Information technology such as electronic health records—particularly as they mature with new capabilities—can support growth strategies at health systems and hospitals as they grapple with business challenges including reduced reimbursement rates.
"I always look at information technology initiatives as a way to enable growth. Basically, these initiatives give you the tools and resources to achieve the outcomes that you need. Electronic health records definitely fit in that category," says Michael Browning, MBA, CFO of OhioHealth in Columbus, Ohio.
Investments in information technology generate several organizational benefits, Browning says.
"It allows health systems and hospitals to become more competitive and quicker to market for new services. For example, health systems and hospitals that can afford to invest in an electronic health record can provide EHR services to other organizations that may not be able to afford those kinds of services. So, having a good EHR base does help support growth."
Other examples of EHRs promoting growth include using EHRs to manage patient bed utilization and EHR innovations to reduce administrative burden on clinical care teams, he says.
After devoting substantial time, manpower, and financial resources into development of EHRs, these investments are starting to pay off for health systems and hospitals, says Subra Sripada, MS, managing director and technology effectiveness leader at Navigant.
"Broadly speaking in the hospital industry, the past decade has been spent implementing electronic medical record systems, with an eye on achieving meaningful use and not getting penalized by the federal government. For many of these EMRs such as Epic and Cerner, most healthcare organizations are not leveraging the capabilities and benefits of these systems to solve their business and clinical issues," he says.
Generating more value from EHRs represents the biggest opportunity in healthcare information technology, with collaboration between clinical and IT staffs, says Sripada. "You can bring these people together to address patient flow issues and any number of operational issues to have better automation."
Harnessing AI and predictive analytics to support growth
Novant Health is adopting a new artificial intelligence capability that will position the Winston-Salem, North Carolina–based health system to manage and support growth, says Eric Eskioglu, MD, executive vice president and chief medical officer.
Novant has contracted with a Seattle-based AI company to deploy a machine learning and predictive analytics system that can manage patient flow, particularly in the emergency department. The technology is designed to reduce delays, interruptions, and cancellations that are common in the ED setting. The system predicts patterns of patient demand, which can allow operational leaders to plan staffing levels, Eskioglu says.
"Most healthcare institutions have to send out daily census reports for each hospital down to the unit level on spreadsheets, which tell you how many patients you have on a given day and how it reflects on the labor—how many nurses and physicians you need," he says.
With this AI technology, we will be able to look at more data and account for the impact of scheduled events in the community, Eskioglu says.
"For example, we had the Democratic Party convention here four years ago, and we have the Republican convention coming up. We know what our upsurge was during the Democratic convention—how many patients showed up at the ER, what kind of conditions they had, and how many more nurses we had to get. So, we are going to be ready before the Republican convention to be able to predict—based on the attendees expected to come into town—how many patients we are going to see in the ER and how we can handle the flow," he says.
This technology can support growth at the operational level.
"The patient flow through the hospital needs to be so efficient that we sort out the patients; and, as they come in, we can predict when they are going to be discharged. Then we know how many nurses and how many physicians we need," Eskioglu says.
The 2019 HealthLeaders analytics in healthcare survey, Investing For the Future: Analytics, AI, and ROI provides insight on healthcare executives' views on the value of analytics technology. One hundred twenty-eight leaders across the country were surveyed on this topic.
In the survey, respondents describe their organizations' ROI for analytics: 41% say their ROI is acceptable, 30% say ROI is good, and 14% say ROI is very good. Only 16% say their ROI is poor (12%) or very poor (4%).
The survey respondents also predict their investments in analytics in the next three years: 63% say their organization plans to increase analytics investments, with 35% saying that investments will stay the same. A scant 2% report that their organization plans to decrease analytics investments.
Screening patients for asymptomatic carriage of Clostridioides difficile at the time of hospital admission could help reduce infection rates, new research finds.
In the hospital setting, screening for asymptomatic carriers of Clostridioides difficile (C. diff) at the time of admission could reduce infection rates, a study published this week says.
C. diff is a deadly diarrhea-associated infection, with more than 400,000 U.S. cases annually that are linked with nearly 30,000 deaths, earlier research shows. Hospitals have focused on reducing transmission of C. diff from symptomatic patients. However, the new study published in Infection Control & Hospital Epidemiology found asymptomatic carriers of C. diff spores are at significant risk of progression to symptomatic C. diff infection.
The lead author of the study says the new research could prompt hospitals to conduct screening of inpatients when they are admitted.
"It has generally been assumed that patients get the bacteria during their stay in the hospital. However, when we tested patients being admitted to the hospital, we found that many of them were carrying the bacteria that causes this diarrhea in their bodies already and often went on to develop the infection," Sarah Baron, MD, MS, director of Inpatient Quality Improvement in the Department of Medicine at Montefiore Health System, said in a prepared statement.
C. diff screening results
The research was conducted on 220 asymptomatic patients at Montefiore Medical Center in Bronx, New York.
The researchers focused mainly on patients from skilled nursing facilities based on earlier studies that had identified SNF residents at high risk for C. diff infection. Of the 220 patients enrolled in the study, 76% were nursing facility residents. All of the patients enrolled in the study were identified for C. diff screening within 24 hours of hospital admission.
The study generated several key data points:
21 or 9.6% of the patients screened positive as asymptomatic carriers of C. diff
10.2% of nursing facility residents and 7.7% of the community residents screened positive as asymptomatic carriers of C. diff
8 or 38.1% of the asymptomatic carriers progressed to symptomatic C. diff infection within six months
For most of the asymptomatic carriers of C. diff who progressed to symptomatic C. diff infection, the progression process was less than two weeks from enrollment in the study
Among the 199 noncarriers of C. diff, only 4 or 2.0% developed symptomatic C. diff infection within six months
"These findings might mean that we can predict who will develop C. diff and try to stop it before it starts. More work is needed to determine how we can protect everyone, even the patients who already have the bacteria in their colons, from developing this dangerous form of diarrhea," Baron said.
Interpreting the data
Identifying asymptomatic carriers of C. diff could help hospitals address the spread of C. diff infections in two ways, Baron and her co-authors wrote. "First, isolation of C. difficile carriers could reduce transmission to uninfected patients, and second, interventions targeting C. difficile carriers could potentially prevent progression to symptomatic C. difficile."
The finding that 38.1% of the asymptomatic carriers progressed to symptomatic C. diff infection (CDI) means that asymptomatic carriers could be a significant source of CDI in the hospital setting, Baron and her co-authors wrote. "Due to the high rate of progression, it is possible that a substantial proportion of "healthcare-facility onset" C. difficile may actually result from the progression from C. difficile carriage to symptomatic C. difficile, especially within the first two weeks of hospitalization."
Baron and her co-authors called for more research on asymptomatic carriers of C. diff.
"Asymptomatic carriers may represent a significant reservoir for transmission of C. difficile, and progression from asymptomatic carriage to symptomatic CDI may account for a significant proportion of CDI that is classified as 'healthcare-facility onset.' Therefore, identification of asymptomatic carriers could reduce the spread of C. difficile."
Market conditions are putting intense pressure on the acute healthcare sector. The shift from the fee-for-service business model has driven down inpatient admissions as patient volumes move to lower-cost settings and payers clench tight fists on reimbursement rates.
This economic scenario causes two challenges, says Michael Browning, MBA, CFO of Columbus-based OhioHealth.
"First, not-for-profit hospitals and health systems are no longer seeing 3%–4% increases in service volume. In many situations, they are seeing reductions in volume. Second, payers are no longer giving what many would deem a fair increase in reimbursement rates," he says.
Health systems and hospitals are facing a stark choice: cut costs or pursue growth strategies—with growth seen as the more attractive option, Browning says.
"With flat revenues and lower service volumes, growth strategies become more and more important for organizations to be able to afford the infrastructure that they have developed over the years. Many of us have several hospitals and extensive infrastructure; and, in order to afford the replacement of that capital and to give our employees inflationary raises, we're all trying to improve the growth strategies in our markets," he says.
With healthcare organizations under pressure, leaders are looking for ways to position their businesses for growth. This year, here are the opportunities that rise to the top.
Growth Strategy: Postacute Care
Postacute care presents an opportunity for growth in the healthcare market as home care grows and there is anticipation of increased demand for skilled nursing services as the country's population ages.
This year, ProMedica completed the integration of HCR ManorCare, which is a postacute care provider that the Toledo, Ohio–based nonprofit health system acquired in July 2018 for $3.3 billion with real estate investment trust WellTower.
ProMedica's new postacute care business division operates in 27 states, with 171 skilled nursing and rehabilitation centers, 54 assisted living communities, 108 home health and hospice agencies, and 51 outpatient rehabilitation clinics. Since the 2018 acquisition, HCR ManorCare has brought more than $100 million in cash to ProMedica.
In addition to integrating HCR ManorCare facilities with ProMedica's health system, says David Parker, president of ProMedica HCR ManorCare, the organization is working with several other health systems to build out and develop postacute services within the healthcare enterprises, with ProMedica HCR ManorCare as their postacute care partner.
ProMedica's new capability to provide healthcare services across the entire continuum of care is a powerful negotiating tool, he says.
"It might be in a joint venture, or it might be us providing a postacute solution on a hospital campus. Those conversations have advanced at a rapid pace since the merger with ProMedica. Health systems are more likely to be engaged in those conversations because they see our ability to blur the lines between levels of care in the acute and postacute settings," Parker says.
ProMedica HCR ManorCare facilities are already in business relationships with 2,000 hospitals, he says.
An increasing number of health systems and hospitals are positioning themselves for growth in postacute care, says David Burik, MM, a managing director in the healthcare practice at Navigant Consulting, which was recently acquired by Guidehouse, a portfolio company of New York–based Veritas Capital.
"As more and more sophisticated care is going to the home setting, home health is a good business. As hospitals look at their current business, and they wonder whether there is deeper penetration for any of those businesses, they are taking another look at homecare and postacute care in general," he says.
The SNF and home health sectors are expected to grow over the next decade. According to the Centers for Medicare & Medicaid Services Office of the Actuary, through 2027, spending on SNFs is expected to increase 5.4% while spending on home health services is expected to increase 7.0%. National health spending, meanwhile, is expected to increase at 5.5% annually.
In the postacute care setting, Parker says there are many opportunities to improve clinical care and master new reimbursement models. "We're all trying to figure out the added value of finding new ways to deliver care, and how that will be reimbursed through Medicare, health plans, and the private market."
The most important challenge for ProMedica HCR ManorCare is determining how the organization can be more efficient, create quality outcomes, and generate value for patients, health systems, and payers, he says.
"We're connecting specialty physicians and surgeons who are working in our acute care space and throughout our provider community with our skilled nursing facilities and within home health and hospice through ways such as telehealth, digital imaging, and other resources that are allowing us to deliver better care more efficiently and more cost-effectively for the payer. These initiatives also drive better outcomes," Parker says.
ProMedica, which also has a health plan business division, is well positioned to succeed in postacute care settings, he says.
"With all these divisions within our company, we can have some test cases that we can work on in both Toledo and across the country. Then we can use that experience with other health systems and other payers to make it deployable in other markets," Parker says.
Motor City market reflects SNF growth strategy
ProMedica HCR ManorCare is taking a long-term approach to financial sustainability in SNF care that is based on the organization's business trends and an expectation of more admissions as the nation's population ages, Parker says. "We're expecting the market is going to change with the demographics, and we'll start to see occupancy and volume increase over current levels."
He says ProMedica HCR ManorCare is pursuing this long-term strategy in the greater Detroit market, where the organization has eight SNFs. One of these facilities is a 125-bed SNF that does almost 220 admissions and discharges per month, with an average length of stay of about 19 days.
ProMedica HCR ManorCare's rehospitalization rates (16%) are below the national average. The national average is about 17%, Parker says.
"We have physicians who are making rounds daily. We have nurse practitioners who are in the facility daily. And we are delivering a level of care that is far different than what was delivered just 10 years ago," he says.
Parker says the vision for the Detroit SNF market mirrors ProMedica HCR ManorCare's national SNF strategy—admitting patients based on their clinical needs through a clinical skill inventory and making sure patients are moved through the continuum of care to the right level of care at the right cost with the right outcome.
Growth Strategy: Telemedicine
In recent years, telemedicine has been a prominent growth area at Cleveland Clinic, says Peter Rasmussen, MD, medical director of digital health at the Cleveland-based health system.
"Telemedicine is definitely a growth opportunity," he says. In fact, telehealth is an essential element of Cleveland Clinic's goal to double the number of patients it serves within the next five years, he says.
Three areas have been particularly effective in generating telemedicine growth, Rasmussen says.
1. Telemedicine is an opportunity for improving patient access: "We use telehealth as an access tool predominantly. Our forte is in expert diagnosis that requires advanced imaging or diagnostic services, and in high-end surgical care. In that regard, telehealth is a way for us to access those potential patients," he says.
2. Telemedicine is an avenue to provide online, on-demand service: "Particularly in the winter months in the cold and flu season, patients with significant upper respiratory tract infections will access our Cleveland Clinic Express Care Online platform to help them understand whether they have the flu, and whether they would benefit from in-person testing or flu medication therapy," Rasmussen says.
3. Telemedicine can increase patient visits: "A great example is the movement disorders arena. It's very challenging for a patient with advanced Parkinson's disease or other movement disorders to travel any distance to see a neurologist for evaluation and treatment," he says. "By using virtual visits, patients can see their expert more frequently than they would in an office environment."
In 2018, the number of annual virtual visits at Cleveland Clinic grew 68%. The health system is posting several other impressive numbers in telemedicine:
In Ohio, Florida, and Nevada, more than 40 clinical departments are offering scheduled telehealth visits
About 60% of virtual patient visits are being delivered in a scheduled fashion
The patient satisfaction score for telehealth visits is 91%
Cleveland Clinic is projecting that 50% of outpatient visits will be conducted virtually within the next five years
From both clinical and financial standpoints, telemedicine is one of the fastest growth areas in the healthcare sector.
In 2018, the global market for telemedicine was valued at $38.3 billion, and the market is expected to be valued at more than $130 billion in 2025, according to Global Market Insights.
A survey published in July 2019 by San Francisco–based Doximity found the number of physicians reporting telemedicine as a skill doubled from 2015 to 2018. Among physician specialties, radiologists and psychiatrists showed the highest level of interest in telemedicine job opportunities, the survey found.
Telepsychiatry: Reaching 'patients at scale'
Telepsychiatry is a significant growth area within telemedicine.
Telemedicine is a good fit for behavioral health for several reasons, says David Whitehouse, MD, MBA, medical director at New York–based AbleTo Inc., a provider of virtual behavioral health services.
There are practical advantages with telepsychiatry compared to in-person office visits, he says. "Imagine a new mother with postpartum depression dealing with the demands of her new baby while also trying to navigate the logistics to schedule a therapy appointment."
Telepsychiatry also can help bridge the gap between the country's shortage of therapists and an overwhelming demand for behavioral health services, he says.
"Telemedicine helps us make the best of behavioral healthcare widely available, allowing us to reach many more patients at scale. Areas of the country that might not have been able to attract top-flight practitioners to move there can now bring the best of the best into their homes. It also helps get undiagnosed people the access to services they need," Whitehouse says.
Telepsychiatry can play an essential role in providing access to behavioral health services in rural areas of the country, says David Fingerhut, PhD, MS, MA, director of mental health services at Indianapolis-based Activate Healthcare and an assistant professor of clinical psychology in the Department of Psychiatry at Indiana University School of Medicine in Indianapolis.
"Here in Indiana, we have a similar geography to many other states, where you have multiple metropolitan areas and wide swaths of territory that are rural. In many rural communities, you don't have a mental health provider within 50, 60, or 70 miles. Conducting telemedicine opens avenues to treatment in these rural areas," Fingerhut says.
Marina Montez, MS, LPC-S, owner and practitioner at Bluebonnet Counseling Services in San Antonio, says telemedicine—which accounts for about half of her client visits—is well suited for her therapy work with children and adolescents.
"Treatment is usually six months long to address the negative thinking the child may be experiencing. With telehealth, I am no longer dependent on a parent bringing a child to an appointment—it's a lot of work to get your child to a therapist's office. If a parent must miss work, the reality is that they only have so many days they can take off. With telehealth, it is very cost-effective for the parent to have a child in therapy—people can do it."
Financially, telemedicine has helped grow Montez's therapy practice. "I started out as a sole proprietor, and telehealth made it possible for me to become an agency and hire clinicians to work for me," she says.
Bluebonnet Counseling Services offers telemedicine visits through South Jordan, Utah–based AdvancedMD, which has not only a telehealth platform but also business function support, Montez says. "At the end of the session, I can bill for it, and the claim is pushed through a clearinghouse. There is a scrubber to make sure that the claim is clean, and it is pushed on to the insurance companies for payment."
Therapy sessions at Bluebonnet Counseling Services cost $90 per hour, she says. "With the insurance, the payers pay the same amount whether the patient comes into my office or I see a patient on telehealth. So, seeing patients through telehealth does not impact my bottom line. The insurance pays $70 for my visits; so, there is a $20 copayment as well."
Telepsychiatry is a prime example of recent advances in behavioral health, Fingerhut says. "I am much more optimistic about where behavioral health is going than ever before, and I'm very excited to see where we go from here."
Photo credit: David Parker is president of ProMedica HCR ManorCare in Toledo, Ohio. (Tom McKenzie/Getty Images)
Although medicine is arguably no longer a male dominated profession, gender discrimination remains widespread, a new survey finds.
A new survey found that most female physicians have experienced gender discrimination, and most believe they are paid less than equally qualified male physicians.
American medicine was a male dominated field through most of the 20th century. Researchers have found a persistent and widespread gender pay gap among physicians, including a Journal of Hospital Medicinearticle published in 2015 that showed female hospitalists earned $14,500 less than their male counterparts.
The new survey, which was published by the physician search firm Merritt Hawkins, found 74% of female physicians believe they earn less than their male peers.
"Women are entering medicine in record numbers and are having a profound impact on the medical profession. However, despite these achievements, female physicians continue to be paid less than their male counterparts and face other forms of workplace discrimination," Travis Singleton, executive vice president of Merritt Hawkins, said in a prepared statement.
The new survey is based on data collected from more than 400 female physicians across the country. Merritt Hawkins is a subsidiary of San Diego-based AMN Healthcare.
Gender discrimination data
In addition to the pay gap finding, the survey includes several key data points:
39% of survey respondents said they earned less than their male peers in their current practice setting
76% of female physicians reported experiencing gender discrimination as medical students and professionals
Inappropriate or offensive verbal communication from another physician was the most commonly cited (75%) form of gender discrimination
41% of survey respondents who reported exposure to gender discrimination said they had experienced verbal sexual harassment and 14% said they had experienced physical sexual harassment
79% of survey respondents said gender discrimination in the medical field is a serious or somewhat serious problem
73% of survey respondents said gender discrimination lowered morale and career satisfaction
29% of survey respondents said gender discrimination had prompted them to reconsider their career choice
89% of survey respondents said gender discrimination in medicine would not spur them to discourage young women to enter the medical field
Given the physician shortage in the country, gender discrimination is a high-stakes problem, Singleton said. "Gender discrimination is more than just a challenge for individual doctors. "When it diminishes the overall supply of physicians, it becomes a matter of public health."
Gender pay gap causes
Survey respondents cited two primary factors as the cause of the gender pay gap in medicine: unconscious bias and level of aggressiveness in negotiating compensation.
Unconscious discrimination against female physicians in compensation was cited by 76% of survey respondents. This finding suggests cultural considerations in the medical field have a major impact on compensation for female physicians, the survey report says.
"When presented with two physician candidates for the same position who have equal training, skills, and 'bedside manner,' employers may unconsciously imbue the male candidate with a higher financial value, even if consciously acknowledging that both candidates have equal clinical ability," the survey report says.
Attitude or mindset was cited by 68% of the survey respondents as a cause of the gender pay gap in the medical field, saying, "female physicians are less aggressive or adept at salary negotiations than male physicians."
Attitudes or skills in negotiating compensation could be related to gender roles and behaviors, the survey report says. "Whether or not assertiveness is a learned or innate behavior, both female and male physicians could benefit from more training on the business aspects of medicine."
Other factors that survey respondents said play a role in the gender pay gap included conscious discrimination (38%) and fewer female physicians working as self-employed professionals (27%).
A new report shows an increase in the average value of paid claims as well as a hike in the proportion of claims exceeding $5 million.
There has been a dramatic upward trend in hospital medical malpractice claims over the past two decades, according to a new report from Aon and Beazley Group.
Over the past two decades, the medical professional liability insurance marketplace has been hardening in response to higher paid claims. The evolving market is putting upward pressure on premiums and downward pressure on insurance industry capacity.
Average paid claims in 2018 were 50% higher than in 2009, Valentina Minetti, U.S. hospitals focus group leader at Beazley, said in a prepared statement. "The average paid claim with indemnity closing in 2018 was 6% higher than in 2017. While that is only a single-digit increase from year to year, the cumulative effect of similar rises has taken the average paid claim from $400,000 in 2009 to almost $600,000 last year."
Multimillion-dollar paid claims are taking a toll on insurers and healthcare organizations alike, she said. "The double-digit million-dollar claims are having a chilling effect on the medical liability community. Awards of this size drive hospitals to increase their self-insurance, can cause premiums to rise and industry capacity to decrease, so there is certainly a shared interest in seeing these rising costs stabilize."
Multimillion-dollar malpractice claims
The new report, which is based on Beazley claims information that represents 47% of U.S. hospital beds, includes a pair of key data points about large claims:
The average indemnity paid for claims over $5 million was $8.6 million from 2013 to 2015, compared to $10 million from 2016 to 2018
The proportion of claims exceeding $5 million has increased steadily since 2000, with a steep increase in recent years: 2000-2002, 0.5%; 2003-2006, 0.7%; 2007-2010, 1.0%; 2011-2014, 1.2%; and 2015-2018, 1.9%
"News headlines from around the U.S. commonly detail $30 million, $80 million, and greater than $150 million jury awards with no apparent end in sight. As plaintiff attorneys have become successful in achieving these high value verdicts in their hometowns, they have become more confident in trying cases in new venues," the report says.
Claims defense strategies
There are five primary defense strategies when healthcare organizations face malpractice claims, the report says.
Use mock juries and focus groups to prepare for trials.
Deploy defense counsel to counteract the strength of the plaintiff's counsel. "While a healthcare organization may have a long-standing relationship with one firm, they may not be best equipped at managing defense of a claim depending on the strength and previous success of plaintiff's counsel," the report says.
Hold workshops and retreats for defense counsel to share best practices.
Try to resolve claims quickly, which tends to reduce litigation time, costs, and claim values.
When a quick resolution is elusive, healthcare organizations should be prepared to go to trial.
As the medical professional liability insurance marketplace hardens, healthcare organizations should establish strong teams to handle claims, the report says. "This includes not only the internal risk management or financial leaders of the healthcare organization itself but reinforcing the need to have support from healthcare industry-focused brokers, consultants, actuaries, insurance carrier partners, and even experienced and effective defense counsel."
There have been leaps forward in patient safety over the past 20 years but harm remains far too common, two experts say.
Progress has been made in patient safety improvements but many more advances are needed, a pair of experts say regarding the 20-year anniversary of the landmark reportTo Err Is Human: Building a Safer Health System.
The 1999 report included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Yet despite two decades of attention, estimates of annual patient deaths due to medical errors have since risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
HealthLeaders recently spoke with two experts to discuss how far healthcare has come since the release of To Err Is Human, and what progress still needs to be made regarding patient safety.
Eric Eskioglu, MD, is executive vice president and CMO of Winston-Salem, North Carolina-based Novant Health, a practicing neurosurgeon, and a former aerospace engineer at Chicago-based Boeing.
Anne Marie Benedicto, MPP, MPH, is vice president of the Center for Transforming Healthcare at The Joint Commission, based in Oakbrook, Illinois. The Center for Transforming Healthcare was formed in 2009 to help healthcare organizations achieve zero harm in patient care.
The following is a lightly edited transcript of the conversations with Eskioglu and Benedicto.
HealthLeaders: Gauge the progress in patient safety since the publication of To Err Is Human.
Eskioglu: There have been advances, but they are not enough. In my view, we have advanced, but we have not advanced at the rapid clip required. I came from the aerospace industry, where there was a huge advance in safety from 1989 to now. That's why we have done really well in airline safety and reducing deaths in airline crashes. We have not come far enough in healthcare.
Benedicto: There has been some progress, most strikingly in the declines of healthcare-acquired infections such as central line-associated bloodstream infections. However, from the perspective of 20 years, there is some disappointment. People are still being harmed in the course of receiving or giving care. There are practices in healthcare that fail routinely; for example, hand hygiene is only being done 50% of the time. Wrong-side surgery is an example of an extreme adverse event that never should happen but does happen. So, we are still seeing routine common harm as well as adverse dramatic harm 20 years after To Err Is Human.
HL: Give an example of a major leap forward since the publication of To Err Is Human.
Eskioglu: One of the biggest advances we have made is the process of double checking such as the surgical checklist developed by Martin Makary at Johns Hopkins. That was a big advancement in the operating room field. Before that, we didn't have a surgical pre-op checklist. What we ended up having were many wrong-sided surgeries, wrong implants, even wrong patients operated on because once you put the patient under anesthesia, they don't know what is going to happen to them.
HL: Pick one or two areas related to patient safety that are on your wish list for improvement.
Benedicto: I would give healthcare organizations enormous improvement capabilities and capacity. They would have a workforce that is familiar with improvement methods and use them in their daily work, so they would be constantly improving. One of the biggest gaps in achieving zero harm is there are so many things that could be improved in healthcare organizations and there is a lack of improvement skills. At hospitals, which are complicated organizations that often have thousands of employees, there may only be 30 people who are trained in improvement skills. That is not enough to solve all of the problems and challenges that healthcare organizations encounter every day.
Eskioglu: I would stop all the preventable deaths from falls, missed diagnoses, and delayed treatment, as well as remove burdens from the physicians so they could concentrate on what they do best—taking care of patients—rather than being data entry clerks. We need to help physicians with artificial intelligence and analytics. Artificial intelligence is not going to tell doctors what to do, but it will be like flying a plane; if a pilot mistakenly does something wrong, an alert system comes on and says, "Are you sure you want to do this?" We don't have that in medicine.
HL: Give an example of a remaining major obstacle to improving patient safety.
Eskioglu: One area where we are lagging is data. Each patient's data is like a Woolly Mammoth locked up in a glacier. It's waiting to be unfrozen and used to the betterment of the patient. The next time you go to your primary care physician, ask, "How far do you go back in my records before you see me? Is it one note? Two notes?" If you have been with the same physician for 15 years, you probably have accumulated at least 30 notes. Does your physician go through all 30 notes and look for patterns? I can tell you that does not happen.
Benedicto: We need to aim higher—not just aim for better—and go for zero harm. We need to make healthcare as safe as established high-reliability organizations such as commercial airlines or the nuclear power industry. Even though they operate in high-hazard environments, they have the systems and structures to achieve exemplary safety records. Healthcare is not there yet, but we can achieve high reliability. Leadership commitment to zero harm is the first step. Working on culture also is important because high-reliability organizations have strong safety cultures. We also need strong improvement capacity and capabilities.
HL: What would zero harm in healthcare look like?
Eskioglu: It would be multiple, relentless, obsessive checks and balances just like the aerospace industry did. It doesn't mean that you are never going to have another preventable death over the next 10 years in any hospital. But it is going to be so rare that that one unfortunate incident is going to make us look at the root cause and not repeat that mistake again. To me, that is relentless pursuit of safety and doing no harm.
Benedicto: The obvious answer is we would see harm go away. Patients would not fall. People would not get injured. There would be no pressure ulcers. There would be no healthcare-acquired infections. But the benefits of zero harm go beyond the clinical areas. The focus on consistent excellence that creates the ability to reach zero harm means that you would have an organization that is focused on consistent excellence in all areas. Your billing department would be strong. You would be strong operationally. Your supply chain would be strong. Many factors influence zero harm, clinical outcomes, and patient care.
Unintended consequences of assigning hospitalists to one or two inpatient units include the temptation to increase patient loads on the clinicians.
Assigning hospitalists to an inpatient unit—also known as geographic cohorting—increases direct care time with patients but often comes with unintended consequences, a new journal article says.
Geographic cohorting of hospitalists is becoming a common practice at U.S. hospitals, with a 2017 survey finding that 30% of medicine group leaders reported clinicians rounded daily on one or two inpatient units. Other research associated geographic cohorting with reduced costs, length of stay, and mortality when the staffing method was included in an accountable care team model.
The new journal article, which was published online by Journal of Hospital Medicine, features a time-motion study of geographic cohorting (GCh) hospitalist teams and non-geographic cohorting (non-GCh) hospitalist teams.
"Cohorting’s benefits are theorized to include increased hospitalist time with patients, while its downsides are perceived to include increased interruptions," the journal article's co-authors wrote.
The new research data supports the theories:
GCh hospitalists were found to have the highest predicted time for direct care encounters with patients at 9.5 minutes.
GCh hospitalists were interrupted at a significantly higher rate than non-GCh hospitalists. In the morning, GCh hospitalists were interrupted once every 14 minutes and non-GCh hospitalists were interrupted once every 13 minutes. In the afternoon, GCh hospitalists were interrupted every 8 minutes and non-GCh hospitalists were interrupted every 17 minutes.
Interpreting the data
In comments provided to HealthLeaders via email, two of the journal article's co-authors discussed their research findings, including the observation that GCh hospitalists spent more time with their patients.
"The increased proximity between the physician and the patient may facilitate multiple visits with patients on the same day, as well as longer visits," said Michael Weiner, MD, MPH, professor of medicine, Indiana University School of Medicine, Indianapolis, and research scientist, Regenstrief Institute, Indianapolis; and Areeba Kara, MD, MS, assistant professor of clinical medicine, Indiana University School of Medicine, and hospitalist, Indiana University Health, Indianapolis.
Interruptions appear to be a drawback of geographic cohorting, they said. "Interruptions were pervasive among hospitalists but more commonly noted in the geographically cohorted group. With geographic cohorting, the increased presence of the hospitalist on the unit fosters interprofessional relationships and collaboration, which may increase both timely and untimely communication."
The time-motion study found that the time of each patient visit decreased 14% when the patient load on hospitalists increased from 10 to 20 patients. Hospital leaders should avoid the temptation to increase patient loads on GCh hospitalists, Weiner and Kara said.
"Experience suggests that the anticipated gains in efficiency from cohorting lead to an expectation that cohorted teams should be able to manage more patients. This was noted in our study and has also previously been raised as a concern in a national survey of hospitalists. Ironically, higher patient loads were associated with shorter visits, thus seeming to erode the benefits of cohorting."
The four different approaches to establishing geriatric emergency department services vary in the amount of resources required.
Over the past five years, four primary models for geriatric emergency departments have emerged, according to a new journal article.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
In 2014, guidelines were published for the formation of geriatric emergency departments based on consensus reached by the American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine.
"The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care," the co-authors of the new journal article published by Annals of Emergency Medicine wrote.
The article presents four models that serve as "practical examples" for establishing geriatric EDs.
1. Geriatric ED unit
A geriatric ED unit is a dedicated space within an emergency department that can include enhancements such as flooring and beds that are designed for older adults to reduce risks, including falls and delirium.
Screening assessments are used to determine which older adult patients should be treated in a geriatric ED unit, the co-authors of the journal article wrote. "Screening tools or criteria for the unit are required because for most EDs the volume of older adults is higher than the capacity in these units, and ED resources must be focused on patients who will most benefit."
Advantages of geriatric ED units include having the expertise of a dedicated staff, which often features geriatric practitioners, social workers, physical therapists, occupational therapists, palliative medicine consultants, and pharmacists. In addition, training costs are relatively low because education is focused on a single team rather than the whole ED staff.
Limitations of geriatric ED units include the potential for limited operating hours because of staffing constraints and disparities of care when the unit is closed.
2. Geriatrics practitioner model
This model provides geriatric care throughout an ED rather than in a specialized unit within an ED, the journal article co-authors wrote.
"The entire ED adopts a geriatric-focused approach that may include structural changes, screening with geriatric assessment tools, or both. A geriatric nurse, nurse practitioner, allied health specialist, geriatrician, or all four are available in the ED. Evaluation by these geriatric practitioners occurs concurrently with routine ED care."
Geriatric practitioners work with social workers, case managers, or nurses who are adept at care transitions and matching patients with community resources such as home health care.
Advantages of this model include geriatric assessments provided by caregivers with specialist training as well as lower costs and increased flexibility compared to the geriatric ED model.
Limitations of this model include the potential for long ED length of stay to accommodate interdisciplinary geriatric evaluations.
3. Geriatrics champion model
In this model, there is no geriatrics clinician in the ED, but a geriatric champion plays a leadership role in initiatives and establishing care pathways.
"This model may be chosen because of small patient volumes or staffing costs of a geriatric practitioner. Instead, the model relies on initial assessment in the ED and close ties to outpatient resources and outpatient geriatric assessment for patients. The geriatric champion is a physician or nurse with expertise in geriatric ED care," the journal article co-authors wrote.
A key role of the geriatric champion is to provide staff training and to develop protocols that improve ED care.
When ED physicians determine that a patient needs a geriatric assessment, the patient is either hospitalized or is referred for timely follow-up with a geriatrician in an outpatient setting.
An advantage of this model is improving geriatric care at low cost.
A limitation of this model are barriers to outpatient care coordination. "Outpatient care coordination can be challenging to initiate during an ED visit if appropriate resources are not in place, and clinicians may revert to traditional care practices on high-volume days or when time is limited," the co-authors wrote.
4. Geriatric-focused observation unit model
This approach is a combination of the geriatric ED unit and the geriatrics practitioner models.
"An ED observation unit is a unit within the ED (typically 10 to 20 beds) that divides patients into cohorts for evaluations longer than a 4-hour ED stay but not requiring an inpatient stay beyond 48 hours. The targeted 8- to 24-hour observation period allows a full interdisciplinary geriatric assessment," the journal article co-authors wrote.
With the potentially long ED length of stay, patients can be held overnight then receive geriatric assessments from in-hospital consultants or interdisciplinary teams the next morning.
"This model can be used with a dedicated geriatrics team in the observation unit or in conjunction with the hospital's inpatient geriatric consultation service, eliminating the need to hire ED-specific staff. This model adapts and repurposes already existing inpatient services (geriatrics, physical therapy, speech therapy, occupational therapy, pharmacists, case managers, and other consultants) for ED patients," the co-authors wrote.
Advantages of geriatric observation units include decreasing return ED visits and hospitalizations, research shows.
Identifying patients who can benefit most from a geriatric observation unit can be difficult, the co-authors wrote. "High-risk patients may require greater resources than those available within a 24-hour stay, or may need a full qualifying admission for nursing facility placement."
New research largely supports the claims of freestanding emergency department critics.
Freestanding emergency departments increased spending on emergency care in three of four states examined in a recent study.
Advocates of freestanding emergency departments claim they can ease overcrowding at hospital-based emergency rooms and provide prompt care in convenient locations. Opponents of freestanding emergency departments claim they increase spending on emergency room services because the care can often be provided in lower cost settings such as urgent care centers.
The recent study, which was published in the journal Academic Emergency Medicine, examined freestanding emergency department data collected in Arizona, Florida, North Carolina, and Texas from January 2013 to December 2017. The researchers focused on total spending on emergency care, out‐of‐pocket spending, utilization, and price per visit.
The research generated three key observations, the lead author of the study told HealthLeaders.
"Entry of an additional freestanding emergency department in a local market was associated with an increase in spending per capita in three of four states. Entry was generally associated with an increase in emergency visits per capita, as well as out-of-pocket spending," said Vivian Ho, PhD, director of the Center for Health and Biosciences at Rice University's Baker Institute for Public Policy in Houston, Texas.
The research features several data points:
In local markets in Florida, North Carolina, and Texas, entry of an additional freestanding emergency department resulted in a 3.6 percentage point increase in emergency provider reimbursement per insured beneficiary
In local markets in Arizona, entry of an additional freestanding emergency department resulted no significant reimbursement change
In local markets in Arizona, Florida, and Texas, entry of an additional freestanding emergency department increased the number of emergency care visits by 0.18 per 100 insured beneficiaries
In local markets in North Carolina, entry of an additional freestanding emergency department did not significantly change the utilization rate
In local markets in Arizona, Florida, and Texas, entry of an additional freestanding emergency department increased the average estimated out-of-pocket payments for emergency care by 3.6 percentage points, but out-of-pocket payments decreased 15.3 percentage points in North Carolina
Interpreting the data
The research is a cautionary tale about freestanding emergency departments (FrEDs), Ho and her co-authors wrote. "Rather than functioning as substitutes for hospital‐based EDs, FrEDs have increased local market spending on emergency care in three of four states' markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate to better understand their potential health benefits and cost implications for patients."
The utilization findings provide weak support for proponents of FrEDs, Ho told HealthLeaders.
"Some of the observed increase in utilization may have led to increased convenience for patients seeking emergency care. However, the overall increase suggests that FrEDs don't serve as a substitute for hospital-based emergency care. And other studies in the literature have found that entry of FrEDs do not lower waiting times at nearby hospital emergency departments," she said.
The spending findings support the claims of FrED critics, Ho said. "The results are consistent with critics' concerns that FrEDs increase spending on emergency care. FrED operators have come to realize that, 'If you build it, they will come.' Other research suggests that much of the care that patients receive at FrEDs could be obtained at much lower costs at urgent care centers."
Patient experience has become a top priority in the healthcare industry as the transition to value-based care unfolds. In the current market conditions, patient experience not only drives consumer loyalty but also helps health systems and hospitals to gauge whether they are delivering value to their patients.
To that end, UnityPoint Health has been investing resources to improve patient experience.
This year, West Des Moines, Iowa–based UnityPoint Health's UnityPoint Clinic division achieved a top 10% ranking from Press Ganey Associates, a national leader in patient satisfaction surveys.
In a conversation with HealthLeaders, David Williams, MD, president and CEO of UnityPoint Clinic and UnityPoint at Home, highlighted four examples of initiatives and capabilities that have boosted the health system's patient experience.
"It's our job to grow out an exceptional experience. We have been trying to do that in pockets of our organization forever, but we're better organized now and able to spread an exceptional experience throughout the health system," he says.
1. 'High touch' readmission reduction program
In 2016, UnityPoint implemented its "Heat Map" readmissions reduction program, which combines predictive analytics with the efforts of nurse care managers.
"We take our analytics and analyze hundreds of data points in a readmission reduction tool. We have found many of the triggers to find out before someone decompensates and gets sick," Williams says.
The Heat Map program allows UnityPoint to target patients who are at risk of readmission, he says.
"For many years, we had been seeing patients one week after hospital discharge for follow up. With our readmission tool, we have found that our follow-up visits miss some patients because many decompensate about three days after they get out of a hospital. For other patients, they look great a week after leaving a hospital, then two to three weeks after their hospitalization they decompensate," he says.
Nurse care managers play a crucial role in the program, he says.
"We use our readmissions reduction tool and put it in the hands of our care managers—that's where the personal touch comes in. These nurses reach out to the patients. Many times, they know the patients on a personal basis. They not only have an empathetic relationship with the patient but also have the patient's confidence. If these nurses tell patients when to get in for follow up and what they need to do to care for themselves, we find patients follow that direction almost 100% of the time. The care coordinators develop trust, they get patients into our clinics before they decompensate, and it is the best example we have of patient segmentation," Williams says.
The Heat Map program has attained a significant reduction in hospital readmissions, Williams says.
"There has been a dramatic drop in patients who have been readmitted by using both the predictive analytics and the high touch of dedicated care coordinators. Our early findings over the past year have shown that we have decreased the rate of readmissions in a fragile population by two-thirds. It's not statistically proven yet, but we'll get there."
2. LGBTQ-friendly clinics
UnityPoint has launched two LGBTQ-friendly clinics. In January 2018, the health system opened the first clinic in Waterloo, Iowa. In April, the second clinic was opened in Des Moines, Iowa.
"These clinics came into being because we had dedicated physicians who wanted to take care of a population that has been discriminated against and underrepresented in healthcare. It's a shining example of the personalization of care that we can provide," Williams says.
Staff in the clinics receive Safe Zone training, which covers issues such as letting patients choose the pronoun they want to be identified with and overcoming biases, he says.
The clinics are open every two weeks at night. "These are doctors and nurses who work in our regular clinics during the day," Williams says.
There are plans to open several more of the LGBTQ-friendly clinics, he says. "We currently have nine regions in three states. These are the first two LGBTQ clinics, and we will be expanding them to other communities. I have had medical leadership in every one of our regions ask about opportunities to open these clinics."
3. Patient service representative training
In April, UnityPoint initiated "PSR University" to bolster the training of patient service representatives.
These employees play an essential role in patient experience as they are the first people who make contact with patients, such as scheduling appointments and warmly greeting people as they come through the clinic's doors, Williams says.
PSR University, which is a yearlong program, is designed to strengthen the ranks of patient service representatives, he says.
Twenty patient service representatives were selected to participate in the first PSR University class, Williams says.
"We have a cohort of people who can help address patient complaints and do a better job when problems arise. We have them as brand ambassadors and role models in each one of their regions," he says.
The trained patient service representatives also participate in hiring new representatives to ensure that the patient experience culture stays consistent, Williams says.
4. Patient portal
Williams shares three examples of popular capabilities on the health system's MyUnityPoint patient portal that have had a positive impact on patient experience:
Online scheduling for primary care visits
Access to clinician notes documented in the Epic electronic health record system
A "Fast Pass" feature texts patients if an appointment with a specialist becomes available earlier than a scheduled appointment
"The key to our digital transformation is definitely our patient portal. This is where we have built our brand ambassadorship," he says.
