Clinicians can avoid ethical and liability concerns by exercising good judgment and placing limits on provision of care.
When treating family members, friends, colleague, or themselves, ER physicians face ethical, professional, patient welfare, and liability concerns, a recent research article shows.
Similar to situations arising in the treatment of VIP patients, ER physicians treating loved ones or close associates may vary their customary medical care from the standard treatment and inadvertently produce harm rather than benefit.
"Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician," the authors of the recent article wrote in American Journal of Emergency Medicine.
There are several liability concerns for clinicians, the lead author of the article told HealthLeaders.
"Doctors would be held to the same standard of care as for other patients, and if care is violated and leads to damages, they could be liable. Intuitively, family and friends might be less likely to sue but that is not true of subordinates. In addition, as we state in the paper, for most ED physicians, practice outside of the home institution is not a covered event by the malpractice insurer," said Joel Geiderman, MD, professor and co-chairman of emergency medicine, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles.
Hospitals also have liability concerns, he said. "In California and some other states hospitals cannot directly employ doctors or control their practices. However, if they have policies in place and negligently allow rules to be violated, they could be liable."
Ethical entanglements
ER physicians who care for loved ones, colleagues, or themselves encounter a range of ethical concerns:
Autonomy: An ER patient seen by an ED physician loved one or colleague may feel reluctant to express a free choice regarding provider or treatment.
Beneficence: A clinician has a duty to provide benefit to patients and guide patients to the most qualified physician.
Nonmaleficence: In treating loved ones and colleagues, clinicians should not practice outside the limits of their training and abilities.
Objectivity: Loss of objectivity is often the most daunting problem when ER physicians treat seriously ill loved ones and colleagues, with not only risk of harm to the patient but also the clinician if there is a negative outcome.
Practice guidance
Geiderman and his co-authors offer nine recommendations to limit concerns when ER physicians treat themselves and patients with whom they have a close relationship:
Recognize the ethical, medical, and psychological considerations when treating loved ones and colleagues
In all emergency situations, provide care until another clinician is available
In general, risks are low when conditions are minor and episodic, and the possibility of failure is low
Know the legal requirements and limits in your state, local, and professional jurisdictions
If requested, give advice about other provider options
It is generally acceptable to honor requests for help reviewing laboratory and imaging reports as well as interpreting physician orders
Offer questions that the patient can ask the physician of record
Encourage second opinions when the patient is uncomfortable with care
ER physicians should lobby their professional associations to set policies for treatment of themselves, loved ones, and colleagues
It is challenging to set firm guidelines between minor and major conditions, particularly under emergency circumstances, Geiderman said.
"It is hard to be exhaustive. Ear aches, sore throats, simple wounds, and sprains are obviously minor. Long-term care and invasive procedures or life-threatening events like a rapid arrythmia or shock should be avoided. Physicians should exercise good judgment."
Artificial intelligence and natural language processing have the potential to boost patient safety.
A million-dollar partnership between University of California San Francisco and The Doctors Company is set to explore the intersections of digital health and patient safety.
The shift from paper-based information systems to digital formats has generated reams of information that has the potential to augment clinical judgment and improve patient safety with digital health tools.
"Artificial intelligence and algorithms can be used to help physicians and nurses select the right assessment information to gather and guide selection of medicine or therapy," Kerin Bashaw, senior vice president of patient safety and risk management at The Doctors Company, told HealthLeaders this week.
"The evidence indicates that—on the whole—we are practicing safer care because we have digital tools in place," Julia Adler-Milstein, PhD, an associate professor at UCSF School of Medicine, told Healthleaders.
The partners are well-matched, Bashaw said. "The Doctors Company is a leader in medical malpractice, so we have been a thought leader in patient safety, and UCSF is a leader in medicine and medical education."
"Malpractice claims are the ultimate data when things have gone wrong," Adler-Milstein said. "This allows us to try to help solve the problems that involve high patient risk, where there is actual harm. That is data that is very hard to come by."
Digital health safety opportunities
Bashaw and Adler-Milstein said artificial intelligence (AI) is presenting several opportunities to improve patient safety.
Using natural language processing (NLP) to review clinical charts from the previous day to check for omissions in patient assessments
Using AI to review notes and predict risk of harm
Using technology to boost clinical documentation with chart reviews, information integrity, and diagnosis support
Designing digital tools that accommodate the complexity of care but also support the ways teams communicate and interact with each other
Embedding AI algorithms into frontline clinical decision making
Limits of artificial intelligence
Technology is not going to replace physician judgment, Adler-Milstein said.
"We'll probably never get to a state where we would rely wholly on algorithms. There is always going to be a combination of algorithmic input and clinical judgment. We are not headed toward a healthcare system where we won't have doctors anymore."
It's crucial to strike the best balance between clinical judgment and incorporating an algorithm, she says. The key is weighing algorithmic evidence with all the other factors a clinician considers.
"If you think about the number of clinical decisions that are made today and how many have had input from artificial intelligence or an algorithm, we're probably at less than 1%. We are in the early days of finding ways clinical decision making can be supplemented or augmented with algorithms. Where you see it most often today is in image analysis; for example, detection of pulmonary embolism."
Providing home health services helps health systems and hospitals manage patient outcomes after hospital discharge.
Many health systems and hospitals across the country are either fine-tuning their existing home health capabilities or integrating new home health capabilities into their organizations. The reason why?
Home health services can play a key role in containing cost of care. For example, hospitals and health systems can deploy home health services to avoid financial penalties under Medicare's Hospital Readmission Reduction Program for a half-dozen conditions including heart attack, pneumonia, and coronary artery bypass graft. Beyond the HRRP penalties, readmissions increase total cost of care.
Dan Dietz, president and CEO of Milford, Ohio–based CHI Health at Home, says providing home health services can drive several clinical and financial benefits at health systems.
"We're providing home health, hospice, home infusion, and home respiratory care. All of those services have the ability to help health systems improve the quality of health for their patients, reduce readmissions, and decrease length of stay," he says.
CHI Health at Home also provides services that help reduce utilization of healthcare services, Dietz says. "We have a program where we do emergency department avoidance. So, if a patient shows up at the ED, we will admit directly from the ED into home health, and hopefully avoid a hospital admission."
There are several recent examples of CHI Health at Home generating positive results for its corporate parent, Chicago-based CommonSpirit Health:
Quality outcome: In data collected from April 2017 to March 2018, improved medication management for CHI Health at Home was 78.6% compared to the Centers for Medicare & Medicaid Services national average of 66.7%.
Hospital readmissions: CHI Health at Home's Avoiding Re-hospitalization through Care at Home (ARCH) program uses a predictive algorithm to identify and place patients into the ARCH program based on the risk of readmission once patients are receiving home health services. In 2018, ARCH reduced the 30-day hospital readmission rate from 14.3% to 13.3%.
Length of stay: CHI has helped several hospitals reduce length of stay through its Care Coordination Model. From May 2016 to December 2017, Jewish Hospital in Louisville, Kentucky, achieved a 4% decrease in length of stay through the care coordination program.
"We're tracking all sorts of data points—quality outcomes, patient satisfaction, patient engagement, as well as operational performance measures. Eighty percent of our locations have four-star ratings or greater with the Centers for Medicare & Medicaid Services. We currently have three locations within our organization that are at five stars, and none are below three-and-a-half stars," Dietz says.
CommonSpirit was formed earlier this year in a merger of Catholic Health Initiatives and Dignity Health.
At health systems, there are two primary models for providing home health services, he says. "If you're going to do this right, you either integrate fully with a health system or health systems develop a narrow network of home health providers."
1. Wholly owned approach
The full integration model helps health systems harness data, Dietz says.
"We became part of Catholic Health Initiatives in 2010. We brought on the individual markets to a national platform; so, we have one EMR. We can track every location for quality results, patient satisfaction, growth, and patient experience. We can scorecard those metrics across our entire footprint."
Capturing the benefits of scale are another advantage of the full integration model, he says.
"We believe in standardization—looking at best practices. As we have brought organizations onto our platform such as our 10 health system partners, we have adopted new best practices and extended them across the entire platform. We benefit from the size and scale in program development and clinical programs. Our scale also allows us to have a lot of specialty programs—if we were in one market, we would not have the ability to develop those programs," Dietz says.
For health systems, scale is an essential element for success in providing home health services, he says.
"There is value in the consolidation that we are seeing in the home health space across the market. Some of the benefits come from having a larger home health organization. If a health system just goes out and acquires a local homecare provider, they will eventually have to look for a larger partner."
Attaining large home health scale enables health systems to maximize home health capabilities, Dietz says.
"CHI Health at Home could not be doing the things that we are doing if we were only in one market. I might be able to pull off half of our activities—whether it's the clinical programs, or our expertise, or folks looking at data to help us develop solutions for health systems. There is value to scale in this business."
2. Narrow network approach
Establishing a narrow network of home health providers can work effectively at health systems, Dietz says.
"If a health system is not going to wholly own or partner with a home health organization on a formal basis, the second-best alternative is developing a narrow network of postacute care providers in which you can set some standards. The standards can be quality outcomes or how quickly patients are admitted to home care."
These narrow networks are mutually beneficial, he says.
"Home health providers are willing to adhere to requirements in order to be identified as a preferred vendor for a health system. When we talk with prospective health systems, the first question they typically will ask is about our quality scores."
Home health market evolution
The evolving healthcare market is putting a premium on home health services, he says.
"In the past two years, we have seen a much greater focus on home-based services and the importance of them. We have partnership programs with health systems outside of CommonSpirit. We are getting a lot more inquiries about partnerships because of executives seeing the value that home health, hospice, home infusion, and home respiratory care can bring."
New payment models are a primary driver of home health growth, Dietz says.
"It started with the development of accountable care organizations. You're seeing it with bundled payment models in the value that home services can bring. There's much greater focus on how to avoid an admission to a hospital. Home health can play a significant role to move that needle."
Diverting patients from emergency departments with telemedicine can save more than $1,500 per visit.
Telemedicine visits generate cost savings mainly by diverting patients away from more costly care settings, new research shows.
The primary market opportunity for telemedicine visits is the value proposition that they can both expand access to patients while also reducing costs compared to alternative care settings.
The new study is based on data collected from 650 patients who used the JeffConnect telemedicine platform at Philadelphia-based Jefferson Health.
"In our on-demand telemedicine program, we found the majority of health concerns could be resolved in a single consultation and new utilization was infrequent. Synchronous audio-video telemedicine consults resulted in short-term cost savings by diverting patients from more expensive care settings."
The cost of a JeffConnect visit was a $49 flat fee.
The bulk of the cost savings from the telemedicine program was generated in diverting patients from emergency departments. Each avoided emergency department visit garnered cost savings ranging from $309 to more than $1,500. Cost savings from other alternate care types was below $114 average savings per visit.
"The net cost savings to the patient or payer per telemedicine visit of $19 to $121 represents a meaningful cost savings when compared with the $49 cost of an on-demand visit. The primary source of the generated savings is from avoidance of the emergency department, as this is by far the most expensive of the alternative care options provided," the researchers wrote.
Offsetting increased utilization
About 16% of the JeffConnect patients surveyed said they would have "done nothing" as an alternative to a telemedicine visit—representing potential increased utilization of services. But cost savings outweigh possible higher utilization of services due to telemedicine's easy access, the researchers found.
"A substantial shift would be necessary to outpace the savings from diversion. Conversely, this population of patients who would have done nothing may represent improved access and incorporation of patients into the healthcare system that might not have participated previously. This might actually prevent more costly care further down the line."
Most women who die of cardiovascular disease during pregnancy or the postpartum period were not aware that they had cardiac conditions.
Recently released guidelines for cardiovascular care of pregnant women have the potential to achieve significant reductions in maternal morbidity and mortality. The guidelines, which are detailed in a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG), feature 27 recommendations.
Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions such as scarring, congestive heart failure, and exacerbation of congenital heart defects. From 2011 to 2014, cardiovascular disease was the leading cause of maternal mortality, according to the Texas Department of State Health Services.
"Cardiovascular disease is a major problem in obstetrics-gynecology," James Martin, MD, chair of the ACOG Pregnancy and Heart Disease Task Force, said during a May 3 conference call highlighting the new guidelines.
Cardiovascular care is critically important during and after pregnancy, he said. "The risk for cardiovascular disease can accelerate during pregnancy, and it can persist postpartum."
"There is a great need to follow-up with these patients and be very careful with postpartum care. As many as 40% of pregnant women do not return for postpartum care. That is a very sad statistic and reflects some of the need to change our payment models, so physicians and patients realize the importance of coming back for continuing care. If these patients have cardiovascular disease, it is likely to become worse during their lifetime."
Detection improvement needed
Screening for cardiovascular disease is another opportunity to reduce maternal morbidity and mortality, Pregnancy and Heart Disease Task Force executive member Afshan Hameed, MD, said during the conference call.
"The vast majority of mothers who die from cardiovascular disease either had undiagnosed cardiovascular conditions or had new onset of cardiomyopathy after their pregnancy. These are women who presented multiple times to healthcare providers for symptoms of shortness of breath, fatigue, or cough that were either dismissed or misdiagnosed," she said.
There is an urgent need to identify cardiovascular disease during and after pregnancy, Hameed said.
"We recommend screening all pregnant women and postpartum women to assess their individual risk for cardiovascular disease. This would allow for early diagnosis and treatment. … The overwhelming majority of women who die of cardiovascular disease during pregnancy or during the postpartum period were not aware that they had cardiovascular disease."
Team approach to care
Care teams should be assembled for women who are at risk of cardiovascular disease during and after pregnancy, Janet Wei, MD, said during the conference call. "A pregnancy heart team is multidisciplinary, with a minimum requirement of an obstetrics provider, a cardiologist, and—in moderate to high-risk patients—a maternal fetal specialist, and an anesthesiologist."
Pregnancy heart teams take a broad approach to care, said Wei, who is liaison for the American College of Cardiology on the Pregnancy and Heart Disease Task Force.
"The pregnancy heart team should have a comprehensive plan established for the pregnancy, delivery, and postpartum period. The plan should include the review of cardiac medication safety for the mother and the fetus, and the risk to the fetus from congenital and genetic conditions."
Top recommendations
The first 10 ACOG recommendations drawn from consensus and expert opinion feature advisories for maternal health as well as fetal and neonate care.
1. Knowledge: Clinicians should be familiar with signs and symptoms of cardiovascular disease.
2. Assessment: Ideally, a cardiologist should evaluate women with cardiovascular disease before pregnancy or as early as possible during the pregnancy for diagnosis, assessment of the effect pregnancy will have on cardiovascular conditions, risks to the woman and fetus, and treatment of underlying cardiac conditions.
3. Patient management: Women with cardiovascular disease risk should be managed through pregnancy and the postpartum period by a pregnancy heart team.
4. Patient engagement: Women with cardiovascular disease should be advised that pregnancy can contribute to a decline in cardiac status, risk of maternal mortality or morbidity, and fetal risks such as preterm birth.
5. Individualized care: To support the mother's decision making, the care team should take a personalized approach that accounts for maternal and fetal hazards linked to specific cardiac disorders and the patient's pregnancy plans.
6. Assessment tool: The California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit should be used to assess all pregnant women for cardiovascular disease.
7. Ongoing evaluation: A pregnancy heart team should conduct ongoing evaluation of all pregnant and postpartum women with known or suspected cardiovascular disease.
8. Testing protocols: For women with cardiovascular disease and symptoms such as shortness of breath, chest pain, or palpitations, testing of cardiac status during pregnancy and the postpartum period is warranted.
9. ECG testing: Pregnant and postpartum women with known or suspected congenital heart disease, valvular and aortic disease, cardiomyopathies, and a history of cardiotoxic chemotherapy should have echocardiogram examination.
10. Fetal testing: For women with congenital heart disease, there should be fetal echocardiography. Conversely, when congenital heart disease is found in a fetus or neonate, screening for parental congenital heart disease could be warranted.
Vision impairment poses multiple challenges for hospitalized patients, including the inability to perform simple tasks such as locating call buttons.
Vision-impaired hospital patients have worse clinical outcomes, more readmissions, longer length of stay, and higher costs of care than non-vision-impaired patients, recent research shows.
Vision impairment including blindness affects nearly 4 million U.S. adults, and the figure is expected to increase significantly with rising rates of macular degeneration, glaucoma, diabetic retinopathy, and other eye conditions.
Compared to hospital patients without vision impairment, the recent research found vision-impaired Medicare beneficiaries and patients with commercial health insurance had significantly higher healthcare utilization and costs during and immediately after hospitalization.
"Extrapolating these findings to older adults suggests that hospitalization of patients with vision loss is associated with excess estimated healthcare costs of more than $500 million annually," the researchers wrote.
The research features data collected from more than 12,000 patients with and without vision impairment. The study, which was published in JAMA Ophthalmology, includes several key data points:
Compared to hospital patients with no vision impairment, Medicare beneficiaries with severe vision loss had longer mean lengths of stay, 6.48 days vs. 5.26 days.
Medicare beneficiaries with severe vision loss had a 23.1% readmission rate, which was 4.4% higher than patients with no vision impairment.
Medicare beneficiaries with severe vision loss had 12% higher costs of care compared to patients with no vision impairment.
For older patients with vision impairment, the total excess cost of hospital care was estimated at more than $580 million.
"These findings suggest that identifying the presence of vision loss during hospitalization or the discharge-planning period and employing strategies to assist these patients may be associated with improved outcomes, fewer readmissions, shorter LOS, better patient satisfaction, and (if applied across the United States) a cost savings of more than $500 million annually," the researchers wrote.
Vision-impairment challenges
Vision-impaired hospital patients are not typically targeted for special attention, which contributes to negative consequences, the researchers wrote. "Empirical evidence suggests that persons with vision loss may have difficulty following hospital routines and, once discharged, may struggle to read discharge orders and medication instructions, which may result in poor outcomes."
Hospitalization pose challenges for vision-impaired patients.
Documents such as consent forms, preadmission protocols, and post-discharge instructions are often inaccessible to vision-impaired patients. Many healthcare organizations are ill-equipped to address the needs of vision-impaired patients such as providing documents in larger fonts or braille. In an earlier study, only 23% of physician offices and hospitals offered large-print documents.
In the hospital setting, simple tasks can be daunting for vision-impaired patients, the researchers wrote.
"Indicating food choices, locating nursing call buttons, or identifying support staff can be difficult for hospitalized patients with vision loss. Ambulation is generally desirable during hospitalization to reduce risk of venous thrombosis and pressure ulcers. Yet for many patients with visual impairment, ambulation requires assistance from someone to address possible obstacles in hallways and patient rooms, which may increase the risk for injuries."
Caring for vision-impaired patients
The researchers say there are several measures that hospitals can deploy to meet the needs of vision-impaired patients:
Patients should be evaluated during the admission process for their ability to read documents
Patients who are identified with vision impairment should receive a hospital bracelet similar to bracelets provided to indicate fall risk that alert staff members to the need for additional assistance
Visual impairment should be noted in the electronic health record to make sure proper accommodations are provided during hospitalization and discharge
Care instructions should be provided to patients in accessible formats such as documents with large-font text
Patients should receive referrals for eye-care follow up for newly identified vision impairment during hospitalization
"Although some costs may be incurred to make facilities and hospital personnel better equipped to care for these patients, the potential savings and improvement in quality of care may make this undertaking a good investment," the researchers wrote.
In this inpatient program, patients are weaned off opioid medications while participating in a wide range of therapy and coping skills training.
An inpatient chronic pain program for children and adolescents in New Jersey has been adopted by Rady Children's Hospital-San Diego.
More than 10% of hospitalized children show signs of chronic pain, and approximately 3% of pediatric chronic pain patients need intensive rehabilitation. The annual total costs to society to care for children and adolescents with moderate to severe chronic pain has been estimated at $19.5 billion.
In April, the Rady Children's inpatient program was launched in partnership with New Brunswick, New Jersey-based Children's Specialized Hospital. The RWJBarnabas Health children's hospital has had an inpatient program for children and adolescents with chronic pain for six years.
"The goal of our program is to increase function, decrease pain, and promote the use of adaptive coping skills so our patients can return to functioning lives. We work on reducing the use of pain medications—any pain medications but specifically opiates," says Katherine Bentley, MD, director of the pain program at Children's Specialized Hospital.
The chronic pain program, which is targeted at patients age 11 to 22, has generated positive results at Children's Specialized Hospital:
In a 2016-2017 patient survey, participants reported knowledge of their condition improved 81%, quality of life improved 41%, compliance with care improved 89%, and depression improved 57%.
A Children's Specialized Hospital outcomes report found that from admission to discharge patients' average pain level dropped from 6.6 to 3.9 on a 10-point scale.
"We evaluate the patient before they enter the program. We have an open and honest discussion—our program is a functional program where we use the body to get better as opposed to outside factors," Bentley says.
Treating chronic pain in children and adolescents
Broad scope has been the key to success of Children's Specialized Hospital's chronic pain program, Bentley says. "It's interdisciplinary and comprehensive."
The inpatient program offers a wide range of therapy and training in coping skills:
Physical therapy
Occupational therapy
Child, life, and recreational therapy
Meditation
Yoga
Aqua therapy, with pool activities and games offered five days a week
"We work on diaphragmatic breathing. We have biofeedback in our program, so patients can see the mind-body connection. We work on coping strategies. We work a lot on home exercise programs—for many people with amplified pain or who have a bad pain day, exercising is the best thing for them," Bentley says.
The inpatient program takes a sophisticated approach to weaning patients off pain medications, she says.
"What we do is develop a safe weaning schedule, but the great part of the program is weaning is not done in a vacuum. Patients get physical therapy, occupational therapy, coping strategies, and meditation. So, weaning is done in a safe way that is both physiologically safe and psychologically safe."
Allowing autonomy for advanced practice practitioners continues to be contested state by state.
At the beginning of this year, the National Commission on Certification of Physician Assistants predicted that the reform of scope of practice, supervision, and delegation of authority legislation would be a top trend regarding physician assistants.
The NCCPA's expectation seems to be correct as more states are pushing for legislation to expand scope of practice for advanced practice practitioners.
But expanded scope of practice for advanced practice practitioners has been contentious. Physician groups have insisted on medical-doctor supervision of advanced practice practitioners. For example, in 20 states, a physician must co-sign a percentage or number of physician assistant charts, according to the American Medical Association. In 39 states, there are limits on the number of physician assistants a physician can supervise or with whom a physician can collaborate.
However, advanced practice practitioners have been equally insistent on gaining expanded scope of practice across the country. For example, in several states, laws that expand scope of practice for physician assistants (PA), nurse practitioners (NP), and advanced practice registered nurses (APRN) have already been adopted.
Twenty-two states and the District of Columbia allow NPs to function in a "full practice environment," which includes evaluating patients, ordering and interpreting diagnostic tests, managing treatments, and prescribing medications.
Now the decades-long struggle over regulation of advanced practice practitioners is playing out in Rhode Island and Florida.
Efforts to change state law
In Rhode Island, legislation would allow physician assistants greater autonomy from physicians, with the creation of a more collaborative model. The legislation also would end physician legal liability for the work of physician assistants.
In Florida, Florida House Bill 821 and its Senate companion, SB 972, are moving through the state legislature and would grant expanded scope of practice to PAs and APRNs.
The Florida legislation would allow PAs and APRNs to work independently of physicians as long as they had not been disciplined in the previous five years, had accrued at least 2,000 clinical practice hours within a three-year period, completed graduate-level courses in pharmacology, and maintained specified levels of professional liability coverage.
However, the legislation is not expected to become law this year, says Deborah Gerbert, PA-C, co-chair of the Legislative and Governmental Affairs Committee at the Florida Academy of Physician Assistants.
The legislation has passed the Florida House, but it has not passed the state Senate and this year's legislative session is set to conclude on May 3.
"I never say never until the last gavel is put on the table, but the fact that it has not been heard at all in the Senate committees has been a deliberate block of the legislation by the chairman of the Health Policy Committee and the president of the Senate. They do not want this issue heard," Gerbert says.
If the state Senate does not pass the legislation this week, advocates of the scope-of-practice expansion would have to start over next year, she says.
Weighing educational requirements
Representatives of physicians and nurse practitioners have starkly different views on the proposed Florida legislation's clinical practice hour requirement.
Jay Epstein, MD, a practicing anesthesiologist and chair of the American Society of Anesthesiologists' Florida chapter Committee on Governmental Affairs, says the training of physicians is superior to the training of advance practice practitioners.
"I had to do 12,000 hours over a three-year anesthesiology residency. I then passed my anesthesiology boards to be board-certified in anesthesia, then I passed my boards in critical care medicine. So right off the bat, I had six times the clinical hours of this legislation's requirement," he says.
Epstein says the proposed Florida legislation should have more specificity about the level of clinical practice hours and the specificity of those hours.
"My 12,000 hours over three years were in the operating room, in the labor suite, in the pain clinic, in the intensive care unit, and in the cardiac catheter lab—wherever the patient required surgical or procedural sedation. Florida House Bill 821 does not define where those 2,000 hours are going to come from," he says.
However, Taynin Kopanos, DNP, NP, vice president of state government affairs for the American Association of Nurse Practitioners in Austin, Texas, says the proposed Florida legislation's clinical practice hour requirement is overkill.
"AANP believes that these requirements are unnecessary for safe practice by nurse practitioners and can impede direct access to patient care. We understand that some state legislators find that this is a political compromise option that they are willing to move forward from," Kopanos says.
"Nurse practitioners follow the literature on evidence-based outcomes and the evidence supports that care provided by nurse anesthetists is safe, high-quality care and the patients have the same outcomes as they do from physicians. So, the evidence on patient outcomes do not support that there is a difference in quality of care between the two providers," she says.
Addressing physician shortages
Part of Kopanos' argument for scope-of-practice expansion is that it could help ease the country's physician shortage, she says, making it essential for advanced practice practitioners to work independently of physicians and to bring their full knowledge and skill set to the treatment of patients.
PAs are widely viewed as part of the solution to the country's physician shortage.
"A clarifying point around this issue is the word independent. What we are looking at in Florida is whether it is legal for an NP to provide care to patients outside of a relationship with a physician. Right now, it is illegal for nurse practitioners to bring their knowledge and expertise to provide care to patients based on existing licensure laws," she says.
Kopanos says HB 821 and SB 972 are a step in the right direction to not only improve access to care but also focus on other challenges. "These bills are about making it legal for people to practice their profession and help address healthcare shortages and disparities, provide better choices, and address healthcare costs in the state."
However, Epstein says requiring advanced practice practitioners to work under the supervision of a physician is the safest way to help address physician shortages.
"APRNs and physician assistants working in a care team would be ideal. That is the model we have had for a long time in anesthesia, and it's a model that can be widely applied to other specialties. It gives you the benefit of the physician being present for preoperative optimization, intraprocedural care, and postoperative complication management," he says.
Epstein says supervision of advanced practice practitioners is essential for patient safety in acute care situations, making an analogy to the aviation industry.
"Things go quite wonderfully most of the time; but the minute there is a problem, you need the education, the background, and the experience to make critical decisions. We are always going to have a situation where physicians are needed to be available for immediate rescue. There are cases in the hospital that are less acute where we can start talking about broadening the supervision ratio to something higher than 1 to 4," he says.
Resolving the controversy?
Kopanos says states that have expanded scope of practice for advanced practice providers have shown that NPs, PAs, APRNs, and physicians can cooperate effectively and safely as equals.
"For example, there are networks in Washington state where pharmacy boards, nursing boards, physician boards, and their associations get together and craft legislation on how those providers who are going to write controlled substances manage them, and all of those providers are treated equitably," she says.
The struggle over scope of practice should be viewed as an effort to modernize licensure laws, Kopanos says.
"It really is incumbent on states to move forward with full practice authority. With 50 years of evidence for safe, quality NP care, this is not a turf war. This is about recognizing that healthcare has evolved and grown, and that NPs have expertise in health disciplines that can help address patient care needs in the country," she says.
However, Epstein says legislators should not take a one-size-fits-all approach to scope of practice for healthcare providers.
"As a first step, we should determine what is appropriate for a given situation because nothing is ever black and white, it's always gray. We should determine where it makes sense to use physician extenders without physician supervision or with limited supervision, or with full physician supervision," he says.
Patient safety should be the paramount concern, Epstein says.
"If we also start with the safety of the patient and what's in the best interest of the patient, we'll settle this controversy quicker. It will help turn down the heat on the discussion if we have a rational dialogue on differentiating between an acute care specialty like anesthesiology and the practice of other specialties in medicine like family practice, where the decisions are not as acute."
New research indicates incentives for clinician assessments of hospital-discharged skilled nursing facility patients should be strengthened.
At skilled nursing facilities, hospital-discharged patients who are not visited by a clinician are nearly twice as likely to be readmitted to a hospital as patients who receive visits, recent research shows.
About 20% of hospitalized Medicare patients are discharged to a skilled nursing facility (SNF). Readmissions have become a crucial metric for hospitals, with quality and financial dimensions. For example, Medicare has been penalizing hospitals financially for readmissions linked to several conditions such as pneumonia since 2012.
The recent study, published in Health Affairs and LDI Research Brief, found clinician visits to hospital-discharged patients at SNFs were strongly associated with readmission and mortality rates:
SNF patients who received at least one clinician visit had a 14.3% hospital readmission rate. SNF patients who received no clinician visits had a 27.9% readmission rate.
SNF patients who received at least one clinician visit had a 7.2% mortality rate. SNF patients who received no clinician visits had a 14.2% mortality rate.
The researchers examined data from more than 2 million Medicare fee-for-service SNF stays.
"Patients transitioning from hospitals to SNFs are often medically complex and at high risk of poor outcomes, with one in four of these patients deceased or re-hospitalized within thirty days. Results from this study suggest that missing and delayed care from physicians and advanced practitioners occurs during this vulnerable time," the study authors wrote.
Improving care at SNFs
Better incentives are needed to promote clinician assessments of hospital-discharged SNF patients, the researchers wrote. "Current regulatory and payment policies do not incentivize timely physician assessment of patients discharged from hospitals to SNFs. Medicare requires only that a physician complete an initial assessment within 30 days of SNF admission."
The lead author of the study, Kira Ryskina, MD, MS, told HealthLeaders that some new payment models are promoting enhanced SNF care. "Payment reform such as bundled payments that penalize hospitals for their patients' postacute care outcomes aim to encourage hospitals to invest more resources in SNFs."
Medical assessments of patients at SNFs generally feature three elements, she said.
"Typically, an effective assessment has an admission history including a review of medical records from the preceding hospitalization and medication reconciliation, physical examination, and delineation of plan of care," said Ryskina, an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine.
The primacy of online reviews in the marketing of medical practices is the 'new normal,' according to a recent survey.
Online reviews are playing a pivotal role in how patients pick their healthcare providers, a recent survey shows.
For clinicians, online reviews should be a primary concern for several reasons: review websites such as HealthGrades and Vitals are collecting information and posting it across the country, online reviews can be robust marketing tool, and reviews can help hone clinician performance.
"This is the new normal for medical practices in 2019. Choosing a doctor based on online profiles and patient reviews is the old word-of-mouth at today's scale and speed. Number of reviews, average star rating, and convenient hours and locations are essential 'shopping' details that patients expect to find before stepping foot into a waiting room," the recent survey's report says.
The survey, which features responses from more than 800 people about online reputation and patient reviews, generated several key data points:
74.6% of respondents had researched doctors, dentists, or medical care online
69.9% said a positive online reputation is very or extremely important in selecting a healthcare provider
51.8% of patients who had submitted negative online reviews about a medical practice had not been contacted to address their concerns
Patient satisfaction doubles when a medical practice addresses a negative online review
"While satisfied patients are more prevalent online than unhappy ones, the fact remains more than 1 in 3 patients who've shared their experience online have submitted a negative review. Negative reviews are going to pop up—they're an unavoidable aspect of customer service for any business, in any industry," the survey's report says.
Responding to negative reviews
The survey—which was conducted by Santa Monica, California-based PatientPop—shows the key role online reviews are playing in patients' selection of healthcare providers.
"This illustrates just how influential reviews are in patients' decision-making process. If a doctor or practice isn't making a strong first impression with online reviews, that's the difference between a newly acquired patient and a lost one," says Joel Headley, director of Local SEO and Marketing at PatientPop.
The powerful impact of addressing negative reviews was an unexpected finding of the survey, he said.
"It was surprising to see just how much patient satisfaction can increase—99%—following a negative review based on just one action: practices reaching out to address the patient's concerns. We assumed that good common courtesy and customer service would bump up respondents' satisfaction rates, but I don't think we expected they would double."
There are a handful of best practices when responding to negative reviews, Headley says.
"First, being prompt is critical—practices should respond to any negative review by the next business day. Second, whomever is responding for the practice should keep it short and professional, being clear that the patient's concerns are important and stating they want to help remedy the issue. They should also offer to reach out directly to the patient and take the conversation offline. Finally, practices must keep HIPAA compliance in mind, never including any personal health information or care details within the response even if the patient does."