What Nebraska’s Physician Shortage Says About the Emerging Healthcare System Nationwide | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

What Nebraska’s Physician Shortage Says About the Emerging Healthcare System Nationwide

April 17, 2018
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A new report looks at Nebraska’s physician shortage—and the potential role of HIT in resolving some staffing issues nationwide

I read with interest a report issued earlier this month by a work group at the University of Nebraska Medical Center, which focused on the widespread, challenging physician shortage in the state of Nebraska. The report, entitled “The States of the Healthcare Workforce in the State of Nebraska,” revealed that while there has been an 11 percent increase in the number of physicians in the state over the last 10 years, there are 13 counties that still do not have a primary care physician, according to a press release published by the University of Nebraska Medical Center (UNMC).

According to the April 4 press release published by UNMC, that finding was one of a number of key findings in the 64-page report. Among those challenges, the report found “the reality that nearly one-fifth of physicians in Nebraska are more than 60 years old, and thus likely to retire in the near future”; found that “18 of 93 Nebraska counties have no pharmacist”; and found that “demographics in many counties are becoming more diverse, but the current health workforce doesn’t necessarily reflect the populations being served.”

Inevitably, physician assistants and advanced nurse practitioners (PAs and APNs) are filling in the gaps in Nebraska. “Since 2007, there has been a large increase in the number of active physician assistants (PAs) in the state,” the report noted. “There are 908 PAs (or 47.3 PAs per 100,000 population) versus 598 (33.5 {As per 100,000 population) in 2007—a 52-percent difference in number of PAs. PAs currently provide a total of 35,878 work hours, equating to 897 FTE PAs. Half of the PAs are 40 years old or younger, and over 70 percent of PAs are female.” Further, the report stated, “Analysis of the distribution of PAs by county showed that 16 counties in Nebraska do not have an active PA.”

Meanwhile, the reported noted that, “In 2017, there were 1,148 nurse practitioners (NPs), 36 certified nurse midwives (CNMs), 49 clinical nurse specialists (CNSs), and 308 certified registered nurse anesthetists (CRNAs). The number of NPs rose from 767 to 1,148 in 2007-2017—a 50-percent increase. For CNMs, the increase was from 22 to 36 professionals.”

Importantly, the report’s authors state, “Our results highlight the substantial deficit in the supply of physicians across counties in Nebraska, particularly for the primary care specialties of internal medicine, OB/GYN and pediatrics. In addition, nearly one in five physicians in the state are older than age 65, and thus are likely to retire in the near future. In contrast, the number and rates of physician assistants and nurse professionals have grown substantially over the last decades and provide wide-ranging geographical coverage in Nebraska. The greater reliance on physician assistants and nurse practitioners,” they wrote, “has helped to offset the inadequate supply of primary care physicians.” Even so, they added, “[T]here remains substantial variation in the rate of nurse professionals across the state, with relatively low numbers of RNs, LPNs and APRNs in west and central Nebraska.”

Can healthcare IT be part of the solution?

Of course, Nebraska is far from alone among states with widely dispersed, broadly rural populations; Nebraska’s situation mirrors the situations of nearly all of those states. What’s more, with both the physician and nurse cadres aging these days, all of those states are facing accelerating challenges in providing high-quality care to their populations, including those sub-populations living with single or multiple chronic illnesses—particularly diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD).

But here’s the thing: the potential for leveraging important technologies is quite considerable in states like Nebraska. We all know that the adoption of telehealth technologies, strategies, and care delivery are advancing rapidly everywhere in the U.S., but particularly in states like Nebraska, which have a few large metropolitan areas, with medical specialists, imaging centers, and academic medical centers and other teaching hospitals, along with vast rural areas that have shortages of all physicians, including primary care physicians, as well as of mid-level professionals.

But there’s more: as value-based care delivery and payment move forward, the need to shift as much administrative burden, as well as, as many clinical and other tasks that can be shifted off primary care physicians, will only increase. As a result, multidisciplinary care team-based models are moving forward, even in less-advanced (until now) managed care markets. And the leveraging of clinical information systems will absolutely be a critical success factor in that regard. Not only will electronic health records need to be hyper-accessible and super-usable; all of the clinical decision support tools and the tools needed to optimally care-manage patients with chronic illnesses, will need to be architected for use by those multidisciplinary care teams, with data beautifully organized for use by the physicians, physician assistants, advanced nurse practitioners, registered nurses, licensed practical nurses, nurse case and care managers, social workers, psychologists, pharmacists, therapists, and all others connected to those care teams. And that architecture will perforce have to include dashboards for use by physicians and care managers, to evaluate patients’ health statuses and outcomes; data analytics for executive and leadership use; and as much operational software and revenue cycle management technology as possible, for financial and operational success in an increasingly value-based operational world.

What’s more, key technologies will be part of the solution to managing the care and health of patients when they are in their homes and navigating their daily lives, as well—as it will need to be. But there’s great opportunity there, as patients/consumers connect themselves to mobile technology that can in turn be connected to the formal clinical information systems that help clinicians and care managers enhance and improve their patients’ clinical outcomes and health statuses. OpenNotes, too, could prove valuable in engaging patients in their care, including in enhancing what is often described as “patient compliance” (a terrible term, really, but it’s the one commonly used and understood) in relation to physician instructions and prescriptions—not to mention support and education from care and case managers to patients/consumers.

In fact, it’s impossible to think about the future of healthcare delivery in states like Nebraska and not think about the role of healthcare information technology. And that puts healthcare informaticists and other healthcare IT leaders in a unique position, as facilitators—at the highest level—of change and change management, in healthcare delivery, on behalf of the patients whom we’re all saying should be at the center of all this.

So when it comes to physician shortages, the aging of physicians and nurses, and all the broad staffing and care access challenges that face communities and regions in states like Nebraska, let’s keep in mind that healthcare IT leaders can be heroes in all this—and need to help their colleagues move forward, into the challenging, exciting, rapidly changing, emerging healthcare system of the mid-21st century. Nebraska, you’re not alone. Nor will your solution be yours alone.

 

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/news-item/population-health/all-us-team-building-data-browser-researcher-workbench

All of Us Team Building Data Browser, Researcher Workbench

January 23, 2019
by David Raths, Contributing Editor
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Software tools to help researchers explore, analyze research data set

As the national All of Us research program begins collecting health data, its Research Hub, which will house an array of data collected in the program, is developing software tools to help researchers explore and analyze the All of Us Research Data Set.

The Data and Research Center (DRC) located at Vanderbilt University Medical Center houses the All of Us research database. In a newsletter, the Research Hub noted that in 2019 it expects to release information that participants provided via surveys, physical measurements, and electronic health records. Researchers will be able to access participant research data, with personal identifiers removed in order to explore how various factors contribute to individual health and disease.

The EHR information included depends on what kinds of healthcare has been received and what types of providers a patient has seen. The All of Us Research Program employs Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) Version 5 infrastructure to ensure feasibility and standardization across EHR data for researchers. EHR data will be accessed longitudinally throughout the life of the program. Within the context of the Research Hub tools, EHR data will be presented at the highest level of granularity, which is by EHR Domain. Domains include: Demographics, Conditions, Procedures, Drugs, Measurements, and Visits.

In the first half of 2019, the DRC plans to release a Data Browser that will allow anyone to view aggregate counts of participant research data. Counts will be available for survey data collected from participants, physical measures collected during exams, and medical concepts from electronic health records (EHR) data. This tool will be available to anyone, with no registration or login required.

A “Researcher Workbench” is slated for release by the end of 2019. The Workbench is an analysis platform designed for researchers to create cohorts of individual-level participant research data, review these cohorts, and analyze and visualize the data in a Jupyter notebook using Python or R.

The initial version of the Workbench provides three tools for working with data:

• Workspaces: Create a project workspace. Store cohorts and notebooks. Share with team members.

• Cohort Builder: Build and review a custom data set.

• Notebooks: Analyze your cohort. Create graphs or tables to showcase your work.

To ensure participant privacy, researchers will be required to register and verify their identity in order to use the Workbench.

The DRC noted that it has sought input from an array of potential users of the Research Hub, collated their feedback, and leveraged these insights to help guide iterative development of the tools. 

Currently, the Research Hub is in its first beta launch within the DRC. The purpose of this release is to open the Research Hub up to vigorous internal testing that includes quality control, quality assurance, data characterization, data validation, and user testing as well as security and functionality testing. 

 

 

 

 

 

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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.

 

Related Insights For: Population Health

/article/population-health/kaiser-creating-evidence-based-complex-care-models

Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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