A decade-long process to secure the safety and security of the pharmaceutical supply chain is nearing the finish line.
The pharmaceutical supply chain is gearing up for the final deadline of the Drug Supply Chain Security Act (DSCSA).
The DSCSA is a federal law passed in 2013. On Nov. 27, 2023, pharmaceutical supply chain entities such as manufacturers, distributors, and pharmacies will be required to provide serialized data in transaction information when a product changes ownership such as a sale from a manufacturer to a distributor.
To discuss the DSCSA and the 2023 deadline, HealthLeaders recently spoke with Elizabeth Gallenagh, JD, general counsel and senior vice president of supply chain integrity at the Arlington, Virginia-based Healthcare Distribution Alliance(HDA). The following transcript of that conversation has been lightly edited for brevity and clarity.
HealthLeaders: What is serialized data?
Elizabeth Gallenagh: Serialized data in this context means that the supply chain will have information related to transactions—sales of pharmaceutical products from supply chain partner to supply chain partner. This data will be at a finite level. Right now, we have serialized product at the manufacturer level, which is uniquely identifiable. We also have data exchange of transaction information that is being passed along, but that information is at the lot level. In 2023, the information will be unit-level data tied to a serial number for each product.
For example, now, we are passing transaction information statements and history that is not necessarily tied to a specific serial number. After the deadline, that serialized number will be incorporated into the data.
HL: What are the central purposes of the DSCSA?
Gallenagh: The overarching purpose was to protect the U.S. domestic supply chain for prescription drugs and to make sure that bad actors and counterfeit products were kept out. As part of those purposes, the goal was to put a framework in place so that if there was a bad actor or counterfeit product that entered the supply chain, that would be stopped and there would be a trail to enable prosecutions and find the source of bad products. For example, if a counterfeit was detected at a wholesaler, there are provisions in place in the law for identifying and investigating suspect or illegitimate product.
There is also a requirement for all trading partners engaged in the U.S. supply chain to be only dealing with authorized trading partners. So, the onus is on each entity—manufactures, wholesalers, third-party logistics providers [such as UPS], and pharmacies—to ensure that they are checking to make sure that their trading partners are properly licensed or registered with the Food and Drug Administration in the case of manufacturers.
Safety and security were the main goals, but another goal was uniformity. Before 2013, safety and security were tackled at the state level, and it got to the point where we had a 50-state patchwork of laws, particularly for wholesalers and the licensure area. It became clear it would not benefit the entire supply chain if California had one track-and-trace law, and Florida had another, and Virginia had a different approach, for example.
HL: What are the key elements of the 2023 deadline?
Gallenagh: First and foremost is the unit-level data exchange—what we call unit-level tracing capability. Right now, because DSCSA is a phased-in law over 10 years, many pieces of tracing capabilities are already in place. We already have serialization. We already have data exchange for each transaction. What we do not have is serialized data exchange, which requires many connections and interoperability across the supply chain. We also do not have a lot of engagement at the pharmacy level—they have the authorized trader requirement, and they also must be able to provide information when they are returning a product to a wholesaler. But pharmacies are facing more robust requirements. Hopefully, the entire supply chain will come full circle, and everyone will achieve the serialized-data level.
HL: What are the primary challenges of meeting the 2023 deadline?
Gallenagh: There are many challenges. The primary challenge is probably the connectivity piece—making sure that every trading partner can connect and exchange data with every other trading partner that they do business with. There are other factors that are related to connectivity and data exchange such as data quality and bar code quality. A product could be serialized and there could be systems in place at all trading partners, but there might be errors in capturing the bar code on the product, or there may be readability issues.
The other big challenge is that there is another component of the law related to uniform licensure for wholesalers and third-party logistics providers, and that has not been finalized by the FDA. There is a lot of work to be done in this area. The goal is to streamline what the states are doing and how enforcement across the states is working. In this area, there is a gap of knowledge in the supply chain about knowing what to expect on inspections and licensure. There is also a knowledge gap on the powers of the state boards of pharmacy and departments of health as well as how their interactions are going to work with FDA.
Another challenge for the 2023 deadline is a lack of understanding and engagement among the pharmacy community. There is a lot of concern that there is a gap in understanding on the part of some of the pharmacy customers of what they need to do, how they need to do it, and their level of engagement. The health system pharmacies and the large pharmacy chains have been engaged—many of them have been working on their own projects and testing. The bigger concern is the small, independent pharmacies, which may not have adequate resources and may be depending on their trading partners to help them.
HL: What are the main capabilities that pharmaceutical distributors should have in place before the 2023 deadline?
Gallenagh: We are hoping that many pharmaceutical distributors have capabilities in place already because of the ramp up over the past decade. They are going to need to have a mechanism to ensure that their suppliers and customers are authorized trading partners—whether they have staff or a system to check licensing. They are going to need to be able to receive and distribute serialized product. They are going to need to be able to receive and share serialized data, so they need to have connections established with their trading partners. They are going to need to have processes in place for identifying and investigating suspect and illegitimate product as well as be able to engage with their supply chain partners and FDA or the states on those investigations.
Many pharmaceutical distributors are testing now or trying to ramp up to get into compliance well before the 2023 deadline, but this is something that does not work with just one entity or just one segment of the supply chain. DSCSA was designed to be interactive, so all parties must do their part in order for interoperability to work.
The HDA will be holding its 2022 Traceability Seminar from Oct. 12 to Oct. 14 in Washington, D.C. The event will include discussions about the 2023 DSCSA deadline.
Researchers examined payments to male and female physicians from the 15 highest-grossing U.S. medical supply companies.
A new research article has found that male physicians are paid significantly more by medical supply companies than their female counterparts.
Several studies have found a salary gap between male and female physicians. Medical companies spend more than $30 billion annually for advertising and promotion, with most of the money directed at physicians.
The new research article, which was published by JAMA Surgery, features data from the Open Payments Database for female and male physicians who received the most payments from the 15 highest-grossing U.S. medical supply companies from January 2013 to January 2019. The companies selected for the analysis were Abbott Laboratories; Baxter International Inc.; Becton, Dickinson and Company; Boston Scientific Corporation; Cardinal Health Inc.; Edwards Life Sciences Corporation; Fresenius Medical Care AG & Company KGaA; Medtronic PLC; Novartis International AG; Olympus Corporation; Siemens Healthineers AG; Smith & Nephew PLC; Stryker Corporation; Terumo Corporation; and Zimmer Biomet Holdings Inc.
The research article has several key data points:
Among the 1,050 payments examined, 96.9% of the five highest earners were men and 3.1% were women.
Over the study period, female physicians were paid a mean of $41,320, and male physicians were paid a mean of $1,226,377.
From 2013 to 2019, the payment gap between female and male physicians jumped from $54,343 to $166,778.
For all academic ranks, male physicians received higher median payments than female physicians. For example, male physician professors received median payments of $129,499 compared to $19,559 for female physician professors.
Male physicians received higher median payments across all specialties. The largest payment gap was in orthopedic surgery, where male physicians received median payments of $1,752,573 compared to $24,387 for female physicians.
Even in the female-dominated obstetrics and gynecology specialty, male physicians received higher payments than female physicians. The median payment for male obstetricians and gynecologists was $87,596 compared to $31,166 for female physicians.
"This study found that male physicians received significantly higher payments from the highest-grossing medical industry companies compared with female physicians. This disparity persisted across all medical specialties and academic ranks. The healthcare industry gender payment gap continued to increase from 2013 to 2019, with a wider compensation gap in 2019," the study's co-authors wrote.
Interpreting the data
The medical company payment gap was dramatic, the study's co-authors wrote. "We found that in the 15 highest-grossing medical industry companies from 2013 to 2019, there was a median 3-fold increase in the compensation of highest-earning men compared with the highest-earning women. Only 3.1% of women were within the 5 overall highest compensated physicians."
Payments to male physicians were higher than payments to female in all specialties—even female-dominated specialties, the study's co-authors wrote.
"We looked at all medical fields, including but not limited to surgery, radiology, pathology, dermatology, internal medicine, and obstetrics and gynecology and found that men earned significantly more than women regardless of their medical specialty. Obstetrics and gynecology is a female-dominated specialty of which women [comprise] more than 60% of all physicians. Our study showed that 52 of the physicians receiving industry payments were from obstetrics and gynecology: 31 women and 21 men. Despite a higher female-to-male ratio, male obstetricians and gynecologists received 3 times the amount of payment compensation from industry," they wrote.
Top healthcare executives from across the country are set to participate in a special HealthLeaders leadership summit this month in Atlanta.
Staffing shortages and slippage in some clinical areas such as quality are primary challenges as Providence emerges from the coronavirus pandemic, says Hoda Asmar, MD, MBA, executive vice president and system CMO at the health system.
Asmar is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit scheduled for this month at the Loews Atlanta Hotel in Georgia. Asmar will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing of plans, thoughts, strategies, and impressions of the future of the healthcare industry. HealthLeaders coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Asmar's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the pandemic has passed, what are the primary clinical challenges you are facing at Providence?
Hoda Asmar: The challenges are multifaceted, but one of the main things we are facing is workforce-related challenges. Do we have enough staff? Do have enough people wanting to relocate or to take new roles? We have a shortage of licensed professionals, and we need more flexibility in the work schedule. What is happening with the workforce shortage is we are asking the same people to take on more and more shifts. There are also workforce concerns around burnout and the well-being of the staff who are on the frontline.
A second challenge for us that is related to the pandemic is a slippage in some of the clinical measures such as quality. So, Providence is focused on going back to the march toward top quartile and top decile clinical performance and being able to regain some of the performance that was lost during the pandemic.
HL: Give an example of where you have experienced slippage in quality.
Asmar: An example is managing sepsis. We are focused on managing sepsis, which is a diagnosis that carries with it high morbidity and mortality. Before the pandemic, our sepsis performance was better than expected—we had bent the curve significantly to better than expected on metrics related to sepsis management. During the pandemic, we lost some of that ground. Now, we are focused on getting back to better than expected.
HL: How are you addressing workforce shortages?
Asmar: We have a senior team that is focusing on workforce shortages, including our chief nursing officer.
We are taking a multifaceted approach. We are looking at the principle of functioning at the top of license—we are looking at people's roles and functions and trying to reduce the tasks that someone with a high-level license does not need to do. We are also looking at the schedule and offering our workforce more options in flexibility, types of shifts, and the shifts they work.
We are piloting a virtual nursing program at Covenant Medical Center in Texas. On one nursing unit, we are supporting the in-person nursing team with a virtual nursing team for tasks that do not need to be done directly in-person. This pilot will be ongoing for 90 days, and we hope the virtual nurse model will support frontline nurses.
For the virtual nursing program, we had the nursing staff at the hospital sit down with the hospital's senior leaders. They went through every task that is being done to separate the tasks that have to be done in-person with tasks that can be done virtually. The tele-nurse checks with the patients on any tasks that can be done virtually. Examples of virtual tasks include checking on the patient verbally, tasks related to documentation, and tasks in the electronic medical record.
HL: In this new phase of the pandemic, what are your primary COVID-19 challenges?
Asmar: Now that we are in the endemic phase of COVID-19, there are a couple of things we are focusing on. We need to remind people that for us to remain in the post-pandemic phase, we still must take infection precautions. We also are hoping that the vaccines will become like the flu with annual vaccinations. We want people to stay alert about COVID-19.
The good news is we are seeing less acute patients and less inpatients, but we must remember that COVID-19 is still here. It is in an endemic phase, and we still must practice certain precautions and certain measures such as vaccination to be able to continue to protect our patients, our staff, and our communities. We must make sure that we do not go back to the first and second waves of COVID-19 and the negative impact we had with morbidity and mortality. We do not want to go back to the height of inpatients that we had with COVID-19.
HL: In the next year, in what areas would you like to launch clinical initiatives?
Asmar: We are in the middle of preparing for our 2023 priorities. We will continue to be focused on safety measures such as reducing mortality for sepsis as well as hospital-acquired infections and complications, including central line- and catheter-associated infections. We are also going to be focusing on falls, particularly falls with injuries. These are the clinical initiatives we are focusing on in terms of quality and safety.
Another area we are going to focus on is supporting our caregivers including our physicians in terms of resiliency, well-being, and mental health. In the past two years, staff on the frontlines have taken on a lot.
HL: Can you give some examples of initiatives you are going to be launching related to the resiliency and well-being of your staff?
Asmar: We launched in 2022 and we will enhance in 2023 an initiative that we call No One Cares Alone. We trained more than 10,000 caregivers basically to support each other. Through this intervention just in 2022, we have identified 300 caregivers who have had signs of depression and even suicidal ideation, and we were able to support them.
In behavioral health, we have taken a telehealth approach and have been providing training and raising awareness for staff well-being. We have been measuring success based on the number of caregivers who access services, surveys on well-being and resiliency, and specific measures such as when we identify someone who may have early signs of depression or burnout. We measure the response to the interventions.
The health system has created a community care program that includes mobile units and neighborhood-based Community Care Centers.
Sentara Healthcare has launched a community care program to provide neighborhood-level access to services for people who are on Medicaid or are uninsured or underinsured.
A primary focus of Sentara Community Care is to help patients address social determinants of health such as housing, food security, and transportation, which have a pivotal impact on the physical and mental health of patients.
So far, Sentara Community Care has launched a mobile unit and two facilities:
Sentara Mobile Care: This bus is serving the Hampton Roads, Virginia, area to work with individuals who struggle with lack of transportation and time constraints. The mobile unit sets up at community events and offers scheduled services at multiple locations, including Queen Street Baptist Church in Norfolk, Ivy Baptist Church in Newport News, and the Center for Global Diplomacy in Virginia Beach.
Sentara Community Care Center—Union Mission: Sentara has opened a Community Care Center at Union Mission, which is a homeless residential program in Norfolk. The care center offers both on-site and virtual care services as well as care navigation and health improvement programs.
Sentara Community Care Center—Berkley/South Norfolk: This care center is located at an affordable housing apartment complex, and it serves one of Norfolk's most medically underserved neighborhoods. The care center provides traditional medical services such as primary care as well as on-site social services and wellness resources.
Sentara Community Care is designed to meet basic medical care needs as well as social service support, says Jordan Asher, MD, executive vice president and chief physician executive of the Norfolk-based health system. "Our integrated healthcare delivery model will provide comprehensive primary care, behavioral health, and social support services. Specific services vary by location and are designed to meet the individual needs of the community."
A range of services are available through Sentara Community Care, including the following:
Food and nutrition security assistance
Cooking and health education services
Healthcare navigation
Substance use resources
Education and career training
Transportation assistance
Housing assistance
Domestic and community violence assistance
Financial literacy services
The health system plans to launch another mobile unit in Harrisonburg, Virginia by the end of the year, Asher says. "Then we have eight different Community Care Center locations on the drawing board slated through 2023 and as many as eight more sites in 2024," he says.
Addressing 'dis-eases of life'
Asher says it is critical to address social determinants of health, which he calls "dis-eases of life."
"We believe that by being out in the communities where the needs are greatest and helping to address social determinants of health—or the dis-eases of life—we can medically care for individuals even better. To truly drive measurable change and advance health equity in the communities we serve, we must focus on addressing the root factors that greatly influence a person's health and well-being beyond the care that we deliver inside of our medical facilities," he says.
Sentara Community Care is based on the belief that dealing with social determinants of health is essential to achieving positive clinical care outcomes, Asher says.
"Sentara Community Care builds on our existing efforts and commitment to address social determinants of health, especially in those who are most vulnerable and have the greatest need. Social determinants of health, such as housing, financial literacy, food insecurity, and transportation needs, directly impact 80% of a person's health and well-being—factors that occur outside the walls of medical offices and facilities. We are focused on treating these dis-eases of life before treating medical diseases."
Targeting community care
Sentara is using data to target neighborhoods for community care services, Asher says. "We spent a lot of time over the past year engaging our communities. We got data points from the grassroots level, including community leaders and faith-based ministers and pastors. So, we came at this from a voice-of-the-customer perspective. We also came at it from a market perspective, meaning, what does the market need by the definition of what data shows us such as geographic information system data, gaps in care for Medicaid lives, and gaps in care for the uninsured?"
Sentara combined geographic information system and insurance data with data collected from communities, he says. "We married that data with qualitative and quantitative data that we got from the communities. That has made a huge difference in where we go and what services we bring to those areas, which might be different from place to place. Most importantly, we are building trust and community commitment because they were part of the data collection to begin with."
Financing community care
Sentara is financing the health system's community care program itself, Asher says. "We are financing the community care program because we believe that a healthier community is better for the overall community. As a not-for-profit, we are a community asset, and the community care program is part of how we are going to fulfill our community role."
Serving the uninsured is part of the financing challenge, he says. "We are an integrated delivery network, so we have an insurance arm. When people come in and they are uninsured, we are working on getting them insurance, and we can do that because we have an insurance arm. That's one of the big social determinants—not having insurance or a way to fund your healthcare needs when you need to fund them."
Community Care Center staff offer uninsured patients affordable options, Asher says. "A lot of these people qualify for services that they don't know they qualify for, and they need someone to help them through the process. So, we can sign up people for Medicaid, and we are able to work with them from an Affordable Care Act standpoint on the individual insurance market depending on their income level. Virginia is a Medicaid expansion state, so enrolling people in Medicaid is one of our major focal points. At our Community Care Centers, we have staff there to help patients get what they qualify for."
IHI is offering two ways for healthcare organizations to participate in its Pursuing Equity initiative.
With sponsorship funding, the Institute for Healthcare Improvement (IHI) is launching a new iteration of the organization's Pursuing Equity initiative.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
IHI created the Pursuing Equity initiative in 2017 to help health systems address healthcare disparities that are systematic, avoidable, and unjust. The Pursuing Equity initiative is based on a framework with five key components for healthcare organizations:
Establish health equity as a strategic priority
Design structures and processes to bolster health equity work
Develop strategies to address determinants of health that healthcare organizations can impact directly
Reduce institutional racism within the organization
Form partnerships with community organizations to improve health and equity
Genentech, which is a subsidiary of the Roche Group, has provided funding that will allow dozens of healthcare organizations to participate in the Pursuing Equity initiative at no cost from January 2023 to June 2024. IHI is offering two opportunities for healthcare organizations to participate in Pursuing Equity:
Learning Network: 40 teams will develop the infrastructure needed at health systems to advance health equity and racial justice at their organizations and communities
Action Community: 10 teams will use quality improvement tools to make measurable positive changes in clinical health equity disparities
Action Community applications are open through Oct. 21 and Learning Network applications are open through Nov. 1. Details about submitting applications, expectations for participating organizations, and IHI support are available online.
Working with IHI on equity
HealthPartners has been working with IHI on equity issues for many years, says Beth Averbeck, MD, senior medical director for primary care at the Bloomington, Minnesota-based health system. "We were one of the Pursuing Perfection grantees two decades ago and equity was one of the aims. So, we have had a number of different collaborations with IHI. Because of the work we have done already, Pursuing Equity has been an opportunity to focus on an area that is important to both organizations."
Participating in Pursuing Equity was helpful during the pandemic, she says. "Some of the concepts that we learned in the Pursuing Equity initiative helped us in the COVID-19 vaccine work that we did. Given some of the distrust that we anticipated, there were potential disparities in COVID vaccination. So, we applied some of the Pursuing Equity principles to how we could be nimble and try things to close equity gaps."
Pursuing Equity complements ongoing equity work at HealthPartners, says Nance McClure, JD, chief operating officer at the health system. "For Pursuing Equity, what we have tried to do is to make sure that the team we have working in the initiative with IHI is directly connected to work that we have in our annual plan. Pursuing Equity has been an accelerant for work that we have in our annual plan. We have not been creating new and different work. In that way, we have not made specific investments in Pursuing Equity."
McClure offered advice for other health systems that are planning to participate in the Pursuing Equity initiative. "You need to make sure there is a solid link between people participating in the Pursuing Equity initiative and the work that is going on in the organization so that it does not become siloed and work that is competing for resources. It must be part of the mainstream work of the organization. … It also helps to keep the team small. Some organizations will have a team of 10 or 15 people, but it is often more productive to have a small team that is accountable for working on the team and incorporating their work with what is happening in the organization."
The Baltimore-based health system has provided more than 1.5 million telehealth visits since the beginning of the coronavirus pandemic.
Johns Hopkins Medicine has surpassed 1.5 million telehealth visits, and the health system expects virtual medicine visits to maintain a brisk pace over the next two years.
At most health systems, hospitals, and physician practices, telehealth visits have increased exponentially since the beginning of the pandemic. New regulations adopted during the pandemic boosted the ability of healthcare providers to offer telehealth visits; and as long as those regulations remain in place, the volume of telemedicine visits is expected to be significant.
Telehealth visits at Johns Hopkins Medicine have leveled off since the early phase of the pandemic, but the volume of visits is expected to be robust over the next two years, says Helen Hughes, MD, MPH, medical director of the Office of Telemedicine at the health system.
"Over the past six months, we have reached a steady state of about 30,000 to 35,000 outpatient telemedicine visits per month across Johns Hopkins Medicine. That is about 15% of our outpatient volume. If we assume no major regulatory restrictions in the near future, we think this is the level of telemedicine our providers want to offer, and our patients want to receive. This is about 400,000 telemedicine visits per year," she says.
Hughes says three types of investments were required to support the increase in telehealth visits at Johns Hopkins Medicine: technical, operational, and training.
"From a technical standpoint, our Office of Telemedicine as well as our Johns Hopkins IT infrastructure quickly spread technical tools that we had prior to the pandemic. We used those tools in the spring of 2020, but we realized that some of those tools were not effective for our patients and providers. For example, we adopted a new video platform in August of 2020, which we continue to improve based on provider and patient feedback."
"From an operational standpoint, it was amazing to see our clinics on the frontline need to pivot and incorporate this type of care into caring for their patients, who they also saw in-person. Our Office of Telemedicine needed to work with all of our operational teams that support outpatient care, including scheduling services, interpretation services, and our frontline clinical support staff to make sure patients were having a seamless telemedicine care experience. All of this was new at the beginning of the pandemic, but we adjusted to integrating telemedicine into the continuum of our usual outpatient care operations."
"From the training standpoint, telemedicine was new to many staff members two-and-a-half years ago, and we needed to conduct a lot of training. Our Office of Telemedicine partnered with several of our training teams both on the clinical side and the education side to make sure our providers and staff knew how to use the technical tools in a way to provide high-quality care."
Clinicians had several options for telehealth training, Hughes says.
"We had training tip sheets, videos, and electronic learning modules, which covered both the technical and the clinical basics. We also partnered with many of the educational leaders—our educational leaders in primary care, our educational leaders in the pediatrics residency training program, our educational leaders in the medical school, and our educational leaders in specialties such as neurology. We wanted to make sure clinicians in their various content areas were trained to use telemedicine as a clinically appropriate tool. It has been multifaceted, from basic education such as how you get on a visit and how you act professionally during a visit to how you use this tool for a neurological exam or a gastrointestinal exam at a distance," she says.
Telehealth adoption by clinicians
About 60% of Johns Hopkins Medicine clinicians have conducted at least one telemedicine visit since March 2020. In April 2021, the health system surveyed its clinicians to understand how they wanted to use telemedicine in the future and how they had used telemedicine during the pandemic, Hughes says. "We found that there were some overall trends in what types of specialists wanted to do more telemedicine in the future—after the acute part of the pandemic. Providers in specialties that are less in-person, less physical exam-dependent or less in-person procedural-dependent such as psychiatry, nutrition, and genetics were more likely to want to do more telemedicine in the future."
When the survey data was examined by specialty, the health system found there was a wide variety in how much individual providers wanted to do telemedicine, she says. "In almost every specialty, we saw a range from providers who wanted to do 100% telemedicine to providers who wanted to do 0% telemedicine in the future, which indicated that there are some specialties where telemedicine works very well, but within each specialty there are early adopters who have loved using this tool and want to do it more in the future. Then there are providers who are hesitant about telemedicine and want to go back to the in-person visits they were doing before the pandemic."
The survey data indicated that female clinicians and providers who had fewer than 15 years in clinical practice tended to want to do more telemedicine, Hughes says.
Emotional exhaustion is highest among nurses, a new study finds.
Emotional exhaustion among healthcare workers has increased significantly during the coronavirus pandemic, according to a new research article.
Emotional exhaustion is one of three scales in a widely used measure of burnout—the Maslach Burnout Inventory. The new research article is the second study published recently that indicates healthcare worker burnout has spiked during the pandemic. A study published last week found that physicians reporting at least one burnout symptom increased from 38.2% in 2020 to 62.8% in 2021.
The new research article, which was published by JAMA Network Open, is based on survey data collected in September 2019, September 2020, and September 2021 through January 2022. The survey respondents were clinical and nonclinical healthcare workers at two large healthcare systems, including 76 community hospitals. Data was collected from more than 100,000 surveys.
The characteristics of emotional exhaustion include feeling drained, overwhelmed, and unable to meet demands.
The new research article features four key data points:
From September 2019 to January 2022, overall emotional exhaustion among the healthcare workers increased from 31.8% to 40.4%.
Emotional exhaustion among physicians decreased from 31.8% in 2019 to 28.3% in 2020, then increased to 37.8% in the second year of the pandemic.
Emotional exhaustion among nurses increased from 40.6% in 2019 to 46.5% in 2020 and 49.2% in the second year of the pandemic.
For all other healthcare workers (HCWs), emotional exhaustion (EE) increased from 31.2% in 2019 to 40.5% in the second year of the pandemic.
"This large-scale survey study of HCWs spanning 3 years offers substantial evidence that emotional exhaustion trajectories varied by role but have increased overall and among most HCW roles since the onset of the pandemic. These results suggest that current HCW well-being resources and programs may be inadequate and even more difficult to use owing to lower workforce capacity and motivation to initiate and complete well-being interventions," the study's co-authors wrote.
The decrease in emotional exhaustion among physicians in 2020 may be related to healthcare practice changes in the early phase of the pandemic, the study's co-authors wrote. "Flexibilities afforded by increases in telehealth and decreases in patient volume may explain some of the 2020 decrease in physician EE."
Addressing HCW well-being is made more difficult when EE levels increase, the study's co-authors wrote. "Initiation of well-being interventions by busy and exhausted HCWs is made more challenging when EE increases, because taking time to do something about well-being then becomes one more thing on an overwhelmed to-do list."
Efforts to address HCW well-being are falling short of the challenge, the study's co-authors wrote. "Existing programs and resources to facilitate HCW well-being were inadequate before the pandemic and now appear to be woefully inadequate."
Top executives from across the country are set to participate in a special HealthLeaders leadership summit next month in Atlanta.
Staffing shortages are the primary challenge as health systems emerge from the crisis phase of the coronavirus pandemic, says Eric Eskioglu, MD, MBA, executive vice president and chief medical and scientific officer at Novant Health.
Eskioglu is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit scheduled for next month at the Loews Atlanta Hotel in Georgia. Eskioglu will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing of plans, thoughts, strategies, and impressions of the future of the industry. HealthLeaders coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Eskioglu's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges that you are facing?
Eric Eskioglu: Staffing is the biggest challenge. Everybody knows about the nursing challenge in healthcare, but we are facing challenges beyond nursing—it's spread into respiratory therapists, phlebotomists, medical assistants, as well as physicians and other healthcare workers. So, the whole environment has been completely disrupted.
Part of the problem is generational. The millennials and increasingly the Gen-Z generation are looking for a different variety of experiences. They do not want to be tied down to a place for more than a year or two. So, there is a pattern of contract labor, travel nursing, and other travel professionals that seems to fit their lifestyle.
HL: How are you addressing these workforce shortages?
Eskioglu: For the next two to three years, for every 10 healthcare workers we used to employ, we are probably going to employ five, contract out traveling healthcare workers for about three, and have the other two automated.
I have been a big proponent of artificial intelligence and natural language processing. We have got to get to the point where we automate a lot of the mundane things that the nurses and the physicians do. Once AI takes over in areas such as documentation, what is left are tasks that require human intelligence that helps us through judgment, which AI cannot do yet. If you ask nurses, they just want to have meaningful work—they do not want to have work that is mindless.
We are trying to make work more meaningful, get rid of hunting and gathering, and eliminate as much of the documentation burden as we can. We want healthcare workers to come to us to work not only because we offer good compensation and good benefits but also because they love the work that they are doing. That is how we are going to differentiate ourselves from everybody else.
HL: Now that the crisis phase of the pandemic has passed, what are your primary COVID-19 challenges?
Eskioglu: The pandemic phase has passed, and we are now in the endemic phase, which means this disease is going to be with us for years to come. Over the past six to nine months, it has been like Whac-A-Mole. We had a wave of delta variant cases at the beginning of the year, then the first omicron variant spiked up, then the second omicron variant spiked up. I do not know whether the next stage of the endemic is going to be a huge spike, with lots of hospitalizations, or whether it is going to be more of a drawn-out spike with less hospitalizations.
We are prepared for all of the scenarios because we have to be prepared—we do not have a choice. But I am hopeful that the new boosters targeted at omicron will be effective.
There also are other infections that we need to address. We have done an incredible job managing monkeypox—we have been able to limit the spread of that disease unlike what we could not do for COVID. We are also going into our flu season, so we are facing a triple threat in the coming months. We feel confident that we can rise to these challenges.
HL: In the next year, in what areas would you like to launch clinical initiatives?
Eskioglu: We are going to have more mental health issues as a country. If you look at national and international events, whether it is the national discourse, the war in Ukraine, inflation, or the recession that might be upon us, a lot more people are going to have mental health issues and there is going to be exacerbation of people who have pre-existing mental health issues. We are going to have more depression and anxiety.
We are focusing on how to address mental health needs better through initiatives such as telemedicine. We are having a lot of touch points with our mental health patients.
Over the next year, we are also going to be focusing on our AI initiatives—that is where we are going to change healthcare in the long run.
HL: Give me an example of where you see AI making a difference at Novant in the next year.
Radiology is a good example. On a busy ER night, you could have as many as 50 images pile up on the radiologist, and everything in the ER is STAT. The problem is that the queuing system is so old-fashioned that you face a logistics challenge. Often, it is first come, first served. That makes it difficult to find the image that might be the ticking time bomb. If radiology images pile up on a radiologist, the first 49 images could be normal and not require an intervention, but the 50th image could be a ticking time bomb with a brain bleed, and it could take 30 minutes to get to it.
We are developing a radiology AI module that collects images from the source and using machine learning it automatically updates the queue to put abnormal findings at the top of the radiologist's queue. It puts the most emergent images at the top of the queue with a differential diagnosis. One of the benefits has been that the radiologists are less anxious—particularly on busy nights—because they do not have to worry about ticking time bombs. It has helped reduce physician burnout and anxiety.
HL: Do you have any other insights on the way forward now that the crisis phase of the pandemic has passed?
Eskioglu: There is going to be more disruption led by Microsoft, Amazon, Apple, Google, Oracle, CVS, and Walmart. Amazon CEO Andy Jassy has said that healthcare needs to be reinvented. There are altruistic motivations behind that statement, but it is also financial—Amazon is a very large, publicly held company that has a for-profit mentality.
I expect the tech companies to make more forays into healthcare, and the feeding frenzy has started. Amazon has bought One Medical, which is a huge primary care group. CVS has bought Signify Health, which is a home health group with lots of physicians.
The tech companies are trying to establish their own niches. Microsoft has taken the role of creating an ecosystem that can nurture and support the healthcare system—provider systems like Novant and other healthcare organizations. Apple wants to be the company of choice for wearable devices.
Amazon is probably the company that is disrupting the most—they are not only disrupting in a big way but also trying to transform and innovate. Amazon is seeking to establish itself in the most lucrative parts of healthcare such as ambulatory care and pharmacy.
Oracle is trying to be the software of choice. They want to be the data repository of choice for healthcare data.
CVS is well ahead of Walgreens because they have bought Aetna, and they are getting into the provider space by buying Signify Health.
Walmart is another disruptor to watch. In all of their neighborhood clinics, they are implementing EPIC, which is the electronic health record that most health systems use. They have also announced a collaboration with UnitedHealth.
All of this disruption does not have to be a negative development for providers like Novant. It is time to think outside of the box. You have seen megamergers happen such as with my competitor Advocate, Aurora, and Atrium. I would not be surprised to see companies such as Amazon, Apple, or Google take a minority interest in health systems to get people on our boards and learn from the inside-out, rather than from the outside-in.
A new report identifies best practices in several areas, including accounts receivable, earnings, expenses, and patient access.
A new report from MGMA highlights the best practices of successful medical groups.
The MGMA assigns Better Performer status based on metrics including compensation and production, cost and revenue, and practice operations. The new report is based on information collected from 4,098 organizations, with 1,129 identified as Better Performers—a 36% increase compared to organizations that earned the Better Performer designation in 2021.
Better Performers excel in accounts receivable, the report says. "Across the board, Better Performer practices collect more A/R in the first 30 days compared to all practices, with the biggest difference (nearly 9%) occurring in primary care collections made in the first 30 days. Primary care Better Performers also had the biggest difference in outstanding A/R in the 120+ days bucket."
Michelle Mattingly, director of data solutions at MGMA, told HealthLeaders that there were three primary commonalities among Better Performers that excelled in accounts receivable.
An emphasis on collecting accounts receivable in the first 30 days of billing, leaving less dollars to be collected in the past due buckets such as 120+ days in accounts receivable
Use of a claim scrubbing tool to catch clerical and coding errors
Running monthly accounts receivable and separate out insurance and patient balances by service date
There were three primary commonalities among Better Performers that succeeded in posting high earnings, Mattingly says.
Better Performers will often show slightly higher total operating cost per full-time equivalent physician
Investments in areas such as staff, medical supplies, building occupancy, and equipment typically help produce greater revenue in Better Performer organizations
Better Performers follow the adage that you have to spend money to make money
With pandemic-related constraints such as higher labor expenses, Better Performers posted lower expenses compared to their counterparts. Two factors were primarily responsible for driving down expenses at Better Performers, Mattingly says.
In some cases, attrition helped practices avoid steep rises in labor expenses
Practices experiencing staffing shortages did not have staff to pay, so they saved on an expense they would have had otherwise
Staffing shortages have put a strain on patient access such as creating longer appointment wait times. There were four primary commonalities among Better Performers that were able to hold the line or improve patient access, Mattingly says.
Better Performers had a higher percentage of same-day appointments
The third next available appointment for new patients was up to four days sooner at Better Performers compared to other practices
New patients were asked to fill out electronic forms prior to their visit
Denver Health's chief medical officer says the program is specifically designed to provide support for healthcare workers.
Denver Health has implemented the Resilience in Stressful Events (RISE) program to help boost the well-being of the health system's healthcare workers, Chief Medical Officer Connie Savor Price, MD, MBA, said during the recent HealthLeaders CMO Exchange.
Stress and burnout are common in the healthcare industry. Healthcare worker burnout has reached alarming proportions during the coronavirus pandemic, a healthcare worker well-being expert has told HealthLeaders. Prior to the coronavirus pandemic, healthcare worker burnout rates on average ranged from 30% to 50%, says Bernadette Melnyk, PhD, APRN-CNP, chief wellness officer of The Ohio State University and dean of the university's College of Nursing. Now, burnout rates range from 40% to 70%, she said.
RISE was developed by Johns Hopkins Medicine specifically to help healthcare workers, Price says. "The concept of RISE is geared toward the specific needs of healthcare providers and what they face in some of the difficulties of being healthcare providers. Healthcare providers are involved in adverse patient events and medical errors, and bearing witness to those can result in emotional or even physical distress."
RISE programming is designed to play a supportive role for healthcare workers, she says. "RISE is basically a service to empathize, listen, validate, and normalize. It facilitates a connection to other providers and resources if that connection is needed. It is available 24/7 and there is strict confidentiality. RISE is not counseling. It is not a problem-solving service. It does not provide psychotherapy or any kind of psychiatric care. It is a support service, with listening and connections to other resources."
Denver Health has launched seven RISE initiatives:
24/7 RISE Line (303-436-RISE): This phone-based service provides 24/7 access to emotional support and psychological first-aid, including a handoff to well-being resources.
Department or team-specific RISE group support: Group support opportunities are available virtually or in-person. Any leader can activate a group support request by emailing dhrise@dhha.org or by calling the 24/7 RISE Line for urgent requests.
RISE Up Staff Support Center: This is a dedicated space staffed by RISE peer responders that provides staff with a place for self-care, reflection, emotional support, and access to resources, snacks, and beverages. The support center has been open seven days a week from 10:30 a.m. to 8 p.m.
Inter-disciplinary virtual RISE group support: These group support opportunities are offered on a weekly basis for various themes of distress and specific affinity groups such as the Black Affinity Group.
Peer Assault Care Team: PACT offers immediate, confidential, and voluntary support for staff after an assault in the workplace. A PACT response can be initiated by any staff member or leader by calling the 24/7 RISE Line and requesting the PACT responder on-call.
RISE outreach: RISE peer responders are available to provide outreach to staff to introduce RISE services and assess needs. The peer responders also provide emotional support, psychological first-aid, and connections to resources. Requests for deployment of outreach services can be made via email at dhrise@dhha.org or by calling the 24/7 RISE Line.
RISE 2 You: This mobile service can be requested to come to a department or clinic. RISE peer responders and other resources are available by requesting a visit via email at dhrise@dhha.org.
Stress in healthcare settings
There are multiple sources of stress among healthcare workers, Price says.
"I am at a Level 1 trauma center and public health hospital, and our provider staff frequently witness distressing events. The problem of being a 'second victim' is you also often feel personally responsible for the outcome. Sometimes, you feel that you should have been able to do more—you question whether you did everything you could have done. So, there are special needs among healthcare providers. There are also factors that we are seeing in the workplace such as an increase in violence. There are ethical dilemmas and moral distress—there are patients who can't access the healthcare they need because they do not have the right insurance. There are tragic events—there is a lot of stress in healthcare teams," she says.
At Denver Health, three dozen themes of distress were identified through RISE from July 5 to Aug. 1 this year, including grief and loss, death of patients and colleagues, physical and mental exhaustion, conflict with co-workers, staffing shortages, isolation and loneliness, and desire to quit.
