Will multi-drug resistant bacteria kill off the greatest weapon we have against infection?
FROM THE EDITOR 7 Healthcare under attack Will multi-drug resistant bacteria kill off the greatest weapon we have against infection? t's one of my friend Sharon's favorite stories: on vacation in New Zealand with her boyfriend, facing the torrential rain and gale force winds of Cyclone Bola, with only a flimsy tent for protection. The result: two cases of acute pneumonia and a deep-seated fear of camping. Thankfully, the former were cured with a short, sharp dose of antibiotics (the latter, sadly, may never be resolved). Sharon's adventure took place in 1988. Today, she might not be so lucky, because 60 years after the widespread introduction of antibiotics, some scientists believe we could be facing a future without them. In just a couple of generations, what were once seen as miracle medicines are in danger of being overpowered by the very bacteria they were designed to snuff out. It's certainly true that widespread misuse of antibiotics by doctors and patients � being prescribed and used too often or not used correctly � has allowed highly resistant strains of bacteria to develop. As more and more bacteria become resistant, very few new antibiotics are being approved for use or even developed by drug companies. According to Professor Tim Walsh of Cardiff University in the UK, "This is potentially the end of antibiotics." Speaking in The Guardian newspaper in August, Professor Walsh raised anxiety to new levels when he described an enzyme called NDM-1 that passes easily between types of bacteria called enterobacteriaceae, such as E. coli and Klebsiella pneumoniae, and makes them resistant to almost all of the powerful, lastline group of antibiotics called carbapenems. NDM-1 I is reportedly widespread in India and has arrived in the North America and Europe as a result of global travel and medical tourism for, among other things, transplants, pregnancy care and cosmetic surgery. Walsh's conclusion was that we have "a bleak window of maybe 10 years" after which our remaining antibiotics will be rendered useless. There are those who don't take quite such an extreme view, however. Jean Patel, Associate Director of the CDC Office of Antimicrobial Resistance, points out that isolates resistant to the carbapenems have been around for a while. She believes that while we may not be able to lean on antibiotics quite so much as in the past, they will instead become part of a multipronged approach that will include better hygiene and infection prevention practices, and stricter control of antibiotic use in both hospitals and in the community. So who's right? For the sake of humanity, let's hope it's not the doomsayers. Have a look at this issue's cover story, and make up your own mind. In the meantime, finish any antibiotics you're prescribed, wash your hands often, and don't go camping in a cyclone. "Antibiotics will always be critical, and we will definitely still be using them in the future, but we will no longer count on them as the sole tool for controlling infections" � Jean Patel, Associate Director, CDC Office of Antimicrobial Resistance Marie Shields Editor CONTENTS 11 32 Go with the flow Nick Pryke takes a look at the professional life of Tom Ream to learn how he carved his own path to leadership success The end of modern medicine? Marie Shields investigates the panic surrounding antibioticresistant bacteria Two hundred years young CEO Peter Slavin on how Massachusetts General Hospital plans to celebrate its bicentennial 38 44 The bird's eye view How mapping the social network is being hailed as the next generation of epidemic prediction 74 CONTENTS 13 52 A matter of life and death Michael Klompas on balancing the need to intubate with the prevention of ventilatorassociated pneumonia 80 Easy does it Boston Medical Center's Daniel Newman takes a step back to look at EMR implementation across the board 86 For the record 58 High-level access EHM rounds up the views of health industry experts on the latest issues in vascular access Why many industry players are beginning to see the value of a fully streamlined digital EMR process that spans more than just the healthcare sector 65 Finding the best fit How doing more equals less when it comes to MRSA screening in the hospital setting 92 Catching the medical identity thieves PwC's James Koenig on stopping health information fraudsters in their tracks 52 Ask the Expert 84 Steven F. Tolle, Ingenix 96 Dan Wolff, McAfee 106 Tyler Harris, NovaRad Corporation 70 Through the keyhole Andrew Onderdonk shows us what's going on behind the scenes in the world of in vitro infectious disease diagnostics 98 Smooth operator How re-aligning patient flow helped Palmetto Richland Hospital make substantial savings and dramatically improve quality of care 98 Industry Insight 50 Pamela Nelson-Artibey, Phillips 60 Bob Heitkamp, Midwest Applied Technologies 68 David Persing, Cepheid 105 Robert Monroe, BioImagene, Inc. and Eric Walk, Ventana Medical Systems, Inc. GOLD S P O N S O R 14 CONTENTS 102 The right image How digital imaging systems could bring us one step closer to becoming paperless Details 122 108 Green from the ground up Anna Gilmore Hall on why we should be introducing environmental principles into hospitals at the design stage 112 From staff-mix to skill-mix and beyond Part two of finding the optimal skill-mix, by Carl-Ardy Dubois and Debbie Singh Executive Interview 62 Francesco Pompei, Exergen Corporation Workshops 48 Progressive mobility, with Amelia Ross and Peter Morris, Wake Forest University Baptist Medical Center 56 VAP, with Douglas Hansell, Covidien 78 HIE, with Earl Jones, GE Healthcare 121 Details 122 Travel: Spain 124 Agenda 127 In review: Teach Us to Sit Still 128 Photo finish 112 SILVER S P O N S O R SILVER S P O N S O R SILVER S P O N S O R The CFO Healthcare Summit September 2011 Marina Del Ray, California The CFO Healthcare Summit is a three-day critical information gathering of the most influential and important financial executives from the healthcare industry. The CFO Healthcare Summit is an opportunity to debate, benchmark and learn from other industry leaders. Legal Information The advertising and articles appearing within this publication reflect the opinions and attitudes of their respective authors and not necessarily those of the publisher or editors. We are not to be held accountable for unsolicited manuscripts, transparencies or photographs. All material within this magazine is �2010 EHM. A Controlled, Professional and Focused Environment A Proven Format This inspired and professional format has been used by over 100 executives as a rewarding platform for discussion and learning. Chairman/Publisher Spencer Green Worldwide Sales Director Oliver Smart Finance Director Jamie Cantillon Content Director Kelly Grant Design Director James West Managing Editor Marie Shields Associate Editor Nicholas Pryke Contributors Ian Clover, Lorna Davies, Lucy Douglas, Rebecca Goozee, Sharon Stephenson, Ben Thompson Publishing Director Andrew Hobson Magazine Director Sarah Wilmott Associate Designers Tiffany Farrant, Elis� Gilbert, Michael Hall, Crystal Mather, Cliff Newman, Catherine Wilson Online Editor Jana Grune Project Director Caitlin Kenney Sales Executives Lucinda Madura, Catherine Saunders, Melody Andoy, Jennifer Clark Production Director Lauren Heal Production Coordinators Renata Okrajni, Aimee Whitehead VP North America Jason Green Operations Director Ben Kelly IT Director Karen Boparoy Marketing Director John Funnell Find Out More, Contact CFO Healthcare 212 796 2000 ext. 467 Subscription Enquiries: +44 117 9214000, www.executivehm.com General Enquiries: email@example.com (Please put the magazine name in the subject line) Letters to the Editor: firstname.lastname@example.org GDS International GDS Publishing, Queen Square House 18-21 QueenSquare, Bristol, BS1 4NH Tel: +44 117 9214000 E-mail: email@example.com www.cfohealthsummit.com 18 UPFRONT The invisible fight Epidemics have clung on to the underbelly of human existence for as long as time cares to remember. They've steered the course of history, brought populations together and torn them apart � but which ones have had the biggest effect on us? T he US has been witness to its fair share of medical epidemics throughout the decades � from polio to typhoid, smallpox to typhus. Irrespective of age, social stature or ethnicity, one thing has always reigned true when it comes to epidemics both past and future: their ability to sweep indiscriminately through entire populations of people has never faltered � and most probably never will. Yet rather ironically, since the days of modern medicine, trying to keep one step ahead of the game when it comes to epidemic predictions and vaccinations has, on occasion, actually had detrimental effects. So, in an effort to highlight under-estimated epidemics of years gone by, EHM has put forward its front-runners. Polio epidemic: 1940-1953 With its presence being announced as far back as 1916 in Brooklyn, New York, it wasn't until the 1940s that the polio epidemic really sunk its teeth into the American population. Although around 90 percent of polio infections caused no symptoms at all, if the virus entered the blood stream then it meant severe and crippling disabilities for the carrier, which unfortunately ended up as the usual precursor to the expiration of life. Spanning just longer than a decade at its peak, the worst polio epidemic in US history came in 1952, where almost 58,000 cases were reported. Out of those figures, 3145 died and a further 21,269 were left with varying degrees of paralysis. The virus also managed to singlehandedly introduce the world to the macabre yet life-saving iron lung that filled the wards of US hospital wards in the mid-50s and breathed for thousands of patients, hundreds of times a day. UPFRONT 19 Smallpox epidemic in Native Americans: 1663-1900 There are no credible descriptions of smallpox-like disease in the Americas before the westward exploration in the 16th century. It introduced itself to the Caribbean and then the mainland in 1520, before working its way into the Amerindian population, and turned out to be a pivotal factor in the conquest of the Aztecs and Incas by the Spaniards. The subsequent settlement of the east coast of North America in 1633 was the precursor to devastating outbreaks of smallpox within the Native American population and subsequent nativeborn colonists. Some estimates have fatality rates rocketing into the 80 to 90 percent zone in Native American populations during the smallpox epidemics, with many fearing to return to their homelands for many years. A disease unique to humans, fortunately today smallpox is one of only two diseases to have been eradicated, with the other � the livestock disease rinderpest � expected to be given an official declaration in 2011. Spanish Flu epidemic: 1918-1920 Although the exact geographical origin of the Spanish flu is still unknown, what is known is that the large majority of its victims were healthy young adults, which stands in stark contrast to most influenza outbreaks that predominantly affect juvenile, elderly or weakened patients. Lasting just over two years, the epidemic spread as far as the Arctic and remote Pacific islands. While estimates vary, between 50 million and 100 million people died, with a further 500 million � or a third of the world's population at the time � being infected with the disease. Tissue samples from frozen victims were used to reproduce the virus for study in the latter half of the 1900s with modern techniques, which concluded that the virus most likely took hold by a cytokine storm � an overreaction of the body's immune system � which would go a long way in explaining the concentrated age profile of its victims. Russian Flu: 1889-1890 and 1977-1978 The first ever detailed recording of a flu pandemic, the Russian flu began � rather unsurprisingly � in Russia in 1889, before spreading rapidly throughout Europe. It reached North America late in 1889 and set up shop as a hub to work its way down towards Latin America, settling in Asia in early 1890. It took the lives of roughly one million people at the time, with many believing that would be the last of it. Unfortunately, it resurfaced again in 1977 in the form of an H1N1 strain, mostly targeting children and young adults under the age of 23, as a similar strain had substantially immunized the remaining adult community in 1947. Fortunately, the virus was included in the 1978-1979 influenza vaccine, minimizing fatality levels and future outbreaks. Bacteria Salmonella Typhi Typhoid fever: 1920-1950 Before the advent of public sewage systems, typhoid was common in the US, occurring in 100 out of every 100,000 people in 1920 � that number had reduced significantly to 33.8 per 100,000 people in 1950 with the introduction of better sanitation and infrastructure. But perhaps the most famous outbreak of typhoid fever in the US came in the early 1900s from a chef called Mary Mallon. Given the title `Typhoid Mary', she was taken into custody in 1907 by local health officials when it was shown that a number of typhoid cases in the area could be traced to kitchens where she worked. She was held for three years on Brother Island in New York's East River and then released on the condition that she never again worked as a cook. She didn't take heed, and five years later was detained again after further outbreaks were traced back to kitchens she had worked in. She spent the rest of her life on Brother Island until her death in 1938. 20 UPFRONT What a dish T Lung taste receptors linked to asthma treatment he social body has always tried to paint science and art as being diametrically opposed: one uses the left half of your grey matter, the other the right. One leans upon the objective � the other the subjective. But whilst there are obvious differences between the two disciplines, modern-day interpretations and innovations have weaved the two together to a point where art truly does meet science � and when it does, it's almost always a beautiful thing. Proving the point, San Francisco-based artist and biotech expert, Klari Reis, has done exactly that. By combining her interests examining the effects of pharmaceuticals on blood under electron microscopes and creating completely mesmerizing and unique works of art, Reis has managed to meld the realms of science and art in the overly modest space of a Petri dish. And, considering the fact that she lives in Northern California, she couldn't have chosen a better place to do it, with more life sciences companies surrounding her there than anywhere else in the world. At the age of 22, Reis was diagnosed with Crohn's disease. As she explains: "As I underwent the trial and error of treatment, I started thinking about the different ways our bodies respond to medication." Now 32, Reis says that her work helps her to "think more positively about science". Once she has seen something to inspire a `Petri-piece' from under the microscope, Reis returns to her studio and, using nothing but memory, recreates what she has seen � an important part of the process as it affords each dish the room to take on individual characteristics � with the use of pigmented epoxy polymer. In a further attempt to recreate the effects of bacterial colonization, Reis also draws on the properties of temperature to provoke peculiar, unpredictable effects in the polymer, which "mimic the repetition of natural cells". Once complete, the Petri dishes are mounted at varying dimensions on their new owners' respective walls to continue the bacteria-inspired effect. A ccording to a new study from the University of Maryland School of Medicine, receptors for bitter tastes found in the smooth muscles of the lungs and airways could help in the treatment of asthma or chronic obstructive pulmonary disease. Researcher Stephen B. Liggett says he was surprised at the fi ndings, which showed that when some non-toxic bitter compounds were tested on mice and human airways, the airways relaxed and opened more widely. "I expected the bitter-taste receptors in the lungs to produce a `fight or fl ight' reaction, causing chest tightness and coughing so people would leave the toxic environment," said = Liggett. "Instead, the compounds all opened the airway more profoundly than any known drug that we have for treatment of asthma or chronic obstructive pulmonary disease." Liggett, who hopes to begin tests on humans within a year, said that eating bitter tasting foods or compounds would not help in the treatment of asthma. Instead, to get a sufficient dose, people will need to use aerosolized compounds that could be inhaled. HRT even riskier than thought N ot only does prolonged use of hormone replacement therapy raise the risk of breast cancer, a study has found it also ups the risk for more severe forms of the disease and increases a woman's chances of dying. The fi ndings, which only apply to estrogen-plus-progestin � or combined hormone therapy � not estrogen-alone therapy, showed that all categories of breast cancer were increased and for the fi rst time, mortality rates were also reported, said the author of the study, Rowan Chlebowski. "Th is reinforces the message that women should take the lowest dose possible for the shortest duration possible. Maybe women should consider talking to their physician about stopping after a certain period of time on hormone therapy," he said. UPFRONT 21 Case study: Creative collaboration A uthor Kursty Groves saw numerous examples of creative collaboration while doing research on her book I Wish I Worked There. The Clay Street Project at Proctor & Gamble turned out to not only be a deliberately inspirational place to work for its staff, but projected that exact ethos into the healthcare ether too. "This is a project where people are taken out of their daily role completely rather than try and juggle it with their main jobs � which is how most people attempt to do innovation projects. So for 12 weeks they take 12 people out of the business and they focus on nothing but this creative challenge. "For this 12 weeks they go to a completely different space, offsite and located in downtown Cincinnati, away from the headquarters. Th is took some employees out of their comfort zone as it used to be a pretty rough part of the city. Th is space is completely blank. It's a converted brewery, and there is brick and big, old wooden floorboards. "These 12 people, who hardly know each other at the beginning, have to defi ne how they are going to work together. They're given a raw space and they're put in this almost entrepreneurial position where they just have to make it work for themselves. "Not only do these people emerge 12 weeks later with some hugely innovative ideas, such as the Herbal Essence brand being completely revised through this, but loads of big business challenges have been solved in this way. These people also come out re-engaged, inspired and with a deep connection to the company and each other. Then they go back into the business with a changed behavior that starts to positively infect other people with this way of working." And if employee perspectives are anything to go by, Proctor & Gamble has worked out a way to not only inspire its staff to be more creative and entrepreneurial, but physically alter the culture of its headquarters by taking its staff as far away from it as possible � a feat not many companies can lay claim to. "It's a totally fascinating and unique experience which you couldn't find all over P&G," explains one employee. "And it's really impactful to both the individual and the team. No other experience is parallel to Clay Street." Redefi ning the workplace has been a real game-changer for the Fortune 500 company � who recently placed sixth in Fortune's `Most Admired Companies 2010' list. But it's far from being the fi rst time they've defi ned their public persona. Back in the 1930s, the company was known largely for its detergents and soaps � and as they sponsored the first radio dramas, the term `soap opera' became synonymous with all the sensationalist life-dramas we've grown to watch in the millions every week. However, after taking a step back from the acting world, Proctor & Gamble now only partially sponsors The Young and the Restless � leaving time for more pressing issues. Proctor & Gamble placed sixth in Fortune's `Most admired companies 2010' Each employee stays at Clay Street for 12 weeks P&G's Clay Street project 22 INTERNATIONAL NEWS UPFRONT Double-digit growth Brazil's retail pharmaceutical market was valued at $12.6 billion in 2009, having grown 14.3 percent between 2008 and 2009. Key growth drivers include the expanding population, improved access to healthcare, and the burgeoning middle class, which is increasingly opting for branded drugs. It is thought that expanding healthcare access is driving this double-digit sales growth. Brazil spent 10.8 percent of its GDP on both retail and hospital prescribed pharmaceuticals in 2009. Fraud uncovered The top two officials of a leading chain of community mental health centers were among four people arrested in Miami in connection with a scheme involving about $200 million in fraudulent medical claims. The four conspired to charge Medicare, the federal health insurance plan, for mental health services that were either unnecessary or never provided to patients. They were charged in a 13-count indictment with conspiracy to defraud the US and to receive healthcare kickbacks and to pay healthcare kickbacks. The fraud was described as even bigger than the ArmenianAmerican crime group charged with operating phantom healthcare clinics, cheating the federal program out of up to $163 million. Bupa sold Resolution is to pay $263 million for Bupa's life, income and critical illness insurance business in a deal that boosts the specialist consolidation vehicle's position in the so-called protection markets. Bupa is a large British healthcare organization with bases on three continents and 10 million customers. Resolution is effectively paying 72 percent of EV for the business, which is in line with previous deals, but higher than where Resolution itself currently trades. Resolution will integrate Bupa's individual protection and group risk divisions into its Friends Provident business, which sits with the Axa UK life business it bought in September. South African aid The South African government is due to receive $193 million from the European Union in development aid, the bloc's executive said in October. The European Commission indicated in a statement that the biggest share of the funds � $175 million � will go straight into South Africa's budget to improve healthcare provision for the poorest. The rest is expected to contribute to better management of development funds, the EU executive added. INTERNATIONAL NEWS 23 UPFRONT Underestimated malaria cases The WHO estimates that 15,000 deaths per year in India are attributed to malaria, but in a study published by The Lancet, it looks as though the numbers could be as high as 2.05 million per year. The study underlines the fact that the WHO estimates are a gross underestimation, with several studies in the past showing that the number of deaths is more than the WHO estimates. The reason could be that the WHO takes into account only those deaths that have are confirmed cases and is restricted to those using healthcare facilities. The Lancet paper shows how wrong the estimates can be if the current protocol is used. Indeed, in this study, 2681 deaths were found to be due to malaria, with 90 percent happening in rural areas and 86 percent away from healthcare facilities. Medical tourism The Taiwan Land Development Corporation plans to build three healthcare villages to capitalize on the surging popularity of medical tourism. The International Technology Research Institute (ITRI) suggests that the global medical tourism industry is worth $40 billion in 2010, with up to 40 million people being medical travelers. Taiwan Land Development Corporation believes that Taiwan offers excellent medical care, so can take advantage of business opportunities in medical tourism as it has gained a reputation in the world and is particularly respected by the Chinese. A recent economic cooperation framework agreement between China and Taiwan will encourage trade and tourism between the two countries Grim status Reports show that most Australians are complacent about getting AIDS. They feel that unless a person is homosexual or an injecting drug user or a sex worker, they are not at risk. The national infection rates, which have stabilized at around 1000 cases a year, have not come down significantly, despite the efforts of healthcare professionals and affected communities. Aboriginal Australians are also vulnerable, with fast-growing epidemics in many of the big cities of south east Asia and some Pacific islands. 24 UPFRONT Envisioning the future of healthcare leadership Is your team prepared to meet the challenges of healthcare reform? H Can a daily cuppa lower your risk of brain cancer? W e know that tea and coffee can boost your energy levels, but regular consumption of the world's two most popular beverages may also shield drinkers against a form of brain cancer. In fact, research from Brown University in Providence suggests that those who drink as little as a half cup or so of coffee per day may lower brain cancer risk by as much as 34 percent. The research, which tracked more than 410,000 men and women across Europe between 1991 and 2000, showed that coffee and tea might protect against brain cancer, specifically in the form of glioma, a cancer of the central nervous system that originates in the brain and/or spinal cord. Th is research builds on previous studies that indicated tea and coffee may also lower the risk for both Alzheimer's and Parkinson's disease. ealthcare reform is presenting unprecedented challenges and opportunities to Boards of Trustees and executive management teams. `Accountable care' has become the linchpin of healthcare reform which will engender a new level of `system-ness'. Now is the time to build a platform from which to deliver an integrated system of care with high-quality clinical outcomes. Steering your organization through this era of reform requires an executive team of leaders who have a complete set of skills, proficiency and experience to address critical areas. Your key human capital investment is in identifying and cultivating candidates for leadership � including physician leaders � who fit well and will drive the success of your organization. As a healthcare "Steering your executive leading your organization toward a organization system of accountable through this care, ask yourself the folera of reform lowing questions: Does the leadership team need requires an an infusion of new talent executive team of with different skills or leaders who have capabilities? Do current leaders need to undergo a complete set of intensive assessments to skills, proficiency identify their skill and and experience to knowledge gaps in deliveraddress critical ing accountable care? How can training and coaching resources be best utilized to maximize the potential of mid-level managers and build bench strength within the organization? And fi nally, do we need skilled assistance in objectively identifying talent from within and outside our organization who will share our vision, understand our culture and fit out team? Whatever the answers to these questions, addressing them proactively will help you develop a strong pool of leadership talent within your management ranks and build the leadership team of an accountable care organization. areas" To learn about how the experienced search consultants of Cejka Executive Search are helping top healthcare organizations successfully develop their leadership teams in an era of accountable care, visit www.cejkaexecutivesearch.com. Q&A 25 David Blumenthal's take on the task of implementing electronic health records nationwide. How did you come to the role of National Coordinator. Did you have a technical background? David Blumenthal. I was not an expert on technology and never have been. I wasn't the kind of person who in high school learned to program and came in on weekends to get all those cardboard cards and run them through the computers. That was never my thing; I was much more a liberal arts person. But I've learned a lot from practicing over the years and many of my research interests were fed by my experience. I began using an electronic system and I came to believe that it would have an important influence on care. Your office has been charged with the goal of catalyzing the adoption of interoperable health information technology by 2014. What will you need to do in order to achieve this? DB. We need to develop a series of regulatory and programmatic foundations in order to achieve this goal. The regulations will govern how we spend the money that the Congress has made available to reward meaningful use of electronic health records. We are in the process of writing the regulations, which is a very carefully scripted process, governed by law and precedent. And we are on the cusp of completing the first set of regulations that will create the rules that will govern the use of the incentives and the rewards that will be available to doctors and hospitals. We'll also govern the evaluation of the records themselves to make them capable of supporting meaningful use. What role will the Regional Extension Centers play? DB. There are 60 Regional Extension Centers around the country. They are going to be available to doctors and smaller hospitals that need help getting up and going with electronic health records so that they can be meaningful users. We are working with the leaders of these new centers, to get them ready to help people in the field. We are creating multidisciplinary teams around the country, each of which is taking responsibility for up to 1500 physicians and a set of smaller rural hospitals. They will be focused on small practices and hospitals, developing whatever resources are needed to make those physicians and hospitals successful in adopting and using electronic health records. Do you expect there to be resistance from prospective users? DB. I do understand that some doctors out there may decide that it's too much trouble. We'll try to help them the best we can, but there will be I think an age-related trend toward more rapid adoption among younger physicians. Coming from a slightly older generation myself, I'm obviously very comfortable using EHR. However, the transition between old and young is inevitable. But we don't want to wait for this new generation to take over; we want to make the existing practitioners part of the 21st century as well. David Blumential is National Coordinator for Health information Technology, DHHS EHR: the way forward 26 UPFRONT Actionable intelligence for the smarter revenue cycle "Implementing best practices in the revenue cycle can be resource intensive. But the right solution can make revenue cycle best practices affordable, sustainable and impactful to the bottom line," says Albert Scarasso, CEO of DaVincian Technologies. The key for successful best practices is actionable intelligence. "Actionable intelligence is combining decisionmaking knowledge with operational data in real-time to prompt the user to immediately address the issues," Scarasso says. "Everyone does data mining, but all too often, the data sits in some database where it doesn't do any good. When technology can grab the mined data � the `decisionmaking knowledge' � and combine it with flexible automation, you can create actions that are required for consistent best practices across the revenue cycle." CFOs need actionable intelligence in all areas of the revenue cycle. But denials, bad debt, missed opportunities and cash-flow delays require solutions on the `front end' of the revenue cycle, before patients are admitted into the facility. "Actionable intelligence is valuable in the backend of the business office," Scarasso says, "but it is truly crucial to have in front end solutions. When you apply intelligence to patient access, you can take action to reduce the amount of human factors that introduce errors in the system � errors that follow the bill all the way out the door. The right solution automates processes so that, based on what you know about the patient, all the eligibility, benefits, authorizations and other requirements are collected up-front." DaVincian offers solutions that work with � rather than replace � legacy systems, gathering the right data from the right source at the right time. To learn more about how DaVincian Technologies provides actionable intelligence for a smarter revenue cycle, go to www.davinciantech.com. New Philips NIV Guide for the iPhone and iPad I n an age when there seems to be an iPhone app for almost everything, perhaps it is not surprising to see that there is now an application created specifically for noninvasive ventilation (NIV). Philips has just introduced the world's fi rst clinical decision support app for NIV. Tapping into its unmatched experience in noninvasive ventilation, Philips has created a unique pocket reference tool for clinicians looking to build or grow their NIV competencies. Using clinical protocols and guidelines developed by leading physicians such as Nick Hill, MD, and Stefano Nava, MD, the Philips NIV Guide app offers pathways, tips and therapy recommendations for NIV veterans and novices alike. For those who fancy themselves as experts in noninvasive ventilation, there is even an NIV "IQ test" where they can pit their knowledge against published data. The goal, of course, is not merely to measure competencies but to open eyes and minds to the many subtleties of practicing NIV. One key area that benefits from particular attention in the app is the patient interface or mask. With so much of NIV's success resting on patient comfort, it's hardly surprising that mask selection, fitting and adjustments deserve an entire section unto themselves. Philips has scoured its knowledge base to provide practical information on the most common types of interfaces available today. What are the differences between an oronasal mask and a total face mask? Where and how should they be used? Philips' goal for their new clinical decision support tool is simple: To help clinicians around the world practice NIV safely, effectively and confidently on more patients. Available for FREE on iTunes, the Philips NIV Guide clinical app is a musthave for clinicians involved in critical care ventilation. 28 UPFRONT MRSA surveillance: are you on the case? T he incidence of hospital-associated methicillinresistant Staphylococcus aureus (MRSA) is still on the rise around the globe, and studies in Europe and the US suggest that 28-34 percent of patients infected with MRSA will die from their infection. These fi ndings have serious implications for patients, physicians and hospitals � including significant potential economic consequences, such as prolonged hospital stays, additional procedures and litigation. As MRSA rates increase, so does the need to implement comprehensive infection control and protect your hospital from potential liability. In the US, many states have already enacted legislation regarding MRSA screening and/or reporting, and federal legislation has eliminated reimbursement for treatment of some hospital-acquired infections, including certain MRSA-related conditions. How is your hospital responding? Currently, only about one out of every three hospitals has an active MRSA screening program. Yet, while results vary according to the hospital setting, several recent studies provide evidence for the clinical and economic benefits of identifying MRSA carriers through active surveillance, including the fact that identifying infected cases alone misses 85 percent of carriers; carriers are 20 percent more likely to infect themselves; and carriers are 16 times more likely to transmit MRSA to others for each day that they spend outside contact isolation. Of course, surveillance alone is not the total solution; a comprehensive infection prevention and control program is needed. But the vast majority of guidelines available today support the idea that active surveillance is a critical component of comprehensive infection control measures � and an important step in protecting your facility from potential liability. One solution for active screening is the Roche LightCycler MRSA Advanced Test, a qualitative in vitro diagnostic test performed with nasal swab specimens from patients suspected of MRSA colonization. The molecular test delivers results within two hours and offers a simple, flexible and reliable way to incorporate MRSA surveillance into your hospital's infection control program. Roche LightCycler� 2.0 Protecting external media: A difficult challenge I n recent years, external media have become very threatening for healthcare facilities. Healthcare professionals are often working from remote locations and transporting sensitive patient data on removable media such as USB drives, SD memory cards, laptops, tablet PCs and smartphones. To maximize data protection, CREDANT Technologies, the largest endpoint encryption and data protection company in the world, specializes in protecting external media devices. In the modern era of electronic health records, being on the cutting edge of technology is crucial for your organization-including mobility in the workforce, which is especially prevalent in the healthcare industry. Employees are now taking advantage of devices such as large-capacity USB thumb drives, SD memory cards and robust smartphones to store sensitive patient information. Each device, however, also carries with it the potential for a serious data breach. Removable media security continues to be one of the most difficult challenges facing security and compliance teams today, especially in the healthcare industry. In the one year since the new HIPAA breach reporting requirements went in to effect, the HHS website is already reporting more than 180 breaches involving 500 records or more. Of these breaches, approximately 40 percent involved a laptop or other portable device. Although removable media security is difficult to conquer, there are strategies that can be used to greatly reduce data breaches through your organizations mobile endpoints. CREDANT is dedicated to making sure organizations like yours are well equipped against potential data breaches. By taking the steps to protect sensitive patient data, your healthcare facility can greatly reduce the risk of harmful data breaches, and in turn use removable media to aid in providing the utmost quality of patient care. For more information, please visit www.credant.com/healthcare. 30 UPFRONT Improving access Lagging behind T he new Patient Protection and Affordable Care Act will expand coverage and ensure that individuals and families are offered new and better services. It is hoped that it will improve patient waiting times that have been so common across the nation for so long. A Getting an appointment with a doctor the same or next day when sick, without going to the ER 30 41 60 73 study of more than 10,000 primary care physicians in 11 countries has found that the US lags far behind in terms of access to care, the use of fi nancial incentives to improve the quality of care, and the use of health IT. In other countries, national policies have sped the adoption of such innovations. Key fi ndings include: � More than half (58 percent) of US physicians said their patients often have difficulty paying for medications and care. Half of US doctors spend substantial time dealing with the restrictions insurance companies place on patients' care. � Only 29 percent of US physicians said their practice had arrangements for getting patients after-hours care. Nearly all Dutch, New Zealand and UK doctors said their practices had arrangements for after-hours care. � Only 46 percent of US doctors use electronic medical records, compared with over 90 percent of doctors in Australia, Italy, the Netherlands, New Zealand, Norway, Sweden and the United Kingdom. � Twenty-eight percent of US physicians reported their patients often face long waits to see a specialist, one of the lowest rates in the survey. Three-quarters of Canadian and Italian physicians reported long waits. Getting advice from your doctor by phone during regular office hours Getting care on nights, weekends, or holidays without going to the ER Any of the above 0 25 50 75 100 So to sleep... K now someone who is fresh and alert with as little as four hours' sleep a night? The answer could be in their genes, according to new research from the University of Pennsylvania School of Medicine in Philadelphia, which found that after several nights of restricted sleep, healthy adults who carried a particular gene variant called DQB1*0602 were sleepier and more fatigued during the day, and had more fragmented sleep than non-carriers. The variant is closely linked to narcolepsy, a sleep disorder that makes people feel sleepy during the day. Namni Goel, who led the study, said the variant could be "a biomarker for predicting how people will respond to sleep deprivation, which has significant health consequences and affects millions of people around the world". If the fi ndings were confi rmed, it could justify recommending that carriers of DQB1*062 take naps or caffeine to help them cope during times of sleep restriction, added Goel. UPFRONT 31 Fatty acids could lower gum disease Business continuity: A life-saving IT strategy T hey're already well known for their antiinflammatory properties, but research has found that the dietary intake of polyunsaturated fatty acids (PUFAs) such as fish oil could be effective in the treatment and prevention of periodontitis, a common inflammatory gum disease. According to a spokesman from the Beth Israel Deaconess Medical Centre, the research could point the way to a less expensive and safer method for the treatment and prevention of periodontitis. "We found that n-3 fatty acid intake is inversely associated with periodontitis. To date, treatment has primarily involved mechanical cleaning and local antibiotic application but given the evidence, n-3 fatty acids could be the key to treating this disease. It could also have the added benefit of preventing other chronic diseases associated with inflammation, including stroke." Foods that contain significant amounts of polyunsaturated fats include fatty fish like salmon, peanut butter, margarine and nuts. H aving immediate access to a patient's medical records isn't a luxury; it's a necessity that can mean life or death for the patient. With the move to electronic health records (EHR), it's important for healthcare organizations to have a plan that ensures patient data is safe on the network. A business continuity plan � network solutions that allow an organization to continue network operations in times of distress � can accomplish this. Whether you're a big healthcare system or a small independent practice, a business continuity plan is critically important to both patient care and legal compliance. Government regulations, like the Health Insurance Portability and Accountability Act's (HIPAA) EHR requirements, make it necessary for healthcare institutions to store patient data on their networks. Failure to comply with these regulations can result in heft y fi nes. However, many smaller practices lack dedicated IT staff or funding to support the necessary network. And, even with regulations in place forcing the move to digital records, some simply choose not to comply, which puts the security of their patients' information at risk. There's no such thing as an all-in-one solution when it comes to business continuity. From data storage, backup and recovery, to colocation, cloud computing and network security; the needs change depending upon available resources and the current state of your network. PAETEC works with customers to implement a customized business continuity plan. With a free network assessment, PAETEC provides recommendations regarding the changes customers need to make. Additionally, PAETEC's unique Equipment for Services (EFS) and Soft ware for Services (SFS) programs allow healthcare organizations to subsidize the equipment/soft ware necessary to build effective business continuity plans. By using these programs, customers can receive reimbursements and upfront capital from the federal government. To learn more about PAETEC's Business Continuity Solutions, visit www.paetec.com/campaign/continuity to download the informational brochure. Company index Q4 2010 Companies in this issue are indexed to the first page of the article in which each is mentioned. 3M 129 Axolotl 77 B. David 37 BioImagene IFC, 105 Boston Medical Center 80 Brigham and Women's Hospital 52, 71 Cejka Search 24, 119 Centers for Disease Control 32 Cepheid 68, 69 Credant 28, 94 Covidien 56, 57 DaVincian Technologies 26, 27 Exergen 2, 62, OBC GE Healthcare 10, 78, 79, 120 GOJO 8 Harvard Medical School 74 Healthcare Without Harm 108 Hill-Rom 4, 48, 49 Ingenix 12, 83, 84 Institute for Healthcare Improvement 98 KLAS Research 102 Lawson 116 Leverage 47 Massachusetts General Hospital 38 McAfee 96, 97 MedNetworks 74 Midwest Applied Technologies 60, 61 Northshore HealthSystems 65 Novorad Corporation 106, 107 PAETEC 29, 31, 91 Palmetto Health System 98 People Click 114 Philips 17, 26, 50, 55 PricewaterhouseCoopers 92 Proctor & Gamble 21 Relay Health 88 Roche 28, 64 Skytron 6 Sutter Health 44 Teleflex Medical 15 Texas Health Resources 86 Thermo Fisher Scientific 73 University of Birmingham 117 University of Montreal 117 Well Spent Health 86 32 COVER STORY Marie Shields investigates the panic surrounding antibiotic-resistant bacteria. COVER STORY 33 F or more than 60 years, we have depended on antibiotics not only for the treatment of routine viral infections, but also during difficult procedures such as transplant surgery immunosuppressant cancer drugs. We've come to take them for granted, but if recent reports in the press are to be believed, our happy relationship with antibiotics may be coming to an end. The emergence of a new enzyme has brought the topic of antibiotic resistance back into the public consciousness. In a paper published in the journal Lancet Infectious Diseases in September, Professor Tim Walsh and colleagues published details of the discovery of NDM-1, which passes easily between types of bacteria called enterobacteriaceae such as E. coli and Klebsiella pneumoniae and makes them resistant to almost all of the most powerful group of antibiotics, the carbapenems. At the time of the paper's publication, Professor Walsh, who is based at Cardiff University in the UK, appeared confident that the discovery of NDM-1 spelled the end of antibiotics as we know them. "In many ways, this is it," he told the Guardian newspaper. "This is potentially the end. There are no antibiotics in the pipeline that have activity against NDM-1-producing enterobacteriaceae. We have a bleak window of maybe 10 years, where we are going to have to use the antibiotics we have very wisely, but also grapple with the reality that we have nothing to treat these infections with." The reality of a life without effective antibiotics could be bleak, with many common medical interventions becoming difficult or even impossible. Transplant surgery, for example: without antibiotics, organ recipients would not be able to fight off life-threatening infections they are subject to thanks to the need for immune-suppressing drugs to prevent rejection of the new organs. Or the removal of a burst appendix: without antibiotics bacteria can get into the patient's bloodstream via an infected incision, resulting in septicemia. Pneumonia could once again become a leading killer of the elderly, gonorrhea could become difficult to treat and TB could become virtually incurable. According to the World Health Organization, "The bacterial infections that contribute most to human disease are also those in which emerging and microbial resistance is most evident: diarrhoeal diseases, respiratory tract infections, meningitis, sexually transmitted infections and hospital-acquired infections." Some important examples include penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, multiresistant salmonellae, and multi-resistant Mycobacterium tuberculosis. The WHO says the development of resistance to drugs commonly used to treat malaria is of particular concern, as is the emerging resistance to anti-HIV drugs. The circumstances that have led us to this point are well known. Antibiotics can be prescribed when they're not needed, often in response to patient demand. Or patients complete only part of a course, which kills the more vulnerable bacteria while allowing the stronger ones to flourish. The widespread use of antibiotics in intensive livestock farming has also contributed to the problem. According to the WHO, "Bacteria are particularly efficient at enhancing the effects of resistance, not only because of their ability to multiply very rapidly but also because they can transfer their resistance genes, which are passed on when the bacteria replicate. "In the medical setting, such resistant microbes will not be killed by an antimicrobial agent during a standard course of treatment. Resistant bacteria can also pass on their resistance genes to other related bacteria through `conjugation', whereby plasmids carrying the genes jump from one organism to another." Resistance to a single drug can thus spread rapidly through a bacterial population. When anti-microbials are used incorrectly � for too short a time, at too low a dose, at inadequate potency; or for the wrong disease � the likelihood that bacteria and other microbes will adapt and replicate rather than be killed is much greater. Growing resistance Global trends that have encouraged antimicrobial resistance include: Urbanization, with its associated overcrowding and poor sanitation, which facilitate the spread of such diseases as typhoid, tuberculosis, respiratory infections and pneumonia Pollution, environmental degradation and changing weather patterns, which can affect the incidence and distribution of infectious diseases, especially those, such as malaria, that are spread by insects and other vectors Demographic changes, which have resulted in a growing proportion of elderly people needing hospital-based interventions and thus at risk of exposure to highly resistant pathogens found in hospital settings The AIDS epidemic, which has greatly enlarged the population of immunocompromised patients at risk of numerous infections, many of which were previously rare The resurgence of old diseases, such as malaria and tuberculosis, which are now responsible for many millions of infections every year The growth of global trade and travel, which have increased the speed and facility with which both infectious diseases and resistant microorganisms can spread between continents Source: www.who.int/en Difficult battle So far, so bad. But humankind has an illustrious history of conquering the most difficult medical challenges. What makes this situation particularly tricky is that bacteria are everywhere � there are 10 times as many bacterial cells in the human body than `human' cells � and they are incredibly adaptable. The more we try to wipe them out, the stronger they get. If we beat them on one attack, that often only means they will regroup, change, and launch a second wave. Th is is why, in the world before antibiotics, death from infection was common; and why the idea that our most successful weapon against them may be rendered useless engenders such panic. Yet this is not the first time experts have sounded the death knell for antibiotics. As far back as 1994, Newsweek ran an article by Sharon Begley titled `The End of Antibiotics', which covered in detail the alarming situation modern medicine found itself in, with bacteria capable of beating back any drugs thrown at them. Here we are, 16 years later, and the worst hasn't happened. Are we really facing bacterial Armageddon, or is this a case of the media leaping on a scare story and running with it? Jean Patel, Deputy Director of the CDC Office of Antimicrobial Resistance, believes that while there is reason to worry, there is no need for all-out panic. "The emergence of NDM-1 is concerning, but we have been seeing isolates that are resistant to carbapenems in the United States for a while, as well as in other parts of the world," she points out. "For example, there is another mechanism of resistance called the KPC enzyme that has a similar resistance profi le as isolates that harbor the NDM-1 enzyme. "These are enzymes that are occurring in bacteria called Enterobacteriaceae, and they are resistant to nearly all antibiotic agents. But usually there are one or two active agents that can be considered for therapy." However, Patel does stress that: "We are facing a situation where there are going to be very limited treatment Discovery of penicillin ing bacteria. So I think we're going to see new drugs becoming available, it's just going to take some time. "There has been a dip in the pipeline, so we need to come out from under that dip and see more drugs that are being developed. But that will Like many cornerstones not be the only answer, and we of modern life, penicillin have to stop transmission and � one of the earliest improve the use of the antibiotand most well-known ics that we currently have." antibiotics � was As part of its frontline discovered by accident. work on this problem, CDC is In 1928, Scottish a co-Chair of the Interagency bacteriologist Alexander Task Force on Antimicrobial Fleming observed that Resistance, which includes fedno bacteria grew around eral agencies within the health the mold of the genus and human services group, inPenicillium notatum, cluding the NIH and the FDA, which had accidentally as well as outside agencies such fallen into a bacterial as the Department of Defense, culture in his laboratory. the EPA and the USDA. The task force coordinates It was more than and communicates antimicro10 years, however, bial resistance work between before penicillin was these federal agencies, prosuccessfully purified and viding a forum for them to tested, extracted and discover how their work might then finally produced on Varied approach either complement or avoid a large scale in 1945. That Regardless of how many new drugs are duplication of work happenyear, Fleming, along with coming to market, we are beyond the point of ing elsewhere. fellow British scientists taking antibiotics for granted. Th is is where the In 2001, the Interagency Howard Florey and Ernst multi-pronged approach comes in, including Task Force developed a Public Chain, received the better hygiene and infection control practices, Health Action Plan to Combat Nobel prize in medicine, and better control of antibiotic use in both hospiAntimicrobial Resistance as signaling the beginning tals and in the community. a blueprint for specific, coof the golden age of "Anywhere that antibiotics are used, they ordinated federal actions to antibiotics. contribute to antimicrobial resistance," says address the emerging threat of Patel. "That includes antibiotic use in the healthantimicrobial resistance. care setting, in the community and also on the Patel calls the action plan farm. Antibiotics can be used appropriately and "comprehensive", pointing out inappropriately in all three of these settings. that it addresses antimicrobial "One of the important strategies to combatresistance, not just in bacteing antimicrobial resistance will be to improve antibiotic ria, but in all microorganisms, and is broken down into use and make sure they are used appropriately in all of the different areas. One of these is surveillance to measure settings in which they're considered. An important way of antimicrobial resistance, determining what is occurring doing this is through educational campaigns and teaching and where. prescribers how to use antibiotics correctly." "Prevention and control of antimicrobial resistance, There are those who accuse the pharmaceutical indusproduct development and research are the other areas covtry of not doing enough to develop new antibiotics, given ered," says Patel. "And within all of those, there are specific that there are fewer fi nancial incentives to working in this action items at the federal level to combat the problem." area than in other areas of lifelong illness, such as cancer The Task Force is currently working on a revised action and heart disease. plan which should be completed by the end of this year. Patel, however, believes that the possibilities for drug One of the aims for this revision is to make the plan a more discovery are great. "Th is is an important topic of research useful document, as Patel explains. "We're developing a and we have great minds thinking about new ways of fightnew vision for how the action plan will work. In the past, choices, and we have seen reports of cases where there are no active antimicrobial agents. This is happening primarily in patients who are already hospitalized with a serious illness. "In that scenario, we would expect to see increased mortality and morbidity because of antimicrobial resistance. But the alarm has been set, and we have ways to address the problem." While Patel is not unduly concerned about the short term, she does emphasize that it will take more than pharmaceuticals to solve the problem: "There's nothing new happening that would make us alarmed that anything more serious is going to happen 24 months down the line. However, longer term we're facing bacteria that are resistant to nearly all antibiotics. And the way we need to address that is with prevention and control efforts and with attempts to increase the number of antibiotics that are being developed. There has to be a multi-prong approach to this antimicrobial resistance problem. There's not going to be one answer." Patel stresses that she does appreciate and share Tim Walsh's concerns, although she prefers not to use quite such alarmist language. "We need to be careful how we use antibiotics." she says. "We need to use them wisely. And our need to use them wisely is going to expand beyond this 10year period [mentioned by Prof. Walsh]." Penicillin wasn't produced until 17 years after its initial discovery "There's nothing new happening that would make us alarmed that anything more serious is going to happen 24 months down the line" COVER STORY 35 DJ. The Interagency Task Force on Antimicrobial Resistance, co-chaired by CDC, FDA and NIH, identified `Prevention and Control' as one of four action items in the fight against antibiotic resistance. While other agencies and interest groups are working with CDC to do their part to promote surveillance, research and new drug development, CDC's Get Smart focuses on slowing the rise of AR through education and behavioral change. What are the aims of the campaign and how are these realized? DJ. The objectives of the program are to decrease the demand for antibiotics by the public and increase appropriate prescribing by providers. Objectives also include increasing patient adherence to appropriately prescribed antibiotics and increasing appropriate antibiotic selection by providers. These objectives are realized through a few approaches. The general public objectives (patient demand and prescription adherence) can be evaluated by conducting community-based studies and documenting patient encounters and/or by conducting surveys with the general public on self-reported behavior. The provider objectives (appropriate prescribing/selection) can be evaluated by analyzing data from CDC's National Center for Health Statistics and private data. Why is it important to get the message across to patients that antibiotics must be used as directed, and cannot be prescribed for viral illnesses such as the common cold? DJ. There are two important reasons that antibiotics should be used judiciously. The first is that antibiotic use leads to antibiotic resistance, so it is important that we reserve the use of antibiotics for when they are truly needed. The second is that antibiotics aren't always harmless. Many patients experience adverse reactions to antibiotics, ranging from stomach upset to conditions that require a visit to an emergency room. The public needs to know that antibiotics are serious medicines. What happens during Get Smart About Antibiotics Week? What tools are available to those interested in taking part? DJ. Get Smart About Antibiotics Week is observed during cough and cold season and it is an opportunity for partner organizations, healthcare providers and consumers to make a concerted effort to do their part. Specifically, organizations spend this week educating their members about the importance of appropriate antibiotic use. Providers take a few extra minutes to educate patients. Consumers share with friends and family that antibiotics are not needed for most cough and cold illnesses. Get Smart Get Smart about Antibiotics Week is an annual effort to coordinate the work of CDC's Get Smart: Know When Antibiotics Work campaign, state-based appropriate antibiotic use campaigns, non-profit partners, and for-profit partners during a one week observance of antibiotic resistance and the importance of appropriate antibiotic use. This year's Get Smart week fell on Nov. 15-20. Darcia Johnson, Program Officer for the campaign, gives us the details. Data suggest that more than 10 million courses of antibiotics are prescribed each year for viral conditions that do not benefit from antibiotics. Why does this happen? Darcia Johnson. Several factors contribute to antibiotics being prescribed for viral conditions. Providers report patient demand as a contributing factor, but also acknowledge that time restraints and diagnostic uncertainty play a role. Why did CDC initially establish the National Campaign for Appropriate Antibiotic Use in the Community, which became the Get Smart campaign? To learn more about available tools and partner involvement, please visit http://www.cdc.gov/ GetSmart/campaign-materials/ week/index.html. 36 COVER STORY ANTIBIOTICS THROUGH THE AGES ANCIENT TIMES The ancient Egyptians, the Chinese, and Indians of Central America all used molds to treat infected wounds. Late 1800s With the growing acceptance of the germ theory of disease, the search for antibiotics began in the late 1800s. 1871 Surgeon Joseph Lister began researching the phenomenon that urine contaminated with mold would not allow the successful growth of bacteria. 1890s Rudolf Emmerich and Oscar Low were the first to make an effective medication from microbes. It didn't always work, however. 1928 Sir Alexander Fleming observed that colonies of the bacterium Staphylococcus aureus could be destroyed by the mold Penicillium notatum. 1942 Howard Florey and Ernst Chain invented the manufacturing process for Penicillin G Procaine, allowing penicillin to be sold as a drug. 1955 Lloyd Conover patented Tetracycline, which went on to become the most prescribed broad spectrum antibiotic in the United States. 1981 SmithKline Beecham patented the semisynthetic antibiotic, Amoxicillin, still commonly prescribed today for bacterial infections. "Prevention and control of antimicrobial resistance, product development and research are the other areas covered" it was a document that was created and used as a template for prioritizing research. So, for example, in my prior life, I worked in an antimicrobial resistance laboratory here at CDC, and I would look to the action plan for what kind of work was important for fighting antimicrobial resistance, and design our work around that. "In the future, though, we want to make our action items more specific, and to provide timelines for when we think this work will be done. That's an ongoing process. We expect to revise the action plan every two years and to provide regular reports of progress toward implementation." The CDC is not the only agency urging action on this front. In 2001, the WHO launched a global strategy for combating the serious problems caused by the emergence and spread of antimicrobial resistance. Known as the WHO Global Strategy for Containment of Antimicrobial Resistance, the strategy recognizes that antimicrobial resistance is a global problem that must be addressed in all countries. "No single nation, however effective it is at containing resistance within its borders, can protect itself from the importation of resistant pathogens through travel and trade," say the strategy documents. "Poor prescribing practices in any country now threaten to undermine the potency of vital antimicrobials everywhere." The strategy recommends interventions that can be used to slow the emergence and reduce the spread of resistance in a diverse range of settings. The interventions are organized according to groups of people whose practices and behaviors contribute to resistance and where changes are likely to have a significant impact at both national and international levels. These include consumers, prescribers and dispensers, veterinarians and managers of hospitals and diagnostic laboratories as well as national governments, the pharmaceutical industry, professional societies and international agencies. According to the WHO, much of the responsibility for containing resistance rests with national governments, which is why the strategy gives particular attention to interventions involving the introduction of legislation and policies governing the development, licensing, distribution and sale of antimicrobial agents. Task forces and action plans and multi-pronged approaches all seem much more sensible and a lot less attractive to the media than mass panic and despair. If this common sense, methodical approach prevails, then we still have a fighting chance of beating our old bacterial enemies at their own game. Patel believes the trick is not to depend on antibiotics quite so much. "Antibiotics will always be critical," she says, "And we will defi nitely still be using antibiotics in the future because they're such a critical piece in treating an infectious disease. But we will no longer be counting on them as a sole tool for combating antimicrobial resistance and for controlling infections. Instead, we'll see a much greater emphasis on infection control to prevent transmission of resistant bacteria,and a continued effort on improving and making sure that antimicrobial use is appropriate." 38 THE BIG INTERVIEW Two hundred years young THE BIG INTERVIEW 39 Next year, Massachusetts General Hospital will begin a third century of healthcare leadership and serving the local community. Hospital President Peter Slavin lets Marie Shields in on the plans to mark this important milestone. I magine it's 1810, and you're a gentleman or a lady of a certain class in Boston: well-off, living in a comfortable home with a few servants and access to good food and wine � and when you're ill, your personal physician comes to your home to treat you with the latest medicines, for which you are happy to pay. Now imagine that one day you receive a letter from two doctors, John Collins Warren and James Jackson. In it, they express concern for the many local residents who have no money to pay for medicines, and sometimes not even homes to be treated in. Warren and Jackson propose the founding of an innovative institution � an acute care hospital � that would provide medical treatment to the area's poor. And here's the catch: they're asking you to contribute a sum of money toward its establishment. What do you do? Luckily, many of those who received Warren and Jackson's letter did agree to fund the new institution, and in February 1811, Massachusetts General Hospital was established by charter. But as current President Peter Slavin explains, the process that followed was not a straightforward one, "It took some time to get the law passed to create the hospital, raise the money and complete the construction on the building � this building we're sitting in right now � and so the hospital opened its doors to patients about 10 years later. 40 THE BIG INTERVIEW Hand hygiene happens over 90% of the time "In many ways the mission of the hospital has remained unchanged over the last 200 years, although how we go about pursuing the original vision has obviously changed" Peter Slavin on HAIs "We have a number of programs aimed at trying to minimize the rate of hospitalacquired infections, one of which is a very aggressive hand hygiene program. We have spies who wander around the hospital and watch individual clinicians to see if they wash their hands or use an alcohol-based hand cleaner before going into a patient's room and after coming out, and we track those findings by patient care unit. "Five years ago hand hygiene happened 50 percent of the time. Now it happens well over 90 percent of the time. And we've seen our rates of the common infections that are associated with lack of hand hygiene go down significantly. "We've also been very focused on central line infection rates, and those have come down dramatically as well. Those are just two examples of what we're doing. We're taking it very seriously, and I wish that the entire healthcare industry was doing the same." " "If you look back at that era, there were similar efforts underway in Philadelphia and New York, and there were hospitals that opened in all three communities at roughly the same time. These were charitable institutions aimed at trying to provide care to the poorest people in society, and what I'm proud of is that that spirit, that initial focus, has not been lost in any way over the last 200 years. "While we obviously now also provide services to people with means, we are still one of the biggest providers to the poor people of this region and we remain intensely committed to meeting their needs." Obviously medicine has changed beyond almost all recognition over the last 200 years, and it's a credit to Mass General that it has kept pace with the latest developments while remaining true to its original vision. Clinical care and medical education were clearly part of that: when the hospital opened, it was also planned as a teaching site for students at Harvard Medical School, which was founded before the creation of the hospital. According to Slavin, one other important mission has been added since then: research, which now makes up about a quarter of what the hospital does. Th is means dedicating a quarter of its employees and a quarter of its budget to research, giving it the largest research program of any hospital in the United States. "In many ways the mission of the hospital has remained unchanged over the last 200 years," Slavin says, "although how we go about pursuing the original vision has obviously changed as medicine has changed dramatically. "Boston has by far the greatest concentration of biomedical research of any community in the world, and I think we're the single largest institution conducting biomedical research in this community. We also have MIT and other parts of Harvard and the other hospitals here in town, as well as a growing number of pharmaceutical and biotech companies. If you want to pursue biomedical research, Boston is the place to be." With that amount of expertise available in the local area, it makes sense for institutions to collaborate, as indeed they are. In 2003 MIT, Harvard and the Harvard teaching hospitals (with funding from philanthropists Eli and Edythe Broad) created the Broad Institute, arguably one of the leading genetics research institutes in the world. Another collaboration spans all the Harvard institutions in stem cell research, resulting in the Harvard Stem Cell Institute, which Slavin says has helped make an even greater impact in the field. And last year, MGH created the Ragon Institute, which is aimed at " THE BIG INTERVIEW 41 developing a vaccine for HIV, and involves a partnership with MIT and Harvard University. Peter Slavin on EHR "I'm delighted that the government is taking a leadership role on electronic health records. At MGH, we currently have virtually all of our outpatient records in electronic format, and all orders for inpatients in the hospital are done electronically, and there's no doubt in my mind that that is a safer way to practice medicine. "It's also more efficient. Where once a physician would have to generate a letter after an outpatient visit, now all that happens electronically, and any other physician who's involved in the care can see that note immediately. "The records also check for quality on a real-time basis, so if a physician orders a dose of a medication that seems out of range, the system will immediately alert the physician to the potential error. "I'm very bullish about the use of electronic records and I'm glad the government is providing some carrots and sticks to get other providers across the country online." Celebrating Slavin sees the bicentennial as a way to mark the past while also looking forward . "We want to use this as an opportunity to celebrate what MGH has been over the last 200 years and the impact it's had on countless individuals and families," he says, "but even more importantly we want to focus on the future and use it as an opportunity to think about how we can do the most for society over the next 200 years. There's every reason to believe that as different as medicine is now compared to what it was in 1811, probably in 2211 it will be even more dramatically different." As medicine moves on, so must treatments, and by extension, the facilities need to perform them. For this reason, perhaps the most important event of next year's bicentennial celebrations will be the opening of Mass General's Building for the Th ird Century. "The thing that we do the most of, and I would argue the most important thing that we do, is take care of pa- MGH's Building for the Third Century 42 THE BIG INTERVIEW tients," Slavin stresses. "In recent years our ability to do that has been hampered by some capacity constraints: we simply, on a day-to-day basis, don't have enough beds or operating rooms. Our emergency room is undersized relative to the number of patients we are serving there, and so the new building is aimed at trying to provide the hospital with additional capacity in those areas, in very patientfocused modern facilities." Slavin underlines that the new building is also being designed with patients and their families foremost in mind, meaning that all 150 inpatient beds will be in spacious private rooms. "When I was a trainee 25 years ago, semi-private rooms and even four-bed rooms seemed like a luxury," Slavin recalls. "We don't have any four-bed rooms left , but we do have lots of semi-private rooms, which don't seem as luxurious as they used to. Increasingly people are expecting to be in private rooms, and this building will significantly increase the number of private rooms that we have available. "The other thing I would point to in the building is the procedural space. In the old days, we had operating rooms and we had separate imaging facilities. Th is space will integrate imaging with operative space so that our proceduralists, our surgeons and other clinicians, can use MRI, CT and other imaging modalities while they're doing surgery to more precisely know where they are and what they're doing, and we think that will be a great advantage in our surgical capabilities. "We have a neurologic intensive care unit where patients suffering from very severe brain diseases are cared for. Currently, when those patients need an imaging test, they need to travel to a different unit downstairs and then be transported back upstairs, and that is an incredible logistical undertaking when they're so sick and on various machines. In our new neurologic intensive care unit there will be an MRI and CT scanner right on the same floor." Peter Slavin on home-based care "It is a very positive development. If I compare how we treat medical conditions now compared to when I was in training here, it's dramatically different. A lot of what was done on an inpatient basis is now done in doctor's offices or at home. "Our goal as a healthcare institution is to keep people healthy and out of the hospital, so if we can do more outside of a hospital setting, that's all the better from my vantage point. "The best test of our success would be if we could go out of business because nobody needed to be in the hospital anymore. We could declare a victory at that point, although I don't see that happening in the near future." Learning In planning the new building, the MGH team reached outside the organization to learn from what others have done recently in constructing hospital buildings. Taking a lesson from the hospital's own history, the new building is also being built with flexibility in mind, because as Slavin points out, the medicine being practiced when the building opens next year will be different from the medicine that will be practiced 10, 20 or 50 years from now. "If we want this building to continue to function, there will inevitably have to be renovations and so we're building it to make that as easy as possible. We want to make sure that this building serves future generations of leaders of this institution and patients and clinicians. "Th is includes making sure that there is ample floorto-ceiling height, because when some of our older buildings were built, the floor-to-ceiling height was maybe 10 or 11 feet. Back in those days there wasn't much in the way of wires, air handling or other things that needed to go into the ceiling and still leave enough height for people to walk around. Timeline: MGH Milestones MGH charter established by Dr. John Collins Warren and Dr. James Jackson 1811 The first X-ray image in the United States is made by an MGH physician just 30 days after the technique is discovered in Europe 1896 A researcher at the Vincent Memorial Hospital, the gynecology service of the MGH, perfects the use of Pap smear to detect cervical cancer 1945 MGH surgeons accomplish the first successful reattachment of a severed human limb 1962 1800 1850 1900 1950 1955 1960 1965 1970 1846 The use of ether as an anesthetic is demonstrated at the MGH. Surgery, performed without pain for the first time 1925 The first tumor clinic founded for the study of cancer 1960 Proton beam therapy is first used to treat tumors of the eye, neck and brain 1964 Research completed at the MGH makes practical for the first time the long-term storage of human blood THE BIG INTERVIEW 43 Peter Slavin on health reform "I'm delighted that health reform passed a few months ago and that we're going to join the rest of the civilized world and provide access to healthcare to almost all of our citizens. "One of the greatest remaining challenges facing our healthcare system is cost. There are a lot of opportunities in healthcare in the US to provide better care at lower cost, and that's one of the things we will be working on as hard as possible here, and I hope that people throughout this country come to that challenge in a very constructive way. "If we don't do it we're either going to create a great economic challenge for our country, or we're going to deliver suboptimal care. I hope by being innovative and relentless in our pursuit of ways to deliver better care at lower costs that we can avoid either of those two other alternatives." Leading light Anniversaries are a time for looking not just backward, but also at what lies ahead, and Slavin sees a bright future for his hospital, as it continues to be a leading light in the healthcare community: "I hope in the future our role is similar to the one we've played over the last 200 years. At least from my perspective, MGH is a place that over that period of time has done everything it possibly can to meet the needs of individual patients and families, and at the same time try to advance the field of medicine to benefit not only our own patients, but patients around the world. MGH dermatologists introduce the field of photochemotherapy, which uses light and special medications to treat disorders such as psoriasis 1974 Researchers at the MGH are among the first to investigate combination therapy treatment for AIDS, using `cocktails' of several anti-HIV drugs to suppress viral reproduction 1990s MGH researchers find a simple blood test during the first trimester of pregnancy may be able to identify women at risk for pre-eclampsia 2002 1975 1980 1985 1990 1995 1980s MGH researchers make numerous key discoveries regarding AIDS and infection with HIV, including showing that the virus can infect the brain and nervous system and detection of HIV in female genital secretions 1987 MGH researchers contribute to the discovery of the first gene associated with inherited, earlyonset Alzheimer's disease " "The amount of material that now needs to go into the ceiling has dramatically increased; therefore the floor-toceiling heights have to be greater in order to accommodate it all. We've erred on the side of having even higher floorto-ceiling heights, because who knows what will be in those ceilings 10, 20, 50 years from now. That's just one way that we're trying to plan for the future." With an eye on our modern concern with environmental sustainability, the new building has been constructed to the LEED Gold environmental standard, the second highest level of `greenness' that a building can achieve. The building's heating and air conditioning systems and the insulation have all been designed to minimize the amounts of energy needed to ensure patients and staff are comfortable. Slavin gives as an example the glass used in the building, which is designed to allow sunlight to partially heat the building, while at the same time ensuring it is sufficiently insulated so that it doesn't let heat escape. The entire roof will be covered in greenery, to consume carbon dioxide and release oxygen into the atmosphere, and materials needed for construction have been sourced as close to home as possible so that the carbon footprint associated with constructing the building can be kept small. "We want to use this as an opportunity to celebrate what MGH has been over the last 200 years, but even more importantly we want to use it as an opportunity to think about how we can do the most for society over the next 200 years" "Exactly how we'll go about doing that in the future is hard to know, because it's not clear where the opportunities to advance care will be or what exactly care will look like at any point in time. I hope that continues to be the spirit and the identity of this place, both providing the most advanced and compassionate care to patients on a day-to-day basis, but at the same time trying to advance care so that we come up with better answers for our patients and their families that improve care in the future." " 2011 MGH celebrates its bicentennial and the Building for the Third Century opens 2000 2005 2010 2004 MGH welcomes the first patients to the Yawkey Center for Outpatient Care, the largest ambulatory facility in New England 44 LEADERSHIP It's safe to say that operational leadership is filled with metrics and guidelines to success. But what happens if you decide to follow your own path? Tom Ream, CIO of Sutter Health, tells Nick Pryke his story. B reaking into the world of C-level leadership is never an easy task. For some, years of hard work and diligence translate into that elusive corner office, unprecedented opportunities and the chance to implement change. For others, it remains a pipe dream, quietly crumbling into obscurity as time takes its toll. These are our usual suspects, our staple business stereotypes. We've seen them come and go with the tides of change, but every so often that tide brings with it someone unique � an anomaly of luck and timing with the talent to succeed and a passion to do so. For these fortunate few, the usual clich�s of `falling into it' and being in `the right place at the right time' don't even come close to telling their story. An epitome of this rare breed of leader, Tom Ream is proof that natural talent, the right timing and a sense of adventure can get you everywhere � quite literally. As current VP and Regional CIO of Sutter Health, a not-for-profit healthcare provider operating in over 100 communities, Ream's professional life was born out of the inquisitive while still at university. "Somebody urged me to run for some kind of office and I eventually became the student body president," explains a laid-back Ream. "I'd been pre-med all the way through my junior year and had just arrived at that point where I wasn't quite sure I wanted to keep doing that. When I got elected to the student body presidency, which is something I had never done before, it gave me a whole new set of insights about myself and what was personally possible. That was a great time for me." With no one in the Ream household having anything resembling prior business experience, there were foreign concepts aplenty to the budding Ream. So he did what any self-respecting student would do � he experimented. "Organizing people, getting them to work together as a team, helping each person feel like an integral part of what was happening; those were things that I experimented with and saw some great responses as a result. It got me thinking: `Th is is kind of interesting. I don't know what it is, but I like it.' I remember having that distinct thought, and then I went on to go to business school later. I had no way of connecting it to anything I'd ever participated in previous to that." Delving into his background, Ream openly admits that he didn't come up through the traditional ranks of being a programmer or operator. While he was interested in the sciences, he never harbored an attraction towards the technology of the day, choosing instead to nurture an interest around information. However, soon aft er his inauguration as student body president, he realized where his true interests lay. "By the time I got an awakening towards leading things, I found that I enjoyed working with people and fi nding out what they could do and how you could form a team and work together. To me, that was very encouraging." His senior year was witness to the culmination of this realization, with a plan to get people from the margins of social inclusion engaged LEADERSHIP 45 GO YOUR OWN WAY with the more `mainstream' culture of the university. "Th at's where a lot of the motivation came from," confi rms Ream, "in terms of looking at the people and realizing that you need to have a place where you can pull people together and comprehend that everybody has something to give. Find out what their passion is and get them `headed'. These days, you fi nd people's passions and get them channeled and directed with the help of literature and training, but back in those days I was discovering this out without any help." From past to present Indeed, `these days' have seen Ream foster an understanding of the dynamics of both leading a team and nurturing one. The fi rst to admit that he is far from a technologist � so doesn't pretend to be � Ream has found his feet in identifying and bringing in the right people to encourage a more collaborative culture. "My job is to fi nd very good people in defi ned categories who like what they do. I bring them in and then spend my time getting them to play together in the sandbox. Help them understand what the general mission is and how they play together for the delivery of a result they couldn't achieve on their own. The job is there to be all you can be in that context, which is all I enjoy doing." It comes as no surprise then that Ream sees himself as more of a facilitator than anything else. "In many ways, that's all I can be," he says. "I can't do their jobs, so my real assignment is to get them to work together to see their individual possibilities and to understand why it's important to have respect for one another." His rather humorous sandbox analogy speaks volumes about his approach to leading a team and the importance of having different players in the game � a leadership principle that has served him well over the years. "My job is to find very good people in defined categories who like what they do" "I try to not hire people who are just like me. I found out early it was hard not to do that, because you like yourself, you like your style. It's just so comfortable; it's who you are. But somewhere along the line I figured that out. You need to learn not to be afraid of hiring people who are a little unsettling to you, whose personalities are at the opposite end to where you are is important." Which is most probably how he ended up walking into the world of healthcare in the first place � the second turning point after his presidency-on-a-whim at university � with help from one of his wife's friends a couple of years after commencing work with Citibank. "He was the President of the Greater Cleveland Hospital Association," chuckles a nostalgic Ream. "We spoke for a bit until he said, `If you're so smart, why don't you come help us? Be a CFO. You're in finances. You know that." I interviewed with a couple of local CEOs and one of them offered me a job to take a 400-bed hospital. They weren't automated in anything and said: `You can go to Wharton and get your MBA and work for Citibank. You can do this with your eyes shut.' Well, he didn't know � and neither did I � but it's one of those things you look back at and think, `There's no way in the world they should have hired me.' But I came and led them through fi nding our fi rst vendor and getting the place automated on some level. Otherwise, it was just Burroughs machines downstairs and everything was manual." 46 LEADERSHIP Lesson learned Of course, in today's cutthroat executive arena, Ream's story would have most likely ceased after the initial meeting. But the point remains that taking risks and throwing yourself into something you know almost nothing about is a leadership trait that cannot be taught, regardless of whether the subsequent result is success or failure. On top of this, it often provokes the splitting of opinion into those with respect and those with disdain. "If there was pushback, no one told me," laughs Ream when asked about the reaction to his appointment as CFO. "But I was probably taking it to the next level of what I experienced with the student leadership role. I'd never done that before and this was a new version of it at another level. Certainly I had my paycheck now, but what do I do? I'd never worked for an IT company, so I immediately went to enroll in a master's program in IT. If the team did catch on that I didn't know much, they never said anything. There was no comparison to be made, so I Tom Ream originally spoke to guess that helped. Their ignorance helped Padraig Hyland for EHM's sister media channel, meettheboss.tv me get through." Ream jokes that "until you get caught, it's a great way to live", but the reality of the situation was that he never got `caught'. He never got caught because he didn't afford anyone that opportunity � a survival instinct and a motivation to succeed were undoubtedly the overriding factors to this � plus the fact that employment attitudes were far more liberal back then. Ironically, his severe lack of technical know-how served to help him bridge the gap between the technical and business worlds. "Because I didn't know the technical aspect, it meant that I had to somehow figure out how to get the right technical people to the teams. I could handle the business talk with other leaders, making sure I would engage with them, understand, come back and figure it out behind the wall. They could live with that comfort. My job then became fi guring out what you put together behind that wall. I led with my strength, which is the ability to communicate with business leaders." The idea of a leader knowing his or her own strengths certainly resonates with Ream, even in the most negative of situations. He talks of a time when he � for want of a better phrase � was "let go" by a company after they had squeezed him dry of his operational expertise. Picking his jaw up off the floor, the well-versed, now former CFO, turned adversity into advantage and fl ipped the metaphorical coin to secure a job with a solution provider. "One of the challenges in this new environment was working out how to forge partnerships that can last and make sense of things and learn how to read people in terms of who will shoot straight with you. Th at may not be the easiest thing to determine, but once you fi nd them it helps you get your environment going where it needs to go and gets things accomplished." Ream went on to work for Siemens in a similar capacity for another 16 years before returning to the hospital setting and a host of new challenges, but he still continues to lead as he always has. the same size. We only have one hospital that has an EMR, and prior to my coming they also had two major failed attempts at trying to get any of the hospitals on such a product � so they've largely been a federation of affi liates. "They didn't control them, except that they came there for the revenue side of participating in managed care contracts that were very adeptly negotiated � so they made plenty of money as players who just hung around on the same team. But in terms of ever changing how they delivered their services and dealing with the cost side, they never paid attention to that until about three or four years ago when they began to recognize they had lost their price point in the marketplace, so decided they needed to change the governance of certain things. "All the affi liates eliminated their boards, then reformed them around five regions, and only now are they beginning to deal with a lot of these things about what it means to standardize and consolidate to get on the same page with business practices." Step back in Tom Ream, who � as these things tend to go in life � has returned full circle to his days at university, dealing with something new and uncharted. The only difference between the Ream of today and that of his youth is that he now has experience on his side. "It will be messy," he asserts with a sense of readiness. "It has been messy and it will continue to be messy for a good while, because people figuring out how to manage something like this with 28 hospitals that have never functioned alike have never needed to before. They made lots of money on the revenue side and always covered their excessive expenses with more revenue. "Now they have to pay attention to that � so the whole notion of getting down to common solutions and technical standards is not pretty some days. When you talk about differentiating yourself, it mostly isn't about differentiation � certainly not in terms of technology. It's more about who you want to be." And perhaps for Ream, that search for an identity is what it's always been about. Seven qualities of a good leader m sias thu En Disc ipli ne Trustworth ines s 1 7 n 2 3 6 Co m m i t m e n t 4 Fo c c Logi 5 Going full circle "The environment I'm in now at Sutter Health, for all the quality of healthcare and the size that it is, certainly in the acute setting, it's running a good deal behind a lot of the other players that might be roughly us Ins pi t ra io 48 WORKSHOP Probing progressive mobility The inherent nature of healthcare often involves the moving of critically ill patients � get it wrong and the repercussions could literally be life changing. But with the right knowledge and practice, it doesn't need to be. Patient repositioning forms the basis of many of our work-related injuries. How can a progressive mobility approach help alleviate this key health and safety issue? Tamera Corsaro, Clinical Nurse Manager, Spaulding Rehabilitation Hospital, Boston, MA Early progressive mobility has the potential to limit the severity of deconditioning, thus dependence the patient may have on the staff. When the progression of mobility is based upon the patient's medical history, hemodynamic stability, mental status and core muscle strength, safety for both the staff and patient is inherent. Cohesive teamwork and coordination of activity is required. Education on proper body mechanics and incorporation of safe patient handling techniques is of the utmost importance, not to mention the associated compliance. Access to appropriate equipment such as walkers, chairs, portable ventilators and beds that facilitate repositioning and allow full chair position with floor egress to facilitate standing are paramount. Amelia Ross is the Clinical Nurse Specialist for Pulmonary/ Critical Care and Dr. Peter Morris is the Medical Director of the MICU at Wake Forest University Baptist Medical Center. They are conducting research funded by the National Institute of Nursing Research to evaluate best practice for early ICU rehabilitation strategies for acute respiratory failure patients. ment of the ICU may be the biggest challenge. The multidisciplinary leadership of the unit should strive to eliminate as many challenges for the staff as possible; the availability of essential equipment is one. Healthcare disciplines with mobility as a common goal and value will promote patient-focused care ensuring a culture of mobility. Standardized protocols or order sets with explicit patient safety parameters have been shown to increase mobility more regularly and help promote the culture of mobility. What are the advantages of using continuous lateral rotation therapy? In your view, what are the key elements of a successful CLRT program? Karen Wells, Director of Clinical, CHS Home Care, Muncie, IN As evidence grows in support of the practice of early and progressive mobility for ICU patients, what is the best way for nurses to deal with the challenge of mobilizing the most critically ill patients? Courtney Thurlkill, RN BSN, Director of Nursing, Warm Springs Specialty Hospital of Victoria, Victoria, TX There are multiple challenges in mobilizing critically ill patients; the culture and/or physical environ- Some of the advantages of CLRT reported in the literature are for the treatment and/or prevention of pulmonary complications such as acute respiratory distress syndrome, ventilator-associated pneumonia, maintenance of skin integrity, mobilization of pulmonary secretions, and decreased length of stay in intensive care. Key elements of a successful program are continuity in the application and utilization of rotational therapy. The multidisciplinary healthcare providers should come to a consensus on patient population criteria for use, guidelines or a standardized order set that includes parameters for rotation, pulsation and percussion therapies, discontinuance of CLRT and outcome metrics. Each institution should examine outcome metrics in their institutional experience with CLRT for efficacy. What do you see as the benefits of a progressive mobility therapy program? Lori Olson, Assistant Director, Nursing, Sunnyside Care Center, Lake Park, MN First and foremost, it is the benefit the patient receives from care that is patient-focused. More often than not, critical care focuses on the emergent tasks at hand to stabilize the patient until feasible to transfer to a lower level of care. With patient-focused care, we must look at and address the iatrogenic effects of the care we provide. The benefits of progressive mobility include, but are not limited to, the financial impact for organizations in the decrease in ICU and hospital length of stay, prevention of complications of immobility like polyneuromyopathy, and increased patient involvement in care with improved progression. 50 INDUSTRY INSIGHT Having your cake and eating it too: Improving care and saving money with noninvasive ventilation Pamela Nelson-Artibey highlights how a proven medical technology can reduce costs whilst improving clinical outcomes. has clinical consequences for the patient � it also carries significant financial consequences for the medical center. To wit, the Centers for Medicare and Medicare Services (CMS) has indicated that it has added VAP to the hospital-acquired conditions for which reimbursement will be denied. I Ventilator-associated pneumonia Whenever a patient is intubated, they run the risk of contracting VAP � one of the most significant risks facing intubated patients on a ventilator. According to the Centers for Medicare and Medicaid Services, the average cost of a VAP infection runs about $135,795 per hospital stay with an estimated 30,867 reported cases of VAP in the US each year. In a statement by the Center for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS) in its 2002 report, patients receiving continuous mechanical ventilation were six to 21 times more at risk for developing healthcare-associated pneumonia than those patients who were not receiving mechanical ventilation. In reviewing cohort studies by various physicians, the fi ndings suggested that implementing NIV results in a decreased rate of nosocomial pneumonia and infections. Dr. Dean Hess compared 12 studies relating to NIV being administered to patients at risk for pneumonia. The study revealed that compared to patients receiving invasive mechanical ventilation (in four studies), the rate of pneumonia was lower with the use of NIV. In addition, Dr. Hess suggested that ventilator-associated pneumonia is a misnomer, and perhaps "endotracheal-tube-associatedpneumonia" is a more accurate term. With NIV, because there is no intubation, there is virtually no risk of VAP. n these economically challenging times, healthcare providers are under intense pressure to find ways to control costs without compromising the quality of care they provide. And so it may come as a surprise to discover that there is in fact a proven medical technology capable of simultaneously reducing costs of care while improving clinical outcomes and the patient experience. Noninvasive ventilation (NIV), when used in the appropriate patient population, has the ability to improve patient mortality, address patient comfort, and reduce costs through shorter lengths of stay. There is strong evidence supporting the application of NIV in patients with congestive heart failure, chronic obstructive pulmonary disease (COPD) exacerbation, immunocomprised patients and COPD patients being weaned from mechanical ventilation. Furthermore, there is also moderately strong evidence to support NIV in patients with asthma, cystic fibrosis, postoperative respiratory failure, obesity hypoventilation and DNI (do not intubate) patients. Sounds too good to be true? Read on. While NIV offers significant cost advantages over traditional ventilation via endotracheal intubation, it also offers equally significant benefits to patients in the form of decreased length of stay, reduced sedation associated with intubation, and decreased morbidity and mortality rates. Furthermore, many patients in respiratory distress may be spared the misery of endotracheal intubation, which takes away their ability to communicate, and the accompanying sedation, which deprives them of their cognitive abilities. Although the need for invasive ventilation will always exist, many patients can be successfully and cost-effectively treated with NIV. Best of all, the practice of noninvasive ventilation has considerable room to grow from where it is today. NIV in the hospital The economic benefits of using NIV in the hospital setting are well documented for both acute and chronic patients. Many studies have shown not only the cost effectiveness of NIV, but the beneficial aspects to patient care. In the United Kingdom, a randomized control trial was conducted in 14 participating centers. They found that noninvasive ventilation reduced the need for intubation by 44 percent and that in-hospital mortality decreased by 50 percent in patients with severe exacerbation of chronic pulmonary disease. Another review in the United States concluded that NIV was associated with lower rates of pneumonia, intubation and mortality. Dr. Nava et al. explained that NIV is widely used today as a valid treatment to avoid intubation and its complications. While conventional invasive ventilation is a lifesaving procedure, the most important risk factor is in fact Conventional invasive ventilation The distinction between noninvasive and invasive ventilation derives from the fact that noninvasive ventilation does not require an endotracheal tube. Even a properly placed endotracheal tube has undesirable side effects due to its `invasive' nature. Contaminated bacteria that may occur as the direct result of intubation can result in a lung infection, frequently referred to as VAP (ventilator-associatedpneumonia). Ventilator-associated pneumonia not only Pamela Nelson-Artibey is a Respiratory Therapist with over 20 years of clinical experience. Her background includes being a Program Director for a respiratory college and working as a Team Lead Therapist at the Mayo Clinic Hospital in Arizona. Currently, she is the Education Manager within Philips' Hospital Respiratory Care group. INDUSTRY INSIGHT 51 "It behooves hospital administrators and clinicians, in close association with their EMS partners, to expand the use of NIV" endotracheal intubation. Therefore, NIV should be considered in early treatment of established acute respiratory failure (ARF) patients to avoid further deterioration and intubation. Dr. Arroliga, head of Critical Care Medicine at the Cleveland Clinic, believes that NIV avoids the complications of intubation, incurs shorter stays in the hospital, lowers mortality rates and lowers healthcare costs. Another advantage he pointed out is that NIV is more comfortable for patients as they can retain the ability to speak, swallow, and protect their airway. NIV success factors European countries are also seeing an increase in the use of NIV for the treatment of patients with COPD. An article featured in the European Respiratory Journal cited that a lack of training was the leading reason NIV was not implemented more often. According to Leger et al., any hospital that has the potential for treating patients with acute and chronic respiratory failure should have NIV available to them. It was also stated that the experience and training of staff to adequately monitor the patient was clearly linked to the success of NIV. This article revealed that with proper training and education, NIV is a very successful tool for the treatment of patients with COPD. With a mounting body of evidence now available for review, NIV is clearly very cost-effective and a more efficient form of treatment for patients who are within the treatment criteria. Today, NIV represents one of the current medical technologies proven to help reduce length of stay, morbidity, mortality, risks of infection and cost of care. As NIV eliminates the fi nancial and clinical consequences of unnecessary endotracheal intubations in both the hospital and pre-hospital settings, it behooves hospital administrators and clinicians, in close association with their EMS partners, to expand the use of NIV. While NIV may not be appropriate for all patient types, understanding NIV protocols and guidelines through training will help clinicians make better decisions for their patients and their institutions. NIV for COPD COPD is one of the leading causes of death, illness and disability in the United States. In one particular study, the cost-effectiveness of NIV, added to the standard treatment, was reviewed and analyzed from the data obtained by several studies. The primary outcomes that the authors were looking for was to see a reduction in hospital mortality and endotracheal intubations. Their cost analysis revealed that using NIV instead of endotracheal intubation in patients with acute exacerbation of COPD resulted in cost savings of $3244 per patient admission. 52 INFECTION CONTROL life death and A matter of INFECTION CONTROL 53 Michael Klompas on balancing the need to intubate with the prevention of ventilator-associated pneumonia. T he Centers for Disease Control (CDC) estimates that in American hospitals alone, healthcareassociated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. As a proportion of this, CDC estimates there are about 250,000 cases of ventilator-associated pneumonia (VAP) in American hospitals every year, meaning about five percent of patients who are admitted to intensive care units and require mechanical ventilation are affected. The key risk factor for VAP is the very fact of being on a ventilator. Th is may sound obvious, says Michael Klompas, Infectious Disease Physician and Associate Hospital Epidemiologist at Brigham and Women's Hospital, but it's an important fact to keep in mind. "When you're on a ventilator, you have a breathing tube inside your mouth that goes into your airway, and that causes a number of problems. On the one hand, it's critical to save your life, to provide you with breathing support. But at the same time, it disrupts the body's natural mechanisms for clearing secretions from the lungs and airways, and it acts like a giant passageway to allow bugs to walk from the mouth right into the lungs. "Simply being intubated in and of itself is what sets you up for the pneumonia. And as you can imagine, the longer you stay on the ventilator, the more likely you are to get it. So the longer your period of ventilation, the greater your risk. Those are the most profound factors. "There are a number of other factors that have been described in literature that have to do with the quality of your oral hygiene, and the positioning of the balloon that keeps the tube in the correct position inside your airway. If that balloon is not inflated enough it's easy for secretions to slip around the tube into your lungs." Another issue is the position of the patients themselves. If the patients are are lying flat, it is easier for secretions from the mouth to enter the lungs than if they are sitting up, because the food can go from the stomach up the food pipe into the mouth and then into the lungs, which is the pathway for acquiring pneumonia. Prevention Given this, Klompas' bottom line for preventing VAP is: if you can avoid putting a person on a breathing machine, avoid it. As Klompas points out, there are alternative strategies to aid breathing, which don't necessarily require the insertion of a tube. "Sometimes you don't have that luxury. You simply have to put the tube in. But if you can, you should try to use alternative means of ventilation. "The alternatives include mono-invasive positive pressure ventilation, in which a tightfitting mask goes over the person's mouth and nose and is strapped on to the face to form a seal. You force air through that mask and it goes into the nose and mouth and can provide a person with extra breathing support. "That only works in patients who are still somewhat conscious. You can't use that for somebody who's completely knocked out for surgery or because they're in a coma. Then you have no choice, you have to put in the breathing tube." Once a patient is on a ventilator, there are a number of different ways that the doctors can manage the patient with regard to sedation and pain control. Such patients need pain control and anti-anxiety sedatives; the difficulty arises in maintaining the fi ne balance between administering enough medication so the patient readiness to extubate on a daily basis. "There are certain tests you can do with the breathing machine to get a sense of what the patient's underlying lung function is like," he explains. "These in turn could inform you if they're ready to extubate sooner than you thought." A third strategy is to encourage nurses and respiratory therapists to play an active role in weaning patients from ventilators. Th is entails setting up formal protocols that tell nurses and respiratory therapists when they can decrease sedation and when they should do reasons-toextubate tests. "It turns out that patients tend to come off the ventilator sooner with this method than if you simply leave it up to the doctor's memory to make these incremental changes, and changing sedation and adjusting the ventilator on a regular basis," Klompas says. "So setting up a formal protocol and giving a lot of autonomy to the nurses and respiratory therapists can be helpful. "These three strategies can decrease the amount of time a patient is on a ventilator by about two days or more." Diagnosis Several types of special endotracheal tubes have also been introduced to the market in a further effort to reduce VAP: a silver-coated "The bottom line for preventing VAP is: if you can avoid putting a person on a breathing machine, avoid it" is comfortable and not giving them too much, so as not to prolong the amount of time that they're on the ventilator. Klompas says there is currently quite a lot of research being carried out into fi nding that ideal balance. Strategies that have been well studied and proven to be successful include stopping sedation completely at least once every 24 hours. Th is allows patients to be checked to demonstrate their underlying level of consciousness, with the potential to discover the patient can be extubated. A second strategy, according to Klompas, comprises a formal assessment of a patient's endotracheal tube, and a suction endotracheal tube (or to give its formal name, continuous aspiration of subglottic secretions). "The theory behind the silver-coated endotracheal tube is that silver is antimicrobial and, therefore, prevents or decreases the amount of bacteria colonized in an endotracheal tube," Klompas says. "The fewer bacteria on the tube, the fewer bacteria that can move from the tube down into the lung. That has been studied in a very large trial called the NASCENT trial. "However, the fi ndings of the study were a little bit subtle in that they reported that it reduced the rate of ventilator-associated 54 INFECTION CONTROL pneumonia by about 35 percent. If you looked more closely at the data, it turned out that the patients who got the silver tube and the patients who didn't had identical outcomes in terms of the amount of time they spent on the ventilator, the amount of time in the ICU, the amount of time in the hospital and the rate of death. "The answer to the paradox has to do with the subtlety as to how we actually diagnose pneumonia; the problem being that our ways of diagnosing pneumonia are not very good. One of the components of the defi nition for pneumonia used in this trial was that the patient had a positive culture of fluid coming from out of the endotracheal tube. There's a circularity where the endotracheal tube is coated with silver so it reduces the amount of microbes on the tube. So if part of your diagnostic defi nition is what can you culture from the tube, you should see a decrease. "But that doesn't necessarily mean you're decreasing true invasive clinical disease inside the lungs. You might just be measuring the reduction in bacteria that are sitting on the endotracheal tube itself. I believe that's what happened with the intervention where they found a reduction in bacteria: that they were measuring the reduction in microbes inside the tube, but won't actually see a decrease in the true lungbased pneumonias. That's why there's no difference in the amount of time these patients spent on the ventilator or in the ICU of the hospital, whether they got the special tube or not." Diagnosing VAP is often difficult, because the relevant patient population is complicated. People on ventilators are generally very sick, with many overlapping serious conditions. There could be changes in the amount of fluid in the body, some of which then spills over into the lungs. These patients are at risk of getting blood clots that travel up to the lungs or of pressure-related damage from the ventilator itself. "If the ventilator gives air to the lungs in an uneven fashion, that part of the lungs might partially collapse," Klompas says. "All of these things I'm describing can look just like a ventilator-associated pneumonia because they all make your chest X-ray abnormal, and they can all interfere with the amount of secretions coming out of the lungs. They can all give you fever. They can all give you a high white count. "There are all these mimickers, things that look like ventilator-associated pneumonia, but if you were to do a biopsy of these people's lungs, you would find that it was something else causing the symptoms. All the signs we use to diagnose VAP are non-specific in this way. We look for fever. We look for elevated white blood cell The three hallmarks of VAP treatment: 1 Start early 2 Choose a broad regiment 3 Reassess often count. We look for more sputum coming out of the tube, and we look for an abnormal X-ray. And all these findings have many potential causes. "If you took a series of patients who were diagnosed with VAP by their doctors and the patients died and you carried out an autopsy or a biopsy, it would turn out that of the patients suspected of having VAP, maybe about half of them would have the disease, and the rest would have something else. "It's not only a problem of overcalling cases; we also miss cases. And often, the patients have two processes going on at the same time. If you look at studies comparing one doctor to another in terms of their diagnosis, there's a lot of disagreement between them. It's a bit of a tough nut for people to crack." Treatment When it comes to treatment, antibiotics are the standard line of attack. Klompas underlines that they need to be started early and they need to be broad spectrum, to cover the possibility that the patient might have a drug-resistant bacteria. He says the third element is to reassess often, because there's a high probability complications include barotraumas: pressurerelated damage from the ventilator if the pressure settings are too high for the patient to manage; and fluid balance: putting too much fluid into the body and having some of it spill over into the lungs. Deep-venous thrombosis blood clots inside the legs that travel up into the lungs and cause a pulmonary embolism are another potential problem. There could also be drug reactions, or bleeding inside of the lung. Klompas points out that some of these things, such as pressure damage or fluid balance, may be due to the nature of the underlying condition. "You have to give a patient a lot of fluid because you're trying to protect their blood pressure, and some of it spills over into the lung. But you had no choice, you had to protect the blood pressure. Th at's what I was alluding to when I said that these are very sick, very fragile patients. You fi x one problem and cause another." Given that VAP can have such serious outcomes, are we doing enough to reduce its incidence? Klompas believes we're on the right path. "Five percent of patients now are get- "The onus on us now with these intervention strategies is to spread them as widely as possible so they become as much a part of the culture of care as we can make them" that you're either overcalling the presence of a VAP, or missing something underlying: "It's important to not just make the diagnosis on Monday and forget about it, but to reassess on Tuesday and Wednesday and to change your course of therapy if things aren't playing out as you would expect. "If the patient is not getting better, you need to consider that something else might be causing the problem. If the patient gets better overnight, it probably wasn't VAP � so you should stop those antibiotics before they cause some harm of their own." Other issues to be considered in the broader category of postoperative pulmonary ting VAP. If you look at studies from 10 and 20 years ago, that number was more in the 15 percent range, so there's been a dramatic reduction over time. We've hit upon some good strategies now to prevent VAP: avoiding intubation, minimizing the duration of intubation and using ventilated management protocols to get the patient off the ventilator as soon as possible. "The onus on us now with these intervention strategies is to spread them as widely as possible so they become as much a part of the culture of care as we can make them. In that way, I'm hoping we can realize even further improvement." 56 WORKSHOP Working for the silent As post-operative pulmonary complications go, ventilator-associated pneumonia is by far the most common. So how do hospitals and healthcare staff ensure they're acting in the best interests of their patients to avoid contracting VAP? "Healthcare organizations should consider partnering with a supplier that has a long track record of focusing on the clinician's needs, as well as on both clinical and economic value. It is not enough to provide devices that improve outcomes; they must do so cost-effectively" What do you believe is the most effective way to prevent ventilator-associated pneumonia? VAP is merely the tip of the iceberg when it comes to the $11 billion problem of post-operative pulmonary complications. However, the single most effective way to reduce the risk of VAP is to get patients off mechanical ventilation as soon as possible. Though much of this is patient dependent, there are technologies that have been demonstrated to help. One method is the use of specific modes of ventilation, such as Proportional Assist VentilationTM Plus, (known as PAVTM+), which works to reduce the amount of work a patient needs to breathe and reduce weaning time. However, when mechanical ventilation is unavoidable, a second data-driven method is the MallinckrodtTM Evac technology, which works to reduce microaspiration of subglottic secretions past the endotracheal tube cuff. What is your opinion of the strategy of removing secretions from above the endotracheal cuff? ICU literature has recognized the role of subglottic secretions in the pathogenesis of VAP for more than a decade. These secretions collect below the cords and above the cuff, making them a challenge to remove with typical suctioning methods. The integrated suction lumen, however, allows direct access to this region for easy evacuation. Multiple randomized controlled trials have demonstrated a reduction in VAP using MallinckrodtTM Evac technology. Are there any technological innovations in endotracheal cuff design that could reduce the risk of microaspiration? Conventional endotracheal cuffs do not offer a perfect barrier to microaspiration. To ensure contact with the trachea at low pressures when inflated, cuffs are designed to have an expanded diameter greater than the diameter of the tra- chea. The result of this design, when inflated in the trachea, is excess cuff material that invaginates, creating longitudinal channels that allow the propagation of material from above the cuff down into the distal respiratory tract. An innovative solution is to change the shape of the cuff to a fully tapered design, which is found on the MallinckrodtTM TaperGuardTM and SealGuardTM endotracheal tube lines. Th is ensures that at some point in the expanded cuff, the cuff diameter will approximate the tracheal diameter and channels will be reduced. Multiple studies have demonstrated decreased leakage with these two new endotracheal tube cuffs. In your view, what do we (hospitals, healthcare organizations) need to do in order to achieve a dramatic reduction in the incidence of post-intubation pulmonary complications? The most studied post-intubation pulmonary complication is VAP, though there are likely many others. Hospitals should consider using strategies that work to fight the mechanism of action of these complications, such as the microaspiration of subglottic secretions. What should a healthcare organization look for when choosing a supplier of mechanical ventilation and respiratory care devices? Healthcare organizations should consider partnering with a supplier that has a long track record of focusing on the clinician's needs, as well as on both clinical and economic value. It is not enough to provide devices that improve outcomes; they must do so cost-effectively. Covidien is committed to developing products that provide clinical value as well as help reduce healthcare costs and length of stay. Douglas Hansell, MD, MPH, is Vice President and Chief Medical Officer for Covidien Respiratory and Monitoring Solutions. A Harvard-based physician, Dr. Hansell has more than 20 years of multi-sector healthcare experience. In addition, Hansell has maintained an active clinical practice in anesthesiology at Massachusetts General Hospital in Boston and has held teaching appointments at Harvard University. Hansell is board certified in Internal Medicine and anesthesiology, fellowship trained in cardiovascular anesthesia and experienced in critical care medicine. 58 VASCULAR HEADING ACCESS High-level access EHM rounds up the views of health industry experts on the latest issues in vascular access. What are the different types of vascular access devices used in chronic illness? What role do they play in delivering appropriate therapy across the chronic disease spectrum? Nancy Moureau. Central venous catheters (CVC) are most commonly used for patients requiring treatment over five days and extending into months and years. The CVCs include peripherally inserted central catheters (PICC), tunneled CVCs and implanted ports, then hemodialysis catheters for renal failure. Short peripheral catheters are used when a patient needs to have intravenous medications for less than five days. PICC lines are considered one of the lowest risk devices for insertion because they're peripheral, which is why they are one of the more common choices here in the US; we're replacing about three million PICCs a year. With acute illness, non-tunneled triple lumen catheters are more common in the hospital setting. In the outpatient or alternate care with chronic illness, tunneled central venous catheters carry a lower risk of infection. PICC lines and tunneled central venous catheters are both used in alternate care. Nadine Nakazawa. In my work, I focus primarily on central venous access devices, and within that, on central venous catheters, with about half of these being acute care central venous catheters. The advantage of a central venous catheter is that it provides reliable venous access. What happens in chronic illness, acute serious illness, or prolonged need for IV therapy whether it's acute or chronic, is that patients' peripheral veins quickly become damaged and diminished over prolonged usage. It could be a matter of days or weeks, months or years. The damage tends to be cumulative, particularly during the acute phase while patients are in the hospital getting multiple venipunctures for repeated peripheral IV restarts. Often the sites have to be rotated more frequently than the CDC recommends, which is no more than every 72 hours to prevent infection, but the reality is that the drugs that we put in are very damaging to the peripheral veins. doctors that have joined together with the help of Teleflex Medical to create a Vessel Health and Preservation Program aimed at developing an intentional selection process that can be applied in all hospitals for all patients. NN. Because vascular access arose from different, very specific, areas of medicine, this can sometimes lead to confusion as to which device to use in a particular circumstance. For example, those working in dialysis are interested in gaining access into the bloodstream to be able to do hemodialysis, so the science around dialysis catheters falls into the realm of nephrologists, vascular surgeons and interventional radiologists, plus dialysis nurses. Catheters used in the intensive care and critical care setting include acute care central venous catheters placed for monitoring purposes, for the delivery of multiple infusions and drips. These would be placed by surgeons or by anesthesiologists or intensivists. Sheryl McDiarmid. Many medical professionals don't prioritize what the catheter is being used for, and they tend to be used not only for the delivery of life-saving treatments such as chemotherapy, transfusions or antibiotics, but also used to give treatments that could be given peripherally. Th is then decreases the life span of central vascular access devices, and when they are needed for the delivery of life-saving therapies they don't function properly. Another option is to use tunneled catheters. These are placed either by surgeons or interventional radiologists and are tunneled under the skin. There is a wide variety of these catheters available, including those impregnated antimicrobial substances. We tend to use these tunnelled devices, Hickman catheters or Broviac catheters, in acute leukemia patients and patients who are receiving total parenteral nutrition, because the complication rate of the device is very low. The last type of device we have experience with is the subcutaneous port. These devices are good for intermittent therapies because they are buried underneath the skin and they have a low risk of Sheryl McDiarmid is an Advanced Practice Nurse in the Corporate Vascular Access Program at The Ottawa Hospital in Ottawa, Ontario, Canada. Nancy Moureau is President and CEO of PICC Excellence, Inc. Nadine Nakazawa is immediate Past President and Presidential Advisor for the Association for Vascular Access. How can medical professionals choose which devices to use to meet the needs of specific chronically ill patients? NM. Enhanced communication between healthcare workers, MDs, RNs and specialty professionals will provide the means to improve the selection process for vascular access, speed selection and delivery of the device and efficiently administer the treatment plan. I am involved with a group of vascular access specialists and "Enhanced communication between healthcare workers, MDs, RNs and specialty professionals will provide the means to improve the selection process for vascular access, speed selection and delivery of the device and efficiently administer the treatment plan" VASCULAR ACCESS 59 HEADING infectious complications. But they do have to be accessed with a needle every time, and for some patients the reason they have a device is because they do not want to have needles. What are the issues involved in tracking patients with existing vascular access devices once they are back in the community? NM. Vascular access devices have become so common -place in the US for alternate care that I believe they are managed quite well, sometimes by home health nurses and sometimes by the patient or family members taught in management. However, processes for tracking patients and their devices are inconsistent due to variations in companies that do alternate care with home health and clinic facilities. I don't have a solution for that as yet. I think that a Vessel Health and Preservation Program could carry over into alternate care and allow for a means of management and tracking of devices in a way that we haven't done before. NN. Most hospitals have a great deal of trouble tracking that kind of information because patients do go from setting to setting once they leave the hospital. They may go to a skilled nursing facility and have the infusions managed there, but it will be the home infusion company that will take responsibility. They may go to an ambulatory outpatient infusion center. They may go to a doctor's office for their infusions or they may go home and do their own infusions through a home infusion company. Most hospitals are unable to track patients once they leave the hospital. You have to have the manpower to do it. You have to have tremendous administrative support, and you have to have the ability to maintain that kind of communication with patients. It's very hard to keep track of an individual patient's contact points with every care provider along the trajectory of the dwell time of their catheter. How do you see the field of vascular access developing in the future? NN. We want to be the voice of vascular access to articulate what is best practice; so we hope to create better consistency in both baseline education and advanced education around vascular access. We also want to promote research around both the design and functioning of devices, as well as research into behavioral aspects. Our goal is certainly prevention of complications. But after articulating best practice, you then need to promote the education around best practice and then you need to promulgate that widely. Those of us who consider ourselves to be experts in vascular access certainly see many hospitals and healthcare organizations at which no one recognizes that this is a specialty; they look at it as a device and its care as a task. If they don't understand the bigger picture of vascular access, complications occur when people do things because somebody taught them that way, and it may not be based on any cumulative science or understanding. CM. More institutions will adopt a central approach for keeping track of vascular access devices. I've seen how successful it has been in dialysis. With dialysis you do have a significant number of patients being dialyzed and they are able to track all of their devices and they know where patients are. In our program we will soon start putting online our recommendations for vascular access devices. Th is will mean that when any patient comes in to our institution they can see our note on why we recommended what we did and what our next recommendation would be when those patients come in? And then they know that they can contact us. 60 INDUSTRY INSIGHT The importance of IV securement Site Saver, a new adhesive-free IV alignment and stabilization device, brings the promise of improved patient outcomes and cost savings. By Bob Heitkamp F or over 100 years, tape and gauze have been used to secure peripheral IVs. Despite their widespread use, tape and gauze are inadequate and inconsistent ways to secure and align IVs. There are three reasons IV securement should be re-evaluated: complications from IV catheter movement can be life threatening; IV complications increase IV restarts, and IV restarts are painful, risky and costly for patients, clinicians and healthcare facilities alike. The lack of adequate IV securement means IV catheters can shift when the patient moves or the IV is bumped. Even small catheter movement can cause phlebitis or swelling of the vein, migration and dislodgment, all of which result in patient discomfort and harm. A more serious problem is infi ltration, which is when the needle or catheter pokes through a blood vessel, leaking fluid into tissue. Side torque can also cause this leakage at the IV entrance site. Leakage of fluids, drugs or blood from the vein into the surrounding tissue is referred to as an extravasation injury, which can cause soft tissue loss and scarring around nerves, joints and tendons. Other dangerous complications that arise from poor IV securement include non-thrombotic or thrombotic occlusions. Non-thrombotic occlusions can be due to trauma to vessel wall integrity from IV catheter movement. Th rombotic occlusions are clots that develop within or around the catheter or in the surrounding vessel. Occlusions represent a significant threat to patient outcomes and require high cost interventions. When a patient experiences one or more of the complications from associated adequate IV securement a new IV is started. According to numerous data, 70 percent of IVs fail in the US alone. With 300 million IVs installed every year, that means 210 million IVs are restarted, costing the US healthcare system a staggering $6.7 billion annually. IV restarts mean additional pain for the patient, not to mention exposure to infection. High restart rates associated with taped IV lines also expose clinicians to the risk of needle stick injuries. In addition, frequent IV restarts consume nurses' time, taking them away from patient care and paperwork. The time drain is significant and may lead to overtime or other avoidable labor costs for healthcare facilities. Patients, clinicians, healthcare facilities and the entire healthcare system pay for the inadequacies from using tape to secure peripheral IVs. Fortunately, an adhesive-free alternative has been developed � Site Saver. Invented by Bob Heitkamp during a long hospitalization from a critical IV site complication, Site Saver offers an innovative way to easily and consistently ensure optimal IV alignment and securement. Site Saver is a technically advanced, simply designed, recyclable, single-use vascular access accessory. Available in various sizes, Site Saver is a lightweight, infi nitely adjustable plastic stabilization device that can withstand a jerking force of more than 100 pounds (four times the breaking point of tested IV tubing). With Site Saver, clinicians can quickly align and secure tubing to prevent IV loss and enhance patient comfort. Site Saver testing has indicated numerous clinical and cost benefits. By keeping the IV tubing still yet allowing for a full range of patient movement, Site Saver can decrease pain, reduce swelling and help prevent phlebitis. Site Saver promotes positive flow thereby improving IV dwell time (to 96 hours) and IV success rates by 90 percent (data on fi le). Because Site Saver is easy to apply and allows for clear visibility for IV management, clinicians could see vast time savings. Longer dwell times combined with lower restart rates could mean an $8 saving for every US patient with an IV - or a $2.4 billion annual saving. Site Saver is designed to mitigate the pain and complications associated with peripheral IVs and to reduce the unnecessary costs associated with IV restarts. Site Saver is currently available for sale in the US and is a powerful, low-impact complement to an arsenal of vascular access products already in use. For more information or to order the product, please visit: www.sitesaver.biz Bob Heitkamp is a serial entrepreneur and inventor. He is currently the founder and President of Midwest Applied Technologies, a new product development company. Its first product, Site Saver, is a vascular access alignment and securement device he invented during a long hospital stay. "With 300 million IVs installed every year, that means 210 million IVs are restarted, costing the US healthcare system a staggering $6.7 billion annually" 62 EXECUTIVE INTERVIEW Ensuring cost savings reality... by virtual innovation Virtual Classroom ensures cost savings, waste reduction, and enhanced patient care by training and supporting millions of caregivers in new thermometry technology. So exactly how does it work? What is the cost savings reality you are referring to? Francesco Pompei. Temporal artery thermometry (TAT) has produced an estimated $100 million in direct cost savings and 10,000 tons of waste reduction in the last few years for healthcare institutions. For a typical 300-bed hospital, this translates to nearly $100,000 in unnecessary costs and two tons of waste eliminated per year. Furthermore, a recent independent study reported that TAT also saves 87 percent of nursing time used for taking temperature. These are certainly impressive numbers. How does new thermometry technology do this? FP. TA thermometry lightly scans the intact skin of the forehead, placing it in the same category as a stethoscope � simply clean between patients with the same wipe used with the stethoscope. Conventional thermometry systems require a probe to be inserted into a body cavity, which in turn requires robust protection from contamination by applying a single-use disposable cover. The dramatically reduced use of disposable probe covers is a major benefit from TA thermometry, eliminating approximately 90 percent of the direct cost of providing this vital sign. In addition, since there is no small fragile probe to be inserted into a body cavity, TAT can be designed to be far more robust than conventional thermometry, and can carry a lifetime warranty. This not only eliminates direct repair costs, but also greatly reduces all of the indirect costs, such as removal of equipment from service, evaluation by biomedical engineering, return to the manufacturer, receipt of the repaired device and reinstallation to service. Since typical payback for TA thermometry is measured in months, hospitals using TAT have effectively eliminated the cost of patient temperature as a vital sign. How can you provide technology training and support for millions of caregivers without substantially increasing your own costs? FP. Comprehensive training for new technology always carries a very high cost, particularly a technology that is used as extensively (millions of users) and across as many skill sets (MDs to RNs to PCAs) as thermometers. The supplier's cost in providing this training necessarily has to be passed along as part of the cost of the thermometry system. For the older thermometry systems, the unending stream of payments from disposables and repairs paid for the costs of training and support. For TAT, since only 10 percent of the cost of the older thermometry systems is available as revenue, we had to innovate to preserve the savings for hospitals. There is also a substantial cost for the hospital in maintaining competency levels on all equipment used in patient care, which new technology should not increase, but preferably reduce. Th is is where avatars and the Virtual Classroom come into play. Why avatars in a Virtual Classroom? FP. Because we found that everyone is fascinated by this medium, and enjoys and pays attention to the content. Training videos, written materials, and even personal in-servicing tend to be boring and are often ineffective, requiring frequent and expensive follow-up by both supplier and hospital educators. Avatars are compelling. The movie of the same name, vast numbers of video games, and extensive social networking are testament to the their effectiveness in capturing the attention of the viewers, which is the most important element in training and support of millions of users. The Virtual Classroom presents familiar scenes and interactions for clinicians, but with avatars substituted for real people. 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 PhD from Harvard, Dr. Pompei also holds an appointment as Research Scholar in the Dept of Physics at Harvard. EXECUTIVE INTERVIEW 63 An important cost advantage to the supplier is the ease in which the Virtual Classroom can be updated to include new training, new products, or new methods. In turn, this lower cost translates into lower cost for TAT users in healthcare. What convinced you that it would work? FP. When five senior physicians in a major university teaching hospital crowded around an iPhone's three-inch screen, watched intently, requested a replay, and then described it as "brilliant", we knew we were on the right track. When 35 nurses crowded around an iPad's 10-inch screen, watched intently, laughed at the avatar interactions as similar to their real life colleagues, and exclaimed "such a great idea" we knew our primary audience would be engaged. And the fi nal test was when 1000 nurses and PCAs were trained for TAT by viewing the Virtual Classroom on a large projection screen. The subsequent written competency exam was passed by 100 percent of the attendees, and the return demonstration was passed by 99.9 percent on the fi rst try. Prior to the Virtual Classroom, the initial pass rates on personal in-servicing could be as low as 50 percent, which was costly for both supplier and hospital to remedy. The Virtual Classroom is a major improvement and cost benefit for both hospital and supplier. How do sales people respond to the Virtual Classroom? FP. With a standing ovation. First they learned what they needed to know very quickly and efficiently, and then realized how easily they could provide excellent training and support for their customers by employing the Virtual Classroom. How about Nurse Educators? FP. They immediately embraced the Virtual Classroom, as it made it possible for them to assure correct training on new technology, without increasing costs. Th is is particularly important given the staff reductions that many hospitals are facing. Nurse Educators have become strong advocates of the Virtual Classroom as an important tool to help them do their jobs. How are hospitals implementing Virtual Classroom? FP. By uploading the Virtual Classroom to their intranet, all clinicians have convenient access at all times. Th is allows staff to review the TAT science and methods at their convenience rather than at specific times that might compete with patient care. Those without an intranet provide a Virtual Classroom CD to all nursing units. The Virtual Classroom also includes internet links for more detailed clinical information. How much does the Virtual Classroom cost the hospital? FP. Zero. We provide this tool free of charge. The Virtual Classroom copyright explicitly gives permission for any use in connection with TAT. A convenient flash version is also available at www.exergen.com/virtualclassroom that can be accessed anytime. High resolution CDs are available on request by emailing firstname.lastname@example.org . "When five senior physicians in a major university teaching hospital crowded around an iPhone's three-inch screen, watched intently, requested a replay, and then described it as `brilliant', we knew we were on the right track" INFECTION CONTROL 65 FINDING THE BEST FIT As the fight against hospital-acquired MRSA continues in earnest, hospitals are sifting through a myriad of different screening techniques to find a best fit � and NorthShore HealthSystems could be one step closer to doing so. 66 INFECTION CONTROL T he battle against infection is an ongoing struggle of one-upmanship � especially when it comes to hospital-acquired infections (HAIs). The point at which you think you've harnessed a specific bacteria's tolerance levels is usually the point at which you realize how far away you are from doing precisely that � and the cyclical nature of infection prevention continues. So what's left in the armory when it comes to dealing with HAIs for hospitals in the US, especially when it comes to MRSA? Well, according to Lance Peterson, Director of Clinical Microbiology and the Infectious Diseases Research Division at NorthShore University HealthSystem, the answer comes down to active surveillance. And, being the fi rst USbased hospital to do so � starting back in 2005 � both the hospital and Peterson have a solid track record in screening for MRSA, with a staggering 70 percent reduction in all disease infections in the last five years. The real question that needs answering, as Peterson asserts, is fi nding out if you can have the same impact by doing less. "When we first started, we could have captured about 80 percent of our patients with MRSA by screening half of the admission instead of all of them," begins Peterson. "But the consensus was that would be more work for the nurses as they would have had to ask a series of questions, so it was just operationally easier to screen everybody, which is really how we got into active surveillance. We added the equivalent of one-and-a-half people to the laboratory to do the testing as they were doing roughly 200 tests per day, with the hospital system consisting of three hospitals and about 750 acute-care beds at that time." And while universal screening is the preferred choice for hospitals, fi nancial and staffi ng issues often mean that it's not a viable option. So, to get the ball rolling, Peterson often suggests a procedure called `point prevalence' to hospitals looking to advance their MRSA screening techniques. In essence, the procedure involves culturing every patient's nose in the hospital, either over a day or a week, to see what percentage of patients are harboring MRSA in their nose � which is exactly how NorthShore started its surveillance. "We did that in 2004 and found that 8.5 percent of our patients had MRSA in their noses. The previous public note had been out of Atlanta based on 1999 data, and about 2.7 percent of their admission had MRSA. Clearly, in the big cities in the US, the disease had tripled between 1999 and 2004, so that was what pushed us into doing something. If you conduct point prevalence and fi nd that you maybe have one percent of patients with MRSA in their noses, there's probably no point in doing anything. However, if you're over about five percent, then it's likely that you have an issue you need to deal with. If you're between one and five percent, then you have to look at the cost benefit of it all." An uphill battle The drive in increase between 1999 and 2004 that Peterson notes comes down to nothing more than the very nature of bacteria and their ability, every once in a while, to produce a strain that becomes efficient at surviving within its relative environment � becoming adept at being adherent to patients and healthcare workers and allowing them to spread with ease: the unavoidable bane of infection control departments across the country. "There's been some elegant work done in England showing that, of the 20 lineages of col changes between hospitals, the fact that they exist and are being implemented is enough to prove that a proactive approach is being taken towards combating MRSA. At NorthShore, the procedure is deliberately simple: when a new room is prepared, a nasal swab with directions is put on the bedside for the nurse to come in and use on a new patient. That nasal swab is taken and sent directly to the lab for testing. It really is as basic as that � but it works. "We happen to use a rapid molecular test to get a fast turnaround time. If it's positive, the technologists in the lab enter the electronic medical record and order an isolation cart directly to the patient's room. At the same time, they also put on our `problem list' that the patient has a multi-drug resistant organism. At that point, once the physician has seen it, they order mupirocin decolonization for the patient." Indeed, the rapid molecular test used by Peterson and his team at NorthShore makes life exponentially easier when preparing a specimen. He notes that in previous years, using their own tests developed in the laboratory, it used to take twice the amount of time when compared with today's results. There are chromogenic agar tests available on the market, but their current sensitivity is about 20 percent less than the PCR, unless you consider enrichment steps � in which case you're looking at a three-day turnaround period. "We happen to use a rapid molecular test to get a fast turnaround time. If it's positive, the technologists in the lab enter the electronic medical record and order an isolation cart directly to the patient's room" regular Staph Aureus that circulate the world, only about six of them are able to tolerate the genetics to make the methicillin resistant," continues Peterson. "There are a few clones of MRSA that are just very good at spreading. For example, when an epidemic strain fi nally made its way down to Australia, within three years it had taken over between 30 and 70 percent of the ICU MRSA disease. These bit clones, once embedded in a population, spread extremely well." And once spread, the battle changes from prevention to treatment. While standard protoThe next step after getting disease and colonization down, is looking at ways to cut back on some of the screening � but, as Peterson affi rms, "I'm not sure we can." The hope is that eventually NorthShore and the US in general can reach the standards of the Dutch, who are streets ahead of the game when it comes to MRSA screening. "Instead of having 50 percent of their Staph Aureus being MRSA, they have about one to two percent," continues Peterson. "They have a good understanding of who the people are that are at risk for carrying it, so they don't need to test everybody anymore. Instead, they only test people coming from high-risk countries or from other hospitals." INFECTION CONTROL 67 Moving on to the subject of the re-screening of patients re-entering the hospital, it would seem that the Dutch have that down too. Where NorthShore � and the US as a generalization � retest patients every time they cross the threshold of the hospital, the Dutch have progressed to what Peterson refers to as a `bank' fi lled with patients who proved negative at the screening stage. Once they enter the bank, they are exempt from screening again. Currently, NorthShore is looking at a similar potential in which, dependent on a patient's data, after a year or so they won't need to be screened again upon re-entry. Although it's only a potential solution, Peterson believes it could be one of many routes to cutting back on screening. "We have a long list of things to look at," explains Peterson, "and this is just one that we haven't got around to looking at yet � but it is important to look at. Certainly, I don't think you could make any conclusions on just screening someone once. About 20 to 25 percent of our patients get readmitted � and now we've screened close to 30,000 people � so there's a large data set we can look at to assess the potential that if you've been screened twice and been negative, what's the possibility of you screening positive later in your life." Prevent the spread Once MRSA has reached a patient and they are considered `positively infected', there are a few standard practices to ensure damage limitation � both for the patient and the remainder of the hospital population. Scrub away Scrupulous hand washing by hospital staff before and after contact with patients is the single most effective infection control measure and should be applied without fail. Take note Patients' notes should be clearly labeled `MRSA' for any future admittance into hospital. It is also important to notify the patient's local GP that the patient is MRSA positive. Isolation MRSA-infected patients should be physically isolated in a single room that is regularly damp-dusted and kept away from non-infected patients. A new start When the patient is eventually discharged from hospital, their room should be comprehensively cleaned of all linen and other clinical waste, and disposed of in specialist bags. Community-associated MRSA Unfortunately, part of the problem is that there is an overlap of traditional MRSA and community-associated MRSA (CA-MRSA) in the large majority of hospitals, heaving up the difficulty levels in producing a standardized test to function across the board. Specific to NorthShore, Peterson cites that their CA-MRSA levels have been holding steady at around the 20 percent mark for the last three years, which would suggest that they're certainly on the right track when it comes to screening. "The CA-MRSA primarily causes skin and soft tissue infections that look like spider bites and things like that, so people don't often get admitted to the hospital. But we fi nd that about the same percentage of those people are nasally positive like the non-community-associated patients. If someone comes in with an infection, they have a good 30 to 40 percent chance of not being nasally positive, but you pick them up by the infection culture. "In my opinion, one of the advantages that CA-MRSA might have is the fact of its ability to adhere to skin, meaning that you don't need to become nasally colonized fi rst. If someone has CA-MRSA and they touch your hand or generally come into physical contact with you in terms of getting near a wound, then you could become infected � you certainly don't need to be nasally colonized." The reality of the situation, irrespective of nation or quality of healthcare infrastructure, is that while HAIs in general � and MRSA specifically � can be monitored and prevented to a certain degree, attempting to reach a complete `zero point' is at best a stretch of the imagination, and at worst a critical misuse of fi nances and time. Fortunately for NorthShore, this is something Peterson is all too aware of. "Our healthcare system is a little bit like the trusts in the UK," says Peterson, "in as much as we negotiate with our insurers. We have four hospitals with patients who keep coming back to us, so it's almost like a small county healthcare system. Our goal, over the next few years, is to be able to defi ne some of the answers to questions that have already been raised, such as `If we've tested somebody twice or three times and they're negative, can we take them off the list of needing to be tested?' "We're also looking at new ways of handling MRSA from an infection control standpoint. Maybe all we need to do is decolonize patients and not even put them into isolation. That would actually make life a lot easier as it costs $300 a day for us to put somebody into isolation. Regardless, there are plenty of additional strategies that still need studying to figure out what the easiest approach to handling MRSA in the long term really is. It took the Dutch and the Swedish between 10 and 20 years to get to the low levels they are at now, so it needs to be a long-term proposition to effectively deal with MRSA." And while long-term propositions are definitely a step in the right direction, the recent wave of EMR overhauls sweeping the US could play a major part in speeding up that process, specifically in the tracking and identification arenas. Peterson explains that NorthShore's four hospitals are all on EMRs already, for both inpatients and outpatients, so tracking the relative data is already ingrained into the institute's psyche. "We're able to look at data sets of several hundred thousand patients or a million patients, rather than just a few hundred. Moving forward, there is little doubt that the EMR is going to be tremendously helpful. The Veterans Administration Healthcare System has between 150 and 160 hospitals for which they do all their own MRSA admission screening. They recently reported their results on their first 21 months, in which they tested 1.3 million patients and noted a significant reduction in MRSA throughout their US healthcare system. Once that gets published, that'll be a huge body of evidence showing that all admission screening helps exponentially. It's going to be tremendously helpful � we've just got to wait for the right minds in technology to help get us there." 68 INDUSTRY INSIGHT The decolonization decision In a new healthcare paradigm, converging pressures encourage rapid MRSA/SA testing. By David Persing, MD, PhD I n confronting the issue of healthcare-associated infections (HAIs), hospitals are soon to be squeezed from two new directions. First, they will be facing a new reimbursement environment in which they will no longer receive reimbursement for infections deemed to be healthcare associated, whether or not the patient is a carrier at admission (carriers of MRSA are at higher risk of infection from their own strain of MRSA). Secondly, by virtue of mandatory reporting laws in many states, hospitals' rates of HAIs will increasingly be subject to public scrutiny. An increasing number of patients carry methicillinresistant Staphylococcus aureus (MRSA), especially if they have had prior hospital admissions or are residents of long-term care facilities. These patients not only have an increased risk of infection, but they may also transmit infection to others. In this new healthcare environment, economic considerations will drive the implementation of the most effective infection prevention strategies. Limiting the opportunity for transmission time by using the fastest test for MRSA and S. aureus colonization has been shown to dramatically reduce transmission events and infection rates. Last year, one hospital saved an estimated $576,000 per year by performing MRSA testing once a day, using a molecular test for patients in the ICU, followed by strict isolation for colonized patients.1 The cost reduction was a result of decreased transmission and infections, even without invoking decolonization. Similar dramatic declines in MRSA infection rates have been observed in the ICUs of the VA hospitals nationwide; rapid testing, followed by barrier precautions has resulted in a 76 percent reduction in ICU infections. colonized with MSSA or not colonized. A follow-up study of colonized patients after they leave the hospital revealed a 20-30 percent risk of serious infection following soft tissue or respiratory tract acquisition and a 40-50 percent risk of serious infection if the initial isolate came from bone, joint fluid, or nares (as detected on a surveillance test). Clearly, being a carrier of SA or MRSA is a significant risk factor; a sort of `horizontally acquired' genetic risk factor for developing an infection. Preventing infections in MSSA and MRSAcolonized patients With the advent of molecular methods for detection of MRSA, we are now armed with the optimal diagnostic tools for recognition of nasal carriers. We can now isolate patients quickly to prevent patient-to-patient transmission. But for individual patients who are carriers, can anything be done to prevent infections in MSSA and MRSA-colonized patients? David H. Persing, MD, PhD, is the Executive VP and Chief Medical and Technology Officer for Cepheid. Previously he served as the Chief Scientifi c Officer at Corixa Corporation and was a member of the Clinical and Research Faculty of the Mayo Clinic. In 1992 he founded and directed the Molecular Microbiology Laboratory at Mayo Clinic. Persing has authored over 240 peer-reviewed articles and served as Editor in Chief for three textbooks on Molecular Diagnostics. Testing and decolonization works Newer studies are showing that indeed, case recognition followed by selective decolonization is highly beneficial to patients who are carriers. In a study published in the NEJM this year, researchers found, "The results of our trial provide solid evidence of the preventive effect of S. aureus decolonization and a good estimate of the size of this effect: the risk of hospital-associated S. aureus infections was reduced by nearly 60 percent".2 In a study in the Journal of Bone and Joint Surgery, the authors demonstrated that implementing a hospital-wide prescreening program for detecting previously unidentified MRSA and MSSA carriers allowed early identification of colonized patients, adjustment of preoperative antibiotic prophylaxis, and early isolation and contact precautions for those who continued to remain colonized.3 Clearly, there is a strong and growing body of evidence demonstrating the effectiveness of rapid identification and intervention strategies for MRSA and Staphylococcus aureus colonization. There are also pressures encouraging the adoption of these strategies. In this demanding healthcare environment, on-demand molecular testing is proving essential, with economic considerations and patient outcomes driving the implementation of the most effective tests and interventions. For the references associated with this article, please see: http://www. executivehm.com/article/the-decolonization-decision/ Decolonization: from the early days to today's greater challenge Although patients carrying MRSA in their noses are even more likely to develop an infection with their own strain of Staphylococcus than those harboring the more benign methicillin-susceptible S. aureus (MSSA), both pathogens are significant causes of surgical site infections. In one study, researchers found that critically ill S. aureus-colonized patients had a 27-fold higher risk of developing a S. aureus infection within 16-19 days after hospital admission than did non-colonized patients. In another study, researchers reported that MRSA colonization either detected at hospital admission or acquisition in the healthcare institution resulted in a 10 times higher incidence of MRSA infection than for patients 70 INFECTION CONTROL Through the keyhole Andrew Onderdonk opens the doors to his microbiology lab and shows us what's going on behind the scenes in the world of in vitro infectious disease diagnostics. W hile nurses, physicians and a battalion of hospital staff regimentally infuse their mantra of hand washing and sterilization with impeccable bedside manners, behind the scenes another dimension prevails � complete with pipettes. Open the doors of any microbiology lab and you are sure to witness a landscape of test tubes, Petri dishes and countless scientific equipment intended to aid and progress the world of in vitro infectious disease diagnostics. Without them, hospitals would be left working in the metaphorical dark, void of an ability to analyze or interpret any potential infectious organism. Heading up a crack-team of technicians at Brigham and Women's Hospital in Boston, Massachusetts, Andrew Onderdonk does precisely that. As Director of the Microbiology Laboratory and a Professor at the hospital, his experience within the field has seen him tackle a whole spectrum of infectious diseases and left him responsible for the isolation, identification and susceptibility testing of a variety of pathogenic infectious agents. "In many ways, our task is more difficult than, for example, a chemistry hematology lab that works with a single sample type. We work with virtually any tissue or fluid that can be obtained from a human body. Because of that, we have to use a whole variety of techniques for doing our job," explains Onderdonk. Indeed, the most common laboratory technique of culturing material still prevails; blood, urine and fecal matter can all be applied to microbiologic media to amplify what's present on agar plates. From there, a fist- ful of different methods can be utilized depending on what shows up on the agar. "Susceptibility testing in this country is highly standardized for a whole variety of reasons and is performed using either automated systems that basically place the organism we're interested in into a broth solution containing all concentrations of antibiotics to see whether they can grow or not. Alternatively, they can also be performed by placing small disks impregnated with antibiotics onto agar plates and measuring a zone of inhibition which then correlates with whether they're susceptible or not. Detection "In our laboratory, as well as most others, the real challenge at the present time is understanding how we deploy and use new technologies available to us. I'm talking specifically about the non-culture-based methods that are available such as polymerase chain reaction (PCR) and other nucleic acid-detection methods. The ones we use range from direct detection methods, which simply use a nucleic acid probe to look for a target sequence in a specimen type. These are commonly employed for specimens where we're looking for things like chlamydia and gonorrhea, where the numbers of organisms are high enough so we don't have to necessarily do any amplification." The second set of methods employed by Onderdonk and his team are those that amplify the target sequence, and are given due priority to the involvement for the detection of viral agents. As Brigham and Women's has an unusually large transplant population, perhaps it's not too Infection rates have been cut by 50% through simple hand-washing programs INFECTION CONTROL 71 surprising that that their focus is on viral agents detected in patients who are immunocompromised in one way or another. "One of the things that has come to pass over the last six or seven years," continues Onderdonk, "has been to apply our techniques to the whole concept of individualized medicine; in fact, a clinical microbiology lab is probably the greatest user of techniques for individualized medicine in any hospital. We do what are called quantitative viral load assays, which again is an amplification method, but tells us how many copies of the viral agents are present. These were initially deployed for the detection of HIV and monitoring antiviral therapy to see whether or not the drugs being used were effective." In more recent years, Onderdonk has started using quantitative viral load assays for issues such as cytomegalovirus, which is often followed in bone marrow transplant patients as a way to determine their immune competency � and also as a way to either ramp up or suppress the amount of immunosuppressant based on the viral load. As it's highly individualized on a patient, according to Onderdonk, these assays are typically run on bone marrow transplant patients once every two months, with adjustments in medication made on that basis. "The most recent addition to our repertoire in terms of infectious agents is an assay for something called BK virus, which is followed in kidney transplant patients. Th is is a solid-organ transplant in which the patients are transplanted, but then the BK virus load � which essentially all of us have � can replicate if the patient is too immunosuppressed and damage the transplanted organ. Th is, again, is used as an individualized way to determine a particular patient's immune competency. "Linked in with that, we also do assays for hepatitis viruses such as HBV and HPV, which are extremely important. In the past year we have also brought on PCR assays for things like Influenza A and B and for sub typing to determine whether we had the so-called 2009 H1N1 type or whether we were dealing with the seasonal flu. Those are probably the most advanced methods that we currently use in the lab. It's interesting because even our own department of pathology sometimes forgets that all the stuff we've learned about measuring viral load assays is directly applicable to the measurement of tumor burden, which is a very individualized way to determine how well chemotherapy � or any other therapy � is working in a particular patient." However, for all of these new methodologies and progressions, Onderdonk is still trying to fi nd ways to automate the processes used in his laboratory, for two main reasons. The fi rst is that it's becoming difficult to fi nd trained technologists to undertake the skilled work that is required by these assays, which is simply down to cutbacks in training funds. Secondly, trying to get a handle on the cost associated with performing these assays is � as an understatement � an ongoing challenge. Another challenge is taking on the notorious realm of MRSA. "Interestingly, it's a huge part of our workload in this hospital," says Onderdonk. "We conduct routine surveillance cultures on inpatients for MRSA for vancomycinresistant enterococci and something called ESBL, which are extended beta-lactamase resistant organisms. These are all essentially what the popular press call `super bugs'. If we can isolate patients with these, and/or provide some sort of an intervention before they come into the hospital, then we can cut our infection rate." Combined with this, Onderdonk's Microbiology lab is also in the process of putting a pre-admission screening system in place specifically to look for staph aureus as well as MRSA. "It's recently been shown that if you detect these agents in the patients before they enter the hospital, then treat them with chlorhexidine showers and a drug called Mupirocin to try to decontaminate them, you can cut your infection rates post-surgery by almost 50 percent," affirms Onderdonk. "This is something that we're going to put in place and we'll see how well is works in our particular hospital setting. But the truth is, surveillance systems just tell you the magnitude of the problem. They don't solve anything. First-hand experience "We have worked very closely with our infection control folks to implement something very simple, which is just a very rigorous hand-washing program for our physicians and nurses between patients. Quite frankly, we've cut our infection rate in this hospital by almost 50 percent strictly on the basis of routine surveillance and an aggressive hand-washing program." Another issue that keeps raising its head above the parapet is C. Diff. Fortunately for patients of the hospital, Onderdonk and a fellow scientist, John Bartlett, discovered the virus back in the 1970s � so they couldn't be in better hands. "We thought we had the whole thing under control," explains Onderdonk. "We showed that it was the cause of this human antibiotic-associated colitis and that drugs such as vancomycin were pretty effective in treating these, so although cases occurred, you didn't see patients dying. Then all of a sudden, back in 2004-2005, we started to get cases again in this hospital of patients with C. Diff diseases, and they were coming with what we call toxic megacolon, which more often than not requires a total colectomy on the patient 72 INFECTION CONTROL � and the survival rates from that is not great. "We were losing patients to C. Diff until we discovered � surprise, surprise � that the organism had mutated to a more viral form and that the strains we were now seeing in the hospital produced far more toxins than the typical `garden-variety' strains. Our surveillance testing for that has therefore increased as well. What we've found is that the way you clean the hospital rooms is probably as important as anything you can do to eliminate the spores that this organism produces." As Onderdonk points out � surveillance only identifies the magnitude of a problem, it doesn't solve it. However, the belief is that if you couple surveillance with aggressive interventions such as hand washing or drugs that are more effective in treating the disease, then the programs have great merit. Off the back of this, the industry is welcoming the influx of new technology entering the market to make surveillance more efficient. Moving forward "There are a couple of new PCR methods that can be used for detecting MRSA in patient samples, or VRE for that matter," continues Onderdonk. "We are looking at those carefully right now. The problem we find is that the automated systems that are used with these are extremely expensive; it's hard to justify those versus using a conventional culture method. Like a lot of other hospitals, for us it's still much cheaper to simply use a culture-based method than it is a nucleic acid-based method. "However, I think that will change with time as competition in the marketplace takes care of things. We anticipate that in perhaps a few years, instead of doing a culture here in the clinical microbiology lab for our preadmission testing service on patients coming for surgery, we might have an instrument right in the preadmission testing area. This would allow you to take a swab sample from the patient, put it on a little cassette and then enter that into a system that would tell you very quickly whether that patient was a carrier or not. There's a tremendous amount of technology that's in the works and it's evolving so fast that it's difficult to keep up with." The speed of technology within microbiology and the laboratory context certainly means it's difficult at the best of times to keep a fi nger on the pulse of what exactly is going on � and Onderdonk and his team are no exception. They're already looking at some highly automated flow cytometry equipment to be used to screen one of their most common samples � urine � for bacteria so they can avoid culturing for the 80 percent of samples that don't have anything present in them. In this case, the screening method is very sensitive and much less expensive than even conducting a simple culture. "We're hopeful that we can implement that in our laboratory as an upfront screen, so that the expensive part of the sample pro- cessing, which is setting up the culture and then having somebody look at it, doesn't occur. We've just fi nished a test of a system using flow cytometry methods that will make some sense for us." While technology and new progressions might be hard to keep up with, the future doesn't seem so difficult to tap in to. "What will happen in the next few years," predicts Onderdonk, "is that using high-throughput sequencing, which is becoming less and less expensive, will replace some of our standard culture techniques with methods that reveal a lot more information far quicker. These methods are in research laboratories under development now, but I've been working with a group at the Massachusetts Institute of Technology called the Broad Institute, which is one of the high-throughput sequencing labs that works on the human genome to see if we can develop methods that are clinically useable for the laboratory. "That will probably be the next major change in how we do business. We're also hopeful that more advanced methods for determining which drugs to use for which organisms will become available, because the methods we're using now are 50-60 years old, but there's nothing to replace them. With sequencing, we could basically identify the resistance gene, and if it's present then obviously we wouldn't select those particular drugs for use. If we can do that quickly, and it correlates with clinic outcomes, then we have a fast way to do something that currently takes around 48 hours." With this in mind, the future of in vitro infectious disease diagnostics seems to lie in the motivation of people like Onderdonk to ensure that the growing resistance of infective organisms is matched by progressions in the lab. MRSA is found in 20-30% of the nasal cavities of healthy people 74 TECHNOLOGY BIRD'S EYE VIEW THE With another bout of flu inevitably on its way � and a history of `non-starter' epidemics in the recent past � a more efficient way of predicting outbreaks is needed as the world's population continues to grow exponentially and bacteria become more resistant. Fortunately, Nicholas Christakis has found a way � by mapping our social networks. By Nick Pryke W ith our seeming dependence on the internet and social media sites in recent years, you could be excused for thinking that we've become meshed with our self-created, virtual world of binary � a world where the only virus you're likely to contract is on your hard-drive, where the volume of Facebook friends dictates your popularity, and where you can harvest fame and fortune with little more than a camera and a few clicks of a mouse. Fortunately, we're not at the levels of this dystopian future quite yet. In the mean time, continuing real-life interactions, building social networks and meeting people face to face will have to suffice. And while it does, our human social networks will continue to divulge information, make and break relationships, nurture ideas � and spread germs. In the current state of play, the translation of germs and bacteria to potential epidemics is monitored and assessed by centralized bodies such as the Centers for Disease Control and Prevention (CDC). And while they have traditionally done all in their power to detect and warn the general public about potential epidemics, the time lag involved between detection and warning usually sees them turning up late to the party. Obviously a more efficient solution is needed, but how do you ensure that you not only have the ability to detect potential epidemics early, but also have the right knowledge in place to warn the relative social network that one is on the horizon? Well, Nicholas Christakis, Professor of Medical Sociology in the Department of Health Care Policy at Harvard Medical School, along with his long-time collaborator James Fowler, has put forward a potential solution � and from his subsequent experiments, it's certainly proved its potential. Working out of his laboratory, Christakis' research as two types of phenomena: the social, mathematical and biological rules governing how social networks form � dubbed "connections" � and the biological and social implications of how they operate to influence thoughts, feelings and behaviours, known as "contagion". Test-run In the tail-end of 2009, having realized that individuals near the center of a social network are more likely to be infected with a germ sooner during the course of an outbreak than those on the periphery, Christakis decided to work against the grain of traditional belief, which presumes that you require an understanding of a global network structure to predict an epidemic or outbreak. Instead, he took a far simpler route by monitoring the friends of randomly selected individuals, as they are known to be far more central within their network. To test the theory, Christakis and his team studied a flu outbreak at Harvard College. Following 744 students who were either members of a group of randomly chosen individuals or a group of their friends, Christakis identified that the progression of the epidemic in the friend group occurred almost 14 days in advance of the population as a whole. More importantly, the friend group also showed a significant `lead time' on day 16 of the epidemic � a whole 46 days before the "peak in daily incidence" in the population as a whole. In identifying the time lag between the two groups, Christakis and his crew had identified the difference between predicting an epidemic early and sweeping up the aftermath. "The gist of the idea is that people don't just live in groups, they live in networks," begins Christakis in explaining the logic behind the theory. "Th is pattern of ties that we have with each other � real face-to-face ties, not online ties � means that some of us are located in the middle of a network and some of us are located on the edge of the network. People located in the middle of a network, on average, are more likely to get whatever's spreading through the network � and are more likely to get it sooner in the course of whatever it is that's spreading." What Christakis was able to do was to show that it's possible to identify central people in the network without mapping the whole network, by using a phenomenon known as the `friendship paradox'. In its simplest form, the friendship paradox explains that you are more likely to be friends with someone who has more friends and less likely to be friends with someone who has fewer friends. Whilst it sounds rather harsh, the reality is that we're socially wired to do just that, whether we like it or not. TECHNOLOGY 75 "With that in mind, if you pick a random group of people and ask them to nominate their friends, their friends have more friends than they do. So your friends have more friends than you do, meaning that the friends of a random group of people are more central in the network than the random people themselves. Th is allows us to study and monitor a group of friends either actively or passively. And if you do that, you can gain an earlier detection about whatever it is that's spreading through the network, whether that be a germ, an idea or a behavior." Alternative routes The beauty of mapping the social network in this context is that it's not exclusive to a one-way input system; neither does it discriminate against non-epidemic topics. Surveillance can be either active or passive, which again will have a change in the input and output results of the network, allowing you to influence as much or as little as desired. To ensure that every possible angle is being covered, Christakis works in collaboration with MedNetworks, a company that deals solely with working on data interpretation and social network mapping from Christakis' fi ndings. "They're commercializing and have licensed some of our stuff from Harvard and they have a number of ap- plications in both the sensor network ideas and influence processes," he explains. "They have a number of examples outside the realms of regular populations of people for other networks, a good example being doctors. So, if you want to look at the diff usion of innovation or you want to know the relative adoption of a drug in a population of doctors, then that's something that we could facilitate." But surely the compliance of the most `central' node will affect, and to a certain extent dictate, the resulting predictions from the relative social network? Well, not according to Christakis. "You could use similar ideas just using passive data collection � for example, mapping out email networks to identify people who are more centralized in a company. Again, the focus is very much on the sensor network idea, which is fi ne, but the important thing to realize is that, because human beings are interconnected in networks in mathematically sensible ways, it means that we can both deliver information to the network, trying to foster diff usion of innovation, workplace wellness, safety practices, innovation and creativity. We can intervene in the network to foster diff usion of desirable properties, and we can extract information from the network. They're two sides of the same coin. The sensor network idea is the obverse of the intervention idea or the flow of influence idea." 76 TECHNOLOGY MedNetworks nsuring that the work of Christakis and his team at Harvard is tested in real time, MedNetworks was formed by Larry Miller, now President and CEO of MedNetworks, and Nicholas Christakis to apply highly validated and fully functional technology to map, analyze and activate social networks across a broad range of constituencies including consumers, patients, health plan members, physicians and hospitals. Using MedNetworks technology, networks, whether existing or created, can be mapped using either single or integrated multiple data sources � from administrative data such as medical and pharmacy claims data, to communications data relating to emails and phone traffic. MedNetworks thrives on a mantra of unleashing the tremendous power of existing social networks by using the "multiplier effect" to create changes in behavior out to three degrees of separation. To do this, the company takes existing data from their customers, who already have extensive information on providers, patients and plan members, and maps out their relative networks. Once this is completed, MedNetworks then situates individuals within their social context, allowing for more efficient and effective targeting for information flows and behavioral changes. In essence, MedNetworks is the commercial side of Christakis' experiments, with both working as part of a reciprocal relationship. Christakis' findings translate into solutions for companies and industries alike, while MedNetworks field work reports back to straighten out kinks in the system that Christakis and his team can then work on to improve efficiency. What MedNetworks has proved is that understanding social networks through mapping them not only improves an understanding of one's business, but also the effects of intervening within that system � for both good and bad. E Nicholas Christakis what and where and with which bundles. Supermarkets know that you buy peanut butter and jelly, so they put them together on their shelves. The question is, how do we use the same kinds of processes to invent or deploy methods that facilitate the diff usion of desirable health behaviors or other desirable public policies?" And with the introduction of EMRs into the healthcare setting, it looks like Christakis could have just found his answer. As hospitals edge further down the road towards complete EMR implementation, security and standardization will become the norm, bringing with it the key to nurturing Christakis' social networking model. Where and when it will be able to jump on the back of the EMR is still unclear, but affording it the security it needs to work proactively should allow it a safe environment to do so. "To the extent that we make anything electronic, we facilitate the ability to process data to learn and to acquire knowledge," concludes Christakis. "So, to the extent that the EMR becomes more prevalent, I think it will facilitate the use of data in the fashion that we're describing." And the potential for the same model in hospitals to map out HAIs? "Absolutely. The same kind of ideas could be deployed in hospitals and amongst other kinds of communities to get an earlier detection of nosocomial infections or other institutional outbursts. Absolutely." For all the critics who claim that social mapping and subsequent influences on the network is another step in the direction of a `big brother' state, there's little to say that will change their minds. But for the proponents of Christakis' work, realizing that having a tool that could predict an epidemic or outbreak significantly quicker than the current standard is just too strong an opportunity to ignore. And for Christakis, it's just too promising to drop. "Supermarkets know that you buy peanut butter and jelly, so they put them together on their shelves. The question is, how do we use the same kinds of processes to facilitate the diffusion of desirable health behaviors" However, despite its potential in mapping and predicting disease in social networks, many critics are extremely weary of the latent dangers of putting such power in the wrong hands � and with good reason. As Christakis himself explains, understanding the dynamics of social networks and their implications when mapping them allows you to interact and influence the network itself, leaving it open to exponential abuse in the wrong hands. But as Christakis asserts, any technological advance has to face the same hurdle. "Pick any kind of human technology that's been invented and it has the potential for evil, so I think the solution is some type of democratic control. You usually want the populace to be able to express its will as to how a certain technology is being used. So my feeling is that this new information technology has the promise of improving our society. But it also, unfortunately, has the peril of harming our society. The challenge is working out how we get the benefits without paying the cost. I believe that transparency is important and I think that a collective expression of will is important. "We have laws about wiretapping and privacy. We have all kinds of laws that regulate what private corporations can know about or sell you and what other private individuals can do, so I obviously think we need a regulation of information that's available in this new computational era. You have to keep in mind that companies use this type of information all the time. Visa tracks who's purchasing 78 WORKSHOP Staying up to date with HIE GE Healthcare's Earl Jones answers readers' questions about health information exchanges. The key to meaningful use appears to be the ability to send and receive data by connecting with IT systems in other locations via an HIE. What are the first steps I need to take to enable my organization to build or become part of such an exchange? Patrick Wylie, Chief Information Officer, Santa Rosa Memorial Hospital, CA more easily and quickly, supporting decision-making and enhancing continuity of care. In the future, many HIEs will likely also be connected to regional and state networks, resulting in broadly connected communities. If I have the choice between joining an HIE and a RHIO, how can I decide which one suits my institution? Laura Keithahn, Director of Technology, St. John's Hospital, Saint Paul, MN Earl Jones is Vice President, GE Healthcare eHealth Solutions. With six years at GE, he brings a wealth of experience from previous roles as partner of a consulting firm, leader at Dell, achieving an MBA from MIT, and serving with distinction as an Officer in the US Navy's Submarine Force. Earl Jones. Stakeholder engagement is the first step to organizational readiness. Helping the business, clinicians and patients understand how an HIE can help to bring better care at lower cost to the hospital and community will facilitate implementation and adoption. Articulating your organization's goals will help clarify program scope (what to implement) and will serve as a benchmark so that future results can be quantified. The next step is to choose the right vendor � one who will stay with you for the long haul and who will implement a bi-directional, standards-based, semantically interoperable HIE infrastructure. This will help ensure that, as your organization's needs grow, your solution can grow with you. Lastly, implement the HIE in stages, focusing first on quick wins that excite clinicians with minimal impact to existing workflows. That way, some success can be achieved quickly, and support for the next stages of implementation will increase. "Don't wait to get engaged in an HIE. Joining an HIE will help you enable information to flow between providers more easily and quickly, supporting decision-making and enhancing continuity of care" What are the basic criteria I need to look for when deciding which HIE to join? Steve Bateman, CTO, Brigham City Community Hospital, Brigham City, UT EJ. The decision to join an HIE or RHIO should be based on your organization's objectives such as increasing revenue, improving patient satisfaction, meeting quality goals and achieving meaningful use. An HIE generally ties affi liated providers together to enable interaction across the virtual enterprise and more efficiently coordinate access and use of shared services (such as referrals, lab, radiology and cardiology). In addition to linking in the referral network, an HIE can simplify the manual processes for sharing information. RHIOs typically have a larger, more regional focus across multiple independent and sometimes competitive stakeholders. RHIOs can support a loose coupling of such stakeholders across a larger region and provide a platform for competitive differentiation and expansion of services. A RHIO can also form when there are referral patterns across regional hospitals, such as a community hospital that sends its patients to a larger health system. There's so much emphasis right now on EHR and HIE. How can we ensure that the systems we end up implementing are sustainable in the long term? Sheryl Bell, Director of Information Services, St. Luke's Medical Center, Boise, ID EJ. Today, the majority of health providers are driving toward establishing a way to exchange health information. However, there are some areas where early adoption has led to multiple HIE options for a given provider. AHRQ, the Agency for Healthcare Research and Quality, suggests that your organization evaluate your needs and align to the HIE that best fits your business and IT goals. Important criteria include network design and functionality, overall leadership compatibility, and billing structure or fees. In addition, consider the overall sustainability of the HIE and carefully review the data sharing agreement. Don't wait to get engaged in an HIE. Joining an HIE will help you enable information to flow between providers EJ. First, invest in robust, scalable HIE infrastructure that is bi-directional, standards-based and offers options for integration to existing EMRs as well as portal-based solutions for non-EMR users. The best standards come from IHE, a global organization that defines interoperability `profi les' that package standards to achieve specific use cases, ensuring tight alignment to business objectives. With such an infrastructure, your HIE will be scalable and can support additional stakeholders and patient populations for varied business models and future community workflows. Also, consider a hosted solution, which has less upfront capital expense, outsources operational risk to the vendor, and has flexible `pay as you go' fee structures. Ask your HIE technology partners to explain their near- and long-term roadmaps for value-added functionality. Finally, given the turbulence in this new market, it is wise to partner with a reputable and stable company. 80 TECHNOLOGY Easy does it As EMRs continue their tour across the US, many hospitals are finding themselves facing new and tougher challenges � but as Daniel Newman shows, keeping your calm can certainly help the cause. A s anyone with the remotest of interests in healthcare or the Obama Administration will tell you, electronic medical records (EMRs) have become part of the staple diet for physicians and patients nationwide. Gone are the days of pushing paper, scrolling through Rolodexes and chasing down the obligatory `missing fi le'; the dusty outlines of files from yesteryear are all that remain. They've been replaced by the age of technology � a world of binary that dualistically extracts information as quickly as it produces it. It has become a slave to our every whim and yet we treat it with the utmost respect. Why? Because its potential is limitless. Of course, your standard computer science PhD student already knows this, but for the rest of us mere mortals, a comprehension of how technology could change the way we interact with our health is still in the process of being unveiled � thanks, of course, to the work of CIOs and CMIOs up and down the country. Their unflagging dedication to bring the healthcare sector up to scratch has allowed for a truly personalized healthcare ethos to prevail. But the burning question on the lips of the masses raises a good point: can it be done within the Obama-allocated window of time? Well, according to Daniel Newman, CMIO at Boston Medical Center, there's no reason why the majority of it can't. "I would say it would be about 70 percent feasible," estimates Newman. "I don't think that we're going to get to everything that was put into the HITECH Act, or indeed meaningful use. That's already been seen in the 2011 guidelines. It's very aggressive � and when I think about where my respective hospital is, where we have all of our positions undertaking computerized physician order entries (CPOE) � we're pretty much all up on documentation across the board, including inpatients, outpatients and digital distribution." And this isn't specific to Boston Medical; plenty of the hospital's peers have found themselves in the same position. However, for the many that have, Newman cites the 75 to 80 percent of doctors that are yet to grasp the concept of EMRs within their system, or are resistant to it, as the fi nal cog in the system that will inevitably slow the push to completion. "It's going to take a little longer than 2015," he admits, "so there are going to be changes to that over the next few years. It's a good impetus to move things in the right direction, if nothing else. The challenge "However, my fear is that if you push people too fast in the EMR setting, you're going to have very poor data that doesn't completely enter the system. We are a very large group of 140 people in our IT department. It's not a huge group compared to others, but we do have all those people working nonstop trying to get projects done and get your information into the system for either the physician quality reporting initiative (PQRI) or meaningful use. I don't know how it's going to work with a small practice of three or four doctors. Who's going to do all that work?" Newman's question raises a valid point: EMRs are fi ne for all the large hospitals who can afford to throw countless man-hours toward reaching implementation, but unfortunately for the smaller hospitals, there appears to be little consideration taken as to how they'll keep up with the pace. Even with the best operating systems on the market, the human touch remains indispensable. With this in mind, many believe that the current government oversubscribed to EMRs within health reform. For Newman, at least, this couldn't be further from the truth. "It's inherently positive," he affi rms. "I don't know how you're going to be able to get it to where it needs to be otherwise. My hope would be that over the next few years, certainly in the next 10 years, we change our model of paying physicians based upon volume or procedure and that we move more towards quality and how you're taking care of your patients." Indeed, the only way to spur on that change is for people to be on electronic systems and for the data to be captured appropriately. In doing so, physicians will feel far more comfortable with patients � in both the numerator and denominator levels � that are then being reported up to the state or governmental levels. "That's the part I get a little nervous about," admits Newman. "The question resonates around whether the data they ask for are going to be appropriate. Are they going to be validated? Are we going to be able to give them good information in return? Ultimately, I do think that you have to do that if you want to change the way we're going to do our healthcare." 81 President Obama's EMR overhaul is intended to be complete by 2014 Newman certainly practices what he preaches, as Boston Medical proudly boasts a knowledge management group set up specifically for the cause � complete with the intelligence to place it in a position where clinicians are making the ultimate decisions as to what the data should be. On top of that, Newman can also lay claim to a data warehouse group; a clever investment as it can be used to show the right eyes the relevant quality metrics. "The missing piece that we have to unite these two projects is the transparency of clinician input. If I log on to my system, I can see that this patient � for a certain PQRI measure or meaningful use measure � doesn't fit into the denominator or the numerator. From here, I can remove them if need be. There has to be that sense of transparency up front." It is here that a worry for the large majority prevails. With the data input and data fields relatively easy to put together with minimal standards, the difficulty stems from an ability to maintain the system once it has been put into place. A handful of institutes are already fi nding that if it's not maintained, it tends to break down extremely quickly � and when it does, the contained data begin to fall apart. "The other piece of the puzzle that is huge for us right 82 TECHNOLOGY now is health information exchange (HIE)," continues Newman. "We have one in our system that's a local HIE, which we're using with the intention of linking up between health centers. It is comprised of 15 in total, working with our EMC system, as well as between our individual applications, so we have three silo applications for inpatient, outpatient and digital distribution. If you don't have good data and know where they are, the HIE isn't going to work � even with a data warehouse � so that's our focus right now." Safe and sound With data management stealing much of the limelight in recent months, security has become paramount. With soft ware and the minds behind it progressing the discipline of security at breakneck speed, hospitals are finding themselves constantly testing, updating and watching their security systems to prevent potential flaws � a time-consuming feat that has left many wondering what direction to take next. "I'm still confused as to where security is going to be," says Newman. "We have the HITECH Act, which is going to be a lot more enforceable, so we're going to have to pay very close attention to where our data are being exchanged. "My biggest concerns are people's smartphones, personal laptops and emails. We have secure email that we can send, but unfortunately it doesn't always get sent that way. For example, I'm a clinician at Boston University (BU) as well as Boston Medical Center (BMC), so I have two different emails. I can send a patient an email from BU and it won't be sent securely because it's going through a different place. These kinds of policies and procedures are making me nervous as to where the data are going to leak out. To try and minimize this, we have an information security officer and privacy officer trying to keep track of all changes so we can follow them up. "We try to write policies and put them through our med exec committee, which we attempt to broadcast, but it's difficult to enforce � and that's where we run into problems. It feels like a loss of autonomy for clinicians and there's a part of me that's still in that mindset that wants me to reject change. Many clinicians have that problem in thinking: `I'm just trying to have a conversation with my patient. You're putting barriers in front of me to do that and it's making it more difficult, not easier, to take care of the patient.' Th is is becoming more of an issue the closer hospitals get to implementation." The fact remains that as important as security may be, it is far from the only problem on the IT table when it comes to EMRs. Newman cites BMC's three biggest challenges as going a little something like this: performance, interoperability and efficiency. Indeed, almost everything is broken down into these groups to assess levels of improvement within BMC. Newman has even set himself a target, out of personal annoyance, to get things happening within five seconds. "When you click something," explains Newman, "it should happen within five. If you can get it within 10 seconds, I'll be happy. Anything over 10, I'm definitely not happy. If it's over 15, it's just ridiculous and is most probably not going to work. "We will hopefully use HIE to improve our data transfer between our individual applications, as well as our health centers, to potentially build a forum on top of it all so that we can integrate the data to view what the doctors are seeing and not just have separate applications that are always behind the curve." But improvements won't just come from the hospital setting � vendors need to begin to talk to each other to truly get the ball rolling in terms of soft ware solutions. As Newman puts it, if the HITECH Act does nothing else, "It puts a real fire under the feet of vendors to start changing and move things forward." On the move And while this future fi re may be nothing more than a plume of smoke at present, the technology is certainly already there to keep up with the mobility of patient health information. Physicians are grabbing at the terminal service initiatives available, offering them a remote log-on point with unbiased devices. Of course, no mention of mobile technology would be complete without a quick reference to the iPad � a tool that Newman has found indispensable since laying his hands on it. "It's great because I can log on through an RDP client that you can download directly from the App Store. I can have my full laptop from my office and run my Legacy apps all on the iPad. It works very well and I was extremely impressed by how we could get things moving quickly with it. We've also been working on developing some other apps for the Blackberry for doctors to use while they're doing their rounds to try to improve their documentation practice. We're trying out a few things at this point and we're going to have to see how it goes over the next few years." It seems as though EMRs are having an effect all across the board: from EMR-specific technologies to tweaking existing consumer technology to work for EMR; what is clear is that its introduction is already changing the way both the patient and doctor interact with their respective health and health information � so where else is it likely to appear? If Newman's prediction is anything to go by, it could go a long way in partnering with the world of personalized medicine. "EMRs and HIEs will be big business for that," asserts a confident Newman. "As people get older now, they want more information. They're going to want it online � and if you want to market to your patients, you're going to have some access to the patient so that they can get on and see their data. "We are always afraid as physicians that patients aren't taking responsibility. How do we get them to understand that they need to take responsibility? It's complex information; it's hard to understand � but they can understand some things in the context of being friends and going through similar situations. In my opinion, you're going to see a lot of positive things when it comes to patients being able to take care of themselves a little bit more over the next few years." "In my opinion, you're going to see a lot of positive things when it comes to patients being able to take care of themselves a little bit more over the next few years" 84 ASK THE EXPERT Finding value in the cloud As physician practices transition to or upgrade electronic health record systems, how should they evaluate the pluses and minuses of `cloud computing' solutions? By Steven F. Tolle D espite years of talk about electronic health records (EHRs), activity has tended to be limited to the largest or most well-heeled physician practices. Nearly 75 percent of physician practices in the US have not made the move � and for good reason. In tough economic times, pouring money, time and effort into technology that has not shown much return-oninvestment is difficult. Now, however, a strong push from federal healthcare reform to better coordinate care, reduce errors and improve efficiency is forcing every physician to consider EHRs with a renewed sense of urgency. Unfortunately, there is a lot of confusion about potential options, particularly about the term `cloud computing'. Understanding the term, however, is essential if physicians are to make truly informed choices. For cloud computing � with its quick start-up, simplicity of use, easy adaptability and reasonable costs � may hold the key to getting physician practices connected. Defining the terms To help frame the discussion, consider the terms that defi ne the three basic EHR options. Client-server. The oldest of the available technologies, client-server refers to a set-up where a server delivers the key soft ware and information to `client' computers. All of the hardware and soft ware is on site and is fully bought and paid for by the practice. Installation involves considerable upfront costs and time. All updates and maintenance tend to be the responsibility of the practice. Client-server's biggest advantage � the ability to fully customize according to individual practice patterns � may ultimately become a non-factor as healthcare moves toward health information exchanges and regulations that demand standardization. Application service provider (ASP). For ASPs, the individual practice server moves to a remote site where an external vendor maintains it. Because a web browser in the physician's office accesses the remote server, some refer to this model as `web-based' or even `soft ware-as-a-service' (SaaS), though that muddies the discussion, because these terms are also associated with cloud computing. Upfront costs and updates for ASP solutions are still considerable, because of the time needed to configure a server for each individual practice. ASP EHRs are, however, easily customized, and because the vendor maintains the server, some of the long-term maintenance costs can shift away from the practice. Cloud computing. Cloud computing refers to the idea that a wealth of shared resources lives in a `cloud' created by the internet � and that a web browser enables users to pull the information and capabilities they need, on demand. With little start-up cost and effort, physician practices can access a standard EHR system that can be integrated with practice management, coding and claims management solutions, and is interoperable with hundreds, perhaps thousands of labs, pharmacies, hospitals and insurers in the cloud. While not as customizable as ASP or client-server solutions, physician practices can be assured that the EHR meets current standards and regulations. When a change becomes necessary � for meaningful use, health information exchanges, clinical guidelines or to add new members to the cloud � the vendor implements the changes once and they are instantly accessible to all users. "For cloud computing � with its quick startup, simplicity of use, easy adaptability and reasonable costs � may hold the key to getting physician practices connected" In the physician's office Consider how a cloud based, fully integrated, CCHITcertified, practice management/EHR solution might work in a small primary care practice. To get started, the only requirement is a web browser and the scanning in of patient records. When a patient arrives, a password-protected link to his EHR arrives at a computer in the exam room; insurance and demographic information arrive at the office manager's desktop. ASK THE EXPERT 85 Steven F. Tolle is a Senior Vice President, and leads healthcare delivery for Physician Solutions at Ingenix. Tolle has 22 years of experience in the healthcare industry. Prior to joining Ingenix, he served as a VP of Solutions Management responsible for the electronic health record (EHR) portfolio at Allscripts. He has also held senior management positions at Pfizer; College of Physicians and Surgeons of Columbia University. The physician's assistant updates information in the electronic chart, including current medications and vital signs. Because of an elevated blood pressure reading and related complaints, the physician prescribes a blood pressure medication and refers the patient to a specialist. The pharmacy connection offers best practice advice on dosage and medication confl icts, while the EHR is automatically available to the specialist. Meanwhile, integration with the practice management and coding solutions allows the office manager to enter the proper coding (and dramatically decrease the chance of a claims denial), as well as be fully aligned for any compliance reporting for meaningful use incentives. A secure portal allows the patient to view his health record when he arrives at home. so costs are ongoing. But purchasing a client-server or ASP system demands more than substantial upfront costs; there is also the cost and headache of ongoing maintenance and upgrades, including new interfaces every time an individual practice needs to add a new lab, pharmacy, insurer, hospital or physician practice to its system. Th is can and does get costly. In contrast, the `one connected, all connected' model of the cloud-based system is much more economical and the costs, from the outset, are more transparent. Are they flexible enough? While not as customizable as a client-server or ASP solution, cloud-based EHRs do offer some flexibility. They also offer the security of knowing that what's customized won't fall outside meaningful use or various regulatory and reporting requirements. The challenges Despite the advantages, three questions commonly arise about cloud-based EHR solutions. Protecting patient privacy, preventing system crashes and having disaster back-up is a significant concern. Any system is vulnerable to either hackers or disasters. But a fully certified and compliant EHR vendor has considerably more expertise and resources to secure its system than individual practices. For vendors selling cloud-based systems, securing their clients' data is a full-time job. The same cannot be said for individual physician practices, whose primary purpose is to deliver medical care. Do they make economic sense? The key is to look at total cost-of-ownership. Some have raised concerns that cloudbased EHRs work on a subscription or on-demand basis, Time, simplicity and value In short, cloud-based systems enable small physician practices to quickly and simply implement fully integrated EHRs that meet all of the meaningful use requirements of the new federal law. Their three main advantages are minimum upfront investment that translates into rapid ROI and comparable total cost of ownership; cumulative value � including improved quality and efficiency � through simple interoperability with a wealth of systems and health industry partners, from hospitals and insurers through labs and pharmacies; and adaptability for an unsure future. From the transition to ICD-10 coding to changes in meaningful use requirements, cloud solutions offer the easiest, fastest and most economical way for physician practices to make the necessary adjustments. 86 TECHNOLOGY For the record TECHNOLOGY 87 W As the race for EMR implementation continues at blistering pace, hospitals and institutions are slowly realizing that it's more than just electronic health records on the agenda � getting them nearer to that streamlined, industry-crossing digital end point seems to have become the new finishing post. hile the balloons and banners have been neatly packed away to await the next mark in healthcare history, CIOs and CTOs nationwide continue to work behind the scenes to complete the first phase of EMR implementation before the much anticipated deadline date. For some, this means tying up over a decade of staggered EMR deployment and reaching the end point of fi rst generation EMRs. For others, it means taking that fi rst step into the unknown realms of digitization and beginning to comprehend what an EMR can do for the doctor-patient dynamic. But regardless of where on the EMR scale you're currently standing, one thing is certain � there is still an extremely steep learning curve ahead of the industry and its key players. For Mark Eimer, CTO for Texas Health Resources, this learning curve involves understanding how to optimize and implement meaningful use within an EMR. Having had the forethought to begin moving their 14 hospitals onto electronic records back in 2004, Texas Health Resources has managed to whittle that number down to just two remaining hospitals left in the pipeline � both of which will be EMR compliant by next year. "It's always a journey," asserts Eimer, "and they've only really defi ned stage one. Stages two and three aren't even defi ned yet." "It's just what CIOs and CTOs have been looking for in healthcare for years," seconds William `Buddy' Gillespie, Vice President and CTO of Well Span Health. And with 15 years of EMR experience already under his Well Span belt, Gillespie knows more than a thing or two about what is needed to get his hospitals up to scratch. "Other health systems haven't even started yet," he confirms, "and physician practices are way behind in terms of technology. "A physician in a small practice is looking at maybe $40,000 in incentives on one hand, but then on the other hand there's the soft ware technology costs, and the cost of training yourself and your staff, so the question they'll be asking is, `Is $40,000 really worth it?' There are, of course, penalties that kick in to reimbursements, but then a lot of physicians aren't taking Medicare anyway, so it's going to be interesting to see how they'll ramp up on it. Now the federal government is saying we need to get there, so for us it should make our job easier, funding the technology and making it happen." Scales of time That may be the case for those fortunate enough to already be trekking down the road to completion, but as Gillespie points out, that TECHNOLOGY 89 road may well be fi lled with potholes for those less fortunate. Regardless of tactical decisions, what is clear for both Eimer and Gillespie is that the Obama-stated timescale is brief to say the least � but that doesn't mean it isn't feasible. "From a feasibility perspective, because they are throwing an infusion of cash into it, we're probably going to get 60 to 70 percent there," predicts Eimer. "The larger healthcare organizations, the ones that are already there, are going to see some consolidation within healthcare, so the smaller community hospitals that can't afford to get into the electronic health record are, I believe, going to have to join some of the larger organizations. Ultimately, everyone in healthcare agrees with the spirit of it; it's a little bit of an ugly baby, but I think we'll easily get three-quarters of the way through it." Where Eimer talks of the differences between big and small, Gillespie highlights the difference in system choice between the two. Ultimately, the vast contrast in options available between the two has led most to believe that smaller institutes will inevitably have to join the bigger fish if survival is of the essence, which is has to be. "The timeframe is brief given the fact that only 18 to 20 percent of physician offices have EMRs today," reveals Gillespie. "There's a large gap to be crossed in order to automate that many physician practices; at least three months to select a system and to negotiate a contract with a vendor and then probably another eight to 10 months to implement the system � and that's just the technology. After that is installed, the physicians and their associates have to change their processes within the practice to adapt to the technology, which is the real bridge to meaningful use." process is a whole different view and I appreciated the fact that the nursing staff had computers on wheels and they were scanning my wristband, checking to make sure I was getting the right meds. I experienced the technology firsthand and I was thinking had I been in a hospital where the technology was not that up-to-date, I'd probably be a little more concerned. It made me realize that it's not just about EMRs, it's all the bedside technology that's there; they're both becoming interoperable and integrative. They have a true continuum of what the physician and nursing staff need when they see that patient's history." Security Of course, the need to visibly show change within wards and throughout the environment of one's hospital will change according to the culture inherent within, but the back-end work for any CIO or CTO will inevitably remain the same, whether that be implementation, optimization or getting to grips with meaningful use. Eimer cites the ongoing swapping of applications to simplify, consolidate or otherwise standardize, while Gillespie is looking towards computerized provider order entry (CPOE) as the "lynchpin to meaningful use", with both ultimately looking to get one step closer to the currently elusive goal of complete and comprehensive `e-care' � where EMRs, technology and the human touch combine for a fully streamlined process. But before that becomes anywhere close to a reality, security issues need to be pushed to the forefront of the EMR collective. "Security will be the biggest challenge moving forward for sure," commits Eimer. "There is High Trust, an organization that companies are subscribing to, to at least get everyone on the same page with respect to security. There's "The larger healthcare organizations, the ones that are already there, are going to see some consolidation within healthcare, so the smaller community hospitals that can't afford to get into the electronic health record are, I believe, going to have to join some of the larger organizations" The human element remains the other half of the battle to implementation, as both Eimer and Gillespie are well aware of, but for the patient, knowing that the hospital they are in has the most up-to-date technology is half of the point � as Gillespie has experienced first-hand. "I was a patient a few years ago and had serious surgery," he continues. "Looking at it from the bedside, being a patient going through that a High Trust Alliance that we're working on in the Dallas area to try to give physicians one set of credentials that can be used in multiple provider settings. Security will undoubtedly become the biggest challenge with moving towards monitoring patients in the home setting, especially with the emergence of telemedicine. How am I going to verify that I'm talking to the person I'm supposed to be talking to? Then you've got all the HIPAA and privacy regulations, so I think security is going to be more of a challenge than implementing electronic healthcare." Unfortunately, the truth of the matter is that while Eimer is right in every sense of the word, nobody really has an answer to the problem yet. Security has always been the least funded discipline in healthcare because it doesn't provide revenue and it doesn't deliver patient care, so why would anybody invest in it? As a generalization, healthcare organizations have under funded security and have done the bare minimum to pass the Joint Commission and HIPAA standards. As Eimer puts it, "HIPPA is getting more teeth into it and you're starting to see other regulations get more teeth, so organizations are going to have to fund security more than they ever have, which is going to take away from electronic health records and the like." As Eimer sees it, there will have to be a shift in attitudes � as he rightly says, you're only as strong as your weakest link. If organizations don't step up to security responsibilities, it's definitely going to hurt in the long run. But security comes down to far more than securing information; in order to do so, you have to fi rst secure your communication links. Or, as Gillespie puts it: "Wireless, wireless, wireless". "The challenge with wireless, particularly in some of the of the older facilities, is sustaining that connection, because you'll have the access points located and the nursing staff will move their carts and netbooks and traverse across multiple access points, so you have to sustain that connectivity as they move. It's not all about what's happening at the bedside or in the physician practice, it's also what's happening on the back end, the data center. "Physicians don't see that, but they do see it when it's not working. When the wireless connection is down, their global device is broken, they see that � but they don't see the entire infrastructure we've built: the servers, the storage, the networks and electronics. While we're doing what I refer to as the `glitz and glamour' at the bedside, we also have to be increasing the capacity of our data center. That back end of technology is extremely important." Digital literacy Th is idea of understanding the importance of, and maintaining a patience for, technology is part of a healthcare culture that is starting to emerge with the introduction of EMRs � not forgetting the accelerated world of consumer technology we find ourselves living in today. However, for all the good that technology does, there will be those from the baby-boomer gen- 90 TECHNOLOGY eration who will, and have, pushed back on the use of technology. As Eimer says, when the industry has functioned so well without electronic records for so many years, some don't see why they should change their ways. With that comes the dreaded admittance of IT illiteracy. "If you look at the nursing workforce today, it's a much older workforce than it ever has been," highlights Eimer. "With an older workforce, most of them don't have basic computer skills, so when you're implementing all these electronic health records and everything is trying to be digitized, you're still having to train people that don't have IT skills. Now with healthcare reform, I've got 10 times the number of vendors calling me because everyone's got a solution to fi x my problems. You need to be very strategic in your vendor selection and understand what is my core set that I want to work with and then simplify, consolidate and standardize on the vendor side as much as you need to do on the IT side." It is without exception that the induction of EMR into the healthcare realm will include the need for IT literacy � even more so further down the line when the likelihood of it colliding with the life sciences sector as a whole grows. With so much information at the click of a button, it would be na�ve to think that EMRs wouldn't reach out towards the worlds of pharmaceuticals, R&D and biosciences. Indeed, with more discrete data being accumulated through EMRs, analytics will grow in importance and efficiency � in turn allowing for comparative and quality reports to a degree that has never been seen before. "We are able to build these repositories of discrete clinical data that we're then able to analyze," explains Gillespie. "We're doing reports right now across our 16 physician practices and we're able to see in color graphics how the practice is doing relative to certain administrators. Some of our practices are doing great, some are not. We're able to go out and show that to the practicing physicians and tell them what needs to be worked on and what's doing well, so it's very visible proof of where we are in the practice of medicine. "We're not just looking at what's happening with our hospital, but also what happens when a patient is discharged and goes back to their family physician. What happens there? We want something good to happen on the discharge basis so the patient doesn't have to go back again, so it's that continuum collection of electronic data that's going to be huge all across the board." What Gillespie alludes to is nothing short of the ultimate goal of EMRs. There will undoubtedly be those against the inclusion of their entire As hospitals continue to get on track with EMRs, Medscape has taken a look at the length of time institutions are taking to reach implementation: Less than six months: Over one year: Six months to one year: Still not implemented: 40.5% 22.2% 25.4% 11.9% The company also asked, "If you're not satisfied with your EMR, are you considering switching to a new one?" No. I've already spent too much on it: Not now, but maybe in the distant future: Yes, within the next two years: 50% 32.8% 17.2% While the figures speak for themselves, Medscape's findings highlight that while there is still undoubtedly some push-back and getting to terms with the new age of digital, for the most part hospitals and their CIO's are making headway with knuckling down and marching towards full implementation. medical record and all the bones of contention tied in with that, but for the large majority an opportunity to become more involved and have more control of their medical record is an opportunity that shouldn't be turned down. "If you look at where we're going, we're moving towards what I call a `self-service' model and we're moving away from full-service � the physician's office, your PCP, knows you and knows if you needed something you'd call them. We're moving to the other extreme of a self-service model where you're going to now be responsible for your own records. It's going to be no one's responsibility other than your own to make sure that if you leave an office, you get your records so you can scan them into EMR," says Eimer. "Th is won't be a challenge for the millennials or the Gen-X, Gen-Y's, but it will be a challenge with the traditionalists and babyboomers because they're so used to someone else doing it. What's likely to end up hap- pening is that the nuclear family will start to have to own some of that for their parents and grandparents in order to help them manage their personal health records. "Technology will also help families manage their parents better than they have before. That's the big shift you're likely to see, if it hasn't happened yet. From the provider side, we need to make it easy for them to manage it, so technology can help in some aspects, but the culture will change to become more proactive all across the board." While EMRs are only just rooting themselves in the healthcare setting, what is glaringly obvious is that down the road we're more than likely to end up with a completely integrated, personalized method of approaching our own medical records and history proactively, with a helping hand from technology, of course. As Eimer concisely concludes: "We need to flip 180 degrees and do it ourselves, but we need to make it easier for people at large in order for that to happen." 92 TECHNOLOGY Catching the medical i PwC's James Koenig tells us how to stop health information fraudsters in their tracks. P art of Jim Koenig's job is to "think like a criminal". On entering a hospital or healthcare practice, he'll be on the lookout for open, unguarded fi ling cabinets, or piles of backup CDs containing patient data waiting to be archived. Whenever he fi nds one of these, he immediately asks himself, "What is this worth?" The answer is, quite a lot. Information contained in health data fi les, including Social Security numbers, health insurance IDs, diagnosis history and family history, can be sold on the black market to provide access to care or drugs, potentially netting fraudsters $40 to $50 per health record. Medical identity theft can also have a huge impact on those whose information is improperly accessed. According to a recent study by the Ponemon Institute, approximately 5.8 percent of American adults have fallen victim to medical identity theft, with an average cost per victim of $20,160. Nearly half of those surveyed said they lost their healthcare coverage as a result of the incident, while nearly one-third said their insurance premiums went up after the event. The fraudulent use of health information is thought to cost the US healthcare system upwards of $1 billion a year. Even more importantly, health and safety can also be affected. Koenig gives the example of an individual improperly using someone else's health insurance to get care. If this person has a different blood type than the person whose health insurance is being used, a potentially fatal situation could result. Another complication is that it can be hard to strike incorrect information from the National Health Database, which could also have long-term consequences for health and safety. The health reform bill does contain elements aimed at tackling fraud: the Patient Protection and Affordable Care Act was amended by the Healthcare and Education Reconciliation Act, with $350 million in fraud surveillance allocated over the next 10 years. However, individuals and institutions must also be on their guard. Koenig says there are many ways in which medical identity theft can occur: "Sometimes it's a provider trying to submit false claims to increase TECHNOLOGY 93 their income; sometimes it's organized crime setting up a fraudulent payment processor and submitting all sorts of equipment and false charges. And sometimes it's an individual trying to get access to healthcare, or reselling somebody else's health insurance ID to people who don't have health insurance, so they can get treatment. "Th is is a newer, growing form of identity theft where the exploitation isn't about money; it's about using the healthcare system to either drive money or goods or services. "People don't always think about this form of crime, and the information needed to be able to perpetrate it is a little bit different than with credit cards. People know credit card and Social Security numbers and bank account numbers are sensitive, but they don't always realize that their health insurance ID, a doctor's DEA number, or other information that routinely shows up in healthcare and elsewhere should be considered sensitive and protected, because increasingly it is being exploited." Inside information It's obvious then, that fi les containing a patient's health information must be protected whenever they leave their place of origin. Unfortunately, though, it's not always that simple; Koenig says that increasingly such crimes are perpetrated by knowledgeable insiders. "Providers or hospitals or insurance companies may fi nd themselves in a situation where organized crime has recruited one of their employees," he explains. "In hospitals, often it's someone in admissions and enrollment � or in the bill collection, janitorial or computer programming staff � people who have access to the information and sometimes computer access codes, or physical keys and access badges to rooms that may have records, where that information may be at risk. "Another example could be a doctor with shared office space who borrows their neighbor's patients' ID numbers in submitting false claims to heighten their income. Or an administrator in the office could take all the health insurance IDs and sell them to organized crime so they can resell them to people without access to healthcare, or to get prescription drugs. When they submit those claims for equipment and prescription drugs sometimes they'll make up a fraudulent provider. "It's still a less frequent crime than more general identity theft, but it is growing, and politicians and advocacy groups are concerned that it will increase with the acceleration of the movement of health information through electronic records and health information exchanges and other avenues." This doesn't mean, however, that the advent of EHR will make our health information less secure. What it does mean, according to Koenig, is that access must be carefully controlled. "Health records are designed to allow every healthcare professional involved in the course of treatment to see a full continuum of information for each patient, to improve the quality of care. "On the positive side, let's say you had cancer or another serious disease. Having your doctor's reports and visits, your laboratory blood work and results, your x-rays and your notes from the cancer care treatment center as well as the hospital, all within one electronic health record will improve the quality of your care, and will also help the health insurance company analyze the course of treatment. "On the negative side, if the right access controls aren't designed in the systems, or the right contractual rights included in the contracts, that information could be viewable by a wide range of people who don't necessarily need to see it. "Also, if the right controls and restrictions aren't put in there, you could have people looking at historical data that are not important. Does your dentist need to see that you had cosmetic surgery 30 years ago? There aren't rules around it and frankly there aren't defined contractual restrictions." TECHNOLOGY 95 "All sorts of other information that routinely shows up in healthcare and elsewhere should be considered sensitive and protected, because increasingly it is being exploited" James Koenig is Practice Leader, Privacy & Identity Theft, and Practice Leader, HIT Privacy & Security, for PricewaterhouseCoopers. Koenig says there are two things that need to be considered when determining appropriate levels of access: what level of security and control do you need to be able to treat the patient and monitor the course of treatment; and, what rights do each of these stakeholders, including electronic health record vendors and service providers, have with respect to using that information in the future? "HIPAA and HITECH largely focus on inappropriate disclosure by people who don't have rights or what causes a breech when it falls into the hands of people who don't have authorization to receive the information," Koenig points out. "But if contractually the rights aren't defi ned between the different players, in the future people could use information for purposes that individuals never contemplated when they originally gave their consent for their information to be included in an electronic health record. "Companies could start marketing to individuals based on their disease state, or doing different things that healthcare hasn't fully defi ned yet. Right now a lot of the regulation focuses on the security, and the accounting for disclosures, for who received the information. But part of what providers and other healthcare professionals need to do is to help clearly defi ne who needs to have what information and for what purposes, so that both the privacy and security of patient information can be achieved while having the right information to promote better healthcare. It's a balance. "There are a lot of laws around privacy and security, and making sure that people are notified of what disclosure happens, but there are no real legal restrictions in many cases for what happens once you've notified someone about how their information will be disclosed. Because of the way health information technology is changing, people may not realize what they're consenting to down the road." tronic form are secure while also not neglecting any data kept in paper form, which must also be adequately protected under the new breach provision of HITECH. "There are specific requirements for electronic health records systems," Koenig says. "If you're using certified technology under the stimulus bill and you apply for stimulus funds, you need to certify that your records system has seven specific privacy capabilities. "The guidance specified by the Office of the National Coordinator of Health Information Technology for electronic health records systems is all-around access control, emergency access, automatic logoff of sessions after predetermined times and activity, and an audit log to track when people have access to information, not just when they make changes. "Add to that encryption and authentication to make sure that people are who they say they are. And the last one is accounting of disclosures: keeping a record on the disclosures made for treatment, payment and healthcare operations in accordance with the requirements under HIPAA and HITECH." Koenig points out that there are additional things that can be done around physical security; for example, keeping an eye on employees who work late or on weekends when this is not part of their normal shift pattern, and cross-referencing these with the names people who are printing excessively on the network � because even though the information is electronic, fraudsters often find the easiest way to transport it is in hard copy form. "So if you look for people who are not supposed to be there compared with who's doing additional printing and you cross-reference those things," Koenig continues, "you can build a profile of those who might be more likely to be committing these types of crimes. If you have access control monitoring in there as well, that's something else that you can correlate. "In summary, there are new techniques, which often combine old technologies and old security information, that providers are using to help better identify potential perpetrators of identity theft." Stolen lives IDENTITY THEFT Identity theft is a form of fraud in which pieces of an individual's personal information are used by another person for such purposes as processing fraudulent credit card charges, accessing bank accounts, opening up fraudulent lines of credit and bank loans or ordering cable and phone services. Careful checks Individuals, for example, should examine the explanation of benefits they receive from their health insurers as closely as they would a credit card statement, and not be afraid to question it if there are things on it that they don't understand or treatment or services or equipment they haven't received. "It may be a mistake," Koenig says, "but it may also be an indication of somebody improperly using their health insurance ID." Healthcare institutions and organizations need to be even more proactive, with the first line of defense being background checks on any staff members who may have the opportunity to access sensitive information. Organizations must also ensure that transfers of information in elecMEDICAL IDENTITY THEFT One of the fastest growing areas within identity theft is medical identity theft, in which criminals fraudulently obtain individuals' personal information, but this time focusing on the health insurance ID number, which allows them to access medical services, submit false claims or to obtain prescription drugs, which are a commodity and can be resold. 96 ASK THE EXPERT The invasion of mobile devices: how to secure medical data? iPhones, Droids, iPads and other mobile platforms are invading the healthcare industry. How can companies enable this `consumerization of healthcare IT', lower cost and still protect patient data? By Dan Wolff T Dan Wolff is Group Manager for Endpoint Products at McAfee, the world's largest dedicated security technology company. McAfee delivers solutions and services that help secure systems, networks and mobile devices around the world, allowing users to safely connect to the internet, browse and shop the web more securely. he consumerization of healthcare IT is all about productivity. That's the finding from a recent McAfee-sponsored survey of organizations that currently allow or plan to allow employees to use personal IT devices and consumer-driven soft ware on the enterprise network. But the increased productivity is not without cost. More than half of the survey respondents also agreed that consumerization of IT increases security concerns, and nearly half (45 percent) feel that managing consumer-owned devices and related technologies within the enterprise network is "critical". But giving employees unfettered access to valuable company data on whatever device they happen to prefer is a risky proposition. The fact that these devices are mobile means that they're also easily lost or stolen, which means that the medical record or patient data they contain is more vulnerable to theft or accidental loss. Finally, because consumer devices are not adequately protected against malware, enabling access through these unsecured devices can open a gaping hole in a company's otherwise secure network. These risks have led many organizations to firmly resist consumerization. The result of the consumerization of IT trend is that the boundaries of a company's information network are not as clearly defi ned as in the past. It used to be that a company's information network ended at its fi rewall, and its valuable data remained relatively secure within that network. But today, data is no longer contained within the walls of your business and the network ends with the user and the user's device (mobile phone, laptop and home computer). In this environment, security is far more complex than in the past. So, how do you handle this situation? What steps can you take to prepare for the consumerization of IT? The following are some strategies we at McAfee recommend. A high priority for any enterprise mobility project is to enforce remote encryption and wiping of all information on mobile devices to protect data in case the device is lost or stolen. We also recommend that customers deploy network fi rewall and network intrusion prevention system (IPS) and configure them to control and monitor traffic to and from all devices, especially specific mobile apps. Many companies already require VPNs for secure connections to corporate networks; consumerization projects can control access from remote, employee-owned computers. Many IT groups also use network access control (NAC) to ensure employee-owned devices have security tools in- stalled and are otherwise compliant with IT standards prior to accessing the network. NAC can control guest devices and other unmanaged endpoints and ensure they have limited ability to access resources or infect your network. Companies should consider virtualized desktops (VDI), where employees can access company applications and data on personal devices, but the application infrastructure and data remain on corporate servers behind the firewall. Also important is the encryption for information at rest and in motion. If a remote device falls into the wrong hands or a transmission is intercepted, encrypted information is unusable. To manage this technology, companies should deploy integrated endpoint security with a centralized management console to ease the effort required by security administrators to manage all endpoints in the system. If you follow these recommendations and deploy a comprehensive endpoint security solution, you'll find it's not only possible to support the consumerization of IT with adequate and effective security, but that doing so yields some nice benefits for the company. Increased productivity is the obvious one. A less apparent benefit is the ability to reduce IT costs by allowing employees to use devices they've purchased themselves. The greater mobility of the workforce and the ability of employees to work from home can also lighten other expenses, such as office costs. Over time these savings can be significant � and when combined with greater productivity, they can make your organization more nimble and competitive. Secure Any Mobile Device. Anywhere. Anytime. More and more healthcare professionals are bringing their personal mobile devices to work to help them do their jobs better. This consumerization of IT can greatly benefit your organization-- with increased agility, improved productivity, and reduced costs. But how do you protect patient data, meet compliance standards, and still reap the benefits of this growing trend? McAfee can help. We understand that it's all about protecting the data with a comprehensive portfolio of integrated, centrally managed data protection and access solutions--for data centers to desktops, for smartphones to handheld monitoring devices. Learn more at www.mcafee.com/consumerizationIT � 2010 McAfee, Inc. All rights reserved. 98 PATIENT FLOW Smooth operator PATIENT FLOW 99 How re-aligning patient flow helped Palmetto Richland Hospital make substantial savings and dramatically improve quality of care. F ive years ago, Ellis Knight had a problem. As Vice President of Medical Affairs at Palmetto Health System in Columbia, South Carolina, one of his responsibilities was to evaluate and carry out root cause analyses of significant adverse events that had occurred in the Palmetto Richland hospital. Invariably one of the fi rst fi ndings in each case would be that these events had occurred during times when medical staff had had to manage a large number of patients in a short period of time. The peaks and troughs in the hospital's case load were more than mere annoyances; they had the potential to cause serious harm. Around this same time, Knight � who is now the health system's Senior Vice President of Ambulatory Services � and his senior management colleagues had signed up for a course in managing healthcare operations given by Eugene Litvak, President and CEO of the Institute for Healthcare Improvement. They came away inspired. "The course took place over nine months with a few on-site sessions in Boston, and some coursework and activity projects in between," Knight recalls. "Over that time, we became quite enamored with his model for managing vari- ability and helping patient flow throughout the hospital, and then, subsequently, made arrangements to work with his team at Boston University to come and help us implement some of that in our own organization." Knight praises Litvak's approach as "unique" and says it got to the root cause of a lot of the problems that his hospital � and indeed, many others � suffer from. These included long wait times in the emergency department, patient dissatisfaction, employee dissatisfaction, lower margins due to an inability to maximize volume and throughput, and most particularly, says Knight, a concern that these bottlenecks in flow were resulting in significant quality-of-care problems and potential patient harm. Many hospitals faced with a similar challenge would solve it by building more capacity, but Knight believes that far from solving the problem, adding more space can exacerbate it. "It seemed to us that by managing the flow, we would get more to the underlying cause of the dysfunction, as opposed to other measures which would simply put a Band-Aid, if you will, on those manifestations that we were seeing. For instance, with emergency department overcrowding, the first thing you think is, `Let's build more capacity.' "One of the genius aspects of Dr. Litvak's approach is that he can show both mathematically and also in many instances where it's been tried, that building new capacity doesn't alleviate the problem, and, in fact, can exacerbate it by creating more capacity and more problems with high f low or peaks. And often at a great deal more expense than what you would have to put into trying to adjust the more basic problem, which is the f low variability." Smoothing flow Knight and his colleagues decided that the best way forward for their institution was to implement Litvak's model for smoothing elective surgical flow through operating rooms. "We did that because � and this is one of the unique aspects of his design, I feel � he can show that the elective surgical flow is something that in most hospitals does come in peaks and valleys and does cause stress on the system, but fortunately it's something that, theoretically at least, we can control. "The flow to the emergency department is more what we call natural variability, and has to do with how many people become ill with contagious illnesses, or trauma, or whatever may be causing those peaks and valleys. But the variability in flow in elective surgeries is all due to something that we can control, and that's the desire of surgeons to operate on a certain day at a certain time and do certain cases. "Th is approach was something we could get a handle on, and Dr. Litvak does a very good job of analyzing your own data and showing you that that would create significant benefits. "We assembled a group of surgeons and began meeting on a monthly basis at the ungodly hour of 6 a.m., when surgeons can fi nd time to get together. We did that for more than a year, and went through a very methodical process 100 PATIENT FLOW where we, first of all, separated the elective surgical cases from the emergency surgical cases, which of course are not under our control. "We had to determine how much capacity we had to set aside for those emergency cases, and make sure that they were dealt with in a timely fashion and in a way that would not compromise patient care. That left us with this elective surgical volume that we could smooth out and therefore create a more even flow." Th is was achieved through adjusting the block surgical time given on the schedule to certain surgeons that allows them to plan ahead and to know when they have time to operate. Knight and his colleagues looked at this block time closely to ensure it was being optimally used. "That's very valuable time, obviously," he says, "and we didn't want to have a significant amount of IT go to waste. Unfortunately we found it was being wasted, and so we had to reallocate that and make sure that the blocked schedules were being utilized in an optimal fashion." "I wish you could snap your fingers and make the culture magically appear, where everybody says, `That's the way we do things around here, and that's the way we always have done them, and that's the right way to do things'" culture that provides its own incentive for the hospital and physicians to engage and work together harmoniously. He says it's more of a challenge in smaller or newer organizations without a 100 percent employed medical staff, and even though at Palmetto Richland the amount of employed staff is growing it will take a while to reach 100 percent, and even when it does, that type of culture takes a long, long time to develop. In the meantime, says Knight, the reality is you have to rely on things like fi nancial incentives or other types of rewards around increasing efficiencies to foster that sort of engagement and alignment. "I wish you could snap your fi ngers and make the culture magically appear, where everybody says, `That's the way we do things around here, and that's the way we always have done them, and that's the right way to do things.' "Unfortunately, you have to use a little bit more innovation in terms of how you incentivize that. I do think though that, especially in the era of healthcare reform, that will be an essential challenge for any healthcare system or hospital of any size to figure out, because I think the days when physicians and hospitals can operate in these kind of independent, autonomous realms is long past and is not going to work in the future." Changes needed The process of separating of elective from non-elective cases and the reallocation of block times took about 18 months. The team were then left to deal with what Knight calls "the hard part": asking surgeons who may prefer to operate on one single day or a couple of days a week � when everybody else may want to operate � to adjust their schedules and to smooth that out. This proved to be a sticking point, as Knight explains. "Quite honestly, that was the point at which we got hung up. Our hospital has a large, independent private practice medical staff, and it was very difficult for us to work through those aspects of asking those surgeons to smooth their case schedules. "The situation in most hospitals like ours is that the medical staff has historically been very independent and autonomous, and to try to engage them in an effort like this, where the motivations and rationale for this may not be aligned, is very difficult. That's not to say that they're wrong. It's just that they're operating in their own environment and according to their own desires and motivations, and they've got their own agenda, and their own agenda has to do with maximizing their own efficiency and their own schedules. "It's difficult when you have those kind of parallel universes and they don't necessarily align, although we do have an opportunity to change that. We, like many hospitals, are employing more of our surgeons, and we plan on utilizing our employment relationship with those surgeons to facilitate those schedule changes that will have the effect that we want. "We are also working with another organization that we've developed � an accountable care organization � that does include independent private physicians, as well as employed physicians." The existing culture of the hospital can also play a role in getting surgeons on-side. Knight points out that there are some long-established institutions, such as the Mayo Clinic, that over a hundred years or so, have developed the kind of More motivation The hospital is also beginning to work on some clinical and cost initiatives that it is hoped will provide incentives to physicians to help motivate them and align them with the overall purpose of the prospect. Unless you can create those alignment structures, where both sides are equally motivated to produce that sort of difficult change, Knight says, it's a hard problem to address. Other changes include the instituion of strict 7:30 a.m. starts and being fi rmer about not allowing people to delay cases so that they become backed up later in the day, all of which has paid significant dividends, according to Knight. He calls the outcome of the project's initial stage "very positive", even though they have not yet implemented everything they would have liked to. As well as increased patient safety, the project brought Palmetto Richland significant fi nancial benefits. Knight puts the figure at $500,000 in increased revenue realized from the measures they were able to implement, net of the cost of the services of Litvak's team. The amount was raised through increased surgical volume and increased margin per surgical case achieved through the Litvak-inspired efficiencies. The projected fi nancial benefits following implementation of the entire PATIENT FLOW 101 $500,000 in increased revenue was realized as a result of the program A recent survey showed 73% satisfaction among surgeons project � including the smoothing of surgical cases � is in the range of $13 million to $14 million. Knight says that even the higher figure is probably an underestimation of the overall fi nancial benefit to the organization from the downstream effect that not only increasing the surgical volume would bring in more revenue, but also in alleviating some of the associated problems of long wait times and patient dissatisfaction. "The other benefit that we obtained was a significant increase in surgical satisfaction," he continues. "We had done a survey of 100 of our medical staff members for two years running previous to this project, and one of the biggest complaints from surgeons was around the prolonged wait times to do elective or emergent cases. "After the project, we did another survey of our surgeons, and there was 73 percent satisfaction, with the ability to easily schedule emergent or urgent cases, so we felt that that was a significant gain, as well, and it resulted in a lot of improved satisfaction in our surgeon staff." When asked whether he would recommend the process to other hospitals and healthcare institutions, Knight responds with an unqualified `yes'. "I would certainly advise, and have on multiple occasions, other organizations to try this. Though it's not without its challenges, one of the main ones being how to achieve that alignment with your medical staff who have to buy in to this to make it work, and those kinds of political obstacles are the major difficulty. "I do think, as I said before, that this is at the root of many, many problems that befall healthcare right now, and if any organizations think they can manage this without addressing the variability and flow, I think they're mistaken. Th is is something that has to be addressed, and more people are realizing this because of the development of joint commission standards now to address it. "Leapfrog Group has also announced that they're going to have a Leap added to their list of things that they advise and incentivize hospitals to do, which will specifically address Dr. Litvak's approach to surgical case smoothing." Value focus Litvak's methods certainly seem likely to become increasingly prominent, aligning as they do with the current focus on value. "A very simplistic approach and one that I use often is value is quality per unit of cost," Knight says, "so the more you can improve quality and the more cost-efficiently you can produce that quality, the higher the value that you produce. "Modifying the patient flow variability accomplishes both of those goals. There's good data in the literature that shows that the less stress on the system, with regard to volume of patients per provider, is a significant marker of quality and a way to avoid adverse outcomes. "As I mentioned anecdotally, when I would do these root cause analyses, almost every one of those started with the phrase, `It was an especially busy day, and that's why this happened.' There are other more quantifiable empiric data out there that prove that that actually does happen, and that one of the root causes of harm events in American hospitals is the peaks in patient flow that occur and put too much stress on the system, so that bad things happen. "On the cost side, it's simply a matter of realizing that the American healthcare system is a fi xed-cost enterprise. Therefore, the higher the volume that can be run through that fi xed-cost model, the better the margins will be. We have opportunities there to improve significantly, and not only to do it in a higher volume fashion, but also to do it at a lower cost per case as that volume improves, which I think is also, when you look at things in a macroeconomic sense, one of the essential challenges of the future if we're going to really achieve true reform. "Lastly, but certainly not least, you've got these reform initiatives that have come down the pike, where larger numbers of individuals are going to now have access to care through more insurability, etc., and so we've got to realize that one way to accommodate that population and that demand for increased access is going to have to be to smooth the flow and to accommodate that through application of these operational flow methods." In Knight's opinion, just building more beds and more facilities and more equipment is not going to be cost-effective. In fact, it could be the opposite, both in terms of cost and escalating the already untenable infl ation of healthcare costs in this country, and, secondly, in terms of having a magnet effect on patient volume, where demand is often drawn by the availability of healthcare resources. "That has to do not only with patient demand," Knight says, "but also, unfortunately, I think it's a truism that healthcare providers create their own demand oftentimes in this country. Therefore, just providing more capacity and more beds, more facilities, more equipment is going to be a magnet for that sort of behavior." 102 IMAGING HEADING The right image As hospitals trek towards becoming completely paperless, digital imaging systems continue to change the lay of the land for the healthcare setting � and working sympathetically with EMRs can only serve to push them that little bit closer. A s the healthcare sector gears up for yet another wave of digital transition with EMRs, the world of digital imaging and picture archiving and communications systems (PACS) awaits it with open arms. With almost every hospital in the US having moved from analogue to digital imaging in recent years, PACS have somewhat exhausted their nationwide implementation. Thankfully, with EMRs weaving their way into hospitals and care settings across the country, digital imaging has the chance at a new lease of life � by collaborating with EMRs to provide truly next generation healthcare technology. As General Manager of Medical Equipment and Imaging Informatics at KLAS Research, Ben Brown knows the lay of the land when it comes to PACS. Having written and released KLAS' most recent PACS report, his fi nger is certainly on the pulse of digital imaging in healthcare, with the report revealing that there are, as suspected, significantly fewer PACS deals to be had. "There are still PACS deals happening in the industry," begins Brown, "but a good majority of the initial PACS installs have already happened. There are still some outpatient IMAGING 103 ambulatory clinics and smaller community hospitals that don't have PACS, but for the most part, you're probably approaching around the 80 to 90 percent mark for hospitals that have gone digital with PACS and imaging, at least in the context of radiology. From a technology standpoint, most of the bells and whistles, features and functions are fairly prevalent in most products, so there aren't huge differences in feature functions." Of course, there are some noticeable differences around usability and workflow � especially in terms of how studies are being conducted through certain imaging systems and how easy they are to customize. But, according to Brown, what's not a commodity at the moment in the imaging business is anything centered around support and an ongoing development plan to further mature the products as more demands come down on digital imaging. "Some people are looking to take that PACS archive and turn it into an enterprise archive and expand the reach from a content management type system," he says. The problem for PACS is that once they've been implemented, there's currently little room for further developments down the line: it does what it says on the proverbial tin. But with the emergence of EMRs and healthcare generally becoming more IT savvy across the board, the health reform may just have answered the PACS' prayers. The privilege of PACS For a few remaining hospitals in the US, using PACS is still outweighed by the cost of implementation, despite the obvious long-term savings accrued through going digital. With that in mind, here are a few other advantages of going down the PACS path. Fiber speed Electronic images travel across communications networks and so don't have to be carried, unlike traditional film packets. Multiple viewings Images can be viewed in more than one department, or indeed hospital, at the same time by different members of staff. Manipulation Digital images can be adjusted by brightness and contrast, magnification and size on a specific area of interest, making it unlikely that examinations will be repeated for incorrect exposure or for further clarity � resulting in lower radiation doses for both patients and staff. Accuracy Computer-aided measurements such as distances, angles and volumes, can be identified on-screen, providing greater accuracy than is currently available. EMRs and security "A lot of what's going on now is imagingenabling the EMR, so tighter integration and interfacing between the patient medical record on the EMR and a tighter context for prior images and history to be linked to the EMR," continues Brown. "In addition, you're also seeing other image-intensive departments looking for tighter integration between cardiology and radiology PACS. Some people are going as far as looking for vendor-neutral solutions to make the archive more vendor-neutral so it can deal with different `flavors' of DICOM." And while this is ideal in theory, in practice � as many CIOs and CMIOs are fi nding out in implementing their respective EMRs � security is paramount. With a large majority of hospitals across the US using single sign-on applications, with strong authentication and security technologies behind them, EMRs and PACS are deemed to be relatively secure. But as Brown points out, security and technology go hand in hand, and thus security needs to keep pace to minimize outside interference. "I'm not familiar with many security breaches or problems with single sign-on systems, but security is a hot topic across the entire industry. HIPPA compliance is at the inpatient and outpatient EMR levels, and then ancillary systems that could also include PACS, because you have so many referring physicians that require the services of radiologists, and some of those radiologists read remotely. "Some of the referring physicians work out of an office-based practice; sometimes they come into the hospital and sometimes they don't, so security is a big issue. In addition to that, more people are starting to talk about disaster recovery and business continuity planning � not only at the hospital level but at the PACS departmental level too." Fortunately, disaster recovery so far has included little more than needing to reboot the problem PACS in question, as most systems on the market today do a good job of proactively monitoring their respective systems. As Brown suggests, there are a variety of glitches that can happen within PACS: whether it's due to a huge CT study clogging up the system or not having enough bandwidth or space on the network � it usually comes down to nothing more than a reboot and a call to the necessary vendor to get it back up and running. And with X-ray being the number one most prescribed diagnostic tool in healthcare, there's little space for PACS downtime, especially in the ER setting. "The most important part of the whole picture is patient care, so safety," affirms Brown. "Being able to go back, look at a patient's history and see that they were in hospital six months prior and had a stroke is pivotal for all concerned. So, as long as you have good information, being able to pull that patient up and see six months ago they came into the emergency department and they had a stroke, and they're back in the ED for a stroke, having that historical data � and having it in context � translates into better patient care. On the f lip side, I talk to people every day who say `I'm so glad we went digital because we're far more efficient now. We can get more done.' Most people don't sit around all day waiting for people to come in and utilize their healthcare services. They're all very busy so it's made them far more efficient." Going paperless It's this idea of being more efficient overall that has led many down the path of throwing 104 IMAGING PACS and digital imaging under the telemedicine umbrella; a fair enough point considering their role within the modern-day global healthcare setting. With the help of PACS, a radiologist in Australia or India can now conduct studies for hospital in the US and vice-versa; there are even tele-radiology companies who make entire businesses out of doing precisely that. "There are radiology groups that will read stuff in rural locations that it might take them five hours to drive to, but they can sit in their office or hospital that they are doing rounds at and read for a hospital five hours away and give coverage. It defi nitely falls under the umbrella of telemedicine because its reach is across borders," says Brown. Indeed, it would seem as though PACS is unstoppable when it comes to crossing borders, and for the most part it is. However, there are areas that, due to their inherent nature, PACS can't infi ltrate � but that doesn't mean that hospitals and department heads aren't trying regardless. "We just had our internal conference this week," continues Brown, "and we had a CIO on our advisory board come along and tell us that they are pushing the envelope to take everything digital. They've got radiology digital. They've got cardiology digital. They've got gastrointestinal and genitourinary digital. Next on their plate is radiation oncology, other radiation or medical oncology-type studies � and they're working on digital pathology. "They're doing some fairly unique, creative ways of digitizing pictures of slides and archiving it in their PACS. Is it a clinical image or a perfect image? Not necessarily. But is it good to share with a patient or good for a referring physician to point something out? Yes. The intent of most hospitals nowadays is to try and get closer to being totally paperless. I recently got off the phone with an oncology administrator who said: `we're this close to being paperless in radiation oncology. We're paperless in medical oncology. We're very close on radiation'. If we want to get to a place where we can use evidence and clinical decision support tools, this data needs to be available digitally � whether it's structured data in a report or otherwise." The future Brown alludes to will involve nothing short of an invitation from the EMR to jump on board and work in collaboration to push the envelope of digital possibilities. But with different paths to follow, the future is far from defi ned. For some, the belief is that an enterprise archive for documents is the best foot forward. For others, the call for a vendor- neutral or department-neutral archive for any type of content � from medical to health information, video to surgical systems � should be heeded. Then there are those who merely want to leverage their current PACS system to the hilt and extend it as much as possible. Regardless of the path chosen, one thing is certain: hospitals are calling for vendors to create truly next generation disruptive technology. "Stealing a quote from one of the CIOs we had: `Something that'll be especially unique is technology that'll make providers faster, more efficient and deliver cheaper healthcare at a cheaper price,'" explains Brown. "On the PACS side, from a feature functionality standpoint the market is very close. There have been demands driving prices down, but a lot of folks would be eager to see some technology that could really take them to the next level and answer questions such as, `Do I leverage my PACS, do I create an enterprise archive for just images and reports, or can I create an archive that has everything in it � from reports and health management information, scan documents, voice, video and images?'" For the hospitals and institutions already using PACS, it's a case of watching and waiting for the future. As Brown astutely compares, vendors are in the same position as Microsoft and their yearly Office package releases: they've most probably got the next few years planned out and lined up, but that doesn't mean it's coming to the market anytime soon. "What if one of the PACS vendors decided to skip to version 10 instead of version two and release it at a much more cost-effective point? I haven't seen anyone do that yet, or know of anyone � and if they were planning on it, they'd probably be keeping it a secret because they'd want to take the industry by surprise." "A lot of what's going on now is imaging-enabling the EMR, so tighter integration and interfacing between the patient medical record on the EMR and a tighter context for prior images and history to be linked to the EMR. In addition, you're also seeing other image-intensive departments looking for tighter integration between cardiology and radiology PACS" INDUSTRY INSIGHT 105 Convergence of personalized healthcare and digital pathology By Robert Monroe and Eric Walk G et ready. The next digital frontier, diagnostics tests that intimately tie together the diagnostic imaging of pathology to the therapeutics of drug treatments, are moving personalized medicine, or personalized healthcare (PHC) closer to reality. It's commonly accepted that a broad-brush approach in treating diseases doesn't always work. And if there's a disease ripe for PHC, it's cancer. The objective in personalized healthcare for cancer is to identify the right patients with the right molecular change, and then hit that patient's specific molecular change with the right drug. Several upcoming cancer tests will help usher in a renaissance in diagnostics. "The biggest change in the next five years will be driven by tissue-based assays that are becoming more molecular � and complex" will provide information on specific genetic events and also on the levels of protein and the presence of specific mutated versions of a protein, resulting in the stratification of patients into therapy regimens. Tools and technologies are being developed that will help pathologists interpret these next generation assays, enabling them to view the images on desktop monitors, using image analysis algorithms to analyze them and provide more quantitative, accurate and reproducible results. In addition, technology advances will allow these molecular tests to move from the few specialized labs doing them today to standard labs, using readily available platforms for test preparation and interpretation. How diagnostic tests will look in the future These companion diagnostic tests exist today. HER2/ neu status is the most common example, where pathologists provide information about the protein or gene copy number that determines whether Herceptin treatment is indicated. Today most pathologists read those tests manually, but this practice is poised to change, along with pathologists becoming a driver of personalized healthcare. The biggest change in the next five years will be driven by tissue-based assays that are becoming more molecular � and complex. For example, 10 years ago non-small cell lung cancer (NSCLC) was considered a single disease from the therapeutic perspective � while its many subtypes appeared histologically different to the pathologist, these subtypes were all lumped together for the purpose of treatment. Ten years later, the genetic underpinnings driving the uncontrolled growth of more than half of NSCLCs can be explained on a molecular level. One breakthrough has been the identification of anaplastic lymphoma kinase or ALK. Early trial results show significant tumor shrinkage in more than one-half of patients given a clinical drug that inhibits the activity of the ALK enzyme. An ALK diagnostic test, being developed alongside the drug's procession through late stage clinical trials, would be performed on all NSCLC patients, with the test outcome determining if anti-ALK therapy is indicated. Other tests performed at the same time would detect other mutations or gene amplifications, such as those involving the epidermal growth factor receptor (EGFR), which also determine therapeutic response. With the use of multiple markers and diagnostic modalities on a single slide, a single multiplex test or assay Dr. Robert Monroe, Chief Medical Officer at BioImagene, Inc., acquired by Ventana Medical Systems Inc., is a board certified pathologist with over 10 years of experience in anatomic pathology, cytopathology, and biomedical research, who leads the company's clinical studies on companion algorithms and digital pathology applications. Changing role for pathology departments The delivery of this tissue-based molecular profi ling for personalized healthcare could become the domain of subspecialty labs, with community and hospital-based pathologists observing from the sidelines. Or, with the enabling imaging technologies and staining platforms already available in the market, it could become part of every pathologist's practice. Strongly supported by oncologists, this pivotal role of the pathologist as the focal point in the delivery of personalized healthcare is also backed by an initiative from the College of American Pathologists, with a subset of pathologists already leading the change. Today, Massachusetts General Hospital pathologists meet with cancer patients to help them understand their pathology reports. In the future, pathologists will utilize advanced workstations to aggregate laboratory, radiology, and molecular data with pathology data, including these multiparameter, multiplex assays, in an integrated report that guides decisions for each patient by defi ning therapeutic targets and prognosis. The sooner that pathologists become comfortable with these new tests and imaging technologies, the sooner they will be ready to embrace their new and exciting role in personalized healthcare. Dr. Eric Walk, Senior Vice President and Chief Medical Officer at Ventana Medical Systems, Inc., a member of the Roche Group, is a molecular and translational pathologist with over 10 years of experience in clinical diagnostic pathology, oncology drug development, oncology translational medicine/ biomarker development and diagnostics. 106 ASK THE EXPERT A frank discussion on the concerns vs advantages of digital mammography A conversation gaining increased attention in radiology circles is whether to eliminate traditional mammography � meaning conventional film, chemicals, processors, folders, filing, etc. � in favor of transitioning to a 100 percent digital mammography PACS environment. While changes to the `typical' way of doing things can cause temporary challenges, evaluating the cost savings and efficiency improvements that can be gained make a strong business case for making the shift. Tyler Harris, NovaRad Corporation's Vice President, Clinical Solutions addresses the issues. I n any business it is prudent to evaluate and weigh both sides of a decision to ensure that it is clinically and fi nancially advantageous when compared to leaving things status quo. When I am onsite at clinics and women's centers, I hear most often the following issues: Is the image quality of digital comparable to film? Because resolution and degradation is of utmost concern when dealing with microcalcifications and other pathology and etiology, there are FDA-approved standards that must be met for monitors and soft ware to ensure high quality, accurate images. In side-by-side comparisons of film and digital images, the image quality of digital studies has proven to be as good or even better than fi lm. In its study "Digital vs. Film Mammography in the Digital Mammographic Imaging Screening Trial", http://www.cancer.gov/newscenter/DMISTQandA, the National Cancer Institute reported that women who will gain the greatest advantages from screenings completed with a digital system include those under 50, those with very dense breast tissue and perimenopausal women. Further advantages provided by digital mammography include the elimination of artifacts and providing better visualization of the skin, retromamillary region, nipple and dense parenchymal areas. Contrast has also been shown to be much better with digital compared to fi lm for fatty tissue and high density areas. When combined with the tools and features offered in digital systems, including advanced hanging protocols, advanced workflow for reading, step-by-step walk through, CAD markers and overreads, a digital system is delivering the added benefit of making reading more efficient, which is helping deliver a higher standard of patient care. Our facility has made a major capital investment in film processing equipment. After factoring in the expenses for purchasing, processing, maintaining and storing film, there is only a small margin of cost recovery per patient. Price sensitivity is what is impacting the industry and causing providers to look for ways to cut costs and increase margins per exam. When comparing the costs of fi lm to digital it is simple to show real bottom-line savings. It is not just eliminating the fi lm costs, it is also time saving for FTEs by eliminating QC for fi lm chemistry, fi lm quality and modalities. Even with the low reimbursement for mammography, typically, most facilities that have installed mammography PACS realize ROI in less than a year, and in many cases in as little as six months. Digital systems also offer space-saving benefits. Archiving mammography studies with a digital system is more convenient and saves space compared to traditional fi lm. Digital images are stored on a server archive, making them easily accessible for repeat analysis, running additional reports or sharing studies online. Electronic fi le storage can also improve productivity. Typically, studies can be retrieved in less than 30 seconds. Th is is a tremendous time saver compared to physically locating jackets in a storage room, and then pulling and hanging fi lms. Overall, the tangible cost savings and intangible space savings to be gained clearly demonstrate the advantages to going digital. The question then shouldn't be `if' the shift from fi lm to digital should be made, but `when'. The sooner the better is proving to be the best business case for facilities that want to gain the competitive edge. Tyler Harris is Vice President, Clinical Solutions at NovaRad Corporation. In this position, he leverages his years of clinical in-hospital experience to help hospitals, clinics and imaging centers improve workflow procedures, productivity and patient care. Prior to joining NovaRad, Harris worked as a licensed radiology technologist. 108 SUSTAINABILITY GREEN Anna Gilmore Hall on why we should be introducing environmental principles into hospitals at the design stage. H from the ground up ospitals form an important and beneficial part of the communities in which we live, providing us with care and support when we most need it. Yet at the same time, as huge consumers of energy and water, they can have a major negative impact on the environment. According to the Energy in Healthcare Fact Sheet, an accompaniment to the Targeting 100 Research Study carried out by the Northwest Energy Efficiency Alliance, healthcare facilities consume four percent of the total energy consumed in the US, including all energy used by industry, transportation and buildings. They use 836 trillion BTUs of energy annually and have more than 2.5 times the energy intensity and carbon dioxide emissions of commercial office buildings, producing more than 30 pounds of CO 2 emissions per square foot. One averagesized US hospital produces approximately 18,000 tons of carbon dioxide annually. Obviously, this is an issue that needs to be tackled, and now may be the perfect time. Surprisingly, despite the recent problems in the world economy, the US healthcare sector is currently experiencing a building boom, as it seeks to replace or refurbish aging buildings constructed with Hill-Burton money in the middle of the last century. Th is high level of construction provides an ideal opportunity to consider how to incorporate energy-saving and waste control measures into hospitals before they are built. Anna Gilmore Hall, Executive Director of Healthcare Without Harm, confi rms this: "There are ways that hospitals could reduce their environmental impact from the very beginning," she explains. "Before the shovel goes into the ground, there are things that you should be thinking about. For instance, the healthcare sector uses a lot of transportation to get its staff back and forth to the hospital, to get the patients back and forth to the hospital, to get the supplies back and forth to the hospital. "This makes deciding where you're going to locate the hospital really important. Put it near a place that has mass transit, so that people can take the subway or the bus. Figure out ways that you can provide incentives to employees to take public transportation. Thinking about those things at the very beginning of the hospital is very important." Gilmore Hall rightly underlines the fact that hospitals are built to last for a long time and are not likely to have multiple owners like office buildings or apartment buildings or houses. A hospital could be in use for 50 to 100 years, meaning the surrounding community needs to think carefully about the impact of that building not only today, but in the following decades. "It's an important community conversation to have," says Gilmore Hall. "Right now, when we're in this huge building boom, we need to think about the kind of hospital of the future that we want. "At Healthcare Without Harm, we have a vision of a hospital that's water balanced, energy carbon neutral and provides a resilience back to the community by being a very helpful place to go and not just a consumer of resources and products and a huge consumer of water and energy. SUSTAINABILITY 109 "What can we do to help hospitals become resilient community partners? That's what architects and planners need to keep in mind when they're designing and constructing hospitals. They also need to think about how the hospital is going to be operated. I have seen hospitals designed by green architects who don't take into account the operations end of things. "For instance, if you really want to have a good recycling program, make sure you keep this in mind in the building design. There's a certain amount of space that's necessary for recycling programs in hospitals. You've got to have the bins for the materials to go in and bins at the loading dock to take them away. Simple little things like that can really make a difference." LEED LEED (Leadership in Energy and Environmental Design) is the system for designing, constructing and certifying the world's greenest buildings. To receive LEED certification, a building must satisfy a number of prerequisites and then obtain a specified number of credits in five categories: � Sustainable site � Water efficiency � Energy and atmosphere � Materials and resources � Indoor environmental quality LEED-certified buildings are designed to: � Lower operating costs and increase asset value � Reduce waste sent to landfills � Conserve energy and water � Be healthier and safer for occupants � Reduce harmful greenhouse gas emissions � Qualify for tax rebates, zoning allowances and other incentives in hundreds of cities � Demonstrate an owner's commitment to environmental stewardship and social responsibility "What can we do to help hospitals become resilient community partners? That's what architects and planners need to keep in mind when they're designing and constructing hospitals" Non-toxic Another potential issue centers on purchasing materials that are VOC-free or at least low VOC. For example, PVC use in a hospital should be kept to a minimum, because of the toxicity involved in its manufacture and disposal. It also emits phthalates that can create toxic fumes, which patients will then breathe in over a period of weeks or months after the building is opened. Daylight � or the lack thereof � is also an important consideration: hospital designers should think about how daylight impacts patients' rooms and break rooms for nurses and physicians. "Daylight helps people feel better, reduces medical errors and can reduce the need for pain medication by patients," says Gilmore Hall. "There are a lot of new studies about the impact nature has on patients and on employees who work in hospitals. "The other thing that we should think about is the fact that hospitals have had a tendency over the last two years to keep on getting bigger and bigger, and in some instances, that size is pretty to look at but maybe it's not quite necessary. We need to ask what can we do to reduce the environmental footprint of the healthcare sector by building smaller buildings in a greener fashion. "We have an instrument called the Green Guide for Healthcare, which is a toolkit to help hospitals and designers and architects think about the siting, design, construction and operation of buildings. It asks questions such as, what are the safest materials we can use in the building? What can we do to reduce the amount of water needed in a building? What can we do to increase drought tolerance in foliage and landscaping? There are ways to reduce water use, such as low f low toilets, and there are ways to reduce lighting use, such as sensors that turn the lights on and off when people go in and out of rooms." Healthcare Without Harm is also working with hospitals to establish a healthcare energy exchange program, in which hospitals hold `energy auctions' and get suppliers to bid on their business. "Th is drives down the price of the hospital's energy purchase," she says. "Some hospitals are choosing to use part of those savings to buy greener renewable energy sources. I would love to see the hospitals of the future be committed to using as much green renewable energy sources as absolutely possible. "There are about 1000 hospitals that are using different parts of the Green Guide. You don't have to use everything. If you're only interested in water, you can look at that. If you're only interested in waste, you can look at that. You can pick what you want to work on. It's a selfregulating system. "People can download it and look at it through our website. We have hospitals in the US and Canada and outside of North America looking at the Green Guide and becoming pilots in different parts of the program. We're also in the process right now of launching a new operations section for the Green Guide. Th is is a pilot program that started in April and about 100 hospitals have indicated they are interested in being involved, to test some new ideas in our operations section and see if they're helpful to hospitals in reducing their expenses and reducing their energy consumption and water consumption." Anna Gilmore Hall is Executive Director of Healthcare Without Harm, an international coalition of healthcare providers, healthcare systems and NGOs interested in healthcare and sustainability with 500 members in 52 countries. Continues over 110 SUSTAINABILITY LEADING THE WAY Hospitals at the forefront of environmental sustainability Dell Children's Medical Center In January 2009, Dell Children's Medical 2 Center of Central Texas became the first enter C T hospital in the wor to receive the LEED spital world Platinum de tinum designation, given by the US Green esignat Building Council. lding Co ouncil. Dell Ch Children's occupies nearly half a hildren's million square feet on 32 acres that were uare once part of Austin's old Mueller Airport. Its nce o Austin environmentally-sensitive design not only nvironmentally conserves water and electricity, but positively impacts the hospital's clinical environment by improving air quality, making natural sunlight more readily available, and reducing a wide range of pollutants. Inside the facility, sunlight reaches 80 percent of the available space. Outside, sustainable and indigenous building materials were used throughout the facade. A 4.3 megawatt natural gas-fired power plant produces 100 percent of the hospital's electricity, heating and cooling. Kaiser Permanente Kaiser Permanente recently unveiled a unv Sustainability Scorecard that requires orecard re ovide environmental data for suppliers to provide environme medical equipment and produc used in its pment products hospitals, medical offices and other facilities. edical othe e Claimed as the healthcare industry's first sustainability scorecard for suppliers, the new initiative could significantly impac how medical tly impact device manufacturers do business in the future, since Kaiser Permanente spends more than $1 billion each year on medical products. The Sustainability Scorecard will allow the healthcare provider to evaluate the sustainability of each medical item it purchases, while encouraging suppliers to provide greener products. It will require suppliers to provide information on the company's environmental commitment, use of potentially harmful chemicals in their products and information about product and packaging recycling. 4 3 1 2 Boulder Community Foothills Hospital oothills Boulder Community Hospital's Foothills ospital's Hospital, was the first hospital in the US to earn a LEED certification. LEED criteria require that fifty percent re of construction waste must be salvaged lls or recycled. The Foothills construction site recycling program, with containers for recycling wood, metal, cardboard and concrete, achieved a landfill diversion rate of 71 percent. This earned the hospital a Certificate of Achievement from the City of Boulder and Eco Cycle in March, 2003. To ensure healthy indoor air quality, workers installed mechanical systems that provide more effective and better ventilation, including operable windows in some areas. The hospital used low-VOC (volatile organic compound) paints, adhesives and carpets to alleviate allergies and breathing problems. A highly efficient power plant provides heat, lighting and hot water for the entire campus. Energy savings are achieved with lighting using compact fluorescent bulbs, and by painting the roof white to reflect summer heat and reduce air conditioning demand. Outdoor lighting was carefully designed to reduce light pollution in the night sky. To conserve water, drought-tolerant plantings and other xeriscaping surround the area. Catholic Healthcare West CHW's sustainability efforts include orts eliminating mercury � since 2001 its ce hospitals have been virtually mercury free, and have organized thermometer mometer mmunities exchange programs in their communities to help remove this toxic substance from ance the waste stream. It has also installed nstalled water-saver devices to wet film processors at its hospitals, and introduced digital X-ray technology, saving more than 100,000 gallons of water per processor per year. In 2005, CHW transitioned to PVC/DEHPfree intravenous bags, solutions and tubing, eliminating approximately 840 tons of this toxic material from both the patient care setting and the waste stream. Its hospitals have also been undergoing a series of energy retrofits. At St. Joseph's Hospital and Medical Center in Phoenix, Arizona, for example, the retrofit is saving electricity sufficient to power approximately 400 homes, natural gas to heat 1000 homes and water sufficient for 320 four-person households. 112 WORKFORCE MANAGEMENT HEADING From staff-mix to skill-mix and beyond WORKFORCE MANAGEMENT 113 Part two: Finding the optimal staff-mix, by Carl-Ardy Dubois and Debbie Singh Skill development One of the greatest challenges facing healthcare organizations in recent years has been how to adjust to the rapid pace of a wide variety of internal and external changes: environmental changes in consumers' tastes and demands; changes in legal requirements; socio-demographic and epidemiologic changes; technological developments and economic fluctuations. To a large extent, organizations' strategic and practical adjustments depend on their members' capacity to transform. An organization updates its responses to changes only when its workforce can learn and utilise the skills required to take on new roles and functions. These additional roles and functions may be at higher, parallel, or even lower level, and they can come about through two distinct processes: role enhancement and role enlargement. Role enhancement Role enhancement involves expanding a group of workers' skills so they can assume a wider and higher range of responsibilities through innovative and non-traditional roles. Enhancing staff members' roles through new competencies gives to employees the opportunity to acquire new competencies and expand their tasks so that they can take on responsibilities traditionally carried out at higher levels. By altering the content of their work, employees are offered opportunities for individual achievement and recognition. Under this model there is greater work depth because employees are involved in tasks that increase their control or responsibility. Role enrichment is considered a vertical and upward expansion of work because it alters authority, responsibility, level of complexity and assignment specificity. In a specific healthcare context, role enhancement describes a level of practice that maximizes workers' use of in-depth knowledge and skills (related to clinical practice, education, research, professional development, and leadership) to meet clients' health needs. Role enhancement does not entail adding functions from other professions. It occurs within a given profession's full scope of practice through the integration of theoretical, research-based and practical knowledge inherent to the development of a discipline. It can also arise from innovative professional activity, H ealthcare organizations have a range of options for ensuring a richer staff-mix: increasing the number of personnel, having higher ratios of qualified workers, having higher ratios of senior staff members, or installing multidisciplinary teams. Despite conflicting findings and the need for further research, a number of studies and systematic reviews suggest that a richer staff-mix may be associated with better outcomes and fewer adverse events for patients. The evidence, however, is highly limited by practical limitations and methodological shortcomings. While many studies have reported positive impacts from enriching staff-mix, they do not offer clear guidance about ideal thresholds in terms of personnel/patient ratios or the proportion of different categories of staff members on teams. More fundamentally, the staff-mix perspective that emphasizes numbers and types of personnel gives less attention to the conditions that determine how staff members' skills are used. Despite the rhetorical use of `skill mix' to describe the different options for deploying healthcare personnel, the focus is, in reality, not on skill but on grades, educational qualifications, job titles and duration of experience that are, at best, proxies for skill levels. An effective system of HR optimisation cannot, however, be restricted to the numbers and types of personnel available. Such a system must also ensure that personnel work to their full potential. Doing so requires a more dynamic approach to skill management that goes beyond the mix of available staff members. Skill management refers to an organization's ability to optimize the use of its workforce. The focus shift s here from achieving a specific mix of different types of personnel to adapting workers' attributes � such as knowledge, skills, and behaviors � and roles to changing environmental conditions and demands. Skill management enables organizations to optimize patient outcomes while ensuring the most effective, flexible and cost-effective use of human resources. A diverse set of interventions have been tested to achieve this dynamic approach to HR optimisation. We divide them into two main dimensions: skill development and skill flexibility. new models of healthcare delivery, and organizational changes that promote development of new knowledge, skills and practices. Th rough experience, continued professional growth and development, and collaboration with colleagues from other disciplines, healthcare workers can develop new skills, abilities and techniques they did not obtain during previous clinical preparation. In addition, as healthcare work expands into new settings, the situational factors that shape service provision in those environments create demands for new skills. In healthcare, role enhancement has been associated with the potential to increase longitudinal and personal continuity and improve patients' health outcomes by enabling one professional to cover a wider range of care needs or by enabling one patient to be cared for by fewer workers. As a result, many healthcare professionals such as nurses, pharmacists and GPs have recently expanded their responsibilities beyond their traditional scope of practice to include more innovative roles. In many cases, these role expansions were initiated in order to ensure that individual professionals would be able to oversee a greater proportion of their patients' care. Primary care and prevention are the main areas in which nurses have taken the lead in delivering expanded services, including health promotion, health screening, and discharge follow-up. Since the 1990s, nurses in UK general practices have been responsible for carrying out well-patient health checks and providing lifestyle counselling and other interventions in accordance with treatment guidelines. Nurses have also expanded their roles by specialising in practice domains and by helping people with particular conditions. Such specialist nurses can be based in either primary or secondary care, and they are particularly active in nurse-led clinics, where nurses assume responsibilities such as managing people with long-term conditions, providing health promotion advice, monitoring and informing patients, and screening for diseases (e.g., cervical screening, cardiovascular screening). Role expansion can also be seen in nurseled outpatient follow-ups, whereby hospital or community-based nurses oversee discharge planning and post-discharge outpatient followup. These examples illustrate the expansion of WORKFORCE MANAGEMENT 115 nursing into areas that were often unmet or inadequately addressed. While retaining their generalist background, some GPs have also expanded their roles. In the US and the UK, GPs who hold additional qualifications or training and who focus on particular areas are sometimes known as `GPs with special interests'. Such physicians can offer specialist care in the community or work as part of multidisciplinary hospital and primary care teams. Similar developments have occurred for pharmacists, whose work has expanded far beyond the distribution of medications to include patient education, health promotion, counselling, medication management, health monitoring, and even, in some jurisdictions, prescribing. In England, the Medicines Management Collaborative involves 146 primary care trusts and 44 trusts, and it aims to engage all members of the pharmacy team in identifying and addressing patients' unmet pharmaceutical needs. Despite major interest in developing enhanced roles, evidence about the impact of these new roles is limited and has focussed mostly on nursing. Overall, the evidence suggests that health professionals can learn specific advanced skills that fall outside the scope of their routine practice and apply them in clinical settings. However the impact of such role enhancement remains uncertain. Some studies have found improvements associated with organizational innovations that draw on nurses with advanced skills, including nurse-led clinics or specialist nurse-led initiatives. Other studies have found fewer or no benefits. However, there are variations in the nursing interventions in these studies which may lead to inconsistencies in the findings and make it difficult to draw conclusions about the effects of enhanced nursing roles on patient outcomes. We cannot be certain whether any observed differences are due to the nurses' roles or to other intervention-related factors (e.g., resource intensity, increased follow-up, access to a multidisciplinary team). Thus, although many studies have revealed connections between nurses' role enhancements and safe and effective care or improved patient outcomes, it remains uncertain whether the benefits are due to specific interventions or nurses' roles. Furthermore, the evidence regarding the oppor- tunity costs of such service developments and marginal gains in terms of health outcomes is still scarce and often confl icting. In addition to patient outcomes, role enhancement also likely affects professionals. Role enhancement echoes research about motivational theory and job enrichment. Motivation may be a function of work factors such as responsibility, advancement, recognition and opportunity to acquire and use vertical skills including, for example, leadership and selfregulation. It has been suggested that enriched jobs that include these factors lead to satisfaction and motivation because they provide workers with more control, responsibility and discretion over how they perform their jobs. Research on role enhancement in various sectors suggests that enriched jobs are more meaningful, less exhausting and associated with greater job satisfaction. In the healthcare arena, role enhancement may also have a positive effect on workforce recruitment and retention, either by providing more advanced roles with increases in pay and status or through the creation of new clinical career pathways. Despite the benefits associated with role enhancement, some caution is required. First, as traditional roles and functions change, confusion and disagreements can challenge professionals' identities and engender confl icts among practitioners and occupational groups. Such confl icts can, in turn, lead to low morale and antagonistic working relationships. Second, work expansion, even in a vertical direction, is not always synonymous with job enrichment or role enhancement. In the absence of an explicit professionalization project, HR management strategies designed to expand practice scopes may undermine professionals' distinctive work domains because they blur role boundaries and make the work of one profession indistinguishable from that of others. Lack of clarity about professional practice means that, in fulfi lling useful, flexible and cost-effective new roles, individuals may serve managerial, economic and patient interests, but their roles may remain limited and lack any obvious benefits for the development of their professions. Some analysts have even suggested that the skill-mix changes that have recently "Enriched jobs that include these factors lead to satisfaction and motivation because they provide workers with more control, responsibility and discretion" gained popularity (e.g., addition of new functions to nurses' roles) are nothing more than revamped versions of rationalization programs, undertakings that exposed workers to a potent mix of resource constraints, heavy workloads, significant role changes and pressures to develop a broader range of skills. These increased pressures to develop new skills and reach higher educational standards may be counter-productive if they demotivate workers who feel they must take on additional work without reciprocal support. Th ird, it cannot be assumed that role enhancement means a general upskilling of workers. Just because staff members must perform more tasks at higher levels does not mean they have been supported by further training. Several influential reports have voiced concerns that the broad range of initiatives being implemented to expand healthcare workers' roles is not always combined with efforts to establish educational and training programs that are consistent with these developments. While some key stakeholders, including governments and employers, have argued for the expansion of scopes of practice in healthcare, the pace of service development has often outstripped the ability of training programs to equip workers. Role enlargement Role enlargement is the horizontal accrual and diversification of employees' skills. Staff members are able to extend their activities and take on roles and functions at parallel levels (horizontal enlargement) or lower levels (downward enlargement). In industry, role enlargement aims to change the scope of jobs in an attempt to motivate workers. Th is practice emerged as a response to excessive specialization in the division of industrial labour, whereby work is typically divided into small units, each of which is performed repetitively by an individual worker. Concerns about extreme spe- WORKFORCE MANAGEMENT 117 cialization and its adverse effects on workers' morale led to calls to restore some of the skill, responsibility and variety that have been lost through work simplification. In healthcare, role enlargement has been part of efforts to shift service delivery from a task-oriented approach towards integrated care carried out by workers who are able to meet patients' multiple and complex needs. While the rapidly shift ing balance between acute and chronic health problems in industrialised countries is placing new demands on healthcare workers, there is a general consensus that healthcare professionals' skills must be expanded in order to provide effective care for people with chronic conditions. Population-based approaches to care that have been part of recent reforms in many jurisdictions move healthcare workers from caring for a single unit (one person seeking care) towards planning and delivering care to defi ned populations, to ensure that effective interventions reach all the people who need them within a given population. To meet this challenge, practitioners must assume new roles such as the ability to manage populations, to assess the healthcare needs of wider groups, and to plan and implement appropriate levels of health and social-care interventions. As with role enhancement, role enlargement succeeds not by replacing one professional with another but by adding new dimensions to healthcare through the expansion of workers' skill repertoires. Such role enlargement has been present in many recent initiatives in which the main focus has been on practitioners' acquisition of additional, basic patient-care skills. These new skills enable practitioners to perform certain routine, frequently provided, easily trainable, and low-risk procedures (e.g., monitoring vital signs, measuring blood glucose level, carrying out venipuncture for blood sampling, measuring peak expiratory flow rate, examining for breast lumps and providing advice on health promotion) that can help bring about more integrated care. Horizontal expansion can also be seen in increased interest in cross-training generic and nonclinical skills, such as patient/client education, technical writing and team dynamics/ communication. The World Health Organization (2005) has identified five core generic skills that transcend the boundaries of specific disciplines and apply to everyone who cares for patients with chronic conditions: patientcentred care, partnering, quality improvement, information and communication technology, and a public health perspective. Skill flexibility Another closely related dimension of skill management is skill flexibility. This term refers to using multiskilled workers that can switch from one role to another while employing various skills as required. A multi-skilled workforce capable of doing different jobs and delivering a wide range of services to clients results from increasing the breadth and depth of work. In healthcare, role substitution and role delegation are two of the main strategies being widely tested. Role substitution Role substitution involves extending practice scopes by encouraging the workforce to work across and beyond traditional professional divides in order to achieve more efficient workforce deployment. In contrast to role development, which occurs within dynamic disciplinary boundaries, role substitution entails competencies required to perform activities that are usually considered to be outside traditional practice scopes. In recent decades role substitution has blurred traditional professional boundaries. In the US for example, physician assistants with a wide variety of backgrounds, including nursing and social care, have become an attractive option for expanding workforce capacity in underserved areas. Similarly, in many countries several types of non-professionally qualified staff members have been used as substitutes for nurses. Substitution of less expensive `care assistants' for more expensive nurses has become increasingly apparent in recent years in response to cost-containment initiatives and nurse shortages. Other role substitution examples include training respiratory therapists to perform electroencephalograms (EEGs) and medical technologists to perform certain radiological procedures. In the field of mental health, nurse practitioners have extended their activities to many areas previously reserved for physicians, including treating depression and anxiety disorders as well as clinically assessing people who are receiving anti-psychotic injections. Meanwhile, both family physicians and midwives have been sharing roles with obstetrician/gynaecologists (in prenatal and postnatal care, delivery and routine screening tests). Over the last few decades, pressures such as rising costs, personnel shortages, and access limitations have raised interest in role substitution as a skill management tool for fostering more cost-effective use of a diversely skilled and flexible workforce. But it remains unclear whether role substitution lowers costs. Substitution of nurses for physicians has received a great deal of research attention. Overall, the evidence supports the view that, in many clinical areas, particularly primary care, there is substantial potential for nurse substitution to lower costs without decreasing quality. Nurses may even extend quality into areas of care not generally provided by physicians. In this respect, several studies have shown that nurses operating in roles that overlap physicians' achieve health outcomes that are as good as those accomplished by physicians and generate higher patient-satisfaction ratings � particularly with regard to interpersonal skills. Substituting nurse midwives for physicians has been also well studied and, again, the findings suggest that health outcomes for patients are comparable for both groups, but that midwives may use less technology and analgesia in intrapartum care. Substituting less qualified personnel for highly qualified nurses is, however, a contentious practice. Although such role substitution offers a way to cope with staff shortages, many studies have suggested that it may adversely affect patient-related outcomes (e.g., decreased satisfaction, decreased care quality) and nurse-related outcomes (e.g., increased on-call work, increased sick leave and overtime work, increased workload 118 WORKFORCE MANAGEMENT for registered nurses). While workforce substitution is often initiated as a cost-saving strategy, evidence about this is weak. Substitute workers may be able to provide equal quality care, yet the impact on costs depends on a number of factors, including whether substitutes answer previously unmet patient needs or, instead, generate new demands for care. It has been suggested that nurses, compared with physicians, spend more time with patients, recall them at higher rates, and carry out more investigations � all of which have cost implications. In addition, although it is generally less expensive to train nurses than physicians, savings may be eroded because nurses tend to have lower lifetime workforce participation rates than doctors. Similarly, while there is no unanimity in this regard, current evidence suggests that substituting nurse aides or nurse assistants for more highly qualified and more expensive nurses may be no more cost-effective because of the various hidden expenses associated with skill dilution: higher absence and turnover rates of less-qualified staff, greater levels of unproductive time due to lack of autonomy and capacity to act independently, and higher rates of adverse events and risks for patients. Another danger with role substitution is that skills that are shared by a broad range of professionals may become a low priority for individual practitioners. Increasing the range of people capable of undertaking particular tasks might mean that those tasks are no longer specifically `owned' by anyone. Reports have shown that practices intended to increase continuity have led, in reality, to role and skills drift as well as to more fragmented care. One example is the reduction of medical involvement in maternity care that has occurred in tandem with the extension of midwives' scopes of practice, leading to situations in which physicians no longer see certain tasks (e.g. suturing the perineum after a delivery) as belonging to them. Role delegation Role delegation involves transferring certain responsibilities or tasks from one grade to another by breaking down traditional job demarcations. In practice, groups of professionals take on roles delegated to them by other groups of professionals. Interest in delegation has been driven by its potential to make highly qualified and high-cost practitioners withdraw from activities that can be competently performed by less qualified and lower-cost practitioners. As a result, the former group can devote more time to the interventions that only they can perform. Some research suggests that between 25 Healthcare assistants could cover about 12.5% of nurses' current workloads percent and 70 percent of physicians' (most often generalists') tasks could be delegated to other healthcare professionals. In the same vein, other studies have concluded that GP workload for specific patient groups can be reduced by up to 50 percent by delegating some activities to nurses, including managing requests for out-ofhours appointments, same-day appointments, and home visits. A more recent estimate of the Wanless report in the UK is that nurse practitioners could take on about 20 percent of work currently undertaken by GPs and junior physicians, whilst healthcare assistants could cover about 12.5 percent of nurses' current workloads. According to other studies, task delegation would allow a significant proportion of nurses' workload to be taken up by healthcare assistants, auxiliary nurses, and other less-qualified staff members. It has been found that in accident and emergency units over a 24-hour period, nursing staff members spent 49 percent of their time on nursing tasks, 21 percent on communicating with patients, 17 percent on clerical work, and 13 percent on housekeeping. These figures mean that a significant proportion of current nursing work could be delegated to untrained personnel such as healthcare assistants or support workers. Evidence concerning the impact of role delegation on both patient and staff outcome is limited and confl icting. The benefits of role delegation need to be balanced by the potential drawbacks that researchers have found. Removing simple tasks from GPs and delegating them to other staff members may affect the sense of connection between patients and their physicians, thus compromising this important relationship. Second, removing relatively simple tasks in order to allow physicians and nurses to manage more complex health problems may deprive physicians of valuable interludes in their work and be counterproductive if it leads to increased stress and job dissatisfaction. Furthermore, unless there is a reciprocal helping relationship or additional resources and support, shifting work from higher to lower-skilled groups can lead to excessive workloads for the latter and fuel the perception that one group is off-loading tasks onto another. Finally, assessment of the scope for healthcare role delegation must take account of the context of workforce shortage. If 20 percent of GPs' and junior physicians' work were shifted to nurses, as suggested by the Wanless report mentioned above, pressure on GPs would decrease. That move could, however, exacerbate nurses' dissatisfaction with their workloads and simply transfer the problem of workforce shortage from one professional group to another. Carl-Ardy Dubois, Faculty of Nursing Sciences, University of Montreal, Quebec, Canada. Debbie Singh, Health Services Management Centre, University of Birmingham, Birmingham, UK. See the Q1 2011 issue of EHM for the next instalment of this article. Reprinted from Human Resources for Health 2009, 7:87 For references associated with this article, please see: http://www.human-resources-health.com/content/7/1/87 Travel | Books | Leisure Travel Splashing out in Spain 121 Agenda What's on this quarter In review Meditation and health p122 p124 p127 Details. 127 124 122 122 DETAILS. TRAVEL 36 hours in... Spain Time : CET ( UTC+1) | Currency: euro | Population : 46 million The real inquisition Forget sombreros and long lazy days � when you're in Spain, there's no time to waste. Instead, follow EHM through its guide to the masters � from art and architecture to soccer and dancing � and find out what it takes to really get inspired. Flamenco From the jaw-dropping remains of Gaudi to the feet-stomping moves of Flamenco, no night on the Spanish tiles is complete without a glance at the aggressively seductive moves of the nation's favourite dance. Having spread its wings into the Latin American countries, Flamenco originally took its roots from the Gypsy clusters in Andalusia, with formal training never on the menu. Today, the majority of professional dancers are precisely that, but they've never lost the tradition, with many dancers still choosing to learn from their elders. In a sense, Flamenco encapsulates everything you need to know about Spain: it's heritage, passion, aggression and lifestyle all emanate from the backbone of the dance that has seduced so many and excluded so few. T he mere mention of Spain usually conjures up images of siestas, picturesque coastlines and lazy days eating tapas and sipping red wine, which is by no means a bad thing. But for a nation steeped in history, passion and tradition, there's so much more to investigate that just the tourist traps and city guides available. Instead, why not run with the nation's spirit of discovery and take a peek at what's really on offer? Architecture of Antonio Gaud� From Barcelona to Cantabria, history's most famous architect has certainly left his stamp on the nation he loved so much. Known to many as "God's Architect", Gaudi became famous for his unique and highly individualistic designs regarded as being far beyond the scope of Modernism. The most notable of these is La Sagrada Familia � a privately-funded Roman Catholic church that stands in the center of Barcelona. The Spanish take such pride in Gaudi's masterpiece that, even though it began construction in 1882, its completion is not expected until at least 2026 for the 100th anniversary of Gaudi's death. But it's not just his masterpiece that you should see; work your way around almost any city in central Spain and you're likely to walk, touch or maybe even sit on a Gaudi piece. The master of gothic, Gaudi was obsessed with basing his blueprints on nature's angles and curves � instead of relying on geometric shapes, he mimicked the way men stand upright. If you want your breath well and truly taken away, there's no better place to go. Soccer When they're not encouraging a skinny man in sequins carrying a red tablecloth to tease a rampaging bull, the Spanish love nothing more than watching a bit of f�tbol. After all, Spain is home to the reigning world and European soccer champions. The biggest match in La Liga (the country's domestic league) is El Clasico: Barcelona versus Real Madrid. The rivalry between these two heavyweights of European soccer is legendary, providing a colorful and raucous backdrop when they clash. These clubs also boast arguably two of the finest stadia in the world � Barcelona's Nou Camp and Real Madrid's Santiago de Bernab�u. Combined, they hold almost 180,000 fans. Tickets for El Clasico are like gold dust but you can purchase tickets for other games online directly from the clubs' websites. If you are feeling brave, and can haggle in Spanish, you can always chance your arm and snag a ticket from a tout before the game, but expect to pay over the odds for the seat. Real Madrid and Barcelona are steeped in history so it would be a shame to come all this way and not take a tour of the stadium and get up close to the silverware on display in their respective trophy cabinets. Don't forget, though, there are 18 other clubs that compete in La Liga: from Malaga in the south of the country, Deportivo in the north west and Mollorca off the mainland to the east. All make for a fantastic night of sporting entertainment. Museum of Dali Everyone knows Salvador Dali, and if you don't, you've got to wonder if you actually exist � or at least that's what Dali would have told you. The master of surrealism's museum nestles itself about an hour and a half outside Barcelona in his hometown of Figueres. Boasting potentially the largest collection of his work anywhere in the world, the museum itself is also considered the largest surrealist object in the world, with its crimson and gold-crusted turrets balancing colossal-sized eggs on top of it. And no, we didn't just make that up. But for 11 a ticket, why not go just to make sure. The Alhambra Having gained global fame as the inspiration of too many songs and stories to list here, the Alhambra was constructed in Andalusia in the 14th century by the Moorish rulers of the Emirate of Granada as both a palace and a fortress. Sound impressive? Wait until you step inside. From ceiling decorations described as "honeycombs" to tessellated wall tiles that have intrigued mathematicians for decades, the Alhambra has one of the most hypnotic and vibrant tapestries anywhere in Spain � made more characteristic by the fact that it never had any organized layout in its inception, instead being quite literally moved from pillar to post over the centuries � lending itself nicely to its Hollywood depiction. If you're looking for that little bit extra over the herds of tourists that visit it, your best bet would be to sneak your way up there just before sunset and watch that molten red ball sink its way into the horizon just as it leaves the Alhambra glowing dusk red. Simply unmissable. Golfing at Valderrama With their practice ground being dubbed "the best in Europe" by Nick Faldo, Valderrama Golf Club glistens to entice golfing enthusiasts from its home in the resort of Sotogrande, in the Andalusia region of Southern Spain. It has a nine-hole, par three course, but its parent 18-hole course is what the serious players come for � more specifically, its par-five fourth hole with a pond to the right of a two-tiered green. And for those who didn't understand that description, their bar and restaurant is just as well known as the course, with countless celebrities and athletes having propped up the bar during the Ryder Cup and various Volvo Masters throughout the years. So why not leave your loved one on the course Wynn Las Vegas while you sip away in reclined luxury. 124 DETAILS. AGENDA Coming up... Dec. 02-11 National Finals Rodeo, Las Vegas Organized by the Professional Rodeo Cowboys Association, the National Finals Rodeo, held at the Thomas & Mack Center at the University of Nevada in Las Vegas, is the grand finale of the modern professional rodeo circuit. It has been held in Las Vegas since 1984. Known as the Super Bowl of Rodeo, this 10-day event puts the talents of the nation's top 15 money-winners to the test as they compete for championship titles. Nov. 25 Macy's Thanksgiving Day Parade, New York The annual Thanksgiving Day Parade presented by Macy's, in New York City starts at 9am EST on Thanksgiving Day. In addition to the well-known balloons and floats, the parade also features live music and other performances, such as the college and high school marching bands from across the country. More than 44 million people watch the parade on television each year. Oct. 12-Jan.01 Wild Lights, Colorado The entire 35 acres of Denver Zoo is transformed into a magical winter wonderland. The family-orientated event offers hundreds of incandescent trees, holiday entertainment, music, warming stations, and refreshments including soft bread pretzels, roasted nuts, funnel cakes, churros, cider and hot chocolate. AGENDA. DETAILS 125 Dec. 03-04 Get Your Pig On Barbecue Competition, Arizona In Fountain Hills, Arizona, inaugural outdoor BBQ festival will feature a Kansas City Barbecue Society sanctioned BBQ competition, live entertainment and a product-sampling pavilion. Nov. 18-20 Grand Rapids International Wine & Food Festival, Michihgan Michigan's premier wine and food experience with over 1000 wines and beers from around the world together with the top fine dining restaurants in Grand Rapids. This event attracts thousands of food and wine fanatics and offers a fantastic array of tastings and cooking demonstrations. Jan. 06-17 Palm Springs International Film Festival, California Dedicated to showcasing the work of exceptional new and emerging talents, as well as the celebrated works of established auteurs. An industry-friendly launch pad for new films and filmmakers, this event combines the best aspects of a casual marketplace with an established reputation as a great audience festival that filmmakers love to attend. Jan. 30 Chevron Houston Marathon, Texas With thousands of runners and spectators, the Houston Marathon is the largest single day sporting event in the city. The marathon is popular because of the flat, fast and friendly course, the cool winter weather and the festive experience with 200,000 onlookers, numerous jazz bands, belly dancers, Elvis impersonators and other entertainers. Your World. 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Available for: US, MENA, Russia Infrastructure Infrastructure provides insight on how developers can achieve critical objectives by integrating leading-edge solutions across their operations � helping them to make informed decisions about technology and operations solutions for all of their areas of responsibility. Available for: US, EU, MENA Find out more: www.americainfra.com Find out more: www.ngoilgas.com BOOK REVIEW. DETAILS 127 Fresh off the press EHM delves into one of the year's most inspiring tales of health, wellbeing and the elusive search for mental serenity. Teach Us to Sit Still: A Sceptic's Search for Health and Healing By Tim Parks F ive years ago, Tim Parks found himself getting up every night to go to the bathroom. Not an excusable once or twice, but a worrying five, six, seven times. Th inking he might have prostate problems, he went and had himself checked out. The results came back negative. But with increasing pain and a severe lack of comfort growing by the day, he knew something was up. Googling incessantly for any hint of an answer, Park gives up coffee before going the same route with alcohol, neither of which offer any discernable change. Having exhausted every possible modern day medicinal avenue, he begins to think about his inner workings. Meeting with an ayurvedic doctor, who tells him he has "a profound contradiction in his character" and subsequently his `vata' � the energy that flows through the body � is blocked, Parks raises an eyebrow and wants to walk off with a patronizing snigger. But with his desperation at an all-time high, he reluctantly accepts the "hippy help" in the hope that he might fi nd a cure. Months pass by. Parks is stricken with impotence and no closer to fi nding an answer to his deteriorating health, despite his prior meeting with the New Age doctor. Th at is until he picks up a book called A Headache in the Pelvis by two American doctors. The book describes his symptoms to a tee and suggests they be treated by a program of breathing techniques � "the concept of paradoxical relaxation". Don't try to run away from the pain, the book advises, but engage with it. At the same time, he has to try to empty his head of thoughts, allowing him to experience his body from the inside. To his amazement, Parks' paradoxical relaxation works. Not only that, but he's becoming engrossed in the practices he once laughed at. Meditation, advanced breathing � nothing remains out of reach to the newly functioning Parks. Soon, he becomes as obsessed with emptying his head of thoughts as he had been previously with fi lling it. In treading new ground and hurling himself head-fi rst into a world supposedly occupied by sensationalists and placebo-takers, Parks manages to fi nd what he's been looking for all along � a sense of his own serenity. From the outset, Teach us to Sit Still could be construed as yet another self-pitying, self-help book � but it truly is anything but. Park's ability to engage with the potential of ancient medicinal practices and logical health techniques not only highlights their efficacy in a world fi lled with impatient get-healthy schemes, but also depicts how implementing their principles can, quite lit- erally, change a person from the inside out. But it's not just Parks' experiences that make the book so enthralling � his talents as a writer transform the book from looking through the eyes of a hypochondriac to one in which you follow a man on a journey where there is no such thing as a silver bullet, an easy answer or a magic formula to good health � merely someone who is trying to shuffle doubtfully toward a glimmer of light. Indeed, his writing has been noted as "intensely engaging", with the capacity to write "wittily and with great beauty about the near indefi nable". It goes without saying that the large majority of us will fall ill at some point in time, yet few will be able to describe that journey with the same verve, insight and radiant intelligence as Tim Parks. Regardless of whether you're a believer or a sceptic, Parks draws you into the advantages of mind over matter � and if you don't mind, then why should it matter? 128 DETAILS PHOTOFINISH All eyes were on California on November 2, 2010, as its population waited for the outcome on Proposition 19: a ballot initiative that, if passed, would have legalized various marijuanarelated activities and changed the face of medicinal marijuana for thousands of patients dealing with the pains of a plethora of treatments. With a 53.9 percent outcome swinging towards the `No On Proposition 19' party, the initiative was ultimately defeated. But what it has left in its wake is a serious message for the big thinkers in both healthcare and law enforcement: the days of free love and hippies are over. With a relatively small margin between success and defeat, California has shown the watching world that there is a significant call for marijuana to help in the treatment and alleviation of pain for both chronic illness sufferers and the people who dedicate their lives to cultivating the medicinal herb. Prior to the outcome of Proposition 19, Californian Govenor Arnold Schwarzenegger said: "I think it's time for a debate. And I think that we ought to study very carefully what other countries are doing that have legalized marijuana and other drugs, what effect it had on those countries, and are they happy with that decision." Whatever the eventual outcome, one thing is certain � this is not the last war cry to be heard from medicinal marijuana supporters throughout the country, and indeed the world.