Healthcare Industry News Summary

May 2008

This News Summary contains synopses of, and commentary on, health-related articles that have been published in the industry and popular press. The Summary is posted by CSC's Emerging Practices Group to this Web site monthly to help you stay abreast of industry issues and trends.  The Summary is not intended to be a comprehensive review of these publications, but it will highlight innovations, advances in the state of the art or practice, interesting facts, and "scuttlebutt" about the industry that will help you keep up with what is happening. The information has been sorted into categories to assist you in identifying information that is relevant to your interests.

Touch on any of the links listed in the table below to jump to news in that category. Hyperlinks are included for sites that maintain access so you can read articles in their entirety.  (However, some of these sites charge access fees for non-subscribers.)  For articles not available on the Web, please contact the publisher. Please note, we offer News Summary as an educational service.

Macro Trends

According to a survey of 453 large employers by the National Business Group on Health and Watson Wyatt of 453 large employers, health cost increases for companies with high consumer-directed health plan (CDHP) enrollment are about one-half of those offering only traditional coverage.  The companies with the lowest rise in annual healthcare costs had increases of 1 percent during a two-year period, while the "poor performers" reported increases of 10 percent.  According to the study, 47 percent of respondents now offer a CDHP, up from 38 percent in 2007 and 33 percent in 2006.  The report’s authors predict that this proportion will increase to 54 percent by 2009.  According to the report, CDHP enrollment is now 15 percent among companies offering them, up from 10 percent in 2007 and 8 percent in 2006.  (Health Care Cost Hikes Are Significantly Lower for Companies with High Enrollment in Consumer-Directed Health Plans, AISHealth.com, April 28, 2008)

President Bush signed a bill into law that will prevent insurers and employers from discriminating against a person’s genetic makeup.  Specifically, the bill would prohibit insurance companies from denying coverage or raising premiums because of information in a member’s genetic makeup – for example, being predisposed to a certain disease.  Similarly, employers would not be able to base hiring decisions on genetic information.  The bill was widely applauded by privacy advocacy groups.  According to  Sharon Terry, president of the Coalition and CEO of Genetic Alliance, "Individuals no longer have to worry about being discriminated against on the basis of their genetic information, and with this assurance, the promise of genetic testing and disease management and prevention can be realized more fully.”  (President Praises Kennedy Role in Genetic Non-discrimination Law, Boston Globe, May 21, 2008)

The FDA announced a data sharing plan to improve oversight of prescription drugs and medical devices on the market.  The electronic system, called Sentinel, will provide the FDA with claims data from hospitals, private health plans, and Medicare in an effort to identify problems with approved drugs and alert the agency as soon as possible.  The WSJ reports that some pharmaceutical companies expressed concern that the system may potentially result in “unnecessary” alerts.  According to the Journal, Sentinel data collection was required by the 2007 FDA Amendments Act, which called for better review of FDA-approved drugs already on the market in response to the well-publicized Vioxx recall.  (Data System to Help FDA Spot Dangerous Products, WSJ, May 23, 2008 – subscription required)

According to a poll released by the Kaiser Family Foundation and reported by the Los Angeles Times, 28 percent of U.S. residents said that they or their families have had a serious problem paying for healthcare or health insurance due to the current state of the economy.  About the same percentage of people said that they are having difficulty finding a good-paying job or getting a raise.  Other problems cited by residents included the cost of gasoline (44 percent), paying rent or a mortgage (19 percent), paying for food (18 percent), and paying off debt (18 percent).  The LA Times reports that healthcare inflation has been rising at about twice the rate of economic growth, with employer-based health insurance averaging $12,000 for family coverage and $4,500 for individuals.  The poll also found that a surprising 7 percent of Americans say they or someone in their household decided to tie the knot in the last year in order to receive healthcare benefits. (Alonso-Zaldivar, R. Getting Married for Health Insurance, LA Times, April 29, 2008)

With all the quality and performance programs underway, the question many are asking is “Are we making real progress?”  According to Carolyn Clancy the Director at the Agency for Healthcare Research and Quality (AHRQ), the answer is, unfortunately, “No.”  Dr. Clancy recently provided her interpretation of progress so far in the journey toward reliable, safe care. Two important sources are the fifth annual National Healthcare Quality Report and National Healthcare Disparities Report, which indicate some areas of improvement, but “overall quality has improved by an average of just 1.5 percent per year between the years 2000 and 2005.” This is actually a decline in annual progress when compared with the 2.3 percent average annual rate between the years 1994 to 2005.  The AHRQ reports draw information from more than 36 databases to measure quality and disparities across 1) effectiveness, 2) patient safety, 3) timeliness and 4) patient centeredness. Although they show that improvements are occurring, the gains are not happening widely enough or quickly enough.  Improvements in patient safety measures are occurring very slowly, on average by only 1 percent each year. That rate reflects measures such as how many Medicare surgical patients were not given antibiotics to prevent infection at the correct time, the percentage of elderly patients given potentially harmful prescriptions, and how many patients developed postoperative complications.  The news is not all bad. There are notable gains in the following areas:

• A 5.6 percent gain in the rate at which myocardial infarction patients received the recommended tests, medications and counseling to quite smoking
• An increase in the success with counseling to quit smoking for this population from 42.7 percent in 2000-2001 to 90.9 percent in 2005
• A reduction in disparities in childhood vaccinations of black, Asian, and Hispanic patients.  Forty-eight states, DC and Puerto Rico all performed above 80 percent for this measure.

(Brady, Ho, and Clancy, Slowed Progress in Improving Quality and Minimizing Disparities, AORN Journal, May 2008 – subscription required)

The European Commission recently published a survey (Benchmarking ICT use among General Practitioners in Europe) that finds 87 percent of European General Practitioners use a computer, and 48 percent have a broadband connection.  The Q3 2007 survey involved nearly 7,000 General Practitioners.  According to the report, European GPs increasingly store and send patients' data (e.g., lab reports) electronically.  The survey found that eHealth applications are playing an increasing role in the practices, but there are significant differences in availability and use across Europe.  For example, Denmark has 91 percent broadband penetration among GPs, while Romania has about 5 percent.  The report also discusses how doctors could offer services such as e-prescribing (currently practiced by only 6 percent of EU GPs), telemonitoring (currently only used in Sweden and the Netherlands, by 9 percent and 3 percent of GPs, respectively), and cross border medical services (done by only 1 percent of the EU's GPs).  (Survey Takes Pulse of e-Health in Europe and Prescribes Wider ICT Use among Doctors, European Union press release, April 25, 2008)

Following two years of strong earnings growth, industry analysts now expect a slowdown in growth in the health IT market.  However, industry experts anticipate that hospitals will remain committed to their IT projects.  Modern Healthcare’s annual IT survey finds that demand for electronic health records (EHRs) and clinical systems remains the greatest driver of demand for IT vendors’ services.  According to William Blair & Co. research analyst Corey Tobin, mergers and consolidation in the industry will continue throughout the year.  He said that another trend is that hospitals are seeking ways to streamline internal operations by working with fewer vendors who offer a wider range of services.  (DerGurahian, Jean. Slowdown Expected in Healthcare IT Market, Modern Healthcare, May 5, 2008 – subscription required)

Consumers

Technology solutions are allowing elderly people to live at home (“aging in place”) while providing a level of monitoring to make sure they are safe and following a routine.   A recent NY Times article cited several studies underway and profiled some of the leading sensor and IT solutions:

• Motion sensors and remote monitoring systems to make sure people get out of bed and take prescription medicines. Alerts are sent to family members when there are deviations.
• Comprehensive monitoring packages with a monthly fee that include the above plus checks for blood pressure, weight, and respiration.
• Wireless sensors and appliances that regulate temperature, light, and appliances,
• A memory bracelet being developed by Intel that vibrates at a specified time to remind the wearer of a doctor’s appointment or to take medications.
• Sensor-infused carpets (aka magic carpets) which measure changes in gait to help avoid falls.

Projects testing these and many other technology solutions are underway across the country.  Dr. Jeremy Nobel, a professor at the Harvard School of Public Health, predicts “a significant increase in the adoption of such systems in two to five years, and widespread adoption in ten years.” One perceived roadblock for wider adoption of in-home monitoring has been the resistance of older people to use the Internet.  However, a recent survey by AARP found that older people are willing to use high-tech devices at home, and to pay about $50 a month for the service.  (High-Tech Devices Keep Elderly Safe from Afar, NY Times on the Web, May 25, 2008)

The recent launch of public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data highlighted the importance now placed on the patient’s perspective on not just the care experience, but the quality of care. With this backdrop, a recent article in the Joint Commission Journal on Quality and Patient Safety reports on efforts by a team of researchers at HealthPartners Medical Group to test “whether patient reports of medical errors via surveys could produce sufficiently accurate information to be used as a measure of patient safety.” They surveyed adult patients or parents of pediatric patients younger than 12 years of age with an office visit in the prior two weeks, asking respondents to identify concerns about a wrong diagnosis, treatment, prescription, or procedure within the past year for themselves of their family. Permission was also requested to review the medical record and contact the respondent for further details. Reported errors were investigated by a nurse who normally handles patient complaints and possible or probable medical errors to the department chairperson for formal committee peer review, if the patient gave permission (some did not). Findings were as follows:

• Respondents reported 12.4 incidents per 100 respondents (11 percent, though the rate is lower because respondents could be citing an incident involving a family member).
• There were 2.65 reports/1,000 visits in primary care, 1.54 in behavioral health, 1.65 in obstetrics-gynecology, and 1.12 in other specialties.
• Medical reviews considered patient-reported errors as “misunderstandings” 45 percent of the time.
• “Another 20 percent of these reported errors appeared to represent complaints about ‘behavior or communication’ problems by medical group personnel.” (e.g., waiting times, rudeness)
• Nineteen percent of the possible incidents were classified as possible errors, one-half of them incorrect medication fills. Because of patient refusal to give permission, only six cases were peer-reviewed. In the end 2 percent were judged as real clinician medical errors.

Although few of the reports were judged to be medical errors, the authors “do not interpret these results to mean that patients should not be surveyed about their care experience or even about their perceptions of errors experienced,” but rather that patient reports are not a reliable measure of technical medical errors and patient safety without further evaluation. HealthPartners is discontinuing use of these data to measure patient safety and compare error rates among medical groups and hospitals. “That forces us to work harder on the service and communication problems that appear to be common.”  (Solberg, L.I., et al. Can Patient Safety Be Measured by Surveys of Patient Experiences? The Joint Commission Journal on Quality and Patient Safety, Vol. 34, No. 5, p. 266-274, May 2008)

On May 5, CMS launched the pilot online personal health record (PHR) program in South Carolina.  The program is available to thousands of Medicare beneficiaries, and gives patients

• Access to physician practice and hospital claims-based data.
• Enables patients to enter prescription and over-the-counter medication information.
• Provides convenient links to Web sites based on patient-specific diseases and health conditions.
• Includes options to share record access with providers, family members, and others designated to receive user IDs and passwords

The purpose of the program is to help CMS learn how patients use PHRs and how to encourage/reinforce further and continued use.  The PHR used is a product of HealthTrio, the claims data is provided by Palmetto GBA, and the project is being managed by QSSI (Maryland). (N Ferris, Medicare PHR Pilot Is Underway in South Carolina, Government Health IT, May 5, 2008)

Two interesting new Web sites for healthcare consumers were announced recently:

• The first is www.YourMedicalTravel.com, which provides information and advice to U.S. residents traveling abroad for medical care.  In addition to travel tips, the site notes legal issues to consider and reviews insurance options.  It also compares procedure costs, quality benchmarks, and follow-up care available from various countries, including Thailand, Singapore, India, and New Zealand.
• The other is www.iGuard.org, which enables consumers to post and research medication side effects.  The service is run by a company of the same name and was funded by Quintiles Transnational Corp, which sells clinical research services.  In addition to side effects, the site also posts patient drug reviews, a drug risk-rating system, drug safety alerts, and recall notices.

(Site Offers Medical Tourism Info, Health Data Management, May 10, 2008; Site Offers Forum for Drug Side Effects, Health Data Management, May 8, 2008)

Beth Israel Deaconess Medical Center Joins Forces with Google Health.  Beth Israel Deaconess Medical Center (BIDMC, Boston) announced on May 20 that it is giving PatientSite portal (BIDMC’s PHR) users the option to export diagnosis, medication, and allergy lists from BIDMC’s clinical information systems to Google Health.  BIDMC CIO, John Halamka, MD, is a long-time supporter of the PHR.  In addition to being one of the 23 experts on the Google Health Advisory Council, he has supported BIDMC partnerships with Microsoft HealthVault and the Dossia Consortium (of employers supporting lifetime PHRs, see EP Notes – March 24, 2008) PHR programs.  Halamka quotes during the announcement included, “We believe that patients should be the stewards of their own data,” and, “The end result will be when patients leave the BIDMC area or see a provider outside the area, they can have all their medical data located in one safe place.”  (Beth Israel Deaconess Medical Center Joins Forces with Google Health, Medical News Today, May 20, 2008)

Health Plans

What health plan Web site features do members use? Forrester Research recently released the results of a Q2 2007 survey of privately-insured, non-elderly consumers who visited their health plan’s Web site within the past year:

• Fifty-one percent used an online tool for find a provider;
• Thirty-two percent used an online health plan selection tool;
• Twenty-seven percent did a drug cost comparison;
• Twenty-four percent used an online health risk assessment;
• Sixteen percent used an online drug quality comparison tool; and
• Thirteen percent compared hospital quality online. 

(Which of the Following Online Health Care Tools Have You Used? iHealthBeat, April 23, 2008)

According to a report published by the New America Foundation, U.S. manufacturers that offer health insurance to employees spend an average of $2.38 per worker per hour on healthcare, compared to about 96 cents per worker per hour by foreign employers.  The author of the report wrote that foreign manufacturers have lower healthcare costs because they operate in nations with systems that are financed by the government and that globalization makes it infeasible to pass on this cost to consumers. According to the report, these findings build on a multi-year trend in which healthcare costs have been rising faster than productivity and wages. (Nichols and Axeen, Employer Health Costs in a Global Economy, New America Foundation, May 2008)

On May 1, WellPoint, Inc. announced a new mobile directory that members can use to search for local, in-network doctors and hospitals through any Web-enabled cell phone or hand-held device, such as a Blackberry.  Search criteria include location, name, specialty, language spoken, and gender.  The tool is now available to affiliated plan members in Connecticut, Maine, and New Hampshire, and will become available in other geographies during 2008.  (WellPoint Introduces Industry's First Electronic Tool to Help Members Search In-Network Doctors and Hospitals, WellPoint, Inc. press release, May 1, 2008)

Aetna is now providing physicians with evidence-based Care Considerations electronically through its provider Web site via NaviNet. Care Considerations alerts physicians to opportunities for improved care when care appears to have deviated from evidence-based medical best-practice standards.  These Care Considerations are derived though the MedQuery® program, which analyzes the plan’s data (claims, patient demographics, etc.).  Data are mined weekly and analyzed to identify potential omissions (gaps in care) or errors of commission (e.g., drug interactions).  Under the new system, once MedQuery identifies a Care Consideration for an Aetna member, the physician is sent a message via NaviNet as an Action Item Alert or as a pop-up screen during eligibility verification. Response to more urgent Care Considerations may also include a telephone call, fax, or letter to the physician.  Physicians can use the NaviNet portal to provide feedback about why a Care Consideration may be inappropriate, for example, if the patient is allergic to the recommended medication.  (Aetna Helps Patients, Physicians Improve Health Outcomes with New Online Capabilities, Aetna News Release, April 30, 2008)

On April 30, J.D. Power and Associates released its 2008 National Health Insurance Plan Study, which measures member satisfaction with 107 health plans in 17 regions by examining coverage and benefits; choice of doctors, hospitals and pharmacies; information and communication; approval processes; claims processing; insurance statements; and customer service.  According to the study, most plan members rate their insurer lowest for communications and information provided to help them understand their plan, with only 45 percent of members reporting that they fully understand how to use their coverage and member services.  The authors assert that health plans can achieve more consistent and positive satisfaction ratings, more renewal business, and additional sales of services to members if they contact plan members regularly and increase their understanding of plan details.  The study, which includes results by region for specific health plans, is available online.  (Satisfaction with Health Plans Varies Dramatically from Region to Region, Largely Due to Poor Communication from Insurance Providers, J.D. Power and Associates press release, April 30, 2008)

On April 29 Houston Mayor Bill White launched a Web site that aims to increase transparency and help residents learn more about their health insurance plan options.  The HoustonHealthChoice.com Web site offers tools for users to compare health plans side-by-side based on premiums, deductibles, and coverage.  Only insurance companies that earn a B+ rating or higher from the Texas Department of Insurance appear on the Web site.  The site also contains links to government agencies and public-private alliances that can help residents determine whether they qualify for prescription assistance, the Harris County Hospital District's Gold Card, Medicaid, or veterans' benefits.  (Cook, Lynn. City Launches Web Site Offering Help on Health Plans, Houston Chronicle, April 30, 2008)

On April 30, America’s Health Insurance Plans (AHIP) released a 2008 census that finds over 6.1 million Americans have Health Savings Account-eligible insurance plans.  This represents a 35 percent increase since last year (approximately 4.5 million Americans were enrolled in an HSA plan in January 2007; 3.2 million in January 2006; and 1.0 million in March 2005).  The report found that enrollment in these plans represents 3.4 percent of the private insurance market.  According to the census, 30 percent of HSA enrollees were in the small group market; 45 percent were in the large-group market; and 25 percent were in the individual market.  The study estimated that HSA plan enrollment as a percentage of privately-insured individuals was the highest in Minnesota (9.2 percent), Louisiana (9.0 percent), Washington, D.C. (8.7 percent), Vermont (7.5 percent), and Colorado (7.1 percent).  The study is available online.  (More Than Six Million Enrolled in Health Savings Account Plans, AHIP Press Release, April 30, 2008;

The GAO analysis of industry and IRS data finds people enrolled in high-deductible health plans with health savings accounts (HSAs) in 2005 had an average adjusted gross income of $139,000, compared with $57,000 for other taxpayers.  Other findings include:

• Forty-one percent of HSA users who made contributions in 2005 did not withdraw any funds that year, and 40 percent of the people enrolled in high-deductible plans did not open an HSA even though they were eligible to do so.  Reasons cited for not enrolling include lack of information, cost, or the belief that they did not need the accounts.
• In 2006 HSA-eligible plans covered about 2 percent of privately-insured individuals.
• Enrollment in HSA-eligible plans increased from about 438,000 in September 2004 to about 4.5 million in January 2007.  The number of tax filers reporting HSA activity nearly tripled from 2004 to 2005 (about 120,000 and 355,000, respectively). 

(Health Savings Accounts: Participation Increased and Was More Common among Individuals with Higher Incomes, GAO report to the Committee on Oversight and Government Reform, April 1, 2008)

The Healthcare Leadership Council (HLC), a coalition of chief executives from a variety of areas within the healthcare industry, has proposed a plan to expand access to care and improve quality. The plan calls for funding public health insurance programs and for using Medicaid and State Children’s Health Insurance Program (SCHIP) dollars to help workers purchase employer-based coverage. It also calls for tax incentives to help individuals and low-income Americans purchase health coverage, and for financing mechanisms to help health care providers invest in information technology. According to the report, premiums for family coverage have increased by 87 percent since 2000, and 80 percent of the uninsured population live in wage-earning households.  The group calls for public-private cooperation in providing “premium assistance” to subsidize low-income individuals and families afford health insurance from their employer. (Closing the Gap: A Proposal to Deliver Affordable, Quality Health Care to All Americans, HLC, May 2008)

A Watson Wyatt survey of 117 U.S. companies that found employers are using the benefits enrollment process to encourage employees to adopt healthier behaviors, by making available health awareness programs and decision support tools.

The survey also finds that, although 67 percent of employers have integrated their enrollment system with their HR portal or intranet, only 27 percent have integrated it with their provider’s system; 30 percent have not integrated their enrollment systems with any other system.  (Employers Using Benefits Enrollment Systems to Drive Employee Behavior Change, Watson Wyatt Survey Finds; Watson Wyatt press release, February 21, 2008)

On May 21, the Massachusetts Medical Society, which represents the state’s doctors, filed a lawsuit against the Group Insurance Commission (GIC), the state’s purchaser of health insurance for public employees and retirees.  The lawsuit alleges that the Commission’s two-year-old physician ranking system hurts physicians and patients.  Under the Clinical Performance Improvement (CPI) initiative, health plans rate physicians on cost and quality measures, and the GIC uses a database of claims from six insurance companies to compare physicians’ performance.  This information is used to rank physicians into three tiers.  Insurers charge patients higher rates to see physicians in the lower tiers.  The Massachusetts Medical Society claims that the GIC’s methodology is flawed and is suing to end the ranking system or require that the GIC use transparent ranking standards.  According to the suit, the existing methodology results in defaming low-ranked physicians and cheating those patients who have to pay more to see them.  Massachusetts Medical Society President Bruce Auerbach said that efforts to improve the ranking program have failed and said the rankings use “inaccurate, unreliable, and invalid tools and data."  (Krasner, Jeffrey. Physicians Group Files Suit over Rankings, Boston Globe, May 22, 2008)

In Southeastern Pennsylvania, health insurers have started compensating providers to track their patients' care and conditions more closely.  Independence Blue Cross, Aetna, and four other insurers anticipate spending $13 million over three years to finance the initiative’s first phase in 32 primary care practices, involving more than 150 caregivers and approximately 220,000 patients.  This program, which is being led by the Governor's Office of Healthcare Reform, will reward providers for how well they dispense proven treatments and keep patients healthy.  Participating practices will use special computer software to track patients, and doctors will set aside unscheduled time to enable sick patients to get appointments within 48 hours.  The initiative also aims to make providers more accessible to patients via phone and e-mail.  (Goldstein, Josh. Insurers Pay Caregivers to Track Patients, The Philadelphia Inquirer, May 13, 2008)

“More than half of hospitals are not seeing enough patients to provide sufficient revenue to fund operations…,” according to a study of almost 3,900 hospitals by restructuring firm Alvarez & Marsal.  In addition, almost 40 percent that do make a profit do not generate enough income to fund basic improvements.  Several sources of financial woes are proposed by Alvarez & Marsal and bankruptcy attorney Gerald H. Gline (Cole, Schotz, Meisel, Forman & Leonard, PA), including:

• Too may beds, too many hospitals
• Competition from same-day surgery centers and ambulatory clinics
• Declining Medicare and Medicaid rates
• More uninsured patients
• Costlier loans resulting from the nation’s current credit crunch 

These experts also see no end immediately in sight.  For example, George D. Pillari of Alvarez & Marsal observes that with the exception of a “top tier” of 500 to 1,000 hospitals, “This whole industry is just kind of sliding slowly into insolvency.”  The trend probably will continue for several more years, and drastic fixes, such as mergers and bankruptcy filings, are required.  (Palank, J. Hospitals Face Financial Squeeze, The Wall Street Journal, May 1, 2008 – subscription required),

A Hospital of the Future initiative was announced April 30 by ThedaCare (Appleton, WI).  The initiative is a three-year, $90 million planned renovation of patient rooms at Appleton Medical Center and Theda Clark Medical Center that:

• Eliminates the use of paper medical records via computer docking station links to PACS and EMR systems in every room
• Eliminates nursing stations via private rooms for each patient with bedside supply cabinets that can be restocked from the hallway
• Uses lights outside rooms and other alerts to notify caregivers when patient records are updated with new orders and/or medications are delivered

When implemented with ThedaCare’s new Collaborative Care model the renovation is designed to facilitate, the average length of stay is expected to be reduced by 21 percent and the cost of care reduced by almost one-third. Collaborative Carel is an inpatient care model in which a doctor, nurse, and pharmacist team assigned to each patient work together to examine and devise a treatment plan.  Construction is expected to be completed at Appleton Medical Center in 2010 and at Theda Clark by the end of 2011.  (ThedaCare Plans $90 Million Renovation of Hospitals, Oshkosh Northwestern, April 30, 2008)

Supplies represent about 15 percent of the hospital operating budget, and a 5 percent savings in supply costs can translate into a 1 percent improvement in margin.  In an industry with very slim margins, it is easy to see why there is a focus on improving supply chain management.   Supply costs currently average $257/patient day, of which only $56 are pharmaceutical costs (where there has been a continual focus on costs for years).  An HFMA survey published in May 2008 examined ways to improve the supply chain.  The respondent base consisted of 111 supply chain leaders and 114 financial leaders in the industry. (Sixty percent of supply chain leaders report to the CFO.) 

• Physician/clinician buy-in was rated the greatest opportunity to improve supply chain by 72 percent of those surveyed – more than 20 percentage points above the next most highly rated approaches:  executive involvement and sharing data/reporting. 
• Techniques for engaging physicians included providing data on current costs and opportunities for savings and involving the physicians in negotiations. 
• Some organizations capped prices and allowed products from vendors who met the price point.   Some commented that without clinician buy-in, it is very difficult to enforce vendor contracts. 

The potential savings are huge. At New York Presbyterian Hospital, a program to gain physician buy-in resulted in a $25 million savings over two years. The biggest change in opportunities for improvement between the 2008 survey and a similar survey in 2005 was an increase in the perceived potential of investing in automation.  In 2008, 37 percent reported this was a high area for improvement versus 23 percent in 2005.  Applications under consideration included automating charge capture, integrating with inventory control, and automated replenishment to replace manual inventories.  Having good data is essential to improve supply chain management.  A typical hospital has 100,000 supply items and 25 percent have double that number.  Keeping data clean decreases costs and allows accurate benchmarking across organizations.  Reducing the number of supply chain items through standardization and increasing the number purchased from a negotiated contract are continuing focuses for improvement.  Currently 80 percent of supplies are purchased via contract – up from 75 percent in 2002.  (Opportunities for Supply Chain Improvement; HFMA Educational Report, HFMA, May 2008)  More examples of actual improvement ideas and challenges and comparisons with past surveys are in an accompanying slide deck – HFMA's 2008 Supply Chain Survey: Methodology, Analysis, and More -- A PowerPoint Presentation, HFMA, May 2008)

The U.S. nursing shortage could be alleviated slightly if a new piece of legislation called the Emergency Nursing Supply Relief Act passes the legislature.  The new bill, introduced by Rep. Robert Wexler (D-FL) and backed by the American Hospital Association (AHA), would set aside 60,000 employment visas over the next three years for foreign-educated registered nurses and physical therapists. Currently, foreign-educated nurses face a multi-year waiting list.  The bill would also fund expansions to U.S. nursing schools to increase the supply of nurses.  Last year, nurse education programs in the U.S. turned away more than 150,000 qualified applicants due to lack of faculty and facilities in which to educate them.  (Description of H.R.5924, Library of Congress, accessed May 12, 2008)

A new report issued by the National Association of Children’s Hospitals and Related Institutions (NACHRI) and the Center for Health Design offers tips on how hospitals can make their physical environments better suited to children and families.  Using an evidence-based method, the authors conclude that facility design can increase patient satisfaction, encourage family participation, and make work more efficient for staff.  Some of the ideas and interventions that they recommend for child-friendly settings include:

• Construct single family rooms in the NICU
• Incorporate circadian lighting in the NICU
• Incorporate incubator noise reduction in the NICU
• Install sound-absorbing ceiling tiles
• Provide space for families
• Provide patient and family control over privacy
• Provide calming music distractions
• Provide positive distractions to reduce anxiety
• Provide access to nature through gardens
• Provide age-appropriate play areas
• Enhance overall ambience and attractiveness

Other ideas and interventions recommended for adult settings include:

• Incorporate effective way-finding systems
• Provide single patient rooms for all patients
• Provide hand-washing dispensers and sinks
• Optimize access to natural light
• Install ceiling lifts
• Develop a noise reduction plan
• Promote visual access and accessibility
• Install HEPA filtration

The authors of the report also comment on other ideas for improvements that have not yet been substantiated by research and make recommendations about the relative priority of the recommendations it makes. (Evidence for Innovation: Transforming Children’s Health Through the Physical Environment, NACHRI and CHD, May 2008)

“…not-for-profit hospitals and systems have proven more comfortable subsidizing [physician practice] electronic health records…” since the May 2007 IRS memo that clarified the IRS position that hospital spending on physician EHR system does not threaten their tax exemption.  San Francisco attorney Gerry Hinkley (Davis Wright Tremaine) is quoted as saying, “The hospital clients we work with that want to go forward with an EHR are figuring out a way to do it…”  The article provides several cases in point:

• Lake Forest Hospital (Lake Forest, IL) that is contributing to the rollout of eClinicalWorks EMR/PMS software to primary care practices.
• The five-hospital Inova Health System (Falls Church, VA) that is offering GE’s Centricity system to 3,000 on-staff community physicians
• Bozeman Deaconess Hospital (Bozeman, MT) that is establishing a “practice donation fund” for practices using NextGen.

The clarifying memo from the IRS also figured prominently in reducing uncertainty at the three sites:

• Matt Koschmann, vice president of business development and external affairs at Lake Forest Hospital, notes that after the memo, “We went back to our board and got a lot of support to get the startup financing…”
• Geoff Brown, Sr. VP and CIO at Inova said he and colleagues have continued to discuss the issue with IRS staff to make sure they stay in compliance
• Liz Lewis, Sr. VP of Operations/legal at Bozeman Deaconess said, “We’d already done it,” but IRS confirmation was welcome.

(Blesch, G., Systems Take Advantage of IRS’ Nod on IT Subsidies, Modern Healthcare, May 15, 2008 – subscription required)

The American College of Emergency Physicians has published a report recommending several low-cost ways to reduce overcrowding in their Emergency Departments.  This problem, experienced by many hospitals, is often a result of shortages of staff and beds on other floors. Simply expanding the department does not solve overcrowding, write the authors, because the temporary relief it provides will only invite a bigger overcrowding problem.  (Adding an observation area, however, can be effective.)  Ultimately, the authors recommended the following simple changes:

• Move admitted patients to inpatient areas such as hallways and conference rooms;
• Discharge patients before noon to make more beds available; and
• Schedule elective procedures more evenly throughout the week.

The report includes several success stories from hospitals that have found ways to improve their patient flow. (Emergency Department Crowding: High-Impact Solutions, ACEP Task Force on Boarding, April 2008)

A pair of articles in the April issue of The Joint Commission Journal on Quality and Patient Safety shed light on the current theory and practice about the role of the hospital board in governing quality.

• First James Conway establishes the foundation for the link between board role and high-performing organizations, citing all of the evidence that has accumulated over the last five years. He describes four different stages of board engagement:

Five things all boards should do:

(Conway, J. Getting Boards on Board: Engaging Governing Boards in Quality and Safety, The Joint Commission Journal on Quality and Patient Safety, Vol. 34, No. 4, p. 214-220, April 2008 – subscription or purchase required)

So, what does this look like in practice? The companion article from Allen Memorial Hospital, Iowa Health System, provides one case in point.

• First the board committed to delivering perfect care, defined as 100 percent reliability on CMS Core Measures.
• Upon recommendation of the medical executive committee, the board approved 10 evidence-based standards of care, represented by 27 measures. These are tracked in scorecards, attached by 10 rapid improvement teams, and reviewed and discussed at management and board meetings.
• The hospital adopted a blame-free policy to encourage voluntary reporting and now informs patients and families of the circumstances when an adverse event occurs.
• Held two major educational sessions for board members, aligned quality improvement with job performance expectations, and attached as much as 20 percent of incentive compensation for executives to achieving quality targets.

The board subcommittee on quality now meets monthly and board members have requested more training and deeper involvement. Probably most significant of all, “the drive to excellence in clinical care was beginning to be ‘hard wired’ into standard processes, monitoring systems, and periodic reviews.”  (Slessor, S.R., et al. Case study: Getting Boards on Board at Allen Memorial Hospital, Iowa Health System, The Joint Commission Journal on Quality and Patient Safety, p. 221-227, Vol. 34, No. 8, April 2008 – subscription or purchase required)

Do hospitals reporting use of the Leapfrog patient safety practices provide better quality of care?That’s the question addressed in a research study from the Harvard School of Public Health, which appears in the June issue of The Joint Commission Journal on Quality and Patient Safety. The significance of the question lies in the fact that more than 1,500 hospitals complete the Leapfrog survey each year concerning their progress toward adopting several sets of patient-safety practices, a fairly narrow focus. Since the results are publicly reported, employers and consumers consulting that information have an interest in knowing whether these results are also associated with better care overall.  The researchers focused on three sets of patient safety practices--implementation of CPOE, ICU physician staffing, and evidence-based referrals for high-mortality surgeries—and examined data from the Hospital Quality Alliance relating to care quality and outcomes for three conditions: acute myocardial infarctions (AMI), congestive heart failure (CHF), and pneumonia.

• “Among the 1,860 hospitals targeted by Leapfrog, those with substantive efforts implementing three sets of patient safety practices had better quality of care for all three conditions, although the differences were small for pneumonia.”
• “We found that hospitals that had begun to implement Leapfrog practices had lower risk-adjusted mortality rates than others, at least for two of the three conditions.”

“Overall, our findings reinforce the validity of the Leapfrog measures by demonstrating that if consumers use the Leapfrog rating system, not only will they likely choose hospitals with better patient safety practices – but also with modestly better process quality and lower mortality.” (Jha, A., et al. Does The Leapfrog Program Help Identify High-Quality Hospitals? The Joint Commission Journal on Quality and Patient Safety, Vol. 34, No. 6, p. 318-325, June 200 – subscription required)

The VHA Foundation, an arm of the VHA Inc. healthcare alliance, has announced a two-year initiative to offer hospital CEOs a forum to discuss patient safety. The initiative, called the “Health Care Safety Network,” will enable executives to learn from peers and patient safety experts about how to improve safety in their organizations.  As part of the program, the VHA will offer CEOs access to a database of leading safety practices, including patient safety content and case studies.  Peer coaching will also be available.  The initiative was created after a 2008 VHA survey revealed that 68 percent of participating hospital leaders have faced a significant patient safety event in the past three years and that less than 21 percent of those leaders felt confident about the practices in place to prevent and handle such incidents. (VHA Foundation Launches National CEO Patient Safety Network, VHA Foundation press release, accessed May 12, 2008)

Maine has passed its own law preventing hospitals from charging for services needed as the result of a preventable error.  Starting July 18, hospitals and ambulatory surgery centers in Maine may not charge patients or their insurers for treatment related to 28 preventable adverse events identified by the National Quality Forum. According to a VP at the Maine Hospital Association, the association worked closely with lawmakers on the bill and is pleased with the final language.  (H.P. 1428 - An Act to Prohibit Health Care Facilities from Charging for Treatment to Correct Mistakes or Preventable Adverse Events, Maine State Legislature, accessed May 12, 2008)

The Journal of the American Medical Association published a study by Dr. Rachel Werner of the Veterans Affairs Department that finds pay-for-performance bonuses for U.S. hospitals may result in penalizing those that treat patients who are uninsured or covered under publicly-funded programs for the poor, as these safety-net hospitals have made the smallest improvements in government performance scores.  Further, these hospitals generally lack money to improve quality ratings.  In a Medicare pay-for-performance simulation, the author found that safety-net hospitals consistently underperformed relative to hospitals with fewer low-income patients, resulting in fewer bonus payments to these hospitals that most need the funds.  The author also found that payments to hospitals with the fewest poor patients grew 32 percent from 2004 to 2006; whereas rewards for those with the highest share of poor patients fell 66 percent, and proposed pay-for-performance rules would widen the disparity with richer hospitals.  An abstract of the study is available online.  (Goldstein, Avram. Hospital Quality Rewards May Backfire for the Poor, Study Finds, Bloomberg, May 13, 2008)

Researchers at Arizona State University used 2006 data from HIMSS Analytics to examine the adoption of patient safety information technology.  HIMSS Analytics collects self-reported data on IT from 5,082 U.S. facilities, but the researchers limited their analysis to 4,561 non-federal, acute care general hospitals.  Although the data are two years old, the comparisons between technologies, regions, and hospitals of different sizes and teaching status are probably still accurate. For a technology to be counted as “installed,” the hospital had to report that it was “live and operational,” not “implementation in progress” or “contracted.”  Of the eight technologies examined, the average number installed was 2.24.  The most commonly implemented safety technology was automated dispensing cabinets (operational at 67 percent of hospitals); the lowest implementation rate was for bar-code medication administration (less than 5 percent), although 26 percent had an electronic medication administration record. Forty-six percent reported having clinical decision support, but only 37 percent had an electronic medical record (EMR), and 14 percent had implemented CPOE.  Twenty-seven percent used bar codes and 7 percent used robotics in dispensing.  

• Larger hospitals (over 200 beds) were more likely to have implemented safety technology than smaller hospitals (less than 50 beds or 50-150 beds).  The gap was largest for CPOE and robotics
• Not-for-profit hospitals had the highest deployment of safety technology, followed closely by for-profit institutions; state and local government hospitals lagged significantly.
• Teaching hospitals were twice as likely to have implemented the safety technologies as non-teaching hospitals.   Again the biggest gaps were for CPOE and robotics. 
• Hospitals in health systems were about twice as likely to have the safety technologies when compared with stand-alone facilities. 
• Urban hospitals were far ahead of rural sites.
• The higher the percentage of Medicare patients, the less likely that the hospital had implemented safety technologies.
• There was a strong geographic influence as well.  Rhode Island had the highest adoption rate – six times that of the lowest state (South Dakota).  The East Coast led the rest of the country in adoption of safety technologies.

One interesting result: state focus makes a difference.  States with patient safety centers had the highest rates of adoption (almost 50 percent higher than states without.); those with adverse event reporting and patient coalitions had about 25 percent higher rates of adoption of patient safety technologies.  [The authors state that their estimates are probably conservative, but to this reviewer’s eyes they appear high.  For example, is it credible that 25 percent of New England hospitals have implemented CPOE?]  (Michael Furukawa et al. Adoption of Health Information Technology for Medication Safety in U.S. Hospitals, 2006; Health Affairs, May/June 2008 – subscription required)

A study conducted at Brigham & Women’s Hospital in Boston showed that using a bar-coded computerized surgical sponge system reducing counting errors. Based on a comparison in 300 surgeries, the surgical sponge system identified ten times more counting errors than traditional counting methods, in cases where the sponges were misplaced or counted incorrectly. (Study: Bar-coded Sponges Reduce Error Risk, Healthcare Informatics, May 13, 2008)

The Commonwealth Fund has published a new report that examines how five healthcare providers are using electronic health records (EHRs) as quality measurement tools.  The five organizations are HealthPartners (Minneapolis, MN), Park Nicollet Health Services (Minneapolis, MN), Geisinger Health System (Danville, PA), Kaiser Permanente of the Northwest (Portland, OR), and Billings Clinic (Billing, MT).  Each organization followed a different approach.  For example, HealthPartners used EHRs to compute their performance on traditional quality measures, saving time and money on compiling data.  Details on other approaches are contained in the report.  Overall, according to the authors, “The providers’ successes in implementing their respective EHR-based quality measures demonstrates that such measures are adaptable to different EHR systems, amenable to improvement and worth pursuing.” (Briggs Fowles, J. Performance Measures Using Electronic Health Records: Five Case Studies, The Commonwealth Fund, May 12, 2008)

One of the challenges of implementing bar-code-assisted electronic Medication Administration (e-MAR) is ensuring durable, readable patient wristband labels. An article in the May/June issue of Patient Safety & Quality Healthcare reports on the successful use of direct thermal wristband printers at Southwestern Vermont Health Care (SVHC). The authors claim that the bands survive a week of wear, 24 hours under water, or temperatures up to 130 degrees F. In addition, bands can be printed one at a time. SVHC also uses 2-D Data Matrix barcode format repeated 15 times around the wristband for ease of reading from any angle. They have achieved a 93 percent scan rate. (Lanoue, E. and C.J. Still, Patient Identification Producing a Better Barcoded Wristband. Patient Safety & Quality Healthcare, Vol. 5, No. 3, p. 12-16, May/June 2008)

A simple checklist of 14 key procedures and precautions can help hospitals prevent infections, according to the initial results of a program adopted by 11 public hospitals in New York City.  Since the checklist was put in place, the number of central-line bloodstream infections at participating hospitals has decreased by 55 percent, and the cases of ventilator-associated pneumonia have decreased by 78 percent.  The checklist was developed by a professor at Johns Hopkins University to be “a simple intervention to help [clinicians] focus and execute.”  According to one official involved in the program, the checklist works because simple things tend to get overlooked in critical care units where workflows are complicated.  (Hartocollis, A. In Hospitals, Simple Reminders Reduce Deadly Infections, New York Times, May 19, 2008 – registration required)

On May 12, the Annals of Family Medicine published a study about providers’ beliefs and concerns regarding the U.K.’s new pay-for-performance initiative, called the Quality and Outcomes Framework (QOF), which in 2004 began financially rewarding family doctors for meeting goals about clinical care, organizational factors, and patients’ experiences.  The study finds that family physicians and nurses believe the pay-for-performance plan has changed behavior and achieved targets, including improved doctor earnings, improved disease-specific processes of patient care, and improved capture of medical data.  Respondents agreed that the pay-for-performance initiative has also had unintended outcomes, including:

• Emergence of a dual QOF-patient agenda within consultations;
• Potential deskilling of doctors due to nurses taking on a greater role in managing long-term conditions;
• Decreased personal/relational continuity of care between doctors and patients;
• Resentment by team members not benefiting financially from payments; and
• Concerns about an ongoing culture of performance monitoring in the U.K.

The article is available online.  (Campbell, Stephen M. et al. The Experience of Pay for Performance in English Family Practice: A Qualitative Study, Annals of Family Medicine, Vol. 6, No. 3, p. 228-234, May/June 2008)

The European Union announced a $3.1 billion effort, called the Innovative Medicines Initiative, to improve drug discovery in the region and “close a growing gap with the United States and Asia.”  The program will provide grants to researchers at academic institutions and small companies to investigate solutions that can address bottlenecks in drug development.  The European Commission will provide half of the $3.1 billion over seven years, with the remainder coming from staff and equipment provided by large drug companies.  While considered a “victory” for European pharma industry, the article cautions that “the program will not yield results overnight,” as the initial research initiatives will not begin until 2009.  (EU Launches $3 Bln Project to Boost Drug Discovery, Reuters, April 29, 2008)

Three major pharmaceutical trade groups indicated they would be receptive to a new user-fee system to help the FDA address its lack of resources around conducting inspections of foreign drug manufacturing plants.  Currently, the industry already pays close to $400 million in “fees” to help fund the FDA’s review of new products.  According to the article, the Pharmaceutical Research and Manufacturers of America, the Generic Pharmaceutical Association, and the Biotechnology Industry Organization would be open to a new user-fee system but “within limits.”  For example, the size of the fees would be an issue, and the trade groups would want assurances that the fees would be used to inspect higher-risk manufacturing sites and that the new system would not “hinder the timely availability of pharmaceuticals in the U.S. market.”  (Drugmakers Open to New Fees for Foreign Plant Checks, The Star-Ledger, May 2, 2008)

The FDA announced it will add more than 1,300 employees by October “as part of a major expansion.”  Roughly 770 of the new positions are a result of legislation requiring higher user fees from the pharmaceutical industry that will be used to improve oversight of drug safety.  Overall, the FDA employs more than 10,000 people.  (U.S. FDA to Add 1,300 Staff, Reuters, April 30, 2008)

FDA Commissioner Andrew von Eschenbach said his agency needs an additional $275 million in funding in order to ensure the safety of foods, drugs, and medical devices.   The FDA is under increasing scrutiny to improve inspections of overseas manufacturing plants after 81 deaths were tied to a blood thinner shipped from a manufacturing plant in China.  According to von Eschenbach, roughly $125 million of the total would be dedicated to food safety, $100 million towards better oversight of drugs and medical devices, and $50 million for “updating the FDA’s science and work force.”  (FDA Seeks Extra $275 Million to Beef Up Overseas Inspections, WSJ, May 15, 2008 – subscription required)

On May 5 Wal-Mart Stores Inc. announced that it has started offering 90-day supplies for up to 350 generic medications for the price of $10.  The company also said it will discount several women's drugs (including drugs to treat breast cancer and hormone deficiency) to $9 for a 30-day supply and that it will also decrease the prices of about one-third of its over-the-counter medicines (including Wal-Mart's versions of Zantac, Pepcid, Claritin, and prenatal vitamins).  That same day, Target Corp. announced that it would match the major components of the Wal-Mart program, including the $10 90-day supply and the over-the-counter drug plans.  (Harris, Peggy. Wal-Mart Expands Low-Price Drug Program; Target Follows, AP/Google.com, May 5, 2008)

New data from Medco Health Solutions reveal that 51 percent of all insured Americans were taking some kind of prescription medication on a regular basis for chronic health issues in 2007.  Forty-seven percent of insured American adults and children were taking one or more drugs for a chronic condition in 2001, increasing to 50 percent between 2002 and 2006.  Experts attributed the results partly to declining public health, but also to availability of more effective drugs to support chronic conditions, increasingly aggressive treatment by physicians, and “relentless advertising” by drug makers.  (Prescription Drug Use Grows in America, WSJ, May 14, 2008 – subscription required)

Regulatory/Legal

Trade groups for brand name drug makers and medical device companies offered public support for a Senate bill that would mandate public reporting of any gifts or payments to physicians.  While the WSJ notes the news may be somewhat surprising, the article speculates that “industry may have decided it’s better to deal with a single, federal law rather than a patchwork of state rules.”  One of the key provisions supported by drug makers is that the legislation would override any state laws around disclosing payments and gifts to physicians, such as those in Vermont or Minnesota.  (Drug & Device Industries Support Disclosure of Payments to Doctors, WSJ, May 22, 2008 – subscription required)

The Joint Commission (JCAHO) has approved a grace period for its new emergency management standards.  According to the commission, non-compliance with the new set of requirements will continue to be cited but will not adversely affect one’s application for accreditation.  The commission will offer this grace period as a time for organizations to assess capacities, usage of supplies and resources, and to build local relationships within the community.  (Advocacy Update, Scoring of the 2008 Emergency Management Standards, American Society for Healthcare Engineering (ASHE), April 2008)

According to one lawyer who specialized in this area, new, more powerful electronic medical record systems present some interesting legal complexity to the organizations using them.

• They contain more information than paper records, including the firing of a drug-related alert and the clinician’s response.
• They maintain a detailed audit trail of when information was entered, viewed, etc., that can be used for legal defense and offense.
• In his view, electronic health record (EHR) vendors have not fully adopted to the new legal framework.
• The legal landscape about legal discovery is shifting, including amendments in 2006 to federal rules of legal discovery on electronically-stored information.

An HL7 work group met recently to continue work on a package of 50 guidelines for vendors, payers, and providers implementing related policies and lawyers involved in healthcare litigation. One need apparently is for the user organization to declare what is the “legal record.” Other areas of the guidelines address infrastructure functions that support management of EHRs. One member of the work group comments that aspects of the guidelines relating to audit trails are in widespread use and included in EHR certification by the Certification Commission for Healthcare Information Technology. (Conn, J. Making IT Legal-size, Modern Healthcare, p. 28-30, May 19, 2008 – subscription required)

Expect the set of externally-reported hospital patient safety and quality measures to expand once again. The National Quality Forum (NQF) has released the next round of 48 new voluntary consensus standards vetted through NQF’s formal Consensus Development Process. The good news is that the “consensus” is among “more than 375 healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality improvement organizations.” The goal is to some day have one set of widely adopted measures, rather than the many sets hospitals have to track today. Noteworthy in the new measures is the expansion of metrics related to readmission, pediatric care, and surgery/anesthesia:

• Length of Stay/Readmission
  • Risk-adjusted average length of inpatient hospital stay
  • Overall inpatient hospital average length of stay (ALOS) and ALOS by DRG service category
  • All-cause readmission index
  • Thirty-day all-cause risk standardized readmission rate following heart failure hospitalization
  • Severity-standardized average length of stay-routine care
  • Severity-standardized average length of stay-special care
  • Severity-standardized average length of stay-deliveries
• Patient Safety, Adult
  • Accidental puncture or laceration
  • Death in low mortality DRGs
  • Iatrogenic pneumothorax
  • Death among surgical inpatients with serious, treatable complications
  • Bilateral cardiac catheterization rate
  • Blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were transferred or admitted to ICU within 24 hours of hospital arrival
  • Congestive heart failure mortality
  • Hip fracture mortality rate
  • Transfusion reaction, age 18 years and older 
• Patient Safety, Pediatrics
  • Accidental puncture or laceration
  • Decubitus ulcer
  • Iatrogenic pneumothorax in nonneonates
  • Transfusion reaction, age under 18 years 
• Pediatrics
  • PICU severity-adjusted length of stay
  • PICU unplanned readmission rate
  • Review of unplanned PICU readmissions
  • Home management plan of care document given to patient/caregiver
  • Pediatric heart surgery mortality
  • Pediatric heart surgery volume
  • PICU pain assessment on admission
  • PICU periodic pain assessment
  • PICU standardized mortality ratio
• Surgery and Anesthesia
  • Abdominal aortic aneurysm volume
  • Abdominal aortic aneurysm repair mortality rate
  • Esophageal resection mortality rate
  • Esophageal resection volume
  • Incidental appendectomy in the elderly rate
  • Pancreatic resection mortality rate
  • Pancreatic resection volume
  • Post operative wound dehiscence, age under 18 years
  • Post operative wound dehiscence, 18 years and older
  • Foreign body left after procedure, age under 18 years
  • Foreign body left in during procedure, 18 years and older
  • Failure to Rescue In-hospital Mortality
  • Failure to Rescue 30-day mortality
• Venous Thromboembolism
  • VTE prophylaxis
  • Intensive Care Unit (ICU) VTE Prophylaxis
  • VTE Patients with Anticoagulation Overlap Therapy
  • VTE Patients Unfractionated Heparin (UFH)Dosages/Platelet Count Monitoring by Protocol (or Nomogram)
  • VTE Discharge Instructions
  • Incidence of Potentially Preventable VTE

(National Quality Forum Endorses Consensus Standards for Quality of Hospital Care, National Quality Forum, May 15, 2008)

The Certification Commission for Healthcare Information Technology (CCHIT) has certified six more ambulatory electronic health records (EHRs) under its 2007 criteria:

• TouchWorks V11.1 (Allscripts)
• Millennium PowerChart/PowerWorks EMR, Version 2007 (Cerner)
• HealthPort EMR V9.0 (HealthPort)
• ChartMaker Version 3.0.5 (STI Computer Services)
• Wellogic Consult Version 3.10 Release 10 (Wellogic) integrated with MEDfx Version 2.8 practice management (GBA Health Network Systems)
• Sunrise Ambulatory Version 4.5C, SP5 (Eclipsys) (conditional premarket)

The full list of 29 ambulatory EHRs with 2007 certification is available at www.cchit.org

A case of six computer back-up tapes containing data on 2.1 million patients was stolen from the University of Miami on March 17. The university said that the tapes contained names, addresses, Social Security numbers, and health information on patients going back to January 1, 1999.  However, according to independent security firm Terremark Worldwide, it would be difficult for thieves to extract any usable data from the tapes as the university used highly proprietary compression and encoding methods to create the tapes.  The university said that it will notify by mail approximately 47,000 individuals whose data may have included credit card or other financial information. The incident is not believed to be targeted at the university but rather one of a series of petty thefts in the area.  (Huge Data Theft at U-Miami, Health Data Management, April 17, 2008)

A new task force made up of representatives from Canada Health Infoway, the Canadian Healthcare Information Technology Trade Association and the Association of Health Technology Information has been formed to accelerate the adoption of pan-Canadian interoperability standards.  To enable the successful deployment of interoperable EHRs, the participating organizations support the use of HL-7 and DICOM for messaging, LOINC and SNOMED CT for terminologies, HL-7’s Clinical Document Architecture for documents, HL-7’s Clinical Context Object Workgroup specification for clinical content management and pan-Canadian interoperability profiles. (Canadian Healthcare IT Leaders Form Task Force to Align on EHR Standards,Healthcare IT News, May 2, 2008)

Physician Practice

According to a “Web Exclusive” study published by the journal Health Affairs, the U.S. faces an impending shortage of between 35,000 and 44,000 generalist physicians for adult care.  Researchers projected that outpatient visits by adults will increase 29 percent between 2005 and 2025, while the number of generalists will increase only 11 percent.  The bulk of the increase in visits is due to the aging of the population – namely the baby boomers.  (The supply of generalists for children’s care should be adequate.)  One of the policy solutions proposed by the authors is for reimbursement reform that would make the “medical home” model financially viable. Under this scenario, teams of physicians, nurse practitioners, and physician assistants could provide care to a greater number of patients through the use of consultations over the telephone or via e-mail.  (Colwill, et al. Will Generalist Physician Supply Meet Demands of an Increasing and Aging Population? Health Affairs, April 29, 2008 – subscription required)

According to the latest CDC report on ambulatory trends, the U.S. had 308,900 office-based physicians in practice in 2005-2006.  The CDC also reported that about 57 percent of office-based physicians made at least one hospital visit in the prior week – a decline of 26 percent from 2001.  However, the use of information technology since 2002-2003 was up significantly: physicians reported a 46 percent increase in the use of clinical health IT, and a 92 percent increase in the use of computerized prescription order-entry.  Many more statistics, including physician characteristics, patient encounters, and revenues are available in the new National Ambulatory Medical Survey.  (Characteristics of Office-Based Physicians and Their Practices: United States, 2005–2006, CDC, April 2008)

New doctors want better work life balance:  according to 60 percent of medical students and 52 percent of residents who participated in the 2007 National Physician Survey in Canada. Reactions to the findings varied.  For example:

• Shaheed Merani, president of the Canadian Federation of the Medical Students, concluded that the survey represents medical student and doctor feelings that a good work-life balance is important not only to a doctor’s family, physical, and mental well-being, “…but it’s also important in the work you do and the quality of care you deliver to patients.”
• Dr. Ruth Wilson, president of the College of Family Physicians of Canada, responded that, “The flip side is there are important demands and important health needs from patients, and those of us who go into medicine to try and make a difference to individuals see those needs and try to work as hard as we can to meet them.”

Proposed responses to potential impacts (such as increased wait times and physician shortage in some rural areas) include increased use of technology that helps streamline practice (such as EMRs), and financial incentives.  (New Doctors Want Better Work-Life Balance: Study, CTV News, April 30, 2008)

The current limitations and potential downsides of electronic medical records (EMRs) are reviewed in a cautionary paper in The New England Journal of Medicine. Among the problems that the authors have seen result from EHR use is “clinical plagiarism,” in which physicians cut and paste portions of text to create notes and letters without thoroughly reviewing and validating the content.  One of the problems with this practice is that trainees can avoid taking histories and arriving at their own conclusions.  For a more senior physician, such cutting and pasting can get in the way of the thoughtful review and analysis that comes with writing.   Furthermore the ease of cutting and pasting means large amounts of information are easily included, often making it difficult for the reader to find the relevant, new developments documented.  Another problem described by the authors occurs when physicians focus more on the computer screen than on the patient, and fill-in-the-box screens that encourage the physician to ask restrictive questions rather than pursuing an open-ended dialogue with the patient.  The bottom line is that physicians must determine how to use EHRs “in the way that is best for patient care, regardless of whether it’s the most ‘efficient’ way.”  (Hartzband, P. and Groopman, J. Off the Record – Avoiding the Pitfalls of Going Electronic, New England Journal of Medicine, April 17, 2008 – subscription required)

“Some 20 percent of doctors say they will quit practicing medicine if universal health-care insurance coverage is implemented…”  This was uncovered by a survey of nearly 1,400 doctors by Alpharetta, GA-based LocumTenens.com (physician recruiting firm).  Forty percent of survey respondents also felt the current/projected physician shortage is a real concern that presidential candidates should address (23 percent who did not think candidates should address the issue). (Survey: Universal Health Care Would Add to U.S. Doctor Shortage, Atlanta Business Chronicle, May 14, 2008)

A recent USA Today article discusses how identity thieves are increasingly using doctors' offices, clinics, and hospitals to steal patient medical information that they can use to get credit card numbers, deplete bank accounts, or falsely bill insurers such as Medicare.  Legal experts say that criminals may gain the assistance of insiders and use sophisticated new techniques to gather data from files, even if those files are encrypted.  Patients are often unaware that their medical information has been breached until they receive phone calls from creditors seeking payment corresponding to fake billings.  A recent survey by HIMSS Analytics and Kroll Fraud Solutions found that 13 percent of healthcare providers surveyed said their facility had experienced a data breach.  Of those, 56 percent had notified the patients who were affected.  (Appleby, Julie. Identity Thieves Prey on Patients' Medical Records, USA Today, May 7, 2008)

On May 7 Anthem Blue Cross and Blue Shield in New Hampshire launched a initiative to let physicians in the insurer’s ePrescribing program use their Web-enabled cell phones to access real-time medical records and medical histories for their Anthem patients.  Participants can also access the new technology, known as Member Medical History, from their office or home computers.  (Anthem Blue Cross and Blue Shield in New Hampshire Announces Unique Enhancement to its ePrescribing Program, Anthem Blue Cross and Blue Shield in New Hampshire press release, May 7, 2008)

The Office of National Coordinator (ONC) of Health Information Technology has awarded six more NHIN contracts. The six organizations will join others already involved to demonstrate live exchange of health records September 28. Winners of the new contracts are the Cleveland Clinic, Kaiser Permanente, and four RHIOs:

• HealthLINC/Bloomington Hospital, an e-health collaborative that serves a 10-county area in South-Central Indiana.
• The Community Health Information Collaborative, a partnership among many provider organizations and public health departments in a rural, 18-county region of Minnesota.
• HealthBridge of Cincinnati, which serves a tri-state region connecting a large number of organizations.
• Wright State University/HealthLink regional health information organization, in West-Central Ohio.

(Six More Organizations Join NHIN Demonstration Project, Government Health IT, May 1, 2008)

With CMS’ decision to stop paying for treatment of many hospital-acquired infections (effective in October), many hospitals are reexamining their infection prevention programs.  Some have turned to data mining in order to identify trouble spots and come up with possible solutions.  One infection control initiative sponsored by Horizon BCBS of New Jersey was able to save $6.4 million over two years and reduce hospital-acquired infections by 10 percent.  News of the success spread, and now Blues plans in at least five other states are also considering sponsoring data mining software to improve hospital infection control programs.  The key benefit of turning to IT is that it allows hospitals to spend less time on data collection and more time on process improvement.  Making infection control an IT initiative is also an easy and cost-effective way to expand the scope from a unit-based or device-based monitoring program to a hospital-wide surveillance program.  (Anderson, H. Opening Doors to Information, Health Data Management, April 30, 2008)

The Wisconsin Technology Network published an interview with Partners HealthCare Vice President and CIO John Glaser on the integration of genetics and electronic health records (EHRs).  Billed as “one of the leading advocates of marrying electronic medical records with information gleaned from genetic tests,” Glaser predicts that as tests become more affordable, genetic information will increasingly be housed within an electronic medical record (EMR).  While ethical considerations exist, data protection could be ensured through technical, operational, and legal means.  For example, accessing genetic data in a patient’s record would require a provider to have special privileges or explicit authorization from the patient.  According to Glaser, “I suspect that over time, people will treat genetic test results as being no different than a cholesterol level or a family history.  Over time, it will be accepted that way, but that's not where we are today.”  (Partners CIO Touts Integration of Genetics and Health Records, Wisconsin Technology Network, April 30, 2008)

DaVinci robots have been on the market for several years now, allowing hospitals to perform minimally-invasive surgeries for patients, giving them the benefits of faster recoveries and fewer complications.  A new study conducted by the University of Maryland and presented at the annual meeting of the American Surgical Association, however, shows that robotic heart bypass surgery also has a positive ROI for hospitals. According to researchers, using a surgical robot increases the cost of each bypass case by about $8,000, but that cost is more than offset by a shorter hospital stay, reduced need for transfusions, and fewer post-surgical complications. Findings included:

• Average length of the hospital stay for patients receiving robotic surgery was four days, compared to seven days for traditional surgery
• Among high-risk patients, average stay was five days with robotic surgery compared to 12 days with traditional surgery
• Complication rate for patients receiving robotic surgery was 12 percent, compared to 34 percent with traditional surgery

For the study, researchers studied 100 consecutive patients who had minimally-invasive coronary bypass surgery using a robot at the University of Maryland Medical Center. (University of Maryland Study Finds that Minimally Invasive Robotic Bypass Surgery Provides Health and Economic Benefits, University of Maryland School of Medicine press release, April 28, 2008)

On April 28, 2008, UPMC and Newcastle-upon-Tyne Hospitals announced a partnership to deploy electronic health record (EHR) technology at three Newcastle hospitals.  UPMC (University of Pittsburgh Medical Center), which last year formed a separate company to grow this commercial business, will install and configure the following applications:

• Inpatient order entry
• Patient administration
• Pharmacy management
• Accident and emergency
• Operating room

The implementation is expected to take 14 months, and following its completion, a joint venture the two organizations have formed will begin offering IT services to other UK hospital trusts.  (UK Hospitals Adopt US Records System, HospitalHealthcare.com, April 28, 2008)

England’s National Audit Office (NAO) has announced that an electronic system for patients' records will not be introduced to every NHS Trust in England until 2014/15 – four years later than planned.  The main projects of the IT program are a centralized electronic medical record (EMR) system for 50 million patients; an online "choose-and-book" system for booking hospital appointments; electronic prescriptions; and fast network links between NHS organizations (aiming to link 30,000+ GPs to almost 300 hospitals).  According to the NAO, the delay results from the government underestimating the challenges associated with implementing this £12.7 billion program.  (Four-year Delay for Patient Records, The Press Association, May 15, 2008)

Technology Review reports a new security camera that uses a machine-learning algorithm to tell when something unusual is happening on screen.  This enables the camera to record at a variable bitrate, lowering the amount of data that needs to be stored.  When nothing “interesting” is happening, the camera records at a very low resolution to conserve storage space.  Then, when something out of the ordinary happens, the camera automatically ramps up the resolution to get a high-quality image. (Smart Security Camera, Technology Review, p. 36, May/June 2008 – registration required)

Despite advances in medical diagnostics, two-thirds of the world's population has no access to imaging technologies. But with cellular and other wireless networks, reports BusinessWeek, clinicians could soon deliver crucial medical services remotely.  Researchers and super-users are adapting consumer technologies to double as diagnostic equipment.  For example, professor Boris Rubinsky at the University of California has demonstrated how a portable electromagnetic scanner can be made to work in combination with a smart phone and computer, saving thousands of dollars, as well as bypassing the need for rare technical skills to maintain and repair traditional equipment.  According Rubinsky, “A cell phone can cut the cost of almost every (diagnostic) device, from ultrasounds to heart monitors.”  Much of the renewed interest in mobile applications has been spurred by the Apple iPhone, a relatively inexpensive device with a large color screen and full Web access.  Software company Life Record uses the iPhone to enable physicians to view patients’ medical records and to order prescriptions.  At an industry-wide level, consulting firm Ambient Insight estimates that sales of phone-related software for healthcare are expected to rise from $111.8 million in 2007 to $276 million by 2011.  (Kharif, O. Medical Advances – Through Your iPhone? BusinessWeek, April 30, 2008)

Back in the 1970’s, a professor at the University of California at Berkeley theorized and mathematically proved that there should be a fourth element of passive circuits (in addition to resistors, capacitors, and inductors) called a memory resistor.  Now a team of scientists at Hewlett Packard (HP) announced that the memory resistor or “memristor” does exist and have developed not only a mathematical model but also a physical example.  Why is this so important? A computer that incorporates this new kind of memory circuit would never lose its place even when the power is turned off; meaning it never needs to boot up when the power is turned back on.  Think of the time saving for millions of computer users. (HP Develops New Type of Memory Circuit, Internet News, April 30, 2008)

GE Healthcare has asked the Federal Communications Commission (FCC) to give greater protection to the part of the wireless spectrum used by medical telemetry systems.  Medical telemetry systems run on a dedicated channel (Channel 37) but can be interfered with if adjacent channels are overloaded.  GE has requested that Channels 36 and 38 be restricted to certain devices in order to reduce the likelihood of problems.  If the FCC does not agree to impose the restriction, then GE will recommend clients use an “emissions mask” to protect Channel 37 by limiting the signal strength of certain frequencies on the adjacent channels. (GE Asks FCC to Protect Telemetry, Health Data Management, May 7, 2008)

The Mayo Clinic (Rochester, MN) has announced that it will test the new and yet-to-be-approved 802.11n wireless networking standard as part of an enterprise-wide overhaul of the networking technology at its facilities. The 802.11n wireless standard can support a 100 Mbps data exchange rate, which is about 50 times faster than the current 802.11b standard. The Institute of Electrical and Electronics Engineers (IEEE) has not yet approved the new standard, but some vendors have already begun using it in production devices, including Cisco.  At Mayo, the technology will be deployed across about 3,000 access points, controllers, and other network devices across its three facilities. A variety of clinical devices and applications will be tested over the new network, including VoIP phones, infusion pumps, and pulse oximeters.  (Mayo to Test 802.11n Technology, Health Data Management, May 12, 2008)

Cell phones are taking on a new role – telemedicine device.  For example, researchers in Brazil and the U.S. have designed a prototype system that combines cell phone cameras with paper-based diagnostic tests that undergo color changes when exposed to certain disease markers (e.g., urine test strips). Using the camera, a scientist took pictures of the color-changing test strips and transmitted them remotely to an off-site expert who was able to diagnose the patient’s problem. The system is ideal for developing countries or remote areas lacking medical equipment and trained specialists. The system can also be used to transmit urgent medical data from battlefields, disaster zones, and other dangerous locations. (Telemedicine Mobilised with Cell Phone, Wireless Healthcare, May 7, 2008)

Investment in wireless in the healthcare industry is expected to continue to increase through 2012. Since 2005, there has been a 23 percent annual growth with an estimated total market spending to reach $10 billion by 2012, according to a new report from Kalorama Information. “Wireless in Healthcare 2008” predicts that the compound annual growth rate will increase from 22.9 percent to 19.5 percent.  The wireless technologies included are Bluetooth, RFID (radio frequency identification), Zigbee, UWB (ultra-wide band), WWAN (wireless wide area networks), WMAN (wireless metropolitan area networks), and WLAN (wireless local area networks).  The shortage of skilled care givers and cost/efficiency pressures on hospitals were cited as major reasons why health delivery organizations are implementing wireless solutions. (Healthcare Wireless Market to Approach $10 Billion by 2012. Healthcare IT News, May 12, 2008)

A new ocular imaging device by EyeMarker Systems (Morgantown, WV) makes it possible to detect toxins in a person’s body instantly, compared to traditional methods, which can take hours or days to return results.  The device will be helpful in the field as well as stateside, in the event of a terrorist attack using chemical or biological agents. The device, called the RTD1000, can detect markers in individuals who have been exposed to certain chemicals and nerve agents because many toxins cause small physiological changes to the way a person’s eyes respond to light. Among the advantages of the digital ocular device are that it is lightweight, portable, fast, non-invasive, and does not require specially trained personnel to operate it. (New Devices Detect Toxins, Federal Telemedicine News, May 13, 2008)

The use of biosensors is not new, but there have been problems with signal effectiveness and comfort wearing the biosensor patches since the embedded antennas need to be large in order to maximize signal strength.  These problems have impacted adoption and solution development. A new type of antennae developed by experts at Queen’s University Belfast with funding from the Engineering and Physical Sciences Research Council has gotten around these limitations. Using the “creeping wave” effect, the new antennae maximize the amount of signal radiated out of the antenna’s side.  The new antenna is 50 times more efficient and has reduced thickness (from 34mm to less than 5mm), improvements that make it much more effective and comfortable. The goal is to use this new technology to gather data on heart rate, respiration, posture, and gait and then transmit the information by radio signal to a control unit, also on the person’s body.  The data could be assessed by the patient’s caregiver via the Internet or mobile phone. (Body Sensors Benefit From New Wave Technology, Wireless Healthcare, May 22, 2008)

In an April 30 extensive review of the personal health record (PHR), Howard Anderson of Health Data Management at one point summarizes the current status of the PHR by saying, “For now, it’s difficult to assess whether PHRs ultimately will prove to be a passing fad or a ubiquitous technology.”  The popular argument for the PHR is its potential to become the longitudinal medical record that helps the industry cut costs, reduce errors, help providers and patients work together to coordinate their care, and help providers at different sites do the same.  Those advocating caution note difficulties in exchanging information with important sources, such as hospital electronic medical records (EMRs), practice EMRs, and RHIOs, as well as privacy concerns, particularly since many PHRs are not subject to HIPAA regulations.  Numerous examples of commercial and other PHR efforts illustrate how extensively the initiative is being explored, by payers, vendors, consulting groups, and community-based organizations.  (H Anderson, PHRs: Where Are We Headed? Health Data Management, April 30, 2008)

The Congressional Budget Office has released a new report that warns against relying on estimated health IT savings as a means to funding other programs and proposals.  The CBO agrees that health IT does provide some clear, direct cost savings.  For instance, the use of health IT:

• Eliminates the need for medical transcription;
• Eliminates or substantially reduces the need to physically pull medical charts from office files for patients’ visits;
• Prompts providers to prescribe generic medicines instead of more costly brand-name drugs; and
• Reduces the duplication of diagnostic tests.

However, the CBO disapproves of recent estimates that stretch into the tens of billions of dollars, saying that they “are not an appropriate guide” for policymaking.  In particular, the report challenges the RAND and CITL estimates that health IT could generate $80 billion in savings annually.  According to the CBO, this figure represents the total potential savings, not the likely savings after taking into account various factors that would impede full adoption and limit effectiveness.

• Many healthcare IT benefits, such as reduced redundant testing, benefits parties outside the provider organization investing in the system (e.g., payers) and, therefore, reduce provider incentives to invest.
• In fact, the way public and private payer reimbursement is structured, using healthcare IT to reduce some costs, such as redundant testing, can actually reduce provider revenue (presenting providers with a disincentive).
• Smaller practices, because they do not benefit from economies of scale, find it harder to realize some of the more commonly cited healthcare IT savings, such as chart handling costs (and one-half of physicians are in small (1-4 MD) practices).
• “By itself, the adoption of more health IT is generally not sufficient to produce significant cost savings;” e.g. “[P4P] programs do not create a strong incentive to invest in health IT systems…, because the payments are too modest.”
• Purchase, maintenance, and implementation costs are high.  Implementation costs, particularly training, template development, and other physician-focused activities are so imposing that they often impede successful implementation, and, therefore, also reduce returns.

The CBO also argues that the figure from RAND and CITL is based on a biased sample of empirical studies that includes only studies that demonstrated savings and excludes those that did not. (Evidence on the Costs and Benefits of Health Information Technology, CBO, May 2008)

A national survey examining trends in healthcare technologies has found that convenience, productivity, and compliance are the top three areas of interest for organizations looking at identity management solutions.  The survey was conducted by Zoomerang and polled 171 healthcare IT decision makers and executives nationwide.  According to researchers, organizations are moving away from conventional, less secure practices in favor of technologies that give employees greater ability to access the network applications securely, regardless of their location.  Other findings included:

• Eighty-five percent of respondents said they are looking to use tablets or mobile devices;
• Roaming desktops are used by 41 percent of respondents; and
• Nearly 75 percent of respondents said they offer VPN access, while 35 percent offer portal access for remote users.

(Healthcare IT Study Finds Mobility and Convenience Key to Productivity, Imprivata press release, May 27, 2008)

The National Alliance for Health Information Technology (NAHIT) has released to the public its report “Defining Key Health Information Technology Terms.”  The purpose of the report, which was originally submitted to the Office of the National Coordinator for Health Information Technology (ONCHIT) in April, is to help bring the terminology of health information technology closer to consensus.  NAHIT focused on defining six key terms at a high level of abstraction, leaving the task of developing detailed specifications to standards development organizations.  The six definitions reached by the group are:

• Electronic Medical Record (EMR): “An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.”
• Electronic Health Record (EHR): “An electronic record of health-related information on an individual that conforms to nationally-recognized interoperability standards and that ca