This article appears in the September 2012 issue of HealthLeaders magazine.
When then President Richard Nixon in 1971 called for a "cure for cancer," he envisioned a crusade akin to the efforts that developed the atomic bomb and led to the moon landing.
But more than 40 years later, it has proven to be an elusive goal, and one that has changed dramatically over the decades. Now, the vision has transformed from seeking a singular cure for cancer to finding a multitude of cures for a complex disease that differentiates into the hundreds of types. The emerging singular focus now in the so-called war on cancer is personalized medicine, which involves tailoring drugs for each patient to attack that person's individual kind of cancer. Some have dubbed it one pill for one patient, or even named it individualized medicine. Others have a different take, describing it more as precision medicine, narrowing treatment for groups with certain ailments.
To pursue and exploit innovative technology, some health systems are developing service lines or special institutes for personalized medicine, with a focus on one-patient-at-a-time cancer care. While some healthcare systems are making slow and cautious moves into the frontier of personalized medicine, others are moving quickly in a this-is-the-future-right-now environment.
Some are moving ahead because they "perceive themselves on the frontier of the movement in personalized medicine," says Edward Abrahams, president of the Personalized Medicine Coalition, an education and advocacy organization based in Washington, D.C. "Not only do we hope systemic expenses can be cut with personalized medicine, but also the possibility of adverse events by targeting cost-effective diagnoses. Researchers will use tumor and patient genomes to find new therapies and drugs for individual patients."
There are economic gaps that personalized medicine advocates believe can be bridged over time, particularly related to government reimbursements. As of now, there are technological improvements for genomic sequencing that are reducing costs significantly, according to Maurie Markman, MD, senior vice president of clinical affairs and national director of medical oncology for the Cancer Treatment Centers of America, which has five acute care hospitals and is headquartered in Schaumburg, Ill.
"The future is here," Markman says, noting that there have been gradual and significant cost reductions for genome sequencing over the past decade or so. "Within the next year, it will be possible to sequence the entire genome of a tumor and the corresponding normal genome of an individual cancer patient for $3,000. Twelve to 15 years ago, it would cost about $6 million."
CTCA has contracted for genomic research with a biopharmaceutical firm, but does not have active clinical trials linked to the partnership yet. As part of its personalized medicine focus, CTCA includes available molecular-targeted therapy approaches for breast cancer and hormone screening, according to Markman.
Terry Hisey, vice chairman and U.S. life sciences leader for Deloitte, agrees that genome cost reductions are a "major tipping point" for development of personalized medicine and, like Markman, has seen reductions in time and money. "A few years ago, it took a year and $75,000 to do the gene sequencing of a person, and now it takes a day and $1,000," Hisey says. "In terms of care capability, it's going to help the industry with the number of therapies available. Things are happening to accelerate and enable it."
The approach to target drugs for care will reduce not only costs but the time it takes to get needed pharmaceuticals, says William Dalton, MD, PhD, founding director of the Personalized Medicine Institute at the H. Lee Moffitt Cancer Center in Tampa, Fla., and CEO of M2Gen. "Ultimately, this approach in personalized medicine will reduce costs by getting the drugs right the first time," he says. His organization, along with the Sanford-Burnham Medical Research Institute in Orlando, Fla., and the 2,224-bed Florida Hospital, also in Tampa, have a personalized program partnership for research and clinical programs.
"Too often, people are treated with the same regimen, and only a portion of the patients will respond," Dalton says. "It's almost a trial-and-error approach. The personalized medicine approach increases the probability that patients will respond the first time, and that's good for everybody."
While the genomic costs are decreasing, some note that the reimbursement system for diagnostic tests has not evolved to accommodate the advances.
"The cost of testing, the jury is still out on third-party payers," comments Matthew Ferber, PhD, assistant professor of laboratory medicine and pathology at the Mayo Clinic, a 1,150-bed organization based in Rochester, Minn. He also is codirector of the Clinomics Transitional Program within the clinic's Center for Individualized Medicine. Ferber is planning a personalized medicine service line with an initial focus on cancer patients where physicians have been stymied in their care.
"While there has been some real success, it's too early for insurance companies to say this is the standard of care. There is still more work to do. Insurance isn't going to cover to perform the lab tests. But the technology is causing a paradigm shift. There may be no ROI right now; it's the ‘I' for investment. You are looking at the future where we need to be."
Smaller organizations may face the "financial burden" of building an infrastructure for personalized medicine, and "they might want to let it mature," Ferber adds. By engaging in partnerships with pharmaceutical companies, however, hospitals and health institutions may ease that fiscal burden.
Moffitt Cancer Center's Dalton acknowledges the journey toward personalized medicine is a complicated one.
"Our biggest challenge is not the technology," Dalton says. "The technology is there. We can sequence the entire genome, at a reduced cost. That's not the challenge. It's what you do with all this information; how do you learn from it?"
Success key No. 1: A team approach
At the 537-staffed-bed Oregon Health and Science University Hospital in Portland, the Knight Cancer Institute has begun treating patients using personalized medicine specializing in cancer care, with a multidisciplinary team of physicians and researchers, according to Alan Sandler, MD, oncologist and professor of medicine in the division of hematology and medical oncology at the institute.
OHSUH saw success from the advent of personalized medicine in its backyard years ago.
A hospital physician, Brian Druker, MD, was among the first to develop personalized medicine drugs at a time the hospital was already collecting tumor information. The drug, Gleevec, was approved by the FDA in 2001, and is used to treat chronic myelogenous leukemia, a blood cancer that strikes about 5,000 people a year, and other cancers. The discovery of the drug was based on a specific genetic signature. Its usage has been linked to long-term survival of patients compared to alternative therapy, and is considered more cost effective.
The discovery "changed the course of the disease, adding years to the patient's life. It is also a pill, as opposed to intravenous chemotherapy," says Sandler.
The Knight Cancer Institute includes a multidisciplinary team of physicians who review treatment options with patients, with one added element: Researchers are involved with personalized medicine. The physician teams work closely with the hospital's diagnostic lab staff to analyze a patient's tumor for potential genetic abnormalities that may help lead to appropriate treatment. The advanced diagnostic testing allows researchers to examine genetic differences in the cancer cells.
As an example of the personalized medicine approach, the cancer facility highlights the case of a woman who previously had lung cancer but was later diagnosed with a brain tumor as well. KCI researchers found that the same changes in the cells of the lung were involved in spurring the brain tumor. Subsequent testing identified the exact mutations unique to the tumor, within the cell, and indicated a genetic defect. Using that information, KCI began to use a personalized approach for her care, and tailored drugs for her specific needs.
For a series of patients, a wide range of genes is analyzed, with hopes of generating genetic profiles. Like many facilities, OHSUH has not released the number of patients involved in its personalized medicine program, nor has it defined outcomes yet. That will be resolved when clinical trials are completed, Sandler says. There are a "number of different approaches using molecular targeted therapy," he says. For each patient, within a few weeks after diagnosis, the hospital obtains pharmaceutical information about drugs that may be suitable. "We start with more traditional therapy and that way we haven't lost any ground while waiting for information," Sandler says. The hospital also has biorepositories that store cancer tumor samples for future treatment decisions.
"A number of patients don't have mutations discovered yet," Sandler adds. "For those that do, we have some medication for them. At this point, some 'abnormalities' lack effective therapy. That's where we have the emphasis on clinical trials."
One of the most significant clinical trials involving the institute is known as the I-SPY 2 trial, which is testing the possibility of new therapeutic agents for cancer compared to standard chemotherapy. The focus is on women patients with newly diagnosed, advanced breast cancer. As part of the process, researchers are using genetic or biological markers from individual patient tumors that will be screened for potentially promising treatments.
"We have scratched the surface,'' Sandler says. "The concept of personalized medicine takes on a number of different approaches, and one that is most topical now is using molecular targeted therapy," he says.
Success key No. 2: Cooperative ventures
The Moffitt Cancer Center's Total Cancer Care program measures the expression of approximately 30,000 genes that make up a tumor to find the unique genetic fingerprint for each person. It has teamed up with the Sanford-Burnham Medical Research Institute and Florida Hospital to initiate medical research and clinical care in personalized medicine. In addition, it is forming relationships with as many as 15 community hospitals in 10 states in a consortium also designed to advance personalized medicine.
In February, Moffitt, Florida Hospital, and Sanford-Burnham announced collaboration on the Personalized Medicine Partnership of Florida. The partners were brought together to deliver what they described as the "complementary strengths" of the various organizations: Florida Hospital's large population, Sanford-Burnham's fundamental research expertise and technology platforms, and Moffitt's biospecimen bank, data warehouse, and personalized medicine capabilities, says Dalton, Moffitt's director.
While creating the Personalized Medicine Institute, Moffitt also developed a research arm, a for-profit biotechnology subsidiary called M2Gen, which serves as a repository where research tissues can be stored for long-term use. For an array of clinical trials in personalized medicine, Moffitt has enrolled at least 90,000 people in the program. It also has built an informatics platform "that allows us to categorize the tumors' genetic and genomic profiles," Dalton adds, referring to the collection of data focusing on patients' genetic makeup. "None of that existed when we started this. The capacity didn't exist."
To date, the center has collected 32,500 tumors and profiled 16,000 of those tumors.
While storing data to be analyzed by researchers for potential long-term cancer care, Moffitt also has begun to focus on cancer patients who relapsed, Dalton says. "We are working to define the best therapy for these, including clinical trials for these patients," he says.
Of the patients who have been invited into Moffitt's Total Cancer Care program, most accepted the offer to be included in personalized medicine, according to Dalton.
In developing the cancer care protocol, Moffitt formed a patient advocacy and ethics council to assist, especially for any questions related to personalized medicine. As part of that, Moffitt developed a patient portal to the data warehouse that provides patients with their own medical histories, data, and other significant information, Dalton says. Eventually, the portal also will be used to enable patients to make informed decisions.
"What makes the Total Cancer Care study more than just a repository and tissue bank," Moffitt stated in its annual report, which touched on its personalized medicine program, "is the effort to integrate the collection, profiling, analysis, and long-term storage of biological samples with other patient information, all gathered on a large ongoing scale with active follow-up for the rest of the patient's life." The report also noted that the National Cancer Institute awarded Moffitt a Specialized Programs of Research Excellence Grant for lung cancers. The report states that it "involves basing the selection of treatment and molecular and genetic characteristics of tumors using gene therapy."
By working with other hospitals, Moffitt is developing a "hub and spoke" model for improved personalized medicine care throughout the region, says Dalton. The hospital has a five-year plan "involving many other sites and partners. Our hope is to partner with other National Cancer Institute–designated cancer centers," he says.
Success key No.3: Focus on the intractable
The Mayo Clinic is initiating a personalized medicine service line with a focus on cancer patients where physician care has been stymied.
At least two Mayo Clinic facilities, in Florida and in Arizona, are engaged in clinical trials for patients with intractable cancer, such as those of the brain, kidney, liver, pancreas, and skin, and other cases with patients who have cancer with suspected underlying genetic conditions, according to Matthew P. Goetz, MD, associate professor of oncology and pharmacology at the Mayo Clinic College of Medicine.
The protocols will be included in the Mayo Clinic's Individualized Medicine Clinic, scheduled to open this fall at the three locations. Patients have been enrolled at Mayo Clinic Florida and Mayo Clinic Arizona for a pilot on whole genome sequencing, although final numbers have not
been released.
While the clinical trials are under way, patient care will be evaluated, Goetz says. The plans include multidisciplinary approaches, including a team of oncologists, as well as genomics and cancer researchers. The Mayo Clinic's centers "as mandated, are to rapidly move forward in individualized medicine in different ways," says Goetz. "We are doing that by supporting research to the tune of millions of dollars." Goetz did not disclose the full amount of Mayo Clinic research linked to personalized medicine.
"If you look at the healthcare landscape right now, there's a sort of personalized approach that has been going on for decades. We didn't call it personalized," Goetz adds. "With the best data we have now, there is not a smoking gun for what causes cancer. We are left with how do we best understand genetic alterations, and the resistance to our best therapies. We are not going to get rid of the old therapies, but probably will continue them, and understand what are the mechanisms for resistance, and study them in a way it doesn't take 18 years to find an answer."
At the Mayo Clinic Florida and Mayo Clinic Arizona, hospital researchers are examining specific types of cancer and how personalized medicine may make a difference.
Patients enrolled at Mayo Clinic Florida are diagnostic odyssey cases–people whose symptoms are suspected of having an underlying genetic condition or heritable cause but have eluded traditional diagnosis. These are often rare or poorly understood conditions. Hospital officials believe the whole genome sequencing may offer more clues for diagnosis, as well as potential treatment and prevention, Goetz says.
At Mayo Clinic Arizona, researchers have been using whole genome sequencing to look for novel treatments for intractable and incurable cancers. Now, patients who have exhausted traditional treatments will have their tumor genomes sequences to identity pathways to make them suitable targets for therapeutic drugs. Then physicians can identify unusual or experimental chemotherapies, such as drugs that may be usually used for breast cancer, but also may be suited for lung cancer. The tumor genome analysis also can help researchers understand why some tumors respond better than others to chemotherapy, Goetz says.
A significant Mayo Clinic undertaking in personalized medicine includes its Breast Cancer Genome Guided Therapy Study, in which 200 patients have been identified and will participate in a clinical trial examining mutations that would allow some tumors to adapt and thrive during chemotherapy.
The project focuses on women with high-risk cancers. As part of the study, patients are paired with mouse "avatars" that are expected to help doctors identify the best individual treatment, according to Judy C. Boughey, MD, associate professor of surgery at the Mayo Clinic. The patients' tumor tissue will be kept alive by implanting cell lines in immune-compromised mice before and after chemotherapy. The use of the mice will let researchers study the impact of chemotherapy on each patient tumor without risk of harm to the patient.
The study has "real potential to bring individualized medicine to our patients," Boughey says. For patients who have a "higher risk for reoccurrence" of cancer, the project can open the door to "go forward and identify drug development and focus on these patients," she adds.
Patients are increasingly showing willingness to undergo tests to receive advanced experimental treatment in clinical trials, according to a study by the Mayo Clinic and the Translational Genomics Research Institute in Phoenix.
Success key No. 4: Pharmaceutical contracts
For personalized medicine, more hospitals are forming contractual relationships with pharmaceutical companies to develop drugs that may give them an upper hand in the race for improved cancer care.
"We have a long history of working with pharmaceutical companies, over five years," Moffitt's Dalton says. Moffitt has developed a strategic partnership with Merck & Co., which helped underwrite some of the cost of building the infrastructure and has partnered for scientific discovery, Dalton says. By collaborating on a framework with a pharmaceutical company, new drug targets are being developed, he says.
M2Gen, the wholly owned subsidiary of the Moffitt Cancer Center, is supporting the operation of the research initiative, according to the hospital's annual report. M2Gen is partnering with Merck and other pharmaceutical and biotechnology companies to launch clinical trials using the biorepository for data on an IT platform with Oracle.
The Moffitt-Merck research collaboration was formed in December 2006. Funding sources included Hillsborough (Fla.) County, the city of Tampa, and the state of Florida. According to the report, the M2Gen venture is "dedicated to using molecular technology to identify biological markers." Under the plan, M2Gen operations "assist in collecting and processing data, while also carrying out certain monitoring responsibilities."
Without disclosing specific details of the arrangement with the pharmaceutical firm, Dalton adds, "They don't know who the patients are, but they are able to mine the data we are creating and determine new drug targets, then develop drugs effective in patients not responding to new therapy."
Other healthcare enterprises also are working with pharmaceutical companies to develop personalized medicine programs. Earlier this year, the Cancer Treatment Centers of America announced it reached a research collaboration agreement with Merrimack Pharmaceuticals, a Cambridge, Mass., biopharmaceutical company, to better understand cancer on the molecular level and accelerate personalized treatments for the disease. As part of the collaboration, CTCA will provide archived tumor biopsies from its extensive tumor databank and collect tumor samples for analysis.
The collaboration could result in companion diagnostics to guide treatment. Merrimack CEO Robert Mulroy said in a statement that "the collaboration represents the future of individualized treatment, where a hospital and biopharmaceutical company work together on research, which we hope will ultimately result in much better treatment of cancer patients."
The Mayo Clinic also acknowledges the importance of working with pharmaceutical companies for potential personalized medicine drugs. Those discussions are for "early-stage development of drugs, or maybe drugs that haven't been developed yet and we provide a target," says Goetz, of the Mayo Clinic oncology department. "We are looking at collaborating with multiple pharmaceutical companies and an array of partners."
Indeed, pharmaceutical companies are actively pursuing personalized medicine, with as many as half the U.S. drug companies developing personalized medicine programs, according to Christopher-Paul Milne, DVM, MPH, JD, director of research at the Tufts Center for the Study of Drug Development in Boston.
"I haven't heard that companies are backing off their commitments to push forward with personalized medicine, especially as they are increasing their efforts to demonstrate the value of their products compared to competitor products or other therapeutic options," Milne says.
The government also has become deeply involved in promoting personalized medicine, with the Federal Drug Administration coordinating programs for oversight of its research centers to specialize in such programs.
More than 40 years after Nixon's declaration, the White House this year released its national bioeconomy blueprint that laid out strategies in U.S. biotechnology, noting that "advances in recent technologies have increased the momentum of personalized medicine, customized healthcare based on specific genetic or other information of an individual patient."
Reprint HLR0912-7
This article appears in the September 2012 issue of HealthLeaders magazine.
The other day, our 20-year-old son Max, afflicted with a painful throat abscess and its aftermath, was a patient in a suburban Maryland hospital. He smiled for the first time in days when he started feeling hungry and called the cafeteria from his bed, asking about available menu options.
Max was surprised at the range of possibilities, even though his diet was limited to soft food. "Desserts, too? And cookies, and cake?" he asked, stunned. Yes, no problem.
Our son didn't go for the desserts after all. Still, when he finished eating his meatloaf, and macaroni and cheese, he said, "Really good. Yummy."
Only a month earlier, we all were in Florida, where we dined one evening at the Cheesecake Factory in Coconut Grove outside of Miami. I remember Max exclaiming, "Really great, I'm stuffed."
Surely, there is no comparison between the high-quality Cheesecake Factory food and the better-than-average fare of the hospital, he remarked later. Then again, controlling infections and repairing throats is not the Cheesecake Factory's line of work. Nor is scrumptious food a specific hospital specialty.
But over the past month, there's been a lot of "food for thought" debate about how the highly regarded restaurant chain attained excellence, and whether hospitals can be mentioned in the same breath—not for the food, but for their overall line of work.
Criticizing healthcare delivery, Gawande wrote, "unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreal." Gawande, MD, is a surgeon at Boston's Brigham and Women's Hospital and professor of surgery at Harvard Medical School.
Was my son in a facility that should be run more like the Cheesecake Factory?
Indeed, Gawande's article has prompted much debate. Some say it points to exactly what healthcare needs to do in order to revamp fix itself by developing standards and more effective protocols. Others maintain the comparison is purely bunk, because the food service and healthcare industries don't mix.
One of the most interesting commentaries was from Steve Denning of Forbes,who noted that the notion that the Cheesecake Factory model or any other model is the best prospect for change in healthcare is to "fail to realize that the U.S. healthcare is a collection of different problems that will require different solutions, not a single model."
James Merlino, MD, the Cleveland Clinic's chief patient experience officer and vice president of the hospital's digestive disease institute, doesn't completely buy the whole Cheesecake Factory idea, either. But he supports most of it.
Healthcare in general "needs to be figuring out how we can reproduce things we do consistently, reliably, [and] in a precise manner that is cost effective," Merlino adds. "No question, it's the future, and 80% of the (Gawande) analogy is correct."
Then there's that 20% that the Cheesecake Factory model can't deliver, and that's the human element, Merlino says. "You can't take somebody out of fellowship into positions at Cleveland Clinic and expect the infrastructure to carry them," he adds.
A personal experience
I thought of those different models and the delicate balance of healthcare delivery, while we spent a day and night over the weekend in our son's hospital room.
It was a surprise to us that Max landed in the hospital Friday after battling a sore throat for days. On Thursday, his physician recommended an ear, nose and throat specialist do a procedure. After seemingly successful outpatient surgery, my son, who was battling dehydration, was immediately shaken with violent chills, and later, intense sweats.
The doctor matter-of-factly said we could drive him to the emergency department for IV rehydration, if we wanted, or we could go home and see how he did. We thought our son looked awful, so we opted for the hospital, which the ENT contacted to inform of our arrival.
I dropped off my wife and son and went back to work. When I showed up again an hour later at the hospital, my wife hurriedly told me my son's temperature had spiked to 104.8%, his heartbeat raced to the high 170s. He was whisked back to a bed, where doctors and nurses surrounded him to work on him "stat!"
The situation could have been serious. Their care stabilized him within an hour, as his fever and heart rate lowered with treatment. Our son stayed at the hospital two nights before he was allowed to go home. And when she called our house to check on him, my son's primary care physician told us it could have been a life-and-death matter.
I was seeing healthcare up close and personal and it wasn't pretty.
Why didn't the ENT suspect anything when our son was shaking with chills in his office after this dreadful procedure to remove the abscess? What would have happened if we had driven him home instead of going straight to the ED?
During the hospital stay, other things popped up: some nurses were incredibly nice and helpful; others were brusque. The staff told Max they wouldn't wake him up until the early morning, but instead put on lights at 3, 4 and 5 a.m. to check on him.
Before he was discharged, nurses advised seeing another doctor because his blood work indicated double the level of liver enzymes compared to normal. "Are you sure?" I asked the nurse. She called the physician on duty. "Oh, it's OK," she said later, apparently coming up with a cause for the elevated numbers after conferring with him.
It was an episode of healthcare showing initiation, teamwork, and purpose, but with some small, and not-so-small miscues along the way. Despite Max's big, one-bed room, and the dimly lighted hallways, and the flat screen TV and Wi-Fi access, some things were out of kilter. Not a lot, but enough to spike our concern.
Still, this was a hospital and health system trying. Outside the rooms of stroke patients were signs warning the staff that these patients had a tendency to fall. There were notes from the CEO on every floor asking for comment about the patient experience.
Our ENT doc followed up with a call to the hospital to ask how Max was doing.
And we were sent home with instructions, and a trifold invitation from the CEO to write our story—but I'm doing it here.
Even in that short time in the hospital, I witnessed the "variability of care"—those moments when a hospital has a chance to work smoothly in an assembly line fashion like the Cheesecake Factory. It worked beautifully in the ED.
Afterward, it was a tad more difficult. That's because healthcare must rely on vulnerabilities of the human condition, for better or worse. It reflects the frailties of the staff, not necessarily the patient. But the food was good.
A big hospital's take on the Cheesecake Factory
That double-edged sword, and the hope for efficiencies and the expectations of staff, are among the reasons that Merlino, the Cleveland Clinic's chief patient experience officer, doesn't see the whole Cheesecake Factory idea as being the answer for what ails healthcare.
Top officials of the Cleveland Clinic read the New Yorker article and evaluated it, while weighing the hospital's own procedures, Merlino says.
Looking at the article through a "data" microscope, Merlino says that its proposals to link healthcare to "reliability, precision, and operational efficiency" is certainly needed and being developed in healthcare. "That's about 80% right," he says.
But about 20% of the Cheesecake story is off the mark, Merlino says,
because there is an element in healthcare that involves experience among staff, involvement and passion, "that differentiates this kind of custom approach" from a restaurant chain, and can't be duplicated.
"When you get into complicated disease management, I may be biased because I'm a surgeon, but nobody behaves like everybody else, that's where skill and experience play a role," he adds.
"They can't come up in an assembly-line mindset. There may be up the road some diagnostic treatment computer that functions like some Star Wars machine. There's no question, 50 or 60 years from now, it will come to that. Now, there is still a requirement of the skill level and very important experience for a delivery of customized care that doesn't just roll off the assembly line."
At Cleveland Clinic, there are at least a dozen high-volume surgeons, "who are grounded by this tremendous process," Merlino adds. "But you can't put anybody in that role and you still have the skill mix and skill experience to make it a customized approach in healthcare to take care of the very sickest of patients. There's that highly skilled piece to manage patients, with experience that you can't get off the assembly line to do cookie cutter medicine."
One of your top cardiologists, a crackerjack moneymaker for your hospital, just had a great meeting with you about clinical goals. Everyone is smiling.
When the meeting ends and everyone disperses, your doc colleague is a different guy. Out of your view, he is loud and intimidating. He questions others' judgments and cuts people off in mid-sentence. He's abusive to the nursing staff and aides. Essentially, his behavior can undermine everyone's work, and be a detriment to patients. His actions are the very model of disruptive physician behavior, a phrase gaining weight in the healthcare lexicon.
This behavioral scenario isn't a figment of my imagination, or an anomaly. It is a too-common occurrence in hospitals and physician groups, and can even crop up in the operating room, says Liz Ferron, manager of clinical services and senior consultant for Physician Wellness Services in Minneapolis, MN, a company that helps physicians and health organizations through issues including managing behavioral problems.
Top experts from Sanford Health and other leading organizations demonstrate early intervention techniques and a range of effective resources that can help you reduce behavioral problems, retain star physicians, and create a healthier workplace.
No tolerance for mistakes
"The physician is feeling frustrated by some processes, or things aren't moving quickly enough," Ferron says, by way of explaining some of the "reasons" behind the behavior. Of course, there are a host of them, anywhere from stresses at home to the most likely: "someone who's a perfectionist, who doesn't allow mistakes or tolerate them," as Ferron puts it.
But the cranky outbursts are also open for public view. "Patients themselves see and know what's going on, and they may say, ‘we really don't like the way he treats other staff," Ferron says. "If these physicians are never given feedback, they are truly clueless about how they are impacting people around them."
Unfortunately, physician and hospital leaders too often tolerate such behaviors and don't give culprit docs the necessary feedback to halt the improper conduct, says David Danielson, JD, CPA, senior vice president for clinical risk management at Sanford Health, the largest medical facility in the Fargo, ND and Sioux Falls, SD regions.
"If there's a failure anywhere, it's with leadership"
Danielson oversees enterprise-wide clinical risk management programs and evidence-based practices to improve coordination of care. Dealing with disruptive individuals is an integral part of overall safety/risk/quality management programs run by hospitals and physician practices, he says.
"What's interesting is that if there's a failure anywhere, it's with leadership," Danielson explains. "They get scared at the last minute and back down, and yet the behavior goes on. Once leadership gets on board, there's a call for action. "
Those calls for action have been intensifying over the years.
In 2009 the Joint Commission issued an alert about "behaviors that undermine a culture of safety," noting that "intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction" and cause unwarranted employee turnover.
In 2011, a study of 840 physicians sponsored by the American College of Physician Executives (ACPE) and QuantiaMD, found that 77% were concerned about disruptive behavior at their organizations. More than one third of physicians said that disruptive behavior occurs at least once a month at their institutions, while more than one quarter reported incidents once per week. And more than 10% said that such incidents occur on a daily basis.
At least 99% of physicians believe that disruptive behavior ultimately affects patient care.
Physician stress / burnout a factor
While the survey reported that more than two-thirds of those who responded believe their organizations have a "clear, well-enforced policy" and "structured method" to report disruptive incidents, almost one quarter did not feel comfortable "directly confronting" the behavior, or feel well prepared to deal with incidents.
Last year, in a Physician Wellness Services/Cejka Search survey , 87% of physicians identified themselves as moderately or severely stressed and/or burned out, and 62.3% of physicians identified themselves as more stressed and/or burned out compared to three years ago.
Get out in front of bad behavior It's important to "look for early signs before a disruptive event occurs," says Alan Rosenstein, MD, MBA, medical director of Physician Wellness Services. He has focused research on the impact of disruptive behaviors on nurse-physician relationships, as well as patient safety and operational issues.
"Creating a solid foundation must start at the organization level, to create strong clear policies, and it applies to everyone—no exception," Rosenstein says.
For both hospital systems and physician practices, disruptive physician behavior can be expensive if left unaddressed, causing fallout from potential litigation to the cost of hiring replacement physicians, Rosenstein says.
The expense of problematic behavior can run as high as $1 million or more. That estimate covers impaired productivity and efficiency, as well as the costs to recruit and hire new staff as well as litigation expenses, according to Rosenstein.
Despite the potential impacts, only less than 16% of organizations have initiatives in place to deal with stress and/or burnout, they're either a) not enough, b) not relevant, c) not access or d) unknown, according to a Physician Wellness Services/Ceja Search study.
Hospitals and physician groups need to step back, evaluate their personnel policies, examine how their physicians are interacting with staff and patients, and let physicians know that there may be consequences for their negative behaviors.
Termination is only one option At the same time, it is important to make it clear that the physician doesn't necessarily have to be fired, or quit, depending upon their actions, says Danielson of Sanford Health. Through an extensive, cooperative process, the physician can maintain his or her position by taking steps to acknowledge, and eventually overcome, the abrasive behaviors, according to Danielson.
Sanford Health's human resources department works with its clinical and administrative staff to ferret out the root causes of such behaviors, and it organizes individual approaches to deal with disruptive behaviors, Danielson says.
"You have to feel you are ahead of the curve. Identify [the problematic] people and give them the assistance they need," he says. In some cases, the process can save hospitals from firing a physician, he adds.
Danielson works closely with Physician Wellness Services. Danielson also has been involved in the Vanderbilt University's Patient Advocacy Reporting System, an evidence-based assessment process designed to address behavioral issues that could impact patient safety and quality, as well as help reduce malpractice claims.
Various tools can be used to not only prevent disruptive behavior, but to deal with it if it occurs, according to Rosenstein.
Once a physician is agreeable to being counseled about disruptive behavior, he or she can be involved in "focused assistance." This offers various options, including coaching, various wellness activities, educational seminars, and revised scheduling. Beyond that, anger management counseling, and support for substance abuse are offered, according to Rosenstein.
Physician Wellness "tries to partner with physicians to be successful," says Ferron of Physician Wellness Services. "We're doing a psychosocial assessment of various different factors that may be contributing to behaviors."
Stop bad behavior before it starts Overall, it's important to stop disruptive behavior, or recognize the signs, even before it starts. "We try to head it off at the pass, working with the doctors and what's driving their behaviors and ideas, so that you can prevent it before you get to the disruptive stage," says Scott Hurst, who most recently served at CHRISTUS Spohn Health System in Corpus Christi, TX, as director of physician alignment and recruitment.
Putting up with the disruptive physician is getting old. "Everyone's been getting sick and tired of disruptive behaviors, notwithstanding Greg House on ‘House'," says Danielson. He was referring, of course, to the title character in the Fox TV show, "House," an irreverent misanthrope who is chief of diagnostic medicine at a leading teaching hospital. A look at some of the things House has said, reveals his abrasiveness.
"The integrity and reputation of an organization is more than any one individual, no matter how good he is, even Greg House at his best," Danielson says.
This article appears in the August 2012 issue of HealthLeaders magazine.
Officials at Metro Health Hospital in Wyoming, Mich., have been extremely pleased with the hospital's HCAHPS scores.
"We do very well in HCAHPS, and one of the things is we have a beautiful new hospital," says Cindy Allen-Fedor, RN, MPA, CPHQ, executive vice president for quality. "Just being in a beautiful place doesn't necessarily make a patient happy, but it's a nice place to be," she says of patients' attitudes about the hospital.
The 208-staffed-bed, $150 million medical center with six floors for patient care opened its doors in 2007 with what hospital officials described as "spacious patient rooms, curved corridors, plentiful natural light" as well as expansive outdoor views.
The facility has enough amenities to help the HCAHPS scores, Allen-Fedor says. For instance, patients gave the hospital higher ratings than the national average for being quiet, and the bathrooms were considered much better, too. For the most part, patients liked nurse and physician communication. Overall, 81% of patients gave Metro Health a high rating, compared to the national average for all hospitals of 68%.
But that doesn't mean hospital leadership is free of the pressure to do even better in HCAHPS, Allen-Fedor says.
There are two nearby hospitals, and Metro's new facility won't stay new forever, Allen-Fedor notes.
"You can never rest," she adds. "Everyone around us is getting better and maybe working harder than we are. Still, we are focused all the time. We know patients can go anywhere they want and we appreciate them coming to us, and we tell them that."
"After you leave a flight with an airline like Delta, they say, 'Thank you for choosing Delta.' It's the same thing with healthcare; it's very competitive, and thanking people for choosing Metro is an important part of what we do," Allen-Fedor adds.
The hospital relies on specific teams that oversee specific aspects of patient satisfaction areas covered by HCAHPS. Each team has a champion who coordinates its efforts, Allen-Fedor adds.
Each champion, who may be a nurse, clinical director, or physician, reports to a hospital quality improvement committee and medical executive committee. Those committees, in turn, report to the hospital C-suite. "Different areas of the hospital have dashboards, and they monitor their own unit scores," Allen-Fedor says "They work on any improvements needed."
Metro has worked closely with consultants to tweak nurse and physician interactions with patients to improve HCAHPS scores.
"You tell the patient you are taking care of them, you are knowledgeable, and you are glad they chose Metro," Allen-Fedor says, referring to when nurses, for instance, greet newly arrived patients. "If a patient is waiting, you might say, 'We expect you to be in the room for 15 minutes.'" If you can explain why there will be a delay and how long it will be, it helps. "You explain procedures so patients understand."
This article appears in the August 2012 issue of HealthLeaders magazine.
Angioplasty and the insertion of stents are among the more widely accepted and seemingly understood medical procedures, even among laypeople. For instance, my octogenarian mother told me the other day about an acquaintance with a heart condition. "He's only in his 40s, but he's had a stent, and he's doing great. You know, an angioplasty." She's no M.D., but she is conversant in the subject.
But after decades of acceptance, this commonplace surgical procedure is at the center of many heated discussions in medical circles these days. Academics and doctors are clashing over the proper surgical procedures for stents and angioplasties and, even more surprisingly, challenging the fundamental necessity for stents, the "tiny mesh sleeves" designed to keep coronary arteries open.
It's not an open or closed case.
Stents are under the microscope now more than ever, especially with the recent focus on the for-profit hospital chain investigating HCA in the wake of a New York Times report of allegations that some HCA hospitals were performing unnecessary and sometimes dangerous heart procedures with the aim of driving up revenue.
One of the key focuses of the investigation is whether there was unnecessary stenting for patients who did not have significant coronary artery blockage. About 1,200 cardiac interventions that were deemed to be unnecessary were completed at the Lawnwood Regional Medical Center in Fort Pierce, Fla., according to the Times.
The 4,000-member Society for Cardiovascular Angiography and Interventions (SCAI), a Washington, D.C.-based organization representing invasive and interventional cardiologists, is one of the main special interest physician groups whose constituents perform such procedures. SCAI is watching the unfolding scenario involving HCA closely.
The group also monitors clinical trials and studies that often report contradictory findings about stent use, raising concerns among physicians. The question of unnecessary stenting goes to the heart of what SCAI is trying to do to improve outcomes for hospitals as well as physicians, and especially patients, says Jeffrey Marshall, MD, president of the SCAI, who practices at the Northeast Georgia Medical Center in Gainesville, GA.
With all the controversy involving stents, SCAI is stepping up its accreditation process for cardio labs and stepping up calls for hospitals to use registries to document stent use.
The organization has partnered with the American College of Cardiology to form a separate not-for-profit named Accreditation for Cardiovascular Excellence "to evaluate and accredit cath labs in our country," Marshall says. The organization was established two years ago. "These things started before (the HCA questions arose,) and now there is beginning to be a groundswell of support in the medical community for it," Marshall says.
"There's a vigorous evaluation of cath labs. Processes are being examined for quality. So the SCAI has been way ahead of the curve on these things."
Indeed, there has been a curve, in the unsteady and contradictory studies and reports on the use of stents or angioplasty. One of the most significant and highly publicized was the 2007 COURAGE study (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), which essentially found that patients undergoing medical therapy had outcomes that were just as good as angioplasty or stent placement to relieve their angina.
The study revealed that percutaneous coronary intervention (PCI)—the medical term for angioplasty—offered "no benefit over aggressive medical management when performed in patients with stable artery disease and suggests that PCI may be deferred in patients with stable disease as long as medical therapy is optimized and maintained."
On the flip side, another recent clinical trial gained attention this year because it seemed to favor stenting in particular cases, although it was never completed, prompting even more debate. That study, from St. Jude Medical, a medical technology company, called FAME II, examined the outcomes of 888 patients with significant blockage of at least one coronary artery.
Researchers used a new technique—known as fractional flow reserve—to decide if a patient should have a stent or not. The study authors suggested that FFR could help doctors figure out whether a patient's coronary blockage was going to put them at risk for a heart-related emergency, such as a heart attack or chest pain. The trial was stopped early because those who had not received stents experienced more heart attack symptoms and emergency hospitalizations than their stent counterparts.
St. Jude Medical acted after the Data Safety and Monitoring Board found "increased patient risk for major adverse cardiac events among patients randomized to optimal medical therapy alone compared with patients randomized to optimal medical therapy plus (fractional flow reserve) guided PCI. At the time the study was stopped, 12.7% of patients without stents had experienced one of these cardiac events while only 4.3% of people who received stents had.
In an understatement, the American College of Cardiology Foundation and SCAI issued a report this year on cath lab standards that notes stents have become a "particular hot button issue since the publication of certain politically provocative articles."
The report noted that stents have been overwhelmingly successful, citing, among other things, a Mayo Clinic report in 2009 that published 25-year trend data regarding the hospital's experience with angioplasty or PCI procedures. It found that despite an older and sicker population with more comorbid conditions, the success rate from PCI had improved from 78% to 94%, while hospital mortality had fallen from 3.0% to 1.8%.
But as my colleague Cheryl Clark writes, a study reported this year in the Journal of the American Medical Association noted that inappropriate angioplasty "still goes on—a lot." Of 14,737 non-acute patients who underwent a PCI, 11.6% did not meet the necessary criteria for a 15-month period ending in September 2010.
One of the ways that physicians can evaluate stents is by becoming involved in registries, SCAI's Marshall says. Indeed, the American College of Cardiology report notes that it strongly encourages all laboratories to participate in national registries. That way, "all laboratories can benchmark their performance and make appropriate corrections."
The controversy over the use of stents will not go away, no matter how familiar the little artery openers are to the patient population. From Marshall's perspective, patients' quality of life generally improves with angioplasty or stents. "I think it's very clear, in certain situations—specifically if you are having a heart attack, for instance—the best treatment, and to save lives, is to have a stent," Marshall says.
But, he adds emphatically, "SCAI is very concerned, I would say deeply concerned about any inappropriate use for stenting," referring to the HCA allegations. "There's a real sense of dismay, and that bothers us." Marshall says. "Ultimately, quality of life is what we are most concerned about."
This article appears in the August 2012 issue of HealthLeaders magazine.
It sounds like a conflict of epic proportions when you talk to some healthcare leaders. As David Levin, MD, former chairman of the department of radiology for the 969-bed Thomas Jefferson University Hospital in Philadelphia puts it, "There are turf wars, and there's been a big turf war between interventional radiologists and vascular surgeons."
Levin is referring to a longstanding healthcare issue: the disputes between interventional radiologists and other physician groups that center on which medical professionals should do certain procedures. Today, more health systems see the value in working to overcome the conflicts and finding ways to thrive in models where radiologists collaborate with physicians from different service lines.
Interventional radiologists' main focus is minimally invasive techniques that can produce improved outcomes, reduced infection rates, faster recovery time, and shortened hospital stays. But, as more cardiologists and vascular surgeons use interventional techniques—and as interventional radiologists move into the other physicians' territory—doctors and hospital officials see an increased need to manage a delicate balance of these relationships.
Hospitals are intently working to improve collaboration among physician groups. Experts say that team approaches are crucial for improved outcomes and more efficiencies of care. To that end, hospitals are ensuring that radiologists and other physician groups consult with one another and are working on programs that rotate their reading of x-rays and work with CT scans.
Interventional radiologists saw themselves years ago as among the first minimally invasive specialists; they were using their expertise in angioplasty and catheter-delivered stents to treat peripheral arterial disease. Soon, cardio and vascular surgeons increased their use of interventional techniques, which set the stage for territorial disputes.
"Historically, interventional radiologists have been doing catheter-based interventional procedures literally since 1963, when the first angioplasties were done," says Timothy Murphy, MD, medical director of the Vascular Disease Research Center at the 719-bed Rhode Island Hospital in Providence. "Surgeons for years denigrated the interventional procedures and wanted to operate on people. But then they had an epiphany, decided that surgery wasn't so great and they wanted to adopt interventional radiology procedures."
But the reverse was also true: Other specialties saw interventional radiologists infringing on their work.
"I think at one point in time interventional radiologists encroached on other people's turf," says Eric Russell, MD, FACR, a neuroradiologist and chair of the department of radiology for the 894-staffed-bed Northwestern Memorial Hospital in Chicago. "I don't see it as a unidirectional issue. We are trying to find a middle ground once conflicts have potential to rise, and try an approach that is good for the patient. It's hard when you are doing business, but ultimately that is what we have to focus on."
In recent years, interventional radiologists have expanded into new areas such as nonsurgical ablation of tumors to kill the cancer without harm; carotid artery angioplasty and stenting to prevent strokes; and treating liver tumors with intra-arterial yttrium-90 radioembolization, or tiny beads of radiation, to improve outcomes.
Some hospitals, such as the 960-bed Emory University Hospital in Atlanta, have launched cooperative vascular programs, involving vascular surgeons, interventional radiologists, and interventional cardiologists. Radiologists rotate in programs with other specialists and work in vascular clinics while consulting with other cardiovascular specialists, according to Kevin Kim, MD, director of interventional radiology and image-guided medicine and associate professor of radiology obstetrics and gynecology, hematology, and medical oncology and surgery at the Winship Cancer Institute of Emory University.
"Interventional radiology covers a wide spectrum of disease, from peripheral vascular to spine disease to cancer therapies, you name it," says Kim. "Our field is a young field, but it has advanced substantially in light of imaging technology advances and is making image-guided interventional therapies less invasive and more efficient and cost effective.
"I cannot say there is no turf war even in our system, but when it comes to liver cancer, for instance, all the specialists come together with their own expertise and evaluate the patient. The patient comes in and everybody literally sits together. The patient gets the benefit of opinions, and the expertise of the multiple specialties in the same visit," Kim adds. "We work hand in hand in collaboration," which also means sharing in reimbursement.
Interventional radiologists grapple with one overriding issue: their relatively low profile to the public. "A major obstacle is that people aren't familiar with interventional radiology as a name. It has low recognition compared to something like cardiology, which is a chronic problem for interventional radiology as a whole. We just have to get the message out there that we have a lot to offer patents," says Dan Brown, MD, director of interventional radiology at Thomas Jefferson
University Hospital.
Interventional radiology—a recognized medical specialty by the American Board of Medical Specialties, which certifies these specialists—also has trouble commanding respect within the larger physician community. Murphy expresses concern that other physicians besides radiologists have been able to obtain interventional privileges without proper training. "The problem is the board of examination process," he says. "There should be a higher bar to get privileges, not a lower one."
Success key No.1: Team concepts
Russell, the chairman of the department of radiology for Northwestern Memorial Hospital, years ago began to look around the landscape of interventional radiology at his hospital and saw it was changing immensely. For one thing, vascular surgeons were performing procedures that interventional radiologists had handled for many years. "You lose control of the situation to some degree; that is a common theme," he says.
It was important for the radiologists not just to lose control, but also to initiate cooperation, he says. As a result, Russell began a cooperative program with other specialists that led to improved working relationships among physicians, while delivering more efficient patient care. The hospital started seeing so much improvement in patient outcomes, in fact, that vascular surgery and interventional radiology departments combined resources and shared expenses to form a vein center within the Northwestern Medical Faculty Foundation. The center provides treatment for patients with varicose veins, spider veins, and vein-related pain. Performing minimally invasive procedures is a cornerstone of the program.
"We have had collaboration, so as turf issues developed, that helped to overcome any problems," Russell notes. "We had institutional backing throughout the hospital to keep things balanced. Now we have a shared practice in cardiac-specific imaging, so we've been able to avoid any real conflict." Interventional radiologists are seeing increased volume related to other interventional procedures, primarily interventional oncology, he says. "We also have taken on the responsibility of taking over interventional radiology programs at smaller, local hospitals," he says. It was important, too, for interventional radiologists to become involved in cancer therapies. "That's a key program for us," he adds, noting that interventional radiologists can't simply rely on vascular procedures to generate income. If that was the case, "we would have suffered a drop in overall procedure volume if we didn't have new avenues," he adds.
To continue overcoming turf wars, Russell says it is important that the hospital coordinate an enhanced training opportunity for both interventional radiologists and vascular surgeons. "We worked out a system where vascular surgeon trainees could come down to the interventional radiology team, and our trainees would go up to vascular surgery. Because we have radiologists and vascular surgeons who respect each other, we've been able to accomplish that," he says.
To thwart turf wars, the 570-staffed-bed Harbor-UCLA Medical Center has designated champions for specific aspects of care, either interventional radiologists or other physicians, to coordinate patient care and multidisciplinary surgical programs. "A decision is made upfront about what procedure is best for the patient, with the single person as the point person to determine what is equitable and honest," says Matthew Budoff, MD, director of Harbor UCLA BioMED CT Reading Center. Those champions could be an interventional radiologist or vascular surgeon or cardiologist, for instance, he adds. Various team champions are designated for areas of cancer or cardiac care, for instance. Patients are evaluated on a case-by-case basis, and champions determine whether interventional radiologists or other specialists should lead the procedures.
"When you have a motivated radiologist who wants to do a cardiac CT, he knows he's treading somewhere in the cardiac space, and knows he should reach out to cardiologists. And vice versa. When a cardiologist is in the interventional radiologist's space, he knows he should reach out to an interventional radiologist. I think there's motivation to work together. It's harder and harder for small radiology groups to own their own equipment. We have rotation of reading images. I think there's a motivation to work together. They can refer patients and control the patient flow. It's a win-win situation."
"I see the turf wars going away largely," he says. "I train quite a few cardiologists and radiologists for CT, and both groups are in my office working side by side."
Success key No. 2: Improved patient outcomes
Improvements in the technology used by interventional radiologists are advancing their status as well. For instance, implanting small radioactive beads that cause tumors to die are enhancing programs in the treatment of liver cancer for improved patient outcomes, says Brown of Thomas Jefferson University Hospital, which is stepping up the procedures. As patient outcomes improve, Thomas Jefferson is finding its results are drawing the attention of patients seeking interventional radiology treatment for their own cancer. Over the past four years, there has been a 35% increase in patients being treated by interventional radiology with a sizeable increase in cases for liver cancer at Thomas Jefferson University Hospital, with about 600 seen annually, Brown says. "It has grown so much. It's a huge part of our interventional radiology practice, a large chunk of what we do. It makes the hospital happy and gives us much professional satisfaction. We've had good results and the work has built itself up."
Primary liver cancer forms in the tissues of the liver, and secondary liver cancer spreads to the organ from other parts of the body. This year, an estimated 28,720 new cases are projected, along with 20,550 deaths, according to the National Cancer Institute. Brown says advances in interventional radiology for treatment of liver cancer use a technique that allows for a very high dose of radiation to be delivered without much impact to healthy tissues in the body.
In the Journal of Vascular and Interventional Radiology, the Jefferson team reported on improved results using yttrium-90 radioembolization, a treatment that consists of radioactive microspheres (tiny beads) that are injected through a catheter from the groin to an artery supplying the tumor. The beads cause tumor cells to die.
While radioembolization is not a cure for liver cancer, the treatment has fewer side effects than other cancer treatments and it extends life. Thomas Jefferson researchers found in a study of 81 patients treated for primary or metastic liver tumors that the radioembolization is not only a safe treatment, but 90% of the people in the study who received infusions showed no or few changes in liver function, according to Brown, who was the senior investigator on the study.
Northwestern Memorial Hospital also is performing the procedure, which allows for increased doses of radiation to the tumor while sparing nontargeted adjacent normal tissue. The beads, smaller in diameter than a human hair, are injected into the liver, and irradiate it for 12 days. A key element of the procedure for cancer patients is that it offers them the opportunity to be treated without facing radiation or chemotherapy side effects, such as loss of hair or nausea.
Success key No 3: Less cost, more safety
For years, peripheral arterial disease, a common circulation problem popularly referred to as "hardening of the arteries," has been a major focus of interventional radiology treatment. PAD is narrowing of the blood vessels in the leg, which limits the supply of oxygen and nutrients to the leg, causing pain and discomfort. It affects 10 million people in the United States and can lead to heart attack or stroke.
The interventional radiologist often can treat PAD using minimally invasive techniques, relying on miniaturized tools, x-rays, and catheters to perform angioplasty or insert stents. Occasionally, open surgery is necessary to remove blockages from arteries or to bypass clogged arteries in procedures performed by vascular surgeons.
Another area where turf wars have developed is in the area of determining whether the PAD techniques of cardiologists and vascular surgeons are equitable to those of interventional radiologists. Murphy, at Rhode Island Hospital, wanted to verify what he thought would be improved outcomes for interventional radiology compared to other specialists.
He did.
In a review of treatments for 14,000 Medicare patients 65 and older, endovascular lower-extremity revascularization procedures were shown to require fewer repeat procedures, less intensive care use, lower costs, and shorter hospital stays when done by interventional radiologists compared to vascular surgeons.
Overall, there were lower costs, too, according to the study Murphy published earlier this year in the Journal of Vascular and Interventional Radiology, in which the outcomes of PAD treatments were reviewed. The average one-year procedure cost by interventional radiologists was about $17,640, which is $1,372 less than the same procedure done by vascular surgeons. Such savings could translate to $20 million a year, according to Murphy.
Murphy says the study proved the importance of interventional radiology, particularly in PAD, and the likelihood that it should be incorporated into other programs. "When vascular surgeons do the procedures, they are not as invested as interventional radiologists, in my opinion, because if the procedure doesn't work, they have a fallback and can provide an open surgical procedure. Interventional radiologists have no other procedures and get it right the first time," he says.
A decade ago, interventional radiologists were doing a greater percentage of PAD cases than today, because many other specialists are now performing them, Murphy says. However, the volume of cases "is still large and still growing." He says he did not carry out the study to perpetuate turf wars, but to reinforce the need and importance of interventional radiology in procedures.
Success key No. 4: A new building, new imaging
As soon as the University of Buffalo Medical Center and Kaleida Health teamed up to build the new, 10-story Gates Vascular Institute, which includes the Kaleida Health Gates Stroke Center, the turf wars started deteriorating, says Elad Levy, MD, FACS, FAHA, director of the endovascular stroke service for the Gates Stroke Center.
It began with a new structure, and also with new imaging technology improvements.
Having a new building adjacent to the 610-licensed-bed Buffalo General Hospital made it easier to develop multidisciplinary approaches and overcome turf wars. The building features four floors dedicated to surgical and interventional management of cardiac, vascular, and neurological conditions, as well as interventional labs, CT scanners, and MRIs.
"Doctors are working right next to each other and it forces doctors to work together from different disciplines. We are constantly interacting all day long," Levy says. "Before, you'd be in silos. In the old hospital, the physicians would be on a different floor. We have multidisciplinary work on a daily basis."
Imaging technology improvements also were important to not only bring the team members together, but also for better patient outcomes, according to Levy.
"Cardiologists have been using stents in the heart for a decade before we have begun to use it in the brain," he says. "We were seeing how we could adapt that for a stroke. Out of that has come new stroke technology."
A Kaleida Health Gates Stroke Center study found more than $2 million in annual cost savings with installation of a new CT system that dramatically reduced the time it takes to diagnose stroke symptoms. Patient length of stay also was reduced, through advanced imaging technology, improved training, and multidisciplinary approaches, according to the hospital system. The study had compared inpatient data before and after installation of the imaging technology.
The most advanced CT scans can take in an entire brain in a single pass, producing videos that show the brain's structure, movement, and blood flow, whereas previous CT scans can only capture a portion of the brain. Levy credits the new technology—known as Toshiba Aquilion ONE—with allowing hospital physicians to perform whole brain perfusion and digital angiography more efficiently.
The hospital reported a decreased length of stay from six to five days for a stroke. The hospital also reported a 14.8% improvement among patients discharged to their homes, and a 48% reduction in patients discharged to skilled nursing facilities.
Every day, Levy finds that multidisciplinary teams, working together, are overcoming the turf wars for meaningful returns.
In one incident, "we were doing a brain procedure and the patient was having a heart attack on the table," Levy recalls. "Normally, that would be a disaster, but right next door to us was the interventional cardiologist. He did what he had to do with the patient's heart. There was no lag time. He was 10 feet away. He saved the patient's life."
This article appears in the August 2012 issue of HealthLeaders magazine.
Hospitals are finding that excellent clinical outcomes don't always translate into patient satisfaction. A top notch surgery track record can be trumped by a lousy bedside manner. In a split second, a shift change or some other personnel move, can alter the patient's experience from "great" to "get-me-out-of-here."
As hospitals try to improve their satisfaction scores, physicians are playing a crucial role to bridge that clinical and patient satisfaction gap, with many federal dollars at stake.
David Fox, president and CEO of the 326-bed Advocate Good Samaritan Hospital in Downers Grove, IL, attributes his facility's high clinical and patient satisfaction scores to long-term planning for improved clinical and patient satisfaction. Thomson Reuters (now Truven Health Analytics) named the 326-bed Advocate Good Samaritan Hospital as being among the nation's top healthcare systems.
Fox connects much of the hospital's success to an intense concentration on training and hiring staff, particularly doctors and nurses. As the hospital evaluates the potential staff, Fox says there also is a major focus on how a prospective employee might impact patient attitudes. "We, as human beings, can have a tendency to remember the negative and it overwhelms the positive," Fox told me.
"So we've gotten very focused on who gets to work here, and how we train them on customer service. We used to hire for skill and pray for attitude and cultural fit. Now we screen for skill, but hire for cultural fit and attitude. As a result, we get many wonderful letters from patients in almost all categories."
Advocate Good Samaritan uses "peer" interviewers, including physicians, to screen job applicants. At least 450 employees within the system are trained to conduct behavioral-based interviewing, he adds. In that way, the hospital targets potential employees who would be a good fit in their organization, those who will demonstrate a terrific attitude and focus about the job.
When peer reviewers have a "bad feeling about the employee, they would tell the manager to try again," Fox adds. "It gives an extra check on the person we are bringing in, and it creates some ownership for the employees they help hire. It also gives us strong behaviors and a good cultural fit," Fox says.
From his C-suite position, Fox spends nearly two hours a week getting to know new hires. "About eight years ago, if I spoke to 30 people (newly hired), there might have been 10 in the room who were physically present but not really engaged. It used to drive me crazy," Fox says. "That has changed. If someone doesn't have 'life behind their eyes,' we don't hire them anymore."
The hiring process is one of the first steps for Advocate Good Samaritan and others to bring together the clinical and patient outcomes, with an eye on improving HCAHPS scores. Under the government's value-based purchasing program, the Centers for Medicare and Medicaid Services plans to pay bonuses from an $850 million pool to hospitals that score "above average" on certain quality measures. In 2014, patient satisfaction scores will determine 30% of the bonuses, while clinical process of care will make up 70%.
For Advocate Good Samaritan and other hospitals, once a staff is assembled, weekly rounds have become increasingly important—not only to improve clinical work, but also to improve patient satisfaction.
Improved education programs also are important for physicians and nurses, with hopes of making these healthcare professionals more sensitive to the needs of patients, and aware of the patient concerns. Physicians, in particular, are being advised to exhibit a better bedside manner by sitting near the patients' beds, possibly holding the hand of an older patient and looking him or her in the eyes.
Obviously, communication is an integral part of the program, but that's easy to say. For hospitals and healthcare systems, it's how that value is implemented.
The Iowa Health System is another system that is not only examining its clinical improvements, but also focusing on HCAHPS scores through a Patient Experience Team, says Gail A. Nelson, director of learning and innovation for the Iowa Health System, based in Des Moines. The system includes 10 hospitals in Iowa and one in Illinois. The team, which includes physicians and nurses, emphasizes that patients should be communicated with in ways that they understand.
While HCAHPS surveys are important, they only go so far. "We have a broader focus on patient satisfaction and experience than what we can learn from surveys," she adds. "In this work, we have defined for each Patient Care Unit the meaning of 'ideal care' – what our patients and families will say to us (is) the care they want and need," Nelson says.
"These skills are spreading from our hospitals to our home care agency and physician practices across the state," she says. Nelson adds that the hospital uses the adaptive design initiated by John Kenagy, MD, author of Designed to Adapt: Leading Healthcare in Challenging Times, that emphasizes creating solutions to problems "as they happen on the front line."
"We are extremely pleased about our work with adaptive problem solving. It changes culture, engages everyone, reduces harm to patients and alters the way we think about moving patient experience and satisfaction scores," Nelson says. "It isn't about chasing HCAHPS scores; it's about smoothing processes, working together as teams and delivering on ideal care. Patient satisfaction and experience scores have improved as teams and clinical units improved their process of problem solving and focus on ideal care."
In essence, the health system is exploring ways to "improving care delivery across the continuum," says Alan Kaplan, MD, MMM, FACPE, FACHE/ VP and chief medical officer, Iowa Health System and President of Iowa Health Physicians. In discussions with patients, physicians and nurses "ask if they have the help they need at home, and whether patients receive information on symptoms (about their conditions) to look for after they leave the hospital," Kaplan says.
After those conversations, the hospital compiles data on whether that communication was successful or whether "targets are not achieved or we are trending in the wrong direction," Kaplan adds.
In this month's Health Leaders Media Intelligence report, 54% of health leaders say HCAHPS is not an effective measure of patient experience. Although some health leaders I've spoken to aren't thrilled about HCAHPS, they find that the surveys are effective in pushing hospital systems in the right direction.
HCAHPS are but one of many data points that health systems are measuring for clinical and patient outcomes. As health systems evaluate all of them, they must decipher what is the best fit.
"We have CMS, and they have certain metrics important to them. When we talk about ACOs (Accountable Care Organizations), each commercial insurer has their own sets of metrics, and then state Medicaid programs may come with their own set of metrics," says Kaplan.
Achieving good outcomes "has been a major focus for us, with all of our internal meetings, the meetings of the executive board and the meetings with community stakeholders," he says. "Ultimately, we need to deliver the service that matches our science."
Fox of Advocate Good Samaritan Hospital says sometimes it's that "moment in time" that makes all the difference in how a patient feels about the hospital experience, including relationships with physicians and nurses.
"For the patient, on average, they spend 3.7 days at a time in a hospital and may interact with 70 people, possibly," he says. "If one employee isn't doing a good job, or a physician, then the patient is going to go away probably with a good experience, but probably not an overwhelmingly great experience."
This article appears in the August 2012 issue of HealthLeaders magazine.
The Stony Brook (N.Y.) University Medical Center's staff role-plays scenarios about what can go wrong with patients at the 597-staffed-bed hospital and how to make it right. In these make-believe scenarios, "patients" may fuss. Demand. Need above-and-beyond assistance.
They are ... well ... being impatient patients, and the idea is for hospital staff, especially nurses, to keep their cool, while showing that they are concerned. Do the right thing. Care.
The medical center on Long Island's North Shore finds that playacting improves its staff's performance in real life, and it uses this approach to learn more about keeping patients satisfied during their hospital experience. While a hospital stay often lasts for fewer than four days at a time, the patient may encounter dozens of healthcare professionals and other hospital personnel during that time. "We have actors pretending to be patients, and these four-hour sessions are scenario-based, for nurses specifically to hone their communication skills," says Michael Maione, director of customer relations for Stony Brook. Maione is responsible for evaluating patient satisfaction measures for the hospital.
Indeed, the hospital is among thousands across the nation trying to not only improve patient satisfaction, but also obtain ROI for doing so. Under the government's value-based purchasing program, the Centers for Medicare & Medicaid Services plans to pay bonuses from an $850 million pool to hospitals that score above average on certain quality measures. In fiscal 2013, patient satisfaction scores will account for 30% of the bonuses, while clinical process of care will make up 70%.
Stony Brook is among many high-achieving clinical facilities that have done well at improving patient satisfaction scores in some areas while struggling in others. For instance, Stony Brook won awards this year for its cardiology care, but scored only a 73% from patients—compared with 77% for the national average—for how well nurses always communicate with patients. The hospital also scored just 57% from patients about receiving medication information, compared with 61% for the national average.
The scores are part of the Hospital Consumer Assessment of Healthcare Providers and Systems 27-question survey given to a random sample of eligible patients after discharge to assess their perspectives on their healthcare. Questions include: Would you recommend this hospital to your friends and family? How often did nurses explain things in a way you could understand? How often did doctors listen carefully to you? How often did the hospital staff do everything they could to help you with your pain? How often was the area around your room quiet at night?
The high bar of 'always'
In HCAHPS, most of the questions offer four response choices: never, sometimes, usually, and always. But healthcare organizations only receive credit for the "always" responses. "The patient has to feel every single interaction has been correct and there is a right interaction, and that's a high bar," Maione says. "It's a challenge and we're looking for ways to make an impression for patients to have a great experience."
To that end, Stony Brook isn't just playacting its way toward better performance for its patients. It also has taken steps to improve educational programs for physicians and nurses, with hopes of making them more sensitive to the needs of patients and more aware of their concerns. The hospital initiated weekly rounds when hospital leadership visits patients' rooms, asks patients questions, and evaluates the responses in internal reporting and committee meetings. The effort is to continually improve the process.
Hospitals want to give patients that one-on-one feeling whenever they can. They are improving bedside reporting by increasing how frequently nurses relay updates to each other on patients' progress throughout the day; adding time to nurses' visits in patients' rooms; and encouraging physicians to sit down near patients' beds, possibly holding the hand of older patients, and definitely looking them in the eye. Hospitals call patients or write to them—within hours after discharge. An oncology patient recalls just returning from the hospital, still sorting out the prescriptions on the kitchen table when the phone rang. It was the hospital, asking, "How did we treat you?" Hospitals tell the frontline staff, "Be nice. Be friendly." And, they hope, the patients will notice their outstanding efforts to care.
"We really have to put ourselves in the same area as hotels. Patients expect hotel-like service, with the food and people responding to their calls. We have to be able to do that," says Wendy H. Solberg, FACHE, CPHQ, vice president of quality and patient safety at Baptist Health System in San Antonio, Texas, which has 1,674 beds at five acute-care hospitals. But it's not really a hotel, and that's a big issue for hospital leaders, Solberg acknowledges. One of the problems is that "you are dealing with perception," she says. "You can treat [patients] great, but if you aren't nice to them, it takes some of the shine off a great thing you've provided in healthcare."
Hospitals tackle dealing with patient satisfaction in different ways. Some evaluate job applicants with an eye on the prospective hire's personality and possible relationship with patients. Others are continually evaluating how physicians and nurses interact with patients, taking steps to intervene to improve patients' perception of the professionals' care. Most hospitals have a steady stream of action plans and reports that flow to and from the C-suite on how they are doing with patient satisfaction.
Dealing with the disconnect
For those hospitals that have extremely high clinical rankings, when relatively low HCAHPS scores are delivered, it's a wake-up call.
Stephen Weber, MD, chief medical officer and vice president for clinical effectiveness at the 547-licensed-bed University of Chicago Medicine, talks proudly about how UCM has worked diligently to improve infection rates at all of its hospitals, but concedes that it has fallen flat in patient satisfaction. Scores show that UCM falls slightly below state and national averages in measures of how physicians communicate with patients. UCM received a 78% rating in this category, compared with the state and national average of 80%. UCM also received 53% on how often patents received help quickly from hospital staff, compared with the state average of 62% and national average of 65%, according to HCAHPS, as of June 2011.
While Weber offers no excuses, he points to the complex patient mix of a large-scale academic institution. He also suggests that the medical center has had an almost singular focus on improving clinical quality, possibly at the expense of patient satisfaction.
"We need to move away from saying these measures are terrible and not paying attention to them and instead move toward constructive collaboration," says Weber. "We want to enhance the reliability of our numbers. We don't feel we are chasing a number; we feel we have external measures that reflect something uncomfortable and accurate about us," Weber says.
Weber provides no explicit details of the institution's plans to improve its HCAHPS scores, though he outlines some broad-brush plans. "This has been a major focus for us. We have had meetings about this with our boards and community stakeholders. We need to deliver the service that matches our science. It's a great little sound bite, but it means we apply the same kind of rigor, the same kind of commitment, to make the patient experience better, setting new expectations. We know we have a lot of work to do, and we have the resources and the expertise to match that."
Benefits of planning and training
About 22 miles west of Chicago is the 333-licensed-bed Advocate Good Samaritan Hospital in Downers Grove, Ill., which was recently named by Thomson Reuters (now Truven Health Analytics) as among the nation's top healthcare systems. Recognized for a third time as one of the nation's best large community hospitals, Advocate Good Samaritan issued a statement saying the award was a "testament to our physicians and associates who are dedicated to delivering the highest quality of clinical care and health outcomes to the patients we serve."
Unlike the UCM, Advocate Good Samaritan Hospital has had relatively good patient satisfaction scores, for the most part. The HCAHPS scores show that Advocate Good Samaritan is above the national average for how patients rate the hospital overall, how well pain was controlled and how well nurses communicated with patients, and essentially tied with the national rate of how well doctors communicated with patients.
David Fox, president of Advocate Good Samaritan, attributes the high scores to long-term planning by the hospital since 2004 for improved clinical and patient satisfaction—well before the government came into the picture. He attributes much of the success to an intense concentration on training and hiring staff, particularly nurses and other caregivers. "We have gotten very focused on who gets to work here, and how we train them in terms of customer service," Fox adds. "We used to hire for skill and pray for attitude and cultural fit. Now we screen for skill, hire for cultural fit and attitude."
Like other hospital leaders, Fox also points to procedures performed daily in the hospital that can influence HCAHPS scores. Daily rounding is pivotal to not only improve various processes, such as communication, but also to ensure that patients get help going to the bathroom or have their pain routinely monitored, all important considerations for HCAHPS scores.
Regular, personal interaction
At Stony Brook, two Fridays a month, administrators and senior staff personally make rounds and interview patients and staff to ensure quality goals are achieved. If there are any problems, emails are sent to the responsible hospital official, whether it's a nurse manager, administrator, or physician, Maione says. "It's very comprehensive in areas ranging from how well the room is cleaned, to the quietness of the room, to how well they have maintained the patient's pain."
Solberg of Baptist Health agrees that a standardized protocol for nursing staff is a key element for improved patient scores—and the hospital is still working on that element. "Nurse communication is the domain driving the focus [of patient satisfaction]. If you nail that, you can get a lot accomplished," she says. Although much has changed over the years, some patients still have a lower expectation of physicians in their day-to-day care. "If a doc saved your life, do you really care about that stuff?" Solberg asks, referring to meeting the patient's daily needs. "But a hospital staff has to care about that. It has to be accomplished with a number of nurses, the ratio of nurses on the floor, and the education component," she says, referring to how nurses talk to patients to meet their needs.
For many hospital systems, improving clinical techniques is the path they pursue to improve patients' attitudes about their facilities. These medical providers focus on reducing readmissions after 30 days, addressing patient medication adherence, and initiating medical homes to let patients know that their healthcare system cares.
Considering readmissions and care processes
While the Iowa Health System strategic plan examines its clinical improvements such as reducing readmissions, it also focuses on HCAHPS scores to improve care, says Gail A. Nielsen, director of learning and innovation for the 2,421-staffed-bed system based in Des Moines.
The health system has established a patient experience team—which includes physicians, nurses, nurse educators, managers, executives, data analysts, and performance improvement experts—that emphasizes how to communicate with patients in ways that they understand. The team wants healthcare professionals to ask patients whether they will have the help they need at home and to consider what information the patient may need after leaving the hospital.
"These teams are joining the efforts of the readmissions teams because we believe that the best way to improve patient experience is to improve and redesign the processes of care that touch our patients and their families," Nielsen says.
"Patient satisfaction and experience scores have improved as teams and clinical units improved their process of problem-solving and focused on ideal care," says Nielsen.
Maintaining clinical integrity
Some hospital officials have mixed feelings about patient scoring, noting that sometimes patients seek expensive and unjustified treatment. If those requests are denied, it certainly could undermine patient satisfaction.
"HCAHPS are very difficult to get a grip on," says Alan Kaplan, MD, senior vice president and CMO at Iowa Health System. "You can think of it as an outcome but also a process. There's a trade-off between satisfaction and outcomes. Patients may be a lot happier if I gave them inappropriate antibiotics. And I do believe focusing on patient satisfaction will be increasingly challenging as we manage patient populations and move toward accountable care organizations. I believe it has to be approached with integrity."
For now, hospitals are examining the patient evaluations, one question at a time.
One of the toughest issues for hospitals centers on the question of noise: During this hospital stay, how often was the area around your room quiet at night?
Both the University of Chicago Medicine and Advocate Good Samaritan registered their lowest marks in
those categories.
Advocate Good Samaritan tallied a patient score of 44%, compared to the national average of 58%, according to HCAHPS.
Fox attributes the low scores to the fact that the hospital, which opened in 1976, has mostly semiprivate rooms. However, he says the organization is taking steps to reduce noise by converting some rooms to private. "In that way, we are going to make a better experience for the family and a more quiet experience for the patients," he says. "We find when patients are complaining about noise, mostly it's from the noise of a roommate or a caregiver coming. We were at a disadvantage because of the semiprivate rooms. We don't use that as an excuse, but we will have a better experience for the patients."
This article appears in the August 2012 issue of HealthLeaders magazine.
For physicians, data sharing with the government is becoming essential and will impact how they get paid, receive bonuses or are penalized. While the data collection process is crucial, Niall Berman, director of the CMS Office of Information Products and Analysis, concedes it's fraught with uncertainty among providers.
Physicians have to realize, he said at a recent Washington D.C. conference, that "the game has changed."
At the daylong eHealth Iniative session on data and analytics this month, Berman cited one hot-button data sharing area the government is working on as it slowly moves from a fee-for-service world to a value-based one in healthcare. That sensitive area? It's determining physicians' pay.
Earlier this year, in a pilot program, CMS sent confidential reports to certain groups of physicians to allow them to "quantify and compare" their quality of care with peers, a data-sharing exercise that would ultimately impact their payments.
Physician Feedback reports were mailed to more than 23,000 Medicare fee-for-service physicians in large medical group practices in Iowa, Kansas, Missouri and Nebraska.
The reports detail physician per-capita cost and quality reporting information from 2010 that will be used under what is known as a "value-based modifier" for Medicare pay under the Affordable Care Act of 2010. The modifier is a key to providing different payments to physicians or groups of physicians under a fee schedule based on quality of care compared to costs.
Medicare is required to phase in the payments beginning in 2015 to physicians' groups of 25 or more. The value-based modifier payments would apply to all physicians in 2017.
CMS anticipates that payment incentives and penalties will be based under a proposed rule published July 30 in the Federal Register. The Affordable Care Act has authorized CMS to penalize physicians who do not participate, up to 2% of allowable Medicare charges, with the same amount as incentive payments.
For those Midwest physicians who agreed to get an early taste of the move from fee-for-service to value, they haven't shown that they liked the data collection process very much—at least in early reports. The Medicare contractor for the area emailed the physician practices a web link to access the reports, but only 3,300 out of 23,730 downloaded them as of April, about 18%, giving a "cold shoulder" on filing the reports, according to the American Medical Association (AMA). Further updates haven't been released.
Last month, the AMA and more than 60 organizations pledged to help physicians better improve use of the data, which includes insurer information, to "enhance the quality and value of patient care."
Brennan concedes that some physicians are exasperated with the weekly and monthly flow of information. CMS wants the physicians to sort through the material, and evaluate their own practices. Unfortunately, some docs are overwhelmed. "We're physicians, not data analysts," Brennan recalled some physicians complaining.
Physician trepidation is not without merit, Brennan said, citing individual practioner concerns over privacy issues, for instance. "There is tension, of course," he said, noting that the government is working diligently "so we don't compromise individual privacy. We're trying to deal with that tension," he said.
Ultimately, failure by physicians to embrace data sharing will be counterproductive. Eventually, "every physician will be evaluated by quality resources based on (their information) that would result in bonuses or not," he said.
"We're harnessing raw data into actionable information at the point of care." CMS hasn't much choice, Brennan said. The organization can't say a physician is "good or bad" without data.
CMS has been using the Physician Feedback reports over the past several years in evaluating proposals for value-based payment modifiers. The reporting "allows us to test different methodologies and to obtain stakeholder feedback that can be used to further refine the reports and inform our policy proposals and recommendations," CMS said in a statement about the proposed payment rules.
In addition, CMS said it "believes these quality initiatives aim to empower providers and consumers with information that would support the overall delivery and coordination of care and ultimately would support new payment systems."
Despite the upbeat presentation by CMS, some physicians think otherwise. Peter W. Carmel, M.D., the former AMA president, said in a statement that the association continues to "have serious concerns that there are too many unresolved issues with these reports for CMS to use."
Lack of physician enthusiasm for CMS proposals is nothing new. After electronic reports were made available to 1,600 physicians and medical groups in 2010, fewer than 10% were downloaded, the AMA said, citing a Government Accountability Office report.
Barbara Sack, MHSA, executive director of the Midwest Orthopaedics medical staff in Shawnee Mission, KS, questioned the complexities of the reporting and wondered how CMS can evaluate quality to determine pay scales because of so many differences in an individual service line, with many subspecialties.
An orthopedics practice reflects many areas where there may seem to be quality differences, but because of variations of patient conditions, not how the work is performed, Sack told CMS in a recent conference call.
For instance, a sports-medicine physician may have lower costs because he sees "sports-minded people" as opposed to a foot and ankle surgeon who sees "patients who have uncontrolled diabetes" that may "cost more, but it's not due to his treatment," according to Sack. "It is due to the uncontrolled diabetes."
So the physician quality reports may differ dramatically without a true reflection of the quality of the doctor's work, she suggested.
"I'm trying to figure out how you're determining quality if you are basing it on these (reports)," she told CMS. Officials there acknowledge that they are still sorting out the role of subspecialties, but they believe a "tiered" structure would be implemented to take into account such quality differences among patient conditions.
Still, the data processing questions remain. CMS insists it is taking steps to engage physicians, but many docs aren't buying the CMS outreach, or are simply finding the process confusing. Part of it is CMS's fault; another part, the physicians.
Obviously, "we're probably not where we want to be. We are just at the beginning of a sea change how we interact with providers," Brennan said. The government seeks "to harness the data to actual points of care," he said.
Sometimes, government feels caught in the middle, but certainly docs feel the same way about the data collection process. "You're damned if you do and damned if you don't," Brennan said.
For eight years, the top doctor at the 496-bed Northwest Community Hospital in Chicago was, in fact, a doctor—but with an asterisk. Besides being a non-practicing doctor, he couldn't practice because his medical license had expired in 1999.
In June, Leighton Smith, MD, left his position as chief medical officer and vice president of medical affairs. The C-suite knew he wasn't a practicing physician, and the top brass didn't seem to care.
The local media, however, raised questions after the fact, about whether having a CMO who wasn't a practicing physician in some way compromised the hospital's patient care efforts.
Smith's lack of a license surfaced during a Northwest doctor's internal appeal of a review, and Smith resigned shortly thereafter. Hospital executives disclosed they knew about his lack of a license when he was hired. Like many other states, Illinois doesn't have licensing rules for chief medical officers.
Now that Smith has left, Northwest Community Hospital officials are looking for a replacement. In the view of the American Medical Association and others, a licensed physician should be the hospital's chief medical officer, says Arthur D. Snow Jr, MD, chair of the organized medical staff section governing council of the AMA.
Having a license, ensures that physicians receive continuing medical education with the assurance that "the doctor's knowledge and skills remain intact," according to the AMA. Snow is a licensed physician based at Shawnee Mission Medical Center, near Lenexa, KS.
It may surprise some, but the CEO at Northwest Community Hospital tells me that they are looking for the best candidate, and sure enough, if it isn't a licensed physician, so be it.
"As we search for a new CMO, we are evaluating the broadest possible range of physicians," Bruce Crowther, CEO, tells HealthLeaders Media, which is reporting the Northwest plans for the first time. "All of our finalists will possess leadership skills to advance our mission and meet state qualifications for the position, which does not require a medical license for what is an administrative position."
"Major hospitals today require chief medical officers who can lead large teams of physicians in producing the highest-quality care and the most effective delivery of services," he adds.
So, despite the controversy over Smith, the hospital is looking for a physician, but not necessarily one with a current medical license. On one level, Crowther's decision shows a stubbornness and reluctance to give in to criticism about Smith.
By not having a licensed physician in a leadership role, however, the decision may continue to generate criticism of the hospital over issues such as patient care and malpractice that critics say could be impacted without a licensed physician in charge.
On another level, the CEO's decision reinforces the evolving nature of healthcare, in which some hospitals are looking as much at the business component of hospital leadership, as well as at the clinical piece. Crowther is clear on that.
"We are analyzing physicians who also have training in medical management, including those who have MBA degrees," he adds. "Our next CMO will have superb credentials and share our operational vision for excellence and teamwork in a patient-centered environment."
The AMA has several guidelines for the position of hospital medical director, including those in managed care positions, Snow says. While some guidelines simply address "the role of the hospital director and not what his qualifications should be," others say that a physician who is involved in making clinical decisions or involved in peer review procedures "shall hold an unlimited current license to practice medicine," he says.
"Clearly, if that is carried over to a hospital, the (CMO) should be a member of the medical staff and meet all of the qualifications of those he is interacting with," Snow adds.
Although the AMA believes licensed physicians should be in CMO positions, the organization acknowledges that there's a demand for physician leaders with increased business acumen.
More physicians are pursuing degrees beyond MD, including masters of public health, also juris doctor, and MBAs, "just to practice medicine," Snow says. Among the reasons: a more complicated healthcare terrain, especially with larger group practices "that are put together like hospitals, single specialty and multispecialty groups. They want somebody to lead that group, and for a physician to do that, it is best to have som business training," he adds.
An increasing number of physicians are getting MBAs in addition to their medical degrees, the New York Times reported last year. Since the late 1990s, the number of joint MD/MBA programs in the nation has increased from under 10 to 65, according to the Times, which noted that the "trend is being driven by the need to become more entrepreneurial and savvy as the business of medicine grows more complicated."
Smith, the former CMO at Northwest Community Hospital, apparently is now in business for himself, too. He denies that his employment ended because he is not licensed, but declines to comment further, citing a confidentiality agreement, according to media reports.
Currently listed as president of Leighton Consulting Inc. on Linked in, Smith describes himself as a "physician executive with over 25 yeas of progressive leadership in a variety of complex and diverse healthcare settings. Proven abilities in program development and improvement through teamwork, with a focus on customer service, quality patient outcomes, medical staff relations and managing institutional priorities."
When Smith was hired, leadership at Northwest believed they had found what they were looking for. At Northwest Community Hospital, the CMO is "responsible" for clinical excellence, operational effectiveness and the management of more than 1000 physicians who care for 450,000 patients a year, the CEO Crowther says.
Despite the controversy since Smith's departure, "in recent years, we have built one of the most respected medical staffs in the area," Crowther adds. He mentions a list of them: "recognition from U.S. News and World Report for six different medical specialties and the highest award from the Joint Commission, the nation's predominant healthcare accrediting body."
By not disclosing Smith's lack of a license, however, Northwest didn't help itself in being "transparent" about its medical operations. The local media says that the hospital is in a fight with rivals to gain a larger share of its market, including the fact the hospital hasn't posted an annual operating gain since 2008.
While Northwest Community Hospital evaluates who will be its next CMO and may continue to spur debate about qualifications for that position, some hospital systems don't have a CMO to begin with.
Snow's hospital, the 445-bed Shawnee Mission Medical Center, part of the Adventist Health system, only hired its first CMO nine months ago. "That came about because the CEO had perceived there would be difficulties implementing computerized physician order entry systems, and our hospital electronic medical records," Snow says. "It's a very difficult process and very difficult for physicians."
The new CMO, Larry Botts, MD, "will help us continue our tradition of open communication with our medical staff so that we can ensure we're providing the highest quality care possible for our community," said Shawnee president and CEO, Samuel H. Turner, Sr. said in a statement.
For the record, Botts is a licensed pulmonologist.