Daniel McQuillen, MD, says the IDSA has played a leading role in the pandemic response and needs to address misinformation about COVID-19.
The new president of the Infectious Diseases Society of America (IDSA) says his organization is focused mainly on the ongoing coronavirus pandemic.
Daniel McQuillen, MD, took on the leading role at the IDSA last week. In addition to serving as president of the IDSA, he is a senior physician in the Division of Infectious Diseases at Beth Israel Lahey Health and Lahey Hospital & Medical Center, and an assistant professor of medicine at Tufts University School of Medicine in Boston.
He recently spoke with HealthLeaders about a range of issues, including his agenda as IDSA president and the role of infectious disease specialists during the pandemic. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of your agenda as the new president of the IDSA?
Daniel McQuillen: It is obvious that the COVID-19 pandemic is not going anywhere fast. That is going to be something that our society must pay a lot of attention to. My role is to help us get through the pandemic work successfully, both for the members of the society and for our role in trying to move the country along during the pandemic.
Our board developed a five-year strategic plan in 2019, and we were all set to move forward with initiatives such as speeding up our guideline development. We also felt that we needed to spend time communicating what is valuable about having infectious disease specialists, trying to grow our workforce, making sure that we are appropriately compensated, and driving national progress on antimicrobial resistance. Those were the areas that we wanted to focus on; and when we started to dig in and get to work, COVID hit.
We had to pivot what we were doing. Since the onset of COVID, our staff, who were all heavily involved in our board's priorities, have been heavily involved in our response to the COVID pandemic. Probably 85% of their time is spent on work related to the pandemic. In addition to addressing the pandemic, we will be focusing on the workforce and compensation issues for the next 15 months.
HL: Why is the infectious disease specialist workforce a priority issue for the IDSA?
McQuillen: Over the past decade, one of the things we have had trouble with is attracting trainees. When we talked with people who had considered going into the infectious disease specialty, the number one reason they moved in a different direction was that the pay for infectious disease physicians is among the lowest of all the medical subspecialties and considerably lower than specialties where physicians do procedures. When you come out of medical school with an average debt of at least $200,000, compensation is a major consideration when selecting a specialty.
HL: How has the coronavirus pandemic illustrated the importance of infectious disease specialists?
McQuillen: Every day, you turn on the news and you see at least two infectious disease specialists—Anthony Fauci and Rochelle Walensky—talking about issues that inform how the country is dealing with the pandemic.
Personally, when we had our initial COVID patient surge here in Boston, our group of five infectious disease doctors at Lahey Hospital & Medical Center saw nearly every patient in our hospital, from March through the end of May 2020, who either had COVID or was suspected of having COVID. Like many physicians during that time, none of us had any days off.
We played a role in both diagnosing cases and figuring out treatment plans. We also developed protocols for keeping our providers safe in terms of what kinds of protective equipment they needed to wear. We are still doing that protocol work.
The IDSA and the National Institutes of Health are the two main sources of both infection prevention and treatment guidelines for COVID. We managed to get our guidelines out before the NIH did. We have been updating our guidelines whenever there is new peer-reviewed information that would impact care.
One of the big things IDSA has done in terms of messaging is that the Centers for Disease Control and Prevention came to us early in the pandemic and asked us to go into a cooperative agreement with them. That cooperative agreement involves more than a dozen other societies, and we have developed the COVID-19 Real-Time Learning Network, which is an online resource for any healthcare worker that includes links to the NIH guidelines and addresses any particular issue that COVID patients have. The learning network site is updated daily. We have IDSA members who volunteer to do that work.
In addition, the IDSA has been doing twice monthly webinars for frontline healthcare professionals—not just infectious disease doctors. These webinars typically get 800 to 1,000 viewers.
In the community, many of my colleagues have served as infectious disease consultants for organizations such as churches, school boards, and universities to help them figure out how they can get back to normal activities and keep people safe at the same time.
The infectious disease profession is central to getting our country through and out of the pandemic. Our profession is also central to looking back and seeing what things were not successful in trying to prevent the pandemic. We will be trying to figure out how we can get an infrastructure in place so that when the next pandemic comes along, we will be ready for it. That is vitally important.
HL: As the pandemic drags on, what other roles should infectious disease specialists be playing?
McQuillen: There is also another pandemic going on—misinformation about COVID on all levels. There is misinformation about the vaccines, medications, and the virus and illness itself. We feel that the IDSA is an authoritative voice to counteract the misinformation. We want to get the data out, so people can understand it.
In addition to being a reliable source of information, infectious disease specialists need to be thinking ahead to what the next pandemic is going to be. It is not necessarily going to be a virus. It could be a bacterial infection. Antimicrobial resistance is already a pandemic. Even before the coronavirus pandemic, we started to see a lot of bacteria for which we might have one or two antibiotics that are effective.
HL: Why is reimbursement reform a top issue at the IDSA?
McQuillen: The problem is that infectious diseases is a cognitive specialty. I am not doing a procedure on the patient. I am thinking about the symptoms the patient has, I am figuring out what infection the patient has, then I am helping to treat the patient by either giving an intervention such as an antibiotic, or advising the patient that they need a procedure such as getting an abscess drained. I am not draining the abscess—those procedures often get paid more than what I get paid spending an hour with the patient figuring out a diagnosis and treatment plan. The system does not reward infectious disease specialists for their work.
At the same time, we do services for our health systems and hospitals such as the response to COVID-19 that do not involve direct patient care. Those services that are non-direct patient care do not get paid well despite the positive impact that we have on hospitals and other healthcare organizations. For example, we have an impact on readmissions to the hospital within 30 days and length of stay, and the penalties on hospitals go down.
We are working on creative ideas to try to compensate us for the extra effort we are doing. It is a long battle.
HL: What advice would you offer to new physicians considering a career as an infectious disease specialist?
McQuillen: As an infectious disease physician, I get to see every kind of patient in the hospital and clinic system. I am not restricted to doing just diabetes, lung disorders, and other conditions. I see everybody.
It is an incredibly challenging field, but it is also incredibly intellectually stimulating. It is fascinating to see patients, figure things out, and make a difference in people's lives.
The new virtual primary care practice, CloseKnit, offers a full range of primary care services along with behavioral health care.
Telehealth has expanded exponentially during the coronavirus pandemic. Healthcare organizations have launched telehealth offerings in a wide range of specialties, including primary care, behavioral health, cardiology, oncology, and neurology.
Among those organizations include Baltimore-based CareFirst, which recently launched a virtual primary care practice.
CareFirst is a not-for-profit healthcare company that offers a comprehensive portfolio of health insurance products and administrative services to 3.5 million individuals and employers in Maryland, the District of Columbia, and Northern Virginia. In early September, CareFirst opened its CloseKnit subsidiary, which is a virtual primary care practice available to commercial health plan members.
"CloseKnit is a primary care practice [that] offers a full range of primary care services, including sick care, well care, and preventive care. It also has behavioral health integrated, so it has behavioral health specialists. It has insurance navigation and care coordination—those are nonclinical functions in the sense that they are not involved in the delivery of care, it is more supporting people in getting and receiving care. These are dedicated teams that work on behalf patients," says Mary Jane Favazza, MBA, CEO of CloseKnit.
CloseKnit patients will have a clinician who serves as their primary care provider. In addition, they will have a full complement of professionals who work with the PCP to help with care, including physician assistants, nurse practitioners, insurance navigators, care coordinators, and mental health specialists.
CloseKnit is designed to be patient-centric, Favazza says.
"We are trying to build true longitudinal relationships with patients by putting them at the center of care. We do a lot of research on patients, particularly with those who are not engaging in primary care. We want to know the kinds of things that are causing patients not to engage in primary care—what are the obstacles and barriers that get in their way. They talk about things such as unavailability of appointments on a timely basis, or the wrong time of day relative to their work schedules, or the difficulty of getting their mental health professional and their physical health professional on the same page working together. Patients end up having to do a lot of legwork to make that kind of coordination happen," she says.
The virtual primary care practice offers telehealth visits on a 24/7/365 basis.
"One of the top reasons that people told us it was hard to find a primary care provider who worked for them was because of the lack of evening and weekend availability. If a patient is working certain shifts, they may not have the typical 9-to-5 availability that others do. So, it was an important feature for us to create access for patients who have significant barriers to accessing primary care," Favazza says.
To be able to offer visits around the clock throughout the year, CloseKnit has hired a full-time staff of clinicians, she says.
"It is a full-time staff of MDs, DOs, physician assistants, and nurse practitioners. We do not employ a model that many others use, where we allow clinicians to sign up for available space in the system. We have dedicated, full-time employees who work for CloseKnit. We just think that works better for our model—we want to build relationships with patients, so they can see the same provider all the time. To do that, we need to have providers who are working full-time for CloseKnit—not just working at times when they have availability."
Insurance navigation and care coordination
Insurance navigation is an important service for CloseKnit patients, Favazza says. "Insurance navigation is there to support patients. For example, insurance navigators can say what the benefit allows patients to do in terms of steps that they might have to take such as whether a referral is required and who are the specialists beyond primary care that are in network who are close to the patient."
Care coordination is equally important, she says. "Care coordination includes getting appointments, getting the scheduling done, and if patients need to see someone else, that gets followed through. Care coordinators make sure that records get back to primary care—we work hard to reduce care fragmentation and make sure the PCP can know where you are in the healthcare system."
Price transparency
CloseKnit is committed to price transparency, Favazza says.
"As any provider does, we have access to information about how much a patient's set of responsibility is for any given service. We are choosing to promote the fact that we work with patients to make that responsibility visible to them, talk with them about their options, and we do that in a way that does not require a visit. Patients can chat with a navigator and say, 'What would this cost? What would the difference be if I did the service here versus there?' We are hoping that moving that conversation upfront and before things happen gives people the support that they need to make good choices and fully understand what is going to happen."
Patients have a couple of options to have conversations about the cost of services, she says. "You can ask to speak to someone straight away and you can chat asynchronously. We are trying to make ourselves as available as possible to people based on their preferences for communication."
Virtual visits versus in-person visits
At CloseKnit, whether a patient needs a virtual visit or an in-person visit is up to the discretion of the CloseKnit clinicians, Favazza says.
"Often, the providers reach a point in the conversation where a visit needs to be done physically. Some of those are easy to tell upfront such as if a patient needs a women's health exam that requires a Pap smear or pelvic examination. We know there are limits to things that can be done virtually. Then there are situations that may start as a virtual visit—there can be questions about a rash or about abdominal pain and the provider can go through the care process. If they feel that the patient needs to be seen in-person, they just make that decision and transfer the patient to in-person care."
When an in-person visit is required, CloseKnit can refer patients to clinicians who are in CareFirst's network of providers, she says. "We work with the patients to say, 'What is important to you? Is it better to be closer to home? Is it better to be closer to work?' We ask whether the patient has preferences about the type of in-person specialist that they might need to see. It can be about gender or training, whatever the case may be. We do our best to find somebody who fits the patient's immediate need."
Researchers show that rural hospital mergers result in decreased services for maternal and neonatal care, surgical care, and behavioral health care.
Mergers of rural hospitals with health systems or other hospitals can achieve financial sustainability, but the deals can be followed by the reduction of services lines that are essential to the community, a new research article says.
Adults living in rural areas are more likely to be poor, have health conditions, and have greater unmet health needs than adults in living in urban areas, the new study says. Rural communities often depend on their hospitals to provide acute inpatient care, as well as outpatient services such as routine chronic, urgent, and emergency care instead of primary care, the new study says.
The research article, which was published today by Health Affairs, focuses on 172 rural hospitals that merged between 2009 and 2016 in 32 states as well as 549 comparison hospitals. The study features several key data points.
Before the mergers, 74.5% of hospitals that merged provided maternal and neonatal services. This percentage decreased 13.4 percentage points after the mergers to 61.1%. The percentage of the comparison hospitals providing these services was stable during the merger time period (64.3% and 65.1%.)
The surgical service line decreased by 5.0 percentage points at merged rural hospitals versus the comparison hospitals.
As measured by hospital discharges, average mental health and substance use disorder volume fell by 10.4% at merged hospitals but the discharges increased 41.1% at comparison hospitals.
In examination of catchment area data, there was no lasting decline in inpatient care at merged rural hospitals, which indicates that hospital mergers did not reduce inpatient care access. "However, whereas stays for mental/substance use disorders in the catchment areas of merged hospitals remained stable from the pre to the post period (1.0% decrease), they increased by 12.4% in areas of comparison hospitals," the study says.
Interpreting the data
After mergers, rural hospitals eliminated some service lines, the study says. "This study found that rural hospitals that merged were more likely than hospitals that remained unaffiliated to eliminate certain services lines in the first and second years postmerger, specifically for maternal/neonatal and surgical care. Merged hospitals in rural areas also showed reductions in the volume of mental/substance use disorder stays, whereas hospitals that remained unaffiliated showed increased volumes."
Mergers impacted utilization of behavioral health services, the study says. "The stable trend of mental/substance use disorder discharges within the catchment areas of merged hospitals, versus comparison catchment areas where mental/substance use disorder discharges increased, suggests that communities with merged hospitals may have experienced decreased access to behavioral health care."
Although mergers can boost rural hospitals financially, the deals come at a cost to the communities that the merged hospitals serve, the study says. "Although mergers might salvage hospitals' sustainability, they do not necessarily mean that all service lines are retained or that hospitals are as responsive to community needs as before the merger. Specifically, we found that merged hospitals had reduced maternal/neonatal, surgical, and mental/substance use disorder services."
The Delta variant, which is highly transmissible, has led to a surge of COVID-19 patients across the country.
The spread of the Delta coronavirus variant put financial strain on health systems and hospitals through August, a new Kaufman, Hall & Associates LLC report says.
The highly transmissible Delta variant has led to a surge of COVID-19 patients nationwide. The surge has been accompanied by longer length of stay for patients in the inpatient setting and greater numbers of high acuity patients.
The Kaufman Hall report, which was published this week, features several key data points.
The 7-day moving average of new coronavirus cases increased 80.8% from 88,143 on Aug. 1 to 159,333 on Aug. 31, according to the Centers for Disease Control and Prevention. The 7-day moving average of new hospital admissions increased 72.3% from 7,105 on Aug. 1 to 12,243 on Aug. 31.
Hospital operating margins remained low in August. The median Kaufman Hall Operating Margin Index was 3.1% in August, not including federal CARES Act funding. With the federal aid, the operating margin index was 3.9%, which was down 11.8% from pre-pandemic levels.
Operating margins for the first eight months of 2021 were up considerably compared to the losses reported in the first eight months of 2020. Operating margin increased 83.1% year-to-date and operating EBITDA margin increased 57.1% year-to-date, not including CARES Act aid.
Key metrics for hospital volumes remained down compared to pre-pandemic levels but above 2020 levels. Adjusted discharges were down 4.8% year-to-date compared to the first eight months of 2019 but up 8.7% year-to-date compared to 2020. Emergency department visits dropped 11% year-to-date compared to 2019 but increased 7.3% year-to-date compared to the first eight months of 2020.
The average length of stay increased above 2019 and 2020 levels as hospitals experienced more high-acuity cases requiring longer hospital stays—including more severe COVID-19 cases—which also increased expenses. Average length of stay increased 7.9% year-to-date compared to 2019 and increased 4.5% year-to-date compared to 2020.
The increase in higher acuity cases boosted hospital revenues compared to both 2019 and 2020 for a sixth consecutive month. Gross operating revenue rose 9.6% year-to-date compared to 2019 and 16.6% year-to-date compared to 2020, not including CARES aid. Outpatient revenue posted the biggest increases at 10.0% year-to-date compared to 2019 and 20.3% year-to-date compared to 2020. Inpatient revenue increased 5.6% year-to-date compared to 2019 and 11.8% year-to-date compared to 2020.
Costs were higher than both 2019 and 2020 levels. Total expense per adjusted discharge increased 16.6% year-to-date compared to 2019 and 1.3% year-to-date compared to 2020. Non-labor expense per adjusted discharge increased 18.3% year-to-date compared to 2019 and 0.7% year-to-date compared to 2020. Labor expense per adjusted discharge increased 15.1% year-to-date compared to 2019 but decreased 0.1% year-to-date compared to 2020.
There is little relief in sight for hospitals this fall, the report says.
"The fall months hold continued uncertainties for hospitals and health systems. While overall cases and new hospital admissions began to taper in the first half of September, hospital officials in areas hard hit by the Delta variant said their organizations may need to ration care due to shortages in equipment, staffing, and beds to accommodate high acuity patients. With cooler temperatures coming, vaccinations waning, and increases in severe COVID-19 infections—especially among the unvaccinated—the continued pressures on the nation's hospitals are unlikely to abate anytime soon," the report says.
Nashville General Hospital is addressing patient food insecurity and working with faith-based organizations to boost education attainment, health literacy, and healthcare access.
Nashville General Hospital in Nashville, Tennessee, is committed to addressing social determinants of health and health equity.
Social determinants of health such as food security and housing have a greater impact on health outcomes than clinical care. Health equity has become a hot topic in healthcare during the coronavirus pandemic, with the disproportionate impact on vulnerable populations such as African Americans highlighting health inequities in the United States.
The national health inequities during the pandemic have played out in the Nashville area, says Joseph Webb, DSc, MS, chief executive officer of Nashville General Hospital. "We have a marginalized population. We have the disproportionate impact that occurs on certain populations—which has been pronounced during the COVID-19 pandemic. Health disparities seem to surface with any type of epidemic or pandemic particularly as it relates to the marginalized population."
Nashville General Hospital has several programs targeting social determinants of health and health equity, including a "food pharmacy" that addresses food insecurity and an initiative featuring faith-based organizations that focuses on education attainment, health literacy, and healthcare access.
Addressing food insecurity
The Food Pharmacy at Nashville General Hospital provides free food for patients who screen positive for food insecurity. "We realized there were several individuals whose food insecurity conditions were exacerbating their health outcomes," Webb says.
All hospital patients are eligible to receive assistance from The Food Pharmacy, he says. "For each patient that encounters our hospital—whether that contact point is in our emergency room or one of our clinics—a food insecurity questionnaire is administered. If someone indicates that they are struggling with food insecurity based on the questionnaire, then that individual is referred to The Food Pharmacy by their physician. Initially, 12 weeks of free food are provided, then we reassess them for that food need."
The program has improved the survival rate of the hospital's cancer patients, Webb says. "We have a cancer care program here and cancer patients rely heavily on maintaining a certain weight so they can tolerate chemotherapy. Any time cancer patients struggle with food insecurity, it puts them at greater risk of mortality. So, by having this program in place, we have a section of The Food Pharmacy with high-calorie food to keep our cancer care patients healthy and at a certain weight level."
The hospital's director of food services plays a leading role in selecting and supplying the food. The major food bank in Nashville—Second Harvest—also allows the hospital to purchase food at a reduced price. There are several sources of funding that go into purchasing the food, including donations to the hospital's foundation and employee contributions that are earmarked for The Food Pharmacy.
Faith-based initiative
Nashville General Hospital, which is a safety net hospital with 150 inpatient beds, has launched a faith-based initiative to address social determinants of health and health equity called the Congregational Health and Education Network (CHEN). More than 100 congregations are members of CHEN. The hospital's chaplain plays a leadership role in the nonprofit organization and a manager runs the program.
There are three pillars at CHEN, Webb says. "Number One is education attainment because we believe that there is a strong correlation between education and all of the other social determinants of health. If you can impact education, you can typically impact income, housing, and other social determinants of health. The other two pillars are health literacy and access to healthcare."
CHEN has multiple approaches to boosting education attainment, he says. "CHEN has aligned with our health sciences program here at the hospital. We have several educational programs that produce graduates. For example, we have radiology technologists and certified nursing assistants. We teamed up with CHEN and the state in a workforce development program. In addition, CHEN has gotten awards for scholarships that are distributed to congregation members."
The hospital has held health literacy forums for CHEN members and there are materials that go out to the church networks for addressing health literacy. Webb calls health literacy a "silent giant" in health disparities.
"Health literacy is the ability to take the information that is being provided to you by a healthcare provider, interpret that information, and apply that information to your condition. If you can do that, you are health literate. If you cannot do that, then there is a risk that when you go home you will do almost none of what you were instructed to do. If you are not carrying out what you were instructed to do, that is a disparity," he says.
Within the healthcare access pillar, CHEN is making sure that individuals understand that they have access to healthcare and that healthcare is available to them regardless of their ability to pay, Webb says.
"For us, it is much more cost-effective and effective in terms of health outcomes if we can get you into our ambulatory division and start providing care to you before you get into crisis and must come into the emergency room or go to the ICU, which is where the cost in healthcare starts to spiral. We see providing care access as a way of controlling costs; and as a safety net hospital, it is cost avoidance. Any time we can engage in cost avoidance, those are dollars we can use for other efforts," he says.
The hospital provides financial counseling to patients. For patients who are uninsured, the hospital tries to enroll them in health plans such as Medicaid. "After we exhaust all opportunities to get them under some kind of coverage, then we will put them into our charity program."
The health equity challenge
Health equity poses a daunting challenge for U.S. healthcare, Webb says.
"We are not going to cure health inequities until there is a more equitable distribution of the social determinants of health. Social determinants of health are the drivers of health inequities and health disparities. If we cannot address this maldistribution of social determinants of health, how then are we going to ever address health equity?" he says.
It is going to be hard to address health equity without universal health coverage, Webb says.
"There is no magic wand that you can wave so that everyone is going to have equity in healthcare. That is not going to happen because the national, state, and local policies are never politically going to get to the point where they create a completely equitable healthcare system. The issue is that healthcare in this country is not a right. That creates the framework for how we execute healthcare delivery in this country. There is no mandate that everyone has healthcare. So, we have that disparity and inequity to begin with at a national level."
To eliminate health disparities, health systems must be able to capture how patients self-identify and how they are experiencing health outcomes differently.
To address health equity, health systems need to improve the collection, storage, and processing of patient data, according to Kedar Mate, MD, president and CEO of the Institute for Healthcare Improvement.
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.
Mate has made addressing health inequities a top priority at the Boston-based Institute for Healthcare Improvement (IHI). He recently discussed the importance of data in the effort to ameliorate health inequities with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why is data a key component of addressing health equity?
Kedar Mate, MD: In any kind of improvement work, it is difficult to improve what you cannot measure. That holds as much for equity concerns as it does for other areas of quality. Local data on disparity and inequity is often gathered poorly.
For example, there is a recent Government Accountability Office report about the understanding that we have about the race and ethnicity of the people who are affected by COVID and those who have received a single dose of the vaccine. We only have the data on about 47% for each of those two measures—the data on the race and ethnicity of the individuals who have been infected or received a single dose of the vaccine. For the majority of the records that we have around this incredible public health emergency, we still only have less than half of the available information about how this pandemic has been affecting our communities and how we have been responding to them.
HL: What kind of data is critical for addressing health equity?
Mate: The data that are important are the characteristics that people self-identify that matter to the health concern that we are talking about. In certain circumstances, the race of a patient might matter. There may be Black versus White differences or Hispanic versus White differences that matter. In other circumstances, rural versus urban residence of the patient might matter. In other circumstances, whether the patient has a disability might matter.
HL: Why do health systems need a data infrastructure to address health inequity?
Mate: Health systems need a data infrastructure to address health equity, but it is a broader consideration than that. Health systems need data infrastructure to create improvements in health and health outcomes. Health systems have known this for a long time, and they have been operationalizing a data infrastructure to help improve health, healthcare, and healthcare quality for many years. We are adding to that a layer of understanding of the individual that is deeper and richer than we have had historically.
We have often taken in information and understanding about the system itself and the system properties and outcomes. We are adding to that an understanding of how people experience their care differently and how people are experiencing health outcomes differently. We are not seeking wholesale changes of the data infrastructure, nor I am suggesting that we must add a tremendous amount of change at a time when health systems are incredibly stressed. But we must leverage the existing data infrastructure and coach it to collect more information to help understand who is affected and how they are affected differentially by our healthcare and our health systems.
HL: How can health systems go about creating this new layer of data infrastructure?
Mate: A lot of what IHI has learned in our Pursuing Equity program is there is a tremendous amount of work that health systems can do to improve their information technology data collection systems to help guide them to capture the necessary information. A big part of this is prioritization. Healthcare informatics teams are probably some of the most stressed teams inside of a health system. They are constantly being asked to attend to myriad concerns and considerations.
If a health system makes health equity a strategic priority, then we must ensure that healthcare informatics teams are rating the work on health equity appropriately on the long list of the things that they face. If the health system makes it a priority, it should be a priority for the data teams. We must give our data teams and clinicians the tools to ask patients how they self-identify such as race, ethnicity, language, and gender identity. We must give our clinicians and the other people who are meeting patients the necessary tools to ask patients how they self-identify.
We must have a place for clinicians to easily report the answer to these questions. So, when someone is asked a question about how they self-identify, it must be placed in a prominent location in the record, so that people can see it, understand it, and use that information.
Lastly, we must have teams within the organization that are prepared to use the data to take action. One of the observations that we made in our Pursuing Equity work is that the teams that tended to respond to the information the best were either the quality improvement team or the population health team. They are responsible to take action. They need to look at the data, process the data, pick some priorities, then take some action.
The new behavioral health unit is designed to meet both the medical needs and the mental health needs of patients.
A Shreveport, Louisiana-based behavioral health hospital has opened a 30-bed unit for coronavirus-positive patients who need immediate behavioral health care.
Most acute care hospitals are not equipped to treat behavioral health patients who also have a COVID-19 diagnosis. With the coronavirus pandemic's Delta variant surge and Hurricane Ida's aftermath, acute care hospitals in Louisiana are struggling to find enough inpatient beds to treat patients.
In January, a joint venture between Plano, Texas-based Oceans Healthcare and Ochsner LSU Health Shreveport opened a new 89 bed behavioral health hospital—Louisiana Behavioral Health. Oceans Healthcare operates several behavioral health hospitals in Louisiana, Texas, and Mississippi.
Early this month, Louisiana Behavioral Health established a 30-bed unit for behavioral health patients who also have a COVID-19 diagnosis. The new behavioral health unit meets a critical need, says Stuart Archer, MBA, CEO of Oceans Healthcare.
"When you take a behavioral health patient who has a unique set of needs and on top of that has an active COVID diagnosis, you have a patient who needs a special inpatient unit. Historically, these patients would be stuck in an emergency room for days or weeks. Or they could take a bed in an inpatient medical unit. There really wasn't anywhere to move that patient," he says.
The new behavioral health unit gives patients access to both mental health care and COVID-19 care, Archer says.
"Most behavioral health hospitals in Louisiana and nationally are designed with semi-private settings to improve socialization and help people as they go through their treatment. So, most behavioral health hospitals are a very hard place for a patient with an active COVID diagnosis simply because of the precautions that must be taken. You do not want to make other patients sick. It has been tough to take an active COVID psych patient on a behavioral health unit. By opening this specialized unit, we can address both needs of the patient. We can address their COVID diagnosis in a way that does not make others sick, and not delay treatment for their behavioral health condition," he says.
The new behavioral health unit is equipped to treat patients with a COVID diagnosis, Archer says.
"All of the infectious disease protocols and standards are followed on the unit, and they are similar to what you would see on any other active COVID unit. The nurses and other caregivers have the appropriate personal protective equipment. So, we have a strong behavioral health component on the unit along with a strong medical component. Patients are seen by both a medical physician and a psychiatrist during their stay. Their medical condition is monitored closely," he says.
Most hospital are not equipped for these kinds of patients, Archer says.
"When you add a COVID diagnosis on top of a behavioral health diagnosis, historically there have been very few beds for those types of patients. These patients have been stuck in an ER or they were put on a medical unit where their COVID diagnosis could be monitored but there were few resources for their behavioral health diagnosis. Under those conditions, the patients' behavioral health condition worsened while they were inpatients receiving treatment for COVID. Our unit is equipped to address both issues simultaneously," he says.
The benefits of Cleveland Clinic's internal coaching programs include professional development, employee retention, and reduction of burnout.
Cleveland Clinic has robust coaching programs for the Cleveland-based health system's physicians.
Coaching programs can help health systems address physician wellbeing and retention. The coaching programs at Cleveland Clinic are credited with helping the health system avoid $84 million in physician turnover costs over the past decade.
Cleveland Clinic has two programs that provide coaching services to physicians. The Center for Excellence in Coaching and Mentoring provides physician peer-based coaching. The Mandel Global Leadership and Learning Institute (GLLI) provides non-physician coaches for physicians.
"We have two core components. The Center for Excellence in Coaching and Mentoring is physician-led peer physician coaching. The Mandel Global Leadership and Learning Institute features coaches who are not physicians; however, 60% to 70% of the people we coach are physicians," says Ashley Villani, MBA, senior organization development consultant at GLLI.
The programs work in concert, she says. "The intentionality around it is that the programs collaborate with one another. I collaborate with the Center for Excellence in Coaching and Mentoring to complement and align our coaching initiatives. We align our training for both our physician coaches and non-physician coaches, with the idea to not compete with one another because we are here for the same reason—to provide coaching for all caregivers and physicians."
Villani says GLLI has 42 non-physician coaches, which are drawn from two sources. About half of the coaches are leaders in the institute or organization development consultants at the institute. The other half of the coaches are "enterprise coaches," she says. "Those are formal or informal leaders in the enterprise who went through the same training as all of our other coaches. Examples are chief nursing officers, executive directors, chief operating officers, and human resources senior directors."
Coaching benefits
Physicians and physician coaches generate several benefits from being involved in the coaching programs, Villani says.
"Physicians benefit from coaching by having dedicated time to pause and focus on their own development with a confidential thought-partner. An example of a benefit is increased resilience during times of change. Additionally, participants have reported increased leadership role consideration and attainment as a result of their participation, as well as increased academic output, including grants, publications, and presentations," she says.
The coaching programs also reduce physician burnout, Villani says. "Our coaching programing drives fulfillment and satisfaction as well as increasing resilience and a sense of relationship for participants. These are components of wellbeing that can mitigate burnout."
The coaching has been linked to increased physician engagement, which helps address burnout, she says. "When engagement increases, wellbeing often increases, and burnout likely decreases."
Physician coaches benefit from their coaching, Villani says.
"It's been found that the physicians who coach other physicians get as much value from the experience as those they are coaching. Additionally, they report using the skills across contexts outside of the formal coaching with colleagues, patients, and at home. Coach training surveys in 2019 showed a 62% increase from pre-to-post training in their ability to apply coaching skills in daily interactions with colleagues, a 58% increase with patients, and a 55% increase in their personal lives," she says.
Physicians have cited the coaching programs as part of the reasons why they decided to stay at Cleveland Clinic, which helped the health system avoid millions of dollars in turnover costs over the past decade, Villani says. The avoided costs include recruitment costs, onboarding costs, and training costs, she says.
Boosting physician retention also avoids the opportunity costs associated with filling a physician position, Villani says. "It takes time to recruit a new physician. Especially with the nature of our academic medical center, there are unique medical specialties, and it can take a long time to replace a physician."
Advice for establishing internal coaching programs at health systems
Establishing internal coaching programs at health systems requires an intentional effort, Villani says. "Implementing an internal coaching program and a coaching culture is a journey. It is important to understand the organization's perception of coaching prior to implementing a formal coaching program, to identify what you want the coaching program to be known for, and to use this information to inform the creation of a realistic implementation plan unique to the organization."
She says health systems should be mindful of several other considerations when establishing internal coaching programs.
Obtain support from the highest levels of leadership that coaching is valuable
Provide recognition for those who serve as coaches to maintain engagement of the coaches and to drive acknowledgment from the organization that coaching is a valuable offering
Understand the needs of your employees with a needs assessment and recognize that needs may vary based on roles within the organization
Promote a coaching culture where coaching is seen as a positive way to support personal and professional development
Make sure employees know that coaching is available and know how to request a coach
Ensure that employees know the difference between coaching and mentoring—coaching includes focusing on reflection and building upon an employee's personal assets, whereas mentors can offer employees advice
Telediagnosis on the grand scale experienced since the beginning of the coronavirus pandemic is an evolving science, researchers find.
More research is necessary to ensure diagnostic quality and safety in telemedicine, a new report published by the Society to Improve Diagnosis in Medicine (SIDM) says.
Telemedicine utilization has expanded exponentially since the beginning of the coronavirus pandemic. As noted in the new report, most research on telemedicine has focused on the maintenance health, but the use of telemedicine for telediagnosis at a grand scale is not as well understood.
The new report, which is based on information collected from healthcare organizations, clinicians, vendors, and patients, includes several key findings.
Remote patient monitoring is "an important enabler of continuity of care and patient support" in telemedicine that can facilitate diagnostic quality and safety.
Many clinicians interviewed for the report said that the skillset necessary for a good diagnosis in an in-person visit is similar to the skillset necessary to make a good telediagnosis.
Clinicians reported that a primary barrier in telediagnosis is the inability to perform a physical exam.
A crucial area for more research is in determining when a virtual visit is appropriate and when an in-person visit is necessary.
Many patients interviewed for the report had developed their own triage framework for determining when a telemedicine visit is appropriate. For example, patients said they would be comfortable with a telemedicine visit to assess familiar symptoms such as a recurring earache.
Insights from the report
Remote patient monitoring has significant potential to improve telediagnosis quality and safety, Suzanne Schrandt, JD, a co-author of the report and senior patient engagement advisor at SIDM, told HealthLeaders.
"We talked with a number of folks involved in remote patient monitoring, including vendors and clinicians who use those services. It seems to have a great deal of promise, particularly for early detection in an otherwise healthy person who has new symptomology or in a person with an underlying health condition who starts to see some worrisome changes," she said.
Remote patient monitoring can also boost patient engagement, Schrandt said. "One of the things that jumped out to me is there seems to be some value from remote patient monitoring in keeping the patient engaged and active in their own care. Patients can be aware of their own symptomology, vital signs, and any other measurements that are captured."
The inability to conduct a physical exam can be problematic in telediagnosis, she said. "What we heard from the 50 listening sessions is that the most important thing is the presenting symptoms. Clearly, there are some symptoms that do not require a physical exam; and in that case, most clinicians and patients felt comfortable with the virtual care. But there are trickier, more amorphous symptoms that require a physical exam such as abdominal pain and swelling that are difficult to perceive over a camera."
Clinicians interviewed for the report said they had found innovative ways to avoid the need to conduct a physical exam, Schrandt said. "We heard many great examples from the clinicians we talked to about things that they figured out in the moment. One was assessing strength over the camera by asking the patient to pick up increasingly heavy objects as opposed to assessing strength in a physical exam by pressing down on limbs. Clinicians can also ask patients to do their own self-exam while the doctor is watching, so they could isolate an area of pain or an area of discomfort."
Equipping patients with simple diagnostic instruments can also obviate the need to conduct a physical exam, she said. "There are some great opportunities to figure out how instruments such as oximeters and blood pressure cuffs can be used by patients to supplement when a clinician cannot do a physical exam."
When asked about the skillsets needed to conduct telediagnosis versus diagnosis in person, clinicians interviewed for the report had two opposing responses, Mark Graber, MD, report co-author and SIDM president emeritus, told HealthLeaders.
"One was that the same skills you use to be effective in person would help you be effective virtually. The opposing view was that telediagnosis was a whole new ballgame, with new rules, new tools, and new everything. Those with the opposing view said that virtual care did not come naturally, that there was a learning curve, and that instruction and practice and feedback were valuable. Someone even mentioned having done simulated sessions to get up to speed, and that this experience was valuable," he said.
Conducting a virtual visit and a physical exam are different in many ways, Graber said.
"A simple example is the ongoing debate on how to evaluate someone who is short of breath. This is a piece of cake in person—you see how fast the patient is walking, whether they are pale or blue, how fast and how heavy they are breathing, and you probably already have a set of vital signs taken that include the respiratory rate, the heart rate, and even a pulse oximeter reading if you are lucky. Contrast that to the virtual encounter, where you may get the same short-of-breath complaint, but there is ongoing debate about how you evaluate this," he said.
In-person visits versus virtual visits
The report found there are five decision factors when deciding whether a patient should have an in-person visit or a telemedicine visit, Schrandt said.
"The first decision factor is the urgency of symptoms. There are some symptoms that warrant immediate, in-person attention such as chest pain. There are some symptoms that are clearly nonurgent such as a rash. However, what about the gray area? A patient could have a symptom that is unusual, but it is hard to determine the urgency. We need more research on methods for making those sorts of determinations. We need to know from the clinical perspective and the patient perspective what constitutes urgency."
"The second decision factor is the underlying health of the patient. Is this a chronic disease patient with very specific risk factors at play, or is this an otherwise healthy person? We need research to determine whether there are conditions that are going to require in-person assessment."
"The third decision factor is the familiarity of the symptoms. Is this the same earache you have had five times or is this a new symptom you have never experienced? We might be able to develop an algorithm tool that could flag when there is a symptom that calls for an in-person visit and when it is probably OK to do virtual care. We need much more research on that."
"The fourth decision factor is the relationship between the patient and the provider. This can get complicated. If there is a well-established relationship, there could be more comfort with virtual care, or at least a virtual-first approach. On the flip side, a patient can be matched with a clinician in telemedicine who the patient does not know, and we need research to know whether there are situations where that model works well or whether there are certain scenarios when that is not the right approach."
"The fifth decision factor is the quality of the virtual care. Is the visit being done over the phone? If the visit is being conducted via video, is the quality of the video clear? The concern over inequity and access to broadband came up repeatedly during the project. You cannot make decisions about whether to have in-person visits or virtual visits unless the virtual is an option."
Spreading coronavirus misinformation could cost physicians their medical licenses and medical board certifications.
The Federation of State Medical Boards (FSMB) and several medical certification organizations are calling for disciplinary action against physicians who spread misinformation about coronavirus vaccines.
The spreading of misinformation about coronavirus vaccines is widely viewed as playing a role in vaccination hesitancy across the country. Joseph Mercola, an osteopathic physician in Cape Coral, Florida, is one of the most influential spreaders of coronavirus vaccine misinformation in the country, according to The New York Times.
The FSMB, which represents medical licensing boards across the country, recently released a statement that seeks to discourage coronavirus vaccines misinformation by physicians.
"Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession and puts all patients at risk," the statement says.
On Sept. 9, the leaders of the American Board of Family Medicine, American Board of Internal Medicine, and American Board of Pediatrics issued a joint statement on the dissemination of misinformation about COVID-19 by board certified physicians.
"We at the American Board of Family Medicine (ABFM), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP) support FSMB's position. We also want all physicians certified by our boards to know that such unethical or unprofessional conduct may prompt their respective board to take action that could put their certification at risk," the joint statement says.
Taking a stand against misinformation
Physicians who engage in coronavirus vaccine misinformation are violating hallowed obligations, Richard Baron, MD, president and CEO of the ABIM, told HealthLeaders.
"Physicians have a professional and ethical obligation to advise patients on the current state of scientific knowledge and in their field. That is what patients are relying on physicians to do. Physicians occupy a position of considerable authority and considerable trust—there are a lot of things that you get to do if you are a physician that you cannot do if you are not a physician. Part of why physicians have that privilege is the extent to which they can be counted on to be faithful to a scientific community that defines what good care looks like," he said.
Physicians have a duty to provide accurate information about coronavirus vaccines, Baron said.
"The information physicians should be giving is that vaccines are safe and effective. The number of medical contraindications from getting the vaccine are extremely small—it is mainly people who can have allergic reactions to the vaccines. This is something that has been given to hundreds of millions of people, and the number of complications is tiny. At the same time, we have more than 650,000 people in the United States who have died from a disease that the vaccines seem to prevent successfully. So, physicians should be encouraging their patients to get COVID vaccine because they are at much higher risk of dying of COVID if they do not get vaccinated than they are of any bad outcome from the vaccines," he said.
Coronavirus vaccine misinformation from physicians takes a toll, Baron said. "It is hugely damaging because it provides support for things that are just not true, and that support moves around fast. We know that misinformation moves faster on Twitter than true information. So, when physicians use their position of trust and authority to put out misinformation, the impact ripples far beyond the people who hear it because it gets repeated and disseminated. When misinformation is attributed to a physician, it has more than casual authority."
Coronavirus vaccine misinformation degrades the medical profession, he said.
"Lots of people rely on and trust what physicians tell them, and misinformation is damaging not only for the patients who hear it but also damaging to the profession because it undermines trust in physicians. Frankly, one of the biggest reasons that we put out the statement we did was to provide clear support for the doctors who are trying to do the right thing and feel beleaguered and undercut by other doctors who are putting out information that is terrible, dangerous, and wrong."
