Despite leading the world in healthcare spending at more than $3.5 trillion of expenditures annually, the United States lags other high-income countries in many health outcomes such as maternal mortality. The National Quality Task Force was formed to address continuing challenges and emerging issues in the pursuit of improving health outcomes and reducing medical errors.
The task force's five recommendations are as follows.
1. Appropriate, safe, and accessible care
Healthcare leaders need to focus on building a culture and workforce that is committed to delivering a safe, appropriate, and efficient patient-centered experience as a standard of care.
"The cultural transformation must motivate the whole healthcare system to innovate continually and improve reliability of care processes—using proven virtual care capabilities to remove place-of-service barriers and advanced analytics to address misuse, overuse, and underuse," the task force report says.
2. Seamless flow of reliable data
The proliferation of healthcare data is becoming overwhelming. This development is creating opportunities to improve care but also presents challenges to achieving effective, safe, and appropriate use of personal and clinical data.
"Consistent, comprehensive, high-value care requires providers, payers, and other system stakeholders to have real-time access to standardized, valid information from a variety of clinical and nonclinical data sources while safeguarding people from harm and bias. The seamless flow of reliable information is necessary to optimize the healthcare experience, efficiently improve health outcomes for individuals, reduce burden, and enable true, comparative benchmarks," the task force report says.
3. Financing patient-centered care and healthy communities
The shift from fee-for-service healthcare to value-based care is moving too slowly. Health systems, hospitals, and physician practices need to focus on creating a healthcare delivery system that accounts for the whole person, puts a premium on keeping people healthy, and reduces health disparities.
"Investing more in primary care and prevention and accelerating the transition to population health models can promote more efficient use of public and private resources, and liberate systems to implement person-centered strategies that integrate community resources and care across modalities and settings to deliver care. Such care will produce better care experiences and outcomes that deserve payment and improve health equity across diverse communities," the task force report says.
4. Engaged patients
The key stakeholders in healthcare—patients and caregivers—need actionable information to become more effective care partners.
"The healthcare delivery system must redefine quality and value from the perspective of educating an engaged consumer. To help consumers make informed healthcare decisions, care options must consider evidence as well as individual goals and needs. Evidence-driven information and consumer priorities must define what quality is and how it is measured and reported," the task force report says.
5. Transparency
The healthcare sector needs to match the achievements of high-performing industries that are committed to improving quality performance and expectations.
"Progress demands the transparency that provides actionable intelligence and valid value comparisons. Healthcare must establish transparent, consistent, and verifiable safety and quality standards that motivate all stakeholders to pursue the best value by providing effective, transparent comparisons of consumer experience ratings, clinical outcomes, and total cost as essential to achieving this goal," the task force report says.
Views of task force leaders
In comments to HealthLeaders, the co-chairs of the task force gave their perspectives on the recommendations.
"The powerful role that culture has on performance and outcomes is well established. To consistently deliver high-value care, we must ensure there is a unifying culture of safe, appropriate, person-centered care," said Kenneth Kizer, MD, MPH, chief healthcare transformation officer and senior executive vice president at the Washington, DC-based consultancy Atlas Research.
Data and accurate information are crucial for driving change in the healthcare sector, said Shantanu Agrawal, MD, MPhil, National Quality Forum president and CEO.
"There is fundamental need across the [healthcare] ecosystem for creating seamless, standards-driven, reliable data and information sharing processes. It will aid in accelerating technology-enabled processes to improve data sharing, utilization, and communication among stakeholders; help strengthen requirements to capture and publicly report measures that address consumer priorities; and standardize quality data to move beyond claims data," Agrawal said.
Improving the flow of information has key benefits for healthcare providers, Kizer said. "Standardizing quality data and better aligning performance assessment across the quality enterprise should significantly lessen some of the 'performance measure fatigue' that currently exists and in so doing would help address physician burnout."
Care options must consider evidence as well as individual goals and need to help consumers make informed healthcare decisions, Agrawal said. "There is a need to strengthen approaches to developing consumer-defined measures, increase transparency and usage of information desired by consumers, and integrate evidence-based shared decision making into prioritized care processes."
The National Quality Task Force recognizes that progress demands transparency that provides actionable intelligence and valid value comparisons, Agrawal said. "We need to establish transparent, consistent, and verifiable safety and quality standards that motivate all stakeholders to pursue the best value by providing effective, transparent comparisons of consumer experience ratings, clinical outcomes, and total cost as essential to achieving this goal."
Telehealth visits for chronically ill patients have advantages compared to in-person visits such as providing visibility of patients' home environment.
For healthcare providers, telehealth is an opportunity to generate revenue and boost the quality of care when working with chronically ill patients, a chief transformation officer says.
Telehealth visits can drive value for chronically ill patients. Telehealth visits are not only more convenient for chronically ill patients than in-person visits, they also are far less expensive than a trip to the emergency room.
"Instead of going to the emergency room for an unneeded visit and a very large charge, patients can get on a telehealth platform and speak to either a physician or a nurse who bills through their insurance. Providers can bill through an evaluation and management code such as a 99213," says Janice Coffin, DO, a practicing family medicine physician and chief transformation officer at the Medical College of Georgia, Augusta University.
Conducting telehealth visits with chronically ill patients generates five primary revenue opportunities for physician practices, Coffin says.
In value-based contracts, telehealth and remote monitoring for patients with chronic conditions enables physicians to achieve quality of care goals and lower unnecessary readmissions, which results in higher incentive payments
Chronically ill patients with concerning health conditions can schedule a telehealth visit with their primary care physician rather than going to an emergency room or urgent care center
During the coronavirus pandemic, chronically ill patients who are reluctant to schedule in-person visits are more likely to schedule telehealth visits
Partnering with a chronic care services company that uses remote monitoring and telehealth provides a steady stream of revenue
With telehealth, primary care practices and specialty physicians can reach out to chronically ill patients who are overdue for physicals or follow-up visits
"With the rules changing and Medicare giving a lot more leniency in terms of reimbursement for telehealth visits, now physicians can get reimbursed the same amount of dollars for a telehealth visit without having to bring patients into the office," says Debbie Fisher, chief operating officer for Augusta, Georgia-based NavCare, which provides chronic care management services to Augusta University.
There are five primary best practices for conducting telehealth visits with chronically ill patients, Fisher says.
As is the case with in-person visits, clinicians conducting telehealth visits should use situation, background, assessment, and recommendations (SBAR) or other standard tools to document clinical assessments
Clinicians should have a checklist for social determinants of health and the home environment, including an assessment of food in the home and checking for fall risks
Recommendations to the patient should include a plan of care for clinicians or a chronic care management team to follow up appropriately
After a telehealth visit, clinical protocols should be provided to remote patient monitoring or chronic care management teams, so that care and interventions can occur timely and appropriately
Clinicians should adhere to coding guidelines as well as code new and ongoing chronic conditions to the highest level of specificity, which can impact reimbursement and clinical interventions
Having visibility of a patient's home environment during a telehealth visit is advantageous compared to in-person visits, Coffin says.
"Patients can go into their kitchen and show me what they are eating. They can show me what medications and what dosages they are taking by putting their bottles upto their device camera. There is a lot of information that can be obtained when a patient does a telehealth visit because they are in their own living environment, which gives providers a better overall picture of the patient."
Compared to the general population, researchers found that risk factors for physician suicide include older age and job problems.
Compared to the general population, physicians who die by suicide are more likely to experience job and civil legal problems, recent research indicates.
It is estimated that a doctor commits suicide every day. Research published in 2018 indicates that nearly half of physicians nationwide are experiencing burnout symptoms. There are overlapping risk factors for suicide and burnout, including depressed mood and job problems, according to the Maslach Burnout Inventory and the National Violent Death Reporting System (NVDRS).
The recent research, which was published by JAMA Surgery, examines NVDRS data collected from January 2003 to December 2016. More than 170,000 individuals who died by suicide were identified. Of that total, 767 individuals (0.5%) were physicians. Non-surgeon physicians accounted for 63.2% of doctors who committed suicide, dentists accounted for 23.3%, and surgeons accounted for 13.4%.
The research generated several other key data points:
Compared with the general population, suicide risk factors among physicians included Asian or Pacific Islander ancestry (2.80 odds ratio), job problems (1.79 odds ratio), civil legal problems (1.61 odds ratio), physical health problems (1.40 odds ratio), and treatment for mental illness (1.45 odds ratio)
Among the 103 surgeons, orthopedic surgeons (18.5%) and neurosurgeons (12.6%) accounted for the highest number of suicides
The mean age of physicians who died by suicide was 59.6 years, compared to a mean age of 46.8 years in the general population
Compared to the general population, suicide risk factors for non-surgeon physicians included Asian or Pacific Islander ancestry (2.29 odds ratio), civil legal problems (1.80 odds ratio), job problems (1.72 odds ratio), physical health problems (1.53 odds ratio), older age (1.003 odds ratio per year), and receiving treatment for mental illness (1.32 odds ratio)
Compared to the general population, suicide risk factors for surgeons included Asian or Pacific Islander ancestry (5.41 odds ratio), job problems (2.19 odds ratio), older age (1.004 odds ratio per year), and receiving treatment for mental illness (2.12 odds ratio)
Interpreting the data
The JAMA Surgery researchers hypothesized about why physicians had higher suicide risk factors than the general population.
Older age: "One hypothesis is that the transition into a senior career position or retirement introduces new challenges regarding sense of purpose, finances, changes in routine, and restructuring of family dynamics," the researchers wrote.
Asian and Pacific Islander ancestry: "The cultural stigma of experiencing mental health challenges among this population may contribute to low rates of diagnosis and treatment of mental illness," they wrote.
Job problems: All three physician subgroups—surgeons, non-surgeons, and dentists—were at higher risk for suicide than the general population if they had job stressors. "Given the time and economic investment expended in training to become a healthcare professional, the inability to practice may carry a larger burden of emotional distress," the researchers wrote.
Civil legal problems: The link between civil legal problems and suicide was strongest for non-surgeon physicians. "Physicians who practice in specialties that have a high risk of incurring malpractice claims may be more accustomed to handling such claims. In contrast, physicians who practice in specialties in which malpractice litigation is less common may experience more emotional distress when malpractice claims occur," they wrote.
Suicide prevention opportunities
The researchers identified two primary opportunities for healthcare organizations to improve suicide prevention.
"Our data suggest a need for increased screening of healthcare professionals, particularly among the high-risk groups comprising racial minorities and those in the late stages of their careers," the researchers wrote.
"Because job problems and civil legal problems were associated with a significantly higher likelihood of suicide among healthcare professionals, institutions can aim to ensure sufficient human resource and legal support for professionals experiencing litigation," they wrote.
Physicians in crisis can seek help by calling the National Suicide Prevention Lifeline at 800-273-8255.
WakeMed Health & Hospitals was spared a dramatic impact in the first wave of the coronavirus pandemic and is ready if a second wave hits.
The coronavirus disease 2019 (COVID-19) pandemic has had varying impact across the country, ranging from dire hot spots such as New York City to Montana, which reported 505 confirmed cases as of May 29. In North Carolina, there were more than 44,000 confirmed cases and more than 1,100 deaths as of June 14, according to ABC.
Raleigh, North Carolina–based WakeMed did not have to increase bed capacity in response to the COVID-19 pandemic, but the health system learned the following eight key lessons and positioned itself to respond to a potential second wave of infections, a pair of clinical leaders from the organization says.
1. Be flexible
The COVID-19 pandemic put a premium on flexibility, says Seth Brody, MD, MPH, senior vice president of physician services. "We had to evaluate ideas that were new and different. We needed to have flexibility and willingness to listen to others," he says.
For example, supplies of personal protective equipment and directives for its use shifted several times through March and April, he says. "We had to continually modify our policies for N95 masks. As more information came out, it became clear who truly was at risk."
WakeMed had to foster flexibility in its staff, Brody says. "Getting the staff to work with us through change was critical. We had to help them understand that we were adapting as quickly as we could, we were trying to be rational, and we were trying to work within our supply chain limits. We had messaging that leadership was going to be flexible and the staff needed to be flexible with us."
2. Discover your institutional potential
Harnessing WakeMed's potential as an organization was critical in the health system's response to the pandemic, says Chris DeRienzo, MD, chief medical officer and senior vice president of quality. "When we approached the first lockdown orders—the first crisis period—members of our command center learned a lot about each other and the organization. We found that we could function under high intensity pressure and focus on needs and outcomes."
WakeMed began activating the command center in January and had a 24/7 operation by March 6, DeRienzo says. At its peak, the daily incident command call had more than 60 people. The operational command teams had as many as 300 people.
"We stood up entire functions and pillars to support the COVID response that did not exist before in terms of disaster planning, inventory, testing, and other functions. We learned what we could do as an organization when we brought the focus down to things that we had to achieve," he says.
3. Implement change quickly
Under the pandemic pressure, WakeMed was able to launch and implement initiatives quickly, Brody says. "Things that would take three to six months in the past could be accomplished in three days. It was a great lesson learned in terms of how to work together to get things done. We had the talent. We had the skills. We had people to lead change."
For example, WakeMed ramped up a modest telemedicine capability within days, he says. "We had talked about telemedicine and we had it up and running, but before the pandemic we might only see 10 patients a week via telemedicine at our physician practices. When we launched telemedicine across the outpatient continuum of care, within a week we were doing more than 60 telemedicine visits at the same time."
4. Find your untapped talent
WakeMed's response to the pandemic benefited from actualizing the potential of talent within the health system, Brody and DeRienzo say.
For example, David Kirk, MD, director of the WakeMed Pulmonary and Critical Care and director of WakeMed eICU took on a key new role, helping to lead the command center's critical resources team.
"That team turned around our critical resources dramatically. Our normal supply chain people are very good, but this was a different kind of crisis. The critical resources team figured out the burn rates for our PPE and targeted critical resources. They did vetting—we were getting 15 offers a day for PPE from around the world that were 15 to 20 times the normal cost. They also helped with communication to our healthcare workers, which gave our workers more confidence," Brody says.
Kirk has been promoted to associate CMO and critical resources management will remain one of his responsibilities.
5. Appreciate your community support
The Raleigh-area community supported WakeMed on several fronts, including money for the health system's foundation, Brody and DeRienzo say.
"Our service mentality for our community is reflected in the community's service mentality to us. As we walked into the depths of the most challenging aspects of the past 12 weeks, the community stood up for us and served our people in ways that I had certainly never seen before in my career. There were donations from food to supplies, and salutes from law enforcement and first responders," DeRienzo says.
6. Ensure your physicians are compensated
During the first wave of the pandemic, WakeMed did not lay off or furlough any physicians.
Hospital-based physicians such as critical care physicians and hospitalists were kept at their pre-pandemic salary levels, and a new payment system was created for physicians on productivity-based compensation such as operating room surgeons.
"On the frontline in the hospitals, we maintained physician salaries. We realized our doctors had to get us through the crisis," Brody says.
With overall patient volumes down and the cancelation of elective surgery to boost hospital bed capacity for COVID-19 patients, physicians on productivity-based compensation were at risk. Brody led an effort to compensate these physicians at fair market rates during the crisis, with a reconciliation process after the crisis had passed.
"We are sustaining their cash flow at a very reasonable fair-market rate throughout the crisis. It's almost like an interest-free loan for an extended period of time, so that they can stay at a fair-market level throughout the crisis. We will reconcile the compensation later, but they never dropped below a fair-market level," Brody says.
7. Cooperate instead of compete in crisis
WakeMed is based in Raleigh, one of the points in The Research Triangle region of North Carolina. Competing health systems are based in the other two points of the triangle—Duke Health in Durham and UNC Medical Center in Chapel Hill.
The rivals have cooperated during the pandemic.
"With the supply chain, it made more sense for us to work together. We shared masks and swabs for testing. We also aligned policies. For example, we created similar policies for hospital visitation. Our community benefited from getting a common message from all of the health systems," Brody says.
The cooperation extended beyond The Research Triangle, DeRienzo says. "The cooperation was not just with Duke and UNC. There was cooperation at the state level—North Carolina's health systems tried to begin thinking and acting in the statewide response. When I think back to the end of March and early April, we were not just on our internal incident command calls; we were having calls with Duke and UNC, we were having statewide healthcare leadership calls, and we were having calls with local and state officials."
8. Plan for surge capacity
One of the most valuable work products of the WakeMed command center has not been used, yet.
A capacity management team with about 30 members devised a plan to increase WakeMed's patient capacity from about 1,000 beds to more than 1,500 beds. The team was led by a senior nurse, with participation of ED clinicians, surgeons, hospitalists, and others.
The surge capacity plan has three phases.
Phase 1: Increase bed capacity by at least 25% through conversion of spaces that could readily serve COVID-19 patients such as operating rooms, endoscopy units, and post-anesthesia care units.
Phase 2: Increase bed capacity by another 20% by setting up cot facilities in conference rooms and a rehabilitation gym.
Phase 3: Establish a temporary hospital at a facility in the community.
"Having developed these plans, we now have them in hand. If COVID in the fall requires us to walk through that progression, we are ready. This is work that is tremendously valuable for whatever comes our way next," DeRienzo says.
New research provides guidance for managing the adoption of behavioral health integration.
Four factors have a major impact on adoption of behavioral health integration at healthcare organizations, a recent research article says.
About 20% of U.S. adults have a clinically significant behavioral health condition. Prejudice against people with behavioral health conditions and shortages of behavioral health workers has limited effective treatment. Integrating behavioral health into medical care is a top strategy to address behavioral health conditions.
The recent research article was published by Annals of Internal Medicine and funded by the American Medical Association and The Commonwealth Fund. The study features interviews with 47 physician practice leaders and clinicians, 20 behavioral health integration experts, and five vendors.
The researchers found four factors impact the implementation of behavioral health integration initiatives.
1. Physician practice motivations for behavioral health integration
There are three motivations for behavioral health integration at physician practices, the research shows.
Behavioral health integration can expand access to services when there are shortages of behavioral health clinicians. "One primary care physician explained that before implementing behavioral health integration, the practice was frequently unable to respond quickly to new behavioral health needs," the researchers wrote.
Behavioral health integration can boost the responsiveness to behavioral health screening. "Some practices reported that, before behavioral health integration, nonbehavioral health clinicians felt unable to respond when behavioral health screens identified behavioral health needs. This sense of helplessness led some clinicians to screen inconsistently," the researchers wrote.
Behavioral health integration can bolster a physician practice's reputation. "For example, a psychologist working for a mid-sized gastroenterology practice affiliated with an urban academic medical center explained that behavioral health integration was 'something cutting edge that sets [the practice] apart from other competing institutions in the area,'" the researchers wrote.
2. Crafting tailored approaches to behavioral health integration
Physician practices tend to tailor their behavioral health integration models in accordance with the practice's patient population needs, workflows, resources, and financial opportunities. Most of the practices in the study adopted a form of co-location—which features onsite behavioral health clinicians providing enhanced access within physician practices—because the co-location model can be a good fit with pre-existing practice workflows.
3. Behavioral health integration barriers
The research found three primary barriers to behavioral health integration.
There are cultural differences between behavioral and nonbehavioral health clinicians. "Several interviewees reported that behavioral health clinicians, who may be accustomed to 50-minute patient visits and long-term patient relationships without substantial staff supervision responsibilities, could have challenges acculturating to medical clinics," the researchers wrote. Methods identified to bridge cultural divides include utilizing organizational champions and practice leaders to engage both behavioral and nonbehavioral health clinicians.
There are barriers to flow of information. "Most participating practices reported that behavioral health records were shared infrequently with nonbehavioral health clinicians or were accessible only with special permission," the researchers wrote. Causes of poor information flow include electronic health record systems that are not designed for behavioral health integration and overly restrictive interpretations of laws and regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
There are billing challenges. "Several practices in our sample reported that billing for behavioral health integration could be complex, burdensome, and unfamiliar to behavioral health providers," the researchers wrote.
4. Impact of payment models
About one third of the practices examined in the study reported losing money on behavioral health services. The practices used a range of payment models:
Internal organizational support that was not covered or fully covered by reimbursements received for behavioral health integration
Grant funding to launch behavioral health integration
Medicare fee-for-service billing codes
Alternative payment models such as shared saving and capitation
"There was no one-size-fits-all payment model that practices used to support behavioral health integration," the researchers wrote.
Promoting behavioral health integration
Leadership is crucial to overcome cultural barriers to behavioral health integration, says Patrice Harris, MD, MA, a practicing psychiatrist in the Atlanta area who stepped down as president of the American Medical Association on June 7.
"We have to start at the top, and we have to make sure there is a commitment on the part of the leadership of the organization to make it work. Then the leaders can bring together clinicians, administrators, and everyone working on all the teams to develop a plan of action," she says.
To foster the flow of information needed to achieve behavioral health integration success, staff members must have a firm grasp on the intricacies of HIPAA, Harris says. "You want to make sure everyone is on the same page regarding what is appropriate and what is not appropriate. In the service of their patients, clinicians can share information."
A team effort is required to address billing challenges, she says. "Usually, there are billing challenges regardless of the integration model. When you are having these conversations, you need to have your chief financial officer and billing team in the room. There are definitely workflow changes to process claims."
Behavioral health integration efforts can generate return on investment, but ROI should not be defined narrowly, Harris says. "We have seen financial returns, but we have to be candid—those financial returns do not always accrue immediately. That is why you have to think about patient outcomes and longer term returns on investment."
As the first drug found effective against the novel coronavirus illustrates, medications to treat the infection are likely to be initially scarce.
Decisions about allocating scarce inpatient medications for coronavirus patients should be guided by a four-part ethical framework, a recent journal article says.
The antiviral drug remdesivir is the only medication that has been shown to be effective in treating hospitalized coronavirus disease 2019 (COVID-19) patients. As is expected in the initial deployment of new COVID-19 therapies, there is a shortage of remdesivir. Healthcare providers have criticized the federal government's distribution of the drug.
The recent journal article, which was published by the Journal of the American Medical Association, calls for the setting of parameters to guide allocation of scarce COVID-19 medications.
"Evidence-based, fair guidelines to allocate scarce drugs for COVID-19 could help physicians make difficult decisions. Transparent guidelines will help promote trustworthiness when not all infected patients can receive a medication that is in short supply," the journal article's co-authors wrote.
The journal article proposes a four-part ethical framework as the foundation for allocating scarce COVID-19 medications:
1. Decreasing mortality is a primary guiding principle because reducing deaths benefits entire communities. Taking an evidence-based approach also is essential, the co-authors wrote. "Allocation policies should be revised as evidence develops. During a shortage, medications should be prioritized for indications for which peer-reviewed, randomized clinical trials have demonstrated efficacy and safety."
2. The preferences of patients should be respected, but their desired course of treatment may not be possible when there is a medication shortage.
3. Fairness should be a guiding principle when allocating scarce medications. Guidelines should avoid discrimination and ease health disparities.
4. Allocation guidelines should be established in a transparent, accountable, and responsive manner. The policies should be crafted to fit the situation such as the status of the pandemic.
"Specific goals derived from this ethical framework can provide practical clinical advice," the co-authors wrote. For example, a portion of scarce medications should be allocated to clinical trials to promote evidence-based findings.
Drug allocation recommendations
The JAMA article makes six recommendations for the allocation of scarce COVID-19 medications:
1. Distribution of scarce medications should be evidence based. Patient groups should be prioritized for a medication if clinical trials have shown the patients benefit from the therapy. When there is a shortage, compassionate use unsupported by evidence should be limited.
2. Discriminatory guidelines and administration of a scarce medication should be avoided. "Prioritization should not exclude patients based on age, disability, religion, race or ethnicity, national origin, gender, sexual orientation, or perceived quality of life," the co-authors wrote.
3. Existing Food and Drug Administration-approved medications should not be denied to patients who depend on them for non-COVID-19 therapy.
4. Evidence should guide decisions about which patients could benefit most or least from a scarce medication. "For example, although older age, diabetes, hypertension, and coronary artery disease are risk factors for poor prognosis in COVID-19, predictors of poor prognosis do not necessarily predict response to a new treatment. Physicians should provide new therapies to patients with these conditions, unless evidence emerges that shows that they do not respond to the therapy or respond less well than patients without these conditions," the co-authors wrote.
5. Fairness should be a consideration, they wrote. "Random allocation, such as by lottery, is the fairest way to allocate a very scarce drug among eligible patients. A 'first-come, first-served' approach should be avoided because it is not random, and it disadvantages those who experience barriers to seeking care. Within a lottery, workers in essential jobs may be given some priority."
6. Rationing scarce medications can prompt emotional reactions from patients and their loved ones, so clinicians should have support in making difficult decisions.
To accommodate the city's coronavirus patient surge, NYC Health + Hospitals increased critical care capacity and retooled emergency departments.
It was a nightmare scenario.
Emergency rooms were overwhelmed with coronavirus patients—sick patients walking through the door and dozens of seriously ill boarded patients awaiting inpatient beds. In some metropolis hospitals, demand for ICU beds exceeded supply.
It was March and April in New York City, and The Big Apple's 11-hospital public healthcare system—NYC Health + Hospitals (NYC H+H)—was at the U.S. epicenter of the global coronavirus pandemic. As of May 22, the city had 193,000 confirmed cases of novel coronavirus disease 2019 (COVID-19) and more than 50,000 hospitalizations, according to the New York City Department of Health and Mental Hygiene.
NYC H+H's efforts to increase critical care capacity and retool emergency departments is featured in a new article published by Health Affairs.
"As health systems nationwide prepare for potential resurgence of COVID-19 infection with relaxation of social distancing measures and the frightening prospect of a second peak, principles and actions taken by New York City Health + Hospitals provide a model for how hospitals across the United States can expand critical care capacity and manage frontline ED care to lessen the toll on human life," the article says.
Boosting critical care
Before the city's coronavirus crisis began in March, NYC H+H had about 300 ICU beds. When COVID-19 patients surged, the health system provided ICU care to more than 1,000 patients.
NYC H+H pursued three primary strategies to increase critical care capacity.
1. Increasing ICU beds
The health system organized ICU resources in two categories: "primary" spaces that were already equipped with the full suite of ICU equipment such as adequate power supply and physiology monitors, and "flex" spaces that could be quickly converted into fully equipped ICUs. Flex spaces included post-operative areas, operating rooms, procedural areas, and critical care rooms in the EDs.
For infection control in the ICU setting, the virus that causes COVID-19 was assumed to be aerosolized and airborne.
In many primary ICU spaces, individual patient rooms had negative pressure, so total personal protective equipment (PPE) only had to be donned by caregivers working in a patient's room.
Flex ICU spaces were more challenging because they often did not have single rooms that could serve as an individual isolation unit, requiring all staff to wear total PPE.
The most seriously ill COVID-19 patients were treated in primary ICU spaces.
Some hospitals experienced higher demand for ICU beds than others, so critical care beds were shared across the health system. In the six-week period starting March 20, more than 850 critical and noncritical patients were transferred between health system locations.
2. Increasing ICU staffing
Ambulatory clinic and elective surgery staff were reassigned to serve in critical care roles. Several of these staff members had specialized skills well-suited to the ICU setting such as anesthesia clinicians who could lead intubation teams and surgery staff who were familiar with proning patients.
To maximize the effectiveness of experienced critical care staff, the health system used a tiered staffing model in ICU settings, with experienced clinicians and nurses leading teams of reassigned healthcare workers. This approach freed up critical care physicians and nurses to manage more patients than pre-pandemic levels.
The health system recruited staff from across the country, including volunteers and military personnel with medical training. For example, more than 100 respiratory therapists were recruited. To maintain efficiency and efficient workflows, experienced staff members led teams of recruits whenever possible.
3. Increasing critical care equipment and infrastructure
The health system's supply of ventilators was supplemented with acquisitions from federal stockpiles and vendors. Ventilators also were sourced internally such as using operating room anesthesia machines. At the peak of the patient surge, about 1,000 patients were on ventilators, which was about five times the utilization level in pre-pandemic spring months.
COVID-19 patients require volumes of oxygen that are beyond the capacity of free-standing oxygen tanks, so installing piped oxygen systems was crucial.
Many seriously ill coronavirus patients require renal replacement therapy, and the health system had to redistribute dialysis machines and establish new peritoneal dialysis programs at some sites.
Ventilators and renal replacement therapy machines have several disposable parts such as filters and circuits. The health system had to redistribute these parts between hospitals to help manage supply shortages.
The high volume of patients put pressure on the health system's supply chain for common supplies such as IV tubing and dressings. Frontline staff and supply chain leaders monitored the "burn rate" for these supplies.
Managing emergency departments
NYC H+H established an action team featuring health system and local ED leaders to focus on three areas.
1. Protecting staff
Initially, suspected COVID-19 patients were placed in dedicated areas, where staff donned full PPE.
As the patient surge intensified, all EDs and ICUs were designated as "hot zones" requiring clinical and nonclinical staff to don full PPE.
2. Matching resources to clinical needs
The action team initiated text message campaigns to urge city residents with mild symptoms to stay home and monitor their conditions, which helped avert ED overcrowding.
As the patient surge intensified, the health system issued a citywide open letterthat gave residents more detailed medical advice such as how to self-isolate from other household members and when to seek medical attention.
The health system built a telehealth capability paired with the city's 911 call-center to provide clinician assessments of coronavirus symptoms. If more medical attention was warranted, the telehealth clinicians would direct patients to the appropriate care setting.
Some low acuity COVID-19 patients transported by ambulance were taken to urgent care centers or tents outside EDs for triage.
To increase ED throughput, protocols were created for the evaluation of potential COVID-19 patients such as streamlined clinical work-ups. Many high-risk patients were admitted, but those who did not meet admission criteria were often held in the ED for observation.
A home-monitoring program was established with text messages and phone calls to enhance discharge safety.
3. Increasing capacity and improving efficiency
ED-based ICUs were created to board seriously ill COVID-19 patients who were awaiting hospital admission. Some EDs boarded as many as 100 of these patients at a time.
Staffing was increased and workflow efficiency was improved to increase time for bedside care. Staff onboarding processes were accelerated—the duration of onboarding was reduced from a few months to a few days.
Staff efficiency was improved through methods such as dividing clinicians into key teams, including ventilator monitoring, transport, and proning.
Documentation for COVID-19 patients was streamlined in the electronic medical record, which also was updated with coronavirus-specific ordering tools.
The COVID-19 crisis has been a financial fiasco for physician practices, including decreased patient volume and canceled elective surgeries.
There are strategies physician practices can pursue to weather the financial storm associated with the coronavirus pandemic.
Ninety-seven percent of physician practices experienced a negative financial impact from the coronavirus disease 2019 (COVID-19) pandemic, according to a Medical Group Management Association survey published in April. The financial hits have included decreased patient volume and loss of income associated with the canceling of elective surgery.
The COVID-19 pandemic poses an existential threat to the primary care sector, says Ann Greiner, president and CEO of the Primary Care Collaborative in Washington, D.C. "If we do not respond to the financial challenges that primary care is facing, we are going to see an already damaged foundation of our healthcare system crumble."
Physician practices can pursue four primary strategies to keep their business finances afloat, says Al Crawford, chairman, CEO, and co-founder of Davie, Florida–based Bankers Healthcare Group.
1. Hold on to cash
"Do not spend if you do not have to spend. You should just hoard cash. The more access you have to cash, the better," Crawford says.
During the COVID-19 pandemic, physician practices should limit new spending to practice enhancements related to the pandemic such as air purification systems, he says. "There are expenses required during the COVID-19 pandemic, but I recommend that you do not go beyond those required expenses in an environment like this. We are in the middle of a pandemic, and what you do not need you should not buy."
2. Don't pay off debt, yet
"I would not be looking to pay down debt right now because of the No. 1 principle—cash is king," Crawford says.
Medical professionals should be careful about taking cash and paying down debt, he says. "For the next 90 to 180 days, I would try to stay cash-rich. If we're all back to work, there is a vaccine in the fall, your practice business is good, and you have saved a lot of money by being ultraconservative, then I would look at paying my debt down."
Although the Federal Reserve System has been taking actions to promote lending, physician practices cannot count on finding a lender if they experience a cash crunch, Crawford says. "You do not want to pay debt off, then something does not go right, and you go back to the banks and the banks are not lending. Then you do not have access to capital and that can kill your business."
"You have an interest-free period for 24 weeks, which is fantastic. It is probably one of the best gifts that the U.S. government has ever given. If you follow the rules, such as spending 60% of your funds on payroll, and you get the loan forgiven at the end of 24 weeks, it is a home run," he says.
Even if a physician practice cannot get a PPP loan forgiven, the debt terms are a bargain, Crawford says. "If you can't get the loan forgiven or you can't pay your rent, it is an inexpensive loan. It is a 1% interest rate loan. So, it may make sense to do the 30-month payback and carry the loan if you can't financially afford to bring your staff back."
For physician practices that have gotten PPP assistance, the funds should be kept in a dedicated account to pay for program-approved expenses such as payroll and rent, he says. "When a practice pays for insurance or pays for payroll, they should reimburse out of the separate PPP account for the exact, specific payments. If they are making specific payments for rent, insurance, or payroll, they will have the proof for the bank and for SBA that the PPP funds were used for the purposes outlined."
PPP has been a lifeline for the Brownsville, Texas–based general surgery practice of Carlos Barba, MD. The cancellation of elective surgery in Texas hit the practice hard, Barba says.
The general surgery practice has a 10-member staff, including another surgeon and a physician assistant. "Fortunately, the federal government created the small business assistance program. We applied to that program, and I was able to get a loan. I did not have to reduce hours or cut my staff," he says.
4. Apply for private loans
Lending from banks and brokers also can stabilize a physician practice's finances, Crawford says.
Bankers Healthcare Group has established an "assistance loan" that ranges as high as $500,000. Borrowers do not have to make a payment on the loan for the first 89 days.
The terms of the assistance loan can be crafted to limit the size of monthly payments, Crawford says.
"We are giving the medical professional a term that goes out as long as 10 years. For the borrower, the additional years lower the monthly payment. In my opinion, right now everything is about the monthly payment. If you can lower the monthly payment, increase your savings, and decrease your spend, you have a much better shot of getting the business back to running well," he says.
Primary care payment reform
Reimbursement for primary care services must be reformed, Greiner says.
"This pandemic has laid bare that fee-for-service has been an epic failure. It is a system that is based on face-to-face visits, which obviously does not work in a pandemic when you are trying to keep both patients and clinicians safe. So, the pandemic has prompted a lot of conversation both at the national level and the state level about moving to a prospective payment system," she says.
During the pandemic, the Centers for Medicare & Medicaid Services (CMS) as well as private health plans have moved in the right direction on advance payments, Greiner says. "What both CMS and private health plans have done by putting advance payments in place is help primary care practices keep their doors open. That could be a step on a path toward prospective payments, but this is a conversation that has been going on for a long time."
In addition to establishing a prospective payment system for primary care, government and private payers need to provide significant and appropriate reimbursement for innovative care delivery models such as telemedicine, she says. "We have to get to a payment system that is agnostic about the way care is delivered."
From 2009 to 2018, hospital electronic health records met basic safety standards less than 70% of the time, researchers found.
Much work remains to be done to fully realize patient safety gains from electronic health record (EHR) systems, recent research indicates.
In 1999, the landmark patient safety report To Err Is Human: Building a Safer Health System estimated that 98,000 patients died annually due to medical errors in hospitals. The Institute of Medicine report said that medication errors were the most common preventable harm and called for adoption of EHRs with computerized physician order entry and clinical decision support to improve patient safety.
The recent research, which was published by JAMA Network Open, examines EHR data from 2009 to 2018 collected at more than 2,300 hospitals.
"These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems," the research co-authors wrote.
The researchers assessed computerized physician order entry and clinical decision support data collected through The Leapfrog Group's annual Leapfrog Hospital Survey. The data features information from the survey's computerized physician order entry EHR evaluation tool, which simulates physician medication orders and exposes error rates. The study targeted whether a hospital's computerized physician order entry EHR system produced an alert or stop after a simulated order that could result in an adverse drug event.
The researchers generated several key data points.
The overall mean total score for computerized physician order entry EHR systems rose from 53.9% in 2009 to 65.6% in 2018. In other words, EHRs met basic safety standards less than 70% of the time.
The mean score for basic clinical decision support rose from 69.8% in 2009 to 85.6% in 2018.
The mean score for advanced clinical decision support rose from 29.6% in 2009 to 46.1% in 2018.
Drug-allergy was the highest performing category, with the mean score rising from 92.9% in 2009 to 98.4% in 2018.
Drug-diagnosis contraindications were the lowest performing category, with the mean score rising from 20.4% in 2009 to 33.2% in 2018.
A hospital's EHR vendor accounted for 9.9% of performance variation.
"We found that overall safety performance increased modestly, while the number of institutions taking the test has increased 10-fold. Improvements in basic clinical decision support were far greater than in advanced clinical decision support, consistent with other studies," the researchers wrote.
Creating safe EHRs
The researchers suggest three ways to improve EHR patient safety performance.
1. Hospitals should conduct computerized physician order entry safety assessments at least annually and after upgrades. "Continuous assessments are also critical to identify unanticipated problems that may occur as systems are updated and customized," the researchers wrote.
2. The results of safety assessments should be shared with EHR vendors to spur development of safer systems.
3. Policy makers could include computerized physician order entry safety assessment scores in publicly reported process quality measures.
EHRs are a pivotal element in hospital patient safety, says Dawn Allbee, MA, executive director of customer engagement at the Oakbrook Terrace, Illinois-based Joint Commission Center for Transforming Healthcare.
"Leaders need to consider that the success of EHRs is an essential tool in their quest for zero harm. This includes optimizing EHRs to help keep patients and organizations safe. Patterns of errors and safety incidents need to be eliminated through the use of an orgnb anization's improvement tools," she recently told HealthLeaders.
At hospitals, a safe EHR is part of a broad landscape of patient safety efforts, Allbee says. "From our perspective, a safe electronic health record is one that is coupled with strong, understood processes for use across the organization. Having an EHR cannot take the place of extensive quality and improvement training that empowers employees as change agents."
The Joint Commission Center for Transforming Healthcare supports the use of the Safety Assurance Factors for EHR Resilience (SAFER) Guides released by the Office of the National Coordinator for Health Information Technology in 2014, she says.
The SAFER Guides feature nine guides organized into three categories.
1. Foundational guides: high priority practices and organizational responsibilities
2. Infrastructure guides: contingency planning, system configuration, and system interfaces
3. Clinical process guides: patient identification, computerized provider order entry with decision support, test results reporting and follow-up, and clinician communication
For seriously ill coronavirus patients, acute ventilator recovery units serve as a bridge between ICU care and acute rehabilitation facilities.
Northwell Health has opened two acute ventilator recovery units (AVRUs) to care for coronavirus patients who have been on ventilators for extended durations.
Many coronavirus disease 2019 (COVID-19) patients with acute respiratory distress require at least a week on a ventilator to support lung function while they recover from the illness. With immobilization required for mechanical ventilation, these patients need physical therapy once they are well enough to move and respond to commands.
AVRUs feature physical therapy while COVID-19 patients are being weaned off ventilators, says Mangala Narasimhan, DO, regional director for critical care at the New Hyde Park, New York-based health system.
"These patients are so behind the curve with long sedative times and long ventilator times that they need aggressive physical therapy to get back on their feet. To do that in ventilated patients is very difficult because most of the PT units that exist are for patients who are not on ventilators. Most acute rehab units want patients to be off a ventilator," she says.
On May 27, Northwell opened two AVRUs at Glen Cove Hospital in Glen Cove, New York, and Northern Westchester Hospital in Mount Kisco, New York. The AVRUs have a total of 27 beds and cost about $1 million each to equip. Most of the expense was associated with equipment such as monitors and oxygen systems.
"It took about three weeks from the thought process to actually opening, and that time was needed mostly for getting equipment installed and staffing in place," Narasimhan says.
The staffing includes hospitalists, pulmonary clinicians, respiratory therapists, physical therapists, and nursing. "Both units have a pulmonary team that is rounding on all of the ventilated patients," she says.
Acute ventilator recovery unit care
For most severely ill COVID-19 patients, Northwell expects its AVRUs will serve as a bridge between ICU care and discharge to an acute rehabilitation facility, Narasimhan says. "In the ICU setting, the focus is not necessarily on physical therapy and ventilator weaning—the focus is on survival and getting patients to a point where we are not hurting them with the ventilator such as reducing the oxygen. In the AVRUs, the goal is to get patients off ventilators."
Ventilated COVID-19 patients must meet three primary criteria for transfer from an ICU to an AVRU, she says.
Patients must have a tracheostomy for airway stability.
Patients must be hemodynamically stable. For example, they cannot be on vasopressors.
Patients must be able to participate in physical therapy—they must be awake and able to follow commands.
Each AVRU coronavirus patient has a tailored physical therapy regimen, Narasimhan says. "Some patients are just doing passive range of motion and trying to get their muscles strong. Some patients are doing active PT, where they are sitting up and standing. It really depends on where the patients are in that spectrum and how much muscle loss they have experienced."
The pair of AVRUs are expected to meet service demand at Northwell, for now, she says. "Whether we expand the program depends on whether we have a second wave of COVID."
