Improving communications among clinicians is becoming more urgent by the day, as both nurses and physicians experience more intense, task-packed workdays, and as inefficiencies and delayed care become literally more expensive for patient care organizations moving into value-based healthcare delivery and payment.
Clinician leaders at Advocate Health Care, based in the Chicago suburb of Downers Grove, and which is one of the largest integrated health systems in the Chicago metro area, were facing the same challenges as everyone else, when they first began looking at some of the communications breakdowns in their organization. The average turn-around time at Advocate hospitals was 20 minutes for a doctor, nurse or other care team member to get in touch with a fellow clinician in order to coordinate patient care. Clinicians had also voiced difficulty tracking their attempts at communicating with care team members. With awareness of the national evidence caused by communication breakdowns, coupled with their own need to align patient safety with consistent clinical communications, Advocate Health Care completed implementation of an enterprise secure clinical communications solution in 11 hospitals in 2014. For the next deployment phase, the largest health system in Illinois rolled out the solution to its 1,200 employed physicians who used Advocate’s call center.
To speed up clinical communications and drive enterprise acceptance of the solution, Advocate IT leaders launched an “optimal enablement” initiative that measured three parameters of adoption success. If all three parameters are met, physicians are deemed fully compliant using the solution. As a result, the following innovations have taken place:
> Hospital-based clinicians are now able to contact physicians and advanced practice clinicians through the software without going through a third party.
> Physicians use the platform to communicate with colleagues and vice versa.
> Any care team member can initiate and receive clinical communication via an iPhone or Android device using a smartphone app.
Secondly, to maintain its optimal enablement initiative driving adoption, Advocate IT leaders went a step further improving upon this metric. They’ve developed a three-pronged sustainability strategy to maintain adoption momentum necessary to achieve compliance of seamless and secure standardized clinical communications across the continuum. That strategy encompasses the following:
> Instituting a governance structure. Advocate formed a hospital steering committee comprising acute to post-acute network stakeholders: administrators, hospitalists and employed physicians, nurses, clinicians representing multiple disciplines, and IT professionals. As the foundation for sound decision-making and ethical practice, a governance structure is paramount to ensure asynchronous communications. The steering committee promotes mandated tool adoption and user accountability in the communication of care management.
> Maintaining metrics and reporting. To ensure fine-tuning and usage of the tool, Advocate established key performance indicators (KPIs) and key result areas (KRAs) to achieve clinical communication goals specific to each user. For example, Advocate measured response times from initiating to receiving messages between physicians and nurses and vice versa.
> Determining future goals. Advocate plans to tackle utilization management for chronically ill patients, ensuring providers are communicating frequently with them to help reduce preventable overuse of care services, such as ED visits. Advocate also will enroll more community care managers and advanced practice clinicians onto the platform.
Advocate leaders report the following results from implementing an enterprise clinical communications solution, provided by the Knoxville, Tenn.-based PerfectServe, to support this initiative:
> With the solution designated the standard method for physician communication, primary care physicians, hospitalists and specialists report enjoying more efficient and speedy communications across both the acute and post-acute network.
> More than 95,000 secure messages per month equating to roughly over a million annually are read within 10 minutes of receiving—a dramatic decrease in response time. Advocate is experiencing steady improvement in this metric.
> Physicians and nurses using the solution’s mobile app can verify if a message has been read or not, thanks to an auto indicator within the message thread. Having this notification empowers clinicians specifically to quickly communicate necessary clinical information and feel confident that their message is being read and addressed.
> All data regarding attempts for contacting physicians are recorded.
Recently, Healthcare Informatics Editor-in-Chief Mark Hagland spoke with two Advocate Health Care leaders about this initiative: Chris Jamerson, M.D., vice president, clinical informatics-Advocate Medical Group; and medical director of informatics-Advocate Children's Hospital; and Dennis Giles, director, Support Services, Tech Help Desk, Communication, and Information System, for Advocate Health Care. Below are excerpts from that interview.
Dr. Jamerson, could you tell me a bit about your involvement in this initiative, and your role at Advocate Health Care?
Chris Jamerson, M.D.: I’m a general pediatrician, have been with Advocate and Advocate Medical Group for over eight years. A year ago, I stepped into the role of the CMIO, essentially, for the ambulatory side. So I’m responsible for the EMR; I’m kind of the interface between the providers and the IT team, around the EMRs.
And you, Mr. Giles?
Dennis Giles: I’ve been here at Advocate for 15 years. My role is with the communication and collaboration products, including PerfectServe. I’m also involved in support for the hospitals. The name of our department is now Health Informatics and Technology.
How did the goal of standardized clinical communication across the enterprise, emerge?
Giles: We identified the need for better clinical communications. That started at a time when Advocate was a system of hospitals that were pretty independent, and left alone to manage things their own way. We’re much more corporate today. And one hospital, Good Shepherd, and put together a committee to discuss the patient safety issues around clinician communications. They ended up choosing PerfectServe as a solution. We rolled it out and other hospitals heard about it, and then we ended up rolling it out to all the hospitals, and it became a corporate standard.
Is this essentially messaging software?
Giles: It started out with using a single phone number. Nurses had had rolodexes with paper, and phone numbers in desk drawers, or they would end up calling hospital operators. This software allowed us to call one number, and using logic, route that call to the physician on call. So it might be Chris today, but let’s say he’s on vacation; it will route the call to his practice partner. So it helped us get to the right doctor at the right time. And the software’s evolved; it started out as a paging facility, basically, but has become more robust, and encompasses texting, and now a web portal that allows them to text a message to a physician.
Dr. Jamerson, how did the pre- situation feel, for physicians and nurses? What was the imperative? And what did you accomplish?
As Dennis said, we were going through a corporate consolidation and alignment, and we’ve come a long way in that process since 2009-2010. And one of the things we’ve done is to start down a patient safety/high reliability journey. And this played into that really nicely. A lot of examples emerged as we started monitoring safety events and doing safety calls every day—there were a lot of challenges coming up. Nurses getting in touch with physicians, or physicians getting in touch with other physicians. Being able to quickly do that—the level of frustration got to the point that either the communication wouldn’t happen—the doctor would feel, I don’t have enough time to call and call back, and so on. So simplifying this through telephony and then later through the app, really helped a lot. It’s shown itself to be a real benefit as we’ve continued on this patient safety/high reliability journey.
Dr. Jamerson, can you share the perspective of physicians in practice, on an initiative like this?
Yes. Our clinicians are typically going to multiple sites—hospital, ambulatory—and they need to quickly communicate with each other. And you know, in the old days, the physician would typically practice at a single regular clinic site. But that’s no longer true, particularly as we expand out throughout the Chicago area. And in 2008, 2009, 2010, as we came together as a system, that necessitated the idea that we could quickly come together. And if I’m gone, they need to quickly connect with someone else and get the answer. You need quality discharges that are efficient, with good follow-up plans. You send a patient home and they might need to come in and see you in the clinic tomorrow or the next day—and just relying on a fax or some other outdated form of communication.
And as you move into population health and care management under accountable care contracts, this kind of innovation will only become more important, correct?
Yes, absolutely. Making sure that we’re able to keep patients in the system, so making sure that if they’re headed out of the hospital and are going to a post-acute-care setting like a nursing home or SNF, or an ambulatory care setting, we need good control over that; and we need to know the level and type of care we’re providing. And the nurse case managers, the care managers—that communication, being able to reach out to the right providers, using a reliable form of communication, is really crucial.
And how do you make sure a solution like this makes sense in terms of the technology and technological architecture needed to support it?
Giles: Our strategy moving forward is to really look outside the boundaries of the hospital to account for folks working out in the field like our care managers, and working across our ACO, working with all the teams. That communication platform has been an enabler in that. And our real strategy going forward is that the solution we’ve chosen is our communication tool for communicating anything about a patient to an Advocate clinician. And with that, one of the things we’ve done to make sure Advocate has a voice at the table, is to be part of the vendor’s advisory team. So we work with other patient care organizations across the country, to make sure the software develops correctly, to make sure the technology meets our needs.
Meanwhile, internally, we’ve created several committees to help achieve adoption. That can be a challenging thing when we’re working with private physicians who work at more than one hospital. We’ve looked a metrics to try to improve adoption. One of the messages we got back from physicians was, I try to reach other physicians on my smart phone, but physicians aren’t listed in Advocate’s directory. Or nurses trying to text physicians who hadn’t yet downloaded the app. So we have a steering committee dedicated to this vendor solution that’s more tactical, and a unified communications steering committee that’s more strategic. And on that latter committee, we’re asking, what is it like to create an optimal situation for physician communications. So, do they have the smartphone? Do they have the app on their smartphone? And is the hospital able to reach them directly, and are their colleagues able to reach them directly? And we went to each hospital and started working with the medical leadership of each hospital, and the executive leadership of each hospital. We had one hospital that really embraced it, and mandated the use of the communications tool. And now only two hospitals have not mandated its use. And back in 2015, we started that journey, in terms of governance and adoption. And we’ve made a ton of headway here. At the system level, we currently have an 80-percent adoption of the solution.
What has the physician experience been like, of this new system? What have you heard from doctors?
Jamerson: The overwhelming response to the solution has been positive. There were some pockets of resistance, people not wanting to change the way they communicated, or fears that they couldn’t disconnect. So we had to do some teaching around the rerouting element; and that usually overcome that resistance. Initially, it was just resistance about using new technology. So we had to help them understand that it actually would afford a greater level of communication between physicians and support staff, and that it would be a benefit to patient safety and to them, and would actually afford a broader range of options around call and around contact. And that was something new, something that traditional pager systems didn’t allow to be automated. Once people realized that you could customize this yourself, that added to people’s acceptance.
What have the biggest lessons have you learned around this process so far?
Jamerson: I’ve learned that you need to start by getting the education out there; education around whatever your proposed solution is, or changes, out there, to the frontline physicians and nurses and nurse practitioners and PAs, etc. They’re the end-users, and they can make or break something like this. So they need to know the ‘why,’ which is patient safety and improved turnaround time around communication; and the benefits of it. And it’s not the same thing in a different package, but the same thing plus a bunch of other stuff, that will give you more control. And when you’re talking about messaging, control is very important to physicians. Most practicing physicians right now still want some autonomy as a physician. If you can convince them that this actually provides more autonomy even while you’re standardizing on something, that’s important. Everyone needs to feel special, and feel that they have control. We communicated that, but we probably could have communicated that even earlier.
Giles: From a rollout and implementation perspective, it’s important to make sure you set up governance early, so you have governance teams that can manage issues and develop the strategy. And from that perspective, you also need to determine what metrics you’ll follow. You need to get the measurements out there so that everyone understands how you’re doing in terms of adoption of the product. And the final thing is partnering with all the clinician leaders, physician and nurse leaders. Make sure you set up partnerships. And of course, Chris hit the nail on the head; education is key.
What might happen in the next year or two, as this initiative evolves forward?
Giles: As the platform continues to change, one of the things we’re focused on now is allowing for bidirectional texting of information. Today, the nurse can text the physician, but the physician can’t yet text the nurse, the physician has to call. The technology allows for it, but we have to set up policies around that, around what the communication should look like. And you need measurements around following the policy, to make sure we have some kinds of guardrails around that, so we’re looking at programs that might be able to parse messages… So if we don’t want physicians to send orders around text, that we could monitor for that, and address it. Just making sure we put good thought around this new message.
So you want to set a framework and parameters around what you’d like physicians to share in text messages, and how, correct?
Giles: Yes, that’s exactly right.