressure, heart rate, and respiratory rate and give clinicians an early warning when sepsis is detected.
Finally, Providence is using the EHR to manage care for patients who are admitted to a hospital for a different diagnosis but show signs of sepsis or septic shock.
Using AI to boost sepsis patient outcomes
Another HealthLeaders story from July featured a Baton Rouge, Louisiana-based hospital that has generated positive results such as reduced cost of care and lower sepsis mortality from using an artificial intelligence-driven early diagnosis tool for sepsis.
Our Lady of the Lake Regional Medical Center has adopted IntelliSep, an AI-driven sepsis diagnostic testing system developed by San Francisco-based Cytovale Inc. IntelliSep gained Food and Drug Administration approval in January 2023.
IntelliSep determines the presence or absence of sepsis by measuring the activation of a patient's immune system, says Catherine O'Neal, MD, former CMO at Our Lady of the Lake Regional Medical Center and chief academic officer at Franciscan Missionaries of Our Lady Health System.
"As a patient approaches severe sepsis and septic shock, the immune system is more activated," O'Neal says. "IntelliSep measures the range of activation from a patient who is not activated at all to a patient who has a highly activated immune system against an infection. Highly activated patients tend to be more likely to have septic shock."
IntelliSep is one of several AI-driven sepsis diagnostic tools that have been developed in recent years. Other AI-driven sepsis diagnostic tools include the following:
Steripath, which decreases blood culture contamination to increase sepsis testing accuracy
Sepsis Immunoscore, which is an AI and machine learning software that is designed for rapid diagnosis and prediction of sepsis
Targeted Real-Time Early Warning System, which is an algorithm developed at Johns Hopkins Medicine that is integrated into electronic health records and is designed for early recognition of sepsis
A study published in Academic Emergency Medicine found that IntelliSep correctly identified which patients did not have sepsis 98% of the time, making it an essential tool for clinicians to rule out sepsis and explore alternative diagnoses.
IntelliSep has decreased the number of blood cultures taken at the hospital, which has reduced cost of care, says Christopher Thomas, MD, vice president and chief quality officer at Franciscan Missionaries of Our Lady Health System.
Data shows that IntelliSep has had a positive impact on patients and operations at Our Lady of the Lake Regional Medical Center, Thomas says.
The hospital conducted 1,800 less blood cultures in six months than the facility did in a six-month span a year ago
Length of stay for sepsis patients in the ICU has been reduced by two days
Since adopting IntelliSep, the hospital has reduced sepsis mortality by 20%
Managing patients with Parkinson's disease should be viewed as part of a hospital CMO's responsibility for patient safety and quality, says this healthcare leader.
Parkinson's patients face three primary preventable complication risks in the hospital setting.
These risks are medication mismanagement such as nonadherence to time-sensitive medication administration; failure to ambulate Parkinson's patients; and failure to screen for dysphasia, which is associated with aspiration and aspiration pneumonia.
CMOs and their care teams need to take steps to avoid preventable complication risks among Parkinson's disease patients in the inpatient setting as part of their quality and patient care strategy, the lead author of a recently published journal article says.
The data on medication management missteps for Parkinson's disease patients in the inpatient setting is "stunning," according to the lead author of the recent journal article, Peter Pronovost, MD, PhD, chief quality and transformation officer at University Hospitals Cleveland Medical Center.
"Of the 300,000 patients with Parkinson's disease admitted to hospitals each year, about 75% of them will have some medication mismanagement," Pronovost says. "One-in-10 receive contraindicated medications that can make their symptoms worse."
In addition to the recent article, which was published by The Joint Commission Journal on Quality and Patient Safety, hospital CMOs and their care teams can learn about managing hospitalized Parkinson's patients at the Parkinson's Foundation's website.
Caring for Parkinson's patients in the hospital setting
The first thing hospital care teams need to do to limit preventable complication risks for Parkinson's patients is to identify them when they are admitted to the hospital, Pronovost explains.
"One of the main risks for patients living with Parkinson's disease when they are hospitalized is most of them are not hospitalized for Parkinson's disease," Pronovost says. "Hospitals need to be able to identify people with Parkinson's disease when they are admitted to the hospital. Most of our electronic medical records can do that."
Hospital care teams should also use alerts in the electronic health record to make sure Parkinson's patients do not get contraindicated medications, according to Pronovost.
"The electronic health record makes medication management much more feasible than having to do it manually," Pronovost says. "It just requires collaboration between the information technology team and quality team to make sure they put alerts in place."
The second thing hospital care teams can do is make sure that Parkinson's patients can get their medications on time, which can be a window as small as 15 minutes at a particular time of day, according to Pronovost.
"The average hospital patient does not get medication on a tight schedule," Pronovost says, "so there has to be a workflow for nursing, pharmacy, and physicians."
The third thing hospital care teams can do is screen Parkinson's disease patients for dysphasia, so they can identify who is at risk for aspiration, then put preventive strategies and protocols in place to make sure patients do not aspirate, Pronovost explains.
Finally, Parkinson's patients in the hospital setting must be ambulated several times a day.
"We put a mobility program in place across all 23 of our hospitals because there are benefits from mobility for all patients," Pronovost says. "Patients must be ambulated multiple times per day."
Ambulating patients requires a culture of collaboration, where roles are clarified, Pronovost explains.
"In our hospital, we decided that patients who were more ambulatory would work with nurses and patients who were less ambulatory would work with physical therapy," Pronovost says. "Then we monitor and measure who is getting ambulated."
How hospital CMOs can help manage Parkinson's patients
There are several ways hospital CMOs can ensure Parkinson's patients receive safe and effective care in the inpatient setting.
"We know that Parkinson's disease patients are at risk," Pronovost says, "so CMOs need to make sure they have a way to identify patients and make sure they get the care protocols and programs that mitigate their risk."
From a CMO leadership perspective, the best thing to do is start an interdisciplinary quality improvement team that includes staff such as neurologists, hospitalists, pharmacists, nurses, occupational therapists, and physical therapists, according to Pronovost.
"This team can look at the risks Parkinson's patients have, the protocols that should be in place, who is going to perform the protocols, and what are the workflows," Pronovost says.
CMOs should establish a culture for clinical care that is collaborative and breaks down siloes, Pronovost explains.
"If there is no clarity about who is responsible for getting the medications exactly on time or ambulating," Pronovost says, "patients are not going to get those therapies appropriately."
Pronovost recommends that CMOs also make sure there are electronic health record standards and safeguards to ensure that patients with Parkinson's disease get their medications on time.
"The same thing applies to mobility and dysphasia screens," Pronovost says. "Our electronic health records can ensure safety and ensure patients who are at risk for harm are identified."
Managing patients with Parkinson's disease should be viewed as part of a hospital CMO's responsibility for patient safety and quality, Pronovost explains.
"CMOs can assemble diverse teams to work together to do new work that has never been done before," Pronovost says. "It requires the CMO to call the teams together with a clear commitment to zero harm and optimizing care for patients with Parkinson's disease."
With physician shortages and the high cost of employing physicians, APPs have become a mainstay of care teams.
The following is an extended excerpt from a HealthLeaders story published in August. Click here to read the full story.
With health systems and hospitals across the country experiencing physician shortages, many are turning to advanced practice providers (APPs) to fill in the gaps.
But does that mean CMOs should scale back their physicians and usher in more APPs instead? There are pros and cons to considering APP-led care teams.
Thomas Balcezak, MD, MPH, chief clinical officer at Yale New Haven Health, sees the workforce benefits in pairing APPs with physicians in a care team.
"There is a long lag time to bring new physicians online because of the years of training that it takes," he says. "You can train an APP in as little as 18 months after an undergraduate degree. If we want to bring more clinical resources to healthcare settings rapidly, using APPs is an efficient way to do that."
"Relying on APPs is a strategy we can use to expand access," he adds.
The differential between physician compensation and APP compensation also makes employing APPs cost effective, Balcezak says.
While some leaders think APPs could be the answer, others are not so sure.
Although APPs have become key members of care teams, they still need to be led by physicians, says Bruce Scott, MD, an otolaryngologist from Kentucky and president of the American Medical Association.
"The American Medical Association strongly supports physician-led, team-based care, where all members of the team use their unique knowledge and skillset to enhance patient outcomes," he says. "Nurse practitioners, physician assistants, and other advanced practice healthcare professionals can all be valuable members of a physician-led care team and help to provide high-quality care, but they are not a replacement for physicians."
"Models of care that remove physicians from the care team result in higher costs and lower quality of care," he adds. "Numerous studies show that patients have better outcomes when cared for by physician-led teams."
Can APPs lead care teams?
While some studies have said no to APP-led care teams, others have shown the effectiveness of nurse practitioner-led care teams. A study published by The Journal for Nurse Practitioners found that a nurse practitioner-led interdisciplinary team reduced the median hospital readmission rate by 64%.
"It is going to be hard for physicians to accept in many circumstances, and initially it is going to take extraordinary individual APPs to serve in leadership roles," Balcezak says. "However, APPs leading care teams will become more common over time."
Circumstances that are well-suited for APPs to serve in leadership roles include when the leadership expectations are around organization, delivery, and scheduling, he says.
"When those are the leadership requirements, the APPs can be outstanding leaders," he says. "APPs who have a clinical background and a mindset that is focused on management can lead care teams."
Where APPs can and cannot take the lead
Yale New Haven Health is moving toward more consistency in its primary care teams, with two APPs supporting each primary care physician along with the nurses, Balcezak says.
"We think this APP model is a much more efficient use of physicians' time and will open up more patient access," he says. "The division of labor in this model is still being worked out, but an experienced APP can do most of what a physician does in the primary care setting. There are some complex patients and diagnostic dilemmas that are better handled in the physician's hands, but most routine screening, health promotion, symptom management, and the urgent care that established patients require such as colds and strep throat can be handled by the APPs."
At Davis Health System, the most common primary care team model consists of one physician with a cadre of nurse practitioners, medical assistants, and nurses working to the top of their licenses, says former CMO Catherine Chua, DO, MS.
"The team approach has been advocated by the American Hospital Association and the American Academy of Family Physicians in order to stretch the ability of a physician to serve patients," she says. "Studies have shown that having the physician as the lead care provider at a primary care practice is the best approach in terms of cost savings, patient experience, and quality. One of the studies that I have seen said that about 72% of patients prefer to see a physician at some point in their care."
Chua says a physician-led primary care team should be designed with specific parameters around decision-making.
"One physician does the primary intake of the patient, then follow-up appointments are handled by APPs," she says. "There are other things like follow-up calls, renewals of prescriptions, and prior authorizations that can be done by the nursing staff. In addition, the nursing staff can prep the patient's visit, so that the nurses get to know the patient and can help the physician field questions from the patient."
The main challenge of this model is when patients present with complex conditions or difficult diagnoses during follow-up appointments. CMOs should ensure that physicians get involved in care when these circumstances arise, Chua says.
To address obesity, CMOs must promote intensive therapies in clinical settings to make a difference on the individual patient level and think globally.
Obesity is a worsening crisis in the United States, according to a recent journal article and the president-elect of the American Academy of Family Physicians (AAFP).
According to the journal article, which was published by The Lancet, nearly three-quarters of the U.S. population aged 25 and older were overweight or obese in 2021. "Without immediate action," 80% of the adult U.S. population will be overweight or obese by 2050, the journal article's co-authors wrote.
"Existing policies have failed to address overweight and obesity," the co-authors wrote. "Without major reform, the forecasted trends will be devastating at the individual and population level, and the associated disease burden and economic costs will continue to escalate."
There is no question that obesity has reached a crisis point in the United States, according to Sarah Nosal, MD, president-elect of the AAFP and vice president for innovation and optimization as well as chief medical information officer at The Institute for Family Health.
"We need to say that this is a crisis, so we can mobilize the resources that we need," Nosal says. "Unless we acknowledge this is a crisis across all communities, we will not mobilize resources, and we will not see a change."
Obesity is associated with several serious medical conditions, particularly diabetes, Nosal explains.
"We are worried about diabetes because it is associated with many other medical problems and diabetes is a chronic disease that can be a burden on its own," Nosal says. "Once you have diabetes, your likelihood is higher of having stroke, heart attack, vascular complications, amputations, and infections."
Other serious medical conditions associated with obesity include high cholesterol, cardiovascular disease, sleep apnea, arthritis, and joint pain, according to Nosal.
"Our bodies are built to carry a certain amount of pounds," Nosal says. "When the amount of pounds that are on our structural system such as our knees is too great, it leads to problems. Many adults are carrying around an extra hundred pounds that joints were not designed to carry."
How CMOs should address obesity
CMOs of health systems and hospitals need to think about obesity beyond the context of an individual patient in a clinic or hospital setting, according to Nosal.
"You need to think about patients as part of a larger community, and CMOs and others running a hospital system need to think about what health is and the interventions to improve health," Nosal says. "That may be promoting that fruits and vegetables are available in the community. That may be promoting funding for more walkable communities or more parks access for kids in communities."
In addition to promoting intensive therapies in clinical settings to make a difference on the individual patient level, CMOs need to think globally about addressing obesity, Nosal explains.
"CMOs need to think about making global changes in the community that can make a difference on the entire population," Nosal says.
How physicians should address obesity
Nosal, who is a practicing family physician, works with overweight and obese patients on what they want to prioritize.
"Their mother may have diabetes, and they are worried about what they should do," Nosal says. "I break down what they should do in steps and help them do longitudinal, intensive work."
Physicians need to help patients manage daily caloric intake and promote consumption of nutritious foods, according to Nosal.
"When you look at the United States and you look around the world," Nosal says, "all of the countries that have calorie-dense and nutrient-poor foods and a shift to those foods being processed rather than resourced locally have a dramatic shift to overweight and obesity."
Research has shown that short-term diets are ineffective at addressing overweight and obesity, Nosal explains.
"People need to make long-term changes for the rest of their lives," Nosal says. "I talk about juice and soda with my patients. Anything that is a liquid calorie is of poor nutritional value."
A single meal in a restaurant is often more calories than a person should eat in an entire day, according to Nosal.
"That is stunning for most of my patients," Nosal says. "The assumption is we should be eating multiple meals in a day, but eating out can put us high in caloric intake. I work with my patients to help them understand how much they should be consuming in a day."
Exercise is an important component of a broad strategy to address overweight and obesity, but it is insufficient on its own, Nosal explains.
"Research shows people can exercise a few days a week and it can make a difference," Nosal says. "But exercise by itself has a limited impact on your weight. It is really about the types of calories we are putting in our bodies and how many calories. We should be eating nutrient-rich rather than calorie-rich foods."
At HealthLeaders, the top CMO trend stories of this year focused on care team composition, deprescribing, 'medspeak,' physician onboarding, and physician leadership development.
As part of our CMO coverage, HealthLeaders has published more than two dozen trend articles this year. The following are the Top 5 CMO trend stories of 2024 (click on the headline link to read the full story):
It's time for physician leaders to say the unspoken part out loud: There will never be enough physicians. And even if you can find them and keep them, it is difficult to pay all of them.
The Association of American Medical Colleges estimates that in the next 12 years, the U.S. will be short 86,000 physicians, with more than half of those being primary care physicians. The future is a zero-sum game, where the clinical need of an aging population runs up against falling numbers of physicians.
To fill those gaps, health systems and hospitals are elevating advanced practice providers and giving them more responsibilities. The resulting change in care team design is forcing CMOs and other executives to think about how they manage their physicians to ensure a productive workplace and positive clinical outcomes.
Since this shift, CMOs have begun to wonder whether they need as many physicians as they thought, especially since the APPs are sometimes carrying out the majority of the tasks.
This begs the question, is it time for CMOs to scale back their physicians and usher in more APPs instead? While the question is in part written in jest, it doesn’t mean there aren't pros and cons to considering APP-lead teams.
For patients on multiple medications, deprescribing is a key strategy to promote patient safety and care quality.
The primary risk with multiple medications is medication interactions. This risk can lead to an increase or decrease in the effects of medications as well as undesired effects and side effects.
Cost and waste are other considerations, according to Karna Patel, MD, MPH, vice president at Tampa General Hospital and president of Tampa General Medical Group.
"As you add more medications, there is more cost to pay for those medicines," Patel says. "Globally, prescribing multiple medications can lead to waste of pharmaceuticals."
When assessing patients on multiple medications, clinic visits and visits in other healthcare settings are an opportunity to go over a patient's medication list, according to Patel.
"At that time, we want to make sure all the medications the patient is taking are appropriate for their conditions," Patel says. "We also check for interactions. That is a great time to try to deprescribe or consolidate medications."
"Medspeak" is characterized as medical terminology used by clinicians that leads to communication gaps with patients. Medspeak gets in the way of effective shared decision-making for clinicians and patients.
There are several steps clinicians can take to make sure they communicate medical terminology and procedures effectively, and it's the CMO's job to make sure their clinicians are aware of medspeak and how to avoid it.
"The jargon, the abbreviations, and the terms we use in medicine seem natural to clinicians, but patients often do not understand these terms," says Donald Whiting, MD, CMO of Allegheny Health Network and president of Allegheny Clinic. "Clinicians can fly through an explanation without getting the patient engaged, then leave them behind."
Onboarding is about more than helping clinicians navigate the hiring process.
According to the Physician and Clinician Onboarding Research Report by the Association for Advancing Physician and Provider Recruitment (AAPPR), successful onboarding programs integrate clinicians into an organization, acquaint clinicians with an organization's culture, and provide clinicians with resources and support to help them excel in their new role. AAPPR compiled this data from a survey conducted in collaboration with Jackson Physician Search and LocumTenens.com.
Providing effective clinician onboarding is pivotal in a health system's success, according to Pranav Mehta, MD, MBA, CMO of HCA Healthcare American and Atlantic Groups. HCA Healthcare, which features more than 180 hospitals, has more than 45,000 employed and affiliated physicians.
"It is critically important that we orient those physicians in a systematic way and approach," Mehta says. "We spend time onboarding them as they come from outside of our organization into our practices. That gives us the ability to make sure they are successful in clinical practice."
Physician leadership development is pivotal for the U.S. healthcare system because many of the top-performing hospitals are physician-led.
Research shows there is a gap between physician interest in leadership development and opportunities to gain this experience.
A report from Jackson Physician Search and the Medical Group Management Association found that 67% of physicians surveyed were interested in leadership development opportunities, but only 18% had been exposed to nonclinical leadership development through their education or experience in clinical practice.
It is essential for health systems and hospitals to offer leadership development opportunities, says Kristin Mascotti, MD, MS-HQSM, CPE, CMO of Penrose Hospital, which is part of CommonSpirit Health's Mountain Region.
At CommonSpirit, there are formal and informal leadership development opportunities for early career and mid-career physicians who have shown influence in their department or on committees, according to Mascotti.
"It is vital to provide physicians with leadership development opportunities," Mascotti says. "Some of the best-performing healthcare centers and hospitals in the nation are physician-led."