Ongoing trends are likely to loom large in the realm of patient safety this year.
A patient safety expert at The Joint Commission says four ongoing trends will dominate the patient safety landscape in 2020.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Anne Marie Benedicto, MPP, MPH, vice president of the Center for Transforming Healthcare at The Joint Commission, recently shared her trend outlook for 2020 with HealthLeaders.
1. Patient advocacy
In 2020, there will be two primary forces at play in patient advocacy, Benedicto says.
"Healthcare providers have become more commercial in how they track patients as 'customers,' and patients are becoming more like consumers and using those skills to help navigate the healthcare system. This means more and more patients feel they have a say in what diagnoses mean for them, how they are treated, and how they engage with their care teams," she says.
With research resources such as WebMD literally at their fingertips, many patients have become savvy healthcare consumers, Benedicto says. "I see it in my personal life, where family members are doing research before they see a physician, or they make sure that they don't go to a doctor visit alone. When you are a patient and a visit is not a routine physical, you want someone else with you to ask clarifying questions because patients can be afraid or preoccupied."
Health systems and hospitals are increasingly embracing patient advocacy, she says.
For example, the Center for Transforming Healthcare is working with a Texas-based health system to boost quality improvement skills in neonatal intensive care units (NICU). The effort initially focused on clinicians, but the health system wanted to achieve quality and safety gains through empowering patients' families, Benedicto says.
"Our biggest surprise has been that the organization not only wanted clinicians trained in improvement skills but also the patient advisory council. We also provided training to parents of babies who were in the NICU for long periods of time. We found that the training gave parents permission to talk about quality issues with clinicians in a way that we had not seen before," she says.
The training for parents has focused on bridging language and skills gaps.
2. Improving the work environment
Ensuring adequate staffing at healthcare organizations is a key element of patient safety, and health systems, hospitals, and physician practices need to step up efforts to care for caregivers, Benedicto says. "This is an ongoing trend because we are already seeing clinician shortages. We are not recruiting and retaining enough medical staff members to meet the demand."
Healthcare organization leaders must shape work environments in ways that ease stress on staff members, she says.
For example, clinicians often struggle to find equipment or supplies such as medication pumps, she says. "They can spend 20 minutes looking for this equipment. It may sound like a simple inconvenience, but it can happen several times daily for a care team. When you put that all together, it can be tremendously wasteful. It also adds frustration and danger to an already stressful day."
She says "the solution to this challenge is to put the proper systems in place such as supply chain management that makes it easier for staff members to do their work."
Another way to improve the work environment at healthcare organizations is to tap into the knowledge and experience of staff members, Benedicto says. "They can not only make their workday better—they can make their patients' day better. If there is no mechanism in an organization to take those ideas and turn them into improvements, then those ideas dry up and stop coming. One of the ways we can retain people in healthcare is to make sure their voices are heard."
3. High reliability
Promoting high reliability at healthcare organizations improves patient safety and reduces wasteful spending, she says. "Going back to the example of a clinician looking for equipment or supplies for 20 minutes—that's 20 minutes of waste. That is time they could spend more cost-effectively on other issues and projects."
Falls with injury are a prime example of persistent patient safety problems that are missed high-reliability opportunities, Benedicto says. "Often, an organization will target falls every couple of years, saying that their fall rates are unacceptable. They come up with a solution, put it in place, it lasts for a few months, then the old practices creep back."
There needs to be an understanding that persistent problems in healthcare persist because they are complex, and they require structured and sustained solutions, she says. "The use of highly reliable process tools is necessary to get to zero harm. It's not just a matter of picking the easiest solution and putting it in place. It's a matter of stepping back and figuring out why the problem is happening, finding out why it is persisting, looking at the contributing factors, then developing solutions."
4. Surgery center safety
With the continuing trend of increasing numbers of procedures shifting from the hospital setting to ambulatory surgery centers, improving safety at surgery centers will be a top concern in 2020, Benedicto says.
"Technology is enabling this trend. In addition, if patients can get care in less complicated settings, then those options should be pursued. However, this opportunity comes with a risk. Many surgical centers do not have the same levels of protection that hospitals have. For example, more and more spine surgeries are happening in surgical centers, and those centers may not know what to do when there is a serious complication."
Surgery centers need to adopt patient safety protocols that have become common at hospitals, she says.
"Over the past decade, hospitals have been investing in process improvement and improvement methodologies, so they could make their care as safe as possible. That same type of trend needs to happen in other settings of care such as surgery centers. Achieving zero harm not only requires embracing high reliability as a goal, it means making sure that resources are in place to get to that goal—stronger improvement skills, stronger safety culture, and leadership commitment to zero harm."
In selecting physicians, surveyed adults aged 50 to 80 say that online ratings are nearly as important as information from friends and family members.
A significant number of older Americans are using online reviews to select their physicians, according to a new poll published today.
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 a robust marketing tool, and reviews can help hone clinician performance.
The new poll, which was commissioned by the University of Michigan Institute for Healthcare Policy and Innovation with support from AARP and Michigan Medicine, found 43% of Americans aged 50 to 80 had reviewed doctor ratings. In selecting a physician, 20% of those surveyed said online physician ratings were very important compared to 23% who said information from family and friends was important.
“People of all ages are turning to the web to find information, so it is not surprising that older Americans are looking up physician ratings online. But it is a bit of a surprise that these online ratings now carry as much weight as recommendations from family and friends," David Hanauer, MD, MS, an associate professor at the University of Michigan and Institute for Healthcare Policy and Innovation member who worked on the poll, said in a prepared statement.
Key data points
The poll was conducted by Toronto-based Ipsos Public Affairs and features data collected from more than 2,200 adults in a nationally representative household survey. The poll generated several key findings:
Among survey respondents who had viewed physician ratings within the past year, 65% used the reviews for a physician they were considering, 34% used the reviews to find a new physician, and 31% used the reviews for a physician they had already seen.
Nearly three-quarters of survey respondents (71%) said they would pick a physician who had many positive ratings even if there were a few negative reviews.
When selecting a physician with online reviews, the total number of reviews was important to 41% of survey respondents.
Among survey respondents who had viewed online ratings more than once in the past year, 67% chose a physician based on good reviews, 57% said they had not chosen a physician based on poor reviews, and 96% said the reviews matched their experience after visiting the physician.
In selecting a physician, the three most important factors for survey respondents were time to get an appointment (61%), the physician's years of experience (42%), and recommendations from a physician (40%).
Only 7% of survey respondents had posted an online rating or review of a physician. Among these survey respondents, 56% had posted because of a positive experience and 35% had posted because of a bad experience.
"While some may think that choosing a doctor using online ratings is something only younger people may do, this national poll shows that this practice is also common among older adults," the poll's report says.
Cancer is among the deadliest illnesses in the United States, according to the American Cancer Society. In 2017, ACS estimated there were 600,000 cancer deaths. Cancer also is among the costliest illnesses to treat. The Agency for Healthcare Research and Quality estimated total cancer treatment costs in 2015 were $80.2 billion.
The recent research article, which was published in Journal of Oncology Practice, found that patient navigation (PN) in cancer treatment drives significant clinical and financial benefits.
"PN has resulted in improved patient outcomes and patient satisfaction and has important financial benefits for cancer programs in the fee-for-service and the alternative payment model worlds, lending support for more robust staffing of PN programs," the article's co-authors wrote.
In a fee-for-service payment models, patient loyalty is the primary financial benefit for healthcare providers, the article's co-authors wrote. "PN can generate financial benefits by significantly decreasing the outmigration of patients to other health facilities for their oncology care."
In value-based payment models, healthcare providers can generate more clear-cut financial benefits from PN programs, they wrote. "In evolving bundled payment systems that financially incentivize high-value care and value over volume, the business case for cancer PN is stronger and more direct. In these payment models, practices can recoup avoided costs through performance-based payments rather than relying exclusively on payments made for billable services."
The article features five examples of patient navigation programs that have demonstrated direct and indirect financial gains for healthcare providers.
1. Patient Care Connect
In 2012, the University of Alabama at Birmingham used a federal grant to develop and launch Patient Care Connect, a navigation program at 12 cancer centers. Patient Care Connect featured nonclinical staff in navigation roles, which included routine distress screening to identify barriers to care among patients.
When compared to a control group on a per quarter basis, cancer patients in the Patient Care Connect program experienced higher decreases in emergency department visits (6.0%), hospitalizations (7.9%), and intensive care unit admissions (10.6%). On a quarterly basis, the lower utilization rates helped reduce cost of care per patient in the PN program by nearly $800, which generated a return on investment estimated at 10:1.
2. Levine Cancer Institute
Charlotte, North Carolina-based Atrium Health's Levine Cancer Institute developed a patient navigation program that featured 25 nurse navigators spread across seven locations.
With the exception of melanoma care, an analysis of 970 cancer patients found patients in the navigation program utilized treatment in an acute care setting less often (18% of the time) than patients who did not participate in the program (30% of the time). Another analysis found that patients who did not participate in the PN program were 52% more likely to experience a 30-day all-cause hospital readmission.
3. University of Pennsylvania Health System
At three University of Pennsylvania hospitals, an internal study showed that a PN program staffed with nurse navigators generated fee-for-service financial benefits for the health system.
Compared to cancer patients who did not participate in the PN program, cancer patients in the program were 10% more likely to stay in the University of Pennsylvania network for treatment. Cancer patients in the program also were more likely to receive related treatments in the health system's network, with 27% higher utilization of infusion services and a 17% higher utilization of radiation oncology services.
4. Sarah Cannon Cancer Institute
At Nashville, Tennessee based HCA Healthcare's Sarah Cannon Cancer Institute, a PN program with nurse navigators supports 65 hospitals in seven states. In 2018, the nurse navigators worked with more than 15,000 cancer patients. The PN program includes PatientID, an internal artificial intelligence capability that helps refer patients to nurse navigators.
The cancer institute's PN program has posted patient loyalty gains for the health system:
Between 2017 and 2018, a 59% increase in patients participating in the PN program was associated with increased patient volumes.
When cancer patients participate in the PN program starting early in their treatment, 90% of them stay in network for care. This observation has been particularly strong in breast cancer care, where patients had historically only stayed in network about 50% of the time.
5. Sutter Health
At Sacramento, California-based Sutter Health, internal surveys in 2016 and 2017 found significant variability in the health system's PN services for cancer patients, particularly in how and when clinicians referred patients to nurse navigators.
The health system launched a pilot program to determine the impact of when a referral to a nurse navigator was made, with some patients referred when there was a suspicious oncology finding and others referred 5 to 12 days after notification of a cancer diagnosis. In a significant patient loyalty gain, 35% fewer patients sought care at other health systems if they worked with nurse navigators at the time of a suspicious finding.
Sutter found that retaining cancer patients for treatment generated financial gains for the health system—an analysis found the retention of two patients could cover the cost of one nurse navigator.
Selection criteria for the Top 10 list include whether a story resonated with the HealthLeaders audience.
At HealthLeaders, the top clinical care stories of 2019 covered a range of topics, including patient safety, sepsis detection, maternal mortality, and hospital staffing.
The selection criteria for the following Top 10 list featured whether a story resonated with the HealthLeaders audience and stories that focused on 2019 pressing concerns in clinical care. Click on the links below to see the full text of the stories.
Maternal mortality: The federal Centers for Disease Control and Prevention documented a steady increase in U.S. pregnancy-related deaths from 1987 to 2014. The Team Birth Project is designed to decrease maternal mortality through two primary methods: improving communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
Sepsis detection: A computer-based decision support tool for sepsis at HCA Healthcare hospitals can detect the deadly infection about 18 hours earlier than the best clinicians.
Hospital discharge: Cleveland Clinic has developed a hospital discharge checklist to improve the handoff of patients to postacute care providers. The discharge checklist features two elements: a medication reconciliation document and a discharge summary.
Patient safety: The Leapfrog Group is pushing for widespread adoption of the nonprofit group's expanded Never Event Policy for hospitals. A "never event" is defined as egregious medical errors such as surgery on the wrong patient. Leapfrog's Never Event Policy is intended to hold hospitals accountable and promote high reliability in clinical care.
Millennial healthcare workers: IU Health has developed a four-part strategy to retain millennials at the Indianapolis-based health system—adopting a new dress code, providing opportunities for career advancement, reforming hiring and training practices, and enhancing tuition reimbursement for continuing education.
Behavioral health: New York-based nonprofit FAIR Health research has documented a spike in the behavioral health needs of children and young adults, including increased prevalence of anxiety, depression, and adjustment disorders. The medical director of Pediatric Mental Health Services at Dell Children's Medical Center of Central Texas shares her facility's holistic approach to caring for children and adolescents with mental health disorders.
Rural hospital staffing: An article published in July by the New England Journal of Medicine predicted a worsening shortage of physicians in rural areas of the country—mainly due to an aging workforce. A survey report published by Alpharetta, Georgia–based Jackson Physician Search features four strategies to boost physician recruitment in rural areas such as including family members in recruitment efforts.
Vision-impaired patients: Research published in April by JAMA estimated excess costs in the care of vision-impaired hospitalized patients at more than $500 million annually. Experts from Baltimore-based Johns Hopkins Medicine and the University of Miami Health System's Bascom Palmer Eye Institute share three best practices for the care of vision-impaired patients.
Home health: A executive from CommonSpirit Health shares how the Chicago-based health system is using home health capabilities to help acute care providers manage patient outcomes after hospital discharge.
Telepsychiatry: The medical director at AbleTo, a provider of telepsychiatry services, discusses the best practices for providing behavioral health services through telemedicine.
The lead author of a new report identifies four ways to promote preoperative assessments by anesthesiologists.
The lead author of a new report that found weak preoperative assessments are a primary cause of anesthesiology malpractice claims says anesthesiologists and surgical teams can rise to the challenge.
The report was published by The Doctors Company, a large physician-owned medical malpractice insurer headquartered in Napa, California. Based on review of malpractice claims from 2013 to 2018, improper management of patients under anesthesia was the most common anesthesia allegation, at 32%. Deficiencies in patient assessments were among the top three factors identified in claims, along with patient monitoring and communication among providers.
Productivity pressure plays a key role in limiting preoperative assessments and selecting the safest care setting, the report says.
"A review of cases revealed limited opportunities to conduct pre-op assessments. Older and sicker patients needed closer investigation, but production pressures often limited testing and input from attending or referral physicians. These pressures also limited anesthesia professionals' opportunities to arrange for the safest location for anesthesia care (hospital operating room versus a remote ambulatory surgery center or GI or cardiac labs) or to prepare for complications," the report says.
Promoting preoperative assessments
There are four primary ways to help ensure that thorough preoperative assessments are conducted, the lead author of the report told HealthLeaders this week.
1. Collaborative care teams: "The old 'surgeon is captain of the ship' is not now a viable model for modern preoperative planning," said Susan Palmer, MD, a board-certified practicing anesthesiologist based in Eugene, Oregon.
Collaboration among members of the surgical care team is good for healthcare providers and patients, she said. "What we now know is best for patients is that all physicians and nurses involved in a patient's care should work as a team, and knowledgeable input from anyone on the team should be considered respectfully. Collaborative practice is recognized as important not just for job satisfaction of healthcare providers, but also to provide the safest possible patient care."
2. Taking finances into account: The financial impact of delaying a procedure on the day of surgery cannot be ignore, Palmer said.
Healthcare providers including the surgeon, the anesthesiologist, and the care facility take a financial hit when surgery is postponed for factors that could have been identified in a preoperative assessment, she said, adding that patients can also incur personal and familial costs when a surgery is postponed. "This is why it is critical that anesthesiologists can be able to access the information they need ahead of time to properly plan the anesthesia care and make recommendations about the location for the surgery," Palmer said.
3. Obtaining records: At least a week before surgery is scheduled, patients should provide consent to obtain records from relevant healthcare providers and anesthesiologists should have access to those records, she said.
"Anesthesiology department leaders must work with their hospital administrators to make sure a pathway to obtaining and assembling preoperative medical records before surgery exists and is appropriately supported by medical records and nursing personnel. Anesthesiologists can review those records and order any indicated tests or obtain any necessary consultations. When this kind of system is in place, the cancellation on day of surgery rate goes way down."
4. Working with patients: Also at least a week before surgery, patients should be able to request a consultation with the procedure's anesthesiologist, Palmer said. "This is optimal if either the patient has concerns, questions, or requests about anesthesia care, or if the patient has chronic medical problems that should be optimized before the stresses of anesthesia and surgery."
Pre-anesthesia evaluation
There are several main elements of preoperative assessments by anesthesiologists, Palmer said.
Medical history
Review of current medications and allergies
History and description of any personal or family problems with anesthesia
Evaluation of chronic medical conditions such as hypertension, diabetes, pulmonary disease, renal disease, cardiac disease, neuromuscular disease, and central nervous system problems
Anything that limits a patient's ability to respond to stress should be quantitatively evaluated
Physical examination of the patient's airway anatomy
Evaluation of cardiac rhythms
"The medical evaluation will aid in the planning of anesthetic techniques, the choice of anesthetic medicines, and the planning for post-operative care," Palmer said.
The Sepsis Alliance has created The Sepsis Institute to offer training for healthcare professionals across the continuum of care.
The Sepsis Alliance, which was founded in 2007 to raise awareness about sepsis among the public and healthcare professionals, has launched The Sepsis Institute to provide training for sepsis care best practices.
Sepsis is a deadly infection that is diagnosed in at least 1.7 million adults annually in the United States, according to the Centers for Disease Control and Prevention. About 270,000 Americans die from sepsis every year, and 1 in 3 patients who die in hospitals are diagnosed with sepsis, the CDC says.
The Sepsis Institute (TSI) is designed to build on the sepsis awareness efforts of the Sepsis Alliance, TSI Education Director Peter Broadhead says.
"At TSI, what we aim to achieve is the same level of success that the Sepsis Alliance has accomplished with the public in giving healthcare providers the educational information that they need to achieve excellence in the diagnosis and treatment of sepsis," he says.
The Sepsis Alliance decided to create TSI to meet a pressing need for sepsis education among healthcare professionals, Broadhead says.
"We assessed the healthcare provider community in a survey and found that 3 in 4 nurses said that there was a lack of support services and training on the core concepts of managing sepsis at their facilities. We believe that in making sepsis education interactive, high-quality, and productive for healthcare providers, we can accomplish a great deal in the healthcare community so that fewer people in this country are dying every year," he says.
Educational offerings
TSI was launched in October with funding from the Biomedical Advanced Research and Development Authority, which is part of the federal Department of Health and Human Services.
Training modules, webinars, and other content offered on the TSI website is free and provides opportunities to earn continuing education credits.
TSI's target audience extends to healthcare professionals across the continuum of care, including physicians, nurses, physician assistants, pharmacists, physical therapists, technicians, and social workers. "[The] time from diagnosis to treatment of sepsis is crucial, and any person in a healthcare provider organization ought to know about sepsis. Anyone in the channel of care can be important in the diagnosis of sepsis, and we are aiming to spread this message as far and wide as we can," he says.
All TSI training content is being crafted to fit into the workdays of busy healthcare professionals, Broadhead says. "We have recognized that healthcare providers need convenient opportunities to engage in learning activities. We have found that it is important to meet them in providing small-bite-format learning. For example, they can engage in an activity for 15 minutes, then stop and come back to that activity later."
Building partnerships
Establishing partnerships with professional associations is a key element of TSI's educational strategy.
"We're reaching out to leading healthcare associations and organizations across the continuum of care, recognizing that the different healthcare provider types need different types of educational activities around sepsis," Broadhead says.
Current TSI partners include the Children's Hospital Association, American College of Chest Physicians, and American College of Obstetricians and Gynecologists. The partnerships have generated several training modules such as a home care module produced in collaboration with the National Association for Home Care & Hospice.
Establishing partnerships generates multiple benefits for healthcare professionals who receive TSI training, he says.
"We believe these partnerships are an excellent pathway to subject matter expertise, content creation, distribution, and, in many cases, accreditation. We're working with the American Physical Therapy Association, which is an accredited provider of continuing education credit for physical therapists. By working with accredited organizations, we can jointly provide a credit type that is suitable for particular provider populations."
TSI also will be serving as a clearinghouse for information generated by partner organizations, Broadhead says. "We are aiming to help the provider organizations with distribution of content that they might want to get out to our population of learners—we have learners who have already registered with TSI and many healthcare providers who are part of the Sepsis Alliance family of learners. The benefits of these partnerships feed both ways."
Ambitious goal
TSI's overall vision is a national healthcare system that is well-prepared for sepsis across the continuum of care, he says.
"To get there, we recognize that we need to create, accredit, and deliver expert content for healthcare providers of all types on the prevention, identification, diagnosis, and treatment of sepsis. Ultimately, what TSI is aiming to do in the healthcare provider communities is to enhance the skills, strategies, and performance of healthcare providers."
A crucial component of TSI's approach to sepsis education is focusing on the quality of care rather than mistakes in care settings, Broadhead says.
"Frequently when people talk about sepsis, they think of mistakes or medical errors that were made. What we are trying to do is disentangle that mindset from our educational activities. We want to make our efforts about accomplishing excellence as opposed to fixing errors."
The Leapfrog Group has selected 120 facilities as Top Hospitals in the country based on data from the nonprofit organization's annual hospital survey.
The Leapfrog Group has awarded the 2019 Top Hospital honor to 120 facilities across the country. The list of Top Hospitals can be viewed on the Leapfrog website.
The Top Hospital recognition designates facilities with the highest quality and patient safety ratings as determined from data in the annual Leapfrog Hospital Survey. Quality and patient safety metrics are key elements of value-based care; and patient safety is a top concern in the healthcare industry, with estimates of annual patient deaths due to medical errors as high as 440,000 lives.
Leapfrog, which is a nonprofit organization based in Washington, DC, was founded in 2000 by large employers and other purchasers of healthcare services.
The 120 Top Hospitals of 2019 were selected in four categories: 10 children's hospitals, 37 general hospitals, 18 rural hospitals, and 55 teaching hospitals. Four states had nine or more Top Hospitals: California, Florida, Michigan, and Virginia.
Last year, 118 hospitals earned the top honor. "We don't set a particular number of Top Hospitals—we pick the hospitals that meet the criteria," Erica Mobley, vice president of administration for Leapfrog, told HealthLeaders last week.
Earning Top Hospital designation
There are several primary criteria to earn the Top Hospital honor, Mobley says.
Participation in the Leapfrog Hospital Survey is required to be eligible for consideration. This year, more than 2,000 hospitals completed the survey.
Hospital survey results are put through Leapfrog's value-based purchasing program methodology, and each hospital receives a single composite score. The top 10% of hospitals rated through the value-based purchasing program methodology get considered for the Top Hospital designation.
Then, several other criteria are applied, Mobley says. "In general, we look at hospitals that report on all of the survey measures that are applicable to them, that abide by our Never Events policy, that fully meet most of the measures in our survey including ones such as computerized physician order entry and ICU physician staffing, and that demonstrate overall excellence as a hospital."
Computerized physician order entry (CPOE) is a key metric in the Top Hospital selection process, she says. "We make sure the top hospitals are entering their medications through a computerized system. … CPOE is important because medication errors are the most common errors that happen in hospitals, and CPOE systems are effective in reducing medication errors."
Hospitals are asked to participate in Leapfrog's CPOE simulation tool, Mobley says. "They put several 'dummy' patients into their CPOE system, and we give them a set of medication orders. We look to see whether the CPOE system is putting out the right alerts. For example, is the system alerting to an adult dosage being prescribed to a pediatric patient?"
Leapfrog Hospital Survey helps drive improvement
Hospital leadership teams can use the Leapfrog Hospital Survey as a quality and patient safety improvement tool, she says.
"They need to look at the performance that they have reported and see the areas where they are doing well and the areas where they can improve. Hospitals can see a variety of different types of benchmarking reports by participating in the survey. For example, they can see how they stack up to facilities in their region or other hospitals in their bed size. They should look at their survey results from this year, identify the areas they need to improve for 2020, and keep working toward those improvements."
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)
