HealthLeaders Innovation Exchange: Three Big Ideas

Healthcare leaders share perspectives on innovation and discuss initiatives such as training clinicians for end-of-life conversations.

This article appears in the September/October 2020 edition of HealthLeaders magazine. 

Innovation initiatives during the coronavirus disease 2019 (COVID-19) pandemic were the primary focus of this month's HealthLeaders Innovation Exchange.

For health systems, hospitals, and physician practices, innovation has been critically important during the COVID-19 pandemic. For example, healthcare providers have dramatically ramped up their telehealth capabilities to continue to serve patients in a safe and effective manner.

The HealthLeaders Innovation Exchange included three big ideas about innovation during the coronavirus pandemic.

1. End-of-life conversations

Asaf Bitton, MD, executive director of Ariadne Labs in Boston and a practicing primary care physician at Brigham and Women's Hospital in Boston, discussed how Ariadne Labs has been promoting end-of-life conversations during the pandemic.

"A distressingly low number of patients discuss their preferences and goals with their clinicians at the end of life. We also know that, unfortunately, many clinicians do not feel comfortable having conversations about aligned care at the end of life," he said.

During the coronavirus pandemic, Ariadne Labs has adapted an existing program that provides training for clinicians to hold meaningful conversations with patients about end-of-life-related topics. The program's serious illness conversation model has seven components:

1. Setting up the conversation, including introducing the purpose of the conversation and asking permission to discuss end-of-life care

2. Assessing a patient's understanding and preferences

3. Sharing prognosis, including allowing silence and exploration of emotions

4. Exploring key topics, including goals, sources of strength, and tradeoffs

5. Closing the conversation, including a summarization, making a recommendation, and affirming commitment

6. Documenting the conversation

7. Communicating conversation to key clinicians

A randomized controlled trial published last year on the impact of the conversation program generated impressive results:

• 90% of clinicians found the conversation effective and efficient
   
• 87% of patients found the conversation worthwhile
   
• Incidence of moderate-to-severe anxiety and depression among patients was reduced 50%

"Very few things—including antidepressants and anxiolytics—reduce depression and anxiety at the end of life," Bitton said during the HealthLeaders Innovation Web Exchange.

To rise to the end-of-life conversation challenge during the COVID-19 pandemic, Ariadne Labs has been able to disseminate feasible and acceptable end-of-life conversation tools with the Centers for Disease Control and Prevention, he said.

"We built open access guides for training ambulatory care clinicians on having conversations with patients who have serious illness before they have COVID-19, so the patients can start articulating their goals, wishes, hopes, and fears. We also have guides for inpatient clinicians, long-term care clinicians, as well as patients and their families."

2. Standardized care

Toledo, Ohio-based ProMedica was able to standardize coronavirus care across the health system's broad collection of metropolitan hospitals, community hospitals, and critical access hospitals, Chief Medical Information Officer Brian Miller, MD, said during the web exchange.

"To scale up standardization, we created a virtual clinical command center. On a 24/7 basis, we had critical care doctors who were connected to the COVID-19 ICUs across our health system to provide consultation for all the clinicians in all those different settings. We also got our clinicians to buy into that process," he said.

The virtual clinical command center helped ProMedica to rapidly achieve a high level of standardized coronavirus care, Miller said. "That care was not necessarily different than the care at most health systems, but we scaled it up as quickly as the evidence would show. We were proning as fast as anyone else. We were doing immunoglobulins as fast as anyone else."

The care standardization effort helped reduce COVID-19 patient mortality, he said. "As a result of our interventions, we had a very low mortality rate in our ICUs compared to the national rate. Our rate for intubated patients was about 20%, which is a very good number when you look at national benchmarks."

3. Innovation vs. transformation

In the healthcare sector, transformation is a preferable term compared to innovation, said Sameer Badlani, MD, chief information officer at Minneapolis, Minnesota-based Fairview Health Services. "I would love to replace the word innovation with the word transformation. Over the past six months, we have transformed ourselves with what already existed. We focused on the gap, evaluated the tools we had, and got it done. This was more transformation than innovation—we just did our jobs."

High degrees of focus and collaboration are essential to achieve transformation, he said.

"What COVID-19 has shown us is that if we all have focus, together we can move mountains. For example, our legacy infrastructure could barely enable remote workers above 2,000, and on a snow day we would see the system get stretched. We scaled up to 29,000 remote workers in less than three weeks. This was mission critical in our collective response to keeping our workforce safe as COVID-19 spread quickly in our communities. Everyone focused and collaborated."

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