A nationwide electronic health record system is within our grasp. But is the opportunity about to slip through our fingers? Page 30
www.executivehm.com • Q3 2009
DOWN TO THE WIRE
Trimming the fat
The AMA’s James Rohack pinpoints key cuts to healthcare costs Page 38
Can’t we all get along?
Why private and public payers need to work together Page 86
Virtual house calls
e-Telmed’s Lance James uses telehealth to help patients and physicians interact Page 110
EHM8 COVER 9.indd 1
13/7/09 13:29:55
BRACCO AD:mar09 09/07/2009 09:30 Page IFC1
A nationwide electronic health record system is within our grasp. But is the opportunity about to slip through our fingers? Page 30
www.executivehm.com • Q3 2009
DOWN TO THE WIRE
Trimming the fat
The AMA’s James Rohack pinpoints key cuts to healthcare costs Page 38
Can’t we all get along?
Why private and public payers need to work together Page 86
Virtual house calls
e-Telmed’s Lance James uses telehealth to help patients and physicians interact Page 110
EHM8 COVER 9.indd 1
13/7/09 13:29:55
BRACCO AD:mar09 09/07/2009 09:30 Page 1
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BIOSCAN AD:JUL09 09/07/2009 09:29 Page 3
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Vocantas.indd 1
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ED NOTE EHM8:july09 13/07/2009 13:30 Page 5
FROM THE EDITOR 5
Wired world Can we build the future of electronic health without descending into chaos?
R
ight now, you’d think electronic health records would be the last things on anyone’s mind. A raging pandemic of swine flu, rock icons dying in mysterious circumstances amid rumors of prescription drug abuse, hospital-acquired infections still causing serious problems – there are so many other health-related stories dominating the headlines. And yet EHRs remain top of the agenda, and rightfully so. They play a major part in President Obama’s plan to revolutionize healthcare under the American Recovery and Reinvestment Act. They hold the key to hauling our health system into the future, while at the same time enabling us to make the cost cuts that will be required down the road. We need a system of EHRs that can interact on a national level. As people become increasingly mobile, moving from one health center to another, we will need the ability to track patients’ treatment plans and ensure they are followed up correctly.
How easy this will be to achieve remains to be seen. In this issue, we talk to four hospital CIOs from different areas of the country about their experiences with EHR implementation. When asked about our chances of meeting Obama’s goal to have all medical records available online by 2014, their views range from hopeful to pessimistic. Among the many hurdles to be overcome, the lack of a single patient identifier looms large. In our freedom-loving, individualist culture, anything that threatens to label us or make us easily identifiable to the authorities generates an automatic negative reaction. Yet the lack of an identifier could sink a nationwide EHR system before it gets off the ground. Yes, we can do without it, but the process will undoubtedly be more drawn out and complicated than it would have been. Security is another issue. Anytime you store such large amounts of data in electronic form, there is a risk that it may fall into the wrong hands, be they those of the government, the news media
or insurance companies. Although when you think about it, the old system of keeping paper records in folders in doctors’ offices was hardly secure either. It’s just that when an electronic system is breached, it generally happens in a big, newsworthy way. The one thing, however, that none of these issues can undermine is the crucial nature of the project itself. We can’t let the potential downsides get in the way of implementing a nationwide EHR system – otherwise we may find ourselves forever mired in a mountain of paper, unable to take our health system where it needs to go. n
“If we’re going to that level of flexibility within our national healthcare system, we have to have one identifier that’s specific for a particular individual” Michele Chulick, Executive Director, Clinical Operations, University of Miami Health System (Page 30)
“You would never eat in a restaurant if you knew there was a four percent chance you would get food poisoning, and the same holds true with respect to hospital care” Jerome Granato, Medical Director, Coronary Care Unit, Allegheny General Hospital (Page 42)
“Until we have a good set of standards and interoperability, exchanging information becomes very difficult, even though we have the infrastructure there” Abdul Bengali, Chief Information Officer, Mayo Clinic (Page 90)
Marie Shields, Editor
BURTON AD.indd 3
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CONTENTS EHM:july09 13/07/2009 10:36 Page 7
CONTENTS 7
Reality bytes Will the real world get in the way of President Obama’s plan to implement a nationwide system of electronic medical records?
42 Journey to zero Wiping out hospital-associated infections at Allegheny General Hospital
30 38
86 When compromise is key Why private and public payers need to get along, according to Robert Berenson
Dollars and sense The AMA’s James Rohack outlines the cost cuts that could save our health system billions
AbsolutelyHC.indd 1
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CONTENTS EHM:july09 13/07/2009 10:29 Page 9
CONTENTS 9 Treating the walking wounded
50
Preventing infection
58
70
Circle of care
46 Fail to prepare and prepare to fail
70 Treating the walking wounded
The CDC’s Steven Redd is on the frontline in the battle against H1N1
Bill Wenmark extols the virtues of ambulatory urgent care
50 Preventing infection
78 In the right vein
John Jernigan shares his thoughts on hospitalacquired infections
Sheryl McDiarmid on the correct handling of vascular access devices
52 History lessons
82 Back to the drawing board
Why Johns Hopkins Medicine’s surgeons are pioneers, past and present
Why hospital designers love a challenge
58 Circle of care Margaret Bauman uses a multidisciplinary approach to treat autistic children
66 Safeguarding the nation’s urologic health Anton Bueschen explains the importance of well-trained urologists
69 Everybody hurts sometimes James Rathmell on the true nature of pain
INDUSTRY INSIGHT 80 Marshall Kerr, PFM Medical, Inc.
90 High tech shake-up Abdul Bengali pinpoints the areas of healthcare technology in need of reform
98 A new era Sarah Sinclair hails the advent of evidencebased practice
EXECUTIVE INTERVIEWS 106 Building the airplane as it flies 36 Mary Dees Griffith, Preferred Health Technology, Inc. 62 Francesco Pompei, Exergen Corporation 64 Timothy Mattimore, MicroBionetics, LLC 104 Jon Kondo, Host Analytics 110 Lance James, e-Telmed, Inc.
How to implement a new technology infrastructure
112 Staying healthy in an electronic world The issues surrounding EHR, according to Lynn Brookshire
EXERGEN AD.indd 1
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CONTENTS EHM:july09 13/07/2009 10:29 Page 11
CONTENTS 11
ASK THE EXPERTS
IN THE BACK
76 Petra Scholl, Navilyst Medical, Inc. 96 Kevin Burton, Burton Asset Management, Inc. 114 Ken Levinson, Absolutely Health Care 119 Andrea Boehme-Hernandez, Medstaff National Medical Staffing
116 A shrinking workforce Julie Brooks explains the economic and legislative strains on healthcare recruitment
Japan
120 Locum labor Ruddy Polhill of NALTO looks at the life of a locum
127 Better together James Levett brings Lean and Six Sigma into the health arena
134 Employee health 138 Wellness 140 Regional focus: Japan 142 In review 144 Photo finish
Wellness
106
Building the airplane as it flies
46
Back to the drawing board
82
Fail to prepare and prepare to fail
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13/7/09 10:31:23
7MEDICAL AD.indd 1
9/7/09 09:25:46
UPFRONT EHM US8:25 June
13/7/09
09:48
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UPFRONT 14
IN THE MIDST OF A PANDEMIC In June, the World Health Organization (WHO) raised its worldwide pandemic alert level for the novel influenza to Phase 6 in response to the ongoing global spread of the H1N1 virus (also known as swine flu). Phase 6 indicates that a global pandemic is underway. According to the WHO, more than 81 countries are now reporting cases of human infection with novel H1N1 flu. This number is
continuing to increase, but many of the new cases reportedly had links to travel or were localized outbreaks without community
spread. The pandemic alert reflects around how many people infected the fact that there are now ongoing with H1N1 will develop serious community level outcomplications or die, bebreaks in multiple cause experience with Morethan parts of world. this virus so far is The WHO limited and influenstressed that its dearenowreporting za is unpredictable. casesofhumanincision to raise the Because novel fectionwithnovel H1N1 is a new virus, pandemic alert level H1N1flu to Phase 6 is a reflection many people may have of the spread of the virus, not little or no immunity against the severity of illness caused by the it, and illness may be more severe virus. There is still uncertainty and widespread as a result. There is
81 countries
UPFRONT EHM US8:25 June
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UPFRONT 15 also currently no vaccine to proThe CDC has issued the foltect against it. lowing guidelines outlining what Most people who have beto do if you should become income ill in the US have recovered fected with the virus. If you are without requiring medical treatsick, you may be ill for a week or ment. However, the Centers for longer. You should stay home Disease Control anticipates that and avoid contact with other peothere will be more cases, more ple, except to seek medical care. If hospitalizations and more deaths you leave the house to seek medin the coming months. In addiical care, wear a mask or cover tion, the virus could cause signifiyour coughs and sneezes with a cant illness during the fall and tissue. Be aware that you may be winter flu season. contagious from one day before H1N1 is a new flu virus of you develop symptoms to up to swine origin that first caused illseven days after you get sick. ness in Mexico and the Children, especially younger United States in children, might potenMarch and April, tially be contagious NovelH1N1 2009. It is believed for longer periods. isanewvirus; manypeoplemay to spread through If you are sehavelittleorno the coughs and verely ill or are at sneezes of people high risk for flu who have the virus. complications, you against it It may also be spread should contact your by touching infected obhealthcare provider or seek jects and then touching your nose medical care. Your healthcare or mouth. H1N1 infection has provider will determine whether been reported to cause a range of flu testing or treatment is needed. symptoms, which include aches, Antiviral drugs – prescription chills, fever, cough, fatigue and medicines (pills, liquid or an insore throat. haler) with activity against influenSince the outbreak was first za viruses – can be given to those detected, an increasing number of who become severely ill. These states have reported cases of medications must be prescribed by H1N1 with associated hospitala healthcare professional. izations and deaths. By early June, In order to protect yourselves all 50 states in the United States and your loved ones, it’s important and the District of Columbia and to stay informed. More informaPuerto Rico were reporting cases tion can be found on the of novel H1N1 infection. CDC H1N1 flu website at Nationwide influenza surveilwww.cdc.gov/h1n1flu. You should lance systems indicate that overall also observe the following precauinfluenza activity is decreasing in tions. Cover your nose and mouth the country, but outbreaks are onwith a tissue when you cough or going in parts of the country. sneeze. then dispose of the tissue in According to the CDC, the the trash after you use it. Wash Southern Hemisphere is just beyour hands often with soap and ginning its influenza season and water, especially after you cough or this may provide valuable clues sneeze. Alcohol-based hand cleanabout what may happen in the ers are also effective. Avoid spreadNorthern Hemisphere this fall ing germs by touching your eyes, and winter. nose or mouth.
NEWS IN PICTURES
United Nations Secretary General Ban Ki-moon says developing countries could need more than $1 billion by the end of this year to fight the H1N1 pandemic
immunity
Researchers at Harvard University have found that those who travel are three times more likely than those who do not to develop venous thromboembolism
The ARRA will invest $19 billion in computerized medical records, $1 billion for research and $500 million to help train new doctors and nurses
The Drug Enforcement Administration has joined the investigation into pop star Michael Jackson’s sudden death. There is speculation that abuse of prescription medications may have been a factor
UPFRONT EHM US8:25 June
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UPFRONT PROFILE
16 THOMAS FRIEDEN, Director, Centers for Disease Control and Prevention Thomas Frieden has been named the 16th Director of the CDC by President Obama. Appointed to the position on June 8, his work as Director of the New York City Health Department since 2002 and his expertise in disease control are sure to have impressed the White House. Obama praised Frieden for his previous work during the naming ceremony: “Dr. Frieden is an expert in preparedness and response to health emergencies, and has been at the forefront of the fight against heart disease, cancer, obesity and infectious diseases such as tuberculosis and AIDS, and in the establishment of electronic health records. Dr. Frieden has been a leader for healthcare reform, and his experiences confronting public health challenges in our country and abroad will be essential in his new role.” During his tenure as Health Commissioner of New York City, Frieden worked to control an outbreak of drug-resistant tuberculosis that occurred during the early 1990s, as well as assisting India in a tuberculosis program. Working with the WHO, Frieden created a network of Indian physicians, building a structure so that the disease could be rigorously monitored and controlled. Tobacco control was a major initiative within his agenda as Health Commissioner. Unconcerned by the controversy that surrounded his often militant program, which he himself described as “an unapologetically aggressive public health agenda,” Frieden banned smoking from restaurants and bars, as well as running aggressive anti-smoking ad campaigns. The program achieved approximately 350,000 fewer smokers in the city. His campaign prompted Mayor Bloomberg to sign the agenda into law. Electronic health records are a major aspect of his work. Whilst he was Commissioner, the Health Department launched the country’s largest community-based electronic health records project to support the shift toward preventative care for more than one million New Yorkers. Frieden replaces Richard Besser as CDC Director, and will continue to lead the fight against infectious diseases and promote initiatives to support prevention.
UPFRONT EHM US8:25 June
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UPFRONT NEWS BRIEF
17
NO SCREENING
NO INSURANCE
DIFFERENCE IN WAIT TIMES
There is disparity in colorectal cancer screening (CRCS) among different socioeconomic and ethnic groups in the US, according to a recent review published by F1000 Medicine Reports. Inadequate medical insurance amongst poorer socio-economic and ethnic groups has influenced the uptake of certain types of screening. Of the several screening modalities currently available, colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT) have been shown to reduce colorectal cancer incidence or mortality. Some screening methods are less likely to detect flat lesions, and patients who opt for these modalities (perhaps for financial reasons) could be at risk of lesions being missed.
FAST FACT
Medical
errors
are the eighth leading cause of mortality in the US
Research conducted by consultants Merritt Hawkins & Associates has found a dramatic difference in wait times to see certain specialists in 15 US cities. In Atlanta, for example, residents wait an average of 11.2 days, the shortest time among the cities polled. Boston has the longest wait times, at an average of 49 days. Wait times in Boston apparently increased after the state of Massachusetts made it mandatory for residents to have health insurance, which had the effect of increasing demand for physician visits. Survey researchers called the offices of five types of specialists (1162 offices in
all) between September 2008 and March 2009. The callers requested the first available appointment for a new patient. In addition to Atlanta and Boston, the cities polled were Denver, New York, Portland, Detroit, Miami, Minneapolis, San Diego, Seattle and Washington, DC. Between 10 and 20 offices in each city were called, for each of five specialties: obstetrics/gynecology,
INCREASING MEMORY Researchers in the US have found the gene that can reverse the effects of memory loss in mice. The study, led by Li-Huei Tsai of the Picower Institute for Learning and Memory at Massachusetts Institute of Technology, was published in a recent issue of Nature. The researchers believe the HDAC2 gene and the protein associated with it are promising targets for the treatment of memory impairments. The gene also seems to bring about long-lasting changes in how other genes are expressed. This enhances memory by increasing synapses and altering neural circuit structure, Tsai explains. Mice were bred to have Alzheimer’s-like symptoms and were then treated with histone deacetylase (HDAC)
cardiology, orthopedic surgery, dermatology and family practice. According to the survey, US residents wait an average of 27.5 days for an ob-gyn appointment, 15.5 days for a cardiology appointment, 16.8 days for an orthopedic surgery appointment, 22.1 days for a dermatology appointment and 20.3 days for a family practice appointment.
inhibitors, drugs that target HDACs, enzymes that control gene expression. When the mice, which appeared to forget tasks they had previously learned, took they HDAC inhibitors, they appeared to regain their long-term memories and were once again able to learn new tasks.
UPFRONT EHM US8:25 June
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UPFRONT INTERNATIONAL NEWS
18
NO MONEY
BIRTHS DOWN
CURE UPDATE
The UK’s National Institute for Health and Clinical Excellence (NICE) has issued its Appraisal Consultation Document for Nexavar (sorafenib) for the treatment of advanced liver cancer. The document does not recommend the use of sorafenib for the treatment of hepatocellular carcinoma (HCC), a decision which directly conflicts with current UK and worldwide guidelines for the recommended treatment of HCC. These are preliminary recommendations and are open for consultation. HCC is the most common form of liver cancer and accounts for 80-90 percent of all primary liver tumors. In the UK more than 3100 new cases were diagnosed in 2005 and liver cancer causes more than 3000 deaths every year in the country. The Hepatocellular UK Group (HUG) recently launched guidelines for the management of suspected HCC in adults, which state that sorafenib is the standard of care for patients with advanced HCC for whom no potential curative option is available.
Low birth rates and high life expectancies have caused a 35-year decline in the proportion of children in Japan’s population. This could cause numerous problems for the country, according to a report by the AP/Miami Herald. The country’s Ministry of Internal Affairs and Communications says, the percentage of children younger than age 15 fell to 17 million, or 13 percent of the country’s 128 million people. The proportion of people older than 65 is on the increase, and now accounts for 22.5 percent of the country’s population. Japan trails 30 other countries in the proportion of children, including the US, where children make up 20 percent of the population.
An experimental leukaemia drug was able to kill cancer-causing stem cells in laboratory experiments, according to the Australian drugmaker, ChemGenex Pharmaceuticals. The company has revealed research suggesting the drug could be used to help cure some patients: evidence shows that it killed as many as 90 percent of stem cells in the tests. At a summary of the test data, presented at the European Hematology Association’s meeting in Berlin, ChemGenex revealed that omacetaxine mepesuccinate – as the drug is called – fought chronic myeloid leukemia in patients who don’t respond to Novartis AG’s best-selling cancer drug Gleevec. Evidence even showed that the new drug could be used in combination with treatments such as Gleevec to rid patients of cancer.
UPFRONT EHM US8:25 June
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UPFRONT INTERNATIONAL NEWS
19
PHARMA HIT
DIABETES DELAY
PILLS HELD
While the economic recession may not have hit the pharmaceutical sector as hard as some other industries, experts believe bad times are on the horizon. This is largely because of the massive loss of income and sales as a result of patent expirations of blockbuster drugs, the decline in prescriptions, doctor visits and the overall consumer spend because of the economic recession. A new report from IMS Health has revealed that the global pharma market is expected to slow down from 4.8 percent to between 2.5 and 3.5 percent in 2009, with the US portion of this market declining by a full percentage point.
Japanese pharmaceutical company Takeda has announced that it will delay seeking European approval of a key diabetes drug candidate from the original target of this year to 2012, in an effort to conduct an additional study on the drug. This news marks the second major setback for the drug. The delay for alogliptin, also known as SYR-322, which Takeda has positioned as the successor to its top-selling drug Actos, does not come as a surprise after regulators here in the US said they wanted more data for their review. But the decision to conduct another study has been made without prompting from European regulators. The new delay means that alogliptin, which belongs to a new class of diabetes drugs called DPP-4 inhibitors, is now far behind other rival candidates that work through the same mechanism of action, but are now in the advanced stages of development.
Generic companies that export drugs to developing countries via Europe are continuing to experience problems. According to a report in The Economic Times, a shipment of the popular antibiotic Amoxicillin was seized in Frankfurt recently. Customs authorities, who seized 3,047,000 pills (quantity equivalent to 76,000 courses of treatment) of the drugs (250 mg), held the shipment – worth €25,000 – for almost a month before releasing it. Sources have said that the consignment was detained on grounds of suspected trademark infringement. However, experts pointed out that there was no valid reason for detaining these medicines since the name Amoxicillin is an international non-proprietary name. In 2008, there were 16 similar cases of seizures of medicines shipped from India in the Netherlands.
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UPFRONT IN MY VIEW
20 CHRIS VIEHBACHER, CEO, Sanofi-aventis My objective is to continue to build on this notion of a global healthcare company as opposed to a pharmaceutical company based in the US and Europe, and therefore have an acquisition strategy that builds upon those things where we already have a strong presence. One aspect of my plan is to bring the outside world into the company and open it up to what’s out there. To a degree, outside research is still seen as adding to internal efforts, and to that I say, “There are plenty of companies outside and they’re doing plenty of things. Why replicate that?” If you look at the aging population as a mega trend, if you’re looking at obesity, you’re looking at a trend for wellbeing, you’re looking at time compression, you’re looking at urbanization of populations. There is going to be a focus on healthcare, but on a certain type of healthcare, and our style of living is creating new healthcare issues. To me, healthcare – especially if you don’t define it too narrowly – is fundamentally a strong area. And you’ve also got major diseases that still are not well treated, such as diabetes, oncology and Alzheimer’s disease. Not everybody can afford the same level of healthcare. We’re seeing an increased presence of government regulation trying to go after the private sector in terms of overthe-counter, or in countries where there’s no real social security or health insurance. In our company we’ve got talented people and we’ve got financial resources. There are a lot of patients out there, and we’ve got the medicines and vaccines to help them. Healthcare is still something that matters more than anything else – there is huge unmet need out there. It’s a massive marketplace, and if we’re a little bit creative and flexible in how we go after it, there are big opportunities.
UPFRONT EHM US8:25 June
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UPFRONT COMPANY NEWS
21
FIGHTING INFECTION In the 1980s, a complex solution was invented for minimizing infections, and is still the market leader: Foam Safe. This device was originally created as Foam Care by Dale Ballard, Founder and President of Ballard Medical, and has contributed to minimizing infections based on the oldest practices, providing efficient and economic value, which is indispensable at the present time. “More than a commodity, its particular square package makes it sound unseen; however, once the spout is in its place the problem starts for the other products in the market,” says Felix Perez, Vice President of Gremed, the company that acquired this product line from Kimberly Clark in 2007. With a primary focus on infection control, Gremed is determined to promote and increase its portfolio of products with new formulations and formats. This product line was created to stay in the market and it was designed to achieve three aspects that affect health staff or when users wash their hands:
dosing, versatility and economy. Based on the belief and habit that many users apply indiscriminate or excessive amounts of liquid to produce foam and wash their hands, which results in irritation and above all produces a high spend for hospitals in this product category, Foam Safe’s patented spout makes the difference, acting as an effective dispenser and providing the user with a generous amount with only two pushes on any of its dispensers. No matter what kind of antiseptic is used, it is safe. But even more impressive is that it complies with all current standards and requirements adjusted to the low budget. A liter of Foam Safe is equivalent to two or three liters of other products dispensed in liquid and foam, which is a significant value. No matter what antiseptic quality you need, the foam makes the difference. This product has successfully conquered a complicated market when it comes to price, such as China, Taiwan, Mexico and others. For more information, please see www.gremed.com
FROM THE VAULT In the Q4 2008 issue of EHM, DAVID BLUMENTHAL, Director of the Institute for Health Policy at Massachusetts General Hospital, examines the gap between our perception of the state of our healthcare system and reality, and outlines his role in the fight to keep it from the brink of collapse. If you would like to read more, go to www.executivehm.com, click on ‘Previous issues’ on the left, then on ‘Issue 6 November 2008’ to read of Blumenthal’s goal for a healthcare system that includes all sectors of society.
NOT GOOD NEWS A study called Frequency of Failure hybrid paper/electronic system. to Inform Patients of Clinically “Failure to report abnormal Significant Outpatient Test Results test results can lead to serious, in the Archives of Internal even lethal conseMedicine reports that quences for the paThose about one in 14 tient,” says Dr. whoperformed cases of abnormal Lawrence test results are Casalino, one werethosepractices not reported to of the study’s withahybrid patients. The authors. “The paper/electronic study found no siggood news is that system nificant difference physicians who use between practices with a simple set of systemand without electronic medical atic processes to deal with test records. Those who performed results can greatly lessen their worse were those practices with a error rates.”
worst
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UPFRONT COMPANY NEWS
22
VITAL STATISTICS
64% of adults 65 years and over received an influenza vaccination during the past 12 months Between
5-20% of the US population get the flu each year
The CDC has antigenically characterized
1567 seasonal human influenza viruses since October 2008 It has also characterized
84 novel H1N1 viruses
Between October and May, the influenzaassociated hospitalization rate for children aged 0-4 was
3.85 per 10,000
FIRST FDA-CLEARED PMMA ALTERNATIVE Cortoss is an injectable, bioactive composite that mimics the physiological properties of human cortical bone and the first alternative to polymethylmethacrylate (PMMA) cement evaluated in a large-scale, prospective, multi-center, randomized controlled study used for the treatment of vertebral compression fractures. The long-term (24-month) outcomes of the 256-patient, pivotal IDE trial comparing the efficacy of PMMA to Cortoss included a composite endpoint success rate of 76.9 percent for Cortoss patients and 73.4 percent for PMMA patients and a statistically significant benefit in function for Cortoss patients with an ODI success rate of 96.7 percent vs 88.4 percent for PMMA patients. At three months the composite endpoint success rate was 82.8 percent for Cortoss patients vs. 73.7 percent for PMMA patients, and the Cortoss patient group experienced a statistically significant benefit in pain success with a VAS success rate of 86.6 percent vs 75.0
percent for PMMA patients. years, the treatment of vertebral Other outcomes for Cortoss fractures relied on the application patients included a 43.4 percent reof a foreign material without duction in subsequent, adjacent much consideration for the level fractures in pamechanical, and none tients treated for a for the biological Cortoss primary fracture at conditions. includedacomposite one level, as meaCortoss is a endpoint success sured at the end material that rateof of the 24-month was designed follow-up period to restore meforCortoss and an average of chanical condipatients 30 percent less materitions and match the al to achieve fracture fill. properties of natural
76.9%
According to John Mathis, MD, of The Center for Advanced Imaging in Roanoke, Virginia, and editor of the original textbook entitled, Percutaneous Vertebroplasty and Kyphoplasty, “For over 20
bone. I believe that its introduction marks the beginning of the next phase in the treatment of vertebral fractures, which will be concentrated on the patients’ physiology.”
Cortoss Bone Augmentation Material, the first FDA-cleared alternative to PMMA in vertebral compression fracture treatment
OBESITY HARMS YOUR HEART Being obese may raise a child’s future risk of heart disease and stroke. A new study found that the unhealthy consequences of excess body fat start very early. Doctors know that certain proteins in the bloodstream are warning signs of a predisposition to heart disease. Many of these ‘markers’ become elevated long before the more familiar cholesterol and lipid levels do. Nelly Mauras, Chief of Pediatric Endocrinology at Nemours Children’s Clinic in Florida, recruited more than 200 obese and lean children. The boys and girls in the study ranged in
age from 7 to 18. They were screened for a variety of known markers for predicting the development of heart disease. The results showed that the markers were significantly elevated, particularly the CRP, Maurus says. “The CRP in the pubertal, simply obese kids was about 10-fold that of the nonobese kids, and the prepubertal ones were almost 12-fold.” Source: voanews.com
Efficacy
Safety
Cost
Vitoss fuses them all together.
Vitoss. The safety and efficacy you demand at a responsible cost. If you’re looking for an alternative to your bone graft material then the choice is clear. Vitoss has been proven to be a viable alternative to autograft and BMP in numerous human clinical studies.* To learn more about the efficacy and safety of Vitoss download our bibliography at www.vitoss.com or call 1-888-4VITOSS.
*Data on file, Orthovita, Inc. Š Copyright 2009 by Orthovita, Inc. All rights reserved. Orthovita and Vitoss are registered trademarks of Orthovita, Inc.
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INNOVATION AND PARTNERSHIP
THE RESULTS ARE IN… People living with HIV and undiagnosed in the United States
21% Undiagnosed
People living with HIV (Estimate):
1.1 million
COST OF CARE SAVINGS According to the WHO, influenza epidemics cost the US economy $71-167 billion per year. With the total cost of care in the billions the correct viral diagnosis will reduce nosocomial transmissions, length of stays, and cost of staff illness. Correct diagnosis for influenza and RSV starts with proper specimen collection to obtain the highest sensitivity. Comparisons between nasopharyngeal aspiration (NPA) and other collection methods show that NPA sensitivities are consistently higher. Translate increased sensitivities into billions of dollars, and NPA saves on total cost of care.
In 2005, the makers of N-Pak designed an all-in-one kit that is easy to use, minimizes discomfort to the patient, and maximizes sensitivities. Essentially every institution that incorporates the NPak as part of its viral diagnosis protocol continues its use today. The healthcare provider simply opens the kit, attaches the catheter, aspirates, caps and sends to the lab. Hospitals can now standardize specimen collection for influenza and RSV and maximize infectioncontrol measures. Can you afford not to standardize with N-Pak?
FAST FACT Between
45,000 98,000 Americans die each year as the result of medical errors
Covidien, a leading global provider in the healthcare industry. Examples of the company’s reof healthcare products, partners with medical professionals around cent innovations include the SILS the world to develop innovative Port Multiple Instrument Access technologies, products and solu- Port for laparoscopic surgeries tions for the healthcare industry. through a single incision; Duet TRS Covidien has been at the forefront Reload, an endoscopic stapler preof innovation, responsible for such loaded with tissue reinforcement breakthrough developments as material; Permacol Biologic pulse oximetry, mechanical ventila- Implant, a biologic mesh for hernia tion, electrosurgery and laparoscop- and abdominal wall repair; and Kendall AMD Antimicrobial Foam ic instrumentation. Dressings, an advanced Covidien’s partnercost-effective wound ships with the medtreatment proven ical community Recent effective against have also driven MRSA. innovations in include the SILS The comareas such as Port Multiple pany recently patient safety, Instrument Access announced two medical accuraPort vascular products cy, professional acquisitions and two training, cancer treatpharmaceutical licensing ment and cost containment. These strong partnerships help to agreements which will accelerate reduce hospital-acquired infections, its growth. VNUS Medical the time required in the operating Technologies and Bacchus Vascular will complement its market-leading room and costly medical errors. With these collaborations, line of vascular solutions. Covidien Covidien delivers tangible solutions is the largest supplier of controlled that save time and money, while pain medications in the United meeting the demands of this ever- States based on number of prechanging industry. With training scriptions and has licensed two topand research facilities around the ical formulations of diclofenac, a globe, Covidien works closely with non-steroidal anti-inflammatory medical professionals daily to im- drug (NSAID), as well as Exalgo prove patient outcomes and re- Extended-Release Tablets, a formumains committed to developing lation of the opioid analgesic hysolutions that will propel advances dromorphone.
innovations
FAST FACT
Cardiovascular diseases kill more than
800,000 people in the US each year
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CIGARETTES CURBED
REVOLUTION IN SKIN PROTECTION The Safe4Hours line is the most inspiration, noxious chemicals and novative infection control protocol environmental pollutants. available. The line consists of two Skin is metabolically active and products: Safe4Hours First Aid requiresexposuretotheatmosphere Antiseptic Skin Protectant and to execute its normal protective Safe4Hours Hand Sanitizer. function and remain healthy. A Both products are formulated completely impermeable barrier with a revolutionary patented represents an undesirable challenge polymer technology that creates a totheskin.Afunctionalbarriermust non-occlusive barrier on have selective impermeability the skin and holds to allow the excretion of active ingrediwaste products and A completely ents topically simultaneously for extended prevent the intrutime. As a resion of pathogens. barrierrepresents sult, the prodSafe4hours First anundesirable challengetothe ucts are active Aid Antiseptic Skin skin longer while proProtectant allows skin viding the continuous and wounds to achieve pathogen kill and allowing northis balance. mal skin function. Safe4hours Hand Sanitizer is Safe4hoursFirst Aid Antiseptic alcohol-free, does not sting and Skin Protectant protects against helps moisturize dry chafed skin. It entry of micro-organisms into soothes and speeds the healing of wounds and helps prevent infecdamaged skin and will not cause tions, reduces bacteria load with dry skin conditions that discourage minor cuts, scrapes and burns while regular use. It is non-allergenic, speeding healing and retaining contains no dyes or fragrances and moisture. It is effective against a leaves hands smooth and silky. broad spectrum of pathogens inAnnually, nosocomial infeccluding CA-MRSA and HA-MRSA tions affect two million patients and and helps relieve chaffed, chapped result in 96,000 deaths. These infecor cracked skin (dermatitis). tions are attributed to transmission Safe4hours First Aid from healthcare workers to patients Antiseptic Skin Protectant adheres and caused by poor hand hygiene to the stratum corneum and perand infection control practices. sists for four to six hours or until Safe4Hours makes good hynatural exfoliation or abrasion regieneandinfectionpreventioncommoves it. It is impermeable to perpliance easy and effective.
impermeable
FAST FACT In Massachusetts alone, it is estimated that
2.4 million
prescriptions are filled incorrectly each year
President Obama has signed into law a bill giving the government historic powers to curb practices by cigarette makers. The law grants the FDA the authority to ban added flavorings and require tough new warning labels. The move is aimed at cutting tobacco use among young people. “The legislation I’m signing today represents change that’s been decades in the making,” Obama said before signing the bill. “And today, despite decades of lobbying and advertising by the tobacco industry, we passed a law to help protect the next generation of Americans from growing up with a deadly habit that so many of
our generation have lived with.” Under the new law, the FDA will create a new Center for Tobacco Products to oversee the science-based regulation of tobacco products. It bans cigarettes dominantly flavored with sugar, fruit and spice by October this year, and forces tobacco firms and importers to submit information to the FDA about ingredients and additives in tobacco products. The measure places strict limits on tobacco advertising in publications with a significant teenage readership, and bans the use of words such as ‘mild’ or ‘light’ in ads that makes tobacco products seem safer.
BIOMARKERS PREDICT RESPONSE A report published in Cancer Research identifies a new biomarker that may be useful in identifying patients with recurrent glioblastoma, or brain tumors, who would respond better to anti-vascular endothelial growth factor therapy, in particular cediranib. Cediranib is a highly potent inhibitor of vascular endothelial growth factor (VEGF) receptor ty-
rosine kinases, and an investigational, oral agent that is administered once a day. The researchers were able to determine, using a form of magnetic resonance imaging (MRI) that looked at the mechanism of action of this agent, even as early as after a single dose of cediranib, which patients who benefited from the agent and which did not.
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DON’T MISS...
PATIENTS TREATED WITH OWN STEM CELLS
38 CUTTING BACK James Rohack tells us how to pare down health costs
The first of 24 heart attack patients taking part in a clinical trial at the Cedars-Sinai Heart Institute in Los Angeles has undergone a successful procedure in which tissue from his own heart was used to grow specialized stem cells. The cells were injected back into his heart, where doctors hope they will repair and regenerate healthy heart muscle in place of that injured by a heart attack. The minimally invasive procedure was completed on the first patient, Kenneth Milles, 39, at the end of June. The operation is part of an FDA-approved phase I investigative trial
funded by the Specialized Centers for Cell-based Therapies at the National Heart, Lung, and Blood Institute and the Donald W. Reynolds Foundation. Eduardo Marban, Director of the Cedars-Sinai Heart Institute, developed the technique and is leading
the trial. He says, “This procedure signals a new and exciting era in the understanding and treatment of heart disease. Five years ago, we didn't even know the heart had its own distinct type of stem cells.” For the study, Marban and colleagues will be enrolling a total of 24 patients whose hearts have been damaged and scarred by heart attacks. A requirement of enrolment is that all patients must have had a heart attack within the last four weeks. In this first stage of the trial, four patients will receive 12.5 million stem cells and two patients will act as controls.
COMPANY INDEX Q3 2009 52 HISTORY LESSONS Learning from the pioneering surgeons at Johns Hopkins
98 A NEW ERA Sarah Sinclair hails the dawn of evidencebased practice
Companies in this issue are indexed to the first page of the article in which each is mentioned. 7 Medical Systems 13 Absolutely Health Care 8, 114, 115 Allegheny General Hospital 42 American Institute of Architects 82 American Medical Association 38 American Society for Quality 127 Bard Access Systems 56 Bioscan, Inc. 2 Bracco IFC Burton Asset Management 6, 96, 97 Cellular Specialists 102 CDC 46, 50 CDH Partners, Inc. 85 Charleston Area Medical Center 112 Cleveland Clinic 98 Covidien 24, 54, 146 Diffusion Technologies, Inc. 57 Disaster Management 103 Dynamic Clinical Systems 109 e-TelMed 110, 111 Exergen Corporation 10, 62, 63 Frost & Sullivan 131 Gremed Products 21
Hemosure 74 Host Analytics 104, 105 International Federation of Employee Benefit Plans 134 J&A Companies 47 Johns Hopkins Medicine 52 Massachusetts General Hospital 69 MassGeneral Hospital for Children 58 Mayo Clinic 90 M.C. Johnson & Company, Inc. 41 MED3000 73 Medstaff, Inc. 119, 122 MicroBionetics 64, 65 NALTO 120 NAFAC 70 N-Pak 24, 45, 75 NAHCR 116 National Healthcare Safety Network 50 Navilyst Medical, Inc. 76, 77 Navara 92 New England Health System 30 NOVACES 129 NWA Chemcial Specialists 49
Orthovita 22, 23 pfm Medical, Inc. 80, 81 PracticeMatch 125 Preferred Health Technology 36, 37, 145 PDM Healthcare 26, 27 Rady Children’s Hospital 106 RelayHealth 95 S2S Design 25 Sprixx 51 St. Mary’s Hospital and St. Vincent Hospital 30 The Ottawa Hospital 78 University of Miami Health System 30 University of Michigan 126 Urban Institute 86 Vanderbilt University Medical Center 30 Virtual Corporation, Inc. 113 Vocantas 4, 100 Xoft 132 ZurickDavis 121
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UPFRONT H1N1 SPECIAL REPORT
29
FLU OUTLOOK
TOP 10
No report Sporadic Local Regional Widespread
US Human (confirmed and probable) cases of H1N1 infection Source: CDC CASES STATE (DEATHS)
A weekly Influenza Surveillance Report prepared by the Influenza Division. Weekly influenza activity estimates reported by State and Territorial Epidemiologists* Week Ending May 30th 2009
1
* This map indicates geographic spread and does not measure the severity of influnenza activity
FUTURE IMPACT OF THE VIRUS The novel influenza H1N1 virus is thought to spread in the same way as seasonal influenza viruses: through the coughs and sneezes of people who have the virus. Since the H1N1 outbreak began in the United States, an increasing number of states have reported cases, with associated hospitalizations and deaths. By July, all 50 states in the United States and the District of Columbia and Puerto Rico were reporting cases of novel H1N1 infection. Nationwide influenza surveillance systems indicate that overall influenza activity
is decreasing, but novel H1N1 outbreaks are ongoing. Investigators are still not sure how serious this novel H1N1 virus will be in terms of how many people will die or develop serious complications, or what affect it will have during the influenza season in the fall and winter. Because it is a new virus, most people will have little or no immunity against it, and this may cause a more widespread and severe illness. Also, there is currently no vaccine available to protect against H1N1. The Centers for Disease control anticipates that there will be more cases, more hospitalizations and more deaths associated with it. At this time, most people who have become ill with novel H1N1 in the United States have recovered without requiring medical treatment and have experienced typical flu symptoms.
2 3 4 5
6
7 8 9 10
Wisconsin
5861 (4)
Texas
3991 (17)
Illinois
3166 (13)
New York
2499 (44)
California
1985 (21)
Pennsylvania
1748 (4)
Massachusetts
1308 (13)
Connecticut
1247 (6)
New Jersey
1159 (9)
Utah
920 (10)
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COVER STORY
President Obama has called for all medical records to be available in electronic format within five years, but how does this translate to the real world? Four hospital system CIOs give Marie Shields the inside story.
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T
here’s a lot of optimism in the healthcare sector at the moment, arising from the election of President Obama and the announcement of the money to flow from the stimulus package. Some of that money is aimed squarely at healthcare IT, but it comes with a caveat: that all health records be available in computerized format within five years. Michele Chulick, Associate Vice President and Executive Director, Clinical Operations, for the University of Miami Health System, believes this five-year goal to be unrealistic. “I don’t think everything can be done in a five-year period,” she explains. “We’re looking at implementing an EHR for the entire health system. In our system, for example, we have over 800 physicians in three separate healthcare facilities and two ambulatory facilities. Quite frankly, I don’t think we could do it in five years because we have so many other priorities in place. It takes adaption. It takes change management. It’s a cultural change. Five years might be a lofty goal. I don’t think that we as a country can get everyone on electronic records in that period of time. “It’s overly optimistic, and again you’re looking at so many different factors. You’re looking at a physician’s office, you’re looking at the dollars that are required to buy the system and implement it. You’re looking at it at hospitals. You’re looking at it for rural clinics. That’s a huge undertaking in a 60-month period of time.” George McCulloch, Deputy CIO at Vanderbilt University Medical Center, disagrees. “I think it’s doable,” he says. “Although it will be a challenge both technically and politically for the country to find solutions and come to agreements on those kinds of things. There’s certainly the technology component, but I think the privacy issues will be the biggest issues we’ll continue to face.” “I think it will be challenging, but optimism is a good thing,” adds Cedric Priebe, SVP & CIO for Care New England Health System. “Hope is based on faith and optimism is based on facts. I think it’s reasonable to be optimistic that we can do this. The technology has gotten to a point where it’s doable. The culture is improving, in that physicians are more and more ready and expecting this to happen, and finally we have some funding. It may be not sufficient but at least there is enough to give the organizations that weren’t necessarily capital rich the opportunity to afford it. “One of my concerns though is the way it’s structured, it doesn’t provide you with the capital up front. You have to invest yourself, get to that point of being a meaningful user and then you’ll benefit. So there still is an access to capital challenge for organizations.” Tanya Townsend, CIO at St. Mary’s Hospital and St. Vincent Hospital, is a little more on the fence. “I can’t say that it’s for sure going to be an absolute going to happen; however I think Obama has got the right strategy around putting the incentives in place to continue to not only enforce it through incentives but also providing infrastructure and budgets to help us implement it. What’s been a
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barrier in the past is partially culture and then partially the cost. It’s been cost prohibitive.”
Implementation The four executives we spoke to are at different points of implementation in their various systems. At the University of Miami Health System, Michele Chulick and her team are focusing on cultural change through technology implementation, aiming to implement electronic medical records system-wide.
“I don’t think everything can be
Miche
le Ch
done in a
Ass o Dire ciate V Uni ctor, C ice Pr ver e Mia sity linical siden t O mi, o Flor f Mia perat and E m ida i He ions f xecut alth or th ive e Sys tem in
32 www.executivehm.com
ulick
five-year period” Michele Chulick
“We are not only healthcare facilities, we also have our physician practice, and under one umbrella we would like to create one record that can be seen whether you’re in the clinic 50 miles away or whether you’re in a clinic that’s right next door to you. The connectivity that you need to have in today’s healthcare environment requires that our healthcare providers should be able to pull up your record in any location and see what the doctor that you saw two weeks ago, three weeks ago, or two months ago prescribed for you so that
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e b e i r P Cedric w e Ne r Car o n f em i CIO Syst and h t l d a SVP n He Isla and ode h R Engl , ce iden Prov
we’re making judgments and prescribing appropriately based on the history of the patient rather than just this particular episodic incident. “Our goal will be obviously to within that IT cultural change improve quality, improve patient safety, improve communication, improve patient satisfaction, and also provide the patient the tools to be able to improve access to us, because that’s really critical. Patients should be able to take their health record on a little portable drive, if they travel during the year throughout the country. We’re looking at options like that so that our patients will be able to feel comfortable knowing that everything that’s been prescribed for them or everything that our physicians are recommending can be carried to that next provider, should that be necessary.” Tanya Townsend has faced the challenge of consolidating and integrating two hospitals at St. Mary’s and St. Vincent. She says the overall goal was to gain efficiencies and reduce the duplication and the levels of redundancy. “We had two organizations that were doing great things,” she explains. “They were just doing them in silos and this was duplicating efforts, duplicating resources and duplicating systems. My primary goal was to look at where it makes sense to consolidate, where it makes sense to reduce that duplication, and then have more availability to do new things “It’s one thing just to merge the people part of it, but now it’s merging the systems as well, so looking into duplication of every possible system and the different vendors in place. They’re right across town from one another, with different vendors for just about every product you can think of, so we have the challenge of trying to pick one and leverage our combined volumes to negotiate with vendors for cost savings.”
Cedric Priebe has been involved with the Rhode Island Quality Institute Project in creating a statewide network for clinical information. “I’m CoChair for the steering committee for the project called Current Care focusing first on the governance and community involvement, and we’ve come a long way in creating a governance model with a lot of community involvement which is manifest by the fact that we’ve gotten statewide enabling legislation passed. We’ve got regulations being written now that will clarify and harmonize some of the disparate patient confidentiality and privacy issues that have been out there. “We have data-submitting partners like our health system and our peer health system and other hospitals all ready to start. Our biggest challenge is that our community involvement led to an insistence on an opt-in model, that the patients will need to actively enroll or authorize enrollment of their par-
“It will be a challenge both technically and politically for the country to
find solutions” Cedric Priebe
ticipation in this, which means we have to grow from zero to a meaningful, critical mass of citizens. “We’ll need to find the opportunities to explain to patients why it’s here, what value it will bring, how it’s protected, and then to physically authenticate and enroll them. Until we get to that critical mass of people or patients it’s not worth even presenting to the physician users or the clinical users, because nine out of 10 times if they go there and they don’t find their patients enrolled they’re going to stop going.” George McCulloch is working on the development and implementation of VUMC’s informatic strategic plan. He believes that by improving quality he can impact cost. “The major driver is the quality initiatives that we have.
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We have established metrics at an institutional level around quality, of which the technology is a component. We’re there to enable the business to focus on the quality issues that they think are important and provide tools for them to manage, disclose and figure out what are the right things to do. “I think we can say that we have one of the best O to E ratios in the country and we believe it’s because of the technology we have in place that allows clinicians to have great clinical decision-making and have a DHR that gives them appropriate information that they can act on, so we really do believe that the technology has impacted that statistic and that’s a very, very important statistic to us and to the country.”
“Security is huge,” adds George McCulloch. “It’s hot. When the Clintons tried to introduce an electronic record, back then it was all about security. It wasn’t about anything else. That’s going to remain the issue: Who gets to see my record? All the security issues around that are going to remain. It’s going to be very challenging to implement. It may be unrealistic if we can’t come to an agreement. I don’t know that we will come to an agreement because there are a lot of competing interests for that, apart from the patient, and again I think a lot of people are worried about their employer or their insurer seeing things that they don’t want them to know about.” Michele Chulick underlines that security issues arise on a daily basis in the healthcare environment. “You have Health Insurance Portability and Accountability Act data breaches. We don’t always realize how capable people are of violating HIPAA or trying to access information, and so facilities have to be extremely careful and extremely diligent in all of their policies and procedures and security rules. It’s only going to be expanded as we look at how we create master medical records within IDMs that expand across states. Look at where we have some of the for-profit facilities or even not-for-profit Catholic health services, where they have multiple facilities. “Data management is something that no one can take for granted. Data security again has got to be at the pinnacle of any system that you look to put in and obviously on a day-to-day basis we all have to be careful that we monitor HIPAA with every employee in the hospital working with patients.” “I have two most frequently asked questions that I get whenever I talk about implementing electronic medical records,” points out Tanya Townsend. “One of them is security, so how do I make sure that my information is protected and confidential? The other one is what do you do when the system goes down for faster recovery; so how do we make sure the information is secure if something were to fail? Those are extremely important, and as we continue to grow electronic medical records and continue to stop relying on paper, those are concerns that we need to have, but they shouldn’t be barriers. “That would be my message: that we certainly want people to feel that their information is protected and private and we have all of the safeguards in place. I think the computer is more secure than paper because at least there’s not a trail, so we can proactively track who’s looking at what, versus on paper you don’t know where it was. The benefits and the efficiencies to electronic medical records are what we should really focus on, and then the security piece is something to be concerned about but should not be a barrier.”
“I think it’s
reasonable
Security
to be
Naturally this idea of giving patients responsibility for their own records leads to questions of security: how to keep data safe from prying eyes once it’s in electronic format. “People who understand IT security need to inform the people who are working to build these health information exchanges to make sure they are compliant with all our regulations and good practices,” says Cedric Priebe. “The high tech legislation has helped clarify some of the levels of privacy and security that health information exchanges need to meet, which is a good thing, but it’s not rocket science. Once you’ve defined the level, it’s just a matter of implementing it. “We’re in a better situation now on that perspective than we have been a period of time ago. I think that if you just limit it to coordination of care it’s pretty straightforward. Once you get into secondary uses of data for either public health or clinical research, then it gets much more cloudy as to who has rights and what is the extent of patient consent for participation.”
optimistic that we can
do this”
George McCulloch
Georg
e McC
Identification
ulloch
Dep u Uni ty CIO ver at V sit and Nas erb hvi y Med i lle, i Ten cal Ce lt nte nes r in see
34 www.executivehm.com
Another challenge facing the implementation of electronic health records on a nationwide scale is the lack of a single patient identifier. According to George McCulloch, this is likely to remain a difficult hurdle for Obama and his government to overcome: “It’s going to remain a huge issue. We tried it a long time ago, and it certainly makes life a lot easier. It’s an enabler. The problem is the privacy issues that surround it, I don’t know if people will change enough to allow us to have a single identifier, but technically it would be fabulous.” In McCulloch’s opinion, though, the lack of an identifier should not prevent us from instituting electronic records. “It’s not a barrier, if we don’t have
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it. We’ll work our way through that. It just makes it harder and there are some risks involved in the technology that does the matching. It’s not impossible, but it’s going to make it a little more difficult.” Cedric Priebe hasn’t yet confronted the identifier issue at Care New England, though he believes that may come. “We may come up against this as we start to grow our master person index to the point where we’re having trouble doing the patient matching. We’ve got a good sense with the tools we have in the product to do the patient matching based on probabilistic algorithms and then manual processes to deal with situations where we can’t do it.” Priebe also believes that the lack of an identifier will not stop the new electronic system from working. “Would life be easier with a national person identifier? Absolutely, but I think we can be successful without it until our culture is ready for that kind of thing. We made a big step forward with the national provider physician identifier. That will help with our provisioning and identification of physician users greatly, but I think we can be successful without a national person identifier. It’s a wonderful goal, but there are some significant operational and civil liberties concerns with it. We’re not a country of individuals who like to be identifiable in all situations, nor do we have a reliable set of infrastructures to identify people.” Tanya Townsend, on the other hand, feels that coming up with some kind of identifier is critical and integral to the development of a national system. “I can use my own organizations as an example,” she says. “My two hospitals, because they’re on two different platforms, don’t share a common master patient index or a common medical record identifier. The same is true of our ambulatory arm, which has between 50 percent and 90 percent of our patients in their system. Even within our own organization to try to share records and information across those platforms is extremely challenging from an IT perspective as well as from the patient perspective. “When a patient goes to see their primary care doctor, then goes to the hospital, while we do have access to the information, it’s not seamless. There are times when we’re asking the patient to repeat themselves or potentially even repeating tasks because patient A didn’t map to patient A on the other side. It’s extremely important to have a master patient identifier so that we know we are talking about Joe Smith across the continuum.” Michele Chulick is also very much in favor of an identifier: “You have to have one identifier. We have so many people who are called David Smith. If we’re going to that level of flexibility within our national healthcare system, should one truly be created, we have to have one identifier that’s specific for that particular individual, otherwise we’re going to have issues of medical malpractice, risk, patient safety, all of the above. I don’t know how anybody could even have a differing opinion. It’s essential. It doesn’t mean that everybody has to have just a number. There can be subcomponents of that number and that identifier, so I think it’s a goal that I think is achievable.”
d n e s n w ya To
Tan
nt ince St. V d n tal a n ospi onsi y’s H r a Wisc , M y . a t nB at S Gree CIO tal in i p s Ho
tory. “It’s an automatic history, so the physician that you saw two months ago, if you see the physicians in the same system they will see what someone else has identified as a problem or prescribed as a solution. “Sometimes patients themselves aren’t great historians. And the older you get the harder it gets to actually be an accurate historian. After all, who accesses the most healthcare? It’s our older population, and so I believe that an electronic medical record will provide you that personalized history’. There’s no question in my mind that it will improve the quality of care, let alone all the issues with drug interaction, allergic reactions, susceptibilities. All of that will be at someone’s fingertips, but more that an accurate history that will be available. George McCulloch also feels that the introduction of electronic records will have a major impact on personalization. “At a macro level I think it will have an impact, but we will have to see what the quality of the data is to see how what the impact is. It’s clearly a good start. We’re involved in genomics as well and we have a large DNA databank, so we’re beginning to use that information even in our own practice.” Tanya Townsend believes that EHRs will lead to more consumer-driven healthcare, so that patients have choices. “They know that they can see their information. They can see the quality initiatives that each organization has, so they can make a choice in where they receive their healthcare, and they’ll be far more involved in their care.” “If they’re well implemented, electronic records will be what makes personalized medicine possible,” says Cedric Priebe. “It will not be possible to do personalized medicine on a grand scale without a strong EMR. The average hospital encounter generates about 60,000 data elements. Once you introduce concepts of personalized medicine, like some human genotyping or other aspects, a single test could be tens of thousands of data points. There’s just no way you could bring all of those data points to bear to that point of decision in a meaningful way without an EMR, so it will be essential.”
“Obama has
got the right
strategy around putting the
incentives in place”
Tanya Townsend
Personalization The question of personalization often comes up in this discussion – how will electronic health records help doctors tailor treatments to suit an individual’s unique needs? Michele Chulick expains that the answer is tied to his-
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EXECUTIVE INTERVIEW
Accelerating patient payments
Mary Dees Griffith explains how rising healthcare costs have significantly increased collection problems for healthcare providers. What problems/challenges are private practices and healthcare organizations facing today? Mary Dees Griffith. Rising healthcare costs have caused increases in health insurance rates for both companies and individuals. To reduce the cost of coverage, many are choosing consumer directed health plans (CDHPs) or high deductible health plans (HDHPs), which only begin paying the provider directly after the patient has paid for their deductible. This shift of payment burden has caused a significant change in the financial situation for most healthcare providers. According to major studies, only 50 percent of what is billed to patients by healthcare providers today is actually collected, representing patient bad debit of $45 billion to $65 billion annually. Under traditional coverage plans, providers needed to collect little from the patient, since the insurer paid the bulk of the healthcare service cost. With today’s plans, the provider frequently sees little to no payment from the insurer and instead must bill the patient for most day-to-day healthcare service. However, since the amount the patient owes can only be determined after the insurer’s network discounts have been reflected, patients are being billed by their healthcare provider after their insurer processes their claim,
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adding an additional 60 to 90 days to the healthcare provider’s collection timeframe. What role does A-Claim play in the patient/healthcare provider process? MDG. A-Claim is the electronic payment solution specifically designed to accelerate patient payments for healthcare providers. A-Claim utilizes secure, proprietary systems to dramatically improve revenue collection at the time of service for healthcare providers, as well as offering flexible payment options to patients, which allow the automated collection of patient financial responsibility, when it has been determined by their insurer what they owe. Why is A-Claim the preferred partner in healthcare payments and benefits/insurance eligibility verification processing? MDG. With the shift occurring in the way medical practices are paid for the services they provide, patient copayments, coinsurance and higher deductibles make up a growing percentage of the total volume of a practice’s accounts receivable. This trend has resulted in medical practices facing higher accounts receivable, longer collection cycles and increased write-offs.
A-Claim is one central system that provides online, real-time verification of patient copayments and benefits information, while allowing the collection of patient payments at the time of service with the convenience of a payment choice for the patient – credit or debit card, checking account or automated payment plan. An integrated financial tool that enables medical practices to lower accounts receivable, shorten collection cycles and reduce writeoffs, A-Claim offers the highest level of online security available. Its technology is quick to implement and its design makes it easy to use, allowing a healthcare provider to achieve an immediate impact to their bottom line. How does the A-Claim system work? MDG.A-Claim delivers information electronically and immediately at patient check-in regarding copayment, coinsurance, deductible, and other pertinent benefit information, allowing the healthcare practice to estimate what portion of the balance the insurer will pay and what portion will be the patient’s responsibility. If the patient’s health plan requires a copayment, the A-Claim system collects the copayment at the time of service automatically. The A-Claim system enables the healthcare practice to provide the patient an estimated payment liability amount, and gives the patient a choice of their preferred payment method at the time of service. Automated payments can be collected from the patient’s debit or credit card or a checking account, and can be set up in any collection interval. If a healthcare provider office receives insurance claim remittance data electronically, the AClaim system can receive these files, match patient responsibility amounts against patient payment methods on file and automate the collection of the patient’s payment – without intervention from the medical practice back office staff. If the medical office receives remittances via paper, a few pieces of data from the claim remittance can be input into the A-Claim system to initiate the automated patient collection immediately or at a pre-agreed time. Automated collection of these amounts improves the practice’s cash flow and bottom line.
Mary Dees Griffith is President and COO of Preferred Health Technology, Inc. She joined the company in 2006.
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THE BIG INTERVIEW
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Dollars and sense James Rohack, President of the American Medical Association and advisor to President Obama, talks to Natalie Brandweiner about the need for a collaborative healthcare infrastructure.
M
edical education standards have always been an interest for James Rohack – he joined the American Medical Association (AMA) during his student days in the late 1970s, and for almost 40 years has involved himself in medical education teaching. “It was because of that association that since the early 1980s, I started to become involved within the AMA’s political structure of the House of Delegates, the Council on Medical Education, which sets standards nationally in the US for medical education,” he explains. Aside from his work at the AMA, Rohack is a medical director for a nonprofit community-based health plan at Scott and White Clinic, an integrated delivery system in the central area of Texas. Due to its numerous size – 770 physicians and nine hospitals – he’s been able to observe those health plans that work, and those that don’t. “The question of how to decrease unnecessary costs in healthcare to make private insurance more affordable for all Americans has been something that has been talked about within the AMA for the last 20 years because of this,” he adds.
The meeting in the White House, of which Rohack attended, resulted in Obama unveiling a target to cut $2 trillion on healthcare costs. Rohack explains the unnecessary costs that would need to be abolished in order to reach that target: “The first major one is administrative waste – we have over 1500 different health insurance companies. All of them have their own unique forms
and processes, and so physicians and hospitals spend a lot of staff time trying to get permission to do different things because of the multiple forms and the multiple processes. It’s estimated that somewhere between 10 and 16 percent of American healthcare is spent in administrative waste that we believe we can get rid of if we all agree on common platforms and forms. “The second real cost is duplication of tests and that is because our electronic systems right now in America don’t talk to each other. At Scott and White Clinic we’ve had our own electronic medical record for 15 years – all 770 physicians are linked to each other and our nine hospitals have interactions with each other. But if a patient leaves our system to go somewhere else, we can’t communicate in any efficient electronic way with other systems. One has to go back to a paper process, which Political profile is not very efficient nor cost effective. So interoperThis path of progression eventually resulted in able medical records will be a second big step. him being elected as AMA’s President this year, but “Then the third step is one of the things that the he has never departed from his political agenda. In AMA has been involved with for the last seven years James Rohack became the 164th President of the June of this year, Rohack met with President and that is what we call our physician consortium on American Medical Association in June 2009. He is also Senior Staff Cardiologist at Scott & White Obama at the White House, providing advice and performance improvement, whereby we bring toClinic in Temple, Texas. entering discussion not only as a medical director, gether the multiple specialty societies and state assobut also as a practicing clinician. ciations to come up with best practices to improve “Having a president that has signaled that this is a high priority for him care for patients, through which we can help reduce unnecessary tests.” has made it easier for the AMA to outline the policies that we’ve developed over 20 years to make this thing happen. Being able to be in the White House to talk Administrative proposals to him, not only about what doctors can do, but also the recognition that part The EMR is one of the biggest topics currently dominating the healthof the unique American healthcare cost is defensive medicine was really helpcare reform discussion. All institutions, both private and public, understand ful. It gave us the opportunity to say that while we’ll try and work on best practhe benefits of an electronic system, but whether a universalized system intice guidelines for high cost, high volume medical care conditions, if we don’t corporating a uniform record format is possible remains to be seen. Rohack get liability protection over not ordering a test that isn’t needed, then the realcompares America’s current electronic interchange with the railroad infraity is that the pressure will be to start ordering those tests even though they may structure in the early 1880s. not be indicated, just because of the fear of not having a defense in a courtroom “When our railroads were first developed, the width of the gauge of the in case you’re sued.” railroad track that the cars traveled on were of different sizes, depending upon
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the company that owned the railroad, and so it required the federal government to come up with a common width of rail line so that cars from one company could use the track of another company and seamlessly move. And that’s where we are in America. “We need the federal government to come up with interoperable standards so you can still have innovation and buy your electronic medical record from a different vendor, but the key is that it has to be interoperable with other systems, and that doesn’t exist right now, and that’s a very important role for the federal government to create those standards. When a physician decides to purchase an electronic medical record they’ll be able to talk to others, which they are unable to do right now.”
“We’re involved with the National Influenza Summit, looking at how we remind patients of steps to prevent the spread of communicable diseases, of which influenza happens to be one. Proper hand hygiene is key – making sure that there is an immunization available for those who are at highest risk of influenza and that they get that in a timely fashion. Also, being able to make sure that we have the latest updated materials for physicians to use in their office through our website, which we’ve ramped up so that we do also have a patient portal for patients that want to get additional information on particular health-related conditions, and that they’re able to access that in a timely way,” he explains.
Good hygiene Prevention needed With healthcare coverage on the political agenda, preventative care is taking center stage. Rohack notes the effect of disease burden on the number of diabetics, those with heart disease, resulting in more patients requiring dialysis and placing pressure on the number of those needing surgery. “We are very aware that our current payment system in the US pays for procedures and treatments, but doesn’t pay for prevention. So we need not only incentives to keep the patients healthy, but also time so that physicians can educate patients about wellness, which means that we have to structurally reform how our payment occurs in the United States. Right now we pay much more for doing a procedure, than we do for a physician to counsel a patient about proper nutrition, proper physical activity, stopping tobacco use, risky use of alcohol and other things that might help prevent the need to pay a higher cost to treat the disease,” he says. In order to fix the current Medicare physician payment system, Rohack describes the current physician payment system as “counterproductive to what we want to do.” He envisions a system that incentivizes individuals to spend time on an outpatient care program to prevent costly patient hospitalization, rather than the current system, which he believes penalizes physicians for such treatments. The more patients that can be transferred into an outpatient program, the greater the cost cuts are likely to be. “Punishing physicians for outpatient treatments ought to be completely abolished and a move should be made toward a payment methodology that’s based on the cost of delivering healthcare, based on inflation, which is the same method that others that participate in the Medicare program – like hospitals and nursing homes – are paid on that Medicare economic index,” he explains. The year 2009 has not been the easiest one for Rohack to begin his presidential tenure. The election of Obama and his focus on healthcare reform has highlighted its dire need for repair, and all of this in light of the current economic recession. Worst of all has been the recent World Health Organization declared pandemic of the H1NI swine flu virus. The AMA has played a role in educating the country about the outbreak, linking with the national federal government’s educational groups through the Centers for Disease Control.
Added to this is the increasing issue of hospital-acquired infections (HAIs), a huge concern for the general American public. Rohack again notes the partnerships the AMA has with other groups in the US – the Joint Commission, the Institute for Healthcare Improvement – as a way of looking at how to help decrease HAIs. He acknowledges Ignatius Semmelweis and his discovery almost 160 years ago that proper hand hygiene is an extremely important simple step, but a key one in trying to prevent the spread of communicable diseases. “One of the barriers that we had, for example, is that we knew that alcohol-based hand-washing material was very effective, but our federal organization, due to safety concerns, prohibited alcohol to be within certain areas of the hospital. So we had to work to try and remove those regulatory barriers that prevented a very simple way for hand hygiene to occur and to be placed in the emergency departments, in hospital rooms and other places. Again, our federal government system has agencies that don’t talk to the others and, as a result, hinders our ability to provide efficient, effective, high-quality care,” explains Rohack. Rohack predicts that Obama’s push to fix a fragmented and desperate system has not come at an easy time and is certain to be no mean feat. He describes America as being on the brink of crisis point, due to the demographics of a baby boomer generation. “In three short years, they start hitting the Medicare population. When four million individuals start hitting the Medicare rolls in 2012 and continue to do so at that pace for almost the next 20 years, it’s going to stress the American system as it currently exists,” says Rohack. “So we are firmly committed to the current burden of those who don’t have health insurance in the US, whose access to healthcare is through emergency departments; these individuals live sicker and die younger and, as a result, aren’t as productive in the workforce as they could be. America’s economic health is related to the health of its citizens and having this health reform. Interoperable medical records, high value in the healthcare dollar, improved quality, and reducing unnecessary costs is an achievable vision for the United States and one that we believe is within our reach as long as everyone is focused on that same commitment and goal.”
“Our current payment
system
in the US pays for procedures
and treatments, but doesn’t pay for prevention”
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INFECTION CONTROL
Journey to
zero
Healthcare-associated infections have recently sparked a media storm, despite the fact that figures are down across the US. Allegheny Hospital’s Jerome Granato tells Natalie Brandweiner why the fight against HAIs is far from over.
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erome Granato’s recent presentation at the APIC conference addressed the continuing concerns of catheter-related bloodstream infections. During an hour’s discussion, the Medical Director of the Coronary Care Unit at Allegheny Hospital highlighted the infectioncontrol work being done at his hospital and the methods that have led to the department’s success in virtually eliminating infections from their patient population. “In the US there are nearly two million of these healthcare-associated infections each year,” explains Granato. “That represents around four percent of all hospital admissions, so the scope of the problem is quite large. Of those two million people who get healthcare infections, there are about
100,000 deaths directly attributable to healthcare-associated infections. “If you look at the 100,000 people who die, the healthcare-associated infections come in five categories. The most common cause of death from a healthcare-associated infection is ventilator-associated pneumonia. That’s then followed by catheter-related bloodstream infections. Then followed by urinary tract infections and surgical site wound infections. “We also include in that, though it’s not necessarily attributed to a cause of death, C. difficile diarrhea, which is an important cause of hospital morbidity and increased stay. We are also looking carefully at the concept of MRSA transmission in patients who come to the hospital; neither of those are included in the statistics that I’ve spoken to just
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now. But ventilator-associated pneumonia, catheter-related bacteremia, tion, we do a root cause analysis. We try to identify why it occurred and nosocomial urinary tract infection and surgical site infections really reptake corrective action. resent the burden of healthcare-associated infection,” he says. “In addition to that, what we’ve done here to combat that is instituted Granato advises that understanding how the infections are transmitvery formal education in the insertion of these catheters and in their care. ted provides insight into understanding how to combat the problems and All of our physicians receive specific training both from an online training find the best solutions. They are infections attained from being inside module and simulation with a mannequin. We do the same thing with our the hospital, rather than infections the patient brings in with them; he nurses, who undergo online training and testing, and we insist that our notes that it was originally thought that these entire staff have annual certification in this techhealthcare-associated infections were one of the nique – much like if you were going to drive a car hazards of being in the hospital itself, but that’s on the open road, you’ve got to have a driver’s test. no longer the case. We think the same sort of standards should be “If you look at catheter-related bloodstream held for invasive procedures at our hospital, and infections, which is what we’ve really focused on in doing so what we’ve been able to do in several at our institution, those infections are brought units is drive our infection rate down to zero. Our into the body from bacteria that reside in the coronary care unit at one point went 16 months skin. They’re brought in when you puncture without a catheter-related infection.” the skin and drag bacteria into the bloodstream through the puncture site, and so it makes sense Elimination Jerome Granato is Medical Director of the Coronary Care Unit at Allegheny General Hospital. that understanding how you cleanse the skin, It is not the only successful statistic that He gave a presentation at the recent conference how you care for the catheter, what type of trainGranato’s approach has generated. The trauma of the Association for Professionals in Infection Control and Epidemiology entitled, ‘Eliminate ing and education the staff have with respect to unit has remained catheter-related infection-free Healthcare-associated Infections: Strategies for these infections will impact on the rate of infecfor 17 months and infections are now considered Success’. tion. That concept of the staff introducing infecan anomaly across the board. There is the occation, or the staff having activities or playing a role sional infection, but the institutional infection in the transmission of this type of infection, really extends across all of rate is now on the order of 0.2 infections for every 1000 line days. Granato those infections we’ve spoke about – whether it be ventilator-associated is quick to note that the results of this work are not contributable to him pneumonia, urinary infection or surgical site infections,” says Granato. or his team solely, but are to be credited to the thousands of people work-
Standardization
He explains that as a result of these findings, the department is primarily focusing on surveillance, education and process improvement. When healthcare-associated infection became a recurring issue and procedures for elimination began to be stepped up, Granato and his team began examining how central lines were inserted, and advised that what was found was nothing other than chaos. “Different physicians had different techniques for putting these in. Some put them in the in upper torso. Some put them in the groin. Some ascribed to a hat, mask and gown. Others didn’t. The nursing care varied across the hospital. Some used chlorhexidine. Some used iodine. The way these sites were cared for over the subsequent hospitalization varied. “Armed with that information as to the real variability in insertion and care, we’d standardize the process. By standardizing the process of insertion and care, we had a significant decline in our infection rate. The challenge comes when you’re dealing with a hospital of several hundred beds – how do you continuously communicate that message, and how do you continuously adapt to changes? “What we found we needed to do over the years is improve our surveillance methods. For example, we now look at our infection rates not quarterly, not monthly, but weekly. When we find that we have an infec-
ing within the hospital attempting to combat the problem. The process of infection elimination began in 2003 and has evolved to become more efficient and effective since. Granato explains that the procedure is the journey to zero – complete elimination wasn’t achieved in the first year, not until the formal training was instituted in 2006. “One of the things that is important to convey is that the journey to zero doesn’t occur in one big step. It’s incremental, and it’s really a journey where you have to continuously review, adapt and modify, and it has occurred over a five-year period. “The challenge we have as managers is maintaining that message on the forefront to our workforce – making sure that everyone is aware of the importance of eliminating these infections. Now, when we review our infections, we don’t talk about an infection rate anymore. We don’t say that the rate for this month or this quarter or this year was X infections per thousand line days. “Instead we say, ‘We had an infection last week in room 622, and Miss Shields was infected.’ What we’ve done is put a face on infection, and we’ve invested our staff into recognizing that these problems really impact on patients’ lives. They impact on their stay, and we’ve made the battle to eliminate hospital infections everyone’s responsibility. And that’s why it’s very important to emphasize that everyone should share in the credit here. This is really an institutional achievement,” explains Granato.
“Medicare will no longer pay for hospital-acquired infections”
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The ‘Journey to zero’ program also advises that patients must take responsibility in ensuring elimination is achieved. Granato explains how the hospital has been educating patients regarding the importance of healthcare-associated infections via visible information across the wards. There are signs emphasizing hand hygiene, as well as insisting the patient ask their doctor or nurse if they have conducted hygiene procedures. “So part of this is educating patients that they have a role and they have a right to expect good hand hygiene,” he says. “We have been absolutely passionate in expecting that from our staff and making sure that our patients know of our expectation and help us enforce that. In association with the society, the Association for Professionals in Infection Control and Epidemiology (APIC), we’ve put together a website designed to help educate patients with respect to hospital-acquired infections and things they can do. The website is called the skinisthesource.org, and it talks about hand hygiene, skin preparation, getting rid of body hair prior to your surgical procedure and the like. So there are some things they could do. A lot of it is awareness and expectation.”
you’re in the hospital, and as a result, that’s been the focus on here that hospitals should be safe places and that really a quality product needs to be delivered. What you’ve found happening across the country is that this message has been underscored by several things. There’s been a big interest in public reporting here in the state of Pennsylvania – you can find any hospital, look up their infection rate for any one of these healthcare-associated infections, and compare hospital performance. “Medicare will no longer pay for hospital-acquired infections. You’ll find that certain private insurers are now using this concept of a quality product in terms of pay per performance programs, where you’ll get paid a dividend if you cannot have any of these what were thought to be accepted complications. So the incidence of HAIs is not increasing, the public awareness of expectation has been increasing.” Granato notes the costs of healthcare-associated infections, and believes they represent a huge financial burden – they cost more money to treat and during the current times of limited resources, often take up a large proportion of hospital budgets. However, the American Recovery and Reinvestment Act looks set to support states in preventing and reducing HAIs via an overall financial budget of $50 million. Granato claims that this is not enough. “When you look at $50 million it seems like a lot of money. There are nearly two million healthcare-associated infections that occur each year in the US, so essentially what they’ve done is allocated two dollars per infection. This is a big problem that costs literally billions of healthcare dollars. $50 million is a drop in the bucket. Now the good news about the elimination of healthcare-associated infections that we, and many other people, have shown across the country is that the solution and the elimination isn’t necessarily high-tech or cost-intensive. It’s really low-tech. “It’s education. It’s surveillance. It’s awareness. It’s leadership. The types of financial resources that need to be put against this type of problem are in the order of hundreds of millions or billions of dollars. But when you have two million of these infections and you’re only putting $50 million against it, it does not seem adequate to me.” Journey to zero remains a priority program for Allegheny General Hospital, but Granato is not misguided in believing that a stable zero across the board is achievable. Many hospitals have reached the zero target with respect to catheter-related infections or ventilatorassociated pneumonias for an extended period of time, but no predictions of guaranteed healthcare-associated infection eliminations can be made. “The message will spread from the leadership hospitals to more of the rank and file hospitals as public reporting really brings this problem into focus across the country. This will also be brought to focus by the Medicare decision not to pay for the infections. There will be a lot of financial and public pressure to tackle this problem, and you will continue to see the incidence fall, and our hospitals will be a safer place for patients.” n
“The journey to zero
doesn’t occur in one big step. It’s incremental”
Patient awareness
However, there is the danger that patient awareness is quickly being formulated by media frenzy outside of hospital education. HAIs have received vast amounts of attention from the media in recent months, but despite the hype, Granato explains that the number of infections continues to fall. “What’s happened here is that we’re viewing healthcare much more like a consumer product,” he says. The incidence of significant healthcare-associated infection is about four percent of all hospital admissions. I assure you that you would never get on a plan if I told you there was a four percent chance you were going to get sick. “You would never eat in a restaurant if you thought there was a four percent chance that you would acquire food poisoning, and so the same analogy now has gone through with respect to hospital care. You have the right to expect that you shouldn’t acquire an illness while
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INFECTION CONTROL
Fail to prepare and prepare to fail
Stephen Redd of the Centers for Disease Control and Prevention tells Julian Rogers why vigilance is the key to fighting the continuing threat posed by the highly contagious H1N1 virus.
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hat began in a small Mexican state quickly spread thousands of miles around the world, killing more than 400 people and infecting almost 100,000 in more than 80 countries. H1N1, commonly known as swine flu, has been declared a global pandemic by the World Health Organisation (WHO), with the alert level elevated to Phase 6. But while the virus has proved to be less deadly than was first predicted, health chiefs are still concerned about how quickly and easily it continues to pass between humans, as well as the theory that it could mutate into a more deadly bug when winter ar-
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rives. Stephen Redd of the Centers for Disease Control and Prevention (CDC) is at the sharp end of pandemic preparedness. “There is still a lot to learn about this virus and the illnesses that it causes,” he reveals philosophically, “and there is also the possibility that what we have learned up until now could change as the virus evolves.” But with hysteria dying down over how deadly the virus actually is, could there a danger of complacency? “There’s a little bit of a sense that this was a big problem a few months ago – in the first half of May a lot was going on and now it’s kind of over – but I think this is very far from what the actual situation is,” he warns. “The virus continues to spread,
continues to infect new people, and there’s a chance that it could change to become more severe and even more transmissible, so there is a lot of work to be done to continue to keep track of what’s going on.” Redd notes that the race between the drug manufacturers to quickly and effectively create a vaccine will continue to be a priority. “We’re going hear a lot more about this virus before we’re finished with the story.”
Origins With the virus being relatively unknown, there is still no clear information on how H1N1 originated. Redd suggests two separate infections
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combined to create this virulent bug. “Our best hypothesis is that this particular virus came about through the triple ‘reassortment’ swine influenza virus that causes illness in pigs and occasionally in people in North America, and also a swine virus that circulated in Europe and Asia; so there was a mixture of these two viruses that resulted in a new virus, composed of other known viruses. Somewhere, either a pig or a person had both infections simultaneously and that progeny virus was this combination of a Eurasian swine virus and a western hemisphere swine virus. That virus had, through prior ‘reassortment’ of events, components of human viruses, avian viruses and other swine viruses. So there were four genomes that could be traced back to either birds or pigs or people.” With so many countries now reporting infections and deaths almost every day, health officials are predicting vast swathes of populations being confirmed with swine flu in August. And with the WHO raising the alert level to phase 6, Redd is keen to point out a common misconception among the public that an outbreak is declared a
“The designation of a pandemic isn’t going to change anything anywhere, but the announcement is a declaration of what is being observed throughout the world” Stephen Redd
pandemic based on the number of countries reporting cases of the virus. “The designation of a pandemic isn’t going to change anything anywhere. An announcement of a pandemic is a declaration of what is being observed throughout the world; it’s a measure of spread rather than the total number of cases.”
Connections People may draw comparisons between H1N1 and H5N1 (bird flu), but Redd highlights two distinct differences between them. “First, the severity of H5N1 is many-fold higher; its fatality
rate and the severe illnesses that it causes in humans are much different from what’s seen in H1N1. Also, there has been very little human-tohuman transmission of H5N1 and so the predominant risk in the world from H5N1 at this point in time is from exposure to poultry that had the infection.” Redd says more research is needed into H1N1 transmissions between animals. “H5N1 is a mainly a problem in animals but with H1N1 we still don’t the full extent of it, although most people get it from exposure to an infected person.” Every state in the US now has confirmed cases of H1N1, with more than 33,000 confirmed
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CDC under the microscope The CDC is one of the major operating components of the Department of Health and Human Services. CDC′s top organizational components include the Office of the Director, six Coordinating Centers and Offices, and the National Institute for Occupational Safety and Health. The CDC works to protect public health and safety by providing information to enhance health decisions, and it promotes health through partnerships with state health departments and other organizations. It is based in the Metro Atlanta area, adjacent to the campus of Emory University.
cases and 170 deaths. With Mexico bordering the US, it is little wonder that the US has become the country most affected by swine flu. “The hospitalization rate is around six percent with a fatality rate of between one and two in every 1000 cases, so it’s still much less to fear than the 60 percent fatality rate with the H5N1 virus,” Redd explains. The CDC has been working on procedures for the past eight years to deal with a potential pandemic, which included screening passengers arriving from a country when the virus originated. The CDC also created a scenario where a fictitious student from East Asia was going to college at Georgetown University in Washington. When he arrived he became sick, was diagnosed with H5N1 and it spread to his swim team classmates. As it turned out, this was similar to the way in which H1N1 played out in the US, with the first case the CDC was aware of occurring in San Diego County and the next on in neighbouring Imperial County. Despite concerns about the relevance of the exercise scenario, Redd said skeptics were proved wrong. “There were complaints that it wasn’t very realistic but, in fact, it turned out to be very realistic. Some things went against our assumptions in real small ways but although there was scepti-
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ILE F T C s: FA case
rmed Confi 31 94,4 o ue t d s 1 h Deat e flu:42 n i w s th s wi es:81 e i r s t Coun rmed ca fi n o c
A woman talks on her cellphone while protecting herself against influenza with a face mask in Mexico City cism before, it [H1N1 outbreak] did turn out pretty much how we planned.” Despite the mock pandemic training there was some confusion over whether this was an outbreak confined to just the US, says Redd. “In the event, it took a little longer to recognize that we were dealing with a problem that was not limited to the United States, and some of that was the exercise scenario we had. That the experience of
uncertainty and demand for decisions or recommendations was very similar in the exercise and the way the event unfolded.” Redd adds: “The feeling that people had, especially in the first couple of briefings, was that it was very similar to the way that we had exercised. In those first few days it felt a lot more familiar than it would have without the exercises, and I think that was critical because we were able to, even
ly 8th for Ju s are Figure
though we didn’t really know very much, organize the things we needed to know and the things that we thought we would have to be dealing with from an implementation or guidance standpoint very early on. Just having that little bit of structure initially was very important.” Stephen Redd is a medical epidemiologist and Director of the CDC’s Influenza Coordination Unit.
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IN DEPTH
Preventing infection John Jernigan of the Centers for Disease Control and Prevention shares his thoughts on hospital-acquired infections and reveals why he is optimistic for the future.
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ospital or healthcare-acquired infections (HAIs) are a serious the CDC, suggests that infection rates for at least some infections have been issue because they can be quite harmful and even life threatendeclining in recent years; however, the rates for other types of infection – such ing to patients, and they increase the cost of healthcare. HAIs as gastrointestinal infections – may be increasing,. account for an estimated 1.7 million infections and 99,000 asRarely, healthcare associated infections may be caused by problems with sociated deaths every year in US hospitals. water contamination, such as Legionnaire’s disease. But more important is The most common types of HAIs include urinary infections and bloodproper attention to standard precautions including hand hygiene and taking stream infections – often caused by the use of catheters, steps to prevent infections caused by invasive devices and infections of surgical sites and pneumonia, and are also procedures. “There is certainly a often associated with the use of artificial ventilators. The SHEA/IDSA compendium represents an imlong way to go with HAIs are finally being recognized as an important portant complement to official CDC guidelines, providregard to making our safety problem and one that we can do something ing a concise, easily applied distillation of current hospitals and other about. Over the past decade, there have been a number guidelines in a format that facilitates translation of offihealthcare settings as of advances in our understanding of the preventable cial guidelines into practice. CDC guidelines are profraction of healthcare-associated infections; that is, what duced by mean of extensive systematic assessment of the safe as they can be” proportion of these infections can be prevented by imquality and weight of evidence to support each recomplementing certain prevention measures. mendation while also allowing public scrutiny and comment. The The CDC issues a series of specific recommendations for preventing SHEA/IDSA compendium is based on a nimble approach that relies on the these common types of infections. The cornerstone of prevention is proper judgment of individual reviewers, which allows rapid production and effiattention to hand hygiene and other standard infection control precautions cient consensus. by healthcare personnel, including the use of gowns and gloves in certain setI am optimistic that we will continue to see advances in the prevention tings. There are also a number of infection-specific prevention measures, such of HAIs in the next few years. Success creates success, and the stunning preas procedure-specific techniques to be used when inserting and using urinary vention successes we’ve witnessed by many hospitals in the last few years have or bloodstream catheters or when performing surgical procedures. inspired similar efforts nationwide. I believe this will translate into fewer inThere is certainly a long way to go with regard to making our hospitals fections and more lives saved. and other healthcare settings as safe as they can be. Data from the National John Jernigan is Deputy Chief of the Prevention and Response Branch Division of Healthcare Safety Network, a national HAI surveillance system operated by Healthcare Quality Promotion for the CDC.
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SURGERY
History lessons Innovation has become a buzzword, overused for almost every industry. But for surgical development it is essential. Julie Freischlag, Chair of Johns Hopkins’ Department of Surgery, tells Natalie Brandweiner of the department’s pioneering history and its revolutionary future.
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ecruiting the best, as Julie Freischlag explains, is key to actualizing the goals laid out by the Department of Surgery. As Chair of the department, Freischlag is responsible for formulating the department’s mission, and central to her strategy is exercising vast amounts of energy into recruiting the best medical students to become residents, as well as recruiting the best residents and fellows to become the department’s faculty. She notes the various sectors within the Department of Surgery – plastic surgery, cardiothoracic and transplant, pediatric, surgical oncology, vascular, trauma and critical care – which are all extremely diverse, and the importance of choosing the right individuals to head these divisions. “We choose the right leaders and the brightest and the best in the country to come here, and we recruit from a wide area because the hospital’s so big. It’s a 1000-bed hospital, and we take care of patients in the city of Baltimore as well as patients within 100 miles that travel to see us for operations. “We also take care of many patients from around the world, so we see a diverse group of patients that have a diverse group of problems;
and that’s probably the most important thing we have that attracts people here. Our department believes in research: not only basic science and translational research, but also clinical outcomes research and looking at better ways to take care of patients. Th rough using the medical research piece, as well as the amazing patient care we have, and the incredible faculty, that’s how we stay ahead and stay fi rst,” explains Freischlag. Managing a department that encompasses so many diverse divisions may not be an easy feat, but for Freischlag, the challenges she encounters due to the sheer scale of the department are what continue to drive her in her role. “They give you energy,” she explains. “If you’re the kind of person that really enjoys developing faculty – which is probably my biggest love – when you meet with all of them and you try to help them attain the goals, it’s actually energizing. It really makes my job easy because they’re so smart, they’re so energized, they’re so innovative that it keeps me ahead of my game as well.”
Surgical pioneers
Freischlag is not the only Chair to display enthusiasm and panache. The department boasts a history of such leadership: the fi rst Surgeonin-Chief, William Halsted, was one of the pioneers of surgical training.
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Freischlag notes the historical procedure of surgeons leaving school and traveling to Europe, where they would spend time with a famous surgeon, learning techniques, without any solidified form of training. “What Halsted instituited was a graduated ability to train that was consistent, so it wasn’t just finding someone to spend time with, such as an apprentice; it was more of a program that allowed you to increase your responsibility and increase your ability to participate in more complex operations. And that’s what made his training program so unique. “Now all of our training is based on that. Residents come and start off with doing simple things, participating in smaller operations, learning how to take care of the patients on the floor, and then going on to learn how to do more complicated operations. We use fellowships where people specialize even more into the areas that they like. “Halsted provided the framework of all surgical training because of the consistency and the graduated training, and that’s what he became noted for. He did invent many operations; he was very innovative and mastered many things, because back then the biggest problem was lack of anesthesia. There wasn’t a blood bank, there weren’t any antibiotics; he had to do operations without all the routine things we know now. “He was radical in that he would push the envelope to make that happen, and then teach others, which was probably his best claim to fame; even though he himself was a great surgeon, his legacy were the people that he trained,” she says.
Research focus
Well known for its talented leadership, the department is also often talked about for its commitment to research, with a vast array of areas being studied. Freischlag explains that the department is organized into themes to allow for core Julie Freischlag facilities, with a new environment that provides easy share of information. The themes range from immunology and cancer, transplantation and cardiovascular medicine, as well as inflammation and infection, and are arranged into groups, which she notes is due to the immensely hectic schedule of the surgeons. “They are so busy doing surgery that they need to be able to have a core lab that maintains the research while they are operating as well,” says Freischlag. “Surgeons by and large tend to do research on the areas that they treat clinically, so if you are a transplant surgeon then your area of research would be in an area that you’re taking care of, because that makes it more relevant. They’re able to get human tissue in order to study it and understand it better; that’s probably the one thing that surgeons are able to do more than anyone, because we operate on people. We’re able to get permission to use some of their tumors and tissue in order to study them, because certainly human tissue is very different than animal tissue or tissue just grown in a Petri dish.
“It gives us an opportunity to look at the human cancer. We’re doing a lot of work with transplant patients where one of our faculties is looking at hepatitis C and trying to eradicate it because it’s such an epidemic, and it’s the number one cause of people receiving liver transplantation. One of our surgeons, Andrew Cameron, is looking at an animal model of hepatitis C, because once you transplant the liver people can get the disease again, because they carry it in their bodies, so we’re trying to prevent it from reinfecting the new liver. “We’re also looking at reasons why people don’t accept kidney transplants “whether or not there are different matchings we should look at according to age and race, and looking at other immunological reasons that perhaps you don’t do well with your kidney transplant.”
Great investigations
Dorry Segev, another surgeon, is looking at access to kidney transplants, including how we should select kidney transplant patients and looking at how different groups do with their kidney transplants using large databases across the country. “We also have a group working under Richard Schulick, which is looking at vaccines that you can use to treat people with pancreatic cancer once and it doesn’t come back. We’re probably one of the major centers in the country for pancreatic cancer and doing the operation, butpatients only survive a year and a half to two years following the surgery. So the vaccines they’re developing – not only for pancreatic cancer but also for colon cancer that spreads to the liver have been very exciting to help prevent recurrence. “One of my other investigators, Steve Leach, is looking at what causes pancreatic cancer and has a wonderful research model using the zebra fish, which actually can grow the pancreatic cancer, and they’re able to look at it and visualize it in trying to prevent it from occurring in the first place, and looking at the genetic makeup of the pancreatic cancer. Lastly the area of vascular medicine we’re looking at the causes of Marfan Syndrome, which is a syndrome that causes aneurisms, and looking again at the genetic makeup of those patients. We work with Hal Dietz, who’s very famous for that, and Jim Black’s my young investigator that’s who is looking at that. He operates on these patients, studies their tissue, and is trying to prevent the aneurisms from growing, because they start in childhood.” Minimally invasive surgery continues to grow within the surgical field, and the same is true at the department. Freischlag notes Mike Choti and Mike Marohn as two surgeons currently involved with minimally invasive and robotics – both general surgeons using laparoscopic techniques. She explains the key to the future being the “amazing way we can imagine things now before we operate on them.”
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CT imaging and MR imaging are the tools used to assess the tissue and tumors in order to understand the extent of what operation needs to be done, which are what Freischlag claims to have revolutionized the extent of minimally invasive techniques. “The key to the future is to monopolize on the imaging, and we’re building new hospitals and making sure that we have imaging capabilities, the ability to use computers to identify where the tumors are,” she explains. “Both of these surgeons then use imaging to be able to target a tumor, and if you have to freeze it or heat it, you can do it the day before in a simulation so you can see it on the imaging. When the patient comes you know exactly where to get that tumor and how to treat it without making a big incision. So imaging is the key for the future. The robots are great, because they’re able to do the procedure – you can line them up and they’re very precise and can remove it, but without the imaging and the interpretation of the surgeon of exactly what the robot is to do, that would never happen. Imaging is the key as we go forward, and we’re trying to put together a group that can be ahead of the curve each time. “Do you need every gadget that gets invented, or should you be focusing on what is the imaging and what would make the operation quicker and safer and better for the patient, versus trying every new device that comes out? With the emphasis on healthcare reform now and trying to be cost-effective, it’s these new things that are very expensive, so it’s very important to make sure that the new gadget does increase length of stay, does make the operation better, does save the patient pain and discomfort, because some of them don’t.
“The new word is comparative effectiveness – if you look at what certain devices do compared to the old way, there’s real no difference, except you tell the patient you’re going to use this new device, which sometimes works for marketing, but doesn’t really make a difference for the patient. So making sure that all the new technology we’re going to spend our money on actually does do something better for the patient is where we’re going to focus our attention,” says Freischlag.
“If we can prevent illness in many patients that’s a wonderful thing, whilst also making sure we don’t eliminate the ability to be innovative”
HAIs
Healthcare-associated infections continue to dominate the healthcare debate and surgical departments have begun to feel the heat of media pressure. Freischlag notes that this has changed certain procedures over the last five to 10 years – there are many measures that are evaluated by the hospital accreditation system to ensure patients receive antibiotics before surgery, for example, as well as making sure that their body temperature and blood sugar is controlled. “We have done all of that,” she explains, “but the sad thing is that even if you do all those things you still get infections. So this year we’re looking at why that happens. “Now that we have done all those things and can document that we do everything the regulatory bodies tell us to do, what is it about certain patients and certain situations that still lends itself to having an infection? We would like that infection rate to be zero, so we’re focusing on the environment of the operating room, looking at who comes in and out, the air, the tables, the cleanliness and so on – everything that happens, the whole environment. We have people observing in operating rooms
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to see if there’s anything else we can do in the environment, because the patient comes in the way the patient is. “There’s no way to make them older, younger, healthier and so on; they are who they are. So its’s a case of whether or not we can help with the environment. The other big push has been hand washing and making sure that we have the ability to wash our hands endlessly between patients and all the time. Even patients’ families and other people visiting the patient need to be cleaning their hands and realizing that they’re in an environment and a situation that they still can become infected.” Heightening awareness, both of the patient, the patient’s family and the healthcare providers, remains of the greatest importance to Freischlag and her department. Examining the environment of care is a current focus of the team, as well as ensuring that all of the measures of regulatory bodies are fully accomplished. By a process of elimination, the department is directly challenging HAIs and their multifactoral presence. However, times are changing, in almost every aspect of healthcare. As well as tackling HAIs, Obama and his administration are placing healthcare reform high on the federal agenda, which presents its challenges to surgeons across the US. Freischlag notes the importance as a surgeon in keeping up with the changes, both administrative and technological, and ensuring that everyone in the department is adequately trained and exposed to new developments.
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“With healthcare reform we’re excited that there’ll be access for everyone; we certainly want everyone to have some form of insurance. But one of the challenges is that we don’t want to lose innovation with trying to be practical. “We are all focused on disease; that’s what we do. We operate on disease. So now the emphasis will be on preventative care, which is great – we would like preventative care because we don’t have the resources to treat everyone. That’s no question. If we can prevent illness and disease in many patients that’s a wonderful thing, and then also be there to treat those that do have it, whilst also making sure we don’t eliminate the ability to be innovative and try new things – and that has to do with cost and making sure that there is part of the system that allows those things to happen. “We certainly see many revolutionary things in surgery because of the innovations of the surgeons, amd we are allowing innovation to stay, even though we know there has to be cost containment. Utilizing technology appropriately, making sure surgeons can be exposed to that and learn about that is the challenge of the future, because that’s where all new discovery is made. Halstead was about discovery and innovation, and we never want to lose that, because surgeons are always thinking about a better way to do things and we want to make sure that avenue is always open.” n Julie Freischlag is Chair of Johns Hopkins Medicine’s Department of Surgery.
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Worldwide Healthcare spends
$40 Billion per year on Surgical Site Infection(SSIs).
Fighting surgical site infections one ion at a time
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PEDIATRICS
Circle of care EHM talks to Margaret Bauman about the unusual facility that uses a multidisciplinary approach to treat children with developmental disabilities on the autistic spectrum.
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he Learning and Developmental Disabilities Evaluation and Rehabilitation Services program – known as LADDERS – is nothing if not unique. It encompasses a multidisciplinary center designed to evaluate and treat children, adolescents and adults with a handicapping developmentally related conditions. Affiliated with MassGeneral Hospital for Children in Boston, the program provides expertise in neurology, developmental pediatrics, gastroenterology and psychiatry/psych-pharmacology. but it’s LADDERS’ commitment to a multidisciplinary approach that makes the program stand out from its nearest equivalents. LADDERS’ founder, Margaret Bauman, didn’t set out to create a unique facility, but as she explains, it was a case of necessity being the mother of invention: “I’d love to tell you that I set out life and planned to do this,” she says, “but what happened was that part of my training as a neurologist was to spend some time in the University Affiliated Programs, which were governmentfunded multidisciplinary teams designed to evaluate individuals mental institutions or the institutions for the retarded that were closing down.
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“This was how I was trained in the model of having a group of people sit around a table discussing a single patient, and I realized that part of my medical training had been lacking in the sense that I really didn’t know what a speech and language pathologist did, or how they evaluated a patient, or what their findings meant, or an occupational therapist, or a psychologist, or an audiologist, or any of those other people, so it was an unusually rich learning experience for me to have this kind of team approach. “Then in the early 1980s, I was working in Cambridge at the Cambridge Hospital, which is a Harvard teaching hospital, and down the street from us was a geriatric hospital. They called one day to say that they needed somebody to monitor their pediatric program, which I did, but then I got bored due to my attention deficit disorder. I convinced them that they needed to expand their reach, and if they were working with young children with developmental disabilities to notify pediatricians in the community, and we started seeing more kids.” Bauman explains that this carried on until the early 1990s, when the program she was running came under scrutiny – it was not a money-maker be-
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cause of the amount of time that went into dealing with each patient. She was told she would have to change the treatment model: “I said, ‘No, I didn’t want to change the model,’ because I really thought it was – you know, this interdisciplinary approach was really important, and so they insisted that this had to be done for financial reasons.” Eventually, after various other ups and downs, in 2000 it was agreed that Mass General would combine with Spaulding Rehabilitation Hospital, which was its sister hospital across the street, and that those two facilities would put provide backing to the LADDERS program. “That’s how it evolved,” Bauman concludes. “It’s not that we sat down and said, ‘Let’s put together a program.’ It evolved because the kids that we needed to see are complicated and we needed to draw in a number of disciplines to see them. Then we’d get more and more people involved over time and they gradually become a team, and that’s what we have at the moment.”
One of a kind In spite of – or perhaps because of – all of its ups and downs, LADDERS remains a unique facility. Bauman says she doesn’t know of any other program like it, even those that charge a fee for service. “There are autism clinics around the country, of course,” she continues. “Some of them are more multidisciplinary than not. There’s an organization that’s been put together called the Autism Treatment Network, which was started after the LADDERS model in 2003 with the idea that there needs to be really good medical healthcare for kids on the autism spectrum, which they frankly aren’t getting in many parts of this country. “Many primary care physicians are put off by their behavior. They’re difficult to examine. They have a meltdown in your office and nobody’s paying you. They’ve torn up the waiting room. And most of your primary care physicians are trying to see six to 10 kids an hour in order to keep their offices open, so their willingness to spend time with families and children like this is really low, and they aren’t getting the kind of healthcare they really need. You’ve got kids that are non-verbal who can’t tell you where they hurt, and they don’t point to it either, so now you’re almost doing veterinary medicine on top of everything else. “The ATN was put together with the idea that there would be five sites that would develop common protocols, and that we would begin to look at things such as the prevalence of GI tract issues in autism, because nobody really knows. What’s the prevalence of sleep disorders in autism? If you have a kid with sleep disorder, what should you do about it? There is currently no data for that. “That got pretty expensive, and so the program was turned over to Cure Autism Now, which was a parent driven group on the west coast. Cure Autism Now then came under the administration of what’s called Autism Speaks, which in January of 2007 said, ‘This is a great model, but we think we need to have more of them,’ so they put out a request for proposals, and now there are 15 such sites throughout the United States with the concept of putting these multidisciplinary clinics together. “That said, none of them are as multidisciplinary as LADDERS as yet. The goal is to help make them that way, but this is a work in progress. The concept is there, and people are willing to do it, but again it’s a question of who’s going to pay for it and are hospitals going carry the financial burden of a program like this all by themselves?”
Through the process LADDERS is medically driven, which Bauman says differs from the way other clinics work, many of which are psychologically driven. The clinic is also unusual in that it sees adults as well. “This is a ‘birth to grave’ program,” she explains. “We’re in the Department of Pediatrics, but we see adults. We’ve been in business long enough that our kids have grown up, and they have no other place to go. We’ve now hired two adult neurologists, and we’re going to hire an intern this summer, because our population is aging. “In terms of the referral process, whoever wants to make a referral makes a referral, and it comes to the intake social worker who speaks to the family on the phone, and sends out an intake packet, which is a series of forms. We request any records that this person has had, including lab work and birth records. Then we assign the person depending on who’s got a slot – unless the family has asked for a specific doctor – and that person then reviews the records in advance.
AUTISM FACTS Experts estimate that 2 to 6 children out of every 1000 have autism Boys are 4 times more likely to have autism than girls Between 1 in 500 and 1 in 166 children have autism 24,000 of the 4 million children born in the US each year will eventually be diagnosed with autism Up to 500,000 individuals younger than 21 have autism
“The first step is taking a history, observing the child, doing an examination, reviewing the records, then sitting down with the family. There very few families, even families of young children, who have come to us who are totally surprised about a diagnosis of autism. The PR is out there so much now that the family will usually come in and say, ‘We’re concerned about him because he’s not talking,’ which is the common symptom. And so my style is to get as much information as I can to look at the child, and then I usually say to the parents, ‘What do you think is going on here?’ And almost to a one, they’ll say, ‘We’ve been worried that he might be on the autistic spectrum.’ “Then we decided if we need to do further evaluations, and if the family is not from the local area, we give them the numbers of specific people they can call who we know will do a good job. It is their responsibility to make that contact. But I also give them my email, and so does everybody else in the clinic, so that if it doesn’t work out, I need to know that so that we can either make a referral or we can run interference for them because I want those evaluations done. Then I usually meet with the family after the evaluations are done,
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and we’ll pull the child apart and we’ll put him back together again. We’ll that if they get into trouble, they can pick up the phone and call us – that hopefully have started services for this child so that he’s getting home-based there’ll be somebody there who will help them – and I hope this reduces the services from somebody.” anxiety and the stress they have in their lives. Bauman explains that if the case involves a school-aged child, LAD“The other thing is that’s helped us all is that we have all learned from DERS often sends someone out to look at the school program, because a each other. I can just walk down a hall and grab a therapist, or I can grab the great education plan could be compromised by a bad classroom, or vice child psychiatrist or the GI guy and say, ‘Can you just come in and look at this versa. And if the family needs an advocate or a lawyer, LADDERS staff try for a minute and tell me if we need to do a more extended evaluation, or is to help with that as much as they can. “The this something we need to solve right here?’ as opposed to makgoal is for us to get these kids the services ing a phone call and then waiting three days for somebody to call they need so they can make the progress you back, and then you’ve forgotten who the child was and what Margaret Bauman is the they are capable of making,” she says. “We the question was. It is a much more immediate kind of way of hanfounder of LADDERS, follow these kids pretty tightly, and the readling kids and their families when they’re in the office.” which is affiliated with son we do that is not that I distrust the parthe MassGeneral ents, it’s more of a distrust of the school Different challenges Hospital for Children in district; if we see the child every three to six While LADDERS does see adults, mainly those who have Boston, Massachusetts. months, then the school system knows that grown up while in the program, its main clientele is made up of some outside person is watching them. A lot children and their families. Bauman says there are particular chalof things could happen that are outside our control. For example, if the lenges involved in dealing with children as opposed to adults. speech and language pathologist goes on maternity leave and the kid does“The challenges are very different. With children, their parents obvin’t get speech therapy for three months, I want to know that, because that ously want their child cured. They want a typically developing child; they’re means he needs to get it someplace else. really anxious to see progress. One of our challenges is trying to keep fami“We also help families negotiate the healthcare system as best we can. lies from doing things that they shouldn’t. Sometimes they go on the web They’re getting tighter and tighter with what they will and won’t fund. We’ve and find somebody who’s said that such and such is going be the cure for got letters of appeal on our computers on templates, because we’ve put out autism, and I get very concerned, not only that they shouldn’t do it because so many of these things. We need to find resources wherever we can find them it’s costly and there’s no proof that it does anything, but also because a lot to help families get through this. This is a 24/7 job for these families, they’re of the stuff that’s on there is frankly risky and somewhat dangerous. I don’t just trying to take care of their kids. To negotiate with the school district, or think families have a way of monitoring that or have the scientific backwith the healthcare system, is not easy. ground to be able to sort it out. “Our hope is that because this is a one stop shop, all the people who are “We try very hard to spend a lot of time giving them as much education working with this child are in a position to talk to each other. Families know as they can. Even despite that, many of them go out and do what they’re going
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to do. My only hope is that we can keep them from doing anything that’s really dangerous. “Along those lines, 14 years ago we started a conference that we run every year called Current Trends in Autism. The gist of it was to bring the science of autism to parents who could speak to families in plain English without talking down to them. We certainly haven’t solved the whole problem, but this conference is oversubscribed every year, and it’s been really helpful for them to be able to hear science.” The other challenge for Bauman and her team has been to ensure each child gets what he or she needs, according to their level on the autistic scale. This ranges from the small subset – about five percent of the patients seen at LADDERS – who are clearly autistic when they are first referred, but by the age of six or seven no longer meet the criteria. Then there are the majority of children in the middle of the scale who make variable progress to one level or another, and then the five percent on the other end who make very little progress, no matter what efforts the doctors make. It is this last subset that preoccupies Bauman the most. “It really bothers me; I feel like they also must have something else that we’re missing. Maybe it’s some kind of underlying metabolic disorder? We’ve started to look at that now, and we’ve discovered that there is a subset of those kids who have what’s called a mitochondrial disorder. Sometimes by treating that underlying disorder, we can help the kids move along a little better.” It can be difficult to deal with some of the medical issues and behaviors demonstrated by the most severely affected children. Bauman explains that aggressive and self-injurious behaviors are often been put down to being part of that child’s autism, but she’s not sure this is the case. “What you’ve got is a nonverbal kid who can’t tell you that they hurt or point to where they hurt who hurt, and a lot of these kids have these GI tract issues, or they have ear infections, or they have an abscessed tooth, and you need to figure out what it is and treat it. And when you treat it and identify it, then the behaviors get
better, and then they can attend school or OT or speech, or whatever it is they’re doing. We try to concentrate very hard on trying to figure out if some of these behaviors have some source in the child’s general healthcare. And the results have been amazing.” One of the key strengths of the LADDERS program is its emphasis on treating developmentally disabled people as individuals. Bauman points out that it’s important to realize that even those on the autistic spectrum are a very heterogeneous group. “You go to some towns and they say, ‘We have a class-
“There needs to be really good medical healthcare for kids on the autism spectrum, which they frankly aren’t getting in many parts of this country” room for autistic kids.’ That’s just great, except each one of those kids is going to be different, and they all have a slightly different learning style, and unfortunately you’re going to have to figure out how Jimmy learns and how Sally learns, and that this is not a one-size-fits-all scenario. “There’s a very apt saying: ‘If you’ve seen one child with autism, you’ve seen one child with autism.’ You’ve got some general concepts that you can bring to this thing, but each one of these kids is different, and it’s critically important to see each one as separate. There isn’t this automatic thing that you do every time. Some kids will do very well with applied behavioral analysis. Some kids will do terribly with it. Some kids will do well with floor time and vice versa. Some kids will need a little of both. It really is hard –you have to see what fits with the child and what fits with the family, and it’s a very individualized thing each time.” n
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EXECUTIVE INTERVIEW
Green cash flow Manufacturer financing for immediate cash flow boost. By Francesco Pompei ment method is a monthly credit card charge by the manufacturer. No complexity of leases, compliancy or contracts. The hospital owns the instruments and pays on an installment basis financed by the manufacturer. For TA thermometers, this charge is less than $15/month per thermometer for 24 months for most GPO pricing. A typical cost for disposables alone for other types of thermometers is about $21/month, thus immediately improving cash flow by $6/month per thermometer. A further cash flow improvement is from elimination of probe replacement and repair charges, which typically are about $100/yr per thermometer. This brings the total immediate cash flow gain to approximately $14/month per thermometer. After the thermometers are paid for, the total cash flow improvement is then 100 percent of the previous cost, or $29/month per thermometer. For a hospital with 500 thermometers, over five years this adds up to nearly a million dollars of free cash flow.
Francesco Pompei is Founder and CEO of Exergen Corporation, and holds 60 US patents in noninvasive thermometry for medical and industrial applications. Earning BS and MS degrees from MIT, and an SM and a PhD from Harvard, Pompei also holds an appointment as Research Scholar in the Department of Physics at Harvard in cancer research.
How does manufacturer-financed new technology increase immediate cash flow for cash-short hospitals? Francesco Pompei. First, a new technology must cost less and deliver improved patient care. In the current climate, unless both criteria are met, a new technology may not be a good deal for the hospital, or for the patient. Second, out-of-pocket cost of acquisition of the new technology must be lower than what it replaces on day one. This means that effective new technology must be financed in some way to allow the hospital to gain its benefits immediate-
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ly, even if there is no readily available cash or financing. The best ready source of this financing may be the manufacturer, who even in the toughest of times always has the lowest financing costs of anyone in the supply chain. This is because its cost of producing any product is always the lowest in the supply chain. An example of this is temporal artery (TA) thermometry, a new technology that both improves patient care and substantially reduces costs. Patient care improvement results from the increased speed and accuracy of measurement, with the inherent patient appeal of a gentle forehead scan. This replaces other methods, which are slower and less accurate, and require an unwelcome probe insertion into a body cavity. The scan of the forehead, like the use of a stethoscope, lightly touches skin with no mucous membranes and requires no disposable – simple cleaning between patients is adequate. Since disposables account for about 90 percent of thermometry costs, this saving is very substantial. How does the manufacturer financing work? FP. The hospital conducts its evaluations, purchase and acquisition in the normal manner, but the pay-
What makes this green? FP. Elimination of waste – particularly nonbiodegradable plastics used in thermometer probe covers. One medium-sized hospital estimated that it eliminated 2.2 tons of waste per year due to thermometer probe covers when converting to TA thermometry. Other thermometers are easily broken due to their design requirement for a probe insertion into a body cavity. Because TA thermometers are entirely non-invasive instruments, they can be designed to be nearly indestructible. This allows the manufacturer to offer a lifetime warranty, eliminating the cost and associated waste for replacing thermometer probes as well as disposables. Why would a manufacturer provide this type of financing? FP.If the manufacturer has the financial strength to offer this service to its hospital customers, then it is an excellent use of resources to help improve the financial health of its customers, which ultimately results in increased sales for the manufacturer. In addition, the manufacturer, together with its hospital customers, makes a significant improvement in care for our patients and care for our planet.
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EXECUTIVE INTERVIEW
Microbial culture test
Timothy Mattimore of MicroBionetics explains the CultureStat Rapid UTI Detection System. What is the CultureStat Rapid UTI Detection System? Timothy Mattimore. The CultureStat Rapid UTI Detection System is a true microbial culture test that uses a vacuum-sealed ampoule containing growth media and indicator and is also a small, automated, multi-wavelength light spectrophotometer connected to a computer to detect and measure bacterial growth in a urine sample. CultureStat reduces typical urine culture testing time for UTI detection from 24-48 hours to two hours or less.
“CultureStat results are extremely accurate despite the short testing cycle” The ampoule is twisted with its tip in a urine sample – this breaks the vacuum seal and fills the ampoule with 7ml of urine. Once at the laboratory, the ampoule is placed in the spectrophotometer, called the CultureStat Reader. The operator clicks the appropriate button on the computer screen, which prompts the CultureStat Reader to perform two simultaneous readings and automatically send the data to the computer. Following a 60-minute incubation, a second set of readings is conducted in the same manner. The CultureStat Database Software Program analyzes the data, displays the results and records all data in an easily searchable format. Because CultureStat measures both cell mass increase and respiration of bacteria within the sample using two wavelengths of light with very high sensitivity, CultureStat results are extremely accurate despite the short testing cycle. The advanced testing methodology also enables CultureStat to distinguish between bacteria in log phase
and bacteria in lag phase. The equipment is extremely inexpensive, and the cost per test using CultureStat is less than current laboratory testing methods.
it can accurately screen out the negative samples in less than two hours and cut the volume of samples that go to plate by 75-85 percent. By using CultureStat instead of firstround plates, negatives can be determined and reported a day earlier, and positives can rapidly go to C&S. Laboratories operate more efficiently, and hospitals can test, treat and discharge patients more quickly.
How can CultureStat aid in the detection of hospital-acquired infections? TM. Because Medicare no longer reimburses for the treatment of catheter-associated urinary tract infections, hospitals are seeking accurate, efficient methods for testing A significant issue regarding the accurate both present-on-admission (POA) urinary testing of urine samples is the time elapsed tract infections as well as hospital-acquired between sample harvesting and the initiainfections (HAIs) for patients who receive tion of testing. How does CultureStat deal catheters during the hospital stay. Culturwith this issue? eStat is the perfect solution for testing for TM. This is a huge problem – a large majority POA infections and HAIs of samples tested far exceed for the following reasons: the consensus two-hour CultureStat requires very time-to-test standard. Most little operator time (15-30 hospital laboratories receive seconds per sample), testing samples both from within is extremely easy to comthe hospital and from outplete, initial results on fresh side sources. Some samples samples are available in are chemically preserved, less than a minute, and are some are not, and rarely do confirmed in one hour, and laboratory personnel know all results are automatically how old a sample is when stored in the CultureStat it arrives. The CultureStat Database, eliminating the Ampoule serves both as the Timothy Mattimore is a Managing need for additional recordtransport and testing vessel. Member of MicroBionetics, LLC, keeping. Because the testing process and serves as Director of Legal and Regulatory Affairs. Before entering the begins as soon as a Culworld of medical devices, he practiced Can CultureStat be used tureStat Ampoule is filled, corporate and securities law in New for the screening of all facilities can easily become York City and in Wilmington, Delaware. urine samples sent to the compliant with time-to-test laboratory for microbial analysis? standards by filling CultureStat Ampoules TM. Absolutely. Statistically, 75-85 percent of at collection sites and using the ampoule as all urine culture samples tested in laboratothe transport vessel. The sample is preserved ries are negative. Laboratories have struggled within the ampoule during transport withfor years to find an accurate, efficient and out chemical alteration, and can be rapidly cost-effective way to properly screen negaanalyzed using the CultureStat Reader when tives so that microbiologists can concentrate it arrives at the lab. Costs are further reduced their efforts on the C&S of positive samples. because extraneous transport and preservaBecause CultureStat is a true culture test, tion materials are not required. n
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UROLOGY
Safeguarding the nation’s urologic health American Urological Association President Anton Bueschen explains the importance of welltrained urologists for the health of the American people.
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rology is both a surgical and medical specialty, as Bueschen explains: “All urologists are trained to do operations on the genito-urinary system, and that includes the kidneys, ureter, bladder, prostate and the male external genitalia. We are involved with urinary tract infections and with different diseases of the kidney that are related to surgical treatments, such as cancer and kidney stones and surgical correction of genital anomalies. Nephrologists, internal medicine specialists, treat non-surgical diseases of the kidney. “We treat everything that is related to the bladder, the prostate and the testes; cancer and other diseases of the male genitalia are also an important part of urology. Kidney stones, male infertility and kidney transplantation are also problems managed by urologists. Pediatric urologists manage congenital anomalies of the genito-urinary system since they often present during childhood.” Urologists receive several years of additional education after graduation from medical school. Bueschen explains that education programs vary by country, but in the United States a residency program is five or six years, with the first year (or sometimes two years) being a general surgery residency, followed by four years of urology. Bueschen points out that there is a residency review committee that in the past 20 or 30 years has helped to improve the standardization and the quality of the education of urology residents. The committee has standardized the more than 100 residency programs in the United States, which Bueschen feels has improved the quality of education for urologists. “Many urologists receive fellowship training of one to three years following completion of a residency,” Bueschen continues. “This could be a fellowship in cancer of the urinary tract, pediatric urology, or urinary incontinence. Those are the three most common ones, but there are other fellowships also in urolithiasis, and now people are taking additional educational training in laparoscopy, which is a new technology for performing urologic operations.”
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The AUA recently announced a collaboration with the Urological Society of India, although Bueschen explains that this is actually just the formalizing of an existing relationship. “About three years ago, we developed a collaboration with four countries: India, China, Brazil and Japan. Recently, though, we developed a more formal relationship with the Urological Society of India confirmed in a written document during the AUA annual meeting in Chicago. “We are continuing to work on the development of educational programs with the Urological Society of India. These programs include providing speakers for their annual meeting, providing a postgraduate course and helping them with the standardization of their residency training programs. We have an exchange program in which two residents a year come to the United States and attend our annual meeting and visit universities in the United States, and two residents a year from the United States are chosen and awarded the opportunity to go to India.”
“Urinary tract infections are such a common problem that they account for more than eight million doctor visits per year in the United States”
AUA publications The AUA publishes a peer-reviewed monthly journal called the Journal of Urology in which urologists compete to have their articles published. Fifty percent of the articles are from authors from countries other than the United States. Forty didactic papers written by those with specialist knowledge in their areas are published each year as AUA Updates, and are used as a teaching tool by most residency programs in the United States. The association also has a monthly newspaper, the AUA News, which gives updates on what is happening in the AUA, as well as scientific summaries and other timely information for members.
der function. Patients with urinary tract infections and abnormalities, such as a neurogenic bladder or congenital anomalies, are more likely to develop kidney stones and more likely to have damage to their kidneys. “Urologists prevent and manage urinary tract infections in younger people. We are not as actively involved with the geriatric population; geriatricians and internists and family practitioners are mostly the ones managing that age group. Anthony Schaeffer, who is the Chair of Research of the AUA, has carried out most of his research studying urinary tract infections. It’s such a common problem that it’s alleged to account for more than eight million doctor visits per year in the United States.”
Infection control One area of interest to the general public within the urinary system is urinary tract infections. As Bueschen explains, they are very common, and urologists are very much involved with their care. “Children have urinary tract infections fairly commonly, often associated with various urologic diseases such as vesicoureteral reflux. We see urinary tract infections in the geriatric population, with a very high prevalence among that group. We also see them in patients with spinal cord injuries who have abnormal blad-
Evaluation The AUA is supporting a bill introduced in May by Rep. Kurt Schrader (D-OH), along with 11 co-sponsors, known as HR 2502, ‘The Comparative Effectiveness Research Act of 2009.’ The legislation would establish a private, non-profit organization, the Health Care Comparative Effectiveness Research Institute, to conduct research evaluating and comparing the implications and outcomes of two or more healthcare therapies in treating a
American Urological Association In February 1902, a group of eight New York Genito-Urinary Society members met and formed the American Urological Association (AUA). In its 107 years of existence, the AUA has grown to more than 16,000 members worldwide and supports its members through the promotion of the highest standards of urologic care, emphasis on education and research and the formulation of healthcare policy. The association concentrated on education for the first 50 years of its existence, but in the last few decades it has become involved with health policy in two ways: to educate its members about the health policy of the government and through frequent communication with federal legislators in both the House of Representatives
and the Senate. The AUA is also active in research and patient advocacy. The AUA offers many different forums for education, including its annual meeting, which is attended by about 16,000 people, about 10,000 of whom are urologists. The meeting is always held in the United States or occasionally in Canada, but about 50 percent of the physicians attending are from other parts of the world, including Europe, Asia and South America. In addition to the annual meeting, there are also eight geographic sections within the AUA that hold their own yearly meetings on a smaller scale, providing further educational opportunities for members.
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What is urology? Urology is a surgical specialty that deals with diseases of the male and female urinary tract and the male reproductive organs. Although urology is classified as a surgical specialty, a knowledge of internal medicine, pediatrics, gynecology and other specialties is required by the urologist because of the wide variety of clinical problems encountered. In recognition of the wide scope of urology, the American Urological Association has identified seven subspecialty areas:
A microscopic view of a glandular portion of the prostate gland of a young human particular medical condition. The institute would not conduct the research itself, but research projects will be contracted to federal and private entities. When asked why the AUA is supporting the bill, Bueschen replies that the association feels that comparing the effectiveness of different treatment methods is something that requires serious attention. “The reason we’re supporting it is because it is involved with an independent board that includes both healthcare people and leaders of healthcare in the public arena, including the Secretary of Health and Human Services, the Director of Health Care Research and Quality and the Director of our National Institutes of Health, and it also has 18 other members from both the public and private sectors, including physicians. “The whole idea is that there will be studies to evaluate the outcomes of different treatment options, and we feel this is very important. Consequently, guidelines will be developed to determine who will be treated and when they will be treated based on quality evaluation of the evidence concerning various conditions, so that we can determine how to prevent, diagnose, treat and manage problems. This is a step in the right direction rather than having an insurance company or the federal government decide how they should be treated. This is going to be an opportunity to objectively assess the outcomes of treatment so that it can be decided what is best for the patient. “For example, in prostate cancer, an area that we treat commonly, there are different treatment options, including different types of surgical options and different types of radiation therapy options for the treatment of localized prostate cancer. There have been no comparative studies to decide who should get what under what condition. We think we might know, but there’s really not good objective evidence. We’re hoping that this act will enable that evidence to be forthcoming so that we can improve the quality of care of all the patients. “It gives us an opportunity to have objective evidence rather than making decisions based on subjective assessments of situations. That is why many specialties in addition to urology are supporting this bill.”
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• • • • • • •
Pediatric urology Urologic oncology (cancer) Renal transplantation Male infertility Calculi (urinary tract stones) Female urology Neurourology
Historically, the subject that established the specialty of urology as being distinct from general surgery was the treatment of obstructive uropathy. This treatment ranges from the correction of obstructing posterior urethral valves or ureteropelvic junction obstruction in the infant to the correction of bladder outlet obstruction from benign prostatic hyperplasia in the older male. Through the decades, we have witnessed a tremendous increase in our general understanding of the diverse functional disorders of urine transport associated with various overt and covert forms of neuromuscular dysfunction. The rapidly evolving discipline of urodynamics has established itself as a major resource in the diagnosis and therapy of such disturbances. Source: www.auanet.org
Bueschen points out that the area of urology has developed rapidly in the past 40 years. “There are new methods of evaluating and treating patients, new imaging techniques and surgical techniques, including shock wave lithotripsy for kidney stones and the robot for treatment of prostate cancer. Robotic techniques are new and indications are evolving as outcomes are evaluated. “Urologists are very interested in improving technology. As new treatments and new medicines evolve, this will direct urologists into the future. Urologists are a group of physicians who have an open mind about doing what’s best for the patients, and as new technologies and medicines promise better outcomes, we will be active participants in delivering these methods of treatment to our patients.” Anton J. Bueschen is President of the American Urological Association.
PAIN MANAGEMENT
Everybody hurts sometimes EHM asks James Rathmell of Massachusetts General Hospital about the true nature of pain. What are the latest technologies being used at the center to diagnose pain and determine a patient’s care needs? James Rathmell. Diagnostic testing is directed at the suspected underlying cause, and all modern diagnostic modalities are used when appropriate. Among the more common diagnostic tests is magnetic resonance imaging, which can be very helpful in determining structural causes for acute and chronic low back pain. Electrodiagnostic testing (electromyography/peripheral nerve conduction testing) can also be very useful in evaluating patients with suspected nerve injury. Finally, some tests remain experimental, but are emerging as useful tests; for example, skin biopsy looking at changes in small nerve fiber density may be useful in diagnosing some neuropathies. We also use ‘diagnostic injections’ – placing local anesthetic on or near a structure we think is causing pain and seeing if this relieves the pain. However, there is a big problem with placebo response in using diagnostic nerve blocks, so the response must be carefully coordinated with the rest of the clinical picture when making decisions about treatment.
Chronic pain is sometimes defined as a disease, not a symptom. Can you explain the reasoning behind this definition? JR. We now know that there are changes in the structure and connections within the nerves that carry pain signals that occur when a patient suffers from a painful injury. In some cases, it seems that these changes in the nervous system are not reversible. Thus, when pain becomes chronic – persisting more than six months – many experts now argue that it is more like a disease than a symptom: a disease of the nervous system. What interventional treatments are used to ease or eliminate pain? JR. There are many and they have very specific uses. Among the most common is the epidural steroid injection, which has been shown to speed the resolution of leg pain (sciatica) associated with intervertebral disc herniations (slipped discs). There are many others, but two of the more advanced therapies that can be useful in patients with severe and ongoing pain included spinal cord stimulation and intrathecal drug delivery. Some patients with chronic low back or leg pain, even those with
ongoing pain after surgery, can benefit from spinal cord stimulation, a treatment where a small electrode is placed over the spinal cord and a very pleasant sensation is placed to overlap the painful region. The therapy can be ongoing through the use of a pacemaker-sized battery to provide the ongoing electrical stimulation. Intrathecal drug delivery involves implanting a small programmable pump that delivers pain medication directly in to the spinal fluid surrounding the lower spinal cord, where the medicine can act directly at the spinal cord level without producing systemic side effects like sedation. This is most useful in patients with severe pain associated with cancer that cannot be controlled by other means.
“When pain becomes chronic – persisting more than six months – many experts now argue that it is more like a disease than a symptom” What teaching skills are used to help patients understand and cope with pain easier? JR. Many, and not my expertise. Specific exercise regimens can be very beneficial. Cognitive behavioral therapy is a structured means that psychologists use to help patients understand the stressors that exacerbate their pain and develop strategies to cope and/or avoid these stressors. What will be the effects of President Obama’s focus on preventative healthcare for pain management? JR. We hope that it will stimulate better clinical research as well as basic science research. I can assure you that our research group here at MGH has been very active in submitting new research proposals that aim to examine everything from the genetic basis of pain to new pain therapies. n James Rathmell is Director of the Massachusetts General Hospital Center for Pain Medicine.
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Ambulatory care
What do you do when you have a sudden medical problem that isn’t serious enough to warrant a trip to Emergency, but can’t wait until you can get in to see your general practitioner? The answer is ambulatory urgent care, according to Bill Wenmark.
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ou have a pain in your shoulder, or a little trouble breathing, or you’re a bit dizzy. What do you do? Head to the overcrowded hospital emergency department? Wait a couple of weeks to get an appointment with your equally busy GP? Neither, says Bill Wenmark. His answer is ambulatory urgent care. “Some people have routine everyday little medical issues that come up that don’t need to be institutionalized or put on hold to make an appointment with your primary care doctor to see you in three or four weeks. We use the term “prudent layperson,” someone who is not a professional but in their own judgment has a level of identification of a certain medical issue that they happen to be affected by. “And what they would normally be relegated to is trying to make an appointment to get in, or going to the emergency room, which is the inappropriate place. Urgent care and convenience medicine have both
provided now opportunities for those people that have these minor issues and need to get seen by a medical practitioner.” Wenmark, who is President of the National Association for Ambulatory Urgent Care, explains that the notion of ambulatory urgent was originally invented in the early 1970s by doctors who noticed the disparity between these minor healthcare needs and the availability of a convenient option for treatment. “There was a beginning effort back then by doctors who realized that the typical type of delivery system that we had, which was largely built around primary care physicians and specialty care physicians and hospitals and public health, while it served most people who had diseases that needed to be managed, did not address these routine little medical problems,” Wenmark points out. “These doctors said, ‘I’m going to go ahead independently and make a difference in the public health delivery system.’ They decided to open
Treating the walking
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up their offices and provide an opportunity for people to walk in and see a physician. They treated it as a consumer service, just like you can walk in and buy groceries any time you would like or walk in and get your hair cut any time you like. “This can also help reduce the costs of medical care, because we’re able to catch things that might otherwise have been postponed by that same prudent layperson and developed into much more serious problems. We’ve been able to pick up things like lung tumors and early strokes and intervene earlier because of urgent care being what it is. It is the ability for the consumer to access a public health delivery system without the complications either by time and sequence or by money, because it’s the most affordable place you can go. You can pay for this out of your pocket. You don’t need insurance to go to an urgent care center. If you have it, that’s great, but it’s designed to be something you can afford. That access is what I call public health.”
Working as partners
Wenmark explains that there are three organizations in the United States that deal with the general concepts of urgent care and convenience medicine: NAFAC, the Urgent Care Association of America (UCAOA) and the American Academy of Urgent Care Medicine (AAUCM).
wounded
“UCAOA carries out more of the business-related activities – products, services, lab equipment, EMR record systems that they own and group purchasing options,” Wenmark says. “All of those things are very important if you’re going to be a business owner in any general sense. And then AAUCM is Franz Ritucci, who has been working almost his entire life as a physician to try to get urgent care recognized in board certification and also develop a residency program to develop the skills necessary to work in an urgent care center. “The doctors you see practicing in an urgent care center now will usually be board-certified family practitioners or a board-certified emergency room physicians. What Franz has been working on for years is to try to develop that recognition of board certification for urgent care, and also develop a residency, university-based program for the specialty training of urgent care. His organization is looking at the clinical, educational, curriculum, academic kinds of urgent care-associated types of things. “And he’s done a really good job. He got the American Medical Association to identify a UCM or Urgent Care Medicine as a self-designated practice specialty, which was very, very good. CMS, our Medicare organization in the government, still doesn’t recognize urgent care per se, but it does have a point of service code that does identify that the service would be given at an urgent care center.”
Community health
In Wenmark’s view, urgent care centers have allowed deeper penetration into communities with public health delivery systems where they’re less costly to build. He points out that it doesn’t cost as much to put a nurse practitioner in a retail grocery store, as it would to build an emergency room or to build a hospital. “The development of urgent care and convenience medicine is an effort to get public health deeper and deeper into the communities where they really need it,” Wenmark continues. “This allows us to postpone the inappropriate use of the more costly structural medicine or healthcare that we have built into our system. Some people like to build these big buildings that they can worship, but that doesn’t do much for the public health of the person there in the community. “Urgent care is available seven days a week, on average 13 hours a day, on average 365 days a year. You can walk in without an appointment. The physicians and the staff are waiting to see you. And then we exercise what’s called triage. In an urgent care center we don’t know how many people are going to be coming in, whereas with primary care, as an example, you already know who’s coming because you made that appointment. You’ve also had the chance to review that medical record of that person who made that appointment. “In chronic care, you need to pay attention to medical management, disease management, the individual patient. You need to spend a little bit more time with them in the sense of managing that medical problem. Whereas that is not what urgent care does. We do not take care of hypertension, diabetes, cancer. We believe a primary care physician or a specialist should be doing the longitudinal care for that.” The ‘urgent’ part of ambulatory urgent care means that anyone could turn up on the spur of the moment. How you deal with that? Wenmark explains that many urgent care physicians started their careers in hospi-
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in with chest pain, or they’re coming in with a broken bone, they don’t expect that to be treated in 10 minutes. “They’re going to give you time, because they don’t want you to rush through their laceration or fracture or chest pain. So they give you an allocation of time. On the flip side of that, if Mom comes in with her little son who has 104 degree temperature and an earache, she’s been through that before. She knows that what she needs is liquid amoxicillin. She’s been there, done that before.”
Customers first
tal emergency departments, which means they have a background in a variety of cases as they come along. “You obviously also learn that by your training,” he says. “You make sure that your staff and your policies and your procedures are as efficient as possible. For instance, as an example, the first interface the patient might have when they walk into the clinic is the receptionist – who needs to be trained in her own or his own level of triage. If you see that the patient is bleeding, you don’t hand them a handful of paperwork to fill out. You say, ‘Come on in; we’ll take care of that.’ “You put them into the procedure room because you know that’s where it’s going to go. The nurse who’s dealing with that floor’s resources and people immediately diverts attention to that particular patient. Because each patient who arrives in the clinic has a perceived notion of how long it is going to take based on their ‘prudent lay’ understanding of what’s going on. For instance, if they’re coming in bleeding, or they’re coming
For Wenmark, the most important thing in urgent care is the consumer interface: the ability to understand and communicate to someone who is interested in being a partner with the physician. He says that the physicians in urgent care who are successful are great communicators. They help people get through those difficult situations, and they’re very informative in terms of communication. He stresses again that urgent care is a retail and customer-oriented experience. “You’re purchasing this. Well, when you’re a purchaser, you’re looking for value, and that’s what really you want to provide as a physician in charge of or in the delivery pathway of doing urgent care/convenience medicine – you want to deliver quality. “When we look at it in a higher goal, silo kind of way, that’s where medicine has gone wrong. You can talk to many people who are disillusioned by going into these huge, empirically designed organizations that are very impersonal, and very cold. People are trained to be more robots in terms of process instead of customer relations. Although, then, on the flip side of that, look at those facilities that have seen the importance of that consumer interface and that consumer satisfaction. “When you have a government provided healthcare system, then that’s when you see it being indifferent. You get the impression the staff are thinking, “Oh, this is my job. I don’t really like my job.” And that impression comes off to the consumer. When you’re in the retail and competitive marketplace, then those other values come through, and that’s what’s happening now in the US.” According to Wenmark, there are currently about 12,700 urgent care centers across the country, including ‘fast lanes,’ delivery systems next to emergency departments, occupational medicine facilities and fully fledged urgent care centers with radiology departments, laboratories and doctors.
“The development of urgent care and convenience medicine is an effort to get public health deeper and deeper into the communities where they really need it”
Certification
In order to help urgent care providers become even more knowledgeable about their work, NAFAC runs the National Urgent Care Practice Center certification program. “The certification is a process that I commissioned about 15 years ago,” Wenmark says. “We looked at it from an absolute detailed letter by letter point of view of every possible thing that you could possibly have in an urgent care center. We identified each of those into different categories,
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and developed the matrix and the examination as a selfexamination tool. “We took a broad brush of a lot of people in the country and developed the NAFAC Certification Program. We also wanted to recognize the fact that we’re not certifying a hospital or a multi-million dollar facility. We’re certifying an urgent care center. By its nature, you want to help it keep costs affordable for the consumer to purchase this public health service. It’s not Cadillac service; it’s really just good fundamental medical care. “We don’t send people out to your center to go and walk through like the Joint Commission does, or the Accreditation Association for Ambulatory Care. We don’t go out there and walk in and actually certify you. We decided that we would do a self-audit: when a center applies we send them out two documents: a center copy and an audit copy. They’re then required to go through and legally audit all of the basic elements of the certification. It takes about three people two weeks minimum to go through their entire center to do a certification. “Once they’re done with that they have it legally notarized that they in fact did that – again, that’s their declaration, i.e. liability is specifically fi rst person. You’re telling us that you did do all of these things. It
National association for ambulatory Urgent care Founded in 1973, NAFAC is an organization that helps its members open new clinics and thrive in the changing world of ambulatory healthcare. the association has more than 500 members from 46 states around the country, representing approximately 1700 clinics. members are predominantly physicians and clinic operators from a range of healthcare provider organizations, including large healthcare systems like Catholic Healthcare West in San Francisco, Deaconess Health System in Indiana or Carolinas Healthcare System in Charlotte; ambulatory surgery centers like Glasgow medical Center in Newark, DE; multi-location urgent care practices like PrimaCare in Dallas; and single office urgent care and primary care practices all over the country. the association publishes Bill’s Book: Developing Urgent Care Centers, and is scheduling regional one-day programs dealing with topics ranging from clinical standards and accreditation, to threats and opportunities facing member practices, to back-office procedures for streamlining administration. NAFAC also lobbies on behalf of members, most recently around a payment concept known as ‘problem-based coding.’
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comes back into our office, we review it, we look at it. We may call you on a few things just to double check and make sure that you actually did these things. And then we provide a certification for three years. Once that’s done, that’s recognized by United Healthcare Corporation as a credentialing for third party reimbursement by insurance companies.” Another important tool that NAFAC produces for the owners of urgent care centers is Bill’s Book, a 300-page compilation containing materials supplemental to Bill Wenmark’s annual NAFAC conference seminar for new owners who plan to open an urgent care center, as well as veterans who are looking for ways to improve their practice. “We have all these people out there that may want to get into urgent care – why shouldn’t we give them a guidebook of how to do it, based on all the things we did wrong?” Wenmark says. “They shouldn’t have to go through it and repeat all the mistakes we made, which obviously increases the costs of creating urgent care. I thought, ‘How can I help people get started in urgent care? Bill’s Book is is a three-ring binder of what you would need to do to develop everything from the business model to internal paperwork to files, cabinets – everything. That’s what’s in Bill’s Book. We send that out to people as a helpful guide to say, ‘Here are the things that you’ve got to be thinking about, that they may or may not have even thought about when they said, ‘I’d like to get into urgent care.’ Maybe it’s that emergency department doc who has been 20 years in their career and now they’re burned out.
“But they’ve got plenty of life left in their medicine, and plenty of life left in wanting to do things, and they want to open up an urgent care center. What do they know about business? Bill’s Book will help them a great deal of knowing about the business of urgent care, not just the medical practice of urgent care.”
Looking ahead
While Wenmark decries President Obama’s plans to bring the US healthcare system under more government control, he does admit they may indirectly prove an advantage to urgent care centers. “Unless urgent care is outlawed – and I wouldn’t put it past Obama to do that –I see tremendous opportunities for express care and for urgent care in the United States. “Right now, 20 percent of our people drive the majority of the cost of our healthcare system. They’re the people who have diabetes, hypertension, cardiac disease. The other 80 percent have routine medical needs that they want taken care of, and these people are going be frustrated because the primary care doctors are now going to be government employees. Urgent care and convenience medicine will see a boom, because people are literally going to be looking for places where they see and talk to a doctor.” n William Wenmark is President of the National Association for Ambulatory Urgent Care (NAFAC).
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ASK THE EXPERT
Ensuring safe infusion therapy Petra Scholl presents her concerns and experience in providing safe and effective infusion therapy for her patients. What do you do when unable to get an adequate blood return from an implanted port? Petra Scholl. The first intervention is to check the needle position, possibly re-accessing the port. Often it is necessary to reposition the patient to free a pinched catheter or dislodge the tip of the catheter from the vessel wall. The catheter is assumed to have a partial occlusion if it flushes slowly and we can obtain blood return slowly; a total occlusion if we cannot flush or withdraw; or a withdrawal occlusion if we are able to flush and not aspirate blood. Tissue plasminogen activator (tPA) is used to attempt to dissolve the occlusion. This may take as little as 30 minutes, or as long as overnight. If there still is no blood return, a dye study is scheduled to evaluate the problem. How does the patient react to this? PS. The patient and family are often very stressed. The delay in chemotherapy treatment can frighten them. They will have to have additional appointments, which can cause problems with transportation or additional time off from work. It takes a lot of nursing time to deal with the emotional issues. It also impacts scheduling and may cause other patients to have to wait for their treatment.
Petra Scholl, RN, OCN has practiced as an oncology nurse for over 25 years. She is currently working in an oncology infusion center in the Pacific Northwest. Questions or comments may be addressed to Scholl at Petra@wamail.net.
What have you done to resolve these blood draw issues? PS. Good patient and family education, and preparing the patient for these possibilities seemed the only way to go until our practice was introduced to PASV Valve Technology from Navilyst Medical. The PASV valve is located in the stem of the port, out of the bloodstream. It is closed when not in use, and opens with the pressure of infusion. When the pressure stops, the valve closes. It is designed to prevent reflux of blood into the catheter during intra-thoracic pressure increases due to coughing or vomiting. Blood reflux also occurs when the needle is pulled out of a non-valved port. This of course can lead to clots in the catheter tip. The valve is also designed to prevent blood reflux when a patient stands up while receiving an infusion. When the level of a non-valved implanted port is higher than the infusion bag, blood can back up into the tubing and into the medication. A port with PASV Technology reduces this risk especially for home infusion patients who are infusing their medications without a pump. Why did you decide to use PASV Technology in your practice? PS. Just by observing the port demonstration itself, I recognized advantages
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of this. Several studies showed its effectiveness compared to a non-valved product.4,5 Baylor University (Carlo, et al., 2004; Lamont, et al., 2003) conducted studies that included nursing time spent, x-rays and the use of tPA and demonstrated significant differences between PASV and non-valved ports. Similar results were shown in a study at Vanderbilt University in their PICC service (Burns, 2005).6 I could see the significant impact this would have on my practice. We were looking at a 50 percent reduction in unproductive chair time. Has the use of PASV Technology impacted your practice? PS. My institution has been using the PASV valve port for over five years now. We had used the port for about six months when I decided to count the number of port declotting incidents. From January 2004 to October 2004, a total of 60 ports were in use for chemotherapy administration, 22 valved and 38 non-valved ports. During that time, we declotted 16 ports once or multiple times. Of these, 15 were non-valved (39.5 percent), and one was valved (4.5 percent). I counted only per port, not per incident. Between May and October 2006, we used 50 percent more tPA on non-valved ports compared to ports with PASV technology.
What does this mean for the patient? PS. At our institution, we have decreased our tPA usage by 50 percent. This has translated for the patient into less time in the clinic, a decrease in stress and anxiety, and ultimately increased quality of life. n PASV is a trademark of Navilyst Medical. The above expresses the opinions of the author and may not be representative or predictive of other clinical experiences. References and Further Reading 1. Kutar D. Thrombotic Complications of Central Venous Catheters in Cancer Patients. The Oncologist. 2004;(9):207-216. 2. Moureau N, Poole S, Murdock MA, Gray SM, Semba CP. Central Venous Catheters in Home Infusion Care: Outcomes Analysis in 50,470 Patients. J Vasc Interv Radiol. 2002;13(10):1009-1016. 3. Kreis H, Loehberg CR, Lux MP, Ackermann S, Lang W, Beckmann MW, et al. Patients’ Attitudes to Totally Implantable Venous Access Port Systems for Gynecological or Breast Malignancies. Eur J Surg Oncol. 2006. 4. Carlo JT, Lamont JP, McCarty TM, Livingston S, Kuhn JA. A Prospective Randomized Trial Demonstrating Valved Implantable Ports Have Fewer Complications and Lower Overall Cost than Non-valved Implantable Ports. Am J Surg. 2004;188(6):722-727. 5. Lamont JP, McCarty TM, Stephens JS, Smith BA, Carlo J, Livingston S, et al. A Randomized Trial of Valved vs Non-valved Implantable Ports for Vascular Access. Proc (Bayl Univ Med Cent). 2003;16(4):384-387. 6. Burns D. The Vanderbilt PICC Service: Program, Procedural and Patient Outcomes Successes. J Assoc Vasc Access. Winter 2005;10(4).
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Vascular access
In the right vein The use of vascular access devices is an important component in the treatment of chronic disease. But they can sometimes cause problems if not handled correctly, as Sheryl McDiarmid tells EHM.
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s the treatment for chronic illnesses has improved and patients are living longer, new issues have arisen surrounding the tracking and removal of vascular access devices, as Sheryl McDiarmid explains, “Where it used to be that these vascular access devices were only used because the life expectance of patients was much shorter, now you can expect to deliver therapy even though it’s not curative. Palliative therapy is delivered for a long time through these access devices.” McDiarmid, who is an Advanced Practice Nurse in the Corporate Vascular Access Program at the Ottawa Hospital, points out that it is important to take this longer timescale into account from the very beginning. “Sometimes I think we start too early on inserting central devices. People who have very good peripheral veins can receive certain therapies peripherally before we get into central devices, or other lines called midline catheters, where they’re inserted and they remain in the upper arm. “For certain kinds of therapies – pain analgesias, certain antibiotics and fluids – we can use those kinds of devices without the risk of central vein thrombosis, which is one of the acute complications of having a central vascular access device. “The most common reason for us not using peripheral vascular access as our first step is that the expertise in insertion of peripheral vascular access devices is diminishing. The literature says that for every
time you need an intervenous started in the hospital it takes an average of 3.2 attempts to have that started. No wonder patients and nurses quickly defer to another device that can be just there and can be used to give you all the treatment you need without having those 3.2 attempts.” “Another problem is that most hospitals do not have well-managed vascular access programs where you have a broad range of devices under one central area,” McDiarmid continues. “We are probably one of the first institutions to have the ability to triage patients for the appropriate device. Our Corporate Vascular Access Program receives all the consults for devices, and then we can look at matching the patient needs with the devices that we have.” McDiarmid points to peripherally inserted central catheters as being useful devices. “They are easily inserted at the bedside. At our institution specially trained nurses put them in using ultrasound technology and a modified Seldinger technique that minimizes the complication rate. They are pretty robust lines and although they were originally intended to be used in the short term, we see them in place now for upwards of a year. “The downside is that they do interfere with your quality of life because when you have this device and the end sticks out of your arm, you’re really limited to what you can do. But in the early 2000s, we inserted almost all peripherally inserted central catheters as our central vascular access device.”
“There’s no mechanism in the system to alert you that you have a patient who has an access device that is not being used”
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Priorities
chance that I would be cured and only a 10 percent chance that the disIn McDiarmid’s view, one of the problems is that many medical proease would return, so I’m going to focus on what if it comes back?’ They fessionals don’t prioritize what the catheter is being used for, and they think if they have the device, they won’t have to worry when it comes tend to be used not only for the delivery of life-saving treatments such as back because they can get treatment right away, rather than recognizchemotherapy or transfusions or antibiotics. They are also used to give ing that the device is there to deliver the treatment and then should be treatments that could be given peripherally. This then decreases the life removed afterward. span of central vascular access devices, and when they are needed for the “Whenever you take the risk when there is no benefit, that’s what I delivery of life-saving therapies they don’t function properly. think is a misunderstanding on the patient’s part and is often not that well “Another option is to use tunneled cathunderstood by the care provider. There’s no eters,” McDiarmid continues. “These are placed mechanism in the system to alert you that either by surgeons or interventional radioloyou have a patient out there who has an gists and are tunneled under the skin. There is access device that is not being used.” a wide variety of these catheters available, inMcDiarmid explains that the majorcluding those impregnated with antimicrobial ity of central access devices are inserted in substances. larger, tertiary care centers. Because of their “We tend to use these tunneled devices, size, these centers often do a poor job of folHickman catheters or Broviac catheters, in lowing up on patients with central vascular acute leukemia patients, and patients who are access devices. They are inserted, and then receiving total parenteral nutrition, because the patients go back into the community and complication rate of the device is very low. The are forgotten. McDiarmid argues that as a last type of device we have experience with is the patient is finished with their treatment, the subcutaneous port. These devices are good for device should be removed.” intermittent therapies, because they are buried In order to remedy this situation, three underneath the skin and they have a low risk of years ago McDiarmid proposed a business infectious complications. But they do have to be case to the Ottawa Hospital for a centrally accessed with a needle every time, and for some managed Corporate Vascular Access Propatients the reason they have a device is because gram. All patient referrals now come they do not want to have needles. directly through that program, so that the “What we’re finding for these devices is that team has an idea of how many patients are once the patient had one in place, and has finout there with vascular access devices. The ished their three week chemotherapy, they don’t program has its own database where it is understand the risk benefit of having a central monitoring outcomes, and the team knows Sheryl McDiarmid is an Advanced device, and so they don’t have them removed, when patients have devices inserted. They Practice Nurse in the Corporate Vascular and they use them for things like having blood also set up mechanisms for contacting paAccess Program at The Ottawa Hospital work drawn.” tients, even when they’re out of hospital. in Ottawa, Ontario, Canada. She is McDiarmid gives the example of a case in McDiarmid believes that in the future, scheduled to give a presentation entitled, which a patient who had a Port-A-Cath put in in more institutions will adopt a central ap‘Vascular Access Options for Chronically 2004 for chemotherapy, and then afterwards she proach for keeping track of vascular access Ill Patients’, at the 23rd Annual Scientific decided to keep the device in place just in case devices. “I’ve seen how successful it has Meeting of the Association for Vascular something happened. She then had five diseasebeen in dialysis,” she says. “With dialysis Access in September. free years, until recently she developed a stenosis you do have a significant number of paaround the device, which is narrowing the blood tients being dialyzed and they are able to vessel, and a thrombosis. So now she has the complications of the device track all of their devices and they know where patients are. without having the benefits of the device for the last five years. “In our program we will soon start putting online our recommendaWhen asked whether such a decision should be left up to the patient, tions for vascular access devices. This will mean that when any patient McDiarmid says that from the point of view of medical professionals, comes in to our institution they can see our note on why we recommendonce the treatment is delivered the device is not seen as a risk. Patients ed what we did and what would our next recommendation be when those get them removed when they interfere with their ability to do their daily patients come in? And then they know that they can contact us. living activities. “We also provide a service where if they do just need an intravenous
Complications
“Otherwise if the device is there and it’s buried under the skin in your chest and you think, ‘The doctors did say there was a 90 percent
started we will start that, and then we’ll monitor that patient to see, okay, is this device adequate? As opposed to what happens whenever there is no overall structure in place to monitor patients – you get a device and unless there’s a problem you’re not monitored.” n
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INDUSTRY INSIGHT
Connection without infection Marshall Kerr examines the growing concern around hospital-acquired infections.
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ascular catheter infections are one of the most serious healthcare-associated infections worldwide. Despite historic efforts to prevent and treat these infections, the incidence, morbidity and mortality, and associated costs continue to rise to a level of intolerance by consumers, government agencies and payors. The current demand for improvement is compelling and the healthcare system is eager to acquire new and smart technologies to eliminate this risk. Catheter-related bloodstream infection begins with colonization of either the extraluminal and/or the intraluminal surface of the catheter. Prevention strategies for the reduction of extraluminal colonization center
“PFM Medical utilizes science and research to develop innovative and effective solutions” around skin antisepsis. Disinfection of access sites, including needleless connectors, injection ports and the internal surface of catheter hubs and stopcocks is a critical strategy for prevention of intraluminal colonization. The Joint Commission’s 2009 National Patient Safety Goals (http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals) require the use of injection site and hub disinfection protocols before accessing vascular catheters but do not designate a methodology for the procedure, such as antimicrobial agent, agent concentration and time or method of application. The 2008 SHEA/IDSA Catheter-Related Bloodstream Infection prevention strategies (Marschall J et. al., ICHE., 2008; 29, supp.1:S22) also include disinfection of injection sites, needleless connectors and catheter
hubs. The recommendation plete turns (as observed by designates use of an alcoholic visualization of an indicator chlorhexidine (CHG) prepabar on the external housration or 70 percent IPA as ing) over 10 seconds. When the agents of choice, but again the Site-Scrub is used on lacks methodology. catheter hubs or any female Currently the 70 percent luer, the unique design of the isopropyl alcohol (IPA) prep multi-sectioned foam conpad is mostly used for connecfiguration allows the foam tor and injection site disinfecsections to be positioned Marshall Kerr is President and tion, but with highly variable within the lumen and to CEO of PFM Medical, Inc. His results. The prep pad device, scrub the lumenal surface of career in the healthcare industry spans over 30 years with a broad designed for skin antisepsis, the hub. It is this unmatched range of experience in sales, is a questionable method for feature that sets the Sitedistribution and R&D. access site disinfection because Scrub apart from all other of the variety of connector condisinfection devices and figurations, lack of established methodology for meets all the requirements and recommenapplication, inconsistent application technique dations for access site and hub disinfection among clinicians, touch contamination with with one device. use, the application time required, and notably Site-Scrub is representative of PFM Medthe inability to clean internal hub surfaces of ical’s focus on safety and device disinfection catheters or stopcocks. as well as the company’s overall approach to Colonization of the internal surface of bringing products to market. With the abilthe hub of the catheter and stopcocks is a ity to first identify and understand problems major risk factor for bloodstream infection that exist in the healthcare system, PFM in both short-term and long-term venous and Medical then utilizes science and research arterial catheters. While this is recognized, to develop innovative and effective solutions. procedures for disinfection of catheter hubs PFM Medical, Inc. was established in 2000 and stopcocks have not been established, as and is a subsidiary of the German company there is no technology available to safely or pfm Produkte für die Medizin AG, which was effectively accomplish disinfection of the infounded in 1971 and has been one of the leadternal surfaces of these devices. ing German marketing and sales specialists PFM Medical has met the challenge with for medical technology products. a device specifically designed to address these The PFM Medical family has offices and issues. The Site-Scrub is constructed of a manufacturing facilities worldwide that are housing containing multi-sectioned polyprocertified to ISO 13485 standards. PFM Medipylene foam brushes. The foam is saturated cal, Inc. is based out of Southern California with a five percent chlorhexidine and 70 perand serves as headquarters for North and cent isopropyl alcohol solution that, along South American marketing, manufacturing with the mechanical scrubbing, minimizes and distribution activities. Through ongoing the agent contact and procedural time to 10 emphasis and efforts in R&D, PFM Medical is seconds. committed to developing and manufacturing The Site-Scrub is positioned onto the new and exciting products and unique soluneedleless connector, injection port or tions that will positively impact the healthfemale luer hub and rotated for eight comcare market. n
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HOSPITAL DESIGN
Back to the drawing board Ray Pentecost outlines the difficulties inherent in hospital design, and explains why their architects keep coming back for more.
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o one can deny that hospitals are incredibly complex and need to comprise a wide range of functions, so it would seem to follow that input from many different specialists would be required in the design and planning stages. Ray Pentecost, Chair of the American Institute of Architects’ Academy of Architecture for Health, says this complexity shouldn’t necessarily be seen as a negative – rather, it is the reason healthcare architects are drawn to the specialty in the first place. “It’s a problem-solving issue of the highest order,” he explains. “The great complexity, and the challenge of that, is what keeps us
coming back time after time. I would add that it is common to find clients on the medical or healthcare side who tell stories about how they almost became architects. And there are almost as many stories of architects who almost became physicians. “I ended up becoming a doctor of public health, but many of us were drawn to the medical field and realized that healthcare architecture was a way to blend our two interests. What helps establish the healthcare architecture specialty is the fact that healthcare architects spend as much – or possibly more – time in the medical literature as they do in the architecture literature. It requires that we develop some measure of facility
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“For the healthcare architect, it is a life with one foot in each of two worlds. And living between the two is fun”
with another whole language, learning about the technology and the procedures. For the healthcare architect, it is a life with one foot in each of two worlds. And living between the two is fun.” Designing a hospital also poses some interesting challenges when compared to designing another type of building, such as an office building. “There are two immediate challenges that come to mind,” Pentecost says. “I used to teach this healthcare design in a school of architecture. One of the questions that I used to ask an audience is, when you design a hospital, who’s your client? That seems like a painfully easy and straightforward question, and very often they’ll say,
‘Well, the doctors.’ And I’ll say, ‘Okay, what about the nurses?’ ‘Well okay, let’s just call it the clinical staff.’ I say, ‘Okay, then what about the folks that maintain and clean the building?’ ‘Well yeah, they have to be considered.” ‘What about the patients? Aren’t they the center of all of this, aren’t we doing patientcentered design?’ ‘Of course, we design for them.’ ‘What if the doctors don’t like that?’ ‘And what about the administrators?’ “We walk them through that conversation and then we say, ‘People come to this building to visit family members, should they be considered?’ By the time that friendly conversation is done, they realize that a hospital has many clients, and you have to satisfy them, and
pretty soon you get to where they understand that almost anybody you can name that goes into that building has to be considered. “That’s one of the learning curves about complexity in healthcare. For example, if you’ve ever been in surgery, you know that they keep the room pretty cold. Is that for the patient, or is that for the doctor? The history of that is, doctors didn’t want to lean over and drip sweat into an open wound. Patients who fl ip over from the gurney on to an operating table that’s ice cold would not call that patient friendly. The challenge is juggling and balancing that and identifying the confl ict and deciding whose perspective governs People have different priorities, different concerns, different interests, and balancing into that equation means that every time is a little bit different for healthcare architects.” In addition to the confl icting needs of their users, Pentecost points out that hospitals contain an incredible number of building systems: mechanical, electrical and plumbing systems, incorporating a range of medical gases and oxygen, as well as the vacuum systems that provide that suction. He compares the difference between an office building and a hospital to the difference between a band that has two guitars, one keyboard and a drum, and a symphony that has 20 or 30 instruments playing interwoven pieces of music. The third major challenge in hospital design, according to Pentecost, is circulation. “There’s the circulation of sterile versus dirty; you don’t want sterile to cross over a dirty area, so they have to be segregated. You’ve got staff versus public. You’ve got supply coming into the building that you don’t want to necessarily be publicly visible. Even within patient groups you don’t want somebody who has come in through the emergency room necessarily transiting through public areas on the way to surgery or to imaging, because very often, they’re not in a condition that would be pleasing to the public eye. “You also have to manage the flow of materials. How do you get food to the rooms, get the food back from the rooms, get linens to the rooms, change them and take the dirty ones out? It’s the same with paper supplies and disposables. How do you roll portable equipment in and out? Just managing circulation is huge.”
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Meeting needs
It’s obvious that meeting all these requirements, as well as the needs of varied stakeholder groups, is going to be something of a challenge. Pentecost points out that although hospital architects try hard to involve as many people as they can, it isn’t always possible to do this effectively, and sometimes they wouldn’t necessarily want to. “There are several dimensions to it,” he says. “One that is not going to be popular, is that very often the cost of these projects is already so huge that adding the additional amount of time it would take to involve all of those stakeholders just is not possible. Sometimes, we offer the client a process that would be very thorough, very comprehensive, and they say, ‘OK, some of this has got to be drawn out of your expertise, that’s why we hired you. And some of this has got to be unique to who we are.’ It’s never quite that cut and dry, but in the back of everyone’s mind, it is always balancing the perfect solution against the affordable solution. “Architects, given their druthers, would like to have that extra input. But in a healthcare marketplace that is competitive, and in a marketplace where information about the hospital and about the performance of the staff of that hospital are becoming increasingly more public, satisfaction scores are making their way into the public consciousness at a level and in a way that is unprecedented. Satisfaction scores in healthcare facilities among patients and family, and among staff, are becoming very, very important because they become a differentiator in the marketplace. The question then becomes, ‘What can we do to raise satisfaction scores?’ “As a result, greater attention is being paid to the role of volunteers and family, and staff of all kinds. What is also fueling that is the staff shortage, among nurses in particular. If a hospital can keep its nursing staff happy, and can create an environment where they want to come to work, then that hospital reduces its cost of recruiting, this potentially reduces its cost of overtime and of temporary labor, and this becomes a very important aspect of keeping the facility fully and appropriately staffed. The same is true with family. Increasingly, families are being included in the caregiving experience, not just at home, but inside the healthcare facility. “So, part of it is a drive to be competitive and perceived favorably in the market. Part of
“Satisfaction scores in healthcare facilities among patients and family, and among staff, are becoming very, very important because they become a differentiator in the marketplace” it is being driven by the concerns about staff shortages and in the marketplace, part of it is being driven by the trend towards greater family involvement in the hospital as actual caregivers.” There are a range of attributes that need to be considered when designing a hospital, including cost effectiveness, flexibility, cleanliness, accessibility and safety. In Pentecost’s view, the most important of these is flexibility. He explains that healthcare has existed in one form or another for many years without always addressing these other issues, but a hospital that isn’t flexible is doomed to failure. “It may be a struggle, but you can run a hospital that’s not cost-effective. You can run a hospital that isn’t necessarily the cleanest, and you can fix things when they go sideways. Physical accessibility is mandated by law. Increasingly, we are understanding how to make hospitals safer, but every day that we understand how to do that better we can look
back on the last 150 years and say ‘They weren’t completely unsafe during that time. We’re just making them better now.’ “But hospitals that aren’t flexible, die. If you look at the life span of a healthcare facility as one curve, buildings are so expensive now that owners are beginning to talk about designing them to last 50 and 75 and even 100 years. Well, let’s just make it plausible. On the other curve, the length of time a building remains current in terms of technology and procedure is getting shorter. “You buy a piece of imaging equipment, and the life on it can almost be measured in months. There are procedures that we couldn’t build fast enough in the 1990s that are virtually unused now. If you look at the accelerated obsolescence of clinical practice, you’ve got two curves that don’t work well together. We can’t afford to build buildings that won’t last 50 or 75 years, and even as we draw them we know that in some cases the drawings will be out of date before we break ground. The technology changes so quickly.” This is why, says Pentecost, if you’re going to have a healthcare facility that will have any measure of longevity, flexibility is key. It’s not just about accommodating change of technology, it’s about accommodating change of care. “What if a technology renders a certain procedure obsolete, and we want to transition to community health, or health promotion, or wellness?” he asks. “Can we do that, is the building flexible? What if the area becomes a Mecca and the population around this facility triples
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over the next 10 years? Can it grow? Can we increase the lab capacity? Do we need to add beds? What if the transition in this community, after it triples, is we don’t need beds, we need more outpatient care? Can we downsize the beds and increase the outpatient clinics? “The challenge to healthcare today is how do we build it to last longer, and be flexible enough during that long life to accommodate any change that might drift along. And that’s a huge challenge.”
High standards
In addition to all that, many hospitals are now working to meet the Leadership in Environmental Energy and Design (LEED) standards, with the aim of making their operations more environmentally friendly. In the past, this may have been considered an additional burden, but as Pentecost explains, that’s not necessarily the case any more. “Last summer I was at a conference that had as its theme discussing or probing the value proposition of what architects do, and
one of the topics in the agenda was, ‘What is the value proposition of LEED?’ And this was a healthcare audience. The speaker got to the end of his presentation and said, ‘Having said all of that, I would reduce the value proposition to this. At this point, the industry has matured and there are enough manufacturers of LEED technology that you can now afford to do the right thing and have the project be cost neutral.’ “I can tell you that not everybody in the audience embraced that conclusion, and I think that’s because in some pockets of the country, maybe some of the technologies are not as available or maybe not as readily accepted. But his conclusion as a national expert was that the industry has matured to the point where it’s cost neutral, you are free to do the right thing, and it doesn’t have to be largely burdensome. “Where people were drawing the line for the most part is that that is an easier statement to embrace if you’re looking at the lower levels of LEED. Because when you get up to the really high levels of LEED, it’s not just about can you
do it? It’s about, of course you can do it, but it means working at the building over a 15 or 20 or more year cycle, with a substantial increase in initial cost to buy certain kinds of equipment, but over the life of the building, those costs level out. “If you’re taking the long view of building life, you can make that statement fairly quickly and say it with confidence. There were those in the audience who said, ‘That’s fine but I don’t deal with clients who can always take the long view. Sometimes I’ve got a client who understands LEED and who understands the value and the life cycle approach but they are absolutely bound by a budget today.’ “LEED in healthcare, LEED in any building for that matter, is always a juggling act between the maturity of the industry, wherever you’re trying to do the project, and the ability of the client to take a life cycle cost view of the project versus being bound by current costs.” n Ray Pentecost is Chair of the American Institute of Architects’ Academy of Architecture for Health.
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Berenson ED:26 June
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FEATURE
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Whenmpromise co is key
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Reformation of the American healthcare system is not a new concept for Robert Berenson, who has been publishing work on physician payment and healthcare cost containment since 2003. Here he explains the need for compromise between private and public payers.
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s a member of the think tank Urban Institute, Robert Berenson’s independent views on policy implementation have been developed during 20 years of medical experience and a number of jobs in previous administrations. He worked on the White House Domestic Policy Staff during the Carter administration, as well as being a political appointee at CMS for three years in the Clinton administration. It’s his work within Medicare payment policy that has shaped his belief that Medicare should be collaborating with other payers to create a better system.
Payer reform
volves trying to improve care for those with chronic illnesses, then that has to include the Medicare patients. “There’s a separate discussion going on as to whether a Medicare-like public program should be an option in the health reform to provide coverage. No one is seriously talking about Medicare itself being the basis for that public plan, although there are all these discussions about whether people approaching the Medicare age should be allowed to buy into Medicare at a fair rate, but that seems to have died down during this year. Medicare’s major role is in delivery system reform and new payment models.”
“There are opportunities for cutting
“Methods for setting fees for physicians in Medicare has been broadly adopted by private payers and they’re using it in their own fee schedules – Medicaid agencies use the Medicare fee schedule as the basis for setting their own fees. “If private insurers use the Medicare fee schedule, then it follows that they should be much more active in what goes into the Medicare fee schedule rather than the current system which defers too much to the AMA’s specialty societies. It’s a process that private payers could be actively involved with,” says Berenson, also citing the patient-centered medical home as another example of the common interest that public and private payers share. “It seems pretty clear that to really make the healthcare system work, to promote real reorganization and new culture in how primary care physicians interact with their patients, you’ve got to get all payers at the table together. First, we’ll see if there’s an agreement on what the concept really is and then address various approaches to promoting it. So far, Medicare will have its own demonstration and private payers in many states are doing their demonstrations, but if you don’t include Medicare patients, it’s not likely to get the real attention of practices. Medicare patients are such a dominant influence, and if the medical home in-
costs
nobody has figured how to come up with proposals that are politically saleable”
but
Geisinger Health System In February 2006, Geisinger unveiled a new strategy within healthcare in a bid to change the way in which it is provided and paid for. The program, named ProvenCare, holds three components: a strict emphasis on evidencebased medicine, a financial mechanism to pay for major surgical procedures and patient engagement.
Micro-care The issue of the rise in multi-chronic diseases and the rising age in baby boomers remains at the very forefront of healthcare concerns. Berenson notes an approach currently being tested in North Carolina, with early signs of success, in the state Medicaid program, that it is now also being be implemented throughout the State of Vermont as it continues unveiling its health reform plans. The strategy is to have a team of non-physician professionals – nurses, pharmacists, social workers, nutritionists – located in the community, either at the hospital or at the health department. The community physicians then have a place to refer their patients to and to interact with on a much more personal level than the disease management approach of having nurses in call centers. “This new model would actually place those professionals in the community. They can go to the patient’s house, be on the phone with them, go with patients to the doctor’s office if necessary, and so it’s essentially an approach to setting up virtual teams of professionals working together. It’s a very interesting model that’s being tested, which would apply to a large part of the country where you still have lots of small, one person doctor’s offices,” he explains. Promoting larger organizations, such as multi-specialty group practices like Geisinger, still remains a popular notion, and with many young doctors opting to work in larger practices – in a salaried pay with scheduled on call and off call hours – it is possible that the long held promise of larger organizations with greater in-office capabilities will finally be realized. “The possibility of more multi-specialty group practices – which would have the ability, because of their scale, to have the nurses, nutritionists and so-
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Urban Institute The Urban Institute gathers data, conducts research, evaluates programs, offers technical assistance overseas and educates Americans on social and economic issues in order to foster sound public policy and effective government. In the mid-1960s, President Johnson saw the need for independent, nonpartisan analysis of the problems facing America’s cities and their residents. The President created a blue-ribbon commission of civic leaders who recommended chartering a center to do that work. In 1968, the Urban Institute became that center. The institute works in all 50 states and internationally in more than 28 countries, and shares its research findings with policymakers, program administrators, business, academics and the public online and through reports and scholarly books.
good policy. I’ve been arguing for substantial increases in primary care incomes as a way of trying to move people into primary care, especially geriatrics. Of course, for extra income, we should expect a certain level of performance from these physicians – especially as regards responsiveness to patient needs 24/7.”
Administrative proposals
The new administration’s commitment to increase healthcare coverage to include all Americans via an affordable plan is likely to place even more strain on the current system. Berenson cites the downfalls of such a policy: “You’d need to spend a lot of money to get everybody covered because most of the uninsured are low-income people who need to be subsidized to be able to get insurance. They can’t afford it and so the current estimates are that the 10-year cost of covering everybody would be about $1.2 to $1.5 trillion. “This isn’t the same situation as bailing out the banks. Apparently Congress has decided that this $1.5 trillion will have to be paid for and therefore you have to look around for sources of revenue. There’s the belief and some evidence that we are spending a lot of money for no particular return in our healthcare system. We’re more expensive than any other councial workers as employees that would work with patients with multiple chrontry on a per capita basis without getting commensurate improved access or ic conditions – is moving forward,” he says. “Medicare can take the lead on quality, so that there are opportunities for cutting costs but nobody has figfiguring out a payment model to encourage that kind of organization.” ured how to come up with proposals that are politically saleable and have a Berenson favors a move away from fee-for-service to population-based paybroad consensus. ment. Here, payment is based on the numbers of people cared for rather “So the barrier this year is to figure out how to finance the coverage exthan the number of services provided. Currently, the focus seems to be on pansion. It looks like we will legislate this year, but maybe we’re not going trying new approaches to what has been called capitation, and moving away to be able to legislate the whole thing in one package at this point. They from those that failed during the eighties and nineties. might set it up in stages, and newer proposals or ideas about how to conBerenson also argues that something needs to be done, and soon, about tain costs, as they become successful, will then result the health professional workforce – the primary care in an ability to cover more people. President Obama physician workforce infrastructure is in dire need of also suggested that we don’t fund all of the expansion change, and without an immediate boost it is likely to coljust from the health system, but instead we could do lapse. “The medical students are not going into primary some more progressive taxation. However, even in care, internal medicine, family practice or pediatrics, and his budget he proposed that the mortgage deduction almost nobody is going into geriatrics despite the fact that and charitable deductions be capped at 28 percent – we have an aging population,” he explains. that would raise a lot of money, but is not favored by Clearly, one of the key factors of this is that in reimCongress. So as of now it looks like the health system bursement schedules, primary care physicians are at the itself is going to have to produce the savings to fibottom of the rung. Berenson expounds on his recent renance the expansion, and there is no consensus as to search, which confirms that for private insurance and for how to do that right now.” Medicare the hourly return for some specialists is apA competitive system between public and private proaching two-and-a-half times what the hourly return results in private insurers starting with a significant would be for a primary care physician; it’s argued that it’s disadvantage compared to a public payer such as actually more stressful and more demanding to be in priMedicare. “It’s pretty well-documented that the cost mary care than in some of those specialties where the Robert Berenson is an Urban Institute Senior Fellow and has of increasing the ability of hospitals in particular, and schedule involves fairly routine and repeated procedures. published widely on a range of topics, including physician increasingly physicians, to gain local market power “We’re sending a signal to medical students that this payment, private plan contracting such that private insurers pay an average 20 to 30 peris an unglamorous specialty and it pays lousy, so anybody in Medicare, healthcare cost containment and malpractice cent more than Medicare pays for the same services,” with a choice is going into something else,” he says. “The reform. He served on the White House Domestic Policy Staff under says Berenson. doctors who used to go into primary care now are bethe Carter administration. “Private payers also have significantly higher adcoming hospitalists and doing their work in the hospital. ministrative costs so they then have to do much betA lot of the residents are coming from international medter using medical management to influence the use of services, and there’s ical graduates, and that raises the whole issue of us trying to fill in gaps in some evidence that they do better than Medicare does in that area. The our health system by robbing other countries of their expertise. It’s not a
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Patient-centered medical home The patient-centered medical home (PCMH) is an approach to providing comprehensive primary care for children, youths and adults. It is a healthcare setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. PERSONAL PHYSICIAN – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. PHYSICIAN DIRECTED MEDICAL PRACTICE – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. WHOLE PERSON ORIENTATION – the personal physician is responsible for providing for all the patient’s healthcare needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life: acute care, chronic care, preventive services, and end of life care. Care is coordinated and/or integrated across all elements of the complex healthcare system (subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. Source: www.pcpcc.net
public debate has been dominated with discussions of a ‘government takeover’ of healthcare, but in many European countries like Germany, France or The Netherlands, hospitals and physicians remain as independent entities and professionals, not part of the government. There are private insurers. There is a lot of loose and misinformed rhetoric floating around about ‘socialized’ medicine. “So at least one compromise was to have a public plan competing with the private plan, and that’s where there’s a major fault line in the current debate. Republicans and the insurance industry are fighting aggressively to
oppose a competing public plan, arguing that a public plan has unfair advantages. And on the other side, Democrats and people who think Medicare functions pretty well think that a complementary public plan could be the only way of reducing costs and going forward. At this point, nobody is seriously talking about moving to a single-payer program and putting out of business private insurers directly and, in fact, people on the left who are single-payer or Medicare-for-all advocates are very critical now of being left out of the debate as Medicare for all is not on the table as an option.”
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HEALTHCARE TECHNOLOGY
High tech shake-up Abdul Bengali, CIO of Mayo Clinic, tells EHM why there are areas of healthcare technology that are in dire need of reform.
H
ealthcare has long been a subject for reform, and as the Obama team prepares to implement their commitment to affordable health insurance and promote public health, there is widespread anticipation of what is to come. But whether these are days of glimmering hope, or merely a façade to gain election votes and stave off pressure remains to be seen. When the smiles have faded and the banners blown away, left to cope with the realities of the accommodation of these policies are those technology teams working across the various healthcare institutions.
Mayo Clinic’s Abdul Bengali has a particular intrest in the health of America’s IT infrastructure. “As Chief Information Officer for Mayo Clinic, I have responsibility for IT activities across the organization, he says. “The infrastructure of organizations make it necessary to have an IT environment and all the solutions that need to be in place to assist the organization in being able to deliver effective and efficient services. It is the whole landscape of IT that I provide leadership for.” The Obama Administration has hailed the reform of electronic medical records as the key to structural change of the health system. “To lower healthcare cost, cut medical errors and improve care, we’ll com-
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“By 2010, all of our 15 medical centers that we have at Mayo Clinic are going to be on electronic health records (EHRs). So it’s not that we are in the early stages of deploying EHRs, we are on the very last mile of completing our journey.” However, EHRs are only one fraction of IT, and with the new Administration solely focusing on this issue there are grave concerns being raised across the industry as to the lack of attention being paid to other areas of technology – Bengali describes the situation as a “significant misunderstanding by the leadership of this country.” “If you talk to senators, congressmen and other people in power, they think that if we put electronic health records in every physician’s office, we have achieved our journey of health IT. They are dead wrong. It is a flawed strategy at the most senior leadership level. All you hear and talk about currently is EHR in healthcare.
IT infrastructure
puterize the nation’s health record in five years, saving billions of dollars in healthcare costs and countless lives,” stated the president in his first weekly address from the White House in January. But Bengali is determined to make clear that making medical records electronic is only one element underneath the IT umbrella, and unless the entire structure is addressed and treated as a means, rather than an end, there is little hope for Obama and his proposed reforms. Computerizing health records is certainly not a new concept for Mayo Clinic. The organization began its journey back in 1992, and with 17 years of labor, is on the brink of reaching the goal that was set almost 20 years ago.
Health IT is broader than EHR. “Clearly, EHR is a big piece of health IT, but it is not the only thing. What we are trying to do at Mayo Clinic in regards to the whole stimulus package that’s being put out there for health IT by the Administration is making clear that from our standpoint, the national health IT landscape is very broad. We’ve identified 10 different pieces of the puzzle that make up the national health IT structure. One of the 10 pieces is the electronic health record. The other nine are pieces that will complement the electronic health record,” he says. The additional pieces of the puzzle include IT interoperability, standards, personal health records, clinical decision support and knowledge management – the latter being one of the major and most important factors. “Being able to disseminate the knowledge that is acquired by one healthcare organization to another, rapidly, is important.” Intelligence gathering in healthcare, which he claims to have been nonexistent for years, is another major part – “once we care for the patient we can now do proactive intelligence gathering to understand trends and directions.” He also notes the importance of administrative simplification and efficiency in healthcare. Bengali has begun a quest to highlight the importance of the entire IT healthcare infrastructure, rather than solely EHR – something he believes the government to be fixated on due to it being one of few aspects within IT that is easy to relate to. “It becomes a centerpiece of agenda, a political discussion. If you go deep into the national level, there are people that understand this national health IT landscape the way I’m describing it, but the people who are decision makers are focused on EHR.” The most important issues Bengali is championing to be addressed are personal health records and clinical decision support. Clinical decision support is still very much in the early stages and needs more attention and focusing for greater understanding.
Clinical decision support
“Clinical decision support is about knowing certain factors before administering medication to the patient: knowing the co-reqs, pre-reqs, what some of the allergies are that can occur, or what can happen if the patient took the medication whilst simultaneously taking an other. It’s all the things that need to be flagged to the physician, the rules and alert
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engines that need to be in place to alert when a bad thing is happening, and that enable the physician to do something before harm is done to the patient. “It is a very broad and deep topic, and many of us are trying to get our arms around it; but because it is so broad and deep, it becomes a very siloed implementation and you really lose the power of a more integrated, coordinated clinical decision support, so that’s a topic that is very important to us in healthcare. Of course, we at Mayo Clinic are undergoing that journey and beginning to put some clinical decision support capabilities and giving our rules and alerts to our physicians to improve the safety of our patients,” he says. In order to bring about this, Bengali notes that there are no fancy means of technology, just the traditional types, and therefore they can be made applicable by all healthcare institutions. Technology is often typed as the non-understandable problem, but he accuses the healthcare processes, nomenclature and terminology as the problem, as well as a lack of national standardization. “If you look back to the piece of the puzzle that describes the national health IT landscape, standards and interoperability is a major enabler of a more integrated and coordinated health IT. Until we have a good set of standards and interoperability, exchanging information becomes very difficult, even though we have the infrastructure there to exchange information. “When I share with you some information that is collected differently at Mayo Clinic than at some other organization, you must now translate that and as you do so, it becomes more burdensome to interpret this data that we are sending and exchanging with each other. So privacy, confidentiality, standards and interoperability are all major roadblocks to enabling a more coordinated and integrated IT hub,” he explains.
“Senators, congressmen and other people in power think that if we put electronic health records in every physician’s office, we have achieved our journey of health IT. They are dead wrong” Uniform standards
Mayo Clinic is setting standards within their own organizations and attempting to combat America’s most problematic area within personal health records: a single patient identifier. Unlike in many European countries where each newborn is provided with a National Health Service number, there are no identifiable standards for each individual in the US. In response to this challenge, the Clinic organized a summit with each of its healthcare providers and peers to identify these problems and become more interoperable as an institution.
The Obama administration has hailed the reform of electronic medical records as the key to the structural change of the health system
“Healthcare in the US is not interoperable. That means a patient seen in one organization cannot go and get care in another organization in a seamless, efficient manner. There are all kinds of barriers that get in the way of providing seamless care. “We need to strive for a healthcare ecosystem that is interoperable, so a healthcare organization like Mayo Clinic can interoperate with Cleveland and Kaiser. Mayo can interoperate with Blue Cross and Blue Shield, the payers. Mayo can interoperate with CMS or Medicare and Medicaid. Mayo can interoperate with pharma. Mayo can interoperate with businesses who are big purchasers of healthcare. There are so many people that now are members of the healthcare ecosystem. “Once you get to eight or nine members that belong to an ecosystem, you have reached an inflection point. That’s what healthcare is reaching at. We need to rediscover ourselves so we can learn to work with each other in a much more efficient manner than we have in the past, and that’s why we spend $2.3 trillion in healthcare today,” he explains. And while quick to point out that there is more to healthcare IT than just EHR, it is still an important factor operating under Bengali’s umbrella. With the knowledge it provides, physicians are able to make more efficient judgments and cost-effective decisions. “It really plays to
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the value equations that Mayo keeps promoting because in the end, we need to provide value to our patients regarding their care,” he explains. “At Mayo Clinic, our value equation is that quality is the numerator and cost over time is the denominator. And if you were to look at the numerator – the quality – we’re looking at three components: safety, service and outcome. In the end, EHRs and personal medicine will all contribute to the value equation and improve safety, outcome and service, but we cannot forget that it needs to be done in a very cost effective way, which is why cost over time is the denominator of that numerator.”
Personalized medicine
EHR plays an important role in personal medicine, but is not the only contributor to furthering its development. Bengali notes the importance of genomics and proteoming, being able to know the genetic types of an individual. EHR provides the clinical information, but in order to understand more about the patient, the personal medicine, it’s the genetic information that’s needed. “What is my gene type? What is my proteomic makeup? Because in the end, genetics means taking your genetic type and fusing it with your clinical type, which will give us the promise of personal medicine, which is also known as individualized medicine,” he says. “Medicine, for the last 100 years, has been practicing as populationbased medicine. Imagine we had 100 patients that had prostate cancer and treated them with this current kind of chemotherapy cocktail. Now imagine that we can guarantee you that 60 percent of the people
react well when they take this kind of a chemotherapy cocktail, but that the other 40 percent did not take it that well and the outcomes were not good. Just imagine someone giving you that kind of a guarantee. You would not take that service. You would never do that, but that’s population-based medicine. “But now that science is movin g forward technologically, we can now move towards personal or individualized medicine. Now if you come to Mayo Clinic we can look at the last 100 patients that we saw who had prostate cancer and met your specific genetic and proteomic makeup, and can now guarantee you this chemotherapy cocktail will take care of your prostate cancer 99.5 percent of the time. So the level of accuracy has been raised and the level of personal delivery is now based on my genetic type, taking results to a whole new level, so now we can begin to provide treatment for patients based on the makeup of the genetic type, not just their clinical types of information. Just imagine the power of medicine when we reach that Promised Land.”
Conclusion
“People are focused a lot on health IT and I can understand why that is, both from a political economics and a social perspective, but health IT is a means to an end, not the end itself. We need to be focused on what is it that in the end we are striving for? Very simply, at least from where I sit and I see things happening, the end is an interoperable healthcare ecosystem, very much like the retailing industry, as well as banking – it’s truly an industry that’s interoperable. You look at supply chain – truly an industry that is interoperable. You look at some of the manufacturing capability – truly an interoperable industry. Healthcare is not an interoperable industry.” So does Bengali believe Obama is the man capable of bringing about the ‘rediscovery’ of healthcare? Will his focus on EHR have a knock-on effect for more intelligent delivery of care and a greater focus on personalized medicine? “It will take us a while to get there because, unfortunately, all of us in healthcare have made significant investments in health IT over the last 20 years and all of us will have to look at receiving some returns on that investment. But this is the time that all of us are looking at as the next generation of health IT, a generation better integrated and coordinated.” n
“Health IT is a means to an end, not the end itself”
Abdul Bengali has been Chief Information Officer for Mayo Clinic since 2001. He joined Mayo Clinic in 1977 and has served in various IT operation and governance leadership roles.
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ASK THE EXPERT
Strategic planning Implementing the best business strategies in the healthcare industry, with Burton Asset Management’s Kevin D. Burton. How can healthcare implement business continuity and disaster recovery solutions to give maximum ROI? Kevin Burton. I think it is important to keep in mind that the solution for these problems is in the thinking and execution of mindful planning – not technology-based solutions. Th is is like having the fox in the hen house when looking for the right strategies. My advice on ROI is to stay away from hardware and soft ware sales people who promise any such thing. The investment you make as a healthcare organization has returns in public health and safety – there is not a traditional ROI model that can be applied to good patient care in a mass casualty disaster. You will make money, through payments from services rendered, but the real pay off is doing it right the first time and short-cycling the effort in the first place.
yourself with a company that can handle this broad spectrum of needs and then engage with hardware vendors as an informed buyer. Clearly, no hardware or soft ware company can provide a ‘silver bullet’ so you need advisory services to straighten this out and lower cost by approaching the whole challenge and avoiding duplication of effort. By using a company with a security background you can address costs and fi nes associated with data breaches as you build your plans – not as a separate activity.
What are the best strategies when implementing a business continuity plan in healthcare? KB. An all-hazards approach that includes disaster recovery, business continuity, security and pandemic is the best strategy. Involve
How can hospitals ensure data compliance with productivity? KB. These two issues go hand in hand. A company familiar with data retention and privacy protection law can significantly lower the cost of records keeping by moving away from digi-
“The real payoff is doing it right the first time and short-cycling the effort in the first place”
tal storage as soon as the law allows. Taking old patient records off line as soon as possible lowers your storage costs considerably. How should hospitals choose the best vendors and options? KB. The best vendors in this space are hardware and soft ware agnostic. To be clear, you need advisory services, much like a family doctor, that can provide advice and give approaches for how to address a problem with multiple symptoms before you talk about specific treatments or cures. In the same manner, a solid advisory services team is your first step to lowering cost- not experimenting with one technology and then the next. For healthcare executives who want low cost, high-yield solutions, the answer to all of these questions is to start with the most comprehensive, solution agnostic approach possible – the downstream saving across the spectrum of disaster recovery, business continuity, security and pandemic planning will be significant. We call this approach fusion. Kevin D. Burton is CEO of Burton Asset Management, Inc. and has helped clients address many issues to increase their IT process efficiencies or to address business process needs.
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TECHNOLOGY
A NEW ERA 98 www.executivehm.com
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Sarah Sinclair of Cleveland Clinic outlines the need for evidence-based practice and the implementation of new technologies to ensure preventative methods are firmly established.
T
he role of Chief Nursing Officer is very much a new one for Cleveland Clinic, but not so for Sarah Sinclair, who carried out a similar role at another organization. The Nursing Institute within the hospital has become much more streamlined in recent years, focusing on standardizing the approach to patient care across the community hospitals as well as the clinic, adopting evidence-based practice standards. Sinclair advises that through a system of trial and error, in those areas in which patient care has had a positive outcome, this is then implemented, performed and practiced across all of the clinic’s hospitals. “That’s what I do every day – I’m bringing groups of nurses together, looking at evidencebased practice, putting in action plans and rolling out strategic initiatives,” she explains. “Right now, one of the main things we have embarked on is our nursing strategic plan across the entire enterprise. We have gone through two sessions, and we have a third one at the end of this month where we will roll out our vision statement, our values and our major themes that we’ll be working on as an organization.”
Evidence-based practice
Evidence-based practice is conducted at the hospital via a research arm in the nursing department, looking at different ways to approach patient care. Sinclair explains that by testing these methods, certain things have come to be known as preventative methods. “For example, we know that if there are four or five things you do when a patient is on a ventilator in our ICU that every single time you can avoid an infection, and we call that bundles of care, meaning there are certain specific things you would do. In that case, the head of the bed would be up 90 degrees. “You would do routine mouth care for the patient, for example. It’s those things that nurses can do without a physician’s order that impact the outcome for the patient. There are a number of other bundles of care that nurses do, but those are based on research over large populations of patients that have demonstrated that if done every single time the right way, there are very good outcomes.” Sinclair advises that the strategic plan is primarily responsible for building teams. Bringing together nurses to build collaboration and teamwork is done via a nurse who demonstrates best practice at an organization, enabling nurses across different hospitals to learn from each other. “The second piece is based on an assessment of the organization – so that you focus the work that needs to be done where you have the greatest
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thing that we’re doing. Technology is really about supporting practices. amount of positive opportunity to impact overall care. So we started out by “That being said, there is a lot of innovative technology that is emerghaving a major group of all the Chief Nursing Officers and Directors across ing. There is the smart bed that has connectivity to the nurse call system, the system from each hospital, but before we went to the first meeting we that has connectivity to the computer. There are small devices that are on conducted stakeholder input. iPods that can be used as training tools for new nurses, for example. They “We interviewed staff nurses across the system, as well as patients and can pull it up and watch a video of a procedure if they’re still in a learning physicians. We also interviewed other kinds of caregivers, like respiratory process to support them in their practice. There are simulation training therapists, pharmacists, physical therapists, and people in the ambulatory units that exemplify a real live experience. setting – anyone that touches a patient. We wanted their feedback on a “Nurses can practice a closed situation where the patient needs immevery specific set of questions, and the questions related to both positive and diate intervention, and they can do it in a real live situation. It’s a dummy opportunity for improvement around nursing delivery of care. patient, obviously, but the impact of that is they can learn real-time without “We went into this day with a lot of feedback from a lot of people, and any risk to the patient. We have a simulation lab that we have in place for then we, as a group, also threw out comments in terms of what we believed nursing, and we want to advance that even further to make it a multidiscito be important in nursing and came up with four major areas. There were plinary simulation center for all folks – doctors, nurses, pharmacists – to hundreds of things on the wall, but we kept narrowing it down until it fit use this high end technology. into four themes. That was a major piece of the work that day. We also had “Anything that we can do that refocuses the nurse on the art of nursa panel of physicians and a panel of staff nurses who came to the meeting, ing, the better, but we don’t want them to get so high-tech that they lose the and we dialoged with them. personal touch,” she says. “That was a very meaningful part of the day, and then at the end of the day we started talking about a vision statement – something that propels a group of people into the future because it has a compelling pull, if you Wellness will. For example, Nike says, ‘Just do it!’ So the afternoon was spent in As well as endorsing Obama’s focus on IT, Sinclair is also directing throwing up those kinds of comments or statements her team toward a strong focus on preventative that we thought would resonate with staff across the healthcare, as opposed to disease-based care. She organization.” notes the gross amount of money spent in the US Hospital acquired infections are a huge issue on healthcare – the figures reaching $2.4 trillion in within the patient sphere, and with nurses having the 2008 and projected to increase to $4.3 trillion this most contact with them, Sinclair is at the forefront of year – and emphasizes the need for employers to be this deadly battle. “In terms of infection control, the raising awareness with their employees regarding most important thing that any caregiver can do is chronic diseases. wash their hands,” she says. “For example, here at the clinic we have around “We have a very comprehensive, focused pro40,000 people that work in our clinic system, and gram around hand-washing, and we actually ask our we’ve made such a commitment to the health and patients to ask us if we have, because we want the pawellbeing of our employees. We have somewhere tients to feel comfortable that the caregivers have done around 6000 people that have joined a free Weight what they need to do. And patients, by definition, are Watchers program, and they’ve lost about 6000 sicker coming into our organization, and that puts pounds since August of last year. them at varying degrees of risk as to whether or not “When you spend a dollar on wellness you’ll they’ll get an infection. But as long as we practice those get it back tenfold in terms of healthcare savings. Sarah Sinclair is Chief Nursing Officer at Cleveland Clinic. A healthcare executive techniques to prevent infection, then there should not And so between our free gym membership and with more than 25 years of leadership be a worry about coming into the hospital setting.” tobacco cessation programs – which have encourexperience, Sinclair came to Cleveland Clinic from Memorial Hermann Health aged around 1,000 employees to stop smoking – all System in Houston, where she served as Administrative policy of those programs say to them, “We care about you, System Chief Patient Care Officer. The Obama administration is gearing up to but you’ve got to partner with us in your health.” unleash a technology focus into all aspects of healthYou’re going to see more and more employers doing care, so how is Sinclair expecting this to affect the Nursing Institute? that because of adolescent obesity. Although she welcomes cutting-edge technology, and embraces it as an “If that adolescent obesity is not brought into check, we have, for the additional tool for patient care, she remains adamant that in no way can it first time in many generations, the possibility that there will be a shorter life replace nursing practice. expectancy of that population that’s coming up now in the teen years.” “As we develop our electronic medical records and electronic docuIn a previous interview with EHM, Michael Roizen, Chief Wellness mentation, we’re looking for ways that that documentation can actually Officer at Cleveland Clinic, explained the unnecessary expenditure on support the practice of nursing – how it can give us information in reports healthcare by the US government, and to little effect. Preventative care is that tell us how we’re doing around specific things that we earmark or trigthe structural reform that is needed to reduce chronic disease, but also to ger for our learning experience. It allows us to continually improve on anyreduce the healthcare budget by 50 percent, he said. “Not to criticize sick
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care – a lot of improvements have been made because of a great sick care system – but it makes more sense and is much less expensive to have great preventative care.” Under the leadership of CEO Toby Cosgrove, Cleveland Clinic has introduced 12 programs to encourage its employees to quit smoking, be it through the smoking cessation initiative, the support from family health centers or the farmer’s market that is located on the campus. Sinclair continues by stating that despite the current economic turmoil, the wellness initiative has had a huge impact on employee wellbeing.
“One of the exciting things that I’m going to be working on is creating the delivery unit for the future” “We haven’t had to do layoffs, and we’ve committed to their health and wellbeing which has caused this population of employees to believe, and certainly it’s true, that Cleveland really cares about them,” she says. But does Sinclair believe that Obama’s goals extending preventative wellness programs, or affordable health insurance to all are achievable? In her words, the policy is “a very laudable goal, and he’s certainly serious about it,” but Sinclair’s primary concern is how this will affect nursing, and whether it will increase patient demand without increasing nurses. She notes the work of Oliver Henkel, Cleveland’s Chief Government
Relations Officer, who works endlessly in Washington, understanding how the legislation is to affect the clinic. “Also, he works very closely with me on regulations in legislation around nursing practice. So whenever I see something, he and I work on that together. We don’t know exactly yet where Obama is going with all of this in terms of affordable health insurance, but there will always be a place for nursing. As we have more and more people entering at the primary care level, I think that we will have more need for advanced practice nurses – nurse practitioners or clinical nurse specialists – to work with these families on the primary care side.
Future care
Sinclair talks of the 2009 as being the year for implementing the strategy of standardized care – regardless of where a patient enters the facilities, the same standard of care is provided based upon evidence. “Secondly, I want to make sure that every nurse in our organization feels really good about their practice, that they are in an environment where they feel supported with, not just technology, but learning – ongoing learning and experience. Being a part of the clinic is fabulous because if a nurse grows tired, for any reason, of being an ICU nurse or another kind of nurse, we have opportunities to move around in our system; so I support that. And part of it is also ensuring leadership for the future. “I’m committed to mentoring and coaching future leaders so that they see the big picture and understand the complexities of healthcare. I want to be known for world-class care from nurses, and one of the exciting things that I’m going to be working on is creating the delivery unit for the future.”n
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EXECUTIVE INTERVIEW
Software satisfaction Jon Kondo explains the importance of corporate performance management in ensuring an efficient business model. Why should companies consider corporate performance management? Jon Kondo. In today’s turbulent economic environment it is critical for companies to remain agile in their financial performance management. Having faster and clearer transparency into their business, along with the ability to quickly adjust their financial plans, allows companies to better weather the current market conditions. Benchmarks are clear that corporate performance management solutions (CPM) help companies thrive in adverse conditions by better understanding the dynamics of their business and factoring in the potential market and economic threats. In these wild times companies who wait for situations to evolve can never get ahead of the market, whereas companies who have robust CPM solutions in place can model and plan for unforeseen changes or events. A dynamic modeling and planning environment gives them the agility to both plan and even react quickly without being bogged down in Excel hell. In a nutshell, today’s economic times require companies to be all things at once: accurate with their numbers, agile in their ability to change and aligned across to the organization. What are the components of corporate performance management? JK. An integrated suite of corporate performance management solutions includes statutory financial consolidation, robust budgeting and planning, revenue planning, financial reporting and scorecards (designed to encapsulate the strategic plan). The scorecards serve as a tool for strategic management, which is the capstone of corporate performance management, but even if a company is not ready for a balanced scorecard, benchmarks are clear – companies that replace Excel as their budgeting and planning tool with a systemized approach to budgeting and planning perform better. Also, with revenue forecasting, a company can better align their operational plans with their financial plans and a financial consolidation system frees up valuable resources from purely aggregating the numbers to actually understanding the numbers.
ly while allowing them to iterate multiple times to accommodate the changing business environment around them. Why should companies consider corporate performance management delivered using SaaS? JK. SaaS implementations are designed to be implemented quickly, provide fast time-to-value, and can be implemented incrementally. Companies purchasing SaaS CPM don’t need to break the bank or be ready to implement across the organization immediately. This allows them to get quick wins or pockets of success before they move to the layer or division. From a purchase software perspective, SaaS shifts the balance of power away from the software vendor and back to the customer. Because the customer is in essence paying for a service, this means that we the vendor have to ensure ongoing success and satisfaction or risk having the customer go away. SaaS delivery also ensures continuous improvement to the product as we strive to improve our functionality and service through frequent upgrades. Because a customer doesn’t have to go through a long custom implementation, we can get someone up and running in a fraction of the time it would take to do an on premise implementation. In fact, the market demands this of us. How can Host Analytics’ SaaS based corporate performance management suite help healthcare companies? JK. We see healthcare companies benefiting from SaaS CPM in five ways over and above the typical value proposition of CPM: managing reimbursement calculations from Medicare/Medicaid/private insurance and so on. We see many of these calculations being currently performed in Excel; Host’s robust modeling environment supports these calculations and the flexibility they require. The second way is through modeling future reimbursements via driver-based rules as legislation changes and budgets get tighter; another by modeling the appropriate level of optional procedures (non-insurance reimbursable) to accommodate changes in economic conditions. The fourth is through optimizing operations via flexible ‘what if’ analysis and flexing a plan; and the final one is through linking the strategic plan to the operational plan. n
“SaaS shifts the balance of power back to the customer”
What is Host doing to meet these challenges? JK. Host Analytics allows enterprises to reap all the benefits of world-class corporate performance management without the cost or long time-to-value of traditional on premise solutions. Host delivers this using a software as a service (SaaS) methodology. This allows companies to see positive results quick-
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Jon Kondo is CEO of Host Analytics. Previously, he was Group Vice President, North American Enterprise Performance Management at Oracle, where he was responsible for all EPM revenue. At Hyperion Solutions, Jon was VP and General Manager of the Americas where he had full P&L responsibility for the entire Americas Field Organization with revenues in excess of $560 million, and was deeply involved in Hyperion’s push into the BI space.
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TECHNOLOGY
Building the
airplane as it flies
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Albert Oriol talks to EHM’s Anna Lee Alden about the challenges of implementing a new technology infrastructure while keeping your healthcare institution up and running.
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n the ever shifting arena of healthcare IT, Albert Oriol feels there is one important aspect that hasn’t changed: safety. He believes that improving the safety and the quality of the care to patients needs to be at the forefront of what healthcare institutions do. Oriol, who is CIO for Rady Children’s Hospital in San Diego, says he believes this can be done while creating efficiency in the system. “This is not to be taken lightly,” he says. “We don’t duplicate a system full of inefficiency with automation; we need to remove that inefficiency in our care-providing process before we automate or as we automate, but definitely safety needs to trump any other aspect of healthcare activity.” At Rady Children’s Hospital, Oriol and his team are currently undertaking a major system implementation. Oriol has been through a similar process in Denver at the Denver Children’s Hospital and was also part of the team that did this at Sarasota Memorial Hospital. He says there are clear benefits from a patient care standpoint in terms of the availability of information to providers to allow for quick decision-making and the availability of clinical decision support to avoid potential errors, as well as the shaving off of inefficiencies across the system is definitely there.
‘The trickiest piece in my mind is, if need be, can these applications be deployed fairly quickly?’ “When we were in Sarasota we did a study that showed turnaround time for tests and after putting in computer physician order entry (CPOE) we went from an average of eight or 8.5 hours to under two hours,” he explains. “This is the time that the clinician is waiting for a decision to be made in terms of closing that decision, which results in quicker decisions that impact the care that the patient receives and helps get patients out of the hospital sooner. “We’ve seen all kinds of other improvements: we’ve seen increased compliance with pain assessments – not necessarily that before it wasn’t being done, but it was maybe not being documented or documented properly. There are secondary benefits in terms of now you can document what you’re doing, which means you get paid for what you’re doing as opposed to in the paper world where you get paid for what you remember to document because you do all your care during the day and you wait until the end of the day to do your dictations, which become your documentation. When you’re documenting real-time, when you’re ordering real-time, all that data is captured and then those charges are captured as well, so that obviously helps also. “The third thing that’s important is: as organizations move to having IT be the bloodline that supplies healthcare professionals with the information they need to make clinical decisions, they need to be up and they need to be up all the time. There won’t be the tolerance for a system that is not always there, that goes away, so the importance of a highly available super reliable infrastructure is paramount.” Oriol points out that unfortunately most organizations haven’t had the means or the focus to invest in a robust infrastructure. Historically, organizations have invested in an application layer to take care of functional needs, and at some point that application layer is too heavy and it doesn’t have the foundational infrastructure to support it.
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“The trickiest piece in my mind, going back to closing the loop in the stimulus package,” he continues, “is, if need be, can these applications be deployed quickly? You might take more or less time to think through your processes and try to optimize them up front or not or, but the deployment is bound to happen when it happens. Having the underlying infrastructure to support that is a different story. That takes time because you can’t close your current hospital to deploy new infrastructure. You’re building the airplane as it flies, and that will be the tricky piece in all of this.”
New priorities Oriol has mixed feelings about President Obama’s plan to have all health records available in electronic format within five years. “Across the nation, people are feeling bearish. Different organizations who have started this will have no problem admitting it. A small percentage of folks are already there. In the children’s space there are probably better adoption rates than in the adult space and for most folks, if they don’t have something in place they’re well on their way to make it happen. “There’s a small portion of the overall provider arena that will get there, but as far as getting there before penalties hit I think in the children’s space that is relatively doable. Of course everything is marked with the caveat that until we know more about what the actual required use is, it’s hard to tell. “Historically, for better or worse, children’s hospitals have seen the need for real-time clinical decision support, because children are not small adults. They have their own little areas of characteristics and things that make their treatment special. You can’t just treat a kid like you would an adult but less, and so there is a need for clinical decision support so that you can do things like weight-based ordering and making sure that you’re dosing correctly. It has probably been more prevalent and identified as an earlier must-have than in the adult world.” According to Oriol, the other tricky piece in the puzzle is finding the professionals to work through these implementations. He believes the economic stimulus package will set the fuse and that we will see a lot of new projects either started or sped up. This will require people who know what they’re doing. “In the last six to nine months we have been seeing more qualified people becoming available as the economy has slowed down. We’ve had access to some pretty phenomenal people that we couldn’t touch with a 10-foot pole before, because we couldn’t afford their rates or they weren’t there a year or two years ago. “For the last six months or so some of these folks have become available, as the closet has shut on the capital side. As people figure out the need to put money in in order to take advantage of the economic stimulus package and to not get penalized for being noncompliant, that workforce component will be critical on the IT side. Those folks who thought that because we’re in an economic recession, we need to take drastic measures and reduce pay and do the types of things that people have to typically do in a recession will find it challenging in an IT environment where we will have more work than resources to do it. I’m concerned that this might become a tough market in terms of employee retention and recruitment for folks who have the right skills. You can’t create those skills in a month or two; it’s going to take a while. “Those are the two challenges: one is infrastructure and the other one is the manpower – the brains to make this rollout happen on a nationwide scale.” Another challenge standing in the way of the development of national computerized patient healthcare record system is the lack of a single patient
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identifier. Oriol believes this to be a big issue, and one that needs someone with the political will to resolve it. “I come from Europe – I was born in Spain, and when I turned 14 I got assigned a card and identity number and had to carry it with me everywhere I went. So I’m probably less paranoid about Big Brother than your average American. I think that without a single patient identifier, it will be tougher to exchange patient information across the board, especially in a society like American society. Somebody can be born in Boston and go to school in Detroit and have their first job in Miami and their next one in Denver and the last one in Seattle and they’ll retire in San Diego. “I think it’s possible to make it work, if a political agreement can be found. The mechanics of it are such that having a true cradle to grave health information system, you either have a national patient identifier, or you give the information to the patient and let them manage their information. “Wherever possible, I think political minds should be working to make this a reality. It’s been 10 years or more since we started talking about a national patient identifier with the first HIPAA provisions, and so far it’s been futile at best. There is hope, but something needs to change in the prevailing political mindset to want to make this work.” Security is another issue in the implementation of electronic patient records. Oriol says the role of security is huge, but that it’s also huge in perspective. “I used to wear the security hat in a couple of previous roles. By default I wear it here as well and we also have an information security officer, so it’s certainly a concern to me in that I feel that protecting the confidentiality and the integrity of patient data is paramount. We need to figure out how to make this happen without it becoming a barrier to better patient care. We need to make sure that we build the security into whatever solution we provide, but we shouldn’t let security trump better quality of care.” One of the other challenges Oriol outlines is that most application providers have built their applications and databases to work in a pre-genomic state. He says it will be critical for them to figure out how to incorporate a new order of magnitude worth of data that their EMRs can use to fire personalized medicine and medical logic rules, driven by the level of information now available at a genetic level. “There is still a lot of growth to be accomplished here. There’s a lot more that we don’t know than we know – this is why application vendors have been somewhat cautious about getting into this space. We still need to define what it is that we want. “EMR can definitely play a role and it will be critical to be able to utilize the information to personalize the care that we provide, but I would say we’re not even in the infancy of this. We’re still in the womb.”
Albert Oriol is Vice President, Information Management and CIO at Rady Chlidren’s Hospital and Health Center in San Diego. In his previous role, Oriol directed the IS Program Office and Privacy/Data Security Officer for The Children's Hospital in Denver. His teams have led large scale EMR implementations and infrastructure deployments.
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EXECUTIVE INTERVIEW
Virtual house calls
Lance James explains the benefits of telehealth interaction for both patients and physicians.
What is e-Telmed? Lance James. That’s my favorite question. eTelmed is a leading innovator in telehealth, an industry that needs to be taken very seriously as demand and need for electronic medical records (EMR) explodes. I started e-Telmed six years ago to address the current US healthcare deficiency by creating a solution that connects patient and physicians from any location they choose, allowing patients to have easier interactions and consultations with physicians, from the comfort of their home, office or any remote location. What differentiates us is our comprehensive fullyintegrated telemedicine solution offering a webbased EMR, video conferencing, personal health record (PHR), and technical, legal and customer support. We make virtual house calls a reality.
Lance James
“The technology allows for a patient to see their physician whether it is in a remote location, a foreign country, urban city or the comfort of their own home”
What are the benefits of e-Telmed to physicians and patients? LJ. For physicians, e-Telmed provides a costeffective solution and technology to help access patients anywhere in the country, which allows their practice to expand its patient base. Physicians have been mandated to switch to an electronic format of medical records by 2011 and will receive penalties from Medicare/Medicaid if they do not comply by 2015. Implementation of our EMR system will also allow physicians to qualify for government reimbursement, which will be distributed by 2012. For patients, e-Telmed provides a medium to access your physician easily from anywhere in the world. Patients have the ability to closely monitor chronic diseases with the help of their physician by logging in and virtually connecting with their physician on a regular basis. It’s ideal for patients located in rural locations who previously had to travel great distances and incur expenses to go visit a specialist. With e-Telmed, a specialist can see the patient in a virtual doctor’s office and determine whether it is necessary for the patient to travel.
Tell me about your exciting project in Alaska. Does e-Telmed only work for patients in remote locations? LJ. e-Telmed was recently selected to provide telehealth services to a federally funded tribal organization that serves native Alaskans in remote
villages throughout the state. We were chosen because of our thorough and comprehensive solution that allows for cost effective communication between urban hospitals and several remote villages located throughout Alaska. The project consists of connecting approximately 1500 villagers to physicians and specialists located in urban Alaska. Each remote location will have all the telemedicine technology necessary to provide the highest level of care. If someone gets sick, they can immediately go to a central location in their village. Once there, they can have complete consultations with a wide array of physicians ranging from pediatricians to cardiologists, thus eliminating expensive travel costs. e-Telmed is not only for the rural locations. There are several uses for patients who need to see their physician while traveling, vacationing or on business. The technology allows for a patient to see their physician whether it is in a remote location, a foreign country, urban city or the comfort of their own home. The benefits provided to remote patients are the same ones that are offered to all of our 60,000 patient members. Patients are not limited to local physicians.
Why is e-Telmed a leader in Telehealth? LJ. e-Telmed is the only full service telehealth solution. It provides one point of contact for technical, legal and customer service, instead of several. Our solution is fully web-based and HIPPA compliant. As a result, it is not necessary for clients to purchase servers or hire IT Managers. e-Telmed hosts the information in secure data vaults placed in strategic locations, providing physicians complete portability for their practice as they can access patient information from their laptop even if they were at the beach on vacation. Ultimately, e-Telmed is a wonderful solution for physicians and patients. The physician receives a state-of-the-art platform without the huge costs usually associated with implementing healthcare technology, and the patient receives easier access to better healthcare. n Lance James is the CEO and Founder of e-Telmed Inc. James has 20 years of experience in creating, developing and marketing medical offices, pharmacies and telehealth solutions. His telehealth solution has since been utilized by medical professionals for over 100,000 consultations and has created a gateway between patient and physicians through the use of advanced telemedicine technologies.
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TECHNOLOGY
STAYING HEALTHY
in an electronic world
Charleston Area Medical Center’s Lynn Brookshire brings EHM up to date on the issues surrounding electronic medical records.
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veryone in the healthcare industry knows by now that President Obama’s plan is to have all health records in electronic format within five years, but just how achievable is this goal? In the opinion of Lynn Brookshire, VP and CIO at Charleston Area Medical Center, the goal is far too sanguine. “We all think it’s a great idea,” she says. “It’s hard to think anything else. But that timeline seems overly optimistic to me, given the complexity of it and the fact that so many of the people involved are private practice physicians or in single practices. I’m fearful that in the area I live, it will simply become an early retirement incentive. “It’s wonderful that there is this raised awareness, both within the healthcare sector and with the public, I think that’s excellent. We need that in order for us to move towards the goal of doing this automation in our country. “The single key thing that the government has not yet done is create a patient identifier. Until that happens my own opinion is that it will be hard to put all these pieces together in a way that one equals one, but that you always know you’ve got the right person. It needs to be HIPAA compliant, but they need to do it. It would make a lot of these other things happen more quickly. “In many ways, it is lost in the shuffle of all this money. We’ve partic-
ipated successfully in those two initial national demonstration projects around health information exchange, but those had a controlled limited scope. If I have a fear it is that there’s all this money that will be spent on what I consider to be workaround solutions, when in fact we could just go after the patient identifier and the money would be better spent. Instead, we will have all these traffic cops and all these matching algorithms and all these other things, and a lot of the money will have to go into making those work.”
“There’s a lot of work that we all need to finish in our own houses before we can have robust exchanges with others” Brookshire’s own institution has already made great strides in implementing EHR and bringing its technological processes up to speed. “For many years, we have been an organization that is proud of our quality and we have been committed to Six Sigma type methodology,” she explains. “We have nine full time Six Sigma black belts as part of our staff who work on quality improvement and process improvement.
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“We’re also working on the deployment of HIPAA regulations. My security officer came LEAN methodology, which is just one of those back from a seminar last week and said, ‘I’m parts. And a current, active initiative is figurnot going to be able to work on any of my other ing out the best way to integrate our technology work. I need to start working on this now.’ implementations with that methodology, so that He’s also the technology guy and we have all we are taking the waste out of processes. At the this other important work. So it doesn’t appear same time, we’re acquiring automation, so that that it will work in the name of administrative it’s not a manual thing.” simplification. Another big challenge facing the nationwide “The impact is that while we have all worked implementation of electronic health records is really hard to be HIPAA-compliant because it’s the need to ensure individual institutions are the right thing to do to, to do security audits, able to exchange information electronically. but most of us smaller institutions can afford to Brookshire believes there is still a lot of work to do a security audit every three years or so, just be done in this regard. to make sure that what we put in place is still “I think the defi nition of the CCR record good. The requirements are now that we do it Lynn Brookshire is VP and CIO at will help,” she explains. “But there’s a lot of every year. that’s another unfunded mandate Charleston Area Medical Center in Charleston, West Virginia. work that we all need to fi nish in our own from the federal government, at a time when houses before we can have robust exchanges one of the California papers reported last week with others.” that over 35 percent of US hospitals lost money And then there’s security. Any time you have data being exin January. changed in electronic format, fears about potential leaks rise to the “I understand why people are nervous about their personal health top of public consciousness. “We are all learning what the new fedinformation. But upping the ante and mandating it when, in fact, all of us eral defi nition of security will be,” Brookshire says. “In the stimulus who are in healthcare know it’s the right thing to do – and not allowing package there is a whole section that further defi nes and expands the us to do it that way − seems costly and burdensome to me.”
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ASK THE EXPERT
The role, advantages and limitations of social networks in healthcare recruiting By Ken Levinson
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rofessional/social networking sites are exploding. Almost everyone has heard of Facebook, LinkedIn, MySpace and Twitter. These types of sites can be fantastic for helping you connect with friends, classmates, neighbors and acquaintances, including people from your past with whom you have completely lost touch. These sites are also invaluable in assisting job seekers and employers to find each other. I grew up in Cherry Hill, NJ, but moved to Florida, and had lost touch with virtually everyone I used to know. After joining Facebook, I started looking up a few people from my past, and requested to become their friend. Once
“Social networks should be seen as a longer-term, slow burner approach” they accepted, and we caught up, I found other people I knew that they were friends with. Before long, I had recaptured my entire youth, reconnecting with many people that I would have never found otherwise. I’ve also met many wonderful new people both personally and professionally through Facebook. Because of my network, if I ever looked for a job, I’d have lots of friends and professional contacts to help me, either directly or through contacts to whom they could introduce me. Now imagine all the healthcare people your employees know and how they could network to spread the word about good jobs at your facility. Our company owns Absolutely Health Care, the largest niche job board on the internet for healthcare and medical jobs. It is a traditional job board: everything is transactional. Companies can post jobs and look for résumés. Job seekers can post résumés and look for jobs. There is no relationship building going on. Professional/social networking sites are the opposite. They are about long-term relationship building and networking. That’s why almost
two years ago we started Medical Mingle, a professional social networking for people interested in, working in, servicing or studying to enter the healthcare and medical field. Julian Stopps, of Broadcasting Online Recruitment News Limited, made the following comment at JobBoarders.com, which I consider right on target: “Online social networks are certainly one tool in the recruitment toolbox, but I just can’t see them replacing job boards completely, as they are very different offerings.” Job boards are used primarily as a tool for sourcing active job seekers. Social networks are more suited to subtle employment branding and advertising to passive candidates. The strength of a social network, from an advertising perspective, is to prime passive and inactive candidates with knowledge about your employment brand. Then, when they switch to being active candidates, your service is the first one they consider. Therefore, social networks should be seen as a longer-term, slow burner approach. Job boards are a ‘we have an unforeseen requirement for five people now’ approach.
We started Medical Mingle to complement the Absolutely Health Care job board. Healthcare professionals used to come to Absolutely Health Care only when they were looking for a job. Now, through links to Medical Mingle, healthcare professionals also come to Absolutely Health Care to make professional contacts and friends, find professional resources, blog, participate in forums, post and view pictures, post and view videos, receive recognition and win prizes. It gives healthcare professionals many reasons to hang around Absolutely Health Care, even when they are not looking for a job. On the flip side, if someone hangs around Medical Mingle directly, when a member becomes a job seeker, they can browse jobs and/ or post their résumé on Absolutely Health Care, right from the Medical Mingle site. They can also network with other Medical Mingle members. Professional/social networking sites, combined with online job boards, are the perfect recruiting complement for both job seekers and employers.n Ken Levinson is the President of Absolutely Health Care.
Ken Levinson is the President of Absolutely Health Care
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RECRUITMENT
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The rising number of America’s uninsured, Obama’s ambiguity on universal provision and the government clampdown on retrogression are all putting further strain on the healthcare recruitment industry. Julie Brooks explains the challenging trends in these tumultuous times.
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s president of the National Association of Healthcare Recruiters (NAHCR), Julie Brooks’ activity within the organization spans over a decade, and it is her wealth of experience that provides her with such insight into the challenges currently dominating the healthcare recruitment industry. One of the NAHCR’s primary roles is to be a source of educational information for its members, providing them with the tools that will teach them how to become successful. Brooks explains that depending on which country the members wish to recruit from, there are many obstacles to the process – the requirements change, the visas differ and so on – and therefore members need to know what guidelines they must comply with in each individual instance. NAHCR plays a role in informing its members how to employ staff from one country and license them into the US via a multitude of educational materials.
Challenges
However, this process is not a simple black or white decision. She advises that enforcing the correct compliance requirements is challenging, specifically when recruiting from abroad. “It depends on the health system,” she explains. “We have some large healthcare systems that include 10 or 12 hospitals. We have other hospitals that are in smaller systems, depending on what the needs are. The other thing that’s very challenging right now is the retrogression and immigration issue, as the US government is currently only allowing so many visas per country and they only allot for so many positions. “For instance, in order for nurses to fall under certain criteria for the H1B visa or similar, a bachelor’s degree in that specific field is required. So there are a lot of things that we have to work within. We have several immigration attorneys that have worked with NAHCR, one being Sarah Tobocman who works out of Miami and who has written the immigration piece in our recruiter’s handbook. So we try to give them the tools and the resources so that they can be successful – doing the research before they venture out into recruiting nurses from another country,” Brooks explains.
She notes that the problem of recruiting from abroad has become a huge issue only recently, due to the clampdown on the allowance of visas by the US governmental authorities – what’s referred to retrogression. “They’re trying to keep illegal people out of the country,” Brooks explains. “They have stopped a lot of the immigration process, and unless somebody is in a high priority specialty area, they’re not granted visas. Several of our hospitals throughout the country have got orders in for workers from other countries, but they’re not able to get those workers because they can’t get them the visas they need to get here. And so it’s quite a challenge, and until the Congress lifts that ban on retrogression our hands are tied. “The difficult part is that many of the companies that participate in international recruitment are struggling because they can’t get the workers here. Their business depends upon the immigration process and them being allowed to come into the country, so it’s been a real challenge for them as well. We are hopeful that at some point this year it will be lifted, but there have been so many issues that make this look even less likely, such as the illegal aliens entering across the border and the issues we’ve seen out in Arizona and New Mexico. That’s really put a clog in the system.” Outsourcing is an increasing trend found across all verticals, but the benefits it provides in other industries will not necessarily provide the answers to healthcare recruitment’s problems. “Working at an institution whereby I’m housed at the hospital I work at, I become an intricate part of the management of this facility as well as of the employees, and in order to build relationships with people you have to be onsite. They have to put a face with a name and they have to know that you will act upon the things that you say that you’ll do,” she expounds.
Universal coverage
The refusal of the government to allow free movement of healthcare workers seems to be a direct antithesis to Obama’s proposal of universal and affordable healthcare cover. An expectation in healthcare
“Several of our hospitals throughout the country have got orders in for workers from other countries, but they’re not able to get those workers because they can’t get them the visas that they need to get here” work is bound to place pressure on those health institutions themselves that are already struggling to fill the amount of workers needed due to the immigration issue. Brooks advises that the president’s ambiguity regarding the actualization of the healthcare expansion policy is a problem, as there is no indication of what the impact will be. The infrastructure still suits the previous system; universal coverage is not what the current system is ready for.
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“I’m very much in favor and agreement with him when he talks of the American need to have affordable healthcare – it’s very frustrating to have so many people that do not have insurance. We have a lot of the indigent care, people that don’t have any health insurance at all, who don’t have the means to pay for it, and those people get sick just like people with insurance. Under the current laws and regulations, if somebody truly comes to the hospital and they are in an emergent situation and they need care, we have to treat them regardless of whether they have the means to pay. “The problem is that we have many illegal people that are here and even though they’re here illegally, they still fall under that criteria of treatment. If they have an emergent care situation, for instance they’ve had a heart attack or have cancer, we still have to treat them regardless of their ability to pay, and that’s part of what is impacting the healthcare system, not just here but across the nation. “All of my recruiters across the nation are dealing with those same types of things. With the economy the way it is there are so many people that have lost their jobs; their working hours have been reduced. A lot of companies have scaled back their benefits or they’re asking the employees to pay a lot more of their portion of the benefits, and so it’s a whole system that matriculates downhill from there,” she explains.
Industry trends
However, the good news for recruiters is that the economy’s f luctuation is forcing physicians to stay within their current placements. The insecurity of the market means that when a good position is found, it is generally now long-term. “A lot of the travel assignments, like in nursing, pharmacy or physical therapy for instance, are pretty much disappearing or being scaled back. The cost of having a traveler as opposed to hiring your own staff member is significantly lower to the organization. We’ve also had a lot of people that have worked in what’s called a per diem status, or a temporary status – rather than commit to working 36 to 40 hours a week, they’ll maybe work one 12-hour shift a week. “However, due to the state of the economy, people are leaving that type of temporary position and are taking fulltime positions, because they need to know that they’re going to be able to get at least 36 hours of work a week and when you’re in that per diem status there is no guarantee. Of course, there’s no guarantee when you have a fulltime job if you don’t have the patient census to support it. “Per diem staff members are the fi rst people that are called off if our census falls down; fulltime staff are the last people to be called off. We might rotate them through different departments, often referred to as ‘floating’: registered
nurses may be hired to work in a med-surg unit but may be transferred to another unit if the census is low in one area versus another.” Brooks notes another concerning trend resulting from the fi nancial downturn. Despite there being a need for more physicians, a large number of new graduates are entering the workforce but are unable to gain employment. “The problem is that because all these other workers have converted from per diem to fulltime, the new graduates are having a challenging time fi nding positions,” she explains. “One of the things that concerns me is that people have got into nursing and healthcare because there was a great need. There was a high demand and people felt that it was very steady employment. The problem that we’re running into this year is that many institutions aren’t even hiring new graduates at all. Now we are still hiring a few, but we’re not hiring nearly as many as we hired in years past. “We’ve also had a lot of healthcare workers that are trying to reenter the workforce – maybe they’ve retired or they’re partially retired – but because of the economy and the crash in the stock market we have a lot of people that are trying to reenter the workforce. Th is is just a temporary situation and soon we’ll be back to where we were five years ago where we’re scrambling to fi nd people because our workforce, in all actuality, is shrinking. That’s one of the things that is frustrating – nobody is addressing the fact that we don’t have as many people entering the workforce as we did 50 years ago because the demographics are very different,” she concludes. Brooks’ fi nal note is the belief that the current emphasis on permanence and job retention is itself a very temporary thing. The rising of share prices, the reversal of redundancies and the reinvestment in insurance plans look likely to solve the current recruitment problems, but when the façade of success fades, the current problem of a shrinking workforce will remain.
“I’m very much in favor and agreement with Obama when he talks of the American need to have affordable healthcare – it’s very frustrating to have so many people that do not have insurance”
Julie Brooks is President of the National Association of Healthcare Recruiters and has over 24 years of healthcare experience. She has spent the last 14 years working in recruitment.
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ASK THE EXPERT
MAXIMIZE YOUR ROI WITH LOCUM TENENS AND ADVANCE PLANNING
While at first glance the cost of using locum tenens physicians may seem high, when compared with leaving key revenue-producing clinical positions vacant, it is well worth considering. Andrea Boehme-Hernandez, CEO of Medstaff National Medical Staffing, explains how planning ahead for physician staffing needs can maximize your return on investment. When to utilize a locum tenens physician
When healthcare executives think of locum tenens, what usually comes to mind is the need to get a doctor in place on an urgent or last minute basis. Certainly, when unforeseen staffing problems arise, locum tenens physicians provide an excellent solution. The best way to maximize your return on investment when it comes to using temporary physicians, however, is to plan ahead whenever possible. By working closely with a locum tenens company, you develop a relationship that allows the agency recruiters to understand and respond to your physician staffing needs, both current and future. We recommend a quarterly review with all of our clients to help them project and plan to cover vacancies due to vacations or sabbaticals, maternity leaves, physicians retiring or leaving the community, seasonal changes in patient volume, or when a new program or service is being developed. By planning ahead for physician staffing needs, you will have more can-
didates from which to choose and more time to get credentialing and billing-related paperwork in order so that cash flow is not interrupted. Locum tenens physicians are highly qualified, experienced and fully credentialed medical doctors who enjoy working as independent contractors for many reasons, including the flexibility it offers and the opportunity to focus on quality patient care rather than on the business side of medicine. We screen our physicians thoroughly to ensure they not only have the clinical capability, but also the right personality to seamlessly fit into your unique setting or group.
What is the cost?
That may be the question that comes to mind, but in truth the consideration should be on the cost of leaving the position open or unfilled. Often, the use of a locum tenens physician is equal to or less than that of a permanent staff physician whose package includes base pay, benefits, incentives, vacation, CME allowance, liability insurance and taxes. Once totaled, the full
Andrea Boehme-Hernandez is CEO of Medstaff National Medical Staffing. Boehme-Hernandez has over 12 years of experience in healthcare staffing and 20 years in employment services management. Since 1985, Medstaff has been a national leader providing locum tenens and permanent placement of physicians in all specialties. The company also provides other physician care solutions and medical management programs including longterm guaranteed coverage in a program called MedstaffONE. For more information, please visit www.MedstaffLT.com
cost of a family practitioner, for example, could be $220,000 or more. On average, that same position filled by a locum tenens would cost $197,000 annually. That is about $780 per day with the physician’s liability insurance included. Once you factor in the revenue produced by the physician in professional fees (in this case approximately $1600 per day) and additional revenue to the hospital via referrals, admissions, and other services such as labs or radiology, you are actually looking at a net gain. The total rev-
VALUABLE REASONS TO USE LOCUM TENENS PHYSICIANS • Produce revenue and profits • Improve continuity of patient care • Retain patient flow and volumes • Avoid overwhelming present medical staff • Maintain physician and nurse retention • Lower liability risk • Create higher patient satisfaction enue generated by a family physician can be up to $4000 per day. This calculation can be done for any specialty. Imagine the cost of an empty operating room or having to transfer patients from your emergency department due to lack of specialty coverage.
How locum tenens physicians improve permanent recruitment
Another ROI issue is related to physician recruiting, which can take several months to a year. If you are in the process of replacing a physician, using a locum tenens physician makes good business sense. Planning ahead to have a locum tenens physician in place while you are recruiting works to your advantage by preventing your existing physicians from becoming overworked, overwhelmed and burned out while waiting for their new associate to arrive. You also give yourself time to find the best candidate for your organization. Improve your bottom line with locum tenens physicians and increase your ROI with advanced planning and developing a relationship with an experienced, professional agency. For the very best results, we encourage our clients to include physician staffing needs in their strategic plans and annual budgets.
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RECRUITMENT
LOCUM
LABOR Staff shortages have always been a major problem in the US healthcare system, and with the economic crisis ongoing, it looks unlikely that this will be resolved anytime soon. Ruddy Polhill explains how locums can help.
A
relatively new organization, the National Association of Locum Tenens Organizations (NALTO) came into existence in 2000 in a bid to standardize healthcare recruitment guidelines. A number of industry players concluded that a better understanding of the industry was needed with a formalized set of rules and procedures for both the recruiters and the employees to abide by. “As far as our mission, we’re here to educate all of players in the industry – the physicians, the clients and the recruiters all wrapped into one,” explains Polhill, the association’s President. “We meet a couple of times a year, and the idea is to create a forum where we could exchange ideas, but if anything it’s to educate and develop a positive image. “We discuss best practices, industry standards more than and ethical guidelines. We have a whole process where if someone does have an ethical or standard of practice problem with another client or another member – the idea is to take the client out of the middle of the competitors in a fairly competitive market segment. For example, if two recruiting fi rms were claiming they were involved in placing a physician, the idea of NALTO is so that they can take the client out of the middle of that and talk it through another forum, and come up with a reasonable agreement.”
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Staff retention
Staff retention is one of the major challenges currently facing the healthcare recruitment sector, in terms of the hospital environment. Polhill acknowledges the problem, and describes the industry as “having always been a revolving door”. During times of shortage, HR programs are rolled out within the hospital to keep employers onboard and happy. “It’s no mystery there’s a shortage of physicians around the country. Locum tenens are coming alongside and helping our clients with that, creating an environment where as patient volume spikes obviously people work harder. We’ve seen this on the nursing side in particular. “In the nursing sector, it is more likely to see job satisfaction than any other, but is often a little bit the same on the physician side. For example, if there’s a five-physician practice, and they don’t really have enough patient volume to bring in another physician as a partner, but maybe they’re all working a lot harder than they want to or they only have so much time to see patients, job satisfaction is likely to go down.
“At that point it might make sense to bring in a locum tenens doctor or physician a couple of days a week just to help with their busy days, so in that way it could help get the handle on it. As a strategy locum tenens are often viewed from a hospital perspective as a little bit of a high-cost alternative. I would challenge that – when dollar benefits are consideration, malpractice insurance and so on, what you pay for a locum tenens doctor, if you really study it, is not a high-cost alternative. “Most hospitals, if they look over their year statistics, will see a lot of times where they’re not as busy, and so be overstaffed. We believe that the perspective of the locum tenens company focuses on the magic number of staffing being different for every hospital. For example, let’s assume that the magic number is 80 percent. The ideal would be to staff at 80 percent of maximum and then in those times when it slides to 85 or 100, due to a work overload, that’s when you bring in the locum tenens doctors to help the excess load and then when the patient load goes down, you don’t have them work those particular times,” explains Polhill. By matching the doctor’s available hours with patient demand, an equilibrium of supply and demand can be achieved, and also result in a
“Everybody wants higher quality healthcare but the real questions is how to get there from where are we now and how to pay for it”
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The meaning of locum tenens
The term ‘locum tenens’ is taken from a Latin phrase meaning ‘to hold the place of’, and most commonly refers to temporary physicians. Locum tenens doctors contract with recruitment agencies to perform medical services for a healthcare organization over a certain period of time. The physician works as an independent contractor paid through the staffing agency, which is in turn paid by the healthcare facility.
The benefits of locum tenens
Locum tenens work benefits both physicians and healthcare organizations. Physicians can be contracted for any number of reasons, from compensating for physician
shortage to covering a permanent doctor’s vacation leave. Healthcare facilities benefit from locum tenens contracts by covering gaps in patient care during periods of growth or physician shortage. The industry continues to grow as more physicians choose this way of practicing medicine and healthcare organizations discover the value of locum tenens staffing. Locums physicians often enjoy higher pay scales, more variety in medical cases, a broad array of work locations from which to choose, and the flexibility to build their own schedules. However, working as a locum tenens physician also requires some patience, good organization skills and the ability to adapt to different environments. Source: www.nalto.org
happier workforce who are more likely to retain their employment positions. The situation is also favorable for seasonality.
Compliance
To ensure that all locum workers uphold to a standardized set of practices during any given time of work, however, is often a laborious task. Polhill advises that one of NALTO’s primary objectives is to hold each of its members accountable to each other, which is done via an ethics committee. “We have an arbitration committee and an ethics committee,” he says. “So, for example, if two companies can’t come to an agreement, instead of involving the physician and involving the client, what we agreed to the membership was to involve NALTO – a company can bring a complaint, whether it be a standard of practice or an ethics complaint, against another company and it’ll be reviewed by a board. “It’s nonbinding but it is helpful, and it’s unbiased because it’s done in a Company A, Company B format. We just get the facts. We don’t know who the personalities are involved in it, but the net effect is we get five or six peers that are in the industry to weigh in on what they think about the situation. Again it’s unbinding, so it’s not done in the sense that you have to agree with what they say, but what we’ve found is that most people tend to understand. Occasionally there may be a situation where for business reasons the other company says, “Well, we just don’t agree with that.” And that happens as well, but it’s a positive outcome more often than not. What’s important is the fact that we use that mechanism to keep the clients and the physicians out of the middle of the dispute between the companies. “Prior to NALTO one thing that’s common, is that due to it being a very competitive industry, you see a lot of companies backbiting, being very aggressive and involving the clients, and that’s a very uncomfortable position for a client and, quite frankly, they just wanted a physician. And you have two companies who are saying that they presented this physician first, so that’s where the standards of practice come in to help us line up and give a peer review to the member companies and say, ‘Hey, really under our standards of practice this particular company is the company that really was the cause for the physician placement.’”
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Challenges
The challenges facing locum workers are far greater than those of permanent. Polhill advises that the biggest challenge for locum tenens physicians is at the beginning of each placement in acclimating and getting comfortable with the staff and the enviuronment. After a period of returning to the placement numerous times, it more often than not works out well as physicians assimilate into their culture. “The first time they go to a new environment they are an outsider looking in. Over time they assimilate great, but that probably would be the biggest challenge, similar to a person starting their first day on a permanent job. It takes a little while for people to get comfortable and to understand how things flow. Another challenge is that it’s very easy for a client if there’s one little hiccup to ask for a temporary physician to be replaced, whereas if it’s a permanent physician they might work harder to work through the communication issues. There’s also a higher standard out there for the temporary physicians because it’s easy to request to have them replaced,” says Polhill. He also explains that a difference in patient population also presents cultural challenges for the locum physician. But despite the problems that can occur, the volatility of the environment is what draws physicians to temporary staffing positions, because they get the variety and they like seeing different geographical locations and meeting people from different parts of the country. The recent financial crisis has also impacted the physician locum sphere. Fortunately, physicians are viewed by hospitals as revenue generators, so there’s still a demand for physicians. The economic crisis has resulted in a decrease in elective surgeries – if patients are having the choice of waiting for surgery, they more often than not are postponing it, so it has actually decreased patient volume.
NALTO’s mission The purpose of the National Association of Locum Tenens Organizations (NALTO) is to provide a foundation of industry standards and ethical guidelines for companies offering locum tenens recruitment services. These guidelines provide the building blocks for relationships between NALTO members and their clients. NALTO is also committed to continuous education for locum tenens physicians, recruiters and clients. It provides a forum for the exchange of ideas about standards of the industry, changes in the locum tenens marketplace, and ethical treatment of physicians and clients alike. Its other aims include taking a leadership role in developing a positive image of the industry, developing an increased market share for its members, and instituting a peer review process based on excellence, honesty and fairness. Source: www.nalto.org
Ruddy Polhill “Being a revenue producer, physicians are not impacted anywhere nearly as severe as the nursing side where they’re considered to be more of an expense from a hospital perspective,” says Polhill. “Hospitals are one of the largest, if not the largest, purchaser of healthcare next to government. The government’s growing; what goes on with the hospitals ultimately affects the demand for our services. “For example, in 2008 healthcare staffing brought around $11.4 billion in revenue. The good news for NALTO members is that the physicians are still being projected to be growing about five percent. Now just to put it in perspective, last year of the $11 billion generated, about $1.8 billion was actually the fees attributed to locum tenens physicians. The analysts that watch our industry are expecting the physician fees to grow to around $1.9 billion. As physicians, we are growing, but will be growing slower than expected as an industry.” As Obama’s healthcare package begins to unfold, Polhill still remains undecided as to how this will affect the sphere of locum workers. “Everybody wants higher quality healthcare but the real questions is how to get there from where we are now and how to pay for it. I’m not sure how it’s going to affect our industry, but I’m hopeful. Anything that increases patient access to care creates more demand for what we do, so from that perspective it will create more demand for healthcare services.” Working within the locum sector certainly brings its share of challenges, both for physicians and the recruiters themselves, but as Polhill explains, 2009 could be the year of governmental change and with an increasing patient demand, the problems of staff retention are likely to work in favor of locum tenens. n Rutherford ‘Ruddy’ Polhill is the President of the National Association of Locum Tenens Organizations.
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six SIGMA
L
ean and Six Sigma – you may have heard the buzzwords, but do you know what they mean? James Levett, Chair of the American Society for Quality’s (ASQ) Healthcare Division, does. “Six Sigma was used initially by Motorola and was then popularized by General Electric in the 1990s,” He explains. “It is very much focused on reducing variation in products that are developed and produced, so it streamlines processes and reduces variation, making you produce a high quality product or output. It has been brought into service industries, including healthcare, more and more over the last 10 years. “Lean comes out of the production system model that has been used for many years at Toyota, and has also evolved into other service industries over the last 10 or 15 years. It’s extremely popular now in healthcare as well, because it has a general focus on emphasizing waste reduction and streamlining processes in organizations. It’s complementary in a sense to Six Sigma. Lean is making things more streamlined and reducing waste; Six Sigma is more looking at a process in detail to reduce variation and output. They both have strengths that complement each other and over the years what’s happened is that a lot of organizations are starting to use some of both of those methodologies to apply to their businesses, and this is true of healthcare organizations as well.” This is where the current trend towards Lean Six Sigma comes in – an amalgamation of the best parts of both systems. Levett agrees that this is exactly what’s happened, pointing out that many organizations
start with Lean, because it requires less extensive training than Six Sigma does. This was borne out in the ASQ’s recent national benchmarking survey on the use of Lean and Six Sigma in hospitals, which showed that the median investment for Lean was $25,000, and it was $96,000 for Six Sigma. “Starting Lean is a little bit easier and a little bit less costly for organizations,” Levett says. “But again, an organization that’s serious about doing these kinds of things will often employ both principles.”
Life or death
One of the main aims of both systems is the avoidance of defects. In car manufacturing or electronics, this might mean something as relatively minor as a dented panel or a component that doesn’t work, but in healthcare a defect can have life or death consequences. “Both of these methodologies allow healthcare providers to implement or start to make changes within processes and policies and procedures that make mistakes less frequent,” Levett says. “In other words, they make the care delivery safer and more reliable. I would say that that’s a major focus for healthcare providers now, the idea of patient safety and reducing errors.” The ASQ’s survey was aimed at determining how many hospitals are doing just that. The association is heavily involved with both Lean and Six Sigma, even offering a Six Sigma certification. “We were aware within our division that there was a lot going on in hospitals who are interested in improving quality and that they were using these concepts,” Levett
Better together
The concepts of Lean and Six Sigma have been going strong in the manufacturing divisions of various industries for some time. Now they’re being used in tandem in healthcare. James Levett gives EHM the lowdown.
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underlines. “As we discussed it more and more, we realized that we had heard a lot of commentary over the last few years, but we didn’t know for sure who was doing what, so we decided that we would take a survey to see what was actually going on in the market. We surveyed 77 hospitals and looked to see what they were doing, if they were using Lean or Six Sigma and which areas they were using them in. “We found that about 53 percent of hospitals had some level of using Lean. Not necessarily full deployment but some level of using it, and 42 percent had some level of Six Sigma deployment. It was a little more popular to use Lean but probably not statistically different. We found they were using them in the clinical setting, in which both were used: hospitals that used Lean and Six Sigma used them most often in the operating room and the emergency room. “With Lean, 61 percent of hospitals were using it in surgery and 60 percent were using it in the emergency room. For Six Sigma, the emergency room was 72 percent and the operating room was 66 percent. The percentage probably isn’t as important, but the idea is that hospitals using both Lean and Six Sigma tended to use those methods in the operating room areas. Those are high volume areas and certainly surgery is a risky procedure overall. In other words, there’s a lot of opportunity for error and it doesn’t surprise me really that the hospitals would have used the methods in those areas.
LEAN Lean manufacturing is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Working from the perspective of the customer who consumes a product or service, ‘value’ is defined as any action or process that a customer would be willing to pay for. Lean is centered around creating more value with less work. Lean manufacturing is a generic process management philosophy derived mostly from the Toyota Production system (TPs). it is renowned for its focus on reduction of the original Toyota seven wastes in order to improve overall customer value. Lean is a variation on the theme of efficiency based on optimizing flow; it is an example of the recurring human tendency toward increasing efficiency, decreasing waste and using empirical methods to decide what matters, rather than uncritically accepting pre-existing ideas.
SIX SIGMA
“For any quality system to be effective or to work in a healthcare setting, you clearly need leadership that will support it and help make resources available to get things done” “I would point out that there were some areas in which they were used in the hospitals as well, which were not just clinical but more ancillary or support service areas, and those areas included admissions and discharge and radiology and imaging. Both Lean and Six Sigma were used for admissions/discharge and radiology or radiology/imaging, which again are areas where you have a lot of things going on, people coming in and going out of the hospital for admissions and discharge, and then radiology has lots of images done every day.” It makes sense that hospitals would start to use Lean and Six Sigma in these high-volume areas where potentially life-threatening or costly errors could be made. Levett admits that if he’d had to guess ahead of time where the two systems would be used, those are the areas he would have chosen.
Money problems
Another question the survey asked was, if a hospital was not using either method, why not? Levett says the biggest reason given was a lack of resources. “The other reasons were that they didn’t have enough information to use them or deploy them, and the third was that leadership
six sigma is a business management strategy, initially implemented by Motorola, that today enjoys widespread application in many sectors of industry. six sigma was originally developed as a set of practices designed to improve manufacturing processes and eliminate defects, but its application was subsequently extended to other types of business processes as well. in six sigma, a defect is defined as anything that could lead to customer dissatisfaction. it uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization, using a system of ‘belts’ similar to that employed in martial arts, who are experts in these methods. Each six sigma project carried out within an organization follows a defined sequence of steps and has quantified financial targets (cost reduction or profit increase).
buy-in was lacking. The point there that I would like to emphasize is that for any quality system to be effective or to work in a healthcare setting, you clearly need leadership that’s behind it and that will support it and help make resources available to get things done. That’s true for any organization, not just healthcare.” If lack of money is a major barrier to implementation, this begs the question of what’s stopping management from buying into these processes that can help reduce costs and even save lives in the long run? The obvious answer is that it requires an upfront investment that may not always be easy to justify in the short term.
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American Society for Quality The American Society for Quality (ASQ) is the world’s largest authority on quality. With more than 100,000 individual and organizational members, this professional association advances learning, quality improvement and knowledge exchange to improve business results, and to create better workplaces and communities. The ASQ has been at the forefront of the quality movement for almost 60 years. Headquartered in Milwaukee, the association traces its beginnings to the end of World War II, as quality experts and manufacturers sought ways to sustain the many quality-improvement techniques used during wartime. Today manufacturing remains a core of the ASQ’s activities, but ASQ it has established itself as a champion of quality in education, healthcare, the service sector and government. The ASQ also offers technologies, concepts, tools and training to quality professionals, quality practitioners and consumers. Globally, it has formed relationships with other nonprofit organizations that have comparable missions and principles. ASQ members have informed and advised Congress, government agencies, state legislatures and other groups and individuals on quality-related topics. The ASQ’s healthcare division has about 3500 members.
“There are data that would suggest savings are accrued,” Levett says. “You do save money when you institute these systems, and there is data out there on both Lean and Six Sigma for healthcare. We didn’t ask that question specifically in the survey, but I expect there will be a lot more information coming out in the next few years around this.” So money remains a major issue when implementing Lean or Six Sigma in a hospital setting. What are some of the other challenges involved? Levett points out that there is also staff time involved: “The nurses, doctors or other staff that are involved with it have to spend time working with a team to accomplish these things to bring this methodology forward, which also takes money. Staff time is expensive and without a balance sheet that’s real strong, if a hospital is struggling a little bit on the margin, then those resources may not be there. You could certainly make the argument that if you’re going to save money in the long run, it’s a great thing to do. I think as more evidence is accumulated to support the use of these methods in healthcare, it will become more popular, as people are convinced that it’s the right thing to do and it will save them money.
“They’ll be wanting to spend the money upfront because they got a positive return on investment. The other point is that if the leadership of the organization isn’t behind it, then what happens is you might start a little project here or there but it doesn’t go anywhere. The successful organizations that have used these techniques have had major culture shifts. They’ve brought Lean, for example, right into the culture and used it on a daily basis so that everybody was involved. “The same goes for companies like General Electric that have used the Six Sigma systems. I believe that having it as an essential and integral part of your culture is key and that, of course, presupposes buy-in at the top. The leadership of the organization has to make that happen.”
Time challenge
Levett points out that bringing in these new processes also takes time. “It doesn’t happen in a month. It might take two, three, five years. So it’s a major commitment to a methodology and to a system of quality, but it is starting to show payoff in organizations that have used it.” As with most new initiatives, it tends to be the bigger hospitals with more money and resources who are the earliest adopters. Levett says that although some small hospitals are using Lean and Six Sigma, it does tend to be the bigger systems that are currently at the forefront of implementation. In terms of the future, Levett foresees Lean and Six Sigma beginning to spread even more widely within the healthcare sector. “Quality is clearly at the top of the list of concerns of interest to healthcare leaders. We’re all measuring more things than we used to. We’re reporting more quality metrics, and I think that this idea of using quality methods in a sophisticated way, in a way that becomes part of your culture is important, and organizations that have used it have been very successful. ThedaCare, for instance, in Wisconsin is a very successful organization that’s used Lean. The Virginia Mason Clinic in Seattle is another one. “As more organizations get into it, publish information and talk about it, you’ll see more of it used and I think that’s good. It’s the right thing to do, and ASQ is out there trying to support organizations and help them get the best from Lean and Six Sigma for their own advantage and that of their patients”. n
“As with most new initiatives, it tends to be the bigger hospitals with more money and resources who are the earliest adopters”
James Levett is Chair of the American Society for Quality’s Healthcare Division and Chief Medical Officer for the Physician’s Clinic of Iowa.
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EMPLOYEE HEALTH
The cost of living Can wellness provide a solution to our spiralling healthcare costs? Lillian Petty, former Manager of Corporate Benefits at Schlumberger and current President of the Alliance for Wellness ROI, explains what it will take to bring business on board.
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illian Petty tells a story that serves as a stark illustration of America’s gathering health crisis. “I was making a presentation at a conference and this guy came up to me and interrupted the group,” she recounts. “He worked for a casket making company and he told us that his costs were increasing because they were having to make larger caskets for everyone from babies to adults.” It’s a morbid illustration of the intersection between life, death and money in the US. But one anecdote can’t really sum up the true enormity of the situation. In 1980, healthcare expenditure in the US sat at $253 billion. By 1990, that figure had hit $714 billion and in 2008 it had risen to a staggering $2.4 trillion, or 17 percent of the nation’s GDP. If this trend continues, America will be spending $4.3 trillion a year on healthcare by 2017. In light of these figures, wellness seems to be a concept whose time has come. Traditionally dismissed by cynics as a woolly and ill-defi ned approach to health issues, these mounting costs are forcing a rethink. The statistics become even more compelling when you consider that as much as 75 percent of these costs are attributable to illnesses caused by lifestyle such as smoking, poor diet or a lack of exercise. Suddenly the simple act of stopping people becoming ill in the first place looks like a banker. The big ‘but’ comes in the challenge of effectively measuring the fi nancial benefits of wellness programs. Business is motivated by the bottom line, never more so than in difficult times like these. If you can’t confirm that an investment is paying off, then don’t expect it to get much play in the boardroom. It’s an issue that Petty, former manager of corporate benefits at Schlumberger and current President of the Alliance for Wellness ROI, is only too familiar with.
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EMPLOYEE HEALTH The formation of the Alliance for Wellness ROI came about directly to counter the uncertainty that has prevented business from really buying into wellness. “There’s no standard definition for wellness, so we’re pushing that in companies,” says Petty. “Are you doing family support programs, or a comprehensive physical program? Just comparatively deciding what a wellness program is has been a huge challenge.” Steve Villella, Vice President and Health & Welfare Practice Leader at employee benefits firm Touchstone Consulting, echoes this concern. “The problem with wellness ROI is you’re trying to measure something that never happens,” he says. “You essentially say by virtue of participating in this wellness plan these claims never happen. It’s somewhat of a dubious task because you’re trying to calculate something that it’s really hard to get your hands around.” Petty’s interest in preventative health goes back quite a while. While working at Schlumberger, an engineering and services firm heavily focused on the energy market, she became aware of the amount that was being spent on life insurance. “In Schlumberger, people come to work pretty much at the beginning of their career, some of them right out of college and high school, working on oil rigs,” she says. “They’d work very hard, and I kept seeing that these people would drop dead five to seven years after retirement. It led me to ask the question: if we’re spending this much on life insurance, what are we doing on preventative? The more I dug down into what they were doing, the more difficult it became to find out what was actually happening in the area of preventative healthcare.” Creating standards about what exactly constitutes a wellness program is key to ensuring their wider acceptance. At Schlumberger, Petty’s answer to this issue was build the program around one key spoke. “We carved out a comprehensive physical exam done by one company throughout the US,” she says. “If I sent all our people to different doctors, who’s to know what we’re getting is really the preventative exam?” Schlumberger partnered with a company called EHE International as the sole provider of physical exams. Having all the information from these exams in one place and one format allowed Petty to see a far more complete picture of the company’s overall health. Problems like high blood pressure and high cholesterol were prevalent; in short, conditions largely associated with lifestyle that had the potential to cause serious illnesses as employees aged. Petty is clear that health and wellness needs to be tackled aggressively, and she sees parallels in the way that business has approached another major issue. “It’s like substance abuse management in companies,” she says. “They have begun to say if you are on substances, you can’t work for us. So you begin to build a culture substance-free. The exact thing has to happen in health. My prediction is that we will get to a point where if people don’t begin to participate in some of these voluntary programs we will begin to say that they have to pay more to be in a health plan. We’ve not done that at this point.” For Petty at least, these more heavy handed tactics weren’t re-
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quired. At Schlumberger, the carrot was employed more frequently than the stick and the response from employees was generally favorable. However, any idea that a wellness plan can be set up and immediately start showing results is misguided. “The biggest challenge is that most employers think they will put in a program, and next year their costs are going to go down,” Petty says. “This has to be a three to five-year continuous program, and it has to be a strategic population impact plan approach, not just one program.” This means offering employees plenty of choice, and even offering rewards for those that sign up. “It’s amazing what people would do to get a cap or a T-shirt,” continues Petty. But while it is possible to draw certain conclusions on the value and effectiveness of wellness programs by looking at a single company, to get a full picture you need bigger numbers. It was this understanding that led to the formation of the Alliance. “I had been participating as a board member for the Council on Employee Benefits here in the US, going to meetings every year with the top 200 companies,” Petty explains. “All I kept hearing was ‘cost shifting.’ My background being more behavioral and socially grounded, I thought that this wasn’t going to go away with a silver bullet of a strategy. To me, it has to go with managing population health over time.” Petty then went to the members of the CEB to find out if they wanted to join together to tackle the issue. Five came on board. The next challenge was taking data from a disparate range of companies and beginning to build a financial model for valuation. Even with only five companies on board, the amount of information that needed to be collated was huge. “It's taken us almost four years to just gather every healthcare claim, every pharmacy claim, every wellness program, information on who's participating and who's not,” she continues. This work involved not only actuaries but also epidemiologists from Columbia Presbyterian Hospital out of New York. Getting these different perspectives was essential, claims Petty: “That was the big difference, because we wanted to have the science of the epidemiologists, the actuaries, as well as the benefits and strategic HR people, involved in coming up with this whole approach.” To crunch the data the nascent Alliance turned to Touchstone Consulting. Steve Villella was involved from the start. “We were able to take the
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EMPLOYEE HEALTH
data from the Alliance’s five founding member companies, which is about 250,000 lives,” he says. “It’s a pretty good data set. We took three years of data for them, did our analysis, and we came up with ROI. Now, although that’s a great number, what we want to do going forward is start producing ROI for multiple combinations of programs and the effect of one program on the other. With 250,000 lives you can start doing that, but we would prefer to have 2.5 million lives. The more lives we get, the more we can do with it, the more credible the results.” Standards are at the very core of changing the perception of wellness from touchy-feely adornment to a valuable business tool. Currently there is no clear definition of what constitutes a wellness program. Two companies could offer a program that bear very little resemblance to each other. Correctly putting a hard dollar benefit on something with such widely differing parameters is a virtual impossibility. To address
this issue the Alliance employs a standards group to annually consult on the factors used to run its ROI modeller. This group once again takes in a wide range of expertise to get a full spectrum picture. “It’s not just the science of the consultant or the science of an actuary, it’s looking collaboratively at those and coming up with the factors that measure,” Petty says. “We think those standards are what’s going get the C-Suite to recognize the value of these programs and understand the fact that they’re managing population health and not just something cutesy like a wellness program.” The statement that ‘people are our greatest asset’ crops up so often when speaking to HR and business leaders that it is in danger of becoming nothing more than a platitude. If companies are really serious about the value of their people, then helping them stay healthy should be a nobrainer. “It’s an investment in your population,” Petty confirms. “Just like you invest in making sure the tools run well and the buildings are kept up-to-date, there has to be investment in Raising the standard the people. In these challenging economic times and even before, we push people all the time to give their best. And The Alliance for Wellness ROI was founded in 2005 as nonprofit they spend more and more time in the world of work.” corporation by BMW North America, Henry Ford Health System, Kraft Foods, MasterCard Worldwide and Sclumberger. The Alliance has identified several key components that should be present in any wellness program. Adoption of these standards is seen as key to building a comprehensive understanding of the true value of wellness. Disease management Employee assistance programs Fitness programs Health risk appraisal Onsite medical program Personal wellness profile
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Screenings/preventive care Smoking cessation Telephonic wellness services Weight management Wellness education/communication Work/life balance
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EMPLOYEE HEALTH But all that’s gone before means nothing if the figures don’t stack up. The commitment to a company’s people will only exist as long as the profit and loss figures are arranged in the right way. The good news for the Alliance, and those employees that stand to benefit from its work, is that early indications demonstrate some very positive results. “For the first five founding member companies in three years of analysis we have looked at individual programs, and we found some really interesting things,” says Villella. “Certain programs take longer to yield a positive ROI. A program may be a good program, but you’re not going to see any return on your investment in the first three years, whereas other programs – such as disease management programs, you see a much quicker return on your investment. The other thing we found is certain wellness programs by themselves don’t really achieve much of a return on their investment, but when coupled with other programs, they boost the return for them, and a good example of that is a health assessment.” According to Villella, this failure to take the impact of multiple components into account has been one of the key reasons that efforts to study wellness ROI in the past have had unsatisfactory results. “They typically looked at individual wellness program components, and what the Alliance wants to do is see what kind of synergies may or may not lie in participating in different combinations of these programs. They call that an integrated ROI,” he explains. Even though the Alliance’s study is at a reasonably early stage, Villella is still able to supply some fairly striking results. “Spend one dollar on a wellness program and you’re going to get two to three dollars back in claims savings,” he says. “That’s pretty good. Even if you were just getting your money back, it’s probably not a bad idea to offer these programs. You talk about a 15,000-employee company and they’re incurring medical claims of $100 million a year. You could be talking about $5 million in savings just by offering these wellness programs above and beyond what you’re spending on them. Five percent of your claims is a good chunk of money.” But even in the face of results like these, much needs to be done for wellness to take center stage in business’s battle against healthcare costs. Perhaps a new administration will provide the required impetus? Petty seems cautiously optimistic: “There’s a leadership group that’s been working in the area,” she says. “Obama uses the words ‘prevention’ and ‘wellness’, and I’m seeing that as definitely a good thing.” Nonetheless many of the hard yards will still have to be made by business. “It’s a huge elephant to turn around, that that’s why we started the alliance,” she continues. “We can’t wait on Washington. Companies pay the money, so if they’re going to wait on government to bail us out it could be quite a long wait.” Th is sentiment is echoed by Villella. “The government, although they seem to push wellness, you don’t see them really giving individuals an incentive to be well,” he says. “But the biggest reason
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why I don’t think we'll see anything in the short run is they have bigger fish to fry right now with the economy. So, I think healthcare is going to take a backseat. But even if it were not to take a backseat to that, it seems like the government is more interested in whether we should have socialized medicine and less interested in what's really producing the claims costs. The old axiom in our actuarial world is 20 percent of the individuals make up 80 percent of the claims. If you really want to affect your claim cost, you got to need after those 20 percent of the people. A way of doing that is through wellness programs.” Ultimately though, a change will have to come. Current healthcare spending is unsustainable and, even if it weren’t, surely it’s better to use funds to prolong and improve people’s lives rather than just paying off their dependents when they die early? But money is only half the picture. People themselves have to want to make this change happen, to alter the lifestyles that are contributing to health problems. Petty remains optimistic but agrees that the road ahead will be a long one. “It will require a big change in our culture,” she says. “Look at smoking. We’ve had success there, but it took years to turn it around. Now if you see somebody smoking, you kind of wonder what’s wrong with them.”
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WELLNESS
Getting better?
Kelli Kolsrud of the International Federation of Employee Benefit Plans sheds some light on the state of corporate wellness.
T
he IFEBP recently completed a major survey into wellness programs. This survey focused on the design of wellness programs and what employers are offering, if they offer them at all. We looked at what types of initiatives were out there, whether organizations were getting adequate participation rates, whether or not they’re offering incentives and if so, what kind of incentives. One of the first questions we asked was what is their motivation for offering wellness. Forty-six percent said they want to control healthcare costs. Another primary reason is they just want to help employees have better overall health. That’s not really startling but it kind of confirmed what we expected. Then we asked about a lot of different initiatives. Screening and health risk assessments and appraisals were popular, near the top of the most commonly offered. Weight loss and fitness are certainly popular as well as some informational initiatives where companies arrange health fairs or give employees web links to useful resources and things like that. Unfortunately a lot of the programs they institute do not have high participation rates and I think that that’s a problem for employers that leads them to offer incentives to try to increase those participation rates. So we asked about specific initiatives and whether employers include incentives or not and also whether they believe they derive certain benefits from wellness. That actually brings up an issue that’s really a challenge with wellness. A lot of employers are not measuring the return on investment. Therefore they don’t have a sense for whether they add value or really do help control costs. When we have an economic crisis like the current one I think the main challenge for wellness programs is that employers don’t have a good sense of how much they save money or add value. These programs are then perhaps vulnerable perhaps to reduc-
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tions, budget cuts and problems like that. Understanding the true value of wellness programs is going to be key to their ongoing success. Academics have gone into companies and tried to do studies and the trick with wellness is it’s a long term investment. You don’t institute a program and then six months later have a huge drop in healthcare costs. It takes years and it’s a difficult task to try to change behaviors and convince employees that it’s
worth their while, both for themselves and for the organization, to change unhealthy habits. All in all, it’s a pretty complicated challenge. I think sometimes employers institute plans and they look upon them maybe as a perk or a nice to have. But for wellness programs to really succeed they have to be an integral part of the health plan and the culture and you need to have support from upper management to realize the full potential. You
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A lot of employers are not measuring the re-
in the program isn’t so hard, getting them to contin-
networking opportunities to benefits and
turn on investment. Therefore they don’t have a sense for whether they add value or help
ue is the real challenge. People don’t necessarily want employers dictating what they consider their
compensation professionals.
control costs. When we have an economic cri-
personal lives and they are sometimes just used to
sis like the current one, the main challenge for wellness programs is that employers don’t have a good sense of how much
eating less healthy foods or not making the time to exercise. We’re creatures of habit and a lot of people don’t feel they have
they save money or add value. These programs are then perhaps vulnera-
the time to exert effort in that regard. Plus, some of those unhealthy foods
ble to reductions, budget cuts and problems like that.
taste really good. But if employers see the value of wellness plans and can
Understanding the true value of wellness programs is going to be key WELLNESS to their ongoing success. Academics have gone into companies and tried
IN THE BACK 139
realize that value then they’ll want to continue to support and enhance
these programs. I certainly think the interest and popularity is growing. We
Healthy figures
• Control costs of high-risk conditions
Highlights of the IFEBP’s recent survey into corporate wellness programs
To a very great extent 1%
• Types of incentives 39%
Non-cash incentives/raffles/prizes Gift cards or gift certificates Cash rewards Insurance premium reductions Gym/fitness center discounts Contributions to health accounts Reimbursement of costs Waivers/reductions for deductibles Additional time off Other No Incentives offered
32% 22% 22% 21%
5% 4% 4%
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need a commitment from the employer to budget for it and allow time for employees to participate and reward them if necessary. Sometimes getting them started in the program isn’t so hard, getting them to continue is the real challenge. People don’t necessarily want employers dictating what they consider their personal lives and they are sometimes just used to eating less healthy foods or not making the time to exercise. We’re creatures of habit and a lot of people just don’t feel they have the time to exert effort in that regard. Plus, some of those unhealthy foods taste really good. But I think if employers really see the value of wellness plans and can realize that value then they’ll want to continue to support and enhance these programs. I certainly think the interest and popularity is growing. We have seen that, but their success may be closely tied to whether wellness plans are able to show their value. But wellness is not purely a financial issue. Another element of our survey addressed the impact it can have on other factors within a company. We actually asked the participants in the
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To a very great extent 1%
20% 5
10
15
20
25
To some extent 18%
To a little extent 12%
Not at all 6%
• Improved worker health
11% 10%
0
To a great extent 3%
Not sure 60%
30
35
40
survey whether they thought some of the benefits derived included things like improved morale, worker health, increased productivity, reduced absenteeism and other things like that. The areas where they most benefit is in worker health and morale and not as much in controlling costs or controlling costs in general for healthcare or of high risk conditions. A lot of respondents to the survey just said they weren’t sure whether they derived benefits or not. That’s telling in itself.
Kelli Kolsrud is Senior Information/Research Specialist for the International Foundation of Employee Benefit Plans. The IFEBP is a nonprofit organization, dedicated to being a leading objective and independent global source of employee benefits, compensation and financial literacy education and information. The Foundation delivers education, information and research, and networking opportunities to benefits and compensation professionals.
But the concept of wellness isn’t something that should only be the concern of employers. News stories today in the States
To a great extent 6%
Not sure 50% Not at all 3% To some extent 27%
To a little extent 12%
are heavily populated with items about childhood obesity and lack of fitness in young people and children. Obviously, if you have that problem at a young age it’s only going to be worse as they age and enter the workforce. It’s a social issue certainly in this country in Europe. and elsewhere in industrialized nations. I think even Japan is having problems. Fast food has taken over the world. As for who is going to take the lead on this going forward the jury is still out. It certainly seems like the new administration is interested in healthcare reform and many healthcare reform proposals include wellness initiatives and improving quality of healthcare and reducing costs. A public health message is certainly part of healthcare reform proposals that are being introduced, but it remains to be seen whether or not they will come to pass. Although we just heard Obama’s budget has set aside a healthy chunk for healthcare reform of course it has to get through the Congress. Yes and there are a lot of people who will be clamoring for that money as well. It’s not a done deal yet. n
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REGIONAL FOCUS: JAPAN
Sleeping dragon
Rich in culture and traditional practices, Japan’s healthcare infrastructure is struggling to cope with its large and aging population.
C
omprised of 128 million people, Japan is the world’s tenth largest population and compromises over 3000 islands. Japan has the highest life expectancy in the world, according to both the World Health Organization and the UN. However, a rapidly aging population is expected to cause strain on the healthcare system. The effect of a post-war baby boom has led to social problems, such as a decline on workforce population and an increase on the cost of social welfare It is compulsory in Japan to be enrolled in an insurance program if you are a resident, the two types being social health insurance and national health insurance. Th is results in two types of services – public and private – but the issue of space poses a problem to the region’s healthcare infrastructure. It is reported that more than 14,000 emergency
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REGIONAL FOCUS: JAPAN
patients were rejected at least three times by hospitals before fi nally being treated. Traditional Chinese medicines were introduced into Japan with other aspects of traditional Chinese culture in the early 9th century, but since 1900 those practicing TCMs are required to be licensed medical doctors. Japan’s healthcare problems are in contrast to the US, being less due to chronic illness and instead owing to poor administration and uneven distribution of health personnel. However, one of the major healthcare issues in Japan is due to the use of tobacco. According to a study, smoking kills more than 100,000 people per year, and is responsible for one in 10 deaths. Japan is notorious for its exceptionally high suicide rate, with figures far exceeding that of the US. The Yomiuri Shinbun, a
141
Japanese newspaper, reported in June 2008 that more than 30,000 people had killed themselves every year during the previous decade. It is estimated that health problems are the factors causing the vast amount of suicide deaths.
Travel focus
Tokyo is the world’s most populous metropolitan area with 35 million people, and also the world’s largest metropolitan economy. It houses the country’s largest museum, Tokyo National Museum, and is bursting with modern, as well as traditional art. The cuisine in Tokyo is highly acclaimed, boasting over 100 Michelin stars, almost twice as many as Paris, its nearest competitor. The birthplace of sushi houses, Tokyo is the place to feel the authentic Asian experience.
Smoking kills
100,000 people annually in Japan
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IN THE BACK
Japanese hospitals
Tokyo Medical University hospital is one of the old medical schools of Japan, receiving university status in 1946. The University Hospital is a private institute, offering educational training through a sixyear medical school program. Most notable, the hospital is partnered with the World Health Organization in order to collaborate in addressing non-communicable diseases and psychiatric health issues.
Akashi Tsuchiyama hospital is a private psychiatric hospital located in Akashicity. One of the more famous hospitals in the region, Akashi Tsuchiyama offers medical facilities of occupational therapy and recreation and treats almost all psychiatric disorders.
Naval Hospital Yokosuka Japan is a medical institution looking after the needs of the Seventh Fleet – the US Navy’s permanent forward projection force – and their families. It is located on Yokosuka Naval Base and is relatively new, having been rebuilt in 1931 following the Great Kanto earthquake. The hospital provides emergency, outpatients and inpatient care services; but more importantly has been recognized for its work during both the Korean and Vietnam Wars.
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IN REVIEW
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On the shelf
EHM rounds up the latest healthcare books.
A Second Opinion: Rescuing America’s Health Care By Dr. Arnold Relman
Written by the former Editor-in-Chief of the New England Journal of Medicine and Harvard Medical School professor, A Second Opinion is Relman’s opinion of what went wrong with our health system, and how he intends to fi x it. Relman diagnoses that profit imperative increases cost and proposes a solution of a single-payer insurance program supported by progressive tax. EHM says: A good, thorough analysis of the US healthcare system with a practical and logical proposed solution. Th is relatively short, well-written book is suitable reading for almost anyone. The author’s background as a physician, author, professor and editor of medical journals give him the necessary background to provide a unique perspective on a controversial subject.
Critical: What We Can Do About the Health-Care Crisis By Tom Daschle, Jeanne M. Lambrew and Scott S. Greenberger
A stab at providing a solution for healthcare’s ongoing problems. Former Senator Tom Daschle answers skeptics and asserts his own analysis. Daschle’s book examines previous attempts at national health coverage, outlines the economic factors needed to be considered for such a policy and lays out his plans for successful change. EHM says: an interesting view into the politician’s mind, but a lack of coverage of many healthcare issues. His Federal Reserve for Health concept, however, could fi nally help to overcome the ideological divisions that have stymied reform so far.
The Cure: How Capitalism Can Save American Health Care By David Gratzer
Drawing upon his experience as a physician in both Canada and the US, Gratzer discredits the involvement of legislative bodies within the healthcare system, believing it to lead to a multitude of inefficiencies and eventually punishing patients. The Cure focuses on reforming the structure to make the individual responsible via a detailed and practical approach. EHM says: an informative account and required reading for anyone wanting to know what went wrong with the US healthcare system. In going against the current prevailing move toward a centralized system, Gratzer makes a strong case for greater deregulation and freedom. May not be to all tastes, but certainly an interesting read.
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AWAYPHOTO ON BUSINESS FINISH
A memorial honoring the life of Michael Jackson on Hollywood Blvd. Los Angeles police are awaiting the coroner’s report on his death before deciding whether to investigate the tragedy as a homicide case or rule it an accidental overdose of prescription drugs.
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