Although clinician comfort with technology impacts the success rate of video visits, patient characteristics such as advanced patient age loom large.
Patient characteristics including older age and ethnicity are associated with the successful completion of video telemedicine visits, a new research article says.
Telemedicine visits have increased exponentially during the coronavirus pandemic. Challenges associated with access to telemedicine services such availability of broadband service for patients have raised concerns about equity.
The new research article, which was published by JAMA Network Open, examines the results of a quality improvement study of more than 130,000 scheduled video visits at an academic health system between March 1 and Dec. 31, 2020. Video visits were considered a success if the service was completed. Video visits were considered a failure if they were converted to a telephone visit.
The study generated several key data points.
90% of video visits were successful and 10% were converted to telephone visits
Lower clinician comfort with technology was associated with conversion to telephone visits (odds ratio 0.15)
Advanced patient age (66 to 80 years old) was associated with conversion to telephone visits (odds ratio 0.28)
Lower patient socioeconomic status including low access to high-speed Internet was associated with conversion to telephone visits (odds ratio 0.85)
Patient ethnic and racial minority status was associated with conversion to telephone visits (for Black and African American patients, the odds ratio was 0.75)
Relatively high patient income ($75,001 to $213,000) was associated with successful video visits (odds ratio 1.18)
Patient use of a tablet or laptop was associated with successful video visits (odds ratio 1.41)
"As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction [such as access to smartphones, computers, and quality Internet connections] should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services," the research article's co-authors wrote.
Interpreting the data
Patient characteristics were the primary variable determining whether a video visit was successful or a failure, the research article's co-authors wrote.
"Clinicians were associated with some variability as a part of the equation, especially those working remotely, with poor network or with Wi-Fi network dropped connections, or those learning how to manage new equipment and workflows. However, this study showed that most of the variability in successful or failed video visits was associated with patient characteristics versus clinician characteristics, particularly regarding sociodemographic characteristics and age," they wrote.
Sociodemographic characteristics of patients such as Internet connectivity and technology literacy are essential to the success of a video visit, the co-authors wrote.
"Internet connection with sufficient bandwidth to facilitate a video visit is often a hurdle for various populations. One-fourth of rural households do not have access to broadband Internet; the digital divide is also present in urban communities, emphasizing the necessity of more inclusive Internet access. Video communication yields higher patient understanding and satisfaction compared with only telephone communication," they wrote.
Several factors may contribute to older patients converting video visits to telephone visits, and this group can benefit from telemedicine visits, the co-authors wrote.
"Older individuals may face more technology barriers, may have visual or movement disorders that make computing more difficult (especially on smaller devices), or may simply be more casual users of the Internet. Despite those assumptions, individuals who are older likely have a higher need for virtual care associated with transportation challenges to and from appointments or other impairments or chronic ailments that make leaving the house difficult," they wrote.
There is a learning curve that impacts the success or failure of video visits, the co-authors wrote.
"As patients and clinicians in the study population became more comfortable with technology, distinct learning curves were found in both user categories. The existence of a learning curve suggests that there are modifiable telemedicine program components, such as technical support or training, that may reduce video visit failures. Previous studies have shown that effective clinician training in telemedicine increases clinician confidence not only in using medical technology but in educating patients in how to have a successful video visit," they wrote.
The research article has important implications for policy makers and healthcare providers, the co-authors wrote.
"A future focus for policy makers should consider inclusion of telephonic services as a form of reimbursable telemedicine. Permanent expansion of low-cost or free broadband Internet for at-risk populations is also critical. For healthcare systems, it will be imperative to improve the ease of use of telemedicine as well as to provide support for patients to access such services," they wrote.
Jeff Ciaramita says being an effective chief physician executive starts with listening and being present.
The new chief physician executive of the Mercy health system's Mercy Clinic says it is essential in his new role to serve as an effective intermediary between clinicians and the health system.
Jeff Ciaramita, MD, was promoted to senior vice president and chief physician executive of Mercy Clinic in October. Mercy Clinic is a large medical group with more than 4,000 providers. The Mercy health system is based in Chesterfield, Missouri, and operates more than 40 hospitals in Arkansas, Kansas, Missouri, and Oklahoma.
Ciaramita first joined Mercy in 2008 as a noninvasive cardiologist and director of cardiovascular education. He served as section chief of cardiology at Mercy Clinic St. Louis for more than five years, then became president of Mercy Clinic South in 2017. In 2019, he became president of Mercy Clinic St. Louis.
HealthLeaders recently talked with Ciaramita about his new role. The following is a lightly edited transcript of that conversation.
HealthLeaders:How can a chief physician executive serve as an effective intermediary between clinicians and their health system?
Jeff Ciaramita: At the minimum, this is one of the most critical parts of my role.
Number One, a chief physician executive can serve as an intermediary by understanding what is going on at the local level. You need to be present and to ask the questions that need to be asked.
Secondly, it is also my role to understand the overall strategy of the ministry. Our primary strategy is to keep our patients at the center of everything. If our clinicians and their teams do not understand that underlying strategy, there is no way that they will be able to understand or accept the things that we need to do to evolve, or to get them the supports that they need to deliver care in their practices.
Lastly, from a strategy perspective within Mercy, most of our strategies to deliver superior clinical care come from our clinicians. So, it is very important for us to identify early on who can help guide us in the next generation of leadership and to look at ways to innovate and to transform healthcare. I need to find ways to collaboratively use my greater than 4,000 providers and their expertise to deliver care for the health system.
HL: What are the keys to success for a chief physician executive?
Ciaramita: First, it all starts with listening and being present. You need to listen to providers. You also need to understand the workforce, which includes physicians, advanced practice providers, and the staff who support them. You need to be willing to sit down and listen to what they have to say rather than tell them how healthcare should work.
Close behind is leading innovation. Healthcare has always been evolving and the rate of evolution today is probably faster than it has ever been, so you must be willing to fail. Part of innovation is failing along the way. In healthcare, physicians have been historically driven by evidence-based medicine and first do no harm. The training of physicians today completely goes against innovation and the willingness to fail.
HL: What are the primary elements of physician engagement at a large medical group?
Ciaramita: You must be present. COVID throws a wrench into that, but engagement is only possible when you are locally present and meet with the people who are responsible for delivering the care.
The second phase of engagement comes when you not only listen up front but also provide support. Listening will only get you so far—understanding how you need to support your physicians is important. You must follow up with support.
Lastly, with every large medical group, including Mercy Clinic, engagement comes down to the practice level. The Mercy health system likes to say we have one care model, and we have many operating and clinical standards that we know can deliver high quality care. But the reality is that engagement in a large medical group comes down to the relationships and collaboration with our practice managers. The focus is individual locations and making sure that despite a singular care model that they are still being heard and understood.
HL: How can a chief physician executive help to address provider burnout?
Ciaramita: Burnout is present unequivocally and unquestionably in physicians, advanced practice practitioners, and our other staff members. Until everybody in the health system acknowledges that, we will not be successful in addressing it.
I need to truly understand what leads to dissatisfaction from a provider's perspective. Burnout could be the result of working too many hours, but it could also be the result of ongoing non-employment issues, lack of support, or performing unwanted job duties. For example, a provider might think they went to medical school to operate on patients, but they spend a significant amount of their day writing notes and charting in the electronic health record, which they never wanted to do.
I need to understand the factors that lead to provider dissatisfaction, then find the tools that can minimize those distractions or sources of dissatisfaction. We will never find that out unless we address burnout individually with every single provider in our ministry.
HL: Are there examples of what you would like to do to address burnout as a chief physician executive?
Ciaramita: I would like to expand programs and minimize the stigma of burnout. I would also like to change the perception of the term burnout—we must realize that the possibility for burnout is going to exist for every single physician. Burnout is a universalizing term to say, "There are areas of my job as a care provider that I absolutely love, and there are other areas that I struggle with." I want to help find the tools for those areas that people struggle with or those areas that create dissatisfaction to allow providers to practice at the top of their license and be able to focus on areas that they enjoy.
I also want to encourage flexibility. In healthcare, taking care of the overall health of a community is not an 8 a.m. to 5 p.m. job. So, our approach to our providers might be creating opportunities for them to deliver healthcare in nontraditional manners and nontraditional hours. From a provider's standpoint, that creates another opportunity for us to be able to deliver care in ways that provide more joy and can address burnout individually.
Nine communities across the country received resources, coaching, and technical assistance from experts to test best methods to promote wellness and equity.
Nemours Children's Health has led an effort to develop a five-part toolkit to help community organizations advance health equity.
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 experienced relatively high mortality rates.
Jacksonville, Florida-based Nemours Children's Health worked with nine communities across the country to develop its five-part health equity toolkit. The communities were Bridgeport, Connecticut, Flathead County, Montana, Guilford County, North Carolina, Los Angeles, Paterson, New Jersey, Philadelphia, Sarasota, Florida, Ventura County, California, and Washington, DC.
1. Community organizations need to establish a common definition and understanding of equity.
Communities seeking to address equity must bring together multiple sectors such as healthcare, schools, and housing to achieve their goals, says Allison Gertel-Rosenberg, MS, vice president of national prevention and practice at Nemours Children's Health.
"When groups come together and agrees on a shared definition of equity, what they are really trying to get to is their North Star. It allows groups to coalesce better around strategy, around thinking who has the capacity and expertise to lead different components of an initiative, and around how the work and the leadership is going to spread across the groups. This way, all the groups can focus on what they do best; and, at the same time, they can focus on what they do best to get to the same goal," she says.
2. Community organizations need to heed the voices of real-world experts through governance and decision-making structures that solicit the perspectives of the community members whom the effort seeks to serve. Community members who participate in this process should be compensated for their expertise.
Enlisting community members to participate in equity efforts elevates the role of end users, Gertel-Rosenberg says. "If you think about other industries, a tech company would not develop a new phone without asking consumers what they wanted to do with the phone."
When communities create and design systems to tackle equity goals, initiatives should seize on the opportunity to ask community members what they want to happen, she says. "We can ask about what is not working. We can ask about what capacities and assets they have as a community that we can build on. Then we can take those answers and combine them with the expertise of people who do this work as their job to come up with the best strategies and best opportunities that will work in the community."
Community members should be compensated for their participation, Gertel-Rosenberg says. "Compensation is important. When we ask a community member who feels strongly about equity to take time away from their family or their job, we need to compensate them for their expertise."
3. Community organizations need to enact data-sharing and data-driven resource allocation to identify groups experiencing inequities as well as carry out community-led mitigation strategies.
She says data related to equity challenges is collected at several sources, including health systems, schools, social programs, and community organizations. "It would be great if we could take these data sets and combine them to start to draw a picture of what is happening in the communities that we are serving. The ability that data sharing presents to us is getting enough data to not only look at overarching data about a community but also start to disaggregate data to see where there are opportunities to address disparities and the inequities that are driving those disparities."
"For example, if we look at rates of food insecurity in a community, what the average looks like could be hiding significant disparities between different parts of the population that could be based on race, ethnicity, or geography. When we start to put that data together and disaggregate the data, we can look at solutions that target at-risk populations and start to raise them up," Gertel-Rosenberg says.
4. Community organizations should conduct "equity impact reviews" to assess the results and potential unintended consequences of current and proposed practices, policies, and strategies, which should be revised as needed.
Equity impact reviews are a tool in a community's equity toolbox, she says. "In the broadest way, equity impact reviews allow a community to break down what is happening with an initiative and what the intended or unintended consequences might be not only for the population as a whole but also for different parts of the population."
Equity impact reviews unify equity efforts, Gertel-Rosenberg says. "If we have communities that are using equity impact reviews, they are sharing data, they are ensuring the voice of the community is at the table, and they are having a shared language. By having equity impact reviews, communities can shape the best strategies that are going to address their shared goals."
5. Community organizations need to embed equity-promoting workflows into daily operations.
Embedding equity-promoting workflows into daily operations elevates equity efforts, she says.
"When we start to embed equity into our daily workflows, we ensure that we are talking about equity at every meeting. We ensure that we are asking questions about disaggregated data and the impact on different parts of the population at every meeting. We need to ask questions about equity and ensure that when we consider a new strategy or a new goal, we ask the same questions about the data, about how the community voices are integrated, and about the impact on different sub-populations. It is not enough to set a strategy or a goal and leave it."
About 90% of survey respondents report that regulatory burdens have increased over the past year.
The coronavirus pandemic has increased the regulatory burdens on medical practices, according to a new survey report from the Medical Group Management Association (MGMA).
Regulatory burden has been a top concern at medical practices for years. The "Annual Regulatory Burden Report" published this week by the MGMA highlights the pain points medical practices are feeling this year.
The survey report has responses from executives representing more than 400 group practices. More than 80% of the survey respondents work at independent practices.
The survey report features several key findings.
91% of survey respondents said the overall regulatory burden on their medical practice over the past year has increased
When asked which regulatory issue was very or extremely burdensome, the Top 3 issues were prior authorization (88% of survey respondents), COVID-19 workplace mandates (71%), and Medicare quality payment programs (71%)
92% of survey respondents said healthcare consolidation such as acquisitions of physician practices by health systems and hospitals is increasing
72% of survey respondents said consolidation is having a negative overall impact on the U.S. healthcare system
75% of survey respondents said regulatory requirements are a significant driver of healthcare consolidation
79% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has increased the regulatory burden on their practices
70% of survey respondents said the move toward value-based payments for Medicare and Medicaid patients has not improved the quality of care
70% of survey respondents said the move toward paying physicians based on value has not been successful so far
93% of survey respondents said the positive payment adjustments of Medicare's Merit-based Incentive Payment System (MIPS) do not cover the costs of time and resources spent preparing for and reporting under the program
80% of survey respondents said that Medicare does not offer an Advanced Alternative Payment Model that is clinically relevant to their practices
Interpreting the data
The pandemic has worsened the regulatory burdens on medical groups, says Anders Gilberg, MGA, senior vice president of government affairs at MGMA.
"Particularly early in the pandemic, it impacted the revenue of medical groups significantly. There was a drop of about 50% across the board in revenues in the early months of the pandemic. Revenue has bounced back but there was a shock to the system at medical groups. So early in the pandemic, it created a situation where the regulatory burden was still high, but practices were forced to furlough staff and lay off staff because they simply did not have patients coming in for visits. This put a strain on practices to keep up with regulatory burdens," he says.
This year, vaccine mandates have created new staffing shortages at medical groups, Gilberg says.
"There are still underlying staffing issues, but we are finding ramifications in 2021 from state mandates and vaccine mandates affecting practices. This is especially true in states where there is hesitancy about getting the coronavirus vaccine. Practices that are attempting to implement vaccine mandates are losing staff. On the administrative side, employees in some of the lower paying positions such as billing are making the choice to leave healthcare—they can find similar jobs outside of healthcare that do not have vaccine mandates. In addition, there is a large percentage of nurses who have been reluctant to get vaccinated, so practices have been losing staff on the clinical side as well."
The latest wave of staffing shortages is heightening regulatory burdens, he says.
"When you do not have administrative staff or clinical staff to process bills or to take care of patients, we are hearing frustration about the growing regulatory burden coupled with not having enough staff members to report quality measures, which practices do not feel are relevant. There are not enough staff members to sit on the phone with payers to administer prior authorizations. There is a confluence of events where the regulatory burden continues to grow, while the resources that medical groups have are shrinking. That is putting an incredible strain on medical groups."
Prior authorization is the most costly and time consuming regulatory burden at medical practices, Gilberg says. "When practices do not have the clinical staff to administer prior authorizations or when physicians are pulled out of direct patient care to authorize care, it creates significant strain on the practice in terms of time, resources, and finances. When you cannot be productive as a physician because you are on the phone with payers, it stresses a practice."
Many prior authorizations are unnecessary burdens, he says. "There are many services that require prior authorizations that are routinely approved, yet you still must jump through the hoops to get these services approved. That creates an unnecessary burden. There are also medical groups that are in value-based payment arrangements, where they are held accountable for cost and quality. In those arrangements, practices are already doing what they can to address the underlying issues that prior authorization also seeks to address."
Regulatory burdens are a significant factor in healthcare consolidation such as the acquisition of medical groups by health systems, hospitals, and other larger organizations, Gilberg says. "Especially in an environment where we have had a shock from the pandemic, which has affected the finances of independent practices as well as the staffing of independent practices, medical practices do not have the finances or the staffing to deal with growing regulatory burdens. As a result, the physicians who own independent practices think about getting someone else to deal with the regulatory burden."
Many medical groups feel trapped in the MIPS program, he says. "MIPS is a quality reporting program that was largely meant to be a bridge as Medicare and the Center for Medicare and Medicaid Innovation created new opportunities for physician to avail themselves of Alternative Payment Models. What we have seen is that many practices are stuck in the MIPS program. In our new survey report, most practices do not find that many of the Alternative Payment Models that are in the Medicare program are clinically relevant to their practices."
More Alternative Payment Models should be launched, Gilberg says. "We are looking for more Alternative Payment Models so we can move more practices out of the MIPS program. We need more Alternative Payment Models so we can create a win-win for value-based care. Many of our practices are optimistic about value-based care, and they would be interested in participating if there were programs that could help them both financially and clinically. But many practices do not have that opportunity. That's why the MIPS program rises to the top of our regulatory burden survey."
Spectrum Health had well-being initiatives in place before the coronavirus pandemic and has launched more efforts during the pandemic.
Grand Rapids, Michigan-based Spectrum Health is one of 44 healthcare organizations nationwide to be recognized by the American Medical Association's Joy in Medicine Health System Recognition Program.
Healthcare worker burnout and well-being have been top concerns during the coronavirus pandemic. The Joy in Medicine Health System Recognition Program is designed to recognize health systems that are committed to improving physician satisfaction and decreasing burnout.
Spectrum Health has had a longstanding commitment to healthcare worker well-being, says Kristin Jacob, MD, medical director of the health system's Office of Physician and APP Fulfillment.
"Even before the pandemic, Spectrum Health was committed to focusing on work-related stress and reduction of burnout. The health system promoted a call to action to improve the well-being of our frontline caregivers, and part of that call to action is submitting an organizational commitment statement to the National Academy of Medicine, which states our dedication to reducing clinician burnout and improving well-being," she says.
The Joy in Medicine Health System Recognition Program provides accountability for well-being efforts at Spectrum Health, Jacob says. "We are continuing to collaborate with other organizations across the country that are doing work to reduce burnout and sharing best practices. The AMA Joy in Medicine Health System Recognition Program provides another layer of accountability for our organization to focus on measuring well-being, building leadership development, promoting teamwork, and measuring work done outside of working hours, which is a huge driver of burnout."
Addressing burnout and wellbeing
At Spectrum Health, the Office of Physician and APP Fulfillment was established in 2019 to initially focus on physicians and advance practice providers. "The reason for targeting this population first was twofold. First, we know that our physicians and APPs are at the highest risk for burnout, suicidal ideation, and a negative impact on patient care due to these factors. Second, we recognized that we needed to start somewhere," Jacob says.
Spectrum Health has been measuring well-being with a validated tool for several years, she says. "We use the Mayo Clinic Well-Being Index to measure the wellbeing of our physicians and APPs. This is crucial to be able to understand where we are and to create reports based on factors such as specialty, gender, age, and ethnicity to develop targeted interventions."
The pandemic has been taking a toll on healthcare workers at Spectrum Health, she says.
"We have seen a significant increase in the distress of our physicians and APPs over the past year as measured by our validated tool and our engagement surveys. We have seen similar increases in distress among our nurses and other team members. This aligns with the trends we are seeing across the country and puts data behind the toll that the pandemic has taken on us. When we think about the drivers of this distress, we are grappling with extreme staffing shortages that are leading to extraordinary workloads. Michigan is also experiencing, arguably, our worst COVID-19 surge, where most of the rest of the country has been turning the corner."
The Office of Physician and APP Fulfillment launched a well-being program called Med+Up before the pandemic, Jacob says. "Med+Up gathers small groups of physicians and APPs together to have monthly facilitated discussions about meaning in work. These gatherings are intended to be a relaxed setting outside of work to facilitate discussions. This is a best practice that has data behind it showing improvement in meaning in work and reduction of burnout. There are about 100 physicians and APPs who are participating in this program."
Spectrum Health also has employee benefit programs that are designed to boost well-being and reduce burnout, Jacob says.
"From a benefits standpoint, we have a robust healthy lifestyles program that promotes a healthy lifestyle, emotional health, and mental health. The healthy lifestyles program has a strong relationship with our employee assistance program, which can provide in-the-moment support as well as appointments. The employee assistance program is a vital component in supporting our team members. An additional benefit is we partner with Headspace, which is a mindfulness app with data behind it for reducing stress. Headspace was established as a benefit in early 2020 for all Spectrum Health employees."
The health system is committed to suicide prevention among patients and healthcare workers, she says. "We have a zero-suicide initiative that is for our patients, but we also have strong education and processes for team member suicide prevention. We have continued to improve education, awareness, and training around those efforts."
Spectrum Health has launched several initiatives during the pandemic to address healthcare worker well-being and burnout, Jacob says.
"First and foremost, during the pandemic, we have been addressing the basic needs of our workforce. Early in the pandemic, this effort included securing personal protective equipment. We have provided additional benefits to support backup childcare, compassionate paid time off, and support for unexpected time off. There have also been generous wage increases. With the support of many leaders, we have initiated widespread delivery of meals, snacks, water, and free coffee through our nutrition services. We also have wellbeing navigators who are rounding to check on people, see what they need, and connect them with resources. We have placed wellness carts in 150 of our highest acuity spaces that include wellness-related items and tangible resources," she says.
During a COVID-19 patient surge last November and December, Spectrum Health enlisted volunteers to pack more than 3,000 COVID support snack boxes that were delivered throughout the health system's clinical care units, Jacob says. "That effort has evolved, and we are doing targeted funding for our leaders so that they can support the basic needs of their teams and other creative ways to deliver meals to make sure that staff members can eat on their busy shifts."
The health system has been focusing on emotional support during the pandemic, she says. "We have had an extensive rollout of many support groups that we have launched for our caretakers over the past year. We also have had a lot of resources and education around psychological safety and secondary trauma. We recently launched a peer support program, which offers one-on-one peer support for colleagues to process difficult events and chronic stress as well as connect team members to resources."
Resources related to well-being at the health system include the employee assistance program as well as a critical incident stress management team and spiritual care team, Jacob says. "We also partner with Priority Health, which has a platform called myStrength that offers content related to mental health support online. Priority Health also provides access to a phone line so that staff members can seek mental health support outside of the employee assistance program."
Hopeful for the future
Despite the challenges posed by the pandemic, Jacob says she has a positive view about healthcare worker well-being. "The long-term prospects are optimistic. There are silver linings of the pandemic, including the way that the pandemic has brought attention and urgency about mental health awareness. In addition, the pandemic has brought attention and urgency to holistically care for the caregivers of our patients."
The pandemic could be a turning point in efforts to boost healthcare worker well-being, she says. "This may just be the pressure that we need to realign our values in healthcare and realize that human capital is our most crucial resource. There is still much work to do, but I am encouraged by our local leaders and their authentic desire to care for our team members. The conversation that is occurring at the national level is also encouraging—it is putting pressure at a high level to think about what regulatory agencies are doing to put standards of care in place that protect healthcare workers."
Clinical decision support tools help clinicians to have up-to-date information about medical conditions.
An effective clinical decision support tool is available at the point of care, is as current as possible, and is accurate, a chief medical information officer says.
Medical knowledge advances rapidly, with a plethora of new studies published daily. Clinical decision support tools can help clinicians stay up to date with the constant changes of information about diagnoses and treatments.
A good clinical decision support tool has three primary characteristics, says Jon Michael Vore, DO, chief medical information officer Southern New Hampshire Health. The Nashua, New Hampshire-based health system features a medical center and a network of more than 400 clinicians.
First, a clinical decision support tool must be easily accessible to clinicians at the point of care, he says. "You want clinical decision support at the point of care when you are taking care of a patient. If you are going to have a clinical decision support tool, it needs to be at your fingertips. If you have to go into a completely separate system or leave the room, it detracts from being able to use a tool. A clinical decision support tool should be directly integrated into your workflow."
Second, a clinical decision support tool must be as current as possible, Vore says. "A good clinical decision support tool should be up to date and peer reviewed. If you are sharing information with a patient, you want to make sure that you have the most up-to-date recommendations in regards to whatever you are talking about."
Third, a clinical decision support tool must be accurate, he says. "A good clinical decision support tool is trustworthy. You need to be able to trust the information that the tool is providing. These days, patients are doing their homework and they are checking up on you. When they leave the office, they are not absolutely assuming that the provider has given them 100% correct information. Many times, they are going home and following up and doing their own review and seeing if the information their clinician has provided is accurate."
Clinical decision support tool in practice
Southern New Hampshire Health has clinical decision support in the health system's electronic medical record as well as Wolters Kluwer's UpToDate clinical decision support tool.
"We have the Epic electronic medical record system. There are a lot of clinical decision support tools in Epic, where you get best practice advisories. You get medication and allergy interactions as well," Vore says.
At the health system, UpToDate is integrated into Epic, he says. "As we are doing our documentation or seeing patients, we have a hyperlink directly in Epic that will automatically log a provider into UpToDate and allow them to do a search for medical conditions. This allows providers to have a clinical decision support tool at their fingertips. Providers do not need to go to another Web browser or type in a URL. Having UpToDate integrated into our electronic medical record makes it quick and easy for clinicians to access information they need to verify their treatment or even review information with the patient in the exam room."
Using clinical decision support tools to address misinformation
A good clinical decision support tool can help clinicians to educate misinformed patients, Vore says. "If you know you have a trustworthy source of information that has the most up-to-date recommendations and the most up-to-date information from studies, that arms clinicians to have sometimes difficult conversations with patients. These days, patients will go to the Internet, go to blog sites, and go to social media such as Facebook. They often do not go to the most evidence-based resources to look for information."
A good clinical decision support tool will approach areas where there is information that needs to be debunked, he says. "Many times, these tools will present information in a way that can be easily transferred to the patients. That may or may not change the outcome with the patient, but the best that clinicians can do is provide them with the most up-to-date information and recommendations to help them move in an appropriate direction for their overall health."
Administrative spending accounts for about a quarter of total U.S. healthcare spending, report says.
Three kinds of interventions could reduce administrative spending in healthcare by $265 billion annually, a new report says.
According to the new report, which was published this week by McKinsey & Company, total U.S. healthcare spending in 2019 was $3.8 trillion, with administrative spending pegged at $950 billion. "The goal is not to reduce administrative spending to zero but rather to gain the highest value for each administrative dollar spent without sacrificing quality or access," the report says.
More than a quarter of administrative spending could be eliminated through three kinds of interventions, the report says.
"Within" interventions are cost-cutting measures that can be made by individual organizations. Within interventions could achieve about $175 billion in annual savings, which represents about 18% of total administrative spending. Examples of within interventions include automation of repetitive back-office work such as human resources and finance.
"Between" interventions are cost-cutting measures that can be made through agreement and collaboration between organizations. Between interventions could achieve about $35 billion in annual savings, which represents about 4% of total administrative spending. Examples of between interventions include creating payer-provider communications platforms that provide unified messaging to patients.
"Seismic" interventions are cost-cutting measures that can be made with broad and structural agreements and changes throughout the U.S. healthcare system. Seismic interventions could achieve about $105 billion in annual savings, which represents about 11% of total administrative spending. Seismic interventions such as new technology platforms and changes in payment design are often based on partnerships between the public and private sectors to coordinate incentives for change.
"Many seismic interventions address the same sources of spending as the within and between ones but take the savings a step further. Accounting for this overlap, we estimate total savings across all three types of interventions at about $265 billion, or 28% of total administrative spending," the report says.
Some organizations have already achieved cost-cutting through within and between interventions, the report says. The keys to success in these efforts include four factors, the report says: "prioritizing administrative simplification as a strategic initiative; committing to transformational change versus incremental steps; engaging the broader partnership ecosystem on the right capabilities and investments; and disproportionally allocating resources, such as capital and talent, to the underlying drivers of productivity."
Seismic interventions are more challenging to achieve than within and between interventions because they are opportunities for change related to a lack of motivation to innovate at the organizational level, the report says. Three stakeholders can drive seismic interventions, the report says.
"Government could set the framework in which other organizations operate. Federal and state bodies can set guardrails for payers, hospitals, and physician groups."
"Investors can prove ideas with pilots. They might create public-private partnerships to test interventions within a state and then scale up success stories nationally."
"Third parties, such as foundations and bipartisan groups, can conduct objective fact gathering and analyses. An arbiter of facts can galvanize action."
The conditions are ripe to tackle administrative spending, co-authors of the report wrote in article published by the Journal of the American Medical Association.
"Economic downturn often leads to health system change. With COVID-19 creating enormous disruption to the healthcare system, a known opportunity to capture more than a quarter-trillion dollars in the next few years without compromising the U.S. healthcare system’s ability to deliver care could be quite attractive. The sooner healthcare administration is simplified, the easier it will be for all to engage the U.S. health care system," the wrote.
Scott Allen, MD, says patient safety must start at the top of a health system's leadership team and extend to the frontline staff.
The new permanent chief medical officer of Farmington, Connecticut-based UConn Health says listening is a key leadership skill in healthcare.
Scott Allen, MD, served as interim CMO at UConn Health for two years before recently being elevated to the permanent role. Allen joined UConn Health as a clinician-educator in 1994 and served as program director of the Primary Care Internal Medicine Residency Program for eight years. He then established the health system's Quality Department and served as chief quality officer before assuming the interim CMO role.
HealthLeaders recently spoke with Allen on a range of issues, including clinical quality, aligning physicians with population health initiatives, and the primary factors for CMO success. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the keys to quality leadership at a health system?
Scott Allen: I refer to the old adage—two ears, one mouth. You need to listen more than you talk.
You need to listen to people and understand what they do. When I was the chief quality officer, I could not work on something unless I understood what the staff did and what their workflow was like.
When we do a safety event analysis I ask questions, not because I am pointing fingers, I just need to understand what happened. Sometimes, I go to the physical site where a safety event occurred to visualize the situation. To me, listening is more important than speaking, so that you understand where the other person is coming from.
Secondly, you need to focus on the patient experience. Quality requires putting the patient first. Part of that is the six Institute of Medicine aims—everything that we do should fulfill the six aims: being safe, effective, equitable, timely, efficient, and patient-centered. If we can keep all six of those aims in mind when we are working on a project or handling a particular issue, it keeps the patient experience in mind. Everything should be about the patient, and you should demonstrate that to everyone in the organization.
Thirdly, you should try to get buy-in from all clinical areas. For example, I have an initiative to try to get the institution to use scorecards. We are seeking to focus on metrics that are meaningful to the clinicians. The acronym that I use to get clinicians to think about these metrics is SMART goals—specific, measurable, achievable, relevant, and time specific.
HL: How do you align physicians with population health initiatives?
Allen: You need to make the case for the "why" for the providers. Why should they be engaged? All providers want to perform well—it is just the nature of being in healthcare—and they want their patients to achieve optimal health. You need to link both of those together. What are the population health outcomes that the doctor wants to perform well and what are the factors to help the patient be healthy—you put those two together and you engage the providers.
We have a population health department at UConn Health and many of the things that they do make it easier for the providers, so they are going to be more engaged.
HL: How does your daily Safety Huddle work?
Allen: We started safety huddles in 2008. At that time, it was called All Hands on Deck. It is a meeting that still occurs Monday through Friday from 8:30 to 9 a.m. Originally, we had all of the clinical units and some of the ancillary departments. The chief nursing officer and I would run the meeting. The CEO would attend. We would have quality reports and initiative reports.
We transformed the meeting and renamed it to the Safety Huddle. We reinforced the tools and techniques of high reliability because we were part of a collaborative with the Connecticut Hospital Association. When everybody went around the room to do their reports, everyone was in tune with the fact that the primary focus was safety.
The other important piece about Safety Huddle and how it has evolved over the years is that we have about 50 individuals who can present reports at Safety Huddle. We have all of the clinical units such as the emergency room and the inpatient units, and we have added many other units such as physical therapy, facilities, clinical engineering, and fire and police. Everybody reports out because every unit is important to patient safety.
HL: How do you get through 50 reports in 30 minutes?
Allen: It is quick. We have a safety event reporting system called Safety Intelligence, or SI for short. Any SI report that has been submitted in the previous 24 hours has to be brought up for quick discussion during Safety Huddle. Some of them do not require delving into details—some of them do. For example, if there is an elevator situation, facilities must report on that. If there is a problem with pharmacy, they must report out. So, the number of reports depends on the day.
HL: What are the keys to promoting patient safety?
Allen: It starts with leadership and your board of directors. It must start from the top. Structurally, our board of directors has a panel called the Clinical Affairs Subcommittee, which is charged with overseeing the medical center. The chair of that subcommittee holds us accountable. Being accountable to an invested board helps drive quality and patient safety because we must answer to the board.
The subcommittee meets publicly. We share our safety event rate. We have developed an institutional scorecard, with input from the board in terms of what they want to see, which is focused on safety. During that meeting, we have peer review. As part of that peer review, we delve into root cause analyses for serious safety events that require a deep dive.
Having the daily Safety Huddle is also important because leaders of the institution—right now it is the chief nursing officer, the interim chief operating officer, and myself as chief medical officer—show management at all levels the importance of safety. With 50 leaders reporting out and as many as 90 people on the call, the meeting demonstrates that all facets of the organization are important when it comes to safety.
The Safety Intelligence medical error reporting system is also important. We have done a lot of training around the SI system for reporting without blame. We want SI to be a reporting tool, not a blame tool. We have made it very easy to get into that system. It is a link within our Epic electronic health record, so all the clinical folks can just click on it, get into the system, and make a report.
Finally, you must involve the frontline staff. Getting the frontline staff involved in safety event analysis has been one of our initiatives. There is a tool that we call Apparent Cause Analysis—ACA for short. When we see the safety events that come in, some of them require a deeper dive so we can find out the causes and prevent them from happening again. This is not as deep a dive as a root cause analysis. We have about four or five ACAs per week and managers are assigned to a multidisciplinary meeting once a week to report out. We talk about the ACA and we come up with a corrective action plan.
We want to make sure that what we have learned from an ACA is getting back to the frontline staff. About three years ago, we created "ACA on the road." We do the debrief of the ACA with frontline staff. It is about a 10-minute meeting. We go over the ACA, which is presented by a nurse manager, then we talk with the frontline staff and get their input.
HL: What are the keys to success for a chief medical officer?
Allen: You must build trust and credibility. You are the bridge between the health system administration and the medical staff. You live in both domains. To play that role, you must be trusted by the health system administration and providers as well as the nurses and other departments that you are affecting.
It helps to have small wins, so people see you as trustworthy and you are set up to take on the bigger battles that are coming.
My style is to lead quietly. I like to listen and understand, then communicate based on a level of trust and credibility. I want to get things done without being flamboyant or autocratic. That is how you build trust and credibility.
It is also important to understand the electronic health record. Everybody uses the EHR for everything. We use Epic. I still maintain some clinical activity, so that keeps me grounded. It helps me appreciate the role that our information technology department and Epic plays for our providers. It also makes me appreciate any changes to the EHR.
Bon Secours Community Hospital is maintaining financial sustainability and working through a $40 million revitalization project.
Bon Secours Community Hospital in Port Jervis, New York, is bucking the trend of struggling rural hospitals.
Rural hospitals across the country are facing multiple challenges—most notably financial woes and workforce shortages. As of July 2021, the Cecil G. Sheps Center for Health Services Research at the University of North Carolina reported that 138 rural hospitals had closed since 2010.
"Rural hospitals face financial challenges. In general, rural hospitals rely heavily on government support and that adds to the challenges these hospitals are facing," says Mary Leahy, MD, MHA, CEO of Bon Secours Charity Health System, which operates three acute care hospitals including Bon Secours Community Hospital. Bon Secours Charity Health System is part of Westchester Medical Center Health Network (WMCHealth).
Rural hospitals face multiple challenges, she says.
"If we start with the people who are living in rural areas, access to rural healthcare is a major issue. When we look at how rural hospitals struggle with low patient volumes, that causes financial hardships for rural hospitals. Another challenge is keeping up with technology—making sure that we have appropriate technology so we can continue to recruit and retain young healthcare talent. When you are talking about rural hospitals, where patients have challenges with transportation and they often must travel long distances to a hospital, it makes the challenge of operating a rural hospital much greater," Leahy says.
Bon Secours Community Hospital has been able to rise to its financial challenges, she says.
"We offset low revenue predominantly with grant funding and funding opportunities through our foundation. Despite the financial challenge, we are trying to provide services so that we can keep care local. We do not want patients to feel that they must leave the area to get the care that they need. That attracts patients to come to our facility, which boosts patient volume. There are also benefits to being part of WMCHealth. They make sure that we are financially sound and can provide all of the services that are necessary to operate a rural hospital," Leahy says.
Grant funding has enabled the hospital to carry out an ambitious $40 million revitalization initiative. "We applied for a state grant and received $24.5 million. It is a $40 million project and we have been very fortunate in the grant money we have received," she says.
The rest of the financing for the revitalization initiative, which is also known as the medical village project, has come from several sources, Leahy says. "We have had other grant opportunities through various private foundations and New York State programs. We have also utilized our fundraising arm to raise money. We are also supporting the project with operations money from Bon Secours Charity Health System and WMCHealth."
The medical village project is making major upgrades to Bon Secours Community Hospital, she says. "Part of our $40 million renovation plan is expanding the emergency department to 10,000 square feet, including behavioral health areas. We have new observation areas for patients who may not need to be inpatients. We are looking at private rooms, which is important for infection control and patient satisfaction. One of the highlights of the medical village project is a brand new, state-of-the-art imaging area that we have established in partnership with Philips. Again, this will attract talent by making sure that young doctors have the tools that they need to provide care."
Committed to accountable care
Bon Secours Charity Health System has established an accountable care organization that helps Bon Secours Community Hospital provide high quality, coordinated care for Medicare fee-for-service patients, Leahy says.
"We are an accountable care organization, and we have strong care management capabilities. We have teams that focus on transitions of care and provide outreach into the community. We make sure that patients who are discharged from the hospital or discharged from the emergency department have what they need to get back to good health. We make sure they do not fall through the cracks and fail to get a follow-up appointment with a primary care provider. We make sure they have access to a specialist if necessary," she says.
Health systems and hospitals are under several pressures to increase their scale, Kaufman Hall report says.
A new report prepared at the request of the American Hospital Association (AHA) finds that there are several benefits generated from hospital mergers, acquisitions, and partnerships.
Many hospitals face challenges to maintaining their viability in a changing healthcare landscape. As of July 2021, the Cecil G. Sheps Center for Health Services Research at the University of North Carolina reported that 138 rural hospitals had closed since 2010.
Mergers, acquisitions, and partnerships are often the best strategy for hospitals to pursue to continue serving patients and communities, AHA President and CEO Rick Pollack said in a prepared statement.
"America's hospitals and health systems—and the 6 million women and men who work there—are cornerstones of their communities, and that has never been more apparent than during the ongoing public health emergency. Some hospitals have found that partnerships, mergers and acquisitions were a necessary response to a changing environment in their community and have allowed them to maintain the vital services they provide each and every day to patients and communities," he said.
The new report, which was prepared by Kaufman, Hall & Associates LLC, says health systems and hospitals are under multiple pressures to increase their scale.
Demographic and economic factors are increasing Medicare's and Medicaid's share of the payer mix at hospitals. With Medicare and Medicaid paying below hospitals' cost of care, hospitals are under pressure to increase efficiencies of scale to reduce costs and control financial losses. With increased scale, hospitals can also spread fixed costs across more facilities, which lowers per unit costs of care.
Health systems and hospitals are entering value-based contracts that are crafted to reduce total cost of care. Assuming risk requires patient populations that are large enough to diversify risk.
The ongoing shift of care from the inpatient to the outpatient setting has led to disruptive competitors such as national retail chains that do not have the high costs associated with providing acute care. Health systems and hospitals need to achieve larger scale to ensure access to capital on competitive terms. Scale also allows health systems and hospitals to attract intellectual talent.
The coronavirus pandemic has had a negative financial effect on health systems and hospitals. According to Kaufman Hall, about a quarter of hospitals had negative operating margins before the pandemic. As of the beginning of 2021, the consultancy says patient volume decreases and increased pandemic-related costs have resulted in half of hospitals operating with negative operating margins.
Legislative and regulatory changes such as site-neutral payment policies and Medicare sequester payment cuts are likely to place new financial pressures on hospitals.
The increased scale achieved through mergers, acquisitions, and partnerships drives three key benefits for hospitals and the patients and communities they serve, the new report says.
Boosting patient experience by investing in consumer-centric strategies that increase care access and convenience
Enabling value-based arrangements with payers that increase the affordability of care for patients
Helping hospitals ensure the most efficient use of resources by obtaining funds for capital improvements, innovation, and intellectual capital at favorable rates
Addressing financial struggles
A significant percentage of hospitals involved in merger, acquisition, and partnership transactions face financial peril, the new report says.
Kaufman Hall analyzed 463 hospital transactions between 2015 and 2019, with some of the transactions including more than one hospital.
About 20% of hospitals (92) cited financial distress as a primary factor in the transaction
Of those 92 hospitals, 31 of the transactions involved hospitals that had declared bankruptcy
The 31 transactions involving bankrupt organizations featured a total of 34 hospitals and only six of these hospitals have closed after the transactions
"Although not necessarily the right choice for all hospitals, partnerships, mergers, and acquisitions have been an essential tool for adapting to a changing environment. Hospitals will need continued flexibility to seek partners as they work to recover from the pandemic's impacts on their staff, operations, and financial health," the new report says.
