Samantha DiGrande

home

authors

samantha-digrande

Prior to the pandemic, physician burnout was a top concern of healthcare organizations, but it has been exacerbated by the pandemic. A new 

 found tracking physician productivity and electronic health record (EHR) metrics may help identify which physicians are at a high risk of departing.

Physician replacement costs (including recruitment, lost revenue, onboarding, and time onboard new hires) have been calculated to cost as much as $1 million to the health care organization per physician departure. At the national level, this equates to about $4.6 billion annually.

Prior studies have uncovered associations between professional physician satisfaction, burnout, intention to leave, and actual reduction in professional effort. Given the amount of physician hours spent on EHR activities and its own association with professional burnout, it is understandable that physician dissatisfaction with the EHR system has been correlated with intention to reduce clinical worth in the next year.

However, the new study counterintuitively found less time on the HER was associated with physician departure. In the retrospective cohort study of ambulatory physician turnover, the authors examined physician turnover, productivity, and EHR use from March 2018 to February 2020 in a large ambulatory practice network inclusive of 141 practices sites in New England.

The study included 314 physicians with a corresponding 5728 physician-months of data. The demographics of study participants included 123 (39%) women, 100 (32%) were aged 45 to 54 years, and the turnover rate was 5.1% per year (10.2% total; 32 physicians departed their position during the study period).

The mean values for physician productivity were: demand, 77%; patient volume, 206 completed appointments/month; and intensity, 2.6 patients/ hour. Mean EHR use values were: total EHR time, 5.5 hours; note documentation, 1.9 hours; work outside scheduled clinical hours, 0.8 hours; time on inbox, 0.70 hours; and teamwork, 23%.

The authors found the factors associated with physician departure were less time on EHR and inbox and lower rates of teamwork on order entry.

This first finding was counterintuitive: spending less time on the inbox management of the EHR was associated with physician departure. The authors have noted that it warrants further investigation in future studies.

Of note, physician age, gender, and specialty were not associated with departure.

Overall, this study identified physician demand, inbox time, and teamwork on orders as key variables associated with physician departure, and potential areas where hospital system can implement change to directly address and reduce physician departure.

“Taken together, these findings suggest that a refined, prospective model of vendor-derived EHR data could help to identify physicians at high risk of departure who might benefit from targeted team-based care interventions,” the authors wrote. “Indeed, low demand for a physician’s service, time on the EHR and inbox, and rates of teamwork on orders may very well be lead indicators for physicians preparing to leave practice.”

Articles

Exacerbated most recently by the pandemic, physician burnout has been particularly pervasive. Prospectively tracking metrics in the electronic health record (EHR) may identify physicians at high risk of departure.

Analysis of EHR record use identified physicians at high risk of departure

 conducted by Pearson Institute for the Study and Resolution of Global Conflicts at the University of Chicago/AP-NORC Center for Public Affairs Research, there is widespread concern among the American public about cyberattacks on U.S. institutions.

The poll included 1071 adults, aged 18 and older, representing the 50 states and the District of Columbia between September 9 and September 13, 2021. Notably, 90% of Americans reported being at least somewhat concerned about attacks on personal information, identity, finances or health records, including 62% who reported being very concerned. Only 9% said they were not very/not at all concerned.

In fact, 90% of Americans polled cited being at least somewhat concerned about healthcare systems falling victim to cyberattacks, including 63% who responded as very concerned. Only 9% said they were not very/not at all concerned.

“The public is clearly worried about cyber-attacks, and many Americans see such attacks as a potential result of international conflict,” Sheila Kohanteb, executive director of external relations at the Pearson Institute, said in a 

. “The survey results show Americans are far more concerned about cyber-attacks from China and Russia than those from other governments, groups, or individuals.”

Almost three-quarters (73%) said the Chinese government is a big threat and a similar percentage (72%) said the same about the Russian government. The Iranian government was also considered a big threat, but to a lesser degree (55%). Only 53% and 44% said groups not affiliated with any government and individuals not affiliated with any group or government, respectively, were a big threat. However, the respondents did still view them as a small threat (39% and 47%, respectively) and few viewed them as no threat at all (7% and 8%, respectively).

The survey found that older Americans are more concerned about cybersecurity than younger Americans. While more than 75% of adults aged 60 years and older reported being very concerned about attacks on national security, government services, and healthcare systems, less than half of respondents between the ages of 18 and 29 said the same.

Similarly, older Americans were also more likely to consider foreign governments a big threat. For instance, 88% of those age 60 years and older considered the Chinese government a big threat compared with 53% of those between the ages of 18 and 29 years.

recent interview with Chief Healthcare Executive

, Jesse Fasolo, director of technology, infrastructure, and cybersecurity at St. Joseph’s Health, discussed cybersecurity threats for hospitals and health systems and noted that hackers backed by foreign governments are a growing threat.

“The study highlights significant and important generational differences in attitudes toward cybersecurity and foreign governments,” said Trevor Tompson, director of the AP-NORC Center in a press release. “These findings also provide evidence of broad potential support for policies designed to increase protection against cyber-attacks on U.S. institutions.”

There is widespread concern among the American public about cyberattacks on U.S. institutions, according to a poll, and nearly all reported being at least somewhat concerned about healthcare systems falling victim to cyberattacks.

Survey reports national concern about cyberattacks on healthcare systems

Despite the massive undertaking, both financially and structurally, that the US federal government took on to digitize the healthcare system by creating and nationally adopting electronic health records (EHRs), the promise of EHRs to significantly improve quality has remained tenuous.

One mechanism by which EHRs were expected to improve quality in particular was the implementation of computerized provider order entry (CPOE), coupled with clinical decision support (CDS) tools. CPOE enables healthcare providers to write orders for patients electronically, as opposed to verbal or written communication. CDS coupled with CPOE then uses EHR data specific to the patient as well as medication reference databases to supplement clinician decision-making and prevent potential adverse drug events, such as ordering a drug a patient may be allergic to or a drug with a potential contraindication.

While CDS tools intervene at the point of care, performance outcomes have been mixed and a significant amount of customization happens at the organization level which results in differences even within hospitals using the same technology.

A potential policy mechanism to incentivize quality improvement is public reporting of performance. However, recent evidence has cast doubt on whether national programs are useful tools in identifying high quality and it remains unclear if public reporting is an effective way to encourage improvement.

In order to determine whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related CDS safety performance, 

 authors conducted a nonrandomized controlled trial that included U.S. hospitals that participated in the CPOE Evaluation Tool in the Leapfrog Hospital Survey. This tool is a is a national quality reporting program that evaluates safety and performance of CDS using simulated orders and patients from 2017 to 2018.

A total of 1183 hospitals were included in the study with a mean CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities rather than advanced CDS.

Overall, the authors found that publicly reported feedback was associated with quality improvement, which suggests that targeted measurement and reporting of process quality may be an effective policy that encourages improvement in specific areas.

Hospitals receiving publicly reported negative feedback improved their electronic health record medication safety.

Public Quality Reporting Associated With Quality Improvement in Hospitals 

Hospitals need to develop better ways to identify and treat patients with alcohol and substance abuse disorders as they represent an increasing percentage of emergency department (ED) visits and hospitalizations in the United States, according to a recent study by researchers at the University of California, San Francisco.

Researchers analyzed data from the National Hospital Ambulatory Medical Care Survey, which is an annual survey administered by the National Center for Health Statistics. Based on patient medical charts, alcohol use disorder and other substance use disorders were identified.

The study, which looked at ED visits from 2014 to 2018, found that adults with alcohol and substance use disorders were visiting the ED at an increased rate of 30%. Additionally, hospitalizations among patients with those disorders increased by 57%.

In fact, during the study period, one out of 11 visits and one out of nine hospitalizations each year was an individual with an alcohol or other substance use disorder.

“These statistics are comparable to common conditions like heart failure, but hospitals and EDs are rarely as equipped to treat addiction as they are to treat cardiovascular diseases,” said Leslie Suen, MD, MAS, of the UCSF Department of Medicine and lead author of the study in a 

The study also found that patients with alcohol and other substance use disorders that presented to the ED were more likely to have Medicaid health insurance, have depression, be experiencing homelessness, have received mental health treatment, and present with injury and trauma.

“Illness and death from complications of alcohol and other substance use are increasing nationally,” said Suen. “Hospitals are one place where we can begin to reverse that trend, but we must be prepared to identify and treat these patients while they are in the hospital and continue following and treating them after they are discharged, as well.”

Of note, these estimates are higher or similar than previous national estimates using claims data. This underscores the importance of identifying additional opportunities to address alcohol and other substance use disorder in acute care settings, especially in tandem with other medical concerns but particularly among visits also presenting with injury, trauma, or coexisting depression.

The number of patients presenting in the emergency department (ED) with alcohol and substance use disorders is on the rise, but hospitals are not equipped to treat addiction.

Hospitals Are Ill-Equipped to Handle an Increase in Patients With Addiction in EDs

COVID-19 vaccines have been free and available to American adults in all states since April 2021. Despite this, as of early September 2021, 25% of adults over the age of 18 in the US remain unvaccinated. This has led to an increase in new cases, hospitalizations and deaths, according to a 

 from Peterson-KFF Health System Tracker.

This surge, which is largely preventable because the vaccines have been proven to be highly effective at preventing severe disease, hospitalization and death from COVID-19, is adding billions of dollars in preventable costs to the nation’s healthcare system.

According to the report, the average hospitalization cost of treating a patient with COVID is around $20,000. According to data from HHS and CDC, there were 32,000 preventable COVID hospitalizations in June, 68,000 in July, and an additional 187,000 in August for a total of 287,000.

Given this, new estimates of the preventable costs of treating unvaccinated patients in hospital total nearly $3.7 billion as of August, almost twice the estimates for June and July combined. From June to August, the total preventable cost reached nearly $5.7 billion.

Of note, the report points out, the monetary cost of treated unvaccinated people for COVID-19 falls not only on the patient but on society at large, including taxpayer-funded public programs and private insurance premiums paid by workers, businesses and individual purchasers.

In an analysis of privately insured patients who were hospitalized with pneumonia, the typical out-of-pocket payment was $1,300. This is, of course, relative to each individual’s insurance plan and would also depend on how COVID-19 hospitalization costs are billed. While this amount is significant for most patients to pay, it is far less than the amount covered by public and private insurance.

The report goes on to note that the Affordable Care Act and other laws prohibit insurers from charging unvaccinated people higher premiums. However, through wellness programs, employers have the ability to impose higher costs. Private insurers have begun reinstating cost-sharing for COVID-19 hospitalizations. The federal government requires insurers to cover the cost of COVID-19 tests without cost sharing for individualized diagnosis purposes, but insurers are not required to cover the cost of COVID-19 testing for employment purposes.

Unvaccinated workers may be required to get COVID-19 tests regularly to return to work physically, and insurers have the ability to, and may shift some or all costs for those tests to the workers. However, adults can largely avoid these out-of-pocket costs and severe illness by getting the free vaccine.

An increase in new COVID-19 cases and hospitalizations among unvaccinated individuals cost nearly $3.7 billion August, according to report from the Peterson-KFF Health System Tracker.

Hospitalizations for Unvaccinated Patients With COVID-19 Cost Billions

As the pandemic continues on, there are many concerns about the nursing workforce that have surfaced. In order to dig deeper into some of the most prominent concerns, namely staffing, the UCSF Health Workforce Research Center on Long-Term Care conducted two surveys in California to assess the current and future supply and demand of registered nurses (RNs). Their findings were published in a recent 

According to the authors, California is poised to face a significant shortfall of RNs over the course of the next five years. This is primarily due to long-term trends that have worsened due to the COVID-19 pandemic. Current estimates place the shortage at around 40,567 full-time equivalent RNs, a 13.6% gap, anticipated to continue until 2026, according to a preliminary analysis from the 2020 Survey of California Registered Nurses and final data from the 2019-20 Annual RN Schools Survey.

California has more than 350,000 RNs employed in hospitals, clinics and other facilities, in addition to more than 450,000 licensed nurses. In fact, California nurses make up approximately 12% of all nurses employed nationwide. Among employed RNs in California, it is estimated that 30% are over the age of 55 years.

“The pandemic is accelerating a broad trend that has been building for some time. To address this, employers need to retain older RNs, while developing career paths for new graduates," said Joanne Spetz, PhD, co-author of the report and director of the UCSF Philip R. Lee Institute for Health Policy Studies, in a 

. "They also need to rapidly develop and implement strategies to mitigate the potential harm of nurse shortages over the next five years."

Underscoring Spetz’ recommendations are further findings from the study: Many older RNs in California have left the field and a large number plan on retiring or quitting within the next two years, while unemployment among younger RNs has increased. Specifically, in 2020, 26% of RNs between the ages of 55 and 64 reported that they plan to leave the field in the next two years, a significant increase from 12% reporting the same in 2018.

Concurrently, employers have been hesitant to hire less experienced RNs presumably because of the challenge in onboarding them amidst a pandemic. Despite this, there is record-breaking interest in the nursing profession. According to Spetz, RN education enrollments are projected to surpass pre-pandemic levels during the 2022-23 academic year.

She summarized the challenge ahead as this: “Can you address older RNs’ burnout and keep them in the workplace part-time to help onboard the new grads?”

California is poised to face a significant shortfall of registered nurses over the course of the next five years, according to 2 surveys.

Shortage of California Nurses Projected to Last Until 2026

While 84% of healthcare revenue cycle teams use productivity standards or quotas to meet goals, healthcare leaders are often lacking insight into how long revenue cycle tasks can take. A 

 uses proprietary data as well as surveys to identify the average time it takes health system staff to complete critical tasks within revenue cycle operations.

The benchmarks included in the report, like financial clearance, billing, and denials, are some of the first for the revenue cycle industry and accurately forecast how to measure productivity for tasks within the focus areas. The survey gathered responses from around 400 chief financial officers and revenue cycle leaders at hospitals and health systems across the United States from May to June 2021 as part of the Healthcare Financial Management Association’s Pulse Survey.

Of the 84% who reported using productivity measures, nearly 70% scaled these across all focus areas within the revenue cycle, including claims management, insurance follow-up, coding, denials management, and financial clearance.

Having accurate benchmarks not only provides leaders with information on a reasonable number of claims or tasks that can be worked on daily for the purposes of staffing and resource needs, but also allows managers to set goals.

“It’s challenging for healthcare revenue cycle leaders to access accurate benchmarks in terms of actual staff productivity,” Amy Raymond, head of revenue cycle operations at AKASA, said in a statement. “You often can’t pull productivity metrics on someone working eligibility, for example, because it often gets mixed in with other things that they’re doing at the same time.”

Information about how long tasks take can also help healthcare organizations identify areas where they might invest in automation to remove time-consuming, repetitive, and laborious tasks from staff members.

Tools and processes, such as automation, have been developed to help revenue cycle staff. Automating time-consuming and repetitive tasks that are essential, but a less strategic use of staff time and talent, can help organizations improve retention in three ways:

Employees now have time to focus on more complex responsibilities and roles

Revenue cycle leaders can develop specialized teams that focus on patient-facing roles that improve the overall patient financial experience

Team members that manage automation efforts build valuable skills that can be utilized to lead other initiatives as organizations expand digital transformation efforts

The area where the fewest respondents said they use productivity standards or quotas was financial clearance (8%). More than 15% said they use standards or quotas for denials management (17%), insurance follow up (20%) and claims management (23%). However, two-thirds (67%) said they use standards and quotas in all areas.

The report included a list of tasks and the average time it takes for a person to perform the task. The most time-consuming tasks were:

Prior authorization (12 minutes and seven seconds): the process includes initiating requests and checking the daily status of requests

Appeal submission (10 minutes and 18 seconds): the process of submitting an appeal to payers to challenge a denied claim includes providing additional information, fixing errors or crafting arguments to support an appeal

Information requested by a payer (10 minutes and 15 seconds): this process requires the collection and collation of payer-request information to get a claim processed

The task that takes the least amount of time on average is price estimation. It takes an average of five minutes and 12 second to calculate an estimated price amount a patient will be responsible to pay for an anticipated service.

Most healthcare revenue cycle teams use productivity standards or quotas to meet goals, which requires insight into how long these tasks can take.

Better Insight Into Revenue Cycle Tasks Can Transform These Roles and Patient Experiences

The need for efficient and timely dissemination of electronic health information (EHI) between hospitals and public health agencies has never been more important, nor received more scrutiny, than amid a global pandemic.

Prior to the pandemic, sharing hospitals struggled to share EHI with as amny as 70% reporting challenges in 2019, 

 from CMS’ Office of the National Coordinator (ONC) for Health Information Technology (IT).

To improve disease surveillance capabilities across hospitals and public health agencies, CMS has adopted policies that require hospitals to meet specific public health objectives in order to participate in the Promoting Interoperability program.

submission, and in some cases receipt of data, for the purposes of immunization registries

The new ONC report utilized nationally representative survey data from the 2019 American Hospital Association IT supplement to shed light on the number and types of challenges hospitals experienced regarding electronic reporting. Notably, while challenges around reporting may have been exacerbated during the pandemic, this report identified ongoing obstacles to health information exchange.

In both 2018 and 2019, half of all hospitals reported a lack of capacity to electronically exchange information with public health agencies

In 2019, seven in 10 hospitals experienced one or more challenges related to public health reporting

Small, rural, independent, and Critical Access Hospitals (CAH) were more likely to experience a public health reporting challenged compared with their counterparts

The types of public health reporting challenges experienced by hospitals varied substantially at the state level

Additionally, the report found that the top two public health reporting challenges in 2018-2019 included interface-related issues and lack of capacity to electronically exchange information among hospitals and public health agencies. Nearly one in five hospitals reported problems with exchanging information due to differing vocabulary standards, as well as difficulty extracting relevant information from electronic health records (EHR).

Small, rural, independent, and CAH institutions were more likely to report:

difficulty extracting relevant information from the EHR

confusion about where to send the information

The findings of this report indicate that there is a significant need to improve the methods hospitals employ to electronically exchange health information with public health agencies. Analyzing hospitals’ experiences with public health reporting a year prior to the start of the pandemic allowed for a broader, more in-depth view as to why the challenges already present were exacerbated when hospitals were faced with an onslaught of patients. Now that these barriers have been identified, they can be addressed and remedied, according to ONC.

The report also noted that as these findings are only reflective of the hospitals’ perspectives — future research should focus on public health agencies’ viewpoints on the obstacles associated with public health information exchange.

A majority of hospitals had challenges related to public health reporting in 2019 with half reporting a lack of capacity to electronically exchange information with public health agencies.