Physicians play many administrative leadership roles at Tampa General Hospital and Yale New Haven Health.
Physician leaders at health systems and hospitals drive better quality, improve efficiency, and influence clinical practice, a pair of top physician executives say.
Physician leaders guide medical staffs and play key hospital leadership roles. They augment the work of nonphysician administrative leaders and bring a clinical perspective to administrative issues.
"For the hospital, we cannot solve problems well if we do not have the physicians' perspective," says Peggy Duggan, MD, executive vice president, chief physician executive, and chief medical officer at Tampa General Hospital. "Having physician leaders helps us understand how doctors work and what is going to work well for them. If we are going to drive better quality, improve efficiency, or optimize utilization of resources, we need physician voices. We need our physician leaders."
Tampa General is one of the largest hospitals in Florida, with more than 1,000 licensed beds and more than 8,000 team members.
Physicians play key administrative leadership roles for Tampa General's medical staff and the hospital as a whole, Duggan says.
For the medical staff, every clinical department at the hospital has physician leaders such as the chief of medicine and the chief of surgery who are elected by their peers. There is also a leadership team of physicians for the medical staff, which includes chief of staff, vice chief of staff, treasurer, and secretary. The medical staff leadership positions are a great way to grow as a physician leader because there are graduated leadership opportunities, Duggan says.
"Most of these leaders start as an ad hoc member of the medical staff officers, then people can move into formal leadership roles. These leaders learn every year, so it is a great way for physicians to gain leadership skills," she says.
In hospital administration, Tampa General has physician leaders in several areas such as hospital operations and care quality. Hospital departments also have physician leaders, Duggan says. "For example, in the neuroscience service line, we have a physician leader for stroke, a physician leader for spine surgery, and a physician leader for neuro critical care," she says. "We take clinically active physicians and part of their schedule includes administrative work such as making their portion of the service line more efficient, improving quality, and opening new programs."
Physician leaders are a crucial component of the administrative leadership at Yale New Haven Health, says Thomas Balcezak, MD, executive vice president and chief clinical officer at YNHH, which is an academic health system that features five hospitals.
Balcezak is the top physician executive for the health system. Each one of YNHH's five hospitals has a chief medical officer, who is the employed physician leader of the organized medical staff. There are elected medical staff leaders in each one of the medical executive committees at the hospitals. There are physician chiefs of each of clinical department who run the clinical operations and academic work for each of the departments.
The health system has many other physician leaders in key posts, he says. There is a vice president for clinical documentation and utilization review who reports to Balcezak. There is a health system chief quality officer who reports jointly to Balcezak and the chief physician executive, who is a Yale School of Medicine employee. There are several physicians who work in leadership roles in the information technology space. There is a clinical operations executive director who reports to Balcezak and works on clinical operations functions such as patient flow and length of stay.
At YNHH's hospital level, there are many physicians who serve as medical directors for inpatient and outpatient services. The medical directors report to the hospital CMOs.
Essential qualities of physician leaders
Physician leaders need to see beyond their own patients and their own practice, Duggan says.
"They should want to drive improvements in areas beyond their day-to-day clinical responsibilities," she says. "There are many phenomenal physicians who want to do clinical care and just that. That's what gets them up every day. Physician leaders must see the bigger picture beyond individual patient care. Obviously, physicians are focused on quality, safety, and patient experience, but physician leaders must be willing to understand the financial side of care. At Tampa General, they need to understand the financial challenges of running a hospital."
Communication skills are important in being a physician leader, Duggan says.
"You need to be able to make sense of the 'why' behind something we are doing and be able to communicate that to a broad audience," she says. "Temperament matters. We have an independent medical staff, so physician leaders must be able to understand the positions of our team members and be able to be patient when we are working on projects."
To influence clinical practice and how physicians work, it is crucial for a physician leader to have credibility as a clinician, Balcezak says.
"Physicians who did not do a residency or did not practice medicine shortly after residency really need a background in clinical practice and the respect of the practicing clinicians in order to influence them," he says. "They must have a background in clinical practice. A good physician leader must have a good grounding in whatever clinical discipline they have trained in. I prefer a physician leader who is a respected clinician."
Physician leaders must be equipped with emotional intelligence and values that align with the organization's values, Balcezak says.
"Physician leaders need to have emotional intelligence and need to be able to influence people because much of what we need to do to move the dial on quality, safety, and operations is not by fiat but by influence. In order to manage by influence, you must have emotional intelligence," he says. "Physician leaders need a moral compass that points in the right direction—meaning I want them to live the values of the organization."
Physician leadership development
In addition to grooming physician leaders in the medical staff's governance structure, Tampa General has a formal physician leadership program in a partnership with the Muma College of Business at the University of South Florida, Duggan says.
"Physicians learn leadership skills, leadership requirements, financial training, operational training, data analytics, and utilizing data," she says. "It is a broad educational platform, and the training lasts for about 18 months. There is also a capstone project—participants work on a project that is important to the operations of the hospital or one of our clinics that aligns with our strategic goals. We have broadened the program to include some of our advanced practice providers and administrative leaders, but it is primarily designed for physician leaders."
Tampa General also has less formal leadership development opportunities for physicians, Duggan says. There is a process improvement training program open to physicians, where doctors are selected for project work and develop their skills individually. And there are special projects with physician leaders that are led by Duggan, the chief quality officer, and the vice president of medical affairs.
The YNHH Institute for Excellence (IFE) provides leadership development programming for physicians and nonphysician administrators, Balcezak says.
"The IFE is our learning and teaching organization within the health system," he says. "The IFE helps our senior leadership team and the cascading levels of leadership below in succession planning and leadership development. The IFE has several programs. For example, seven years ago we committed to being a high-reliability organization, and the IFE provides high-reliability training. With regard to our patient experience, there are several IFE courses that we have about enhancing communication with patients."
Having a CMO involved in physician contracting can be an advantage, particularly in a dyad environment that includes the CMO and the CEO or the CFO.
Chief medical officers should be involved in physician contracting to help guide physicians and set expectations for physicians relative to a health system's or hospital's culture, the CMO of Davis Health System says.
With most physicians now employed by healthcare organizations rather than practicing independently, physician contracting has become a key area of interest for CMOs and other healthcare leaders. Physician contracts are structured to reward doctors for productivity, incentivize quality and safety measures, or combinations of these approaches.
Familiarity with physician contracting is crucial for CMOs, says Catherine "Mindy" Chua, DO, CMO of Elkins, West Virginia-based Davis Health System.
"Part of my job is to talk with physicians about culture and what we expect of them relative to our culture. So, knowing what is in the contracts and what the expectations are can be helpful to guide physicians," she says. "For example, if a physician says they want to work part-time to achieve a better work-life balance, I know how that would affect them financially, how that would affect the health system financially, and how that would affect their patients."
Having a CMO involved in physician contracting can be an advantage, particularly in a dyad environment that includes the CMO and the CEO or the CFO, Chua says.
"The CMO can guide the quality metrics that would enhance the performance of the entire health system and the way that doctors interact with patients. Whereas, the CEO or CFO drives the financial piece of physician contracts," she says. "Together, the dyad players can make a physician contract that is useful for the organization and helpful for the doctors in attaining a favorable work-life balance. Physician contracts also need to be designed to benefit the people you are serving, which are the patients."
At Davis Health System, physician contracts are designed 100% with work RVUs, which is a metric used to measure the work physicians do.
The primary elements of the health system's physician contracts include relatively standard legal terminology as well as how physicians enter into the contract and can exit the contract, Chua says. "From my perspective, the core elements are hours expected to work, call schedule, expectations for productivity, number of hours face-to-face with patients, and salary."
She says one of her goals is to introduce quality and safety metrics into physician contracting at Davis Health System. "Work RVUs do not take into account quality, safety, service, operating cost, and operating margin. If you can build those elements into the physician contract so that you have a situation where the physician is not just being paid for productivity, you can have a contract that is beneficial all the way around."
There are payment models that can guide healthcare organizations to include quality and safety metrics in physician contracts, Chua says.
"For example, you can look at the Merit-based Incentive Payment System (MIPS) requirements for different services such as surgery, ophthalmology, or family practice to see what the Centers for Medicare & Medicaid Services is rating us on in terms of quality and safety," she says. "If you can capture that information, you can give a physician a base salary then increase compensation based on their ability to meet the quality and safety metrics of their specialty."
The MIPS requirements can form the basis for structuring physician contracts to account for quality and safety, Chua says.
"You can take information from MIPS, then go to the chief of a service line and tell them, 'These are the quality metrics that are meaningful to CMS, which of these metrics are meaningful to you and your patients?' Based on that conversation, you can build an incentive package," she says.
There are several pitfalls to avoid in physician contracting, Chua says.
Make sure there is an exit clause in the contract that does not have to be for cause.
Many states are moving away from noncompete clauses in physician contracts.
If you are using 100% work RVU contracting, you want to be very specific in that language.
There are instances where you should not be too specific in contract language. For example, if a physician is contracted to work four 10-hour days per week, but they decide they want to work five 8-hour days per week, you would have to go back and amend the contract.
You should be careful with start dates because there can be delays such as licensing that can affect a start date. Being flexible on start dates can avoid more paperwork.
The physician perspective
For doctors, there are several best practices for entering into physician contracts, says Steven Furr, MD, president of the American Academy of Family Physicians and a practicing family physician in Jackson, Alabama.
"The No. 1 best practice is doing a contract far enough ahead of time. Residents often wait too late in the process because there are many steps that you need to go through," he says. "You should have advisors to help you with physician contracting. It is helpful to have a healthcare attorney who can review a contract and see whether there are issues that you need to address that you may not be aware of. It is also helpful to have a tax accountant to look at contracts to see whether there are any tax considerations."
When they look at a contract, most doctors look at the salary, but a contract is much more than compensation, Furr says. "There are many nuances such as malpractice insurance, getting paid for membership dues, and continuing medical education reimbursement."
Doctors should be wary of restrictive covenants such as noncompete clauses, he says. "Doctors need to address exclusive covenants upfront. They must decide whether working at an organization is so attractive that they are willing to live with a restrictive covenant. Otherwise, they must consider walking away from the opportunity. Some contracts say a doctor cannot practice within a certain area if they choose to leave an organization. Those arrangements can be restrictive, and sometimes the designated geographical areas can be extremely large, which means a doctor would have to leave the area to continue practicing medicine."
There is a shortage of primary care physicians, and with restrictive covenants, if a doctor wants to leave a practice, they are also leaving their patients behind, Furr says. "You are disrupting patient care. For us as family medicine doctors, it is all about the physician-patient relationship, and restrictive covenants by their nature can disrupt those relationships."
Nonphysician healthcare providers such as nurse practitioners should not be allowed to practice medicine independently, they say.
In a new position paper, the American College of Physicians (ACP) stresses the importance of physician-led care teams and makes several recommendations on team-based care.
Team-based care models have been linked to good patient health outcomes and better healthcare-professional collaboration. While physician associations such as the ACP promote physician-led, team-based care, groups including the American Association of Nurse Practitioners say that advanced practice providers such as nurse practitioners can function successfully in an independent and autonomous manner.
"Some healthcare professionals have sought to practice independent of the physician-led healthcare team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care," the ACP position paper says.
Although physician-led care teams generate positive results, the ACP position paper says these teams face barriers "including high implementation costs, insufficient financial incentives, and scope-of-practice changes that permit nonphysician healthcare professionals to practice outside of the physician-led team-based model."
To address these barriers, the ACP position paper makes several recommendations, including the following:
Physicians should lead healthcare professionals functioning in a multidisciplinary team-based care model such as the Patient-Centered Medical Home (PCMH).
Nurse practitioners, physician assistants, and other nonphysician healthcare professionals should not be allowed to practice medicine independently.
Team-based care should be based on the best interests of the patient. Physicians should have sufficient time and financial resources to lead a healthcare team.
Team-based care including physicians, advanced practice registered nurses, physician assistants, clinical pharmacists, and medical assistants is needed to address physician shortages.
Licensing organizations should not consider the skills, training, clinical experience, and competencies of physicians, nurses, physician assistants, and other healthcare professionals as equivalent. State lawmakers should review their licensure laws to make sure they are consistent with this principle.
Healthcare delivery and payment should be redesigned to promote physician-led, team-based care models such as the PCMH. Payment models should be designed to address healthcare disparities and meet the needs of individuals who are affected by social drivers of health.
Physician-in-Chief's perspective
Nonphysician healthcare providers such as nurse practitioners and physician assistants should not be allowed to practice medicine independently, says David Battinelli, MD, executive vice president and physician-in-chief of Northwell Health and dean of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
"Nonphysician healthcare professionals do not have the education, training, and experience that physicians have—it is not even close," he says. "Nonphysician healthcare professionals can do particular things particularly well, but that does not give someone the privilege to practice medicine independently."
Team-based care models such as the PCMH should be physician led, Battinelli says.
"The physician should be the ultimate leader of team-based care models," he says. "The physician possesses the education, training, experience, and specialty expertise to be the leader of a team. What people get concerned about is whether the physician has too much control. As with any good team, when team members can have specific roles that are in their wheelhouse in terms of their education, training, and experience as well as the top of their competency, then a team functions well. But it is ultimately the physician who should lead the team."
Care teams including advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, medical assistants, and other healthcare professionals can help ease physician shortages, Battinelli says.
"There are physician shortages and part of the problem is that physicians are asked to do a number of things that do not require their level of expertise and training," he says. "They could be doing other things and seeing more patients if they had other team members to help them carry out care. That can help address physician shortages."
Even if there were no physician shortages, there would still be a need to have team-based care, Battinelli says.
"Together, a team can provide the best care for patients," he says. "These teams should be physician led, but that does not mean that other team members do not have a particularly important competency-based skill set. Patients often need more than one doctor involved in their care. They need a team of providers led by a physician to take care of them. Depending on the care that is being provided, it may require nurse practitioners, physician assistants, pharmacologists, social workers, psychologists, psychiatrists, or other professionals. Everybody has a role to play."
Licensing bodies should recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurse practitioners, physician assistants, and other healthcare professionals are not equivalent or interchangeable, Battinelli says.
"Some parts of what professionals do are the same and interchangeable but not to the point of practicing medicine independently," he says. "You might have an endocrinologist who specializes in diabetes care, but that doctor can look at the entire patient. You may have a nurse practitioner or a physician assistant who has expertise in managing a patient's blood sugar. But these professionals are not interchangeable with the endocrinologist, who has four years of medical school training, three years of residency training, and three years of training in endocrinology. The nurse practitioner or the physician assistant cannot take care of the entire patient."
There needs to be a restructuring of reimbursement and how team-based care is valued, Battinelli says.
"For example, reimbursement for care such as general internal medicine, primary care, and family medicine is not sufficient; and as a result, you do not have professionals going into those areas," he says. "That has opened the door for people to say we have an access problem and a shortage of physicians, with a need for other allied health professions to fill some of that void. But that is not the proper fill. The proper fill is team-based care, where the patient is at the center of the effort and there is a multidisciplinary team led by a physician. … I would love to see somebody figure out how to pay for the program that is taking care of patients, so that there is enough resources and reimbursement spread out through the program to pay all the team members, including the physician who is leading the team."
Physician leaders will need to respond quickly to opportunities and challenges this year.
In 2024, healthcare will be buffeted by a wave of change, a pair of chief medical officers says.
Healthcare organizations are facing a slew of challenges. Those challenges include workforce shortages that are straining the ranks of physicians and nurses and economic woes that threaten the operations of health systems, hospitals, and physician practices.
1. Recovery and restructuring
For healthcare in general, 2024 will be a year of recovery and rapid restructuring, says Donald Yealy, MD, chief medical officer, senior vice president of the health services division, and chair of emergency medicine at University of Pittsburgh Medical Center (UPMC).
"We have a need to refill and restructure the workforce," he says. "We have a constellation of factors that is making the delivery of healthcare a bigger challenge in the middle of a terrible financial environment. It's not like change never had to happen before, but the timing of change in 2024 needs to be much quicker."
The need for recovery and restructuring is related to the recent threats linked to the coronavirus pandemic, workforce issues, and financial stressors, Yealy says.
"Recovery and restructuring are necessary because continuing to deliver care the same way we have over the past three decades is not the solution to our problems," he says. "The healthcare providers who figure out how to give patients what they need in the manner that they need it as efficiently and effectively as possible will be the ones who dominate healthcare moving forward. We don't have a decade to figure this out. That is why 2024 is a key year for recovery and restructuring efforts."
Restructuring is needed at all levels of healthcare, Yealy says.
"At the individual level, it is a matter of who delivers particular kinds of care and how they deliver it," he says. "The traditional model has had highly trained people doing most of the tasks, such as physicians and nurses. We still need to have a workforce that depends on the primacy of physicians, nurses, pharmacists, and other experts, but we cannot depend solely on them. We need to involve more people and different tools. Artificial intelligence is not going to replace the interaction between a patient who needs care and a physician and a nurse, but it can augment that interaction."
"At the institutional level, whether you are talking about a single hospital or a collection of hospitals in a health system, we are going to have to exist differently to make sure we can respond to patient needs as they change," Yealy says. "A hospital or clinic cannot provide everything to everybody, so we are going to have to restructure the way healthcare is delivered. Over the past 100 years, restructuring in healthcare has occurred at a gradual pace. Now, it is going to happen much more quickly."
Highly trained professionals will remain the backbone of healthcare delivery, but other healthcare workers, including professionals with new titles that have not been utilized in the past, will come to the forefront in 2024, he says. There will be a redeployment of highly skilled healthcare workers as well as a reliance on healthcare workers who can help conduct tasks that do not require highly skilled individuals.
"For example, when a patient comes back for a repeat visit after a care episode or a procedure, an advanced practice provider or a patient care technician could initially assess the patient and gather all the basic information," Yealy says. "Then a physician could focus on the follow-up or the new needs of the patient."
In 2024, healthcare organizations will face a "rocky path," he says.
"Many healthcare providers are not going to be able to adapt quickly enough," Yealy says. "There is going to be an inability to execute on ideas. For many years, you could have a leisurely pace of change in healthcare and do quite well. In 2024, we are going to need to be quicker in responding to opportunities. Some individual providers, hospitals, and health systems are likely to fail."
2. Increased reliance on technology
In 2024, healthcare providers will move more aggressively to adopt and expand technology, says Nathaen Weitzel, MD, associate chief medical officer at University of Colorado Health (UC Health).
"In the perioperative space, there will be a reliance on an improved use of technology such as predictive analytics and AI to refine how we approach the operating room schedule," he says. "We need to optimize our schedules so that we are maximizing the time we have for nursing and anesthesia providers. Technology offers the opportunity to help us balance our resources as appropriately and ideally as we possibly can."
Over the past few years there has been a move toward increased use of robotics in surgery, and that trend will accelerate this year, Weitzel says.
"As we are getting more experience with robotics, we are seeing that patient outcomes are improving and patient length of stay is decreasing," he says. "So, in 2024, we will see more health systems and hospitals increasing the appropriate use of robotics in surgery."
3. More surgeries with patients going home the same day
UC Health is focusing on patient care pathways to select patients who are appropriate for same-day surgery, an option that the organization might not have considered before, Weitzel says.
"We are doing a lot of same-day joint replacements and same-day bariatric surgery," he says. "In 2024, we will be practicing a balancing act, where we will be looking for patients who can safely be taken care of with good outcomes and going home the same day as surgery. They can recover in the comfort of their own home, which frees up bed space for patients who are sicker and having more complex surgeries."
4. Seizing on opportunities to increase efficiency
Driven by workforce shortages, healthcare organizations will be seeking ways to increase efficiency this year, Weitzel says.
"In 2024, we should see an improvement in efficiency to help address the workforce challenge," he says. "In the perioperative space, we have been seeing 10-hour days being stretched into 12-hour days. That extra two hours per day adds up over time, and people start to get exhausted when they are asked to work extra hours. In 2024, we will be looking at the way cases are scheduled, and the way patients are handled. AI has the potential to improve efficiency in the scheduling of surgery and making it work with our level of staffing."
Improving efficiency is the short-term solution to the workforce challenges, Weitzel says, adding healthcare providers cannot significantly increase the number of physicians and nurses in one year.
"There are opportunities to improve efficiency from top to bottom in the patient stay," he says. "You must combine your operating room schedule with your bed capacity. You need to optimize where patients are going after surgery. You need to improve how the post-operative stay is choreographed."
"You need to analyze what type of floor patients are on after surgery and what type of expertise you need on those floors," Weitzel continues. "For example, you do not want to have a hip replacement patient on the same floor as oncology patients who have had complex surgeries for cancer. Those recoveries are different."
Efficiency can be improved throughout surgical episodes of care, Weitzel says.
"You need to streamline patient care, so that patients from the pre-operative phase to the operative phase to the post-operative phase are scheduled appropriately at each stage," he says. "You can cut out inefficiencies, look at the milestones for each day of care, and eliminate gaps in care."
A health system's new AI tool is helping clinicians target the right specialist for a referral, prompt appropriate workups before a referral, and eliminate unnecessary referrals.
Providence health system has developed an artificial intelligence tool to help physicians manage patient referrals more effectively and efficiently.
AI technology is becoming increasingly prevalent in the healthcare sector. For clinicians, AI is being used in a range of applications, including clinical decision support, documentation, and radiology imaging.
Providence identified patient referral management as an AI opportunity and developed MedPearl as an AI product within the health system, says Eve Cunningham, MD, MBA, MedPearl founder and chief of virtual care and digital health at Providence. "MedPearl is a product that lives within Providence. It will probably become its own entity eventually. It has been built and incubated within Providence," she says.
MedPearl is designed to address three common scenarios in patient referrals, Cunningham says.
First, the patient can be sent to the wrong specialist. For example, if the patient has a chronic cough and they see a primary care physician, there are several specialists that the patient could be sent to such as a pulmonary doctor; an ear, nose, and throat doctor; and an allergy doctor. All of those specialists could potentially be appropriate for that condition, and sometimes the patient gets bounced around from specialist to specialist because they don't get to the right specialist at the beginning.
Second, the patient gets sent to a specialist and the specialist says they have to conduct lab tests and workups, then they will ask the patient to come back a second time. A lot of that work could be done on the front-end with the referral. It is common for primary care physicians not to know what workup the specialist would want. If the primary care physician could be given good information to optimize that workup before the patient sees the specialist, access to care could be improved because it can take months to see a specialist.
Third, about 20% to 30% of the time when patients see specialists, they do not need to see a specialist at all. There isn't anything for the specialist to do. If those patients could be kept with their primary care physicians, then the patients who really need to see specialists could see the specialists quicker.
All three of these scenarios are knowledge-sharing challenges in the clinician community, Cunningham says. "The reason why we have these missed opportunities is because we do not do a very good job of sharing knowledge with each other. We are not efficient at it. We do not have a great technology capability to share knowledge with each other in an impactful way that fits into clinician workflows and is easy to use."
Over the past three years, Providence has curated a knowledge bank of referral guides and algorithms to create MedPearl. The referral guides and algorithms have been validated with the clinicians who are using the information. MedPearl features information that is needed at the point of care.
"This information fits into clinicians' workflows, helps get through a patient visit, and helps identify all of the rules of engagement for the next best action for a patient you might need to refer to a specialist," she says. "We have about 600 guides and algorithms in this library. It constitutes about 95% of what a primary care physician does, so when they go into the knowledge base, they are getting what they need."
Generating results
Data shows MedPearl is having a positive impact on patient referrals at Providence.
"We have captured thousands of data points. We have captured search terms. We crowdsource new topics based on when providers are searching for the same thing over and over again," Cunningham says.
Providence conducted a pilot of MedPearl last year. More than 200 clinicians were involved in the pilot, and there were about 14,000 searches in the pilot period. The clinicians reported how the application helped them in their decision-making for referrals.
Twenty percent of the time, clinicians said they did not need to refer a patient to a specialist at all because they got the information they needed from MedPearl and they were able to manage the patient on their own. Seventy-two percent of the time, clinicians said that MedPearl reminded them to order a lab or MedPearl reminded them to start a patient on a first-line therapy before a patient was referred to a specialist. And 20% percent of the time, a clinician changed the specialty or level of urgency for the referral, which seized on the opportunity to make sure a patient did not bounce from one specialist to another.
MedPearl launched at scale in January 2023, and there are now 7,000 users of the AI tool at Providence. Search volume surpassed 150,000 searches this year, and the tool has achieved a 95% search success rate. Early data from 2023 indicates that clinicians have improved their productivity and there is a reduction in unnecessary referrals.
"The way I interpret the data is clinicians feel more confident now that they are using MedPearl that they can refer the patient more appropriately and work them up more appropriately," Cunningham says.
AI and chief medical officers
In adopting AI technology, the primary consideration for CMOs is their workforce, she says. "Their biggest concerns about doctors and clinicians are that they are burned out, there is a shortage of them, or it is difficult to recruit them. CMOs want to make sure that they have a supportive environment for clinicians. CMOs want to be innovative and forward-thinking when they are thinking about different ways of bringing in tools and applications that are going to help assist and augment clinician workflows. CMOs want to be strategic about the types of technology they bring in."
CMOs are the frontline advocates for their clinicians, and they often see problems and prioritize problems that executives in the information systems teams are not prioritizing or are not understanding, Cunningham says.
"When we started building MedPearl, I was the chief medical officer of one of the medical groups when we started identifying the referral problems and started building out the application," she says. "I had many conversations with the information systems team, and they did not understand why we were trying to solve referral problems and why it was such a priority for us. It was because we were living in different worlds to some extent, and we had to translate that for each other and come together with a common understanding."
As members of hospital administration, CMOs must consider the effort required to implement an AI solution, Cunningham says. They need to ask, is it going to scale and is it going to be adopted?
"One of the benefits of MedPearl in this respect is there is not a massive lift for the quality department or the information systems team. We have solved a real clinician pain point, with very little burden on a halo of other teams that must help implement the solution," she says. "In addition, there has been organic adoption. Doctors have talked to each other about the tool and it has caught fire. There was not a need for an internal marketing campaign or a push to get adoption. The tool works in existing workflows. It does not create new workflows. These are all things that CMOs must tick off a list that makes it worth engaging in change management."
UVA Health offers more than a dozen workplace violence resources on the health system's Situational Awareness Violent Event website.
A workplace violence initiative at UVA Health has increased reporting of workplace violence incidents and decreased care team member injuries related to workplace violence.
A recent survey found that 40% of healthcare workers had experienced workplace violence in the past two years. Workplace violence in healthcare settings has several negative consequences such as care team members suffering physical and psychological trauma, according to the survey report. Acts of violence can also disrupt patient care when care team members fear for their personal safety or are distracted by disruptive patients or family members, the survey report says.
UVA Health launched its Situational Awareness Violent Event (SAVE) initiative in 2016. "We have developed comprehensive resources that are available to all care team members through a desktop icon that can be found on any shared health system computer. That desktop icon brings team members to our SAVE website," says Ava Speciale, nursing governance clinical leader at UVA Health.
The staff members working on the SAVE initiative feature an interdisciplinary team. The team includes direct-care clinicians from inpatient and ambulatory settings, an employee health injury coordinator, the Behavioral Emergency Response Team (BERT) leadership, the behavioral medicine consult service, members of the UVA Health security and university police department, Office of Patient Safety and Risk Management staff, and emergency management leaders.
The SAVE website at UVA Health has a range of online resources:
A link that goes directly to UVA Health's workplace violence policy
Links to de-escalation training and other educational resources on workplace violence
A resource for complex behavioral challenges, which usually apply to inpatients, and the resource lists the different teams that can be involved in a complex care meeting
A de-escalation tip sheet
Standard work for the use of "stop signs," which are signs that are hung up outside patient rooms as a visual indicator for the potential for workplace violence
A standard operating procedure for setting flags in the electronic health record that can alert care team members to the potential for workplace violence by patients
A template document that goes with the EHR flags for ambulatory settings, so ambulatory setting staff know ahead of time that a patient is coming who has a flag for the potential for workplace violence, and the document walks team members through how to prepare for those patients
A visitor algorithm that gives care teams tools on how to manage challenging visitor behaviors
Standard work for obtaining a security assessment, which is conducted by UVA Health security staff for ongoing threats of violence
Tools on how to obtain a private security resource, with a description of the private security role and how to escalate performance concerns related to security
A link to the UVA Health Red Book, which is the health system's emergency management manual that has a section on workplace violence
A recovery process for team members, so if a workplace violence incident occurs, the process makes sure that leaders are offering team members resources for recovery
A link directly to the health system's quality reporting system, so a care team member can report a workplace violence event that has occurred
The SAVE leadership team meets monthly, Speciale says. "We have a lot of ongoing work, which includes producing resources and keeping resources updated. We assist with education, training, and presentations to care team members. We report up through our Safety and Security Subcommittee. We are always available on an ad hoc basis," she says.
The robust and comprehensive resources offered on the SAVE website allow team members to problem-solve on their own, but they have support, Speciale says. "When they hit barriers, the SAVE team leadership is available to assist."
Involving clinicians in SAVE
Physicians can avail themselves of SAVE resources, and they have played an active role in launching and maintaining the SAVE initiative, Speciale says.
"We collaborate with physicians. We have gone to some of their groups such as their quality conferences and clinical chairs meeting to present SAVE to our physician leaders, so they can make sure their teams are aware of our resources," she says. "One of our neurology physicians was a great partner in the efforts that started SAVE, including securing many of the resources that we have today."
Recently, the SAVE leadership team has had a graduate medical education resident participate in their meetings and workgroup. "She has helped bring back information she learned about SAVE to her colleagues to educate new interns and residents," Speciale says.
Including residents and interns in the SAVE initiative is important, says Lauren Mathes, a UVA Health clinic manager and co-chair of the SAVE committee. "As an academic medical center, especially with the residency program, we are excited to have the participation of residents because our residents are on multiple units. Because they cross several specialties and clinics, having their participation is great for our team," she says.
Workplace violence efforts beyond SAVE
UVA Health offers workplace violence prevention efforts outside of the SAVE initiative, Speciale says.
For example, in certain departments at the health system, care team members are required to take training that teaches them how to respond to a physical attack. This effort is focused on high-risk areas such as the emergency department.
The physical attack training features Crisis Prevention Institute training, which is common across many organizations, Speciale says. "Team members are trained on how to safely defend themselves if they are attacked. They are trained on physical restraint maneuvers if they need to administer a medication or respond to a situation where someone is physically violent."
As another example, BERT staff respond to workplace violence calls if there is an episode with a patient on a unit or at a practice environment that includes a behavioral health element, Mathes says. "In those cases, the whole BERT staff responds, including behavioral health emergency staff, security personnel, nursing supervisors, and local leadership from the unit or practice. They can help problem-solve those events in the moment. We also have a behavioral medicine team that works closely with the BERT," she says.
Generating results
At UVA Health, the SAVE initiative and other workplace violence efforts have generated positive results at a low cost, Speciale says.
"If you talk to anybody about workplace violence data, there is a challenge of under-reporting. Since we started having our data represented on our internal data portal, we have put a lot of effort into encouraging more reporting and reporting has increased. I have seen statistics from across the country that 80% of workplace violence incidents are unreported," she says.
There has also been a decrease in the number of workplace violence events that result in injury to care team members, Speciale says.
These results have been achieved at a modest cost, she says. "We have incorporated this work as part of our daily jobs. We have pulled together teams where the workplace violence work is part of their jobs, and we have extended that to our leaders, with an expectation to put the resources in place to prevent and respond to workplace violence. Because this is incorporated into our daily work, the costs are minimal."
Health system CMOs are adopting technology to reduce documentation burdens on their clinicians and improve workflows in the OR and other areas.
Health system and hospital CMOs are adopting a range of technology solutions to support clinicians.
They're focused on technology aimed at clinical documentation and other administrative burdens, which have been linked to clinician burnout and clinician dissatisfaction.
"Technology can help clinicians be more efficient, more compliant, and more integrated in our documentation, which allows us to provide coordinated care for our patients," says Carolyn Kloek, MD, chief medical officer of OU Health in Oklahoma. "Technology can become a huge enabler to allow doctors to put patients as the primary focus in their care and not always thinking about the documentation with half of their minds."
"When you are talking about documentation and technology, it is essential for patient quality and safety, which is a key part of what I do as chief medical officer," she says. "I also see technology as a way to help clinicians do their work more effectively and more efficiently. Technology can decrease clinician burnout and help clinicians to take better care of patients."
Technology is an intractable part of the modern care delivery model and needs to be on the CMO's agenda, says Benjamin Mansalis, MD, senior vice president and chief digital and information officer, at IU Health in Indiana.
"Technology can be both an enabler and a source of friction," he adds. "A CMO who engages deeply in working with their technology partners will help shift the balance toward enablement and accelerate the value to both patients and caregivers."
OU Health recently implemented Epic as the health system's integrated electronic health record, Kloek says. That will be the base on which many new technologies and tools will be built.
"We are looking at AI and the clinical intelligence around automated documentation," she says. "There is also clinical decision support in AI that you can lay on top of your electronic medical record. There are algorithms that can help clinicians more efficiently interpret the EMR. These algorithms can present the more pertinent information—they can cull through the EMR and present information to the clinicians."
OU Health is putting building blocks in place to prepare for adoption of AI technology that will be designed to support clinicians, she says. They include Dragon and Nuance, which are specific to the idea of ambient clinical intelligence, which focuses on taking speech and turning it into electronic text.
"We have leaned into that aspect of Epic," Kloek says.
Technology reduces documentation burdens on clinicians
CMOs should be focused on technology that reduces documentation burdens on clinicians, Mansalis says.
"We have seen that technology has become more and more a part of the delivery of healthcare as we create documentation for necessary reasons for healthcare claims for the Centers for Medicare & Medicaid Services and commercial payers," he says. "Creating a record of the healthcare interaction has become an important part of our billing and payment cycles. The art of medicine and the time and space that clinicians need to create therapeutic relationships has been at odds with the need to create documentation of what happens between a patient and a clinician."
Technology that supports documentation is a key component of establishing a therapeutic relationship by removing the burden on clinicians as much as possible. This includes leveraging generative artificial intelligence and large language models, which are particularly good at summarizing and creating clinical documentation that meets the requirements for payments and billing, Mansalis says.
"We are seeing a lot of advancements," he says. "We went from scribes in the exam room typing what the doctor says to create a note to leveraging generative AI models that create the note. A human checks the AI model notes for quality assurance. Now, we have fully automated solutions that provide documentation support for clinicians, so they can focus on the most important aspect of their work, which is creating a therapeutic relationship with their patients."
Optimizing the EMR
IU Health has made improving the EMR to make it more user friendly for clinicians a top priority, Mansalis says. As part of this effort, the health system has invested $50 million in digital transformation technology.
In 2024, IU Health will be expanding a SWAT team program, consisting of a small group of analysts and chief medical information officers, to focus on the health system's Cerner electronic health record.
"The SWAT team will go to ambulatory primary care sites and hospital units," Mansalis says. "They will … talk with the physicians, nurses, frontline registration staff, and other care team members about the utilization of our Cerner electronic health record. They will coach … optimal use of the technology … [and] ask clinicians and other care team members about what they would like to see changed in the EHR to make it work better for them and their patients. We will take that information and use it to make modifications to make the EHR work better for the care teams."
An example of how the SWAT team has already improved the EHR can be found at the Riley Hospital for Children's Pediatric Intensive Care Unit. The SWAT team noticed that it was hard for clinicians and nurses to quickly identify when a PICU patient was deteriorating. They noted that important information contained in the monitoring equipment, such as data on arterial lines and ventilators, wasn't getting to the clinicians and the nurses through the EHR.
"We worked with a company to integrate information in the PICU's monitoring equipment using a tool to capture the monitor information at a high level of granularity," Mansalis says. "The tool runs a machine learning model on the information to determine whether the patient is getting better or the patient is getting worse based on about 20 parameters. It allows nurses to triage patients more effectively and bring in clinicians quicker when a patient is deteriorating."
Clinician technology beyond documentation
IU Health is using several technological solutions to support clinicians beyond documentation.
For example, Rad AI, an imaging prompting tool, helps radiologists comb through massive queues of X-rays, mammograms, and other medical images.
"These kinds of products scan the images, look for things that the radiologist would typically document, then create a prompt and a note for the radiologist based on what would be commonly written to describe the findings in the image," Mansalis says. "This is an assistive capability. Sometimes we find that these imaging tools have a greater sensitivity than a clinician alone. So we are providing greater sensitivity and specificity in our imaging assessments. We are also able to move through more images, so our productivity increases."
The health system is also using Artisight video camera technology in operating rooms.
"We are using this computer vision tool to look at surgeries as they are occurring with an AI capability that helps train physicians in new procedures," Mansalis says. Artisight can evaluate the surgery and provide documentation on open and close time. It helps our physicians who are training residents to learn new procedures and to have feedback to help them achieve the best practice."
Healthcare organizations need to remove access barriers, help patients address financial challenges, and promote care coordination.
When it comes to patient experience hurdles, one of the most vexing challenges for healthcare organizations is when patients struggle to see their providers.
Patients encounter difficulty when trying to schedule timely appointments, run into barriers paying for their care, and face predicaments in care coordination. All these problems detract from the patient experience.
When we think about why it is so difficult for patients to see their providers, it is often because healthcare organizations have made the process difficult, says Laura Pickett, vice president and chief patient and family engagement officer at IU Health. "Patients have been clear with us about what they want. They want us to listen, they want us to partner with them, and they want us to connect with them. But the way we have grown up in the industry does not allow for those things to happen," she says.
So what can healthcare organizations do to help patients?
The primary barriers that make it hard for patients to follow through on seeing their providers are access gaps and long wait times, Pickett says. "With long wait times and trying to be everything to everyone, it is causing a headache in the industry. We need to think about how we can get patients in more expeditiously, which is on the mind of every patient experience officer across the nation," she says.
The long wait times have been accelerated by the COVID-19 pandemic because there are many patients who put off care during that time, and healthcare organizations are trying to catch up with them, Pickett says. The solution is to get back to a proactive state of health rather than a reactionary state. Healthcare organizations need to focus on reaching out to their patients to fill care gaps, she says.
Access is working against healthcare organizations in getting to see their patients. When access is a barrier for patients, they have options for seeking care such as going to an urgent care center outside of their established healthcare organization. "If a patient has to wait a long time to see their established provider, they can select a different option that is in the market," Pickett says.
Healthcare organizations should leverage the voices of patients and families to identify the actions where they would assign value in addressing access gaps and long wait times, she says.
"From that research, we should then act. At IU Health, we are researching this now, so our strategy is built from patient insights and we're addressing the areas within access that have high perceived value to those we serve. Anticipating the research findings, a hypothesis might be: We expand or co-design methods of care delivery (can a patient appointment occur virtually or by phone?) to mitigate access gaps, or for wait times, we can better manage expectations transparently and focus the patient and family on our next step together and what to expect so the patient feels progress. Excellent service and quality delivery can mitigate the stress of a wait time," Pickett says.
Another issue that keeps patients from keeping their follow-up appointments is patients live dynamic lives that change, she says.
"Our industry as a whole does not have mechanisms to react and support change in the moment. For example, if a patient has waited for six months for a follow-up appointment with a dermatologist, and on the day of the appointment the patient wakes up with a sick child in the house, the patient needs to stay home with their child. The patient may not be able to interact with their provider and get another appointment quickly. The provider is not in a position to respond to the life changes their patient may have happen outside of their healthcare needs," Pickett says.
Healthcare organizations can better serve the dynamic lives of their patients and families by considering Plan B and Plan C for them in the event of a shift and offering those options to steep care in patient-centered flexibility, she says. "In essence, we must become less static and more empathetic in acknowledgement of the holistic patient life, not simply the appointment that day.
In the case of the example of a sick child on the day of an appointment, it would be important to engage the patient, Pickett says. "Envision an engagement where a response could be: 'We were looking forward to caring for you. You're important to us and we understand life changes in unforeseen ways for our patients. May I offer you rescheduling options so you can be focused on your sick child? Is there anything we can do to support you in your child's care given she isn't feeling well?'"
Addressing financial barriers
A major reason why patients do not see their healthcare providers is financial considerations, Pickett says. "Cost is a major factor. We have a lot of patients and families in communities across the country who are making difficult choices. Do they get the medicines they need, or do they feed their family? Those decisions can determine whether they can utilize a healthcare provider or not utilize a healthcare provider," she says.
Healthcare organizations can help their patients clear financial hurdles, Pickett says. "At IU Health, we want to ensure that we are competitive from a cost standpoint. Secondarily, you have to consider whether you truly know your patients and whether you know what their barriers might be. There are financial assistance programs, and our access program works closely with patients and families to find a plan that might work well for them financially," she says.
A specific way that healthcare organizations can help their patients navigate troubled financial waters is to assist with understanding government payer programs, Pickett says. "Some of our government payer plans have preventative services that are included in the payer plans. So, it is important to have proactive outreach when patients may consider choosing us to let them know that services may have low or no cost. For example, with Medicaid, we can help with education that can enhance a patient's ability to access us," she says.
Improving care coordination
The primary challenge for patients within care coordination is that healthcare providers are fragmented, Pickett says. "Communication among and between even team members employed by one organization does not always make the care coordination process seamless for the patient or the family. The challenge is even larger if a patient receives care across several organizations," she says.
The solution is to put processes in place that improve communication between team members. Case managers, care navigators, and nursing staff can play a key role in these efforts.
From Dec. 11 to Dec. 15, HealthLeaders celebrates patient experience week with in-depth coverage and digital resources to help you foster a positive patient experience at your organization.
HealthLeaders is offering exciting content to celebrate Patient Experience Week!
Providing a positive patient experience is a top goal for healthcare providers. Patient Experience Week content will share insights and solutions to help healthcare providers attain their patient experience goals.
The content for Patient Experience Week will include top patient experience articles:
Patient experience is crucial to the success of Hospital at Home. Find out how UMass Memorial Health is aiming to make a two-year-old program sustainable by giving patients what they really want: care at home.
In content from HealthLeaders Intelligence Report, "Reengaging the Patient Clinical Experience," learn about what healthcare leaders are saying about patient experience at their organziations.
Patient Experience Week content will also include two podcasts:
Listen to a chat with Rick Evans, senior vice president and chief experience officer at NewYork-Presbyterian. As patient experience gains new meaning and value in a patient-facing healthcare ecosystem, Evans is focused on understanding what patients want and what the health system can do to meet those needs as well as making every interaction meaningful for both patients and care teams.
Listen to a conversation with Arianna Urquia, vice president and CFO of Nicklaus Children's Hospital in Coral Terrace, Florida, about how the hospital has utilized technology in their revenue cycle for a more efficient patient experience.
Patient Experience Week will also feature a downloadable eBookon technology and patient experience. The eBook has three focal points: see how technology in patient experience is a strategy, not a crutch; find out how Denver Health is using customer relationship management tools to forge better patient relationships; and learn about using "inbox ninjas" to close nagging gaps in primary care.
HealthLeaders is delighted to publish this content to celebrate Patient Experience Week to help ensure the success of your healthcare organization.
Children with complex medical needs represent more than half of all hospitalized children and 82% of hospital days. A new medical group aims to change how their care is delivered.
A new medical group has taken an innovative approach to care redesign to serve Medicaid-eligible children with medical complexity and special healthcare needs.
Children with medical complexity make up less than 1% of children in the United States, but they represent 56% of hospitalized pediatric patients and 82% of hospital days in children's hospitals. Children with medical complexity represent just 5% to 6% of children covered under Medicaid, but they account for approximately one third of Medicaid expenditures on pediatric patients.
Imagine Pediatrics launched nearly a year ago with a virtual-first care model that provides care and support services to Medicaid-eligible children with medical complexity and special healthcare needs on a 24/7 basis. The medical group, which features a pediatrician-led multidisciplinary approach, does not replace a pediatric patient's primary care providers or specialists, but is geared to filling care gaps with a high level of access.
"We work in collaboration with their existing doctors and medical homes, so we are not replicating or duplicating care," says Patricia Hayes, MD, chief clinical officer of Imagine Pediatrics. "We bring an extra layer of support for these children.”
"Mostly, we are reinforcing the care plans and meeting these families where they are in their homes virtually," she says. "We address care gaps when a primary care team and specialists are not available. We find this is exceptionally helpful during off-work hours, weekends, and holidays, when these children and their families do not have any access to care."
In addition to its virtual-first care model, Imagine Pediatrics can dispatch paramedics with pediatrics training to the homes of patients. These paramedics offer a range of services, including IV antibiotics, IV fluids, testing for common illnesses, lab draws, and helping with hospital transitions of care.
The medical group is serving 20,000 patients in Florida and Texas, and has full-risk, value-based contracts with three health plans: UnitedHealthcare Community Plan of Texas, UnitedHealthcare Community Plan of Florida, and Superior HealthPlan, which is based in Florida.
"We are unique because we provide 24/7, integrated care delivered to Medicaid-eligible children with medical complexity and special healthcare needs," Hayes says. "Although they are a small percentage of the pediatric patient population, they account for an outsized share of healthcare spending. We are providing them with unprecedented access, when they have historically had limited access to primary care or specialty care."
These patients are frequent healthcare users, often requiring multiple hospitalizations or trips to the emergency room or urgent care clinic. As a result, their care is often fragmented and uncoordinated, leading to care gaps and unnecessary expenses.
Imagine Pediatrics aims to improve that care platform, coordinating care and reducing stress on hospitals and PCPs.
"We have the time, capacity, and access to provide these children with proactive care to keep them from having to have heavy emergency care utilization, which drives a higher cost of care and contributes to taxing an already taxed pediatric care system," Hayes says.
Imagine Pediatrics provides virtual care through multiple channels, including an app and telemedicine platform. The medical group's care team includes pediatricians, nurses, social workers, therapists, care team assistants, pharmacists, and dietitians, along with virtual care support for home health nurses at these children's bedsides, providing an extra layer of support for consultation services.
Providing care coordination
In working with health plans and their networks, the medical group's leadership team says they can work faster than primary and specialty care teams to make sure these families get what they need when they need it. This takes the burden off of PCPs, as well as health system CMOs who are called on to manage care for these patients when they end up in the hospital.
"We do a lot of the legwork and paperwork that it takes to get things done for these families," Hayes says. "We set up appointments for them. We expedite prior authorizations by working closely with their health plans to get them medications, procedures, or equipment."
In many cases, Hayes says, Imagine Pediatrics is in daily contact with patients and their families.
"The idea is to identify gaps and fill them before an emergency situation arises," she says. "We also make sure that everything we do gets communicated back to the primary care teams, so we are all on the same page."
"We do not want to provide care coordination in a bubble and exclude the primary care team," she adds. "We are reinforcing the care plans of the primary care teams and specialists, so these families stay on track and get the support they need. We don't want these families to get into a situation that could have been avoided."
Generating results
Over the past 10 months, the medical group has measured a 15% reduction in inpatient admissions and 20% reduction in total cost of care among engaged pediatric patients.
Patient and family engagement is crucial in reducing inpatient admissions, Hayes says.
"Just in the 11 months that we have been live, we have conducted more than 50,000 care interactions," she says. "That includes virtual visits, in-person visits, and digital messaging through our app. We get ahead of the curve for these families. We are proactive. We are making sure these children stay healthy at home."
Hayes says this strategy helps the medical group reduce total cost of care.
"We try to stay ahead of things, try to prevent unnecessary utilization of emergency care, and try to improve the healthcare experience of these families," she says. "We also try to improve the experience of these patients' primary care team."
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