New research from the Regenstrief Institute gives health system executives specific recommendations on how to use their EHRs to help clinicians identify and prescribe drugs to their patients.
New research out of the Regenstrief Institute gives health system executives specific recommendations on how to use EHRs to reduce dangerous drug-drug interactions.
“Drug-drug interactions are very common, more common than a lot of people outside the healthcare system expect,” Michael Weiner, MD, MPH, a researcher with the US Department of Veterans Affairs, Regenstrief Institute, and Indiana University School of Medicine and senior author of the study, said in a press release. “In the US, these interactions lead to hundreds of thousands of hospitalizations in any given year at an enormous cost. Most of these drug interactions are preventable.”
With the advent of EHRs and digital health technology, health systems are looking to reduce those interactions by pinpointing when they can occur and giving clinicians on-demand access to information to prevent them. But that technology depends on understanding how clinicians prescribe drugs and how they look for dangerous interactions.
“This study was needed because we previously didn’t have a great understanding of how clinicians actually make decisions in assessing these interactions,” Weiner said. “No one had really taken apart the thinking process step-by-step to understand it from the beginning to the end. There's a patient, there's a drug and another drug. There is now a potential interaction. There's been a decision about how to resolve it following an assessment and then a resolution process. Understanding all this is very important if we are hoping to design improvements to the medical system that enhance patient safety.”
The study, recently published in BMJ Open, identified 19 information cues used by clinicians to manage drug-drug interactions, including information on the potential severity of a drug reaction, side-effects, a patient’s expected duration of exposure to an interaction, patient-specific conditions, a patient’s need for those drugs, and the characteristics of safer medications. Using that list, Weiner and his colleagues developed recommendations for designing alerts through the EHR.
They are:
Provide information on the expected range of timing of potential drug-drug interaction effects (days, weeks, months, or years).
Give clinicians a platform to review multiple electronic drug-drug interaction reference sources directly from the alert, side-by-side.
Leverage data analytics to populate drug-drug interaction alerts with "smart" displays of alternative drugs that align with three criteria used by clinicians.
Provide recommendations on the alert along with associated patient characteristics (for example, “monitor, if patient indicates willingness and capability of measuring blood pressure daily”).
Alissa Russ-Jara, PhD, a researcher at the Purdue University College of Pharmacy and US Department of Veterans Affairs, Regenstrief Institute affiliated scientist, and the study’s lead author, said the research highlighted the fact that no two clinicians use the same protocols in assessing drug-drug interactions.
After interviewing all of the clinicians involved in the study, she said in the press release, “many … expressed surprise at how much nuance went into their own decision. Their decisions often occur so rapidly, yet involve so much expertise. Ours was the first study to really unpack that for their decisions around drug-drug interactions.”
“We expect our findings can improve the design and usability of drug-drug interaction alerts for clinicians, and so they can more effectively aid patient safety,” she added. “Our study focused on clinical decision-making, regardless of whether the clinician was warned by an alert or not, so our findings have implications for clinicians, informatics leaders, and patients, and for any EHR system.”
Faced with competition from disruptors, health systems are expanding their pharmacy services to capture additional income and improve clinical care
Amid increased competition from disruptors and retail chains, health systems are expanding their pharmacy operations beyond the hospital, in some cases building stand-alone community pharmacies or co-locating them with clinics to compete directly with the likes of Walgreens, Rite Aid, and CVS.
“It’s a huge opportunity,” says Rebecca Taylor, vice president of the pharmacy service line at UPMC, which now has 17 pharmacies within its network, some located inside clinics. “Ambulatory pharmacies have been around for a long time, but there are a lot of factors that are driving this new opportunity” for health systems to expand their reach.
With intense competition in the healthcare space, health systems are seizing on the opportunity to expand pharmacy services as a means of improving the scope of services they provide to patients. Many want to keep the patient within the hospital’s network, integrating all healthcare services through the medical record, a strategy that segues into the concept of value-based care and the medical home.
Others see the pharmacy as an attractive business line. Through the 340B Drug Pricing Program, health systems can be reimbursed through Medicaid for outpatient drugs sold to uninsured and low-income patients. They’re also looking to capture more specialty pharmacy services and prescriptions lost to neighborhood and community pharmacies, not to mention the profits from other goods and services sold through a retail location.
And while neighborhood and community pharmacies are looking to adopt more healthcare services and become community health centers, they’re also struggling. Rite Aid has filed for bankruptcy, while Walgreens and CVS are closing hundreds of stores, leaving communities without that resource for filling prescriptions. Health systems can fill that gap with their own pharmacies.
Making an Argument for Pharmacy Expansion
Nicole Faucher, MS, president of Clearway Health, a Massachusetts-based company spun out of Boston Medical Center that partners with health systems and hospitals to strengthen their specialty pharmacy programs, says health systems have three primary reasons for expanding their pharmacy services:
Creating a new service line. When patients fill their prescriptions at a local pharmacy, they’re taking business away from the hospital. A health system can keep that business in-house with its own pharmacy service, as well as influencing the patient to consider more health and wellness services and products.
Improving clinical outcomes. By keeping pharmacy services in-house, a health system can link all of those services through the medical record, ensuring continuity of care and reducing gaps in care or siloed services. In addition, the pharmacist becomes an integral part of the care team and the care management plan, improving medication adherence and helping patients with any medication-based issues that might otherwise be delayed or go unanswered.
Improving patient loyalty and engagement. Health systems that include pharmacy services are seen by patients as being more attentive to and involved in care management and coordination. That patient will be more likely to stay with the health system, listen to advice on other services and resources within the health system, and recommend that health system to family and friends.
The decision to expand pharmacy services can’t be taken lightly. These projects are expensive, and they require plenty of research and planning. One look at how Walgreens, Rite Aid, and CVS are doing right now with the healthcare ambitions would be enough to scare anyone away.
“This isn’t just ‘Build it and they will come,’” warns Faucher, who says health system leadership needs to think long and hard about whether to take this on.
Among the considerations that go into planning a pharmacy expansion:
Understanding the patient population and community. Will patients shift their allegiance from local pharmacies to a hospital-run pharmacy?
Site selection and staffing. Will a stand-alone pharmacy work, or should these services be co-located with a clinic, medical offices, or other programs? Building and/or rental costs will figure prominently in this strategy, as will costs for staffing a stand-alone pharmacy.
Delivery. Will this be a traditional pharmacy that handles over-the-counter and walk-in traffic, or will it be strictly mail-order? If the latter, how will deliveries be handled? If the former, will the pharmacy handle prescriptions only or offer other goods and services?
Contract negotiations. A health system will need to handle contracts with pharmacy benefit managers (PBMs), payers, and health plans, along with any delivery services. In addition, there will be contracts with drug distributors to consider.
Sustainability. How much business will a pharmacy need to generate to be sustainable? This will determine what other services or products are offered.
Alongside managing the aspects of a 340B program, Faucher says a health system must also decide how to manage business with other pharmacies. Some 15% of all prescriptions involve medications that are handled by specialty pharmacies.
“There really isn’t a one size that fits” for every health system, she says.
Addressing Both Clinical and Business Goals
At Signature Healthcare, based in southeastern Massachusetts, the decision to expand pharmacy services addressed both clinical and business goals. A significant percentage of the health system’s patient base are members of government health plans, making the 340B program an attractive addition to their bottom line.
“We make a little more of a margin on that,” says Stephen Borges, Signature’s vice president of financial operations.
But the health system also wants to create a more connected health experience for its patients, many of whom are underserved, he says. That means adding pharmacy techs in critical care units, medical offices, and clinics to be part of the care team, and locating a retail pharmacy in their largest physician office building near the hospital.
“We’re reinventing care for our patients,” Borges says.
Signature Health had partnered with the local Walgreens chain prior to this change in strategy, even enabling Walgreens pharmacists to come into the hospital to meet with patients before they were discharged. But there were still gaps in care, he says, that comes with having two separate organizations try to care for the same patient.
“We want our pharmacists to have the ability to do more with our patients,” Borges says. That includes creating a patient assistance program to work with patients who struggle to pay their bills and find other ways of meeting prescription costs.
One of the challenges to implementing this new strategy was getting buy-in from physicians who might not see the pharmacist as a member of the care team. Borges says it took some time and effort to get everyone comfortable with each other; he credits the successful integration to the work of physician champions identified ahead of time by the health system.
Another challenge was getting support from patients who have always gotten their prescriptions filled at the local pharmacy.
“We didn’t anticipate that it would be so hard to convince people to move away from CVS and Walgreens,” Borges says.
Addressing the Patient’s Needs
At UPMC, Taylor says expanding the health system’s footprint to include more pharmacy services gives them the chance to have a greater impact on clinical outcomes.
Pharmacists who are part of the health system and the care team, she says, can work with providers and patients to fine-tune medication management, identifying potential drug reactions and alternatives to costly medications. They can answer patient questions that might not be asked in a separate pharmacy, work with patients who have trouble paying for medications, and collaborate with doctors when a patient struggles with medication adherence or displays adverse effects to taking a certain medication. They can also help the health system with vaccinations and other public and community health outreach programs.
Taylor says the additional service line also enables UPMC to attract and hire skilled pharmacists, especially those who’d prefer to work with a health system rather than a retail pharmacy.
Studies back up the idea that the pharmacist—regardless of whether he/she is employed by the hospital or another company--should be part of the care team. Recent research done at Virginia Commonwealth University found that pharmacists could prevent more than 15 million heart attacks and nearly 8 million strokes and save $1.1 trillion in healthcare costs over 30 years if they were allowed to be more active in managing care for patients.
Taylor sees an improvement in reduced rehospitalizations. Pharmacists who are part of the care team can spot problems before they become serious, she notes, alerting physicians and enabling them to intervene while the patient is at home.
The Impact of Technology
One reason for heightened interest in the pharmacy space is the availability of new technology. Telehealth and digital health tools make it easier for clinicians and pharmacists to communicate with each other and with patients, creating or modifying care plans on the go and prescribing and filling prescriptions virtually. And with the popularity of online and mail-order prescriptions surging, health systems can also take advantage of online platforms to handle prescriptions in bulk and mail them to patients.
“That certainly makes it easier,” says Taylor. “And in the future, there will be other technologies that will make it feasible to do a hub-and-spoke model,” enabling health systems to manage distant pharmacy sites from one central location.
“Internet prescription fills have gone through the roof,” adds Borges.
A report recently issued by the Center for Connected Medicine finds that more than half of health systems with their own ambulatory pharmacies “believe retailers and technology companies are having either a moderate or strong influence on their hospital’s pharmacy strategy.”
According to the report, many health systems are planning to invest in digital health technology to improve their pharmacy services. Among the more popular platforms are integrated patient portals, prescription fills and refills and payments through an app, and medication adherence services (such as reminders).
Faucher, of Clearway Health, says the integration of patient portals and EHRs with pharmacy services gives health systems an opportunity to play a more active role in care management. Doctors can check in with both pharmacists and patients online to make sure prescribed medications are being taken and are effective, while pharmacists and patients can respond more quickly if something isn’t working.
Faucher says health systems have an opportunity to grow their business by single digits with a more aggressive pharmacy strategy, and by double digits if they adopt specialty pharmacy services. Beyond the profit margins, they have an opportunity to improve care by being more of a healthcare partner with patients who are demanding more collaboration with their care teams.
“Health systems need to have a pharmacy strategy,” she says. “This will be a continuing trend.”
Federal officials have unveiled a new strategy to address rising cybersecurity incidents. It includes incentives to improve data security, beefed-up guidelines, and the potential for cuts in reimbursement.
With cybersecurity incidents occurring on an almost-daily basis in the healthcare sector, federal regulators are looking to take a more active role in improving data security.
The Health and Human Services Department has released a new strategy for cybersecurity, centered on four steps aimed at improving the healthcare landscape. The six-page document builds off of the Biden administration’s National Cybersecurity Strategy, which was unveiled last March, and follows recent actions taken by federal agencies to boost security, including the release of healthcare-specific practices and training resources, guidance on medical device security from the US Food and Drug Administration, and new telehealth guidelines from the HHS Office of Civil Rights (OCR).
“The healthcare sector is particularly vulnerable, and the stakes are especially high,” HHS Secretary Javier Becerra said in a release accompanying the strategy. “Our commitment to this work reflects that urgency and importance. HHS is working with healthcare and public health partners to bolster our cyber security capabilities nationwide.”
The information comes at a particularly vulnerable time for the healthcare industry, which has seen an alarming increase in large data breaches and ransomware attacks in recent months. According to the OCR, the industry has seen an almost two-fold increase in large breaches from 2018 to 2022, from 369 incidents to 712, while ransomware attacks have surged 278% in that time.
“Cyber incidents affecting hospitals and health systems have led to extended care disruptions caused by multi-week outages; patient diversion to other facilities; and strain on acute care provisioning and capacity, causing cancelled medical appointments, non-rendered services, and delayed medical procedures (particularly elective procedures),” the HHS report notes. “More importantly, they put patients’ safety at risk and impact local and surrounding communities that depend on the availability of the local emergency department, radiology unit, or cancer center for life-saving care.”
With that in mind, HHS is planning to take a more active role in pushing the healthcare industry to improve its defenses. The agency plans to:
Establish voluntary cybersecurity performance goals for the healthcare sector;
Provide resources to incentivize and implement these cybersecurity practices;
Implement an HHS-wide strategy to support greater enforcement and accountability; and
Expand and mature the one-stop shop within HHS for healthcare sector cybersecurity.
Of particular note are the financial incentives that the government will be offering to health systems who need help becoming more secure. According to the report, the HHS will be launching a program to help struggling hospitals cover the up-front costs of installing “essential” cybersecurity performance goals (CPGs), and a program that offers incentives for hospitals to invest in advanced cybersecurity practices to implement “advanced” CPGs.
In addition, the HHS strategy will include new cybersecurity requirements for hospitals that will be enforced through the Centers for Medicare & Medicaid Services (CMS), an indication that the feds could tie compliance to Medicare and Medicaid reimbursements. As well, the OCR is scheduled to update the Health Insurance Portability and Accountability (HIPAA) Security Rule this coming spring to include cybersecurity requirements.
Not everyone is on board with the HHS strategy. Chris Bowen, founder and chief information security officer for ClearDATA, says the industry should get even tougher.
“While a gesture towards progress, [the strategy] falls critically short of what's imperative in today's climate,” he said in an e-mail to HealthLeaders. “Suggesting voluntary measures is akin to applying a band-aid on a hemorrhage, it's time for HHS to enforce rigorous, non-negotiable cybersecurity standards and to provide the necessary resources and mandates.”
“The sector's talent gap in cybersecurity is no secret, and it places our hospitals at a disadvantage, jeopardizing patient safety,” he adds. “We must look to the strategies of those who have robustly safeguarded healthcare data and replicate their assertive approach. Protecting lives extends beyond the physical realm; it encompasses shielding patients from the lethal threat of cyber-attacks. To accept minimum, voluntary standards is to tacitly endorse a status quo that endangers our patients.”
MIT researchers are working on an ingestible that vibrates when swallowed, tricking the stomach into thinking it’s full
Can a vibrating pill help healthcare providers create sustainable and effective weight loss treatments?
That’s the question researchers at the Massachusetts Institute of Technology are trying to answer as they experiment with the latest in healthcare ingestibles. The MIT team has developed a pill enhanced with technology that is programmed to vibrate for about 30 minutes after being swallowed, activating receptors within the body that signal the stomach is full.
“For somebody who wants to lose weight or control their appetite, it could be taken before each meal,” Shriya Srinivasan, a former MIT graduate student and assistant professor of bioengineering at Harvard University who’s leading the study, said in an MIT news piece. “This could be really interesting in that it would provide an option that could minimize the side effects that we see with the other pharmacological treatments out there.”
Characterized by the popularity surrounding new drugs like Ozempic and Wegovy, healthcare providers are looking for new ways to address obesity and weight-related issues, which play a role in many chronic health conditions. Some 42% of US adults are affected by obesity, and it’s estimated that more than 160 million Americans are on a diet at any given time and spending more than $70 billion a year on commercial weight-loss plans, supplements and other diet programs.
Yet for all the products and treatments on the market, many people struggle to consistently stay within a diet plan, primarily because habits are very hard to break. Healthcare providers have long struggled to design treatment plans that are sustainable and keep patients engaged over the long run.
Digital health tools, such as digital therapeutics, aim to tackle that challenge by targeting behavior change.
One method of tackling behavior change is by tricking the body into thinking it’s full. For Srinivasan and Giovanni Traverso, an associate professor of mechanical engineering and MIT and a gastroenterologist at Brigham and Women’s Hospital, that led to the creation of the VIBES pill, which vibrates in the stomach, affecting the vagus nerve, which then sends messages to the brain that the stomach is full.
Srinivasan, Traverso, and their research team tested the VIBES pill on Yorkshire pigs, who were given the pill 20 minutes before being fed. They found that the pill not only stimulated the release of hormones that signaled satiety, but also reduced the animals’ food intake by about 40%.
The study, which was funded by the National Institutes of Health, Novo Nordisk, and the National Science Foundation, among others, is still in its early stages.
“The behavioral change is profound, and that’s using the endogenous system rather than any exogenous therapeutic,” Traverso said in the MIT news story. “We have the potential to overcome some of the challenges and costs associated with delivery of biologic drugs by modulating the enteric nervous system.”
“For a lot of populations, some of the more effective therapies for obesity are very costly,” added Srinivasan. “At scale, our device could be manufactured at a pretty cost-effective price point. I’d love to see how this would transform care and therapy for people in global health settings who may not have access to some of the more sophisticated or expensive options that are available today.”
Federal regulators are scrambling to create guidelines for the ethical use of AI in a number of industries. Will healthcare collaborate or stake its own claim to governance?
As we head into the new year, the hot topic on every healthcare executive’s minds is AI. And one of the biggest questions surrounding the technology centers on who will regulate it.
The Biden Administration set the tone this past October with an Executive Order that places much of the federal regulatory burden on the Health and Human Services Department and the Office of the National Coordinator for Health IT (ONC), a position held by Micky Tripathi. HHS then set the schedule with a final order in December that calls for more transparency in AI tools used in clinical setting by the end of the coming year.
While much of the action so far focuses on the technology vendors who are designing AI tools, health system leaders are keeping a close watch on how the federal government will affect their use of the technology. Many health systems are developing and using their own tools and platforms and pledging to maintain ethical standards in any clinical applications.
“We have a culture of responsibility that goes alongside agile innovation,” Ashley Beecy, MD, FACC, medical director of AI operations at NewYork-Presbyterian and an assistant professor of medicine at Weill Cornell Medical College, said in a HealthLeaders interview earlier this year, prior to Biden’s Executive Order. “Health systems have a unique opportunity” to establish their own standards for the proper use of AI.
Tarun Kapoor, MD, MBA, senior vice president and chief digital transformation officer at New Jersey-based Virtua Health, says healthcare organizations have the clinical background needed to develop effective and sustainable AI governance. They know how it’s going to be used in healthcare, and can focus on the nuances that federal regulators might miss.
“We have to get a lot better at [regulating AI] because we’re the ones using it,” he says.
Like many health (if not all) health systems using AI these days, Virtua Health has a policy that any AI services have a human being in the loop, meaning no actions are taken on AI-generated content until they’ve been reviewed by at least one flesh-and-blood supervisor. At this stage, when most projects are trained on back-office tasks, that’s a safe bet; but when the technology works its way into clinical decision-making, that additional step may be critical.
“Always put physicians in front of those decisions,” says Siva Namasivayam, CEO for Cohere Health, a Boston-based company that focuses on using AI to improve the prior authorization process. He says the technology should be used to enhance the physician’s role—what he calls “getting to the yes factor—rather than replacing it.
“We never use AI to say no,” he adds.
But who gets to make those decisions? The Biden Administration wants to be part of that chain of command, and is setting its sights on a collaborative environment, having secured voluntary pledges from more than three dozen health systems, payer organizations, and technology vendors to use AI responsibly. The agreement centers on a new catchphrase for ethical use: FAVES, which stands for Fair, Appropriate, Valid, Effective, and Safe.
The healthcare industry, still smarting from having electronic medical records forced on them before they were really ready for adoption, is playing nice for now. But in many hospitals, the C-Suite is facing pressure to take command of AI governance and make it an industry priority.
“You govern yourself at a level higher than the law,” says Kapoor.
He notes that health systems like Virtua Health are being very careful in how they use the technology, and not just green-lighting any potential use.
“Just because you can say anything and create your own [projects] doesn’t mean I’m going to let you say anything and do them,” he points out.
Kapoor says healthcare providers will understand the flaws in AI technology and the risks they present better than anyone outside the industry. And health systems like Virtua Health are addressing these challenges with steering committees that comprise not only clinical leaders but those in finance, IT, legal, and operational areas of the organization.
Arlen Meyers, president and CEO of the Society of Physician Entrepreneurs, a professor emeritus at the University of Colorado School of Medicine and Colorado School of Public Health, says the industry has to step up and show leadership at a time when AI governance is still in flux. He notes hundreds of healthcare organizations have created dedicated centers of excellence for AI, and some have vowed to develop ethics and standards of use. Consumers, as well, could get into the act, helping to form an ‘AI Bill of Rights’ for patients.
“Right now, nobody trusts the government or the industry to regulate this,” he says. “When you look at who should be regulating what … the industry should be setting the guardrails.”
This next year will be pivotal in establishing governance for AI, as more and more health systems use the technology and push the boundaries beyond administrative use and into clinical applications. While the Biden administration is looking to fast-track regulation through HHS and the ONC, many wonder whether the healthcare industry will wait that long, or let a federal agency propose the first rules.
Others are wondering what it will take to create regulations that will work. One look at the current debate over interoperability and data blocking standards makes it clear that just because rules are created doesn’t mean they’ll be readily accepted.
“In the end, you follow the money,” says Meyers, who anticipates that healthcare and government will have to come to some sort of agreement to create something long-lasting. “That’s how the [rules] will be made.”
Redesigning post-discharge care to include mental health resources can reduce return visits and rehospitalizations and improve recovery and clinical outcomes
Health system leaders are constantly looking for strategies to reduce rehospitalizations. A new study says redesigning post-discharge care to include mental health services, including through digital health and virtual channels, could cut that return rate in half.
The study, conducted by a team of researchers at the University of Washington, focuses on the millions of hospitalizations each year that are caused by a traumatic injury. Many of those patients return to the hospital after discharge because of mental health issues tied to that trauma, with as many as 40% dealing with post-traumatic stress disorder (PTSD).
Improving the care coordination process after a hospital visit is one of the top innovation challenges facing health systems. So many care gaps are created when the patient leaves the hospital and heads either to a rehab or SNF facility or back home. Doctor’s orders and prescriptions are forgotten or even ignored, care plans are interrupted or dropped altogether, and recovery is delayed, often leading to negative clinical outcomes, including rehospitalization.
The study, led by Laura Prater, PhD, MPH, MHA, an assistant professor at The Ohio State University of Public Health, and published in the Annals of Surgery, tracked 171 patients who were treated at a University of Washington trauma center. Half were treated via the traditional process, and half were involved in a five-year, three-step program that included enhanced care specific to mental health needs during hospitalization and 24/7 access to mental health services after discharge.
According to the study, 27% of patients undergoing traditional care were rehospitalized within three to six months, compared to 16% of patients involved in the mental health intervention program. After 12 to 15 months, 31% of the traditional-care patients were back in the hospital, compared to 17% of those in the intervention program.
“Being able to manage PTSD and other mental health concerns early on and receive regular follow-up support can prevent adverse long-term health problems and increase a survivor’s ability to live a productive, meaningful life,” Prater said in a press release issued by The Ohio State University.
The intervention program included digital health tools aimed at offering on-demand services to those patients.
“The immediate text message or phone call response to questions and concerns is potentially the most meaningful element of the intervention, from the perspective of the survivors,” Prater said. “A lot of places use MyChart or another form of messaging, but responses can be delayed and that is problematic if someone is feeling overwhelmed. Having an immediate connection helped patients and their families to feel like they weren’t in it alone.”
The study reinforces research done earlier this year at Vanderbilt University, which used a National Institutes of Health grant to study new methods of addressing post-intensive care syndrome (PICS), which can affect as many as 80% of patients discharged from a hospital after an ICU stay. That study found that a reconfigured post-discharge care management and coordination program focused on virtual care could reduce rehospitalizations and improve clinical outcomes.
Both studies point to a need to change how hospitalized patients are treated after they leave the hospital, with more emphasis placed on the traumatic nature of a hospital stay and improved access to mental health services to help patients recover—mentally as well as physically—from their health concerns.
“Being in the emergency department is traumatic in its own right, plus returning to the scene where you first received care following an injury or assault is not ideal,” Prater said in the press release. “Managing trauma and the mental health fallout from that trauma is best done at home, where you’re in a safe location.”
The supermarket chain is redesigning its in-store health clinics to focus on seniors in Medicare plans, who often face challenges accessing primary care and are looking for better services.
A new partnership aims to give seniors another option for primary care: The supermarket.
Kroger Health, the healthcare arm of the Cincinnati-based retailer with more than 2,700 grocery stores in 35 states and the District of Columbia, is joining forces with the Better Health Group to focus its 225 Little Clinic in-store walk-in clinics on primary care services for seniors on Medicare, including Medicare Advantage plans.
Kroger joins a growing list of disruptors from other industries entering the healthcare market with consumer-focused primary and specialty care services. Companies like Amazon, Walmart, Publix, Google, and national pharmacy chains like Walgreens, CVS Health, and Rite Aid are all looking to replicate the success of the retail experience in healthcare for people who face barriers to accessing care or are more comfortable going to a store than a hospital or doctor’s office.
Some within the healthcare industry have called this the battle for primary care, with health systems and medical practices looking to keep their patients and attract new ones in the face of competition from outside organizations. According to a Bain & Company study issued in 2030, these disruptors could capture 30% of the primary care market within six years.
“As the industry continues to shift toward value-based reimbursement, there has been an increase of nontraditional players and models in primary care,” Erin Ney, MD, an associate partner at Bain & Company, said in a press release accompanying the report. “As we look ahead, rising costs, physician shortages, consumerism and digital disruption will continue putting pressure on traditional healthcare models, paving the way for additional growth of models that promote more efficient care, improved outcomes and reduced total cost.”
Health system executives have been urged to improve the patient experience, including adopting virtual care and digital health tools, and embrace retail strategies that focus on convenience and reliability.
With organizations like Kroger, Amazon, and Walmart offering alternatives to the doctor’s office or hospital, experts say health systems need to identify and focus on what they can offer that others can’t—which in many cases is the connection to a respected hospital or medical group. Critics, meanwhile, say cost, complexity, and challenges to access are turning consumers away from healthcare and opening the door for the disruptors.
The Better Health Group, which launched in 2016 at Physician Partners, operates more than 160 VIPcare clinics focused on senior services and partners with more than 1,200 providers. Officials at both Kroger Health and Better Health say the partnership will advance value-based care for a population desperately in need of focused services and better access to care.
The collaboration will begin at selected Kroger supermarkets in the Atlanta area before branching out in 2024 to other stores.
A hardware breakdown prompted Deborah Heart and Lung Center to outsource its data storage services. How do other health systems decide if and when to make that move?
Health systems have different motivations for migrating to the cloud. A catastrophic disk failure may be the best reason.
That’s what happened at the Deborah Heart and Lung Center, an 89-bed New Jersey-based hospital that focuses exclusively on cardiac, vascular, and lung disease. In 2015, the hospital’s systems pretty much shut down for close to two days after a drive ceased to function on its in-house electronic health record (EHR) system.
As the healthcare industry embraces more technology (especially digital health tools) and ramps up its data collection and analysis capabilities, how that data is stored and protected becomes critical. A July 2021 online survey by the College of Health Information Executives (CHIME) found that more than 80% of health system executives are conducting at least some services in the cloud, while nearly 10% are fully invested in the cloud and some 60% are adopting a hybrid approach.
The reasons for moving to the cloud are numerous. According to KLAS, roughly half of health systems are doing so to reduce costs and capital expenses, while 40% see the cloud as an opportunity to expand resources they don’t have on-site. Almost 30% are using the cloud to enhance services or capabilities, while 11% are looking to improve system performance and 9% see opportunities to improve data security.
That was the motivation for the Deborah Heart and Lung Center.
“It took everything down,” says Rich Temple, the hospital’s vice president and chief information officer, who’d come onto the job just six weeks prior. “It kind of came right out of the blue. We were struggling mightily to try to get backup [up and running]. It was the longest two days of my life.”
Temple says the health system had backups in place just for this occurrence, but the initial disk failure was so profound that some of the backups were corrupted as well. Ultimately, a backup file was restored and, two days later, the system was finally brought back up.
Shortly thereafter, leadership decided to outsource data storage and management for its EHR to CloudWave, healthcare data security experts.
Rich Temple, vice president and chief information officer, Deborah Heart and Lung Center. Photo courtesy Deborah Heart and Lung Center.
Moving to the cloud isn’t cheap—that’s the top concern and barrier that health system executives cite in making the decision whether to outsource those services, though studies have suggested it doesn’t take long for a health system to recoup those costs in savings. In a tight economy, with many health systems struggling to stay in the black, giving the green light to a costly capital expenditure isn’t easy.
“We knew then we couldn’t risk that happening again,” Temple says. “But you don’t do this as a money-saver. You do it for risk-avoidance.”
Aside from the initial cost, many health systems struggle with the operational changes required to make the switch. Every department is affected by the transition, requiring the C-Suite to get out ahead and develop a comprehensive change management strategy.
“It’s truly a multi-dimensional project,” says Temple. “We knew there were going to be a lot of twists and turns, and there were even more twists and turns than we expected.”
One familiar problem, he says, was getting buy-in. Despite the chaos caused by the disk failure, some providers were hesitant to want to adapt to a new system and expressed worries about what are commonly called “last-mile issues,” or problems unforeseen and encountered just as the new system is turned on.
“We’ve always done down-time drills, but everyone is so dependent on electronic health records,” says Temple, noting the health system has been using EHRs since 1998.
Temple says the health system worked long and hard to make sure the transition from on-site to cloud was as seamless as possible. That meant identifying everyone who would need access to the system and determining what they could and couldn’t access, creating licensing and multi-factor authentication and understanding the bandwidth needed to support back-and-forth operations, even understanding all the different platforms within the health system that have some interaction with the EHR.
In addition, he says, the fallout caused by the disk failure gave the Deborah Heart and Lung Center’s leadership the opportunity to look more closely at how the hospital handles its technology at a time when things aren’t working. What should a disaster recovery and business continuity model look like? And how should that model be adjusted when outsourcing certain operations to the cloud? Additionally, how does a health system create a plan to stay up and running after a data breach or a ransomware attack?
“Make sure your eyes are wide open before you start,” Temple concludes.
Federal officials say 28 provider and payer organizations have signed on to voluntarily adhere to federal guidelines around the responsible and ethical use of AI in healthcare
As questions arise over who should be in charge of AI governance, the Biden Administration is focusing on collaborating with some of the biggest health systems and payers.
The administration this week unveiled voluntary pledges from 28 organizations “to help move toward safe, secure, and trustworthy purchasing and use of AI technology.” The announcement, coming on the heels of President Biden’s November 30 Executive Order on AI, sets the stage for what’s expected to be lively debate over whether the federal government or the healthcare industry should set the ground rules. Many within healthcare, still hurting from the thorny rollout of electronic medical records and “meaningful use” criteria, are arguing that the industry should be able to police itself.
The administration’s response, authored by National Economic Advisor Lael Brainard, Domestic Policy Advisor Neera Tanden, and Arati Prabhakar, director of the Office of Science and Technology Policy, is focused on working together.
“The commitments received today will serve to align industry action on AI around the ‘FAVES’ principles—that AI should lead to healthcare outcomes that are Fair, Appropriate, Valid, Effective, and Safe,” they wrote. “Under these principles, the companies commit to inform users whenever they receive content that is largely AI-generated and not reviewed or edited by people.”
“They will adhere to a risk management framework for using applications powered by foundation models—one by which they will monitor and address harms that applications might cause,” the three advisors continued. “At the same time, they pledge to investigating and developing valuable uses of AI responsibly, including developing solutions that advance health equity, expand access to care, make care affordable, coordinate care to improve outcomes, reduce clinician burnout, and otherwise improve the experience of patients.”
Those organizations voluntarily committing to that framework are Allina Health, Bassett Healthcare Network, Boston Children’s Hospital, Curai Health, CVS Health, Devoted Health, Duke Health, Emory Healthcare, Endeavor Health, Fairview Health Systems, Geisinger, Hackensack Meridian, HealthFirst (Florida), Houston Methodist, John Muir Health, Keck Medicine, Main Line Health, Mass General Brigham, Medical University of South Carolina Health, Oscar, OSF HealthCare, Premera Blue Cross, Rush University System for Health, Sanford Health, Tufts Medicine, UC San Diego Health, UC Davis Health, and WellSpan Health.
“We have collaborated with these innovative providers and payers to define a set of voluntary commitments to guide our use of frontier models in healthcare delivery and payment,” Paul Uhrig, Bassett Health’s chief legal and digital health officer, said in a LinkedIn posting shortly after the announcement was made.
“We applaud the efforts to convene a diverse group of healthcare organizations to coalesce around landmark voluntary commitments that will be fundamental to the future of AI and allow us to responsibly advance the use of these technologies for the benefit of those we serve," added Sanford Health President and CEO Bill Gassen. "As the largest rural healthcare provider in the country, we were honored to help lead this effort on behalf of our patients, two-thirds of whom live in rural communities in America's Heartland. It has been energizing to collaborate over the last several weeks with colleagues across the healthcare ecosystem on a framework that reflects our shared commitment to harnessing large-scale AI and machine learning models safely, securely and transparently. Such swift progress following the signing of President Biden’s executive order on AI underscores our collective acknowledgement of the myriad ways in which these technologies could help to improve healthcare quality, access, affordability, equitable outcomes, patient experience, clinician well-being and industry sustainability – likely in ways that we cannot fully anticipate today. Protecting our patients who place their trust in us is paramount as we move forward. We look forward to continuing to work with industry leaders, elected officials and the Administration on these critically important efforts.”
Those organizations have pledged to:
Develop AI solutions to optimize healthcare delivery and payment by advancing health equity, expanding access, making healthcare more affordable, improving outcomes through more coordinated care, improving patient experience, and reducing clinician burnout.
Work with their peers and partners to ensure outcomes are aligned with fair, appropriate, valid, effective, and safe (FAVES) AI principles.
Deploy trust mechanisms that inform users if content is largely AI-generated and not reviewed or edited by a human.
Adhere to a risk management framework that includes comprehensive tracking of applications powered by frontier models and an accounting for potential harms and steps to mitigate them.
Research, investigate, and develop AI swiftly but responsibly.
The administration is also highlighting pledges secured earlier this year from more than a dozen technology companies, including Microsoft and Google, to toe the line on developing and using AI responsibly.
“We must remain vigilant to realize the promise of AI for improving health outcomes,” Brainard, Tanden, and Prabhakar wrote. “Healthcare is an essential service for all Americans, and quality care sometimes makes the difference between life and death. Without appropriate testing, risk mitigations, and human oversight, AI-enabled tools used for clinical decisions can make errors that are costly at best—and dangerous at worst. Absent proper oversight, diagnoses by AI can be biased by gender or race, especially when AI is not trained on data representing the population it is being used to treat. Additionally, AI’s ability to collect large volumes of data—and infer new information from disparate datapoints—could create privacy risks for patients. All these risks are vital to address.”
As outlined in Biden’s Executive Order, the federal government’s efforts to govern AI are being led by the Health and Human Services Department. Alongside HHS, other departments have taken action on AI concerns, including the National Institutes of Health (NIH), US Food and Drug Administration (FDA), Office for Civil Rights (OCR), and Centers for Medicare & Medicaid Services (CMS).
“The private-sector commitments announced today are a critical step in our whole-of-society effort to advance AI for the health and wellbeing of Americans,” the three advisors wrote. “These 28 providers and payers have stepped up, and we hope more will join these commitments in the weeks ahead.”
Here’s a sampling of some of the mobile health programs across the country
Editor’s Note: This list accompanies this story. Part 1 of this list can be found here.
With help from the Mobile Health Map and The Family Van at Harvard Medical School, HealthLeaders has compiled short profiles of 11 mobile health programs around the country.
Q. Describe your program, why it's different or innovative, who it serves, how many care providers it features, and how this is improving healthcare access and/or clinical outcomes.
OhioHealth Wellness on Wheels (WOW) is just like a normal doctor’s office, but it meets our patients where they are, delivering primary care, women’s health services, and prenatal care regardless of ability to pay. We have three mobile units, each with two full-service exam rooms and the capabilities to provide prenatal care, primary care, and ultrasound lab services as other wellness services. All mobile clinics are staffed with a provider, nurse, medical assistant, social worker, community health worker, and driver.
Our program is unique from many other mobile unit programs as we offer a patient-centered medical home through a team-based approach, led by a provider, to ensure comprehensive and continuous medical care to patients. WOW serves as a connection point for patients who are seeking services to address various social determinants of health, such as education, food, housing, insurance, and transportation, as well as needing pediatric care, resources to address abuse and behavioral health issues, and much more. To date, 59% of WOW patients screened positively for a social need and were referred to community resources for support.
Our program currently serves vulnerable communities throughout central Ohio. The care model focuses on scheduled appointments (rather than walk-ins), community engagement, chronic disease management, and the use of a community health worker to help understand and meet the needs of our patients.
Amid rising infant mortality rates across the state, WOW has provided comprehensive prenatal, postpartum, and women’s healthcare to women residing in Franklin County’s infant mortality “hotspots.” As a result, WOW programs have an infant mortality rate of 5.3 per 1,000 live births, below the Center for Disease Control and Prevention’s Healthy People 2020 targets and the infant mortality rate in Franklin County, which is 6.7 per 1,000 live births. Our programs also demonstrate impact through reduction in neonatal intensive care unit (NICU) admissions in the communities across central Ohio and helping babies reach their first birthdays.
Wellness on Wheels Primary Care also demonstrated a positive impact on access to care through significant reduction in emergency department use. Over the last five years, visits to the ED by WOW patients have decreased 50 percent within 90 days of establishing care through WOW.
Q. What kind of technology do you use?
Our mobile units are resourced with the same registration and clinical technology seen in our brick-and-mortar clinics. Our team uses Epic as their electronic medical record platform, and our ultrasound images are digitally transferred to the EMR for interpretation and storage, as are EKG and spots vitals units. For connectivity our mobile units use a wireless WAN and jetpacks. Additionally, we have security cameras on the outside of the mobile units to ensure safety of patients and staff. To assist with fleet management our units are equipped with the Verizon Connect Fleet Tracking system.
Q. Why did you choose to launch a mobile program? How does this work better than a brick-and-mortar clinic or virtual program?
In 1993, Wellness on Wheels was created to provide comprehensive prenatal and postpartum care to high-risk and underserved women, especially teens, in central Ohio to improve birth outcomes and prevent NICU admissions. This project was originally referred to as Wellness on Wheels/Project to Reduce Infant Mortality (WOW/PRIM).
WOW was designed as a mobile doctor’s office to provide prenatal care, health education, and psychosocial counseling to pregnant women ages 12 to 44 in the low-income areas. WOW enabled pregnant women to have the quickest available prenatal care appointment, thereby offering early prenatal care that they might not have otherwise had. At that time, appointments with WOW were made by calling directly or through StepOne, a dedicated phone service for scheduling appointments with non-profit prenatal care clinics, a convenient scheduling method that continues today.
Over the years, it became evident that there was a shortage of primary care providers across the United States, and Columbus was no different. OhioHealth noted several areas with limited access to primary care and a tendency to overuse emergency room services for primary care needs. OhioHealth had extensive experience in mobile outreaches, but none that were focused on primary care. Through a partnership with Huntington National Bank, we started Wellness on Wheels Primary Care. This outreach has been serving the Hilltop and Linden communities of Columbus for the past five years and provides a care team focused on embedding themselves within the community and gaining the trust of those who may not otherwise seek care.
Q. What are the biggest challenges this program faces?
The biggest challenge OhioHealth Wellness on Wheels faces is ensuring that our programs can be sustained due to rising operational costs, the increased cost of healthcare, and the augmented need seen throughout the community. Additionally, in staffing our driver/registration position it has become a challenge trying to find CDL-A qualified drivers with the desire to serve the community.
Q. How is this program supported so that it is sustainable?
OhioHealth Wellness on Wheels has a mixed funding model of philanthropic, grants, and sponsorship support. We use grant funding and generous support from OhioHealth to operate as a physician office for those patients without insurance.
Q. How are patients charged for healthcare services? Do you work with payers?
Wellness on Wheels is a no-barriers-to-care model and will serve patients no matter their ability to pay. Our program does register patients who have insurance under their provider, while for the uninsured and underinsured we have a fund through the OhioHealth Foundation that supports the cost of their care. We provide physician visits, ultrasound and lab work to patients without insurance at no cost to them. One key initiative of our community health workers is to identify all patients who qualify for insurance and assist them with the enrollment process.
Q. How do you let people know when and where you'll be located? How do you market your services?
We use OhioHealth’s website for an external audience (Wellness on Wheels | OhioHealth) that promotes our programs and lists our contact information as well as clinic locations. Additionally, our team does grassroots marketing through site visits to community-based organizations, community partners, and events. We distribute brochures, hot cards, and flyers to promote and build awareness of our programs. We also find that word of mouth from our established patients is our best form of marketing.
Q. Do you partner with local health systems, primary care providers, health clinics, or other programs?
Yes. Wellness on Wheels mobile programs are part of the OhioHealth enterprise care system. Our comprehensive primary care uses a medical education model with a family medicine resident and attending physicians from three residency programs working in collaboration with the WOW team. Since 1993, community partnerships have been key to the success and sustainability of Wellness on Wheels. Columbus City Schools, Columbus Public Health, Directions for Youth, Central Ohio YMCA, and the Center for Healthy Families are just a few of our committed local partners.
Q. How might this program evolve? What new technology or strategies would you like to employ in the future?
We would like to expand the use of sprinter vans to support community health workers and social services and expand our geographical reach. Additionally, we would like to implement addiction medicine and behavioral health services into mobile programs, especially after testing a few successful pilot programs.
Q. What is the one thing about this program, good or bad, that has really surprised you? Something you didn't expect to see or experience, an unusual case or treatment, a challenge or barrier you didn't expect to face or didn't expect to be so tough, etc.
Over the years, the WOW team has been heartened to see how women have trusted the comprehensive care team to support their birth experience enough to return for multiple pregnancies and prenatal care. This example demonstrates the impact of years of trust building and how the care team ensure every patient is treated with dignity and respect.
Q. Describe your program, why it's different or innovative, who it serves, how many care providers it features, and how this is improving healthcare access and/or clinical outcomes.
The Night Ministry’s Health Outreach Program brings free healthcare and supportive services directly to Chicago residents who are unhoused or experiencing poverty. The program is unique in its mobile approach to serving patients who face many barriers accessing traditional healthcare and social services. Through consistent outreach, the provision of resources such as food, clothing, tents, and harm reduction supplies, and a compassionate, nonjudgmental approach, the program staff build relationships with patients, earning their trust as a gateway to providing care and connecting them to such resources as primary care clinics, substance use disorder treatment, and more stable housing.
There are three main components to The Night Ministry’s Health Outreach Program: The Health Outreach Bus, Street Medicine, and CTA Outreach.
The Health Outreach Bus visits Chicago neighborhoods with disproportionate rates of homelessness and poverty during the evenings and the weekends, when clinics and social services agencies are generally closed. Street Medicine visits encampments and other areas of the city where unsheltered individuals are living. The CTA Outreach component connects with unhoused individuals who ride public transit for shelter by bringing health care and outreach services twice weekly to select CTA train stations.
The Night Ministry’s Health Outreach Program direct-service staff include two-full time and one part-time nurse practitioners, three volunteer physicians, three case managers, a substance use specialist, and several outreach professionals.
In the last fiscal year, the program’s medical professionals provided more than 2,000 free health assessments. More than half of those assessments resulted in a patient being treated for a medical condition that would have otherwise been untreated. The program also prevented more than 380 trips to the emergency room, saving the public health system an estimated $350,000.
Q. What kind of technology do you use?
Our medical and case management professionals use the AthenaPractice electronic health records system to document their work. Efforts to Outcomes is another platform we use to document outreach data.
With regard to medical technology, conducting outreach in mobile units can be limiting compared to a brick-and-mortar setting. We have recently acquired EKG machines and have an emergency defibrillator. If more extensive equipment is needed for patient care, individuals are referred to primary care, specialty care, or the emergency room.
Q. Why did you choose to launch a mobile program? How does this work better than a brick-and-mortar clinic or virtual program?
The Night Ministry launched and continues to expand its Health Outreach Program because the patients it serves face multiple barriers to accessing traditional healthcare services, from lack of healthcare insurance and transportation to discrimination during previous encounters with the healthcare system. Bringing care directly to where patients live helps address some of these barriers.
Q. What are the biggest challenges this program faces?
The biggest challenges stem from patients not having housing or being unstably housed, which can hinder the ability for them to recover from or manage their health conditions. Inadequate rest, limited access to hygiene resources, polluted living environments, and the loss of medications are among the conditions that compromise patients’ health. In addition, follow-up with patients can be difficult due to their lack of a permanent, fixed address.
Q. How is this program supported so that it is sustainable?
The Health Outreach Program is supported through various revenue streams, including grants from private foundations and government agencies and donations from corporations and individuals. The Night Ministry’s Philanthropic Engagement Department is responsible for ongoing cultivation and stewardship of these funders and securing the funding necessary to operate the program.
Q. How are patients charged for healthcare services? Do you work with payers?
The Night Ministry’s Health Outreach Program operates as a free and charitable clinic and does not charge for its services.
Q. How do you let people know when and where you'll be located? How do you market your services?
Consistency of presence is one of the key tools in connecting with patients. The Health Outreach Bus follows a set schedule, visiting locations on the same day and time on a weekly basis. The CTA Outreach Program also operates at the same public transit stations every week. While the Street Medicine Program operates with more flexibility in its schedule, it regularly visits areas where patients are located, and often coordinates visits by communicating directly with patients. The vehicles used by the program, including the Health Outreach Bus and Street Medicine Van, advertise the services provided. In addition, The Night Ministry builds relationships with agencies and organizations across Chicago that refer patients to our Health Outreach Program.
Q. Do you partner with local health systems, primary care providers, health clinics or other programs?
We regularly refer patients to other healthcare clinics and service providers for further care. We have also established relationships with teaching hospitals in the Chicago area which allow for medical residents to further their training and gain experience in caring for unhoused populations while enhancing the capacity of The Night Ministry to provide services.
Q. How might this program evolve? What new technology or strategies would you like to employ in the future?
The Night Ministry’s Health Outreach Program continues to evolve in many ways, from substance use programming to hiring practices to mental health and programmatic service expansion. We are growing substance use programming by building referral relationships for supportive services, distributing harm reduction supplies, and educating our clients on safe drug use. And for the first time, we are hiring a psychiatric nurse practitioner to bring mental healthcare directly to our clients.
Q. What is the one thing about this program, good or bad, that has really surprised you? Something you didn't expect to see or experience, an unusual case or treatment, a challenge or barrier you didn't expect to face or didn't expect to be so tough, etc.
We are sometimes the only way that people access medical or housing support. We always ask clients where they would go if The Night Ministry wasn’t there to provide services. We find that people avoid seeking support for many reasons, including prior mistreatment, lack of transportation, fear of having their belongings stolen, or separation from a pet or partner. By going directly to clients and establishing trust, clients are more likely to work with us for the long term in navigating the often challenging housing system and securing long-term solutions.
Q. Describe your program, why it's different or innovative, who it serves, how many care providers it features, and how this is improving healthcare access and/or clinical outcomes.
Since 1993, the Yale Center for Clinical and Community Research (YCCR) has operated the Community Health Care Van (CHCV, a 40-foot mobile medical clinic that functions alongside a minivan and storefront office to provide harm reduction and other medical services in New Haven, Connecticut.
The CHCV has long delivered accessible and barrier-free harm reduction and healthcare services at the doorsteps of the community, with an emphasis on New Haven’s most vulnerable neighborhoods. The CHCV served 1,574 clients in 2021. A rotating trio of providers staffs the CHCV throughout the week, alongside two medical assistants and several office staff.
The CHCV serves a significant population of unstably housed/homeless individuals and people who use drugs (PWUD), as well as individuals transitioning from incarceration or treatment programs back to the community. More than 30% of CHCV clients report unstable housing or homelessness, and nearly half experience food insecurity. The CHCV is positioned to meet the needs of these community members, offering services in primary and preventive healthcare, flu and COVID-19 vaccines, HIV care, substance use disorder treatment, and care coordination to stabilize those in crisis or in need. Additionally, the CHCV operates one of the largest overdose education and naloxone distribution programs in the state.
In response to the COVID-19 pandemic, the CHCV expanded its mission to create the Mother-Infant Program (MIP), a mobile unit providing postpartum care for birthing parents and infants with health-related social needs. The MIP addresses health inequality, maternal mortality, substance use, and access to care, and seeks to address the burden of social determinants of health. The MIP aims to decrease adverse maternal and infant outcomes while simultaneously increasing basic needs support.
Q. What kind of technology do you use?
Our 40-foot CHCV has a modem allowing internet access in the van. We use three desktop-style computers on the van, as well as a laptop, which provides us with access to our Epic electronic heath record (EHR) platform. We leverage a working agreement with American Medical Response (AMR), an emergency medical services company, to rent one of their box trucks, which we have retrofitted to provide a space in which to service MIP clients. On the MIP van we use a cellphone hot-spot in order to access our EHR.
Q. Why did you choose to launch a mobile program? How does this work better than a brick-and-mortar clinic or virtual program?
The CHCV has a trusted relationship with the New Haven community, a city profoundly impacted by poverty, substance use, homelessness, and incarceration. It is the 7th poorest city in the US for its size, with more than 25% of its residents living in extreme poverty, often geographically remote from traditional healthcare settings. The mobile nature of the CHCV and minivan allow our team to frequent underserved areas, such as homeless encampments, shelters, hotels known for drug use, residential neighborhoods, and business districts.
We have found that low-barrier access to healthcare increases the use of services amongst our patients. With specific reference to postpartum care, 40% of women do not attend their traditional brick-and-mortar six-week post-partum visit. By comparison, mothers who are seen by the MIP demonstrate an appointment no-show rate of about 4%.
By taking a focused approach on meeting patients at their doorsteps, providing nuanced care, and assisting them in navigating the healthcare system, the CHCV and MIP provide an innovation in service delivery that directly confronts traditional barriers to healthcare access.
Q. What are the biggest challenges this program faces?
Long-term funding and hospital system buy-in.
Q. How is this program supported so that it is sustainable?
The CHCV team continually applies for a mix of research and service grants to support our program. Including federal, state, and philanthropic sources, we piece together various funding to support our staff and the costs of running the CHCV. Clinical billing offsets a small percentage of this but we could not operate the program without grant and philanthropic funding.
Q.How are patients charged for healthcare services? Do you work with payers?
Patients are never charged for CHCV or MIP services. If they have insurance, a bill for services will be sent to their carrier, but patients are never responsible for services provided by CHCV. We work closely with a CHCV-specific billing team to ensure that services are properly billed. Our medical case managers help patients access patient assistance programs to pay for medications when necessary.
Q. How do you let people know when and where you'll be located? How do you market your services?
The CHCV is a longstanding fixture in New Haven, with most of our clients having accessed our services for many years. We keep the same weekly schedule, at the same locations. Print schedules are handed out in our storefront location and posted on our Instagram page. Many of our patients have learned about services through word of mouth.
Q. Do you partner with local health systems, primary care providers, health clinics or other programs?
We partner closely with several community-based organizations and health clinics. Referrals are often placed to two federally qualified health centers (FQHCs) in New Haven. All referrals to the CHCV MIP program come from a local FQHC. Additionally, we refer to behavioral health services, dental services, and other specialty services as needed.
In the summer months, the CHCV services partner with Power in a Shower, which provides showers for individuals experiencing homelessness. We also collaborate often among our non-profit peers, such as the Community Alliance for Research & Engagement, Junta for Progressive Action, Downtown Evening Soup Kitchen, and Integrated Refugee & Immigrant Services. These non-profit connections allow for a clear “window” into the needs of the community. Without the added bureaucracy that often accompanies larger entities, our non-profit peers can facilitate timely conversations around community needs, allowing dynamic responses from entities such as the CHCV and MIP.
The CHCV and MIP serve as vehicles for Yale Medical and Nursing students to see first-hand the challenges to healthcare access experienced by many New Haven community members. Student precepting allows the CHCV and MIP teams to engage the health professions schools in community-based healthcare.
Q. How might this program evolve? What new technology or strategies would you like to employ in the future?
The CHCV continues to represent an intersection of community-based healthcare, harm reduction, and clinical innovation. In the face of New Haven’s profound opioid overdose epidemic, the CHCV (and our brick-and-mortar-based office) have begun using a Fourier-transform infrared spectroscopy (FTIR) machine, which provides a novel mechanism for identifying and tracking harmful adulterants in the drug supply. We combine FTIR testing with real-time delivery of results to our clients and community response teams. Results from testing are accompanied by discussions surrounding safer use and other harm reduction messaging.
Additionally, our MIP team has begun providing dyad-focused care for pregnant and postpartum women (and their children) in SUD residential treatment through Connecticut’s largest provider of addiction treatment services. From the program's inception in January 2022 to March 2023, the MIP completed a total of 157 visits (35 individual moms and 27 individual children). Women living in residence have access to MIP services throughout their 3-8 month stay, and many use the services multiple times for follow-up and personalized care coordination.
The expansion of CHCV and MIP services demonstrates the dynamic nature and nimble response of mobile healthcare. Our vans have flexed to respond to pressing community issues like the COVID-19 epidemic, providing vaccines, hand sanitizer and masks, as well as providing basic primary care, Narcan, and now specific FTIR testing and drug supply alerts.
Q. What is the one thing about this program, good or bad, that has really surprised you? Something you didn't expect to see or experience, an unusual case or treatment, a challenge or barrier you didn't expect to face or didn't expect to be so tough, etc.
Q. Describe your program, why it's different or innovative, who it serves, how many care providers it features, and how this is improving healthcare access and/or clinical outcomes.
Agile Orthopedics provides in-place amputee services including prosthetic limbs through the use of intentionally designed mobile clinics. This care model is unique in that it addresses the intersection of physical disability and social determinants of health. People dealing with amputation and in need of prosthetic services are often limited in their ability to make it to clinic appointments due to transportation and financial constraints. By providing in-place service, these barriers are eliminated, and access to these services is significantly improved.
The population served is anyone in need of these services, but over time the alignment between our service model and the patient population as a whole has become focused on the underserved. The outcomes we track and have seen are increased speed between amputation and ambulation, which in turn leads to overall improvements in physical health. We are also studying how our intervention affects hospital readmission rates. We suspect that our in-place model, which also includes case management, reduces hospital readmissions following amputation surgery.
Q. What kind of technology do you use?
Mobile healthcare is all about trial and error and continuous improvement. After a bit of experimentation, we landed on a system of adjustable modular prosthetic components designed in Iceland that provide an amazing amount of versatility and options for assembling and fitting prosthetic limbs in the field. We also use 3D scanning to capture detailed dimensions of patients’ limbs and changes over time. We are always improving and expanding the capabilities of our specialized mobile clinics that house all the equipment and machinery required for comprehensive on-site prosthetic services.
Q. Why did you choose to launch a mobile program? How does this work better than a brick-and-mortar clinic or virtual program?
After many years of leading traditional outpatient programs, it became clear that the no-show rates were very high, sometimes up to 50%. I took a deep dive into this issue and found that patients are faced with overwhelming barriers to engaging in the requirements of traditional clinics. Social determinants of health, like access to healthcare and economic stability, combined with the real challenges of physical disabilities make it impossible for many amputees to be provided with the prosthetic management they need. Using mobile services for those in need surfaced as a viable solution to remove barriers and improve access and equity to these services.
Q. What are the biggest challenges this program faces?
Recruiting practitioners who are suited for and truly understand mobile healthcare has been a challenge. The requirements to be highly organized, incredibly creative and improvisational, and to operate in variable, unpredictable situations, take a special person with unique perspective.
Q. How is this program supported so that it is sustainable?
We partner with hospitals, physicians, and surgeons to promote patient choice of providers and raise awareness that mobile care is an option. The differentiation and truly patient-centric approach has gained traction over the last several years, which has led to the sustainability of the organization.
Q. How are patients charged for healthcare services? Do you work with payers?
All services we provide are covered through Medicaid, Medicare, and private insurance carriers. We also work with a non-profit organization in order to cover those without insurance or resources.
Q. How do you let people know when and where you'll be located? How do you market your services?
We generally market our services directly to hospitals, physicians, and physical therapists who get the word out about our services. We also attend events and support other organizations that serve the underserved.
Q. Do you partner with local health systems, primary care providers, health clinics, or other programs?
Yes, partnerships are critical, as amputee services require a team approach.
Q. How might this program evolve? What new technology or strategies would you like to employ in the future?
In an effort to provide more community-based amputee care, we have begun to offer amputee-specific physical therapy. This has improved the comprehensive approach to our services. In the future, we plan to add occupational therapy and case management, as these are needs that are predictable within the population we serve.
Q. What is the one thing about this program, good or bad, that has really surprised you? Something you didn't expect to see or experience, an unusual case or treatment, a challenge or barrier you didn't expect to face or didn't expect to be so tough, etc.
I’ve been surprised by how our services have aligned with specific populations over time. So much of our identity has changed since the initial design and marketing of the organization toward anyone in need of prosthetic services who might require or just prefer the mobile model. We have come to align closely with certain underserved communities, like the unhoused, and those within the state and federal department of corrections systems who particularly need mobile services. This type of alignment has driven innovation in our programs to serve very specific needs of those populations.
Q. Describe your program, why it's different or innovative, who it serves, how many care providers it features, and how this is improving healthcare access and/or clinical outcomes.
The Sidney Kimmel Cancer Center (SKCC) Mobile Cancer Screening Van offers multi-cancer screening opportunities tailored to the risk of communities, as well as additional social services to reduce adverse social determinants of health. The van services a seven-county catchment area spanning the Greater Philadelphia region in Pennsylvania and New Jersey.
The van offers breast, prostate, skin, head and neck, and colorectal cancer screening; cervical cancer screening is being onboarded in 2023. The unit also offers services such as hepatitis B screening and vaccination, connection to primary care, and chronic disease screenings for hypertension and diabetes. Services to reduce adverse social determinants of health have included connection to free Internet and technology (tablet computers) and food pantries, as well as assistance in registering to vote. All screenings and services are offered free of charge. For patients who are uninsured, a fund at SKCC covers the cost of screenings and any diagnostic testing needed.
Q. What kind of technology do you use?
The mobile screening van is fully equipped with Epic, our health system’s electronic medical record, to record patient screenings and evaluate impact over time. For breast cancer screening, the mobile van is equipped with state-of-the-art 3D tomosynthesis for screening mammography.
Q. Why did you choose to launch a mobile program? How does this work better than a brick-and-mortar clinic or virtual program?
The SKCC launched a mobile cancer screening van as one way to reduce cancer disparities in our catchment area. Cancer incidence and mortality rates are higher in our catchment area than state or national rates and disparities exist within our populations. Philadelphia County, at the heart of our catchment area, has the highest levels of poverty of any large city in the US, and a majority of residents are battling adverse social determinants of health in their everyday lives.
Innovative care delivery models are needed to overcome traditional barriers to care experienced by our residents, such as lack of transportation, lack of time for medical care, and unfamiliarity with preventive care and cancer screening. By bringing healthcare to residents, mobile cancer screening reduces many of the known barriers to care.
Q. What are the biggest challenges this program faces?
Every cancer screening event is held in conjunction with a community partner; therefore, our team is engaging with hundreds of community partners each year. Some community partners, like primary care clinics, are used to hosting clinical events like a screening day, while others, such as church groups, are less familiar with and unaware of the nuances in patient insurance, screening eligibility, and mobile van requirements.
Also, staff turnover at community partners makes consistency in planning sometimes challenging. Patients who are not engaged in the healthcare system often present at the mobile screening van with multiple healthcare needs and require additional care beyond screening. While this is an opportunity to connect patients to other care, it can be taxing at times on the screening van staff.
Q. How is this program supported so that it is sustainable?
The mobile screening van was launched with generous philanthropic donations that continue to sustain key portions of the program. Additional funds from grants, sponsorships, and government funds support the mobile screening van, as does revenue generated from billing insurance for guideline-recommended screenings. The diversity and combination of these funds ensures that the mobile screening van is sustainable well into the future.
Q. How are patients charged for healthcare services? Do you work with payers?
Patients who have health insurance and receive reimbursable cancer screenings are billed for their care. All payers who have contracts with our healthcare system are accepted on the mobile van. For those who do not have health insurance, screening and follow-up care, if needed, are free of charge.
Q. How do you let people know when and where you'll be located? How do you market your services?
We market our cancer screening events in multiple ways. The community partner often takes the lead on marketing to the individuals in their network; as a trusted community partner, their name and reputation in the community are important for getting the word out. Also, all screening events are posted on our website and anyone can register to attend an event. Lastly, sometimes we do targeted outreach to communities and individuals about particular screening events that need a boost in awareness.
Q. Do you partner with local health systems, primary care providers, health clinics, or other programs?
Yes to all of the above. We also partner with churches, non-profit organizations, public libraries, community colleges, local health departments, employers, and coalitions. We will partner with anyone who wants to bring the mobile cancer screening van to their community.
Q. How might this program evolve? What new technology or strategies would you like to employ in the future?
The program is always evolving to meet the needs of the communities that we serve. For example, we started with a mobile van that only offered breast cancer screening; we are about to onboard our sixth cancer screening exam. There is still more that we can do in cancer prevention and control, such as bringing awareness about lung cancer screening to the community, promoting smoking cessation programs, and providing other cancer prevention services, like HPV vaccination.
We can also do more to combat the adverse social determinants of health of our residents by offering more wrap-around services to meet their needs and better connections to other aspects of healthcare for them and their family members. We are also working to improve the data analysis and evaluation aspect of our program to ensure that we’re offering the highest quality of care in the most culturally sensitive manner possible.
Q. What is the one thing about this program, good or bad, that has really surprised you? Something you didn't expect to see or experience, an unusual case or treatment, a challenge or barrier you didn't expect to face or didn't expect to be so tough, etc.
The demand for the mobile cancer screening van is so much higher than we anticipated. The COVID-19 pandemic caused many people to go without cancer screening for a significant amount of time, coupled with people who are simply disconnected from healthcare for numerous reasons. Communities are looking for ways to bring quality healthcare to their neighborhoods in a way that is convenient and not cost-prohibitive, and mobile cancer screening fills that need.