Key Specialties Roundtable: What's in Store for Service Lines and Their Leaders in 2013?

As the demand for specialized care increases, hospitals have to transform and innovate the care offered by their service lines to meet this demand. Each service line is unique, and the development of each differs. But, service line leaders are confident that with engaged physicians, creative solutions and care coordination, service lines can increase patient satisfaction and quality of care.

In this article, several service line leaders from top programs across the country discuss the opportunities in and challenges facing the oncology, cardiovascular, neurology and orthopedic service lines in the coming year. They also talk about the latest technologies being used in their service lines and offer advice to service line leaders.

Cardiology and Cardiovascular
Question: What are some of the biggest developments or opportunities for growth in the cardiovascular service line in the coming year?

Jennifer Bringardner, Vice President, National Cardiovascular Service Line, Catholic Health Initiatives (Englewood, Colo.): The cardiovascular service line is undergoing significant change. It is expanding from primarily a focus on episodic care to population health. That is, caring for the consumer across the continuum. Primary prevention will be a major area of focus.

New models of care delivery will shift care from hospitals, historically the center of the healthcare continuum, to less expensive and more appropriate settings. As we form our clinically integrated networks, the role of the cardiovascular specialist will evolve and develop to support these new delivery models.

Tom Stys, MD, Medical Director of Cardiology, Sanford Health (Sioux Falls, S.D.): It is certainly a dynamic and fast-evolving world. The general trend is to provide care to patients in a less invasive manner, which also allows for expanding care to patients who are cannot undergo invasive procedures due to age. For example, minimally invasive valve replacement can be used for patients who are not candidates for open-heart surgery.

Q: What are some of the newest technologies or applications that are being used in the cardiovascular service line?

Greg Schwarz, Vice President of Business Development, St. Vincent Medical Center (Los Angeles): We have placed importance on diagnostic procedures and testing because this sets the course for the patient's cardiac care. We have spent a lot of money on improving the diagnostic equipment at the hospital. Additionally, we have placed greater emphasis on less invasive procedures as technology advances.

Paul Colavita, MD, President, Sanger Heart & Vascular Institute, Carolinas HealthCare System (Charlotte, N.C.): We now use telemonitoring. We have an implantable device that monitors blood pressure in congenital heart patients. The data from the device is sent to a large remote diagnostic clinic and to the patient through their cell phone. This helps us make recommendations to the patient regarding medication and diet.

Q: What are some of the challenges currently facing the cardiovascular service line?

Mr. Schwarz: The challenge today, in Southern California, is that the physician community is fragmented. Physicians and hospitals will need to become more organized and create centers of excellence.  This will allow for comprehensive heart care to be delivered under one roof with increased efficiencies, better patient outcomes and lower costs.  

Dr. Colavita: A lot of the challenges have to do with increasing the size of the care team. In the past, physicians felt as though they were pretty much in charge of the patient's care. It was an individual physician-patient relationship. Now, we are creating partnerships with advanced care practitioners, primary care physicians and also pharmacists, social workers and dieticians.

Q: How would you recommend overcoming some of the challenges facing the cardiovascular service line?

Dr. Colavita: One attempt to overcome challenges is to create a community — a community of providers. If someone has heart failure, we should try and ensure that their care is uniform, whether they go to a primary care physician or a specialist or come to the hospital. The care should be similar and evidence-based.

Ms. Bringardner: Recognizing that we are evolving, we are challenged to be patient as our teams learn new skill sets. A stronger emphasis on sharing best practices so time is not wasted on initiatives, which ultimately, will not add value, is needed.

Leveraging the talent of our team members to design innovative, streamlined approaches to transform the way we provide care is essential. Strong data systems and analytics are foundational elements.

Q: What advice do you have for service line leaders for the coming year?

Dr. Colavita: My advice for them is to listen to all the members of their team and formulate plans with input from all those members.

Dr. Stys: My advice would be to definitely stay on top of the newest and latest developments. This is a very rapidly developing field. Also, they should try to secure interdisciplinary collaboration at the institution. We have to work as a team rather than as individual care providers.

Q: What are some of the biggest developments or opportunities for growth in the neurology service line in the coming year?

Debbie Spielman, Assistant Vice President, Florida Hospital Neuroscience Institute (Orlando): For us particularly, the biggest development will be the expansion of our pediatric epilepsy program into an adult program. This program is designed for patients who are not responding to medication for their seizures and includes very comprehensive, integrated, diagnostic technology including a PET/EEG, fMRI, MEG and cEEG to determine if a surgical approach is indicated. Along similar lines, we have also invested in our neurodiagnostic infrastructure by including continuous EEG technology in our 40-bed neuro critical care unit. This allows us to detect sub-clinical seizure activity in our neuro critical care patients.

Kim Springer, MSW, Executive Director of St. Vincent Neuroscience Institute at St. Vincent Indianapolis Hospital: Within neuroscience, as is true with all service lines, the most pronounced opportunity lies in responding to our changing healthcare environment. At St. Vincent, we specifically recognize the opportunity to strengthen physician alignment strategies to better respond to changing patient populations, physician availability, reimbursement models and technological advances. Programmatically, this year will provide the opportunity to enhance our stroke system of care through the development of a statewide telestroke strategy. We will also see growth in the areas of epilepsy/seizure, spine care, neurovascular surgery and neuro-oncology, as well as trauma services and pediatric support.

Q: What are some of the newest technologies or applications that are being used in the neurology service line?

Ms. Spielman: Continuous EEG is one new technology which we have integrated with other neuro monitoring for better care of our most critical patients. We are also investigating the NeuroBlate, which is a minimally invasive laser approach to inoperable brain tumors and lesions. It utilizes our intra-operative MRI technology for guidance. For our brain attack program, we are using the Solitaire and the Trevo, both of which are clot retrieval devices utilized in interventional neuroradiology for stroke patients beyond the window for tPA.

David Houghton, MD, MPH, Vice Chairman of Clinical Development and Division Chief of Movement and Memory Disorders, Ochsner Neuroscience Institute (New Orleans): Teleneurology and that remote ability to manage patients is number one on the list. We are well-established in its application for stroke, and we are expanding it quickly to all aspects of neuroscience. We are also using more functional brain imaging, including DaTSCAN, which is a technology that helps in the differential diagnosis of tremor disorders such as Parkinson's disease.   

Q: What are some of the challenges currently facing the neurology service line?

David Charles, MD, CMO, Vanderbilt Neuroscience Institute at Vanderbilt University Medical Center (Nashville, Tenn.): Payors are reluctant to pay for new technologies that are expensive. In neuro, we have a range of new technologies in different areas, but it is happening at a time when there is huge pressure to reduce healthcare costs.

Ms. Spielman: Probably standardization of care. That's probably a real challenging one that we are going to have to start tackling as it relates to spine disorders as well as many other neuro-related conditions. The challenge within that is bringing our physicians together to be a part of this process and endorse standardization in the areas where the evidence supports it.

Dr. Houghton: The number one challenge, regionally and nationally, is the financial pressure being brought on by the reimbursement models of Medicare, Medicaid and the commercial insurance companies.

Q: How would you recommend overcoming some of the challenges facing the neurology service line?

Ms. Springer: Engaging physician extenders as well as extending the reach of physicians through telehealth are two strategies that will help address the changing physician pool. With neurodiagnostics, "growing our own" quality technicians will help. As for changed reimbursement models, I believe that strong interdisciplinary teams, led by engaged physicians, will help us identify waste and operationalize smarter medical models focused on defined patient populations.

Q: What advice do you have for service line leaders for the coming year?

Ms. Spielman:
Every organization is different with regard to where they are at on the journey, but I think we all have to focus on standardization in the acute-care setting as well as how we expand the continuum of care in the outpatient setting. We will ultimately be held accountable for patient outcomes, so we must begin to design care models that extend beyond the acute care walls.

Dr. Houghton: I think, at the end of the day, they should remember that exemplary patient care is the best model for success. It will drive patient volumes and lead to the best outcomes. And they should think creatively, particularly when fee structures and margins are shifting. We can think creatively, consolidate expertise, use technology like teleneurology and increase both efficiency and patient satisfaction.

Q: What are some of the biggest developments or opportunities for growth in the oncology service line in the coming year?

Andrew Pecora, MD, Chief Innovations Officer and Vice President of Cancer Services, Hackensack (N.J.) University Medical Center: One of the biggest things is the development of at-risk contracting. That has the potential to be transformative. At-risk contracting is where the providers create a product rather than offer services that the payors pay for in a lump sum.

Sonya Greck, RN, Senior Vice President of Operations, Asheville, N.C.-based Mission Health: Here at Mission Health, our focus is always on the patient. The organization and service lines continue to take care of our patients and make decisions by something we call the BIG(GER) Aim. That means we strive to achieve the desired patient outcome first without harm, also without waste and with an exceptional experience for the patient and the family.

In the cancer service line, one of the major opportunities will be to continue to provide the best possible care with decreased reimbursement. Currently, we are participating in a variety of value stream mapping processes to determine how we can add value to the patient experience. This involves process improvement and eliminating waste so that our caregivers have more time to spend with the patients.

Our cancer program continues to grow with inclusive services from genetics to end-of-life care. We are truly multidisciplinary and are constantly seeking ways to provide patients with access to care. This is demonstrated in our multidisciplinary clinics where patients can come to one place, and our physicians and caregivers are in the clinic to provide care. That means that a patient does not have to go from one office to another seeking care. A comprehensive approach is so important to our patients.

Another opportunity is the development of our electronic medical records in the ambulatory setting. The ability to document care and communicate effectively to all caregivers is vital in the patient care setting.

Q: What are some of the newest technologies or applications that are being used in the oncology service line?

Ms. Greck: The continuous development of multidisciplinary clinics is one of the best options to address a comprehensive treatment modality for patients. We continue to see the benefits for our patients and continue to see great opportunity in developing these clinics. For example, partnerships between disciplines like nutrition, pulmonology, thoracic surgery, medical oncology, psychosocial support and the radiation oncology team ensures that the patients have an extensive multidisciplinary treatment plan and access to caregivers.

Electromagnetic Navigation Bronchoscopy is a technology that we have adapted to facilitate the diagnosis and treatment of our patients for lung treatment. Mission Hospital is the only hospital in western North Carolina that provides this new minimally invasive procedure. The process combines GPS-like technology with a catheter-based system —  
threaded through the patient's natural airways — to access hard-to-reach regions deep in the lungs. The procedure can locate, test and diagnose disease thus helping physicians plan treatment and eliminating the need for invasive surgical procedures, such as needle biopsy.

Mission Cancer also offers a wealth of complementary and holistic services to enhance recovery and help patients through healing with less pain, fewer medications, lower stress and better sleep. For example, Mission Cancer pairs each patient with a registered nurse who can help with both the medical and non-medical concerns they face after diagnosis. These nurse navigators support patients from the time of diagnosis, through treatment and into survivorship or end-of-life care.

Q: What are some of the challenges currently facing the oncology service line?

Jack Khashou, Vice President, Ochsner Cancer Institute (New Orleans): We are really facing two main challenges. Primarily, how do we expand the focus on the patient and provide them a more holistic approach to their care during treatment and continue to support them after treatment. The second is staying ahead of the cost pressures and changing reimbursement models. We are attacking this through our pursuit of value initiatives, which aims to provide the best treatment options at the best value. In our opinion, this will be accomplished by carefully assessing best practices and reducing treatment variation.

Deb Hood, Vice President, National Oncology Service Line, Catholic Health Initiatives (Englewood, Colo.): Our biggest struggle in the past three years has been to obtain data — apples-to-apples comparisons instead of apples-to-pencils. In oncology, there are so many different systems and locations where information resides, such as laboratories, imaging centers and physician offices. Without good data, you can't begin to have discussions about how to reduce costs or improve outcomes. We have spent many hours carefully detailing the exact description of an item we want to measure and exactly where the most valid data resides. Since most of oncology work is in the outpatient arena, this data, along with good comparative benchmarks, can be difficult to obtain.

A close second is physician alignment. Catholic Health Initiatives has very few employed oncologists, so working with independent practices in each individual market has been a challenge with various quality initiatives we'd like to implement. This work is much easier to do if you're a Kaiser or another institution where everyone is employed and willingly sharing data or on the same software system.

The other challenge is figuring out the role of oncology in the various new models of care, such as ACOs, patient medical home, etc., that are developing. We're looking at the specialty neighbor model for oncology and have a lot of work ahead for us in this development.

Q: How would you recommend overcoming some of the challenges facing the oncology service line?

Ms. Hood: In the past, I didn't feel that your oncologists all needed to be employed. Today, however, I feel that we need something to link the oncologists and cancer centers in this new era of population health. Maybe that's employment, but it could also be professional or management service agreements. Physicians are lining up with various partners across the country, but some independent groups still want to wait and see what direction everything is headed. I'm not sure we can afford to wait for them. We have a lot of preparatory work that needs to be done now, and we need strong physician partners.

For the work ahead, we also need to be physician-led. Our service line is organized in clinical dyads. My partner, Dax Kurbegov, MD, is the physician vice president, and I am the administrative vice president. Dr. Kurbegov and other physician leaders throughout our system are doing a tremendous amount of work that's preparing us for the future. We need their clinical leadership and expertise embedded in everything we do.

Q: What are some of the biggest developments or opportunities for growth in the orthopedic service line in the coming year?

Dereesa Purtell Reid, COO, Hoag Orthopedic Institute (Irvine, Calif.): More than ever, hospitals and physicians must look for ways to align their goals around achieving the highest quality while driving down the cost of care. With an aging U.S. population and an increase incidence in obesity, the demand for orthopedic care will continue to grow. Optimizing the health of patients before surgery is essential whether it is weight loss or addressing other co-morbidities.

Q: What are some of the newest technologies or applications that are being used in the orthopedic service line?

Ms. Reid:
While orthopedic and spine implants continue to improve, we are focused on evaluating surgical products that improve patient care and also reduce costs. For example, Hoag Orthopedic Institute reviewed several patient-warming methods in the operating room. Keeping patients warm throughout surgery has been proven to reduce the risk of infection.

In the world of neurosciences, the technology continues to advance — deep brain stimulators, neurological drugs and new approaches to neurological rehabilitation.

Akram Boutros, MD, Founder and President of Business First Healthcare Solutions, former COO and CMO at South Nassau Communities Hospital (Oceanside, N.Y.): The introduction of robotics. The RIO™ is a robotic platform designed to improve implant alignment and reduce surgeon error by passively restraining surgeon movement to ensure precision.

Q: What are some of the challenges currently facing the orthopedic service line?

Ms. Reid:
Two key challenges come to mind for any service line, whether it is orthopedics, neuroscience, heart or cancer. The first is that vocational commitment by physicians and the hospital is essential. Building a service line is a multiyear, perhaps multidecade commitment with many financial and organizational challenges. The most successful service lines were built by a core group of individuals that were internally motivated by a "calling" or vocational commitment to build a service line or institute that surpasses what any one individual or hospital can do alone. The second is that with limited resources and the need to produce top quality, not all programs and service lines may be feasible.

Q: How would you recommend overcoming some of the challenges facing the orthopedic service line?

Ms. Reid:
Healthcare reform wills thoughtful consideration as to which service lines a specific hospital or health system can provide at the highest quality and reasonable costs.  Value-based purchasing is creating quality transparency among hospitals and service lines. With limited resources and declining reimbursement, the portfolio of service lines offered by hospitals is likely to narrow.

Q: What advice do you have for service line leaders for the coming year?

Ms. Reid:
Become best friends with nursing! Nurses provide care at the intersection of patient satisfaction and quality. They are the heart of the healthcare organization — serving patients and physicians.

Dr. Boutros: I would advise service line leaders to focus on service line transformation. While in the short-term, the focus on profitable growth is critical, in a highly competitive market, expansion of care beyond the operating room is important for long-term success. A full menu of options and packages from diagnosis to recovery should be aligned for effective delivery of high-value, personalized outcomes.

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