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: firstname.lastname@example.org (Please put the magazine name in the subject line) Letters to the Editor: email@example.com GDS International GDS Publishing, Queen Square House 18-21 QueenSquare, Bristol, BS1 4NH Tel: +44 117 9214000 E-mail: firstname.lastname@example.org 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 thre