Allegheny Health Network doctors using AI to document visits
Allegheny Health Network doctors using AI to document visits

Allegheny Health Network doctors using AI to document visits

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Diverging Reports Breakdown

Allegheny Health Network teams with Pittsburgh-based AI company to advance documentation

Allegheny Health network is using AI software to record conversations with doctors. The software is HIPAA-compliant, meaning nothing is leaked. Dr. James Solava: “It’s really amazing, it’s been transformative” Dr. Solava says it leads to less burnout and better well-being for clinicians. It’s also being used right now in the system’s emergency rooms, ambulatory spaces, and acute care settings. The next steps here with this software involves getting it into the hands of nurses, as well as expanding its use in hospitals. The technology is being tested with dietitians, nurses, and other health care providers in the area as well. The pilot program insights reported that 92% of patients said their provider felt more attentive.

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Artificial intelligence has made some big leaps in the past few years. Now, it’s changing doctor visits in the Allegheny Health network system.

AHN is rolling out AI-powered ambient clinical documentation technology in practices.

Doctors at AHN are using AI software in phones to record AI conversations as they’re talking, with the patients’ permission, of course.

It’s saving them a lot of time when taking notes.

“It’s really amazing, it’s been transformative,” AHN Primary Care physician Dr. James Solava said. “We have 400 docs, 400 providers already using this software – over 40 different specialties.”

AHN announced a partnership last month with Abridge, a Pittsburgh-based company.

That company’s software is what is helping doctors in the system with daily paperwork when they see patients.

“It really enhances their efficiency,” Dr. Solava said.

The process is simple. Solava says doctors open an app on their phone. The patient gives consent to be able to use the software.

He says that some people have had questions, but that the software is HIPAA-compliant, because the data collected is safe and secure behind firewalls, meaning nothing is leaked.

The app starts recording the conversation. After the visit with a patient finishes, the doctor clicks a button, and notes are generated within seconds.

“The technology is impressive,” Dr. Solava said.

Chad Ware of Belle Vernon was used in a demo test exclusively seen by KDKA on Friday. He’s actually been coming there for 10 years.

“It’s amazing to see the notes that it’s captured just from the technology,” he said.

Dr. Solava says it leads to less burnout and better well-being for clinicians. He said that there’s a lot of paperwork and charting that extends into off-work hours and weekends.

“It’s been helping us to close our notes and get all our paperwork done the very same day,” he said.

He says the software has also gotten good marks from patients. AHN’s pilot program insights reported that 92% of patients said their provider felt more attentive.

Doctors can focus on them more when they’re spending less time focusing on the computer screen to make sure they’re jotting down notes.

“They’re actually being able to have a conversation with their doctor, and they connect with their physician much better,” Dr. Solava said.

It’s something Ware feels when he comes to the doctor’s office now.

“So far, the experience has been very good,” he said.

Dr. Solava has been using this since March of 2024. He said AHN has been moving forward with transitioning all of its physicians to that artificial intelligence platform.

AHN is even testing out other areas where it can use tech like this, such as with dietitians. It’s also being used right now in the system’s emergency rooms, ambulatory spaces, and acute care settings.

Dr. Solava added that Abridge is also routinely trying to refine the software.

“They’re constantly on site around our different facilities in the hospitals and in the different offices,” he said.

Dr. Solava says part of the next steps here with this software involves getting it into the hands of nurses, as well as expanding its use in hospitals.

Source: Cbsnews.com | View original article

No cash, no checks. Erie hospital now requires patients pay with credit or debit card

Allegheny Health Network, Saint Vincent’s parent organization, is no longer accepting cash or checks for most medical payments. The new policy took effect July 7. AHN cites reduced administrative costs, improved payment security and record-keeping, and better infection control as reasons for the change. Exceptions will be made for patients who don’t have a credit or debit card.

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AI-assisted summary AHN cites reduced administrative costs, improved payment security and record-keeping, and better infection control as reasons for the change.

Exceptions to the cashless policy will be made for patients without credit or debit cards.

Visiting Saint Vincent Hospital or one of its medical offices for a procedure or exam? Make sure to take a credit or debit card with you.

Allegheny Health Network, Saint Vincent’s parent organization, is no longer accepting cash or checks for most medical payments made at the hospital or in the office. The new policy took effect July 7.

“This policy change allows us to reduce administrative costs, strengthen the security of our payment processing, and improve record-keeping,” AHN officials said in a statement. “Reducing physical contact with paper currency and checks also reduces the spread of germs, improving infection control.”

The Pittsburgh-based health system accepts all major credit and debit cards, including those attached to health savings and flexible spending accounts.

Exceptions will be made for patients who don’t have a credit or debit card.

“AHN will not turn away patients at the point of care,” AHN officials said.

AHN continues to accept cash at nonclinical locations, including cafeterias, vending machines and gift shops.

What is the payment policy at UPMC Hamot?

UPMC still accepts cash and checks for copayments and other payments at its hospitals and medical offices, according to a UPMC Hamot spokeswoman.

It wasn’t immediately known what payments are accepted at UPMC-GoHealth Urgent Care centers.

Contact David Bruce at dbruce@gannett.com. Follow him on X @ETNBruce.

Source: Goerie.com | View original article

‘First-of-its kind’ relationship: Highmark Health, Abridge announce unique collaboration to scale and deploy AI technologies across an entire payer-provider ecosystem

AHN will use Abridge’s AI-powered ambient clinical intelligence platform to enhance system-wide patient-clinician interactions. Highmark Health is working with Abridge to facilitate real-time prior authorization at the point of conversation using AI. With the patient’s consent, the conversation is documented through a secure smartphone app or laptop/ desktop with web recording. The clinical note is presented in real time within the clinician’s existing workflow, allowing the clinicians to review and edit the resulting note as needed. In its own tests of ambient scribe technologies over the last year, AHN reported that 92% of its patients felt their providers were more attentive during their visits when the technology was being utilized. The platform also reduces the after-work hours — known in the industry as “pajama time” — that doctors commonly spend editing their notes, reviewing EHRs and documenting after-care summaries. The implementation of the ambient technology will begin at outpatient locations, but AHN and Abridge plan to eventually deploy the technology across the entire health system footprint.

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AHN will use Abridge’s AI-powered ambient clinical intelligence platform to enhance system-wide patient-clinician interactions; Highmark Health is working with Abridge to facilitate real-time prior authorization at the point of conversation using AI

PITTSBURGH, Aug. 12, 2025 /PRNewswire/ — Highmark Health announced today the launch of an enterprise-wide collaboration with Abridge to deploy its ambient clinical documentation platform, collaborate on a paradigm-shifting prior authorization solution at the point of conversation, and invest in other innovative tools that integrate Abridge’s AI technology.

Abridge prior authorization video. Abridge prior authorization tool.

Highmark Health is a Pittsburgh-based organization that includes a multi-state insurance services division (Highmark Inc.) and a 14-hospital care provider (Allegheny Health Network). Abridge, also based in Pittsburgh, is a pioneer in developing AI technologies to improve patient outcomes and reduce clinician burdens.

The first phase of the collaboration involves implementing Abridge’s ambient clinical intelligence platform at AHN office locations and hospitals. The AI technology assists in clinical documentation so that providers can focus on patient care, rather than note-taking.

“Providing patients with exceptional, personalized care is our highest priority, and that starts with empowering clinicians to be their best,” said Mark Sevco, president of AHN. “Abridge’s technology allows clinicians to spend more time listening to and engaging with their patients, leading to a much better overall experience for both parties.”

Real-time clinical notes from patient-clinician conversations

Abridge securely transforms patient-clinician conversations into clinical notes. With the patient’s consent, the conversation is documented through a secure smartphone app or laptop/desktop with web recording. The clinical note is presented in real-time within the clinician’s existing workflow, allowing the clinician to review and edit the resulting note as needed. Once the clinician reviews and submits the notes, they are directly integrated into the patient’s electronic health record (EHR).

Automating what otherwise would have been a manual effort, the platform frees clinicians to focus more fully on delivering face-to-face patient care — rather than facing away from a patient and typing notes into a computer. In its own tests of ambient scribe technologies over the last year, AHN reported that 92% of its patients felt their providers were more attentive during their visits when ambient scribe technology was being utilized.

The platform also reduces the after-work hours — known in the industry as “pajama time” — that doctors commonly spend editing their notes, reviewing EHRs and documenting after-care summaries. AHN clinicians who piloted the technologies reported dramatic improvements in documentation and workflow efficiency.

“Limiting documentation burden can help to solve for burnout and workforce shortages in the health care industry,” said Bethany Casagranda, DO, MBA, president of AHN’s physician organization and Chief Medical Officer for AHN. “Many of our physicians have described the technology as ‘life-changing’ because they are able to leave work with an empty inbox, and spend more evenings and weekend time with family, friends, and other activities that contribute to their wellbeing.”

While the implementation of the ambient technology will begin at outpatient locations, AHN and Abridge plan to eventually deploy the technology across the entire health system footprint, enabling its use across all hospital locations and practices by physicians, advanced practice providers, and nurses.

“Abridge’s platform will help us close care gaps by generating clinically useful and compliant documentation at various interaction points,” Dr. Casagranda said. “Our roadmap includes utilization in our emergency departments, hospitalist programs, home care environments, and any other area where we believe it can make a difference.”

Pioneering solution for real-time prior authorization at the point of conversation

Beyond the adoption of clinical documentation technology, Highmark Health and Abridge are also collaborating on a new prior-authorization technology that builds upon Highmark’s advanced product and is aimed at facilitating near-instantaneous approvals at the point of conversation.

Prior authorization is the process by which a health insurance plan approves a medical service or medication before it’s provided to a patient, to ensure coverage. The review process can sometimes cause delays in the provision of care or coverage; when delays occur, it’s often because of missing clinical documentation – not necessarily because the insurer doesn’t cover the procedure.

Historically, most attempts at solving the challenges of prior authorization have focused on streamlining the approval process post-encounter. Highmark Health, however, has spent years refining its prior authorization programs and documentation technologies, so that approvals can happen at the point of submission.

“Highmark Health has long been focused on simplifying the prior authorization process, and recently we joined many other U.S. health plans in redoubling our commitment to connecting patients more quickly to the care they need while also reducing administrative burdens on the clinicians who provide that care,” said Tony Farah, MD, EVP, Chief Medical and Clinical Transformation Officer for Highmark Health.

“This collaboration with Abridge marks another important milestone in our journey to bring prior-auth decision-making to the point of care, building upon Highmark Health’s unique Gold Carding program, and ensuring that there are no unnecessary delays in covered treatments and that our members receive care that is timely and evidence-based.”

Highmark Health Plan is already processing a significant percentage of prior authorizations electronically, at the point of submission, through the physician Gold Carding program — which pre-approves doctors based on their historical practice patterns — and other electronic systems.

The collaboration with Abridge aims to accelerate that approval process further. Abridge’s technology will work by comparing, in real time, Highmark’s medical authorization requirements to the information that is being collected during the physician-patient visit. If any pieces of required documentation are missing, Abridge will prompt the physician to gather what’s needed.

By advancing the prior authorization review process to the point of conversation between patient and physician, the physician and the insurer will be on the same page from the start, accelerating approvals and supporting reduced denials for missing documentation. Clinicians remain at the helm of the process, reviewing all AI-generated recommendations before anything is submitted.

“Prior authorization is one of the biggest challenges facing healthcare today, and the costs of waiting for approval can be enormously significant for patients,” said Dr. Shiv Rao, Abridge CEO and Co-Founder. “Our technology opens a powerful path to dramatically reduce the burden of this process at the point of conversation — by helping clinicians ask the right questions and automatically generate documentation that’s both complete and compliant. That transforms a traditionally weeks-long process into one that can take just minutes. We’re excited to refine this new solution with the experts at Highmark Health, who see the real-world impact of these delays every day. Ultimately, it’s about giving clinicians back their time and ensuring patients get the timely care and focus they deserve.”

The collaboration between Highmark Health and Abridge also reaffirms the companies’ joint commitment to further cementing Western Pennsylvania as a hub for developing and investing in next-generation technology advancements that will create more connected health experiences. Various teams at Highmark Health, including the enterprise’s health-tech subsidiary, enGen, are playing key roles in enabling and scaling these technologies.

“AI innovation is a critical component of our organization’s Living Health model and its focus on transforming health and wellness through more effective, efficient, and affordable solutions for the diverse health needs of those we serve,” said Richard Clarke, PhD, SVP, Chief Analytics Officer, Highmark Health. “By leveraging next-frontier technologies and Abridge’s powerful AI platforms, we have a unique opportunity at Highmark Health and AHN to help redefine the patient, member, and clinician experience in our industry.”

About Abridge

Abridge was founded in 2018 to power deeper understanding in healthcare. The enterprise-grade AI platform transforms medical conversations into clinically useful and billable documentation at the point of care, reducing administrative burden and clinician burnout while improving patient experience. With deep EHR integration, support for 28+ languages, and 50+ specialties, Abridge is used across a wide range of care settings, including outpatient, emergency department, and inpatient.

Abridge’s enterprise-grade AI platform is purpose-built for healthcare. Supported by Linked Evidence, Abridge is the only solution that maps AI-generated summaries to source data, helping clinicians quickly trust and verify the output. As a pioneer in generative AI for healthcare, Abridge is setting the industry standard for the responsible deployment of AI across health systems.

Abridge was awarded Best in KLAS 2025 for Ambient AI in addition to other accolades, including Forbes 2025 AI 50 List, TIME Best Inventions of 2024, and Fortune’s 2024 AI 50 Innovators.

About Highmark Health

Highmark Health, a Pittsburgh, PA-based enterprise that employs more than 44,000 people who serve millions of Americans across the country, is the parent company of Highmark Inc., Allegheny Health Network, and enGen. Highmark Inc. and its subsidiaries and affiliates provide health insurance to more than 7 million members in Pennsylvania, West Virginia, Delaware, and New York, as well as dental insurance, and related health products through a national network of diversified businesses. Allegheny Health Network is an integrated delivery network in western Pennsylvania composed of 14 hospitals, more than 2,500 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions. enGen is a wholly owned subsidiary of Highmark Health whose dynamic ecosystem of smart automation and technology supports and streamlines complex operations for health plans and their provider partners. To learn more, visit www.highmarkhealth.org.

SOURCE Highmark Health

Source: Prnewswire.com | View original article

Appropriate ED Utilization Leading to Better Care Coordination

Emergency department (ED) utilization contributes significantly to medical expenditure in the United States. In 2010, nearly 1 in 5 visits were determined to be potentially avoidable and contributed $65 billion to rising health care costs and ED overcrowding. Addressing avoidable ED utilization is a focus for Highmark Health, which has implemented interventions in partnership with providers to reduce preventable ED use. These best practices include patient education, expanded provider access, aligned financial incentives across the care continuum, and health system data sharing. The average cost of treating common primary care treatable conditions at a hospital ED is 12 times higher than visiting a physician office and 10 times more than traveling to an urgent care center for help with the same issues. The Agency for Healthcare Research and Quality estimated that between 13% and 37% of ED visits could be safely referred to 1 of 3 settings: primary care provider (PCP) offices, urgent care, or retail. The Highmark Quality Blue Hospital Program measures return visits to the ED within 3 days post discharge from an inpatient stay.

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Emergency department (ED) utilization contributes significantly to medical expenditure in the United States. Over the past 3 decades, increases in US ED visits have been documented despite decreases in active or operational EDs.1,2

In 2010, nearly 1 in 5 visits were determined to be potentially avoidable and contributed $65 billion to rising health care costs and ED overcrowding.3 The average cost of treating common primary care treatable conditions at a hospital ED is 12 times higher than visiting a physician office and 10 times higher than traveling to an urgent care center for help with the same issues.4 Several factors contribute to patients’ utilizing ED services, such as access to primary care, behavioral health diagnosis, lack of care coordination, lack of empowerment to self-manage chronic conditions, and social determinants of health (SDOH).5 ED visits are a high-intensity interaction and a cost burden on the health care system, as well as on patients.

Addressing avoidable ED utilization is a focus for Highmark Health, which has implemented interventions in partnership with providers to reduce preventable ED use.

Identification of Avoidable ED Utilization

The Agency for Healthcare Research and Quality (AHRQ) estimated that between 13% and 37% of ED visits could be safely referred to 1 of 3 settings: primary care provider (PCP) offices, urgent care, or retail.6 Algorithms to determine potentially avoidable and preventable ED visits have centered around diagnostic and procedure codes. The New York University ED algorithm (NYU-EDA), developed from 1999 to 2001, took a probabilistic approach to determine visits that were in 1 of 4 categories: (1) nonemergent, (2) emergent but treatable in a primary care setting, (3) emergent care required but preventable if appropriate ambulatory care had been received, and (4) emergent care required and not preventable.1 Injuries were not included in the original NYU-EDA algorithms and nearly 84% of ED visits were able to be classified.1

Johns Hopkins utilized the original NYU-EDA and added 2 revised algorithms that included injuries and modified the methodology. In so doing, nearly 99% of all visits could be classified, and it was discovered that 58% of the ED visits in the data set were primary care sensitive.7 Both ED algorithms were developed with the caution that their appropriate use is in research settings, not on individual case determinations. Using the Johns Hopkins algorithms Highmark has been able to leverage potentially preventable ED utilization information to support performance in value-based reimbursement incentive programs.

Support of Provider Best Practices

Highmark has implemented metrics for both overall ED use and preventable ED utilization within its value-based reimbursement programs. Additionally, the Highmark Quality Blue Hospital Program measures return visits to the ED within 3 days post discharge from an inpatient stay. The True Performance Primary Care Physician program has measured overall ED utilization and will narrow the metric to avoidable ED visits starting in 2022. The Highmark field staff who support the value-based reimbursement programs use a variety of reporting methods to identify an organizations’ trends in avoidable ED utilization andto determine where workflow redesign efforts are most warranted.

Highmark Health generates daily reports of ED discharges and lists of members with frequent ED use. These lists provide detailed information about which ED was accessed, admitting diagnosis, final diagnosis, date of service, day of the week, and whether the patient is enrolled in any of the various care management programs available. Additional detail is available through a third-party vendor population health management tool through which analysis and trending at an entity, specific practice, or individual provider level can be conducted. Organizations and individual providers can view a specific patient’s utilization history assisting with care coordination efforts.

Leveraging these insights, the Highmark Health field staff support targeted initiatives for the physician organizations, individual providers, and hospital systems contracted in value-based arrangements. The field staff use evidence-based resources to promote a range of best practices to minimize avoidable ED utilization. These best practices include patient education, expanded provider access, aligned financial incentives across the care continuum, additional case management, and health system data sharing.

Patient education involves identifying a true emergency, monitoring symptoms, and highlighting other existing appointment options, such as PCP, virtual health, retail clinics, and urgent care. Educating patients can be done proactively by the PCP for those who have been identified as high ED utilizers and retroactively during post–ED visit outreach calls. For inpatients, education occurs by incorporating face-to-face technology, integrating behavioral health, and addressing SDOH.

Expanded provider access, case management, and aligned financial incentives are additional key variables that can aid in reducing avoidable ED visits. Provider practices can ensure their schedule allows for timely appointments leveraging extended and/or weekend hours, and virtual visit options. Case management referrals can be initiated in the ambulatory or hospital setting to achieve more coordinated care.2,8 Case management and social work support, either virtually or in person, can be particularly effective while a patient is in the ED so that care coordination with the patient’s PCP can take place. If a PCP is not identified for a patient, the case manager can assist the patient in choosing a PCP and arrange a follow-up appointment.9 Aligned financial incentives within a health system for hospitals, providers, and patients synergize efforts to reduce ED utilization across the continuum of care.

Clinically integrated networks (CINs) and hospital systems that share data between providers have heightened awareness of ED overuse issues, which allows for a data-driven policy implementation. Examples of ED utilization data points that are monitored include hour of the day, day of the week, visit diagnoses, and likelihood of ED use risk calculations. The collection and analysis of these data points allows CIN or hospital system leadership to implement policies and procedures that incorporate best practices to address preventable ED visits—for example, routine identification of patients with a high likelihood of ED utilization and proactive outreach to these individuals prior to weekends when preventable ED visits tend to be observed. Ensuring call center phone tree alignment is another example of a procedure that routes patients to the appropriate point of contact to address their concern and prevent an avoidable ED visit.

When looking at outcomes data, the efforts that have been put into place by the Highmark field staff have shown to be favorable for both the True Performance PCP and Quality Blue Hospital Program. True Performance­–participating PCPs demonstrated reduced ED utilization compared with providers not contracted in the True Performance PCP program, which yielded $66.7 million in potentially avoidable costs. Within the Quality Blue Hospital Program, there were approximately $1.7 million in potentially avoided costs due to fewer returns to the ED within 3 days of an index ED visit between 2016 and 2019.

Follow-up care post ED visits are very important to improving patient care and health outcomes and potentially decreasing future ED visits. Patient engagement strategies are vital in follow-up care and through motivational interviewing practices can better facilitate patient understanding and awareness. Through enhanced practice culture and processes, conversations at all levels of care can help encourage visits to the PCP rather than the ED. Engaging the patient post ED visit can help lead to better understanding of why the patient went to the ED, allow for the opportunity to gauge patient understanding of their care and discharge instructions, assess medication adherence, assess SDOH risk factors, and provide an opportunity for patient education.9

Support of SDOH

One of the biggest contributing factors to avoidable ED utilization is SDOH, which are defined by the CDC as “economic and social conditions that influence the health of people and communities.”10 Highmark’s enterprise SDOH department has identified the following SDOH domains: social connections, financial resource strain, health literacy, food insecurity, transportation, safety, housing stability, childcare access and affordability, and employment. Most, if not all, of these factors have an impact on ED utilization, thus addressing them on an ongoing basis with patients may help contribute to fewer preventable ED visits.

One of the resources used to support provider improvement in ED utilization rates is a ED Utilization Toolkit created by the Highmark Population Health Department. The toolkit references the most cited reasons for avoidable ED use, such as lack of access and lack of education, both of which fall under the SDOH umbrella.11 At-risk populations for ED failures are also discussed in this toolkit. Per AHRQ, included in these populations are those with cognitive impairment, psychiatric illness, alcohol and drug abuse, and poor health literacy.12 This toolkit recommends ways to help combat these problems including data analysis to help predict which patients may fall into one of these categories. Screening for SDOH on a regular basis may help identify which patients will be likely to overutilize the ED related to social factors. The post ED follow-up call is also discussed in detail in this toolkit. Asking open-ended questions related to SDOH may help retroactively identify patients who may continue to use the ED because of social determinants.

The Highmark Population Health Department has also developed an internal-facing SDOH toolkit that has embedded documents that can be shared externally with providers. This toolkit emphasizes the need for screening patients for social determinants. A recent study in the Journal of the American Medical Society showed that “approximately 24% of hospitals and 16% of physician practices reported screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. Federally qualified health centers and physician practices participating in bundled payments, primary care improvement models, and Medicaid accountable care organizations screened more than other hospitals, and academic medical centers screened more than other practices.”13 Although screening is increasing, there remains room for improvement. The SDOH toolkit comprises the Highmark Enterprise SDOH Assessment as well as 3 additional assessments that are nationally recognized. The SDOH toolkit also provides recommendations for implementing SDOH screening into practice workflow.

Highmark Health and Allegheny Health Network (AHN) have various programs and pilots in place that address SDOH and ED utilization. One of programs focuses on Mobile Integrated Health (MIH), which is available across the AHN footprint; this program is headed by Jonah Thompson, CP-C, operations manager of MIH at AHN. Patients are referred via a variety of sources including inpatient, ambulatory, community, and enterprise partner sources. Most AHN clinicians can also make a referral through the Epic electronic health record (EHR) and there is also a mechanism to refer via the Allscripts EHR.

MIH is care that is delivered by community paramedics to patients outside the clinic and outside the hospital to patients who may have been described as “difficult” or “noncompliant” and often have had frequent physician visits and ED visits and recurrent hospitalizations. These patients may have been referred to case managers and community programs but persist with poorly managed health issues and overutilization of ED and hospital care.

The community paramedics work to develop a relationship with these patients and help to determine why they are not connecting to the provided referrals. They meet the patients in person whenever possible—whether it be at someone’s home, the bench at a park, or at a fast-food restaurant—and they closely examine SDOH factors as well as issues in the home that may be affecting the patient’s ability to follow through with resources provided. The community paramedics meet the patient where they are in order to help set goals by looking at the patient’s motivation. Some of the findings are that many of these patients are dealing with loneliness and depression, as well as transport and mobility issues. Thompson describes the program as “understanding why gaps and barriers exist and ensuring we take enough time to really do that in depth with patients who have likely fallen through the cracks or failed more conventional approaches (Jonah Thompson, CP-C, operations manager, Mobile Integrated Health, Allegheny Health Network, conversations and emails, January 11, October 18, and October 19, 2021).

A second program, led by Phyllis Rebholz, RN, MSEd, CCM, executive director of case management at AHN, was initiated at St. Vincent Hospital in Erie, Pennsylvania, and has since expanded to Forbes Hospital and Allegheny General. In this payer-agnostic program, patients who come into the ED and meet certain predictable analytic criteria (based on NYU logic of avoidable ED usage) will generate a “ping” to a social worker from the Care Management Transitional Care Team. The patients are low acuity as their ED visit has been deemed preventable. The social worker will then interact with the patient in real time while they are still in the ED to assess the patient in order to link them to community-based organizations, educate them about medication resources, and connect them to the right provider. The goal is to turn over care to the PCP so the physician office can take over the care coordination and education of the patient. Some of the needs that are frequently seen are related to transportation, food insecurity, and social isolation (Phyllis Rebholz, RN, MSEd, CCM, executive director of case management at Allegheny Health Network, conversations and emails, October 13 and October 18, 2021).

The third program is the Front Door Initiative (FDI) and is funded through a grant from the Jefferson Regional Foundation. Funding began in 2018 and will continue until 2023. Alyson Lush, senior project manager of the FDI at AHN, oversees the program, which targets patients discharged from Jefferson Hospital ED with the goal of helping patients connect with community programs and services that address SDOH to reduce ED utilization. ED staff send FDI referrals for adult patients who visit the ED, screen positive for at least 1 SDOH need, and have been discharged. Community health workers (CHWs) reach out to patients 4 days post discharge and follow up again at 30, 60, and 90 days. Community referrals are made at any or all these contacts depending on need. FDI also reaches out to community-based organizations for resources leading to more targeted referrals to patients and the details of services are compiled so the CHW can use them as a resource for patients. A third objective is training in the ED. Trainings are provided to ED staff at Jefferson Hospital around SDOH, cultural competency, and other pertinent subjects. At this time, FDI is collecting outcome data related to the project. (Alyson Lush, senior project manager, Front Door Initiative, Allegheny Health Network, conversations and emails, October 13, 13, and 18, 2021).

Support for Behavioral Health

Behavioral health and substance abuse disorders are also well-known contributors to overall rising health care costs in the United States. These conditions are the leading cause of combined disability and death among women and the second highest among men. In 2007, approximately 12 million ED visits were related to mental health or substance abuse, which is one-eighth of all ED visits.14 The ED is also highly utilized among patients who suffer from mental health and substance abuse issues. In 2017, HHS declared the opioid epidemic a public health emergency, and in 2019, more than 70,000 people died from drug overdose, according to HHS.15

According to Highmark’s 2020 data, members with severe and persistent mental illness (SPMI) and/or substance use disorder (SUD) accounted for 9% of the total Highmark patient population. Of that 9%, the SUD population accounts for 86%, the SPMI population accounts for 10%, and dually diagnosed account for 4%. Despite accounting for a small percentage of the member cohort, the 9% of patients with SUD/SPMI utilized 33% of the ED visits, and SUD alone accounted for 27%. The total ED utilization cost associated with members with SPMI/SUD was 4.4 times higher than the members without SUD/SPMI, and the cost for the dually diagnosed for outpatient ED utilization was still 8 times higher than for those without SUD/SPMI.

These numbers are staggering. These data demonstrate that a small number of people contribute to high percentages of ED cost and utilization. To address this growing problem, Highmark has developed a Behavioral Health Toolkit to assist PCPs in delivering care to this vulnerable population. The toolkit contains links to information sheets with best practice recommendations, screening tools, and clinical practice guidelines, as well as additional tools and resources that can be incorporated into their practice. Two of the resources available are information sheets for providers: “Follow-up after ED Visit for Alcohol and Other Drug Abuse and Dependence” and “Follow-up After ED Visit for Mental Illness.”

Pharmacist Integration

One of the proven ways to provide the greatest impact on ED utilization across the entire care continuum is with pharmacist involvement. One study estimated that 7.6% of all ED visits are a result of medication nonadherence.16 Recognizing that medication adherence is a significant contributor to positive clinical outcomes, Highmark has moved medication adherence efforts upstream to prevent ED visits and hospital admissions. Involving pharmacists to identify potential adherence barriers, educate patients on the role of their medications, and communicate with providers to simplify complex medication regimens can significantly improve medication adherence.17

Although the goal is ED avoidance, patients may still require emergency services. Therefore, embedded emergency medicine pharmacy services aim to work in a team-based manner to provide the most efficacious, safest, and fiscally appropriate medication management. One study showed that pharmacist interventions in the ED led to more than $1 million in cost avoidance over 4 months.18 By embedding pharmacists in the ED, care can be optimized by providing recommendations on appropriate medication prescribing and reducing the likelihood of medication errors and the associated costly consequences.

Additional services that ED pharmacists provide are medication reconciliation, discharge counseling, and post-ED follow-up calls. Medication reconciliation and discharge counseling during transitions of care have been shown to significantly reduce ED visits as well.19,20 When pharmacists perform post-ED follow-up with patients, they can determineif any additional testing has resulted, provide further guidance or changes to treatment plans, and encourage outpatient management.21

Finally, avoiding revisits to the ED is another area for pharmacist involvement and improvement of care. Studies have shown that up to 70% of medication-related ED visits are preventable.22 Pharmacists embedded in primary care offices offer many outpatient services, including chronic disease state management, that allow patients to remain engaged with primary care, which shifts patient care from reactive to preventive and can significantly reduce ED utilization.23

Enhanced Community Care Management

Those who visit the ED often tend to be in poor health and require ongoing medical support, and additional support systems and better access to care could benefit these patients and help to reduce ED use.24 Effective care management can improve the coordination of care for more complex patients and provide a patient and their family with the ability to improve disease control and self-management, reduce stress, and prevent ED utilization, admissions ane readmissions. Highmark’s Enhanced Community Care Management (ECCM) team accomplishes this by providing specialized care coordination, palliative care, and supportive care free of charge to Highmark Medicare and individual Affordable Care Act high-risk populations.

The goal of the ECCM program is to help members living with serious illness to live their best life possible while maintaining their independence in the community. The interdisciplinary team of the ECCM program includes physicians, advanced practice providers (nurse practitioners or physician assistants), nurses, and social workers. The team is trained in motivational interviewing, health literacy, and how to help those struggling with SDOH. The clinicians provide team-driven care directed by whole person–centered outcomes, such as activating members to engage in the self-management of their chronic conditions, quality of life, symptom burden, emotional well-being, advanced care planning, communication, continuity of care, and caregiver burden. ECCM care is provided both virtually and in the home (including stays in nursing facilities) and the model is flexible, reducing disruption for the member, family, and caregiver by streamlining communication across health care settings to ensure members’ needs are matched with the appropriate resources. By doing this, the team can help to decrease unplanned care or care inconsistent with member’s goals, which in turn decreases the overall cost of care. Highmark’s ECCM team outcomes when comparing engaged ECCM members with a propensity matched cohort of eligible members has demonstrated an 8% reduction in admissions, a 13% reduction in readmissions, and a 7% lower total cost of care.

ED Utilization and Technology

Providers and care teams need to understand when, why, and how patients access the ED to address the reduction of costs and avoid unnecessary visits. Monitoring patient visits to the ED is not an easy task, especially with a multitude of contributing factors such as disease, access to care, patient knowledge and decision-making, and lines of communication between facilities and providers.

Technology plays a large part in monitoring ED utilization. Specifically, telemedicine and care coordination have aided providers in making more precise care management decisions. With the recent pandemic, telemedicine has emerged as a widely adopted technology among providers. A patient may be more likely to attend a telemedicine visit in place of going to the ED, and this also gives the PCP the opportunity to tell the patient if another level of care is appropriate. Thus, telehealth can lead to a stronger, more inspirational patient/physician relationship. Care coordination involves cooperation and collaboration between all parties involved in the patient’s care, and the exchange of information is crucial. Technology supports this via patient portals and interactive medical records.

Other technologies include admission/discharge feeds and care integration algorithms. Admission/discharge feeds notify providers when one of their patients has been seen, allowing office staff to quickly reach out to the patient and make a follow-up visit if necessary. This also allows for potential issues with discharge medications and misunderstanding of discharge instructions to be resolved on a timely basis. Care integration algorithms and proactive transition processes can connect high-risk patients with resources while still in the ED,thereby potentially limiting future ED visits.25

Conclusions

The cause and effects of ED utilization on health care have been well documented. Not all ED utilization can be averted, and focus is shifting to look at what utilization could be possibly avoided, the contributing factors, and how to address those issues and concerns. Addressing ED utilization and other aspects of health care requires continual collaboration and communication across the continuum of care by all members of the health care team, payers, and members. Highmark Health’s mission is to “create a remarkable health experience, freeing people to be their best.” The efforts that the Highmark field teams are undertaking in collaboration across the Highmark footprint have shown positive effects in addressing ED utilization and putting member/family in the center of everything we do, thereby driving to create the future of health care and collaborating to achieve shared success.

This information is issued on behalf of Highmark Blue Shield and its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in 21 counties in central Pennsylvania and 13 counties in northeastern New York. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware and 8 counties in western New York. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

References

Source: Ajmc.com | View original article

Source: https://www.cbsnews.com/pittsburgh/video/allegheny-health-network-doctors-using-ai-to-document-visits/

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