A health system's new AI tool is helping clinicians target the right specialist for a referral, prompt appropriate workups before a referral, and eliminate unnecessary referrals.
Providence health system has developed an artificial intelligence tool to help physicians manage patient referrals more effectively and efficiently.
AI technology is becoming increasingly prevalent in the healthcare sector. For clinicians, AI is being used in a range of applications, including clinical decision support, documentation, and radiology imaging.
Providence identified patient referral management as an AI opportunity and developed MedPearl as an AI product within the health system, says Eve Cunningham, MD, MBA, MedPearl founder and chief of virtual care and digital health at Providence. "MedPearl is a product that lives within Providence. It will probably become its own entity eventually. It has been built and incubated within Providence," she says.
MedPearl is designed to address three common scenarios in patient referrals, Cunningham says.
First, the patient can be sent to the wrong specialist. For example, if the patient has a chronic cough and they see a primary care physician, there are several specialists that the patient could be sent to such as a pulmonary doctor; an ear, nose, and throat doctor; and an allergy doctor. All of those specialists could potentially be appropriate for that condition, and sometimes the patient gets bounced around from specialist to specialist because they don't get to the right specialist at the beginning.
Second, the patient gets sent to a specialist and the specialist says they have to conduct lab tests and workups, then they will ask the patient to come back a second time. A lot of that work could be done on the front-end with the referral. It is common for primary care physicians not to know what workup the specialist would want. If the primary care physician could be given good information to optimize that workup before the patient sees the specialist, access to care could be improved because it can take months to see a specialist.
Third, about 20% to 30% of the time when patients see specialists, they do not need to see a specialist at all. There isn't anything for the specialist to do. If those patients could be kept with their primary care physicians, then the patients who really need to see specialists could see the specialists quicker.
All three of these scenarios are knowledge-sharing challenges in the clinician community, Cunningham says. "The reason why we have these missed opportunities is because we do not do a very good job of sharing knowledge with each other. We are not efficient at it. We do not have a great technology capability to share knowledge with each other in an impactful way that fits into clinician workflows and is easy to use."
Over the past three years, Providence has curated a knowledge bank of referral guides and algorithms to create MedPearl. The referral guides and algorithms have been validated with the clinicians who are using the information. MedPearl features information that is needed at the point of care.
"This information fits into clinicians' workflows, helps get through a patient visit, and helps identify all of the rules of engagement for the next best action for a patient you might need to refer to a specialist," she says. "We have about 600 guides and algorithms in this library. It constitutes about 95% of what a primary care physician does, so when they go into the knowledge base, they are getting what they need."
Generating results
Data shows MedPearl is having a positive impact on patient referrals at Providence.
"We have captured thousands of data points. We have captured search terms. We crowdsource new topics based on when providers are searching for the same thing over and over again," Cunningham says.
Providence conducted a pilot of MedPearl last year. More than 200 clinicians were involved in the pilot, and there were about 14,000 searches in the pilot period. The clinicians reported how the application helped them in their decision-making for referrals.
Twenty percent of the time, clinicians said they did not need to refer a patient to a specialist at all because they got the information they needed from MedPearl and they were able to manage the patient on their own. Seventy-two percent of the time, clinicians said that MedPearl reminded them to order a lab or MedPearl reminded them to start a patient on a first-line therapy before a patient was referred to a specialist. And 20% percent of the time, a clinician changed the specialty or level of urgency for the referral, which seized on the opportunity to make sure a patient did not bounce from one specialist to another.
MedPearl launched at scale in January 2023, and there are now 7,000 users of the AI tool at Providence. Search volume surpassed 150,000 searches this year, and the tool has achieved a 95% search success rate. Early data from 2023 indicates that clinicians have improved their productivity and there is a reduction in unnecessary referrals.
"The way I interpret the data is clinicians feel more confident now that they are using MedPearl that they can refer the patient more appropriately and work them up more appropriately," Cunningham says.
AI and chief medical officers
In adopting AI technology, the primary consideration for CMOs is their workforce, she says. "Their biggest concerns about doctors and clinicians are that they are burned out, there is a shortage of them, or it is difficult to recruit them. CMOs want to make sure that they have a supportive environment for clinicians. CMOs want to be innovative and forward-thinking when they are thinking about different ways of bringing in tools and applications that are going to help assist and augment clinician workflows. CMOs want to be strategic about the types of technology they bring in."
CMOs are the frontline advocates for their clinicians, and they often see problems and prioritize problems that executives in the information systems teams are not prioritizing or are not understanding, Cunningham says.
"When we started building MedPearl, I was the chief medical officer of one of the medical groups when we started identifying the referral problems and started building out the application," she says. "I had many conversations with the information systems team, and they did not understand why we were trying to solve referral problems and why it was such a priority for us. It was because we were living in different worlds to some extent, and we had to translate that for each other and come together with a common understanding."
As members of hospital administration, CMOs must consider the effort required to implement an AI solution, Cunningham says. They need to ask, is it going to scale and is it going to be adopted?
"One of the benefits of MedPearl in this respect is there is not a massive lift for the quality department or the information systems team. We have solved a real clinician pain point, with very little burden on a halo of other teams that must help implement the solution," she says. "In addition, there has been organic adoption. Doctors have talked to each other about the tool and it has caught fire. There was not a need for an internal marketing campaign or a push to get adoption. The tool works in existing workflows. It does not create new workflows. These are all things that CMOs must tick off a list that makes it worth engaging in change management."
UVA Health offers more than a dozen workplace violence resources on the health system's Situational Awareness Violent Event website.
A workplace violence initiative at UVA Health has increased reporting of workplace violence incidents and decreased care team member injuries related to workplace violence.
A recent survey found that 40% of healthcare workers had experienced workplace violence in the past two years. Workplace violence in healthcare settings has several negative consequences such as care team members suffering physical and psychological trauma, according to the survey report. Acts of violence can also disrupt patient care when care team members fear for their personal safety or are distracted by disruptive patients or family members, the survey report says.
UVA Health launched its Situational Awareness Violent Event (SAVE) initiative in 2016. "We have developed comprehensive resources that are available to all care team members through a desktop icon that can be found on any shared health system computer. That desktop icon brings team members to our SAVE website," says Ava Speciale, nursing governance clinical leader at UVA Health.
The staff members working on the SAVE initiative feature an interdisciplinary team. The team includes direct-care clinicians from inpatient and ambulatory settings, an employee health injury coordinator, the Behavioral Emergency Response Team (BERT) leadership, the behavioral medicine consult service, members of the UVA Health security and university police department, Office of Patient Safety and Risk Management staff, and emergency management leaders.
The SAVE website at UVA Health has a range of online resources:
A link that goes directly to UVA Health's workplace violence policy
Links to de-escalation training and other educational resources on workplace violence
A resource for complex behavioral challenges, which usually apply to inpatients, and the resource lists the different teams that can be involved in a complex care meeting
A de-escalation tip sheet
Standard work for the use of "stop signs," which are signs that are hung up outside patient rooms as a visual indicator for the potential for workplace violence
A standard operating procedure for setting flags in the electronic health record that can alert care team members to the potential for workplace violence by patients
A template document that goes with the EHR flags for ambulatory settings, so ambulatory setting staff know ahead of time that a patient is coming who has a flag for the potential for workplace violence, and the document walks team members through how to prepare for those patients
A visitor algorithm that gives care teams tools on how to manage challenging visitor behaviors
Standard work for obtaining a security assessment, which is conducted by UVA Health security staff for ongoing threats of violence
Tools on how to obtain a private security resource, with a description of the private security role and how to escalate performance concerns related to security
A link to the UVA Health Red Book, which is the health system's emergency management manual that has a section on workplace violence
A recovery process for team members, so if a workplace violence incident occurs, the process makes sure that leaders are offering team members resources for recovery
A link directly to the health system's quality reporting system, so a care team member can report a workplace violence event that has occurred
The SAVE leadership team meets monthly, Speciale says. "We have a lot of ongoing work, which includes producing resources and keeping resources updated. We assist with education, training, and presentations to care team members. We report up through our Safety and Security Subcommittee. We are always available on an ad hoc basis," she says.
The robust and comprehensive resources offered on the SAVE website allow team members to problem-solve on their own, but they have support, Speciale says. "When they hit barriers, the SAVE team leadership is available to assist."
Involving clinicians in SAVE
Physicians can avail themselves of SAVE resources, and they have played an active role in launching and maintaining the SAVE initiative, Speciale says.
"We collaborate with physicians. We have gone to some of their groups such as their quality conferences and clinical chairs meeting to present SAVE to our physician leaders, so they can make sure their teams are aware of our resources," she says. "One of our neurology physicians was a great partner in the efforts that started SAVE, including securing many of the resources that we have today."
Recently, the SAVE leadership team has had a graduate medical education resident participate in their meetings and workgroup. "She has helped bring back information she learned about SAVE to her colleagues to educate new interns and residents," Speciale says.
Including residents and interns in the SAVE initiative is important, says Lauren Mathes, a UVA Health clinic manager and co-chair of the SAVE committee. "As an academic medical center, especially with the residency program, we are excited to have the participation of residents because our residents are on multiple units. Because they cross several specialties and clinics, having their participation is great for our team," she says.
Workplace violence efforts beyond SAVE
UVA Health offers workplace violence prevention efforts outside of the SAVE initiative, Speciale says.
For example, in certain departments at the health system, care team members are required to take training that teaches them how to respond to a physical attack. This effort is focused on high-risk areas such as the emergency department.
The physical attack training features Crisis Prevention Institute training, which is common across many organizations, Speciale says. "Team members are trained on how to safely defend themselves if they are attacked. They are trained on physical restraint maneuvers if they need to administer a medication or respond to a situation where someone is physically violent."
As another example, BERT staff respond to workplace violence calls if there is an episode with a patient on a unit or at a practice environment that includes a behavioral health element, Mathes says. "In those cases, the whole BERT staff responds, including behavioral health emergency staff, security personnel, nursing supervisors, and local leadership from the unit or practice. They can help problem-solve those events in the moment. We also have a behavioral medicine team that works closely with the BERT," she says.
Generating results
At UVA Health, the SAVE initiative and other workplace violence efforts have generated positive results at a low cost, Speciale says.
"If you talk to anybody about workplace violence data, there is a challenge of under-reporting. Since we started having our data represented on our internal data portal, we have put a lot of effort into encouraging more reporting and reporting has increased. I have seen statistics from across the country that 80% of workplace violence incidents are unreported," she says.
There has also been a decrease in the number of workplace violence events that result in injury to care team members, Speciale says.
These results have been achieved at a modest cost, she says. "We have incorporated this work as part of our daily jobs. We have pulled together teams where the workplace violence work is part of their jobs, and we have extended that to our leaders, with an expectation to put the resources in place to prevent and respond to workplace violence. Because this is incorporated into our daily work, the costs are minimal."
Health system CMOs are adopting technology to reduce documentation burdens on their clinicians and improve workflows in the OR and other areas.
Health system and hospital CMOs are adopting a range of technology solutions to support clinicians.
They're focused on technology aimed at clinical documentation and other administrative burdens, which have been linked to clinician burnout and clinician dissatisfaction.
"Technology can help clinicians be more efficient, more compliant, and more integrated in our documentation, which allows us to provide coordinated care for our patients," says Carolyn Kloek, MD, chief medical officer of OU Health in Oklahoma. "Technology can become a huge enabler to allow doctors to put patients as the primary focus in their care and not always thinking about the documentation with half of their minds."
"When you are talking about documentation and technology, it is essential for patient quality and safety, which is a key part of what I do as chief medical officer," she says. "I also see technology as a way to help clinicians do their work more effectively and more efficiently. Technology can decrease clinician burnout and help clinicians to take better care of patients."
Technology is an intractable part of the modern care delivery model and needs to be on the CMO's agenda, says Benjamin Mansalis, MD, senior vice president and chief digital and information officer, at IU Health in Indiana.
"Technology can be both an enabler and a source of friction," he adds. "A CMO who engages deeply in working with their technology partners will help shift the balance toward enablement and accelerate the value to both patients and caregivers."
OU Health recently implemented Epic as the health system's integrated electronic health record, Kloek says. That will be the base on which many new technologies and tools will be built.
"We are looking at AI and the clinical intelligence around automated documentation," she says. "There is also clinical decision support in AI that you can lay on top of your electronic medical record. There are algorithms that can help clinicians more efficiently interpret the EMR. These algorithms can present the more pertinent information—they can cull through the EMR and present information to the clinicians."
OU Health is putting building blocks in place to prepare for adoption of AI technology that will be designed to support clinicians, she says. They include Dragon and Nuance, which are specific to the idea of ambient clinical intelligence, which focuses on taking speech and turning it into electronic text.
"We have leaned into that aspect of Epic," Kloek says.
Technology reduces documentation burdens on clinicians
CMOs should be focused on technology that reduces documentation burdens on clinicians, Mansalis says.
"We have seen that technology has become more and more a part of the delivery of healthcare as we create documentation for necessary reasons for healthcare claims for the Centers for Medicare & Medicaid Services and commercial payers," he says. "Creating a record of the healthcare interaction has become an important part of our billing and payment cycles. The art of medicine and the time and space that clinicians need to create therapeutic relationships has been at odds with the need to create documentation of what happens between a patient and a clinician."
Technology that supports documentation is a key component of establishing a therapeutic relationship by removing the burden on clinicians as much as possible. This includes leveraging generative artificial intelligence and large language models, which are particularly good at summarizing and creating clinical documentation that meets the requirements for payments and billing, Mansalis says.
"We are seeing a lot of advancements," he says. "We went from scribes in the exam room typing what the doctor says to create a note to leveraging generative AI models that create the note. A human checks the AI model notes for quality assurance. Now, we have fully automated solutions that provide documentation support for clinicians, so they can focus on the most important aspect of their work, which is creating a therapeutic relationship with their patients."
Optimizing the EMR
IU Health has made improving the EMR to make it more user friendly for clinicians a top priority, Mansalis says. As part of this effort, the health system has invested $50 million in digital transformation technology.
In 2024, IU Health will be expanding a SWAT team program, consisting of a small group of analysts and chief medical information officers, to focus on the health system's Cerner electronic health record.
"The SWAT team will go to ambulatory primary care sites and hospital units," Mansalis says. "They will … talk with the physicians, nurses, frontline registration staff, and other care team members about the utilization of our Cerner electronic health record. They will coach … optimal use of the technology … [and] ask clinicians and other care team members about what they would like to see changed in the EHR to make it work better for them and their patients. We will take that information and use it to make modifications to make the EHR work better for the care teams."
An example of how the SWAT team has already improved the EHR can be found at the Riley Hospital for Children's Pediatric Intensive Care Unit. The SWAT team noticed that it was hard for clinicians and nurses to quickly identify when a PICU patient was deteriorating. They noted that important information contained in the monitoring equipment, such as data on arterial lines and ventilators, wasn't getting to the clinicians and the nurses through the EHR.
"We worked with a company to integrate information in the PICU's monitoring equipment using a tool to capture the monitor information at a high level of granularity," Mansalis says. "The tool runs a machine learning model on the information to determine whether the patient is getting better or the patient is getting worse based on about 20 parameters. It allows nurses to triage patients more effectively and bring in clinicians quicker when a patient is deteriorating."
Clinician technology beyond documentation
IU Health is using several technological solutions to support clinicians beyond documentation.
For example, Rad AI, an imaging prompting tool, helps radiologists comb through massive queues of X-rays, mammograms, and other medical images.
"These kinds of products scan the images, look for things that the radiologist would typically document, then create a prompt and a note for the radiologist based on what would be commonly written to describe the findings in the image," Mansalis says. "This is an assistive capability. Sometimes we find that these imaging tools have a greater sensitivity than a clinician alone. So we are providing greater sensitivity and specificity in our imaging assessments. We are also able to move through more images, so our productivity increases."
The health system is also using Artisight video camera technology in operating rooms.
"We are using this computer vision tool to look at surgeries as they are occurring with an AI capability that helps train physicians in new procedures," Mansalis says. Artisight can evaluate the surgery and provide documentation on open and close time. It helps our physicians who are training residents to learn new procedures and to have feedback to help them achieve the best practice."
Healthcare organizations need to remove access barriers, help patients address financial challenges, and promote care coordination.
When it comes to patient experience hurdles, one of the most vexing challenges for healthcare organizations is when patients struggle to see their providers.
Patients encounter difficulty when trying to schedule timely appointments, run into barriers paying for their care, and face predicaments in care coordination. All these problems detract from the patient experience.
When we think about why it is so difficult for patients to see their providers, it is often because healthcare organizations have made the process difficult, says Laura Pickett, vice president and chief patient and family engagement officer at IU Health. "Patients have been clear with us about what they want. They want us to listen, they want us to partner with them, and they want us to connect with them. But the way we have grown up in the industry does not allow for those things to happen," she says.
So what can healthcare organizations do to help patients?
The primary barriers that make it hard for patients to follow through on seeing their providers are access gaps and long wait times, Pickett says. "With long wait times and trying to be everything to everyone, it is causing a headache in the industry. We need to think about how we can get patients in more expeditiously, which is on the mind of every patient experience officer across the nation," she says.
The long wait times have been accelerated by the COVID-19 pandemic because there are many patients who put off care during that time, and healthcare organizations are trying to catch up with them, Pickett says. The solution is to get back to a proactive state of health rather than a reactionary state. Healthcare organizations need to focus on reaching out to their patients to fill care gaps, she says.
Access is working against healthcare organizations in getting to see their patients. When access is a barrier for patients, they have options for seeking care such as going to an urgent care center outside of their established healthcare organization. "If a patient has to wait a long time to see their established provider, they can select a different option that is in the market," Pickett says.
Healthcare organizations should leverage the voices of patients and families to identify the actions where they would assign value in addressing access gaps and long wait times, she says.
"From that research, we should then act. At IU Health, we are researching this now, so our strategy is built from patient insights and we're addressing the areas within access that have high perceived value to those we serve. Anticipating the research findings, a hypothesis might be: We expand or co-design methods of care delivery (can a patient appointment occur virtually or by phone?) to mitigate access gaps, or for wait times, we can better manage expectations transparently and focus the patient and family on our next step together and what to expect so the patient feels progress. Excellent service and quality delivery can mitigate the stress of a wait time," Pickett says.
Another issue that keeps patients from keeping their follow-up appointments is patients live dynamic lives that change, she says.
"Our industry as a whole does not have mechanisms to react and support change in the moment. For example, if a patient has waited for six months for a follow-up appointment with a dermatologist, and on the day of the appointment the patient wakes up with a sick child in the house, the patient needs to stay home with their child. The patient may not be able to interact with their provider and get another appointment quickly. The provider is not in a position to respond to the life changes their patient may have happen outside of their healthcare needs," Pickett says.
Healthcare organizations can better serve the dynamic lives of their patients and families by considering Plan B and Plan C for them in the event of a shift and offering those options to steep care in patient-centered flexibility, she says. "In essence, we must become less static and more empathetic in acknowledgement of the holistic patient life, not simply the appointment that day.
In the case of the example of a sick child on the day of an appointment, it would be important to engage the patient, Pickett says. "Envision an engagement where a response could be: 'We were looking forward to caring for you. You're important to us and we understand life changes in unforeseen ways for our patients. May I offer you rescheduling options so you can be focused on your sick child? Is there anything we can do to support you in your child's care given she isn't feeling well?'"
Addressing financial barriers
A major reason why patients do not see their healthcare providers is financial considerations, Pickett says. "Cost is a major factor. We have a lot of patients and families in communities across the country who are making difficult choices. Do they get the medicines they need, or do they feed their family? Those decisions can determine whether they can utilize a healthcare provider or not utilize a healthcare provider," she says.
Healthcare organizations can help their patients clear financial hurdles, Pickett says. "At IU Health, we want to ensure that we are competitive from a cost standpoint. Secondarily, you have to consider whether you truly know your patients and whether you know what their barriers might be. There are financial assistance programs, and our access program works closely with patients and families to find a plan that might work well for them financially," she says.
A specific way that healthcare organizations can help their patients navigate troubled financial waters is to assist with understanding government payer programs, Pickett says. "Some of our government payer plans have preventative services that are included in the payer plans. So, it is important to have proactive outreach when patients may consider choosing us to let them know that services may have low or no cost. For example, with Medicaid, we can help with education that can enhance a patient's ability to access us," she says.
Improving care coordination
The primary challenge for patients within care coordination is that healthcare providers are fragmented, Pickett says. "Communication among and between even team members employed by one organization does not always make the care coordination process seamless for the patient or the family. The challenge is even larger if a patient receives care across several organizations," she says.
The solution is to put processes in place that improve communication between team members. Case managers, care navigators, and nursing staff can play a key role in these efforts.
From Dec. 11 to Dec. 15, HealthLeaders celebrates patient experience week with in-depth coverage and digital resources to help you foster a positive patient experience at your organization.
HealthLeaders is offering exciting content to celebrate Patient Experience Week!
Providing a positive patient experience is a top goal for healthcare providers. Patient Experience Week content will share insights and solutions to help healthcare providers attain their patient experience goals.
The content for Patient Experience Week will include top patient experience articles:
Patient experience is crucial to the success of Hospital at Home. Find out how UMass Memorial Health is aiming to make a two-year-old program sustainable by giving patients what they really want: care at home.
In content from HealthLeaders Intelligence Report, "Reengaging the Patient Clinical Experience," learn about what healthcare leaders are saying about patient experience at their organziations.
Patient Experience Week content will also include two podcasts:
Listen to a chat with Rick Evans, senior vice president and chief experience officer at NewYork-Presbyterian. As patient experience gains new meaning and value in a patient-facing healthcare ecosystem, Evans is focused on understanding what patients want and what the health system can do to meet those needs as well as making every interaction meaningful for both patients and care teams.
Listen to a conversation with Arianna Urquia, vice president and CFO of Nicklaus Children's Hospital in Coral Terrace, Florida, about how the hospital has utilized technology in their revenue cycle for a more efficient patient experience.
Patient Experience Week will also feature a downloadable eBookon technology and patient experience. The eBook has three focal points: see how technology in patient experience is a strategy, not a crutch; find out how Denver Health is using customer relationship management tools to forge better patient relationships; and learn about using "inbox ninjas" to close nagging gaps in primary care.
HealthLeaders is delighted to publish this content to celebrate Patient Experience Week to help ensure the success of your healthcare organization.
Children with complex medical needs represent more than half of all hospitalized children and 82% of hospital days. A new medical group aims to change how their care is delivered.
A new medical group has taken an innovative approach to care redesign to serve Medicaid-eligible children with medical complexity and special healthcare needs.
Children with medical complexity make up less than 1% of children in the United States, but they represent 56% of hospitalized pediatric patients and 82% of hospital days in children's hospitals. Children with medical complexity represent just 5% to 6% of children covered under Medicaid, but they account for approximately one third of Medicaid expenditures on pediatric patients.
Imagine Pediatrics launched nearly a year ago with a virtual-first care model that provides care and support services to Medicaid-eligible children with medical complexity and special healthcare needs on a 24/7 basis. The medical group, which features a pediatrician-led multidisciplinary approach, does not replace a pediatric patient's primary care providers or specialists, but is geared to filling care gaps with a high level of access.
"We work in collaboration with their existing doctors and medical homes, so we are not replicating or duplicating care," says Patricia Hayes, MD, chief clinical officer of Imagine Pediatrics. "We bring an extra layer of support for these children.”
"Mostly, we are reinforcing the care plans and meeting these families where they are in their homes virtually," she says. "We address care gaps when a primary care team and specialists are not available. We find this is exceptionally helpful during off-work hours, weekends, and holidays, when these children and their families do not have any access to care."
In addition to its virtual-first care model, Imagine Pediatrics can dispatch paramedics with pediatrics training to the homes of patients. These paramedics offer a range of services, including IV antibiotics, IV fluids, testing for common illnesses, lab draws, and helping with hospital transitions of care.
The medical group is serving 20,000 patients in Florida and Texas, and has full-risk, value-based contracts with three health plans: UnitedHealthcare Community Plan of Texas, UnitedHealthcare Community Plan of Florida, and Superior HealthPlan, which is based in Florida.
"We are unique because we provide 24/7, integrated care delivered to Medicaid-eligible children with medical complexity and special healthcare needs," Hayes says. "Although they are a small percentage of the pediatric patient population, they account for an outsized share of healthcare spending. We are providing them with unprecedented access, when they have historically had limited access to primary care or specialty care."
These patients are frequent healthcare users, often requiring multiple hospitalizations or trips to the emergency room or urgent care clinic. As a result, their care is often fragmented and uncoordinated, leading to care gaps and unnecessary expenses.
Imagine Pediatrics aims to improve that care platform, coordinating care and reducing stress on hospitals and PCPs.
"We have the time, capacity, and access to provide these children with proactive care to keep them from having to have heavy emergency care utilization, which drives a higher cost of care and contributes to taxing an already taxed pediatric care system," Hayes says.
Imagine Pediatrics provides virtual care through multiple channels, including an app and telemedicine platform. The medical group's care team includes pediatricians, nurses, social workers, therapists, care team assistants, pharmacists, and dietitians, along with virtual care support for home health nurses at these children's bedsides, providing an extra layer of support for consultation services.
Providing care coordination
In working with health plans and their networks, the medical group's leadership team says they can work faster than primary and specialty care teams to make sure these families get what they need when they need it. This takes the burden off of PCPs, as well as health system CMOs who are called on to manage care for these patients when they end up in the hospital.
"We do a lot of the legwork and paperwork that it takes to get things done for these families," Hayes says. "We set up appointments for them. We expedite prior authorizations by working closely with their health plans to get them medications, procedures, or equipment."
In many cases, Hayes says, Imagine Pediatrics is in daily contact with patients and their families.
"The idea is to identify gaps and fill them before an emergency situation arises," she says. "We also make sure that everything we do gets communicated back to the primary care teams, so we are all on the same page."
"We do not want to provide care coordination in a bubble and exclude the primary care team," she adds. "We are reinforcing the care plans of the primary care teams and specialists, so these families stay on track and get the support they need. We don't want these families to get into a situation that could have been avoided."
Generating results
Over the past 10 months, the medical group has measured a 15% reduction in inpatient admissions and 20% reduction in total cost of care among engaged pediatric patients.
Patient and family engagement is crucial in reducing inpatient admissions, Hayes says.
"Just in the 11 months that we have been live, we have conducted more than 50,000 care interactions," she says. "That includes virtual visits, in-person visits, and digital messaging through our app. We get ahead of the curve for these families. We are proactive. We are making sure these children stay healthy at home."
Hayes says this strategy helps the medical group reduce total cost of care.
"We try to stay ahead of things, try to prevent unnecessary utilization of emergency care, and try to improve the healthcare experience of these families," she says. "We also try to improve the experience of these patients' primary care team."
With the federal government starting to shape guidance for AI, healthcare organizations are forging ahead with the technology.
Artificial intelligence will take hold in healthcare in 2024, a pair of chief medical officers say.
President Joe Biden recently made an executive order on AI to promote the safe, secure, and trustworthy use of the technology. While the executive order did not provide details on healthcare guidelines for AI, healthcare executives expressed cautious optimism about the government's approach to the technology.
Looking ahead to 2024, healthcare is going to continue to see clinicians embrace and get more comfortable with AI to ease workflows, boost the flow of patient and provider data, and improve quality of care and outcomes, says Peggy Duggan, MD, executive vice president, chief physician executive, and chief medical officer of Tampa General Hospital.
"The important steel thread here is the 'why,' which for our physicians and team members at Tampa General Hospital is the delivery of the highest quality care possible," she says.
Clinical documentation is an example of a key area for AI adoption, Duggan says. There is a lot of work physicians do that is not value added but is required to advance care, so incorporating AI into documentation continues to offer an opportunity to free up clinicians to spend more time with patients and directly provide care, she says.
Managing data is another area where AI can boost healthcare, Duggan says. "It's critical that provider-level data flows freely, as well as patient and system-wide data, so AI will be able to help us identify more opportunities to improve patient care," she says.
In 2024, AI will be used more frequently to guide clinical decision-making, Duggan says.
"At Tampa General Hospital, we are already piloting data-driven technology that supports the proper choice of antibiotics and pathways that prompt when antibiotics can be decelerated," she says. "These are great tools to support our teams while ensuring that a large volume of data—especially at a large academic health system treating some of the most complex conditions—doesn't overshadow a salient data point, which could drive not only safer care but also the delivery of the right care at the right time."
AI is likely to make major advancements in healthcare next year, says Ghazala Sharieff, MD, MBA, corporate senior vice president and chief medical and operations officer for acute care at Scripps Health.
"We recently had a retreat with a two-hour session on AI. The radiologists are asking to use AI more as they are doing their diagnostic readings. Telemedicine made a big splash during the coronavirus pandemic, and AI is the next big thing for healthcare," she says.
"The trend in decreased Medicare reimbursement is not sustainable," chief medical officer says.
A 3.4% conversion factor reduction in Medicare's 2024 Physician Fee Schedule final rule will make a bad situation worse for healthcare providers, says Catherine "Mindy" Chua, DO, chief medical officer of Davis Health System.
The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by the Centers for Medicare & Medicaid Services. The new Physician Fee Schedule final rule will cut the conversion factor from $33.89 in calendar year 2023 to $32.74 in calendar year 2024.
The biggest financial impact of the conversion factor cut will be on health systems and hospitals, Chua says. "About three-quarters of physicians are currently employed by hospital systems. So, for most physicians who are employed at hospital systems, the conversion factor reduction is not going to affect them in their pocket. What it is going to affect mainly is hospital systems and health system-owned physician practices. It will also affect physicians in private practice and physicians at physician-owned practices."
Health systems and hospitals are taking a hit financially, but they are unlikely to pass along the conversion factor cut to their employed physicians' compensation, she says. "The trend in decreased Medicare reimbursement is not sustainable, particularly for hospitals that employ most of their medical staff. The physician fees are going to the hospitals to maintain the physicians they employ. We are not going to be decreasing what physicians are paid because Medicare is cutting our reimbursement—you are not going to keep physicians if you do that."
The conversion factor cut will pose a financial hardship for many hospitals, Chua says. "Hospitals are having to pay more for supplies and staffing. Many hospitals have negative margins, and the cost of operations continues to go up. Then you decrease one of the main sources of income for hospitals—physician billing—and it is not sustainable."
Hospitals may have to cut services in response to reduced Medicare reimbursement, particularly in rural areas such as those served by Davis Health System, she says. Rural community hospitals must provide certain services to serve their patients such as emergency care and general surgery. However, there are services such as oncology, pulmonology, and orthopedics that are not necessary to operate a rural health system, Chua says.
"The unessential specialties are important for our communities, so patients do not have to travel long distances for care. But for health systems like ours, if Medicare continues to make cuts, we are not going to be able to keep these service lines going," she says.
Targeting Medicare reimbursement reform
It is technically impossible for hospitals to maintain a negative margin and the conversion factor cut comes at a bad time, Chua says. "There have been a significant number of hospitals in small communities that have shut down over the past three years because of financial distress. The reduction in the Physician Fee Schedule conversion factor is only going to make the situation worse."
The American Medical Association has made reforming Medicare payments for physicians a top priority. According to the AMA, Medicare's physician payments have decreased 26% since 2001, when adjusting for inflation.
The AMA is on the right track, but Medicare reform needs to be broader than just addressing physician payments, Chua says. "We need to look at Medicare payment reform overall, and the Physician Fee Schedule is just a piece of that reform. We need to be pushing Medicare toward more value-based contracting, so hospitals can maintain their main priority, which is to take care of the sickest of the sick."
Value-based payments are superior to fee-for-service reimbursement, which still dominates Medicare, she says. "Fee-for-service incentivizes us to not provide quality care. It is a broken system. We must make some hard decisions and make some major changes in Medicare reimbursement. From all accounts, it seems that value-based payments are the way that health systems are going to improve quality and reduce costs."
Value-based payments incentivize health systems to move outside of the four walls of the hospital and help their communities to get healthier, which reduces dollars spent on healthcare, Chua says. "Value-based payments also give providers more time to address social determinants of health. They give us more opportunities and resources to engage patients," she says.
The West Coast health system has launched six initiatives to improve clinical care and boost its operating margin.
The chief medical and operations officer for acute care at Scripps Health has developed six facets of operational excellence that she calls the 6 "Rs."
With slim operating margins, hospitals must optimize operational capabilities to remain financially viable. Recent data from Kaufman Hall shows that hospital operating margins are slim but positive: The median year-to-date operating margin index increased from 0.9% in July to 1.1% in August.
Ghazala Sharieff, MD, MBA, corporate senior vice president and chief medical and operations officer for acute care at the San Diego-based health system, has taken a multi-pronged approach to promulgating these guidelines. They have been included in marketing updates, shared with about 300 supervisors and managers who serve on the health system's inpatient management team, parceled out to the health system's physician operations executive team and physician leadership academy, and embraced by the organization's board of directors.
"It has taken on a life of its own," she says.
The six Rs are as follows.
1. Retaining staff
Like many health systems across the country, Scripps has been grappling with workforce shortages, and staff retention has become a high priority for the organization, Sharieff says.
While a primary effort has been keeping pace with market-based compensation for healthcare workers, she says, workplace culture is equally important. Scripps has "Sprint Teams" that tackle challenges and initiatives through engagement with frontline care teams. Supervisors, managers, and chief operating executives are charged with maintaining a culture of openness and communication, and C-suite executives routinely round in the health system's five hospitals to promote visibility and engage healthcare workers.
"Retention is not just about money,” Sharieff says. “It's about making sure the staff feels they are part of the solution to our challenges.”
2. Reducing length of stay
Managing hospital length of stay is important for throughput and revenue purposes, Sharieff says. In one instance, a behavioral health patient has been an inpatient at one of its hospitals for more than 900 days because the health system has not been able to find another facility. As a result, that hospital bed has been tied up for nearly three years, limiting revenue that could have been generated from other patients using the room.
"We have been tying up a bed because there are no resources to turn to in the region or the state," Sharieff says.
To address that kind of problem, Scripps has launched several initiatives to reduce length of stay. The health system is partnering with skilled nursing facilities to move patients out of the hospitals when appropriate.
Scripps has a hospital initiative called 10-12-2. Physician orders should be written by 10 a.m. If appropriate, a patient should be home by 12 p.m. And the patient's room should be cleaned and ready to go by 2 p.m. If a patient needs an X-ray or tests, the hospital tries to expedite the imaging or testing so the work is done on that day prior discharge rather than making the patient come back the next day.
Scripps is also working with county officials to increase the number of behavioral health beds in the region, Sharieff says.
"Increasing behavioral health beds is not going to be a quick process because we have a lot of patients in-house that we cannot discharge because there is no one to take them," she says. "That is a national issue that we are dealing with."
3. Reducing costs and increasing revenue
There are simple ways to reduce costs, Sharieff says. For example, the health system was able to cut rental and maintenance costs by cutting down on the number of printers on campus.
The health system has also adopted cashless registers in its cafes, which has saved thousands of dollars, and is relying on frontline staff to find other cost savings.
"That is why we have the 6Rs, so staff can understand our focus and where we need to go," Sharieff says. "Otherwise, they would not have a good idea of our strategy. When I round at our hospitals, I see the 6Rs on bulletin boards, with action plans on what they can do to reduce costs and increase revenue. For example, some units have cut down on printing documents that are not necessary."
Scripps has launched several initiatives to increase revenue. For example, the health system, which is comprised of north and south regions, formed the North Region Surgery Optimization Team five months ago. This team has looked at several factors, including the best locations for surgeries, blocking surgeon time, rearranging surgeries so they are more efficient and back-to-back, and increasing the efficiency of operating room robots. As a result, the health system performed 5,000 more surgeries over the past five months compared to the same period last year.
"This not only generates more revenue but also improves patient experience," Sharieff says, adding that more efficient and timely surgeries benefit patients.
Other initiatives to increase revenue include boosting hospital throughput, pushing growth in profitable service areas that communities, strengthening partnerships in payer contracting, and advocating for an increase in Medi-Cal reimbursement, which has not increased in 10 years.
4. Repatriation
Scripps has focused on keeping patients in network, Sharieff says. During the pandemic, the health system did not have enough hospital beds to serve patients, and it lost about 20% of its patients. Since then, she says, Scripps has made substantial progress in repatriation.
"No. 1, these are our patients, and we want them back," she says. "No. 2, it is a matter of revenue. If we have patients who are our covered lives, we get charged more if they seek care out of network. We put a Sprint Team together around repatriation, and in 2023 less than 1% of our patients have been seeking care out of network."
5. Raising money through philanthropy
To support the health system's operations, Scripps has stepped up efforts to raise money through philanthropy, Sharieff says. The health system receives philanthropic support mainly from individuals, who are often grateful patients, and from foundations, and it raises an average of $40 million annually through philanthropy.
"Scripps was founded on philanthropy nearly 100 years ago, and it continues to be an important source of financial support, particularly during these challenging economic times," she says.
6. Reassessing and reimagining
The newest of the 6Rs is reassessing and reimagining, which was adopted late this past summer. These efforts are in their infancy, but Sharieff offers a couple of examples.
One idea is reassessing the value and timeliness of meetings. A one-hour meeting with 20 people that is not necessary takes away 20 hours of staff time that could be used doing other things such as rounding or having time to strategize.
Another example focuses on reimagining certain processes or tasks. Sharieff has looked at the assignments she gives to members of her team. For example, one staff member has been chairing the Pharmacy and Therapeutics Committee for 10 years. Sharieff wants to groom the next layer of leaders, so she is going to find a new person to chair this committee, which will allow someone else the chance to learn and the incumbent will have a chance to have more time to do other things.
"That is a simple example of reimagining and thinking about succession planning," she says.
Generating positive results
Pursuing the 6Rs has improved operations and bolstered the bottom line at Scripps, Sharieff says.
"We have had 5,100 more surgeries in five months. The repatriation numbers went from 20% out of network to less than 1%. We have saved millions of dollars with our pharmacy team, supply chain, support services, and consolidation of vendors. We have made progress on retaining staff—we are not paying as much for travelers such as traveling nurses," she says.
A pair of chief physician executives share how their health systems recruit and retain clinicians.
Health systems must adopt a multitude of recruitment and retention strategies for physicians and advanced practice providers (APPs), a pair of top clinical leaders at health systems say.
The physician employment market across the country is tighter than ever, with demand outstripping supply in many specialties. As a result, CMOs are turning to APPs to supplement their physician staff.
Eric Deshaies, MD, MBA, chief physician executive of AdventHealth Medical Group in Orlando, Florida, says AdventHealth's medical group wants to establish a reputation that will support recruitment efforts.
"Career development, mentorship programs, wellness programs, and putting physicians and APPs in the leadership of our medical group all send a strong message externally that this is a medical group that values our physicians and APPs," he says.
Deshaies and Ian Dunn, MD, chief physician executive and chair of neurosurgery at Oklahoma-based OU Health, say their health systems are pursuing nine recruitment and retention strategies for physicians and APPs.
1. Strive to be visible: OU Health takes an approach to recruiting physicians and APPs that is similar to how colleges recruit football players, Dunn says. OU Health makes sure the health system is visible to physician and APP candidates, with multiple physical and virtual touchpoints such as a robust social media presence, he says.
2. Gear workplace conditions for a multigenerational workforce: Health systems should offer workplace conditions that appeal to a range of generations, Deshaies says. For example, younger generations of physicians and APPs are looking for more wellness events, flexibility in schedules, and time off, he says.
3. Be competitive on compensation: To recruit and retain physicians and APPs, health systems must be competitive in compensation in their markets, Dunn says. OU Health is the only academic health system in Oklahoma, which means the health system must have competitive compensation relative to the community health systems in the state, he says. In metropolitan areas with several academic health systems, compensation for physicians and APPs tends to be similar at each of the organizations, he says.
Health systems should adjust their compensation for physicians and APPs on a regular basis, Dunn says. OU Health has redesigned physician compensation over the past year, and the health system is doing the same work with APP compensation. OU Health will be refreshing compensation on an annual basis, if not more frequently, he says.
4. Adopt assistive technology: AdventHealth is planning to introduce artificial intelligence technology that will make daily clinical operations more efficient and allow clinicians to be more efficient in clinics or hospitals, Deshaies says. This will help in functions such as dictating notes, ordering medications, and ordering imaging. The health system plans to use AI to make patient visits smoother and faster, while giving physicians and APPs more face time with their patients, he says.
5. Offer leadership opportunities: the AdventHealth Medical Group has changed its governance structure to give physicians and APPs more opportunities to participate in administrative leadership, Deshaies says. The governance restructuring includes the creation of triads featuring physicians, APPs, and business executives across different specialties. The triads not only give clinicians a stronger voice at the leadership table but also promote value, he says. The medical group triads have quality represented by clinicians and cost control represented by the business executives, he says.
6. Make your health system stand out: To recruit and retain physicians and APPs, health systems should try to stand out compared to other organizations, Dunn and Deshaies say. OU Health promotes its academic focus and deep subspecialty expertise, Dunn says.
"Our physicians and APPs embrace our mission," he says. "It distinguishes the clinicians at OU Health—most of them have faculty appointments at the college of medicine or the college of nursing, in the case of some APPs."
The AdventHealth brand, which includes whole-person care, is attractive to many physicians and APPs, Deshaies says.
"This is particularly the case with Millennial and GenZ clinicians, who are looking for a work-life balance and looking for wellness," he says. "That is in alignment with our whole-person care."
7. Ensure that physicians and APPs enjoy their work: Once a health system has recruited a physician or APP, the organization should strive to make sure the clinicians enjoy their work, Dunn says. This factor is not always about metrics, compensation, or titles. Health systems should make sure that a clinician's job is doable with a favorable work-life balance and that clinicians have adequate resources. Examples of resources include medical assistants and patient service representatives as well as clinical support teams for surgeons, he says.
"What a transplant team might need is going to be different from what an oncology team might need," he says. "But we want to understand the resources that our teams need."
8. Promote retention at academic health systems: OU Health promotes retention of physicians and APPs by making sure they benefit from the opportunities of working at an academic health system, Dunn says. Physicians and APPs at the health system have an opportunity to provide advanced care to complex patients. In addition, clinicians can engage in education and research activities, he says.
"Beyond the clinical work, clinicians can grow in other dimensions," he says.
9: Encourage retention of APPs with educational programs: AdventHealth is promoting retention of APPs with a "transition-to-practice" program, Deshaies says. When APPs are recruited, they are paired with a preceptor, and they have training and coursework. The physicians help train the APPs, who have competency exams similar to what they would see in a residency program. The transition-to-practice program helps to reduce the initial stress of coming to a new organization right out of school and boosts retention, he says.
"APPs are not overwhelmed, then looking to leave a couple weeks later," Deshaies says.
