HIMSS18 and the future of clinical communications

What I learned about the future of clinical communications at HIMSS18

I spoke to a number of healthcare leaders at HIMSS18 about their collaboration strategies and the tools they use to make care coordination easier, and it was obvious that clinicians are still struggling with the friction inherent in today’s communication infrastructure. This friction comes from our industry’s complex workflows and outdated, disconnected communications technology.

Solving this conundrum requires that we reimagine the role and function of clinical communications in care delivery. This means rethinking how we might leverage advances in technology and mobility to make it easier for clinicians to quickly connect with one another — and to deliver actionable information to them so they can better manage care.

The communication technologies that got us where we are today will not get us where we need to be tomorrow, and tomorrow is all about timely patient-centered collaboration that allows clinicans to speed time to care and treatment.

Why is healthcare communication so complex?

Healthcare communication is complex because clinicians employ workflows in which situational variables must be considered to determine whom to contact and how to do so. Figuring this out places a tremendous burden on the clinician who initiates communication to another care team member — a burden that takes the clinician away from value-added patient care activities, is error prone and contributes to delays in care.

We have asked clinicians to solve an extremely complex puzzle amidst an already very busy day. It’s easy to understand how mistakes are made.

How did communication technology become so fragmented?

Over the past three decades, technological innovations in virtually every sector have helped us solve problems and become more efficient, and the same is true in healthcare.

Telephone-based answering services were created to simplify the relay of messages to physicians. Pagers were created to streamline direct-to-provider notifications. Nursing devices were developed to communicate patient needs and facilitate conversations across care team members. Secure texting applications, alerts and alarms systems, real-time location tracking and the like were all created for a specific purpose.

The problem we now face is an inherently disconnected portfolio of communication tools. We are starting to feel the pain of these siloed systems, and we must take steps to bring them together.

How do we prepare for the future of communications in healthcare?

As I observe the movement of healthcare to outpatient settings and the home, it becomes clear that communication processes must overcome geographic and organizational boundaries.

Value-based care and population health management require care team collaboration across providers and care settings that extend beyond the four walls of the hospital or clinic, and so too must our communication solutions.

I spoke with several leaders at HIMSS18 who have come to realize their electronic medical record (EMR) system is incapable of supporting the urgent, time-sensitive communication that occurs outside the EMR. An effective solution needs to transcend the EMR and facilitate collaboration across clinicians in disparate organizations.

Organizations that rely on their EMR as their clinical communications and collaboration (CC&C) platform are building a communications “island” that limits collaboration. The ability to facilitate timely communication across an entire patient-care ecosystem requires a completely different approach.

We must eliminate the friction in clinical communication

The next leap in clinical communication will help our frontline clinicians speed time to care through efficient, patient-centered, cross-continuum collaboration.

I really believe that the healthcare market is ready for a purpose-built CC&C platform that helps clinicians coordinate care inside and outside the four walls of a facility by bringing together a wide range of siloed communication tools. Tomorrow’s care requires a CC&C platform that facilitates intercommunication between these compartmentalized systems and eliminates the friction in patient care.

It is our duty to empower the clinical community with CC&C solutions that support their quest to improve the efficacy of treatment and quality of life for the patients they serve.

The important role nurses play in care transition and reducing readmissions

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

 

Optimize rapid response team efforts with automated, real-time communication

Agnes Cappabianca worked as a stroke nurse manager at NYU Lutheran Medical Center, a Brooklyn-based teaching hospital. She was in the middle of a shift when the unthinkable happened—she suffered a stroke and found herself admitted to the hospital as a patient in her own ward.

The hospital’s rapid response team (RRT)—one that Agnes had helped train and prepare for these critical situations—sprang into action. Within 30 minutes, the team had final results of her CT scan and blood tests and began to administer tPA treatment.

Her role in advocating advances in stroke care within the hospital seems to have saved her life.

The primary goal of rapid response

The American Heart Association and the American Stoke Association® have warned since 2010 that “the benefits of tPA in patients with acute ischemic stroke are time-dependent.” The associations’ guidelines recommend a door-to-needle time of 60 minutes or less for the treatment to be effective.

In most hospital settings, the process for communicating the needs of a newly admitted stroke patient to care team members is manually intensive. These workflows usually have many steps, numerous decision points and multiple handoffs—creating many opportunities for communication breakdowns and delays in a situation in which every second counts.

One of the primary goals all RRTs strive for should be to reduce the number of steps in the communication process—including the number of decision points, communication handoffs and number of people involved in transmitting the information.

Some hospitals have achieved this goal by implementing a unified communication and collaboration solution that automates many of the steps in the RRT process, such as sending notifications to all team members—including team leadership—at the same time. With just one call, schedules are analyzed and the appropriate care team members are identified and contacted simultaneously—based on their preferred contact method.

This eliminates numerous steps and players from the communication processes and makes significant strides toward improving patient outcomes by speeding time to treatment.

Building an effective rapid response protocol

Pre-planning is required for a communication platform to optimize the capabilities of RRTs. Evidence based guidelines and individual hospital protocols determine the number and composition of responding teams. Some hospitals assign different care team members to different teams depending on urgency levels.

For example, Henry Ford Macomb Hospital in Clinton Township, Michigan, has two RRTs. One is dedicated to Level II traumas and does not include an anesthesiologist in the alert system because Level II trauma patients rarely require advanced airway management. However, the Level I trauma RRT—the team assigned to the most critical cases—does include an anesthesiologist.

Deciding whom to alert depending on the urgency of the situation is a key factor in RRT success.

Another important factor is identifying timelines for each care team member’s arrival at the patient’s bedside. For St. Rita’s Medical Center, a 419-bed hospital in Lima, Ohio, the pre-set arrival time for the rapid response nurse is three minutes; it’s five minutes for their 4A nurse. St. Rita’s also set guidelines for both the physician arrival and ordering of the CT scan at 10 minutes.

An effective communication platform feature that aids RRT outcomes is an automated callback and escalation process. This eliminates critical minutes being wasted on resending notifications and manually escalating the issue to another provider when team members do not arrive on time.

The proof is in the results

St. John Hospital and Medical Center (SJHMC) in Detroit aimed to comply with the guidelines set by The Joint Commission and the American Heart Association/American Stroke Association, all of which call for having CT scans interpreted within 45 minutes of the patient’s arrival and having treatment administered within 60 minutes.

SJHMC implemented PerfectServe and used the flexibility of the platform to develop its stroke team protocol. The protocol called for alerts to a multidisciplinary team of nurses, physicians and staff from neurology, the ED and neurosurgery, as well. Each team member’s preferred method of contact was configured in PerfectServe Synchrony so that when a stroke alert is sent from the ED, each member (or their on-call counterpart) is contacted via their preferred method.

The ability to contact team members directly on their personal mobile devices, as opposed to using overhead paging systems, eliminates the potential for missed pages.

After the system and process were implemented, SJHMC saw significant improvements in time to treatment for its stroke patients. The on-call neurologists’ response times dropped 90%, from 22 minutes to just 2 minutes.

Graph 1

Their door-to-CT scan completion time decreased 41%, from 78 minutes to 46 minutes.

Reduce communication times

Additionally, SJHMC was able to administer life-saving tPA to three times more stroke patients than they were before.

Making lasting, life-saving process improvements

Most hospitals in the Unites States have some version of an RRT in place for major medical events. Some hospitals have even included local EMS organizations in their rapid alert processes in order to improve speed-to-treatment times.

There’s no question that streamlined and automated communication aids RRTs in their work to lower mortality rates for stroke patients and other traumatic injuries.

Rapid response alerts have proven benefits for clinicians, too. Having a rapid response alert program in place eliminates stress and frustration for the ED staff, which usually has the primary responsibility of initiating treatment to stroke and trauma patients.

In addition to simultaneous instant alerts to appropriate response team members, PerfectServe’s rapid response alert system also sends activation notices to hospital leadership. These notices include the time the alert was activated and the time each care team member arrived (as input by the nurses involved). This additional insight into rapid response operations gives healthcare leaders the opportunity to identify problem areas and make lasting process improvements that ultimately save more lives.

The top 5 things you can do with PerfectServe

A day in the life of nurses and physicians is fast-paced and full of decisions. Clinicians receive an overwhelming amount of communications each day.

What if there was a way to streamline and consolidate those clinical communications? And make sure you’re contacting the person you need to reach, rather than searching and struggling to find them?

Watch the above video to learn about the top 5 things you can do with PerfectServe.

The what and why of physician engagement

As Mark Dixon pointed out in The Changing Role of the Physician, the healthcare industry continues to undergo transformation that will improve outcomes of not just one patient, but that of the entire population. This transformation will require physicians to step up and lead their peers through these critical changes. Physicians influence every step of the care process. However, physicians’ background, outlook, and training are different from hospital leaders, creating challenges in how to respond rapidly to marketplace and regulatory change.

A seat at the table

Why is physician engagement so critical for a successful patient care experience in hospitals today? A physician from upstate New York said, “When we are not invited to sit at the table, we feel like we are on the menu.”

When physicians feel a lack of engagement, it manifests itself in ways ranging from burnout to leaving their jobs. Physician employment alone does not yield engagement. The same skills of communication and collaboration are needed regardless of the percentage of employed physicians (Perry MR. A Local Solution for Hospital-Physician Relationships. Frontiers of Health Services Management 24(1):31, 2007).

What is engagement?

There are two definitions of engagement. One meaning involves a promise, as in engaged to marry. The other involves conflict, as in engaging the enemy. Perhaps it’s this dual definition that makes healthcare organizations struggle to understand how to get physicians engaged. According to Tom Atchison in Leading Healthcare Cultures: How Human Capital Drives Financial Performance, physician engagement is an intangible process that depends on the degree to which doctors are proud, loyal, and committed to a hospital’s mission, vision, and values. It differs from alignment, which is a tangible, time-delimited state reflecting compensation and contractual mandates.

Easier to pronounce than to achieve

Physician engagement is challenging because physicians and hospital administrators have different backgrounds and outlooks on how to deliver care. Physicians are trained to think in hours or days, whereas administrators’ time horizon may extend for years. Physicians and administrators also may differ in their perception of teamwork. As Joe Bujak wrote in Inside the Physician Mind: Finding Common Ground with Doctors, physicians view themselves as members of an expert culture who conceive of teams in terms of individual performance, like members of a golf team who compete in their own matches. However, administrators tend to see themselves as part of an interdependent affiliated culture, like members of a volleyball team, who dig, set, and spike to win points.

 

Dr. Cohn is CEO of Healthcare Collaboration that works with disgruntled doctors and hospital leaders to improve clinical and financial performance. He has mentored physicians since 1998, finding that physicians enjoy learning from fellow physicians. His recent novel, Dead at His Desk, explores the conflicts between physicians and hospital administrators using the framework of a mystery thriller. His webinar, Physician Engagement: A Case-Based Approach, will take place Tuesday, February 10, 2015 at 1:00 PMEST.