How new technologies are bringing medical care out of the hospital and into the community.
www.executivehm.com � Q3 2010 How new technologies are bringing medical care out of the hospital and into the community Making meaningful use of EHR | Maximizing patient flow | Tackling VAP prevention EDITOR'S NOTE | EHM 9 A long-distance health affair How tomorrow's technology could forever change the doctor/patient relationship. ot so long ago, the doctor/patient relationship was a lifelong one: people might literally be cared for by the same doctor from cradle to grave. Doctors took a personal interest in their patients, making house calls and almost becoming part of the family. Population growth, increasing urbanization, greater mobility among patients and many other factors have conspired to change this, with healthcare moving away from its original basis in the community and into large, central hospitals or health systems. While the modern system does have its advantages, some patients � the elderly, or those living in rural areas far from the nearest big hospital � have found their access to care diminished. Now things may be coming full circle. Advances in information technology could make it possible to take certain types of healthcare out of the hospital and back to the patient, albeit without the direct person-to-person contact. In this issue's cover story, Nick Pryke takes a look at the ways in which telehealth � or e-health � could revolutionize long-distance healthcare. The capabilities of some of the tools now available, or soon to be on the market, are astonishing. Intel, for example, has developed a technology called SHIMMER � Sensing Health with Intelligence, Modularity, Mobility and Experimental Reusability. SHIMMER is designed to be lightweight, wearable and connected to Bluetooth-enabled monitors, and can track the gait and motion of patients in an effort to better understand and prevent falls, which often lead to rapid health deterioration in the elderly. N The most amazing technologies will make no difference if no one is using them, and the US has lagged behind other countries in terms of implementation. But this could be about to change: the Senate Special Committee on Aging's hearing `Aging in Place: The National Broadband Plan and Bringing Healthcare Technology Home', which took place in April, could usher in a new era of advanced healthcare technology in this country. The hearing focused on the spread of broadband throughout the US, how information technology could change the way patients and their doctors relate, the potential for cost savings, and some of the barriers to implementation. Individual hospitals are also getting in on the act. Veterans Hospital System, for example, has implemented its Care Coordination/Home Telehealth Program for 32,000 veteran patients with chronic conditions. The program has resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those veterans who are admitted. Ultimately, with its potential to offer better access to care, improved patient monitoring, and cost savings, it only makes sense for us to maximize our use of advanced healthcare technology. It may not be quite the same as the old days of house calls from the family doctor, but in many ways the modern equivalent is even better. "I do not believe that quality medical care can be provided without advanced information technology systems in the 21st century" Robert Pearl, Executive Director and CEO, The Permanente Medical Group Marie Shields Editor CONTENTS | EHM 13 36 Home is where the health is How technology is revolutionizing the patient-doctor dynamic by bringing healthcare back where it started. By Nick Pryke 74 Climbing aboard the electronic health escalator It's onwards and upwards for David Blumenthal, as he helps hospitals make meaningful use of EHR 98 The paperless trail Health reform + a growing population + shrinking funds: Kevin Williams on how computerization could help save our health system CONTENTS | EHM 15 44 EXECUTIVE INTERVIEW 32 Rodney Ogrin, Sprixx 50 Leslie Swadener-Culpepper, Medical Center of Central Georgia 52 Douglas Hansell, Covidien 96 Sid Mandel, Qnomy Inc. INDUSTRY INSIGHT 42 Earl Jones, GE Healthcare, eHealth Solutions 80 Raymond Scott, Axolotl Corp 82 Paul Lagasse and Bill Thornburg, Ingenix 104 Sharon Moses, Lawson Healthcare 114 Graham Barnes, Concerro, Inc. 62 44 Shutting down the infection superhighway A close-up look at strategies to cut the incidence of ventilator-associated pneumonia 121 62 On the frontline In vitro disease diagnostics and the fight to control infectious disease 71 Maximizing vessel health Nancy Moureau outlines the current challenges in vascular access 84 Sink or swim Why it's time for CIOs to take the plunge into a new era of medical records DETAILS PLATINUM SP ONS OR 121 Travel: Australia 124 In review: The Decision Tree 126 Wellness: Fighting burnout CONTENTS | EHM 17 88 Healthcare and traffic management Eugene Litvak on moving patients through your hospital in an efficient manner 106 Staffing appropriately in challenging times Joelle Lofaso covers the issues currently facing healthcare recruitment 60 108 From staff-mix to skill-mix and beyond Towards a systemic approach to health workforce management, by Carl-Ardy Dubois and Debbie Singh 106 ROUNDTABLE 55 Ventilator-associated pneumonia prevention, with Ed Coombs of DraegerNorth America, Stefano Nava of the Istituto Scientifico di Pavia, and Ernest Waaser of Teleflex Medical ASK THE EXPERT 60 Francesco Pompei, Exergen Corporation 68 Mary Jo Deal, Thermo Fisher Scientific, Microbiology Americas 102 Samantha Carey and Tom Koch, CTPartners 116 Chadd Dehn, Adecco 118 Deedra Hartung, Cejka Executive Search NEXT BIG THING 101 Robert Monroe, BioImagene S P O N S OR SILVER 88 NG Pharmaceutical Summit 2010 25 - 27 October 2010 The Fairmont Turnberry Isle Resort & Club, Miami Find Out More Contact NGP 212 796 2000 Executive Health Management GDS Publishing, Queen Square House 18-21 QueenSquare, Bristol, BS1 4NH Tel: +44 117 9214000 E-mail: firstname.lastname@example.org 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. 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Much better venue for learning what they do" Daniel Adelman, SVP Development & CMO, Alvine Pharmaceuticals Chairman/Publisher Spencer Green Director of Projects Adam Burns Worldwide Sales Director Oliver Smart Editor Marie Shields Managing Editor Ben Thompson Associate Editor Nicholas Pryke Contributors Ian Clover, Lucy Douglas, Rebecca Goozee, Huw Thomas, Julian Rogers, Stacey Sheppard Creative Director Andrew Hobson Design Directors Z�e Brazil, Sarah Wilmott Associate Design Directors Michael Hall, Crystal Mather, Cliff Newman, Catherine Wilson Infographic Designer Tiffany Farrant Online Director James West Online Editor Jana Grune Project Director Caitlin Kenney Sales Executives Melody Andoy, Brian Frank, Matthew Kneller, Lucinda Madura Finance Director Jamie Cantillon Production Director Lauren Heal Production Coordinators Renata Okrajni, Aimee Whitehead Director of Business Development Richard Owen Operations Director Jason Green Operations Manager Ben Kelly 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 www.ngpharma.com GDS International GDS Publishing, Queen Square House 18-21 QueenSquare, Bristol, BS1 4NH Tel: +44 117 9214000 E-mail: email@example.com GE Healthcare Getting the most value from IT requires a partner who can deliver critical information where it's needed�by connecting the healthcare ecosystem in powerful new ways. With Global eHealth Solutions, GE Healthcare is doing just that. A health information exchange can enable clinical data exchange while maintaining critical workflows helping coordinate care across locations, specialties and providers. The results of such an integrated system� better resource utilization, fewer errors, and higher quality of care�make a meaningful impact. And only a proven partner like GE Healthcare can help you achieve it. For more information about sustainability and true organizational transformation, please download our white paper at: www.gehealthcare.com/eHealthDynamic Confidence in dynamic times � 2010 General Electric Company - All rights reserved. 22 EHM | UPFRONT NEW TECHNOLOGY The technology that's revolutionizing healthcare With technology set to revolutionize the world of remote patient monitoring and encourage the adoption of telehealth, EHM goes back to the future to bring you the next generation of e-care devices that could improve quality. Philips' `Simplicity' concept t Philips' annual event in London, UK, the company unveiled two new concept technologies that aim to improve the flow of information to patients. The fi rst sees the transformation of a standard room divider into a fully operational computer that displays key patient data and allows doctors to explain procedures with the help of interactive diagrams. Th ink somewhere along the lines of a projected, interactive touch screen that patients can view from their beds, and you start to realize how useful the concept could be. The second concept is aimed at expected mothers. Known as the Philips blanket, it is placed over the stomach of the motherto-be before a fully 4D scan is created and displayed on a circular display or wall for all to see � without the hassle of an ultra-scan at the hospital. Expected mothers will also be able to compare and morph previous scans to put together a timeline of their little one's progress. Still very much in the early development stages, Philips hopes both these technologies could improve hospital life for patients in the next five to 10 years. A UPFRONT | EHM 23 The iPad Boasting on-the-move, wireless connectivity and the now standard Apple interactive touch screen, the iPad is already working its magic in the world of healthcare. Of course its countless `apps' software will allow remote connectivity with on-site computers and patient data, but the real challenge of the iPad will be how it helps connect patients outside the hospital setting with the necessary physicians and aftercare staff. With over 100 iMedical apps already available in the Apple online shop, perhaps the most successful is Epocrates; an app designed to fill its user in on everything from drug interaction and clinical trials through to pill identification and infectious disease treatments. Within its extraordinary bank of medications, Epocrates also houses over 600 herbal medicines and updates on medical news and drug contents. Healthcare professionals are already using it nationwide, so its use by the patient population should provide a significant change in the dynamic between patients and doctors. SHIMMER technology E Electronic band-aid T he Bluetooth enabled band-aid works on behalf of both paramedics and patients. It allows paramedics to ascertain a patient's blood type, allergies and overall priority thanks to a small screen embedded into the plaster � giving text display and real-time colour coding regarding the patients status. It also gives a complete picture concerning the number of injured parties and their relative severities by pooling all the information within the system and relaying it back to the A&E department, allowing them to prep the necessary drugs, equipment and human resources well in advance of receiving the casualties. On the patient side, the electronic band-aid will allow doctors to wirelessly alter prescriptions straight to the patient without them having to go to a pharmacy or back to their doctor. For the elderly and rural populations at least, this kind of technology could improve quality of life and reduce travel days exponentially. ric Dishman and his team at Intel have been researching and creating Sensing Health with Intelligence, Modularity, Mobility and Experimental Reusability technology � or SHIMMER technology to save your breath � with astounding results in recent years. The technology, which is designed to be lightweight, wearable and connected to Bluetooth-enabled monitors, can track the gait and motion of patients in an effort to better understand and prevent falls, which often lead to rapid health deterioration in the elderly. Currently being used by the team at Intel in conjunction with what they are calling their `magic carpet', the SHIMMER ECG works by picking up the weight, angle and pressure of a person's step, and has allowed physicians and research staff to be able to predict falls in the home and care settings through real-time, kinetic data. In addition to this, they are also trialling their Mobile Clinical Assistant (MCA). Complete with Bluetooth, a built-in camera, an RFID reader and soft ware to track inventory and other electronic records, the MCA aims to add to workflow efficiency to the hospital environment while keeping patients interacting with their prognosis. Vital Monitoring System The Vital Monitoring System allows medical staff to remotely view the vital signs of patients under their care without having to be in the same location. Strapped onto the wrist, the handy device is designed to check body temperature, pulse rate and blood pressure. From there, the data is transferred wirelessly to a digital chart for later review and access. In the unfortunate but unavoidable occasions where a patient's vital signs change significantly, the Vital Monitoring System sends a trigger to the member of staff, who can then immediately see to that patient and administer the necessary care. Not only will technology such as this improve patient comfort and anxiety, but it will also allow for more efficient time management on behalf of the medical staff. 24 EHM | UPFRONT LATEST NEWS US splashes out on healthcare According to a new healthcare study from the Commonwealth Fund, Americans spend twice as much as residents of other developed countries on healthcare. However despite spending more, the healthcare we receive is of a lower quality, less efficient, and we have the least equitable system. When compared to Britain, Canada, Germany, the Netherlands, Australia and New Zealand, the US ranked last. The report found that in 2007, health spending was $7290 per person in the US � more than double that of any other country in the survey. The report looked at five measures of healthcare: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives. More than 27,000 patients and primary care doctors were surveyed across all seven countries in 2007, 2008 and 2009 for the study. 1 COPD cases set to increase F or sufferers of chronic obstructive pulmonary disease (COPD), the condition is a debilitating, life-threatening and progressive lung disease that interferes with normal breathing. COPD refers to emphysema and chronic bronchitis � two commonly co-existing diseases of the lung that are not curable, but can be treated. However, a study presented in May at the American Thoracic Society (ATS) Conference in New Orleans by Education for Health, showed that the economic toll of COPD is set to soar as the largely unknown and misunderstood disease heads towards being the third biggest cause of death globally by 2020. In 2007, the economic burden of COPD in the US was $42.6 billion in healthcare costs and lost productivity, while the condition was the forth leading cause of death in the country. The new survey highlights that society faces a double economic impact from the growing COPD crisis. Not only are patients losing an average of $1800 per year in lost income due to their COPD, but nearly one in five 45-68 year olds are forced to retire prematurely due to the condition, thereby incurring increased health costs and reducing personal contribution from taxation. The primary cause of COPD is cigarette smoke. Today, 1.3 billion people smoke � a number that includes an increase among women and individuals in developing countries. 2 3 UPFRONT | EHM 25 Rising medical costs for employers Medical costs are already a concern for employers, but according to a PricewaterhouseCoopers report titled `Behind the Numbers', these costs are set to rise. With costs rising, workers will be expected to shoulder some of the burden as a large percentage of the American workforce is expected to have health insurance deductibles of $400 or more. The deductibles are the annual amount a patient pays out of pocket for care before insurance coverage starts. They are generally separate from co-payments and coinsurance. Employers typically try to soften the impact of a cost increase by absorbing some of it, changing insurance plan designs or asking employees to pay higher deductibles or a larger coinsurance percentage. Despite a possible nine percent increase, according to the report, this will be slightly smaller than the 9.5 percent jump that the market has seen this year. The main causes of increasing medical costs include: hospitals shifting costs from Medicare to private payers and employers, provider consolidation increasing and because of stimulus funding that begins in 2011 and Medicare penalties that begin in 2015, hospitals will invest billions of dollars in certified electronic health record (EHR) systems. Electronic records are expected to eventually decrease medical costs. Rash or trash? n new report would seem to suggest that despite many people believing they have some form of food allergy... they might not. The report that was commissioned by the federal government said that due to "poorly done studies, misdiagnoses and tests", the general public are often given misleading results. The report conceded that while some people have food allergies that can cause rashes and severe allergic reactions, the true incidence of food allergies is only about eight percent for children and less than five percent for adults. According to Dr. Marc Riedl, an author of the paper and an allergist and immunologist at the University of California, Los Angeles, despite the actual statistics being less than 10 percent, a staggering 30 percent of the population believe they have food allergies. A lot of the confusion lies in what is a food allergy, and what is a food intolerance. Allergies involve the immune system, while intolerances generally do not. The National Institute of Allergy and Infectious Diseases, which funded this study, is working on guidelines for the diagnosis and management of food allergies. The new guidelines, which are expected to be released in their fi nal form by the fall, will help doctors and patients identify food allergies. A 4 5 Money walks ith obesity rates in the US on the increase, it would appear the `battle against the bulge' has now moved to the workplace. With 64 percent of US adults now classed as being overweight and 26 percent being classed as obese, American companies are starting to consider the implications of obesity for their business, and are taking steps with their employees by offering them what can only be considered an incentive to lose weight. It has been reported that up to a third of US companies have started offering fi nancial initiatives, or are planning to introduce them, to get their employees to lose weight or become healthier in other ways. One example has been OhioHeath, a hospital chain whose workforce were mostly overweight, who started a program where they paid employees to wear pedometers and get money for walking. The more they walk, the more they win � up to $500 a year. Could it work for your workplace? HIEs are top priority GlaxoSmithKline (GSK) has teamed up with MedTrust Online, a US-based provider of specialist data and technology to oncologists, to launch CancerTrialsApp, described as "the first free geolocating cancer clinical trials application" for the Apple iPhone and iPad. The `app' enables cancer doctors to find and share information with their patients about experimental therapies in clinical trials. It includes a quick search menu based on 12 common cancers as well as more advanced features that refine searches based on criteria such as gender, age or trial status. Once the relevant trials have been found, the results can be mapped relative to the location of the iPhone or iPad running the application. With e-care slowly but surely introducing itself to the US, it seems as though the CancerTrialApp could spearhead the initial push of integrating technology with healthcare. W 6 26 EHM | UPFRONT Feeling the pain Cleveland Clinic's David Brown talks to EHM about the factors that lead many physicians to misunderstand the true nature of pain. a different approach. The patient may need treatment such as neural modulation or the application of some of the advanced tools, often called dorsal column stimulators. With these, we apply an electrode in the epidural space and stimulate that to mask some of the pain that they're currently having, allowing them to become more active. A lot of it has to do with getting that patient active again and providing pain care. Some of it may just be done through getting their sleep back into balance, as well as taking care of the pain with oral meds and getting them active. There are types of pain that fall into fairly well-defined categories, but every patient must be individualized according to their life setting, because the same medications that you might use for a construction worker might not work for someone who flies an airplane of someone who drives a truck. There's a lot of individual assessment that goes on. You were quoted as saying that a surprising number of physicians are unable to understand pain, and thus are left rather uncomfortable around patients. How can you help to overcome this? DB. Well, these patients very often have a complicated history, and that initial history and physical examination need to be detailed enough so that the patient, as well as the physician, has a pretty good idea of which direction they're heading in after that first meeting. We take physicians from a similar background to mine that can contribute to what we do. We have our palliative care colleagues when patients have cancer pain or other illnesses at the end of life where palliation is the most important thing. Nationally, I chaired the Accreditation Council for Graduate Medical Education (ACGME), which brings together four specialities: neurology, psychiatry, physical medicine and rehabilitation, so that we have a unified training program. We worked from 2001 through to 2007 to make that come to pass, and we've improved pain training across the country. We're not far from increasing that pain training out from annually to two per year, and we believe that will help our patients to find patients that are better trained in a multidisciplinary approach to pain care. David Brown is Chair of Cleveland Clinic's Anesthesiology Institute. What are the most important issues to factor into assessing `pain'? David Brown. Pain in and of itself is invisible to most imaging tools. If you were doing a laminectomy or something similar, the pain is not visualized, which is why the clinical exam and the clinical setting is so important. The biggest tools we use are cross-sectional imaging, either MRIs or CT scans, as well as some electro diagnostics such as EMGs. Putting together a clinical diagnosis from that the patients have told us in the physical exam, along with the history, is probably the most important thing to consider. You always have to keep in the back of your mind that there's always a reason for a patient's pain; it typically is time-limited, and it seems like physicians as well as the general population understand that quite intuitively. Let's change the setting a little bit. Imagine somebody who has had back pain for years, and there are no specific findings on physical examinations or on imaging, yet the pain is very severe. This becomes chronic pain as a disease rather than as a symptom; pain is a biochemical event that sometimes cannot be imaged; there are no blood tests that say `this person is in pain', and that's very different than in many other settings in medicine. How does a patient's setting affect their treatment; is it always individualized? DB. If a person with chronic back pain has had one or two operations, there may be efforts to rehabilitate the patient by physical rehabilitation, getting them active again, and it may take combinations of nerve blocks or it may take Cleveland Clinic's Anesthesiology Institute offers patients care from internationally renowned medical staff and dedicated support staff. A wide range of specialities and departments are all dedicated to improving the quality of life for patients. Specialities and departments include: � General anesthesiology: comprehensive services for all non-cardiothoracic subspecies and outpatient surgery. � Cardiothoracic anesthesiology: anesthesia and critical care cardiothoracic surgical practice. � Pain management: treatment options for patients with chronic and acute pain from disease, surgery or trauma. � Regional practice: anesthesia, pain management and critical care medical services for community hospitals. � Outcomes research: research to provide the evidence for evidencebased anesthesiology. � Clinical engineering and information services: anesthesia support services. 28 EHM | UPFRONT Discounted anesthesia codes, anesthesia crosswalks, free CPT� and ICD9 codes A new prevention technology Preventing catheter related bloodstream infections (CRBSIs) is a national healthcare priority. In fact, Health and Human Services has a goal to reduce CRBSIs by 50 percent in five years. Despite numerous evidence based best practices, hospitals are still struggling to prevent these life-threatening infections. Catheter Connections has developed an innovative device that the company believes addresses several significant gaps in today's prevention strategies. Patients contract CRBSIs when bacteria enter the bloodstream either from the catheter insertion site or when the two primary IV access points, the needleless injection site (NIS) and the male luer at the end of the IV tubing become contaminated. Even though the NIS is a known route of contamination it is unprotected, which puts the burden on the clinicians to adequately disinfect it. Busy nurses often don't know or don't have time to swab the NIS, plus swabbing can be ineffective at killing all microbes. Plus the NIS is only part of the problem; current clinical practice completely overlooks the male luer. While just as susceptible to colonization as the NIS, nothing can be done to thoroughly decontaminate the male luer. Catheter Connections' DualCap is the only product that disinfects and protects both the NIS and the male luer. DualCap is a sterile, disposable device containing two caps each with 70 percent isopropyl alcohol and a patent-pending delivery mechanism. DualCap has been proven, using in vitro studies, to significantly reduce the bacterial contamination associated with CRBSIs. DualCap is easy-to-use, saves time and can help decrease the human variability associated with IV care. For the first time, clinicians have a tool in their arsenal that keeps both connectors disinfected right from the start and keeps them protected between uses. It's just what is needed � a technology solution that gives hospitals the confidence that they are doing everything possible to prevent these deadly infections. B elleview Information Technology Services, LLC (BITS) is a licensed reseller of anesthesia codes from the American Society of Anesthesiologist(ASA) and CPT codes from the American Medical Association (AMA). BITS data is the same data as sold by the ASA and AMA, except we enhance the data with additional information and then sell the data fi les at discounted licensing rates. We also provide free updates if the data is updated at any time throughout the year. When any anesthesia data fi le is purchased, a CPT data fi le and equivalent license is included for free! Pre-order your 2011 anesthesia codes and save an additional 20 percent. As an example of our data content, our procedure FREE OFFER! to anesthesia crosswalk fi les include the CPT code, the Visit our website at anesthesia code linked to it plus any alternatives, the www.datadll.com CPT code description, anesthesia code description, and download a ASA recommended base units plus Medicare allowed FREE ICD9 data file base units. with current year A full description of every fi le, data layout and diagnosis codes and sample content is available on the website. Each data descriptions, no fi le is provided three ways, as a text fi le (.txt), a comma purchase required. separated fi le (csv) and an excel fi le (.xls) so it is suitable This offer is valid for import into Excel or any practice management softthrough 7/1/2011. ware that can import data. BITS will format the data in custom formats, upon request, at no extra charge. CPT is a registered trademark of the American Medical Association. 2009 ASA Relative Value Guide�, CROSSWALK� and the Reverse CROSSWALK� � 2008 American Society of Anesthesiologists The bigger picture Knowing your workforce is pivotal to improving productivity and efficiency, so here's the bigger picture in anesthesia. 1. According to the American Association of Nurse Anesthetists, there are approximately 44,000 nurse anesthetists, including CRNAs and student nurse anesthetists, in the US. 2. 59 percent of anesthetists are female; the rest are male. 3. CRNAs administer approximately 32 million anesthetics to patients each year in the US. 4. There are 109 accredited nurse anesthesia programs in the US, ranging from 24 to 36 months. 5. The average CRNA salary in the US was $189,000 in 2008-2009, according to Merritt Hawkins & Associates' 2009 review. UbiquityMD For Anesthesia UbiquityMD (UBMD) Anesthesia Practice Management Software "Our revenues have increased 8-10% since we started using UbiquityMD" Garth Grant, President, Eastside Anesthesia Group, Inc. Just 3 of the many ways UbiquityMD will improve your access, efficiency and your bottom line! 1) 24x7 internet access with robust full screen functionality both online and offline. 2) Drill down charts that give you the Real Time status of every account in your system, with ability to drill down from a summary view to the smallest details of any account in just a few clicks. 3) UBMD automatically saves an exact copy of every insurance form, patient statement and insurance report in your database, without need to print or scan. For more information please visit: www.ubiquitymd.com, call 859-586-0300 or email firstname.lastname@example.org 30 EHM | UPFRONT The world in your hands What a selection of countries are doing to increase hand hygiene and gain control over hospitalacquired infection he SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organization (WHO) to support healthcare workers to improve hand hygiene in healthcare and thus support the prevention of often life threatening HAIs. Th is initiative is part of the WHO Patient Safety First Global Patient Safety Challenge, `Clean Care is Safer Care' program aimed at reducing HAI worldwide, which was launched in October 2005. The clear and central feature of Clean Care is Safer Care thus far has been to target efforts on the importance of clean hands in healthcare. The program has galvanized action at many levels including, as at November 2009, Ministers of Health from 121 countries having pledged commitment to reducing HAI and support the work of WHO. Th irty-eight nations/sub-nations have also started hand hygiene campaigns during this time. By May of this year, more than 11,500 healthcare facilities had registered their commitment with WHO to improve hand hygiene at the point of patient care. Professor Didier Pittet, lead of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care, commented: "To prevent influenza virus spread, cleaning hands with soap and water or an alcohol-based handrub is imperative both at community level, and in healthcare settings. Although droplet spread through coughing or sneezing is considered a major route of influenza transmission, hand contamination is also a critical contributing factor. "The simple act of hand hygiene will contribute to reducing spread of infection. It is also particularly vital when caring for a vulnerable population, including the elderly and the very young, receiving care in hospitals and other healthcare or social-care environments." T The WHO's 5 Moments for Hand Hygiene The 5 Moments for Hand Hygiene tool has emerged from the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) to add value to any hand hygiene improvement strategy. It defines the key moments for hand hygiene, overcoming misleading language and complicated descriptions. It presents a unified vision and promotes a strong sense of ownership. Not only does the 5 Moments align with the evidence base concerning the spread of HAI but it is interwoven with the natural workflow of care and is designed to be easy to learn, logical and applicable in a wide range of settings. BEFORE ASEPTIC TASK BEFORE PATIENT CONTACT AFTER PATIENT CONTACT AFTER BODY FLUID EXPOSURE RISK AFTER CONTACT WITH PATIENT SURROUNDINGS UPFRONT | EHM 31 Below we look at what a selection of countries are doing as part of the WHO initiative. Australia A Th The National Hand Hygiene In Initiative/Hand Hygiene A Australia H Healthcare associated infect tions have been nominated as a priority area by the Australian Commission on Safety and Quality in Health Care (ACSQHC). Improved healthcare worker hand hygiene (HH) is the highest priority area to reduce the risk of healthcare-associated infections. Reliable indicators of HH compliance are essential, and mechanisms for the wider implementation and monitoring are required. HHA is currently in the process of rolling out the Hand Hygiene Compliance Application (HHCApp) across Australia. The HHCApp is the new tool for HHC data entry and submission and will replace the HHA MS Access Database. The HHCApp is available through the HHA website and will improve data management, enable easier data entry fromm any computer any time, and will enable faster reporting; including quicker and easier access to National benchmarks. England Cleanyourhands campaign Cleanyourhands is a program that aims to help the NHS in England and Wales achieve consistent, evidence, based practice in hand hygiene. The objectives are to ensure staff in the e NHS perform hand hygiene correctly y at the right time in the right place and d so contribute to preventing healthcare e associated infections. The program facilitates local hand hygiene campaigns and supports NHS organisations in disseminating learning and behavior change to all individual staff members. It works closely with the Department of Health and other partners to ensure consistency of practice and the application of national and international evidence. Scotland Germs. Wash your hands of them Scotland's National Hand Hygiene Campaign was launched in January 2007 and is being delivered by Health Protection Scotland on behalf of the Scottish Government Health Directorate. The main aim of the campaign is to improve hand hygiene and reduce avoidable illness. The campaign will run until March 2011. Its main aims are to support NHS Boards as they work to achieve a zero tolerance to a non-compliance with hand hygiene from January 2009 onwards through provision of expertise, awareness raising and relevant, approved material; and to provide the Scottish Government Healthcare Directorate with bimonthly hand hygiene audit reports. In addition to this a public media camp paign was launched in January 2009, a professi sional campaign for staff within NHS Scotland la launched in March 2009 and a dedicated NHS Scotland community campaign implemented in Sc Fe February 2010. Canada Hand Hygiene for Patient and Provider Safety in Canada The Canadian Patient Safety Institute (CPSI) launched a national hand hygiene campaign in 2007 under the theme "STOP! Clean your hands". CPSI is working on this initiative with the Community and Hospital Infection Control Association�Canada, the Canadian Council on Health Services Accreditation and the Public Health Agency of Canada. In 2009 and 2010 the campaign has evolved into a comprehensive safety strategy and experienced a complete update and redesign of most of the materials supporting the effort. Canada's Hand Hygiene Challenge: STOP! Clean Your Hands has now migrated to Safer Healthcare Now! where a variety of materials and resources are available for organizations across the country. United States Grime Scene Investigators: South Carolina As a leader in the US, the South Carolina Hospital Association works with all 67 acute care member hospitals and 10 other healthcare groups using many WHO recommendations and tools, including the 5 Moments. The campaign has several partners covering both healthcare and educational institutions and involves the whole region of South Carolina. GSI:SC is structured to mimic the format of the popular TV drama, CSI. 32 EHM | UPFRONT EXECUTIVE INTERVIEW My 5-Moments means true point-of-care access EHM asks Rodney Ogrin why the call for true point-of-care access to sanitizer means hand hygiene is going personal. In your view, what are the main challenges currently facing those charged with ensuring hand hygiene compliance in a healthcare setting? Rodney Ogrin. The biggest challenge to achieving and sustaining hand hygiene improvements that impact infection rates is making it possible for healthcare providers to respond to hand hygiene opportunities within the patient nest (immediate patient environment) during the busiest times. Current US common practice limits the focus of hand hygiene to entering and exiting a patient room. Without the right tools, getting all providers to significantly change practice can be an overwhelming challenge. What solutions can healthcare organizations put in place in order to overcome these challenges? RO. The WHO recommends true point-of-care access to sanitizers and a multimodal and multidiscipline approach to drive the clinical change. Adapting these tools into a comprehensive system that starts with true point-of-care access to sanitizers is paramount. The system must have the full support and involvement of hospital and clinical leadership. It should include a budget that reflects a commitment relative to patient safety values and the fi nancial stakes involved. The days of spending $1 per patient day on something as critical as hand hygiene, the very nucleus of patient safety, should be soon long forgotten. What is the World Health Organization's `My 5 Moments for Hand Hygiene' campaign? RO. The WHO's My 5-Moments campaign is an opportunity to evolve clinical hand hygiene best practice and patient safety culture. It is much more than an easy way to remember indications for hand hygiene, but a commitment to the evolution of best practice as to impact patient outcomes. It is a call for all providers to respond to every hand hygiene opportunity, especially those within the patient nest during the busiest times. True point-of-care access to sanitizer is required to meet the 5-Moments. Current US common practice is based on the use of wallmount sanitizer dispensers at the entrance of the patient room. The 5-Moments campaign specifically defi nes point of care as, "The place where three elements come together: the patient, the HCW, and care or treatment involving contact with the patient or his/her surroundings (within the patient zone). The concept embraces the need to perform hand hygiene at recommended moments exactly where care delivery takes place. Th is requires that a hand hygiene product... be easily accessible and as close as possible � within arm's reach of where patient care or treatment is taking place. Point-of-care products should be accessible without having to leave the patient zone." Wallmount dispensers at the door fall many steps short of this defi nition. How are companies like Sprixx providing the means to enable healthcare workers to meet the criteria required by `My 5 Moments for Hand Hygiene'? RO. Personal sanitizer dispensers such as the Sprixx GJ offer true ergonomic, point-of-care access to sanitizer. These devices minimize interruption to workflow and are designed to become a second-nature habit in use. Going to personal dispensers is a paradigm shift that transforms clinical hand hygiene from an institutional obligation to a personal, professional commitment to clinical excellence. Making hand hygiene a second-nature habit makes it possible to respond to hand hygiene opportunities within the patient nest during the busiest times. Such clinical patterned behavior requires a sanitizer dispenser that is always predictable in location and that can be operated with one hand. A personal dispenser makes that possible and fits the real-world needs of busy healthcare providers in a complex and dynamic work environment. Personal dispensers send powerful messages about hand hygiene and act as a symbol of patient safety. Personal dispensers are the next logical step to making hand hygiene an advanced clinical skill that is highly regarded by clinicians. My-5 Moments, the WHO multimodal programs, and personal dispensers offers your hospital a powerful way to express your patient safety commitment and significantly impact patient outcomes. Dr. Rodney Ogrin is the owner of Harbor Dental Group and Harbor Medical. He was a practicing dentist for over two decades and has been a professional tooth whitening pioneer since 1990. Ogrin is extending his successful track record as an entrepreneur with the introduction of Sprixx personal sanitizer dispensers. "The 5-Moments campaign specifically defines point of care as, "The place where three elements come together: the patient, the HCW, and care or treatment involving contact with the patient or his/ her surroundings" 34 EHM | UPFRONT RTLS: From location to automation W ithin healthcare, real-time locating systems (RTLS) are commonly known to support patient, staff and equipment tracking. However, these data are very accurate, timely and reliable, then they can also be used to support more advanced applications including automated patient flow, real-time bed management, hand hygiene compliance, nurse call automation and automatic updates within other clinical information systems, for example EHR. For nearly 20 years, Versus Technology, Inc. (Versus) has applied its clinical-grade RTLS to enable accurate location and automation for healthcare in a variety of environments extending hospital-wide (from EDs, ORs and patient care floors) to clinics and long-term care facilities. This automation has produced many benefits including reduced patient wait times, turnover times, overall visit times, capital savings and enhanced patient safety and satisfaction. In 2009, Versus was also the first to formally offer an innovative new use of RTLS automation to healthcare: hand hygiene compliance, and has since been working with the Center for Transforming Healthcare and several prominent healthcare organizations to document hand-washing practices and reduce the number of hospital-acquired infections. Using infrared (IR) and radio-frequency identification (RFID) technologies, Versus offers healthcare a distinct RTLS. "By automatically capturing and time-stamping various stages of the care delivery process, we are able to use location data for process improvement," explains HT Snowday, Versus' CTO. Snowday continues, "In every other industry, we have this concept of applying Lean management to the production process. Historically, this has been exceptionally difficult to apply to healthcare. There are just too many elements to manually capture and factor into care delivery. Versus, unlike any other RTLS vendor in existence, understands these processes and is able to capture, time-stamp and document each stage of the patient flow and clinical workflow processes." Data captured by Versus, whether related to hand hygiene compliance, capacity management or equipment utilization, allows hospitals and clinics to compare automatically captured, unbiased data to baseline performance metrics. They can then use this data to adjust even the smallest variables to determine the impact on patients and staff. Snowday notes: "For the first time, we have Lean management processes applied to healthcare." For more information: please visit www.versustech.com . Managing costs during the transition to electronic health records Network security is a necessity for any business today. However, the dire need for network security amongst healthcare organizations is being driven by Health Insurance Portability and Accountability Act's (HIPAA's) pending Electronic Health Records (EHR) requirement. Government incentives to implement EHR systems will start to decline in the next year, with maximum reimbursements being offered to those who have systems in "meaningful use" by 2011. While large health systems and hospitals are making the switch to electronic records, only 13 percent of physicians have implemented EHR systems in their practices. The transfer to electronic records is no easy task. Organizations must continue to comply with HIPAA privacy statutes, and the network security necessary to ensure this privacy comes at a substantial cost. Networks must be modernized to handle the volume of traffic and data associated with an EHR system, and the proper security measures must be in place to protect the privacy of patient data. However, the penalties for non-compliance are equally substantial. Fines can be as high as $50,000 per incident and include jail time. How can organizations ensure that their networks can support an EHR system while offering the level of protection necessary to maintain HIPAA compliance � at a manageable cost for the company? PAETEC offers exclusive programs called Equipment for Services (EFS) and Software for Services (SFS), which allow clients to use a portion of the money they spend on PAETEC services to subsidize new equipment and software purchases for their networks. In addition, the PAETEC team helps customers implement the proper network security solutions needed to meet HIPAA requirements. A layering of products and solutions is necessary to effectively combat malware, hackers and other malicious activities that may compromise the security of health records. While network firewalls provide a basic line of defense, there are still vulnerabilities that organizations must prepare for in order to prevent a network security breach. For more information on how PAETEC's EFS and SFS programs can help organizations make the switch to EHR systems while managing overall costs and maintaining HIPAA compliance, visit www.hipaa.org. UPFRONT | EHM 35 Company index Q3 2010 Companies in this issue are indexed to the first page of the article in which each is mentioned. 3M IBC Adecco 116, 117 Assurgent Medical Solutions 35, 107 Axolotl 2, 80, 81 BioImagene 10, 101 Boston Medical Center 84, 88 Catheter Connections 28, 70 Cejka Search 118, 119 Cincinnati Children's Hospital 88 Cleveland Clinic 106, 26 Concerro 114, 115 Covidien IFC, 52, 53 CT Partners 102, 103 Draeger Medical 12, 55, 59 Dynamic Clinical Systems 87 Ecolab 19 Exergen 6, 60 Federal Communications Committee 36 GE Healthcare 20, 42, 43 Hill-Rom Company, Inc. 16, 50, 51 Ingenix 82, 83 Institute for Healthcare Optimization 88 Intel 36 Kimberly Clark 49 Lawson Human Resources 104, 105 Mayo Clinic College of Medicine 44 Medical Center of Central Georgia 50 Navaro Medical Systems 28, 29 NorthShore University HealthSystem 44 Norton Healthcare 84 Office of the National Coordinator for Health Information technology 74, 79 PAETEC 34, 78 People Click 110 The Permanente Medical Group 36 pfm Medical 73 PICC Excellence 71 Philips Healthcare 54, 55 Qnomy 96, 97 River Diagnostics 64 Resource Anesthesia 27 Sanford Roses & Associates 112 Skytron 8 Sprixx 14, 32, 33 Teleflex Medical 4, 55, 56, OBC Thermo Fisher Scientific 68, 69 Titusville Area Hospital 36 Triumph Healthcare 98 University of Birmingham 108 University of Michigan Hospitals and Health Centers 62, 65 University of Montreal 108 Versus Technology 34, 92 Vital Systems 36 World Health Organization 30 Contact us: Assurgent Medical Solutions is committed to being the most thorough, well-respected, and successful healthcare staffing firm in the country. We are determined to attract the most highly regarded professionals in the industry, to utilizing the most innovative techniques, and dedicated to setting the standard in client satisfaction, all in an effort to improve healthcare throughout the United States. Our success rate is unmatched within the industry, and we bring to the table some of the best references you will find. We have had success in every facet of physician recruitment, and even the most difficult, sub-specialized search projects have been completed repeatedly by our team of professionals. Assurgent Medical Solutions 3355 Lenox Road, Suite 825 Atlanta, GA 30326 (Office) 877-842-6833 email@example.com www.assurgentmedical.com Please visit us at: ASPR San Antonio, TX August 15-18 MGMA New Orleans, LA October 24-27 COVER STORY Home is where the health is By Nick Pryke Technology thrives in every corner of society; its inescapable ability to connect the world has altered the way people communicate forever. But with patient numbers and levels of care set to rise dramatically in the healthcare sector over the coming years, how can technology revolutionize the patientdoctor dynamic? COVER STORY | EHM 37 elemedicine has been around � albeit in a rudimentary form � for centuries. In its early manifestations, African villagers used smoke signals to warn people to stay away from their village in times of disease. Again in the early 1900s, people living in remote areas of Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service. Fast-forward 100 years, and telemedicine has expanded to include its allencompassing cousin `telehealth'. Unlike telemedicine, which narrowly focuses on communication for the curative aspect of medicine, telehealth � the connection between medical technology and patients in the home setting � encompasses the preventative and curative aspects, and stresses a myriad of technological solutions. The truth of the matter, however, is that while these technological innovations are indeed being created by companies here in the US and elsewhere, Europe remains the only market where the necessary governing bodies are doing anything about implementing telehealth on a significant scale and with sufficient funding. Fortunately, all that could be about to change. Telehealth technologies are evolving to provide both patients and healthcare professionals with real-time, interactive, data-rich health management systems that can engage both patients and their care management teams more fully in the treatment of their conditions. To prove this, the Senate Special Committee on Aging set up its first hearing in six years in April of this year. The hearing, `Aging in Place: The National Broadband Plan and Bringing Healthcare Technology Home', focused on the spread of broadband throughout the US, how information technology could change the way patients and their doctors relate, the potential for cost savings, and some of the barriers to `aging in place'. T Industry experts Breaking down barriers Intel's Eric Dishman cites his four biggest barriers for e-care implementation Imagination: Providers need to imagine the possibility of e-care devices and telehealth past the traditional physicianto-physician context. Incentives: The Medicare reimbursement scheme needs to be flipped from pay-pervolume to pay-per-outcome if e-care is to catch on from a financial perspective. Once this happens, hospitals will be far more motivated to integrate e-care devices into their daily practice. Investment: With a significant majority of funding going straight into R&D and drug diagnostics, e-care technologies need to champion their need for funding from both public and private entities in order to become established and eventually evolve. Infrastructure: On the workforce level, professionals and consumers need to be comprehensively trained and educated on the necessary technologies. On the management level, the FCC's broadband plan needs to be maintained over many years to ensure that its current ethos doesn't become diluted. Mohit Kaushal, Digital Healthcare Director for the Federal Communications Commission (FCC), said at the hearing that one study claimed remote patient monitoring could generate net savings of roughly $200 billion over 25 years from just four chronic conditions. "Although economic studies like these are open to criticism due to the difficulty in quantifying savings," noted Kaushal, "the Veterans Hospital System has implemented its Care Coordination/Home Telehealth Program (CCHT) for 32,000 veteran patients with chronic conditions. The program has resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those veterans who are admitted." "There is also a significant cost saving associated with these improved clinical outcomes," added Kaushal. "The CCHT Program, at $1600 per patient per year, costs far less than the VHA's home-based primary care services, at $13,121 per patient per year, and nursing home care rates, at $77,745 per patient per year." 38 EHM | COVER STORY You may be asking yourself at this point why there's so much emphasis on the elderly population? Well, as Senator Collins stated at the hearing, the two areas where telehealth would provisionally have most the impact would be in the elderly and rural populations, as they encounter the largest array of problems with healthcare � ranging from travel distance to a lack of specialist care. "The benefits of these technologies," said Collins, "both in terms of cost savings and quality of life, are clear. They assume particular significance in rural states like mine, the state of Maine, which have a lack of primary care and speciality physicians and where patients often have to travel long distances to receive healthcare services. Yet the US continues to lag far behind other industrialized nations in the acceleration of these critically important technologies." The current problem remains that, rather ironically, the rural and elderly populations � and especially those that cross over into both categories � suffer a far higher level of IT illiteracy than those based in the city and under the age of 65. More specifically, with the national average of broadband adoption being around the 65 percent mark, the number of those over the age of 65 that are considered to be broadband literate comes in at a disappointing 35 percent. For the remaining 65 percent, the top three reasons for negating broadband adoption were a lack of digital literacy, the perceived irrelevance of digital content and heightened costs � all solvable issues. Elderly healthcare currently counts for 17% of the US' GDP E-care devices could save the industry $700 billion over the next 15-25 years The average national broadband adoption is 65% Another factor that raises the levels of IT illiteracy within the rural and elderly populations is the sheer lack of access to broadband structures. It was claimed by the FCC that up to 70 percent of clinicians outside the metropolitan districts don't currently have access to broadband structures and have to pay three to four times more than their urban counterparts. Reice Altomare, Chief Information Officer at Titusville Area Hospital, Pennsylvania, knows this better than most. Working for a small, rural hospital serving its surrounding community, Titusville is exactly the type of hospital that would benefit from telehealth implementation and federal government funding as discussed at the Senate hearing in April. "There are a few major factors that we are challenged with right now," asserts Altomare. "One is the connection issue. Particularly in rural areas, the internet is relatively redundant, which is not what you want if you're looking towards healthcare depending on such a connection. "Instead, you want two separate broadband fibers coming in, and right now the fibers here cost far too much, especially if you're going to hook up more than one building. Most companies are trying to pay for their R&D and for the build costs, so I understand why it's expensive, but without some type of subsidized program or grant we won't have the connections needed to proceed. On top of that, IT illiteracy also plays a role, but surprisingly, there has been a huge saturation of internet use by folks, even here in rural communities. If you create your portal system COVER STORY | EHM 39 and your services for those patients to leverage that knowledge and intuition already gained through using programs like Office and Hotmail, you can start to make a breakthrough. "Another major hurdle is buy-in. The physicians have to buy into it, and there have been a lot of initiatives in the sector to attempt to get this ball rolling, but there are also plenty of ideas out there in healthcare that are fighting and resisting against this `new-age' medication as we tend to think of it. Also, the patient doesn't necessarily trust it, so there needs to be a buy-in there. I believe the marketing of telehealth and the convenience of it will eventually change that flow. But for right now, all we're concerned about is how we're going to market this to specialists and to the patients so that they are willing to participate in this new form of care." "Once we knew that reimbursement schemes would cover e-care costs, all of a sudden we had physicians willing to participate in the program � and the fi nancial aspect was a huge portion of that. The other portion was patient care in general, but once physicians see it in action that goes away because they realize they can provide better care for their patients, particularly the elderly." Coherence needed Altomare is far from being in a league of his own when it comes to understanding how the ground currently lies and what needs to change in order for e-care devices and the `aging in place' scheme to prevail. At the other end of the scale stands Robert Pearl, Executive Director and CEO of The Permanente Medical Group. With a $20 billion organization on his hands, he has to be sure that every decision he makes is not only right for his staff, but more importantly for his patients. And with EMR implementation approaching fast on the horizon, it is fortunate that The Kaiser Permanente Group is well versed in pioneering innovative healthcare. In an attempt to contextualize the potential effectiveness of e-care devices and tehehealth in general, Pearl describes how The Permanente Medical Group works with technology in three parts. The fi rst concerns itself with ensuring that EMRs are fully integrated within its healthcare system to allow for all medical history to be planted in one, single medical record that can be accessed at any time. The second comes in the form of innovative internet-based tools that allow patients to make appointments, order prescriptions and check laboratory data online and at their convenience. Specific to Kaiser Permanente, the website � kp.org � allows patients to schedule their needs securely through electronic tools, while physicians and medical staff can view patient account progress in real time and update schedules and records accordingly. The fi nal part of Pearl's process deals with video functionality that allows the linking up of Misaligned incentives What becomes clear is that, while IT illiteracy is an issue that needs to be addressed, it can be done so with little more than a commitment to teaching and training. In line with that is the understanding that if people have a reason to be online, then they are far more inclined to be motivated to do so. The bigger problem, as cited by Altomare and almost everybody else at the `aging in place' hearing, is re-balancing the Medicare incentive scheme. As it stands, physicians and medical institutions are rewarded on out-of-date, misaligned economic incentives formed before the days of accelerated technology and telehealth devices, where interaction was on a purely face-to-face basis. Senator Wyden, who chaired the Senate hearing, backed this notion. "The Medicare reimbursement system is flawed," he confi rmed. "We saw in the case of the Medicare reform debate that in many respects it rewards efficiency and generally only pays the elderly when they go � in person � to the physician's office. In effect, you have an initiative that rewards volume and the people who come in, regardless of whether or not that is the correct approach. You will have, in my view, a greater expense in Medicare and for taxpayers than you'll have if you take the kinds of technologies that I've offered the committee here today that would allow for people to be cared for in a more constructive way [at home], producing better quality and more timely care at a cheaper price to taxpayers. "At this point, Medicare barely acknowledges the existence of `ecare'. It spends over $400 billion a year, of which only about $2 million is spent on these technologies. In particular, such technologies could reduce hospital re-admissions and in turn save the Medicare program fi nancial costs in the years ahead." The bottom line is that, currently, e-care technology doesn't come with a reward tag. Physicians and institutions will continue to chase volume numbers because that's what pays the bills. Until this is reversed, and Medicare realizes that telehealth and e-care devices could not only save time and improve quality of life, but also save astounding amounts of money, physicians are unlikely to adopt such technology whole-heartedly in the knowledge that it won't help them, or their institutions, fi nancially. For e-care devices to take their rightful place in this new era of technological innovation, the framework that supports and helps to fund the US healthcare sector needs an overhaul. Returning to Titusville and Altomare, pilot schemes have already witnessed the reversal of attitudes towards reward schemes and the use of e-care devices � almost as soon as the new incentives encouraged it. "I do not believe that quality medical care can be provided without advanced information technology systems in the 21st century" � Robert Pearl doctor to doctor or doctor to patient video calls. This is not strictly a new innovation, as plenty of industries have been utilizing video conferencing for some time now, but it does allow decisions to be made on the spot and in a time-conscious fashion. However, for all that The Permanente Medical Group does to push technological progress, Pearl agrees that the notion of a re-structured incentive and funding scheme is the only true way forward. "I do not believe that quality medical care can be provided without advanced information technology systems in the 21st century," commits Pearl. "It's very difficult to implement such a system. You need every physician's office, you need your hospitals, pharmacies, laboratories, radiology; that's a lot of individuals all correctly using a common electronic system. They have to have both coordination of what they're going to put into place, 40 EHM | COVER STORY coordination of the data flow amongst themselves and then how they're going to use the information that comes out of the EMR at the end. "To do that requires both technological and leadership coherence. Unfortunately for most of America, that simply doesn't exist. I sometimes speak about the fact that US healthcare most closely resembles the 19th century cottage industry in England, where you had fragmentation and a payment mechanism that rewarded volume over outcomes and was typically paper-based. It's a large transition from that cottage industry to the 21st century." A step forward With all the talk surrounding the FCC's National Broadband Plan, President Obama announced a $795 million government program on July 2, 2010, that will see over 900 healthcare facilities across the country receive broadband access. It was stated in the report that the investment will support 66 new Recovery Act broadband projects nationwide, with hopes that it could provide roughly 5000 jobs upfront and spur economic development in some of the nation's hardest-hit communities � helping to create jobs for years to come and push the emergence of e-care devices. In his speech, the President stated that the $795 million in grants and loans has been matched by a further $200 million in outside investment, adding up to a total publicprivate investment of more than $1 billion. For those at the Special Senate Committee on Aging in Place, as well as Dishman, Altomare and others, it would appear as though their calls have been answered, allowing for the groundwork to finally be laid on what is sure to become the first generation of e-care. "However, I believe this will change soon," offers Pearl, "although it will probably take at least a decade to do so. I also believe that it will require patients to demand the same level of outcome and convenience in healthcare that they demand in the rest of their lives. I often use the example of a person who travels to another country and takes out their ATM and expects that the machine will know exactly how much money is in that bank account in whatever country they came from; it will know the exchange rate and will deliver them local currency. Essentially, patients will want that same level of convenience from their healthcare that they receive from the rest of their daily lives." Th is idea of convenience certainly permeates throughout almost every argument in favour of e-care and remote patient monitoring. In terms of fi nancial convenience, the FCC recently released data that confirmed that remote patient monitoring and e-care devices could save the healthcare industry upwards of $700 billion over the next 15 to 25 years. Combine that with the fact that due to aging and its links with chronic disease, healthcare already accounts for 17 percent of America's GDP � and by 2020 it is predicted that it will account for 20 percent � and it soon becomes glaringly obvious that e-care could not only help the healthcare industry, but the economy of the country as a whole. While elderly patients with chronic conditions account for roughly 10 percent of Medicare patients, they take up a staggering 85 percent of Medicare costs. By implementing e-care devices and remote patient monitoring, increased communications in medical technology has the ability to keep seniors more mobile at a far lower cost, which is the ultimate intention of the `aging in place' program. Once this can be placed in an achievable position, the next step becomes an ability to balance an environment that places a priority on patients' concerns and the particular combination of conditions affecting them, versus a greater stress on patients, their families and caregivers to assume a larger role in identifying and articulating their healthcare concerns and interests. It is here that technology and knowledge should coincide and perfect the balance. E-care devices To ensure this happens, Eric Dishman, Intel Fellow and Director of Health Innovation Policy for Intel's Digital Health Group, has spent the past 10 years working with institutions, patients and technology wizards at Intel to provide the necessary data, technologies and evidence to persuade the federal government and the relevant healthcare bodies that e-care is the only way forward. Considered one of the pioneers of e-care devices, Dishman has focused his efforts on what he refers to as "taking healthcare off the mainframe", and concerns himself with an understanding of how behavior can be measured and monitored in a meaningful way through the use of next generation e-care devices. Having worked with 1000 elderly households across 20 countries, Dishman and his team have managed to come up with various disruptive technologies to aid independent living. Perhaps the biggest motivator for this was when Dishman noticed in 1999 that, while everyone else was worrying about old computers going bust on millennium night, demographers were worried about the fact that, for the fi rst time in decades, there were more elderly people on the planet than there were young ones. Dishman labelled this `Y2K plus 10', as the metaphorical tidal wave of COVER STORY | EHM 41 elderly-to-be-patients was building up but not due to crash down on the healthcare system for another 10 years. Unfortunately health reform has given little consideration to this `age wave' of baby boomers about to enter the healthcare system. Regardless, Dishman and his team have evolved some extremely effective technologies from everyday items. The telephone, for example, has been transformed into "surreptitious technology for the elderly that can tell them when to take medication". Amongst its uses, Dishman boasts that it can be used as a cognitive test by monitoring phone usage of elderly patients over a given period of time, and then analysing the time it takes them to recognize who's on the other end of the phone by up to one tenth of a second. In doing so, the subsequent data can be used to detect the onset of dementia. As if that wasn't clever enough, the phone can also be used to measure quietness of voice, which can detect for Alzheimer's and Parkinson's disease and what Dishman refers to as "phone touch" � where detecting, recording and monitoring how a patient's hand tremors change over time can alert physicians and caregivers to the onset of arthritis. Moving on from the phone, Intel have also produced what has become known throughout the e-care world as `SHIMMER technology'; a microchip placed conveniently around a patient's ankle with various plug-ins to record a person's walking stride, gate and stride length in a `real world' context. As an evolution of SHIMMER technology, Dishman has also produced a `magic carpet' that can be placed in the home or care setting. A carpet with embedded sensors, it functions in almost the same way as the ankle microchip, except that it includes weight distribution and tracking with its data. According to Dishman, the point of these technologies is two-fold. Firstly, the collected data can be interpreted to depict if a patient is more likely to fall in a specific setting, and if so why and how that fall came about. Secondly, it allows Intel to collect � for the fi rst time in healthcare history � actual kinetic data outside of the clinical setting that can be used to understand the subtle changes occurring that lead to a fall type specific to elderly patients. With these technologies, Dishman aims to remove 50 percent of care to the home in the next 10 years, stating: "It is achievable, moral and should be done for quality of life." Yet he is quick to assert that such health technology is not meant to replace the doctor-patient relationship, but rather to enhance it using new tools. "Just as email became a new way of interacting with other people that didn't replace all other forms of communication such as phone calls and letters, e-care uses new technologies to create a new way of providing care that complements � but doesn't replace � all clinic visits," he said. At the hearing, Dishman also outlined the four biggest barriers to telehealth implementation. With the obvious two being the aforementioned current incentive scheme and the fact that the large majority of healthcare investment goes straight into R&D and diagnostics for drugs instead of e-care technologies, the remaining two carried just as much weight. Workforce and technology-related infrastructure entered in as a third barrier, with Dishman citing a lack of preparation on behalf of hospital professionals and consumers at home to be sufficiently trained to comprehend the technology on a workforce level. The FCC's national broadband plan also needs to be maintained over a more substantial "Just as email became a new way of interacting with other people that didn't replace all other forms of communication such as phone calls and letters, e-care uses new technologies to create a new way of providing care that compliments � but doesn't replace � all clinic visits" � Eric Dishman period of time � decades not years � to ensure that the infrastructure gains strength and doesn't crumble once its inceptors retire. Dishman referred to the fi nal barrier as a lack of `imagination' on behalf of the providers and government. As it sits, physicians can't imagine what e-care can do for the relationships with their patients as they simply have never experienced it before. Combined with this is the reality that currently no one owns an e-care strategy. For all the right incentives, investments and lateral thinking available � if there is no owner, there is no decision-maker. Continuing Dishman's analogy of taking healthcare off the mainframe, the advantages of e-care become increasingly obvious to see, whilst unfortunately peeking oiut through the cracks of the current chronic healthcare system. What we are left with are too many clear-cut contrasts. Where the `mainframe' is reactive, e-care is proactive; where one concerns itself with periodic, 15-minute examinations, the other monitors 24 hours a day, seven days a week. One utilizes purely biological data, the other a myriad of biological, psychological and behavioral data. And the list goes on. Ultimately, in a world that survives side by side with technology, it's about time it was applied to our healthcare. As Mohit Kaushal put it at the Senate hearing: "It's only once we've done this that we can transform what is currently `sick care' into `healthcare'." 42 EHM | INDUSTRY INSIGHT Want sustainability? Focus on transformation, not automation By Earl Jones O ur nation today faces a singularly important juncture in the history of the US healthcare industry. Unsustainable escalation in healthcare costs, inconsistent care quality, challenges with medical errors and patient safety, and the need to expand care coverage have all converged like the perfect storm. There is growing consensus that the lack of clinical information transparency � that is, clinical information that is either in paper form or siloed away in disconnected soft ware systems � is a key contributor to the problems before us. To help remedy this problem, the federal government is making an unprecedented investment to modernize US health systems. Under the Health Information Technology for Clinical Health Act (HITECH), providers and states are receiving billions of dollars in economic incentives and grants to modernize health IT infrastructure. Janet Marchibroda, from the Office of the National Coordinator for Health IT, crystallized this moment in time, saying, "We will never have this amount of investment again for health information technology; let us not waste this moment." The emerging solution for Connected Care Communities is the health information exchange (HIE). The investment in HIE is growing rapidly: in fact, according to eHealth Initiative's 2009 HIE survey, the number of operational HIEs grew nearly 40 percent from 2008 . The recent $547 million in grant funding by the federal government is further driving HIE adoption. Despite the growth and unprecedented federal investment, many questions remain regarding the long-term sustainability of health information exchanges and health information organizations. Jennifer Covich Bordenick, CEO of the eHealth Initiative, pointedly noted, "Operational does not equal sustainable." To gather insight on the benefits and longterm sustainability of HIEs, GE Healthcare hosted an HIE Sustainability Summit with leading HIE policymakers, industry analysts and HIE executives. Addressing the pressing issue of sustainability and the value of HIEs, speakers shared their experiences and vision for building viable HIE entities. Several presenters reiterated the following points. Build robust HIE infrastructure. A bi-directional, standards-based, semantically interoperable HIE infrastructure provides the connectivity backbone for connected care communities. Automating community workflows through simple secure messaging will provide short-term quick wins, but will not support more complex use-cases and workflows. Pay attention to adoption. Without strong provider engagement, HIE adoption fails. Focus on early provider involvement and change management, and pay careful attention to making workflows as seamless and as simple as possible. Drive for transformation. Health information exchange is a means to an end. Applications such as clinical decision support, chronic disease management, quality and performance reporting, and proactive patient engagement leverage HIE infrastructure to improve care outcomes and bend the cost curve. The value created from these and other performance applications is what will ultimately drive HIE sustainability. Digitizing clinical data through an EMR is an important and necessary fi rst step in this journey. However, when we create connected care communities � providers, patients, payers and health services linked together with seamless and secure clinical information sharing and community-based workflows � we will truly unleash the transformative potential of healthcare IT. Information transparency within a healthcare community will drive better care decisions and outcomes and higher productivity, and will catalyze innovation. Joel Vengco, Director and Chief Applications Officer at Boston Medical Center, commented on their effort to leverage information across their community, beyond pure data sharing. He noted that they began "to think about how to access the data that is now standardized and liquid in an information exchange, by wrapping a set of services around it that really satisfies functional business processes." GE Healthcare's Chief Medical Officer, Brandon Savage, MD, stated that sustainability, often viewed as a destination, is really a departure point on the journey to clinical transformation. "Performance drives sustainability, and sustainability drives growth," he noted. It is with this stewardship and focus that we will begin to transform healthcare. Earl Jones is Senior Vice President and General Manager, 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. http://www.ehealthinitiative.org/sites/default/files/ file/2009%20Survey%20Report%20FINAL.pdf 44 EHM | INFECTION CONTROL With ventilated patients unable to communicate, ventilatorassociated pneumonia can become a difficult infection to identify. Marc-Oliver Wright and Ognjen Gajic discuss strategies to cut off the germ invasion caused by VAP. By Nick Pryke & Ian Clover H ealthcare systems worldwide are in a perpetual struggle to eliminate hospital-acquired infections (HAIs) � no mean feat considering the phenomenal range of infection sources patients are potentially exposed to as soon as they cross the threshold of a hospital or clinic. Developing countries undoubtedly find themselves at the lower end of the success curve, but for developed countries, the battle remains just as aggressive. That battle becomes all the more poignant when it's on behalf of patients who are unconscious and dependent on staff and equipment for their survival. At NorthShore University HealthSystem, the Director of Infection Control, Marc-Oliver Wright, understands how to battle on behalf of his patients � and with an average mortality rate of between two to three percent of all HAIs, that understanding can quite literally save lives. "I'd say a relatively conservative estimate would be at least somewhere between four and 10 percent of all people who are hospitalized will have had an HAI sometime during their stay," says Wright. Ognjen Gajic, Associate Professor of Medicine at the College of Medicine at Mayo Clinic, agrees that HAIs are a huge worldwide and US problem, and that their impact on the healthcare system is costly. "Worldwide, approximately 1.5 million people at any time have HAIs, with close to 100,000 cases in the United States, which is obviously a huge figure. Estimates place the costs to the US healthcare system at $5 billion annually, some $15,000 per infection." Gajic concedes that VAP is the most common of all HAIs, pointing out that one in 10 patients who need to be placed on a ventilator for longer than 24 hours will, on average, develop VAP. "VAP is also one of the most deadly HAIs," agrees Wright. "Yet determining whether a patient has VAP is a very difficult thing to do. In the last couple of years, American medical literature has proposed that VAP is a very poor quality metric, as the subjectivity of assessing who has VAP differs from individual to individual. The Centers for Disease Control and the National Healthcare Safety Network definition for VAP shows that the inter-observer reliability is incredibly poor. That makes it extremely difficult to give an accurate picture of what we look at when we try to define it. "If you look at some of the national data from the National Healthcare Safety Network, we're talking somewhere between two and five VAPs for every 1000 ventilator days, but within some of the published literature those rates vary quite widely. One of our nation's leading experts typically reports that rates are far higher than what we see in the National Healthcare Safety Network. VAP is one of the most subjective HAIs that we try to measure in infection control, and it makes it exceptionally difficult." Hard to identify Indeed, trying to identify whether a patient has contracted VAP when they're unable to communicate certainly has its challenges. In order to diagnose or assume VAP, the medical staff must therefore have a sound comprehension of why VAP would occur in the first place: Any invasive medical device by its very nature � from a ventilator tube to a catheter � bypasses the body's natural protective barrier. When this happens, the potential for problems becomes very real. "When you insert a peripheral IV into someone's arm, it damages the skin, which is there to keep organisms out of the body and out of the bloodstream," explains Wright. "VAP is even worse because your entire respiratory system from your nose and mouth down to your lungs is aligned with protective benefits. When we shove a tube past all the cilia that we have along our trachea, we're basically opening up the `autobahn' to organisms. That's the first problem: You're doing something that your body doesn't want to. That being said, sometimes it's medically necessary. One of the best things you can do is to get that tube out of there as quickly as possible � that's the first and most obvious element." Gajic agrees. "The key issue is, the longer the tube is in, the worse it is for the patient. Prolonged endotracheal intubation is the critical risk factor for death. The normal barriers of your mouth and nose have been breached by the tube and, obviously, defences are lowered so bacteria from the external surroundings can enter a patient's lungs." "Then you have oral contamination," continues Wright, "where someone who is chronically ventilated has a lack of mouth hygiene. It's not like you and I who get up in the morning and brush our teeth, gargle with Listerine and evacuate the organisms inside our mouths. Oral hygiene is incredibly important and if it's not well maintained you start to get a build-up of organisms in the mouth that eventually work their way down that superhighway directly into the lungs. "Other things can include the manipulation of the catheter � whether we're suctioning, adjusting it or trying to extubate a patient � any time we come into contact as a healthcare worker with a tube that's going down into the patient's chest, we have to make sure that our hands are clean and that we're not contaminating the endotracheal tube and not giving organisms a chance to get well and truly down there." "Strict control measures in hospitals are the most important achievable preventative strategy we can adopt," says Gajic. "Easy isolations include controlling pathogen transmission through hand hygiene and other contact precautions, so 100 percent hand washing, in and out, is imperative. Other steps we can take include decreasing the duration of endotracheal intubation as much as pos- 46 EHM | INFECTION CONTROL sible � weaning and sedation protocols had us worried that chanical ventilation, may potentially benefit from several we were retracting the tube too early, but we have learned other strategies too, such as continuous subglottal suction, that we were usually being very conservative. Stricter proa procedure that entails specific suction devices either tocols, such as early ambulation, the use of non-invasive with an ET tube or via a small puncture through the neck, ventilation and wearing masks help decrease the exposure which continuously sucks out secretions before they get and duration of endotracheal intubation, so the conduit to the lungs." between mouth and lungs is not in situ for too long a time." Another important aspect to keep in mind is the Another effective option is to make sure that a ventipatient's position on the bed. "At NorthShore we monitor lated patient, if medically feasible, is sufficiently elevated. what angle the head of the bed is at for the patient, whether Essentially, position is critical to aiding prevention; if a paor not they've received their oral hygiene for that shift, tient is lying on their back, they are far more likely to have whether they've had a GI prophylaxis and whether their organisms traveling down and inhibiting the pulmonary sedation medication has been weaned sufficiently," says system from operating effectively. According to Wright, Wright. "The reason you would want to do that is because an optimal level of elevation should be around 30 degrees. when a patient is on a ventilator they're often heavily seAccelerating from the traditional to the cutting edge, dated. That is often unavoidable, but in order to properly there are also a number of technologies that are adept at evaluate whether they need to continue to be on a vencombating the onset of VAP. "There are things that tilator, you need to wean that sedation medication we as healthcare providers can leverage within the back a little and find out the truth, so to speak. healthcare system that help us actively moni"We then document that in our elector and identify issues before they become tronic medical record and are then able incredibly problematic," says Wright. "For to extract that data at a later point and calexample, patients have been getting their culate the rate at which we are achieving our mouths cleaned in the hospital for quite some process measure. These are the kinds of things time, but we've now applied a different technique using that, if my mother were on a ventilator, I would want something called chlorhexidine, which is a great bacteria done or checked on daily. What we're able to do is to killing agent that we've used in the hospital for a lot of turn around and pull that data out on a regular basis, feed other things, such as prepping the skin before surgery. that back to the manager and physician for the unit and say "They've figured out how to put chlorhexidine into `You and your staff are doing a great job; you're 90 percent some of the oral care agents that we use to clean the at this and 90 percent at that. But maybe mouths of our patients who are we need to work on this area.' on ventilators, and that drastically "Likewise, when we identify a ths from of all dea VAP may account for up to 60% reduces the amount of bacteria, person that has an infection, we often ns in the US healthcare-associated infectio which in theory should also drapull the information for that particumatically reduce the likelihood that lar patient from the medical record in the patient's own oral organisms or an automated fashion where it's easy flora are going to cause problems in to fi nd out what could be contributHealthcare-associated pneumonia patients have the ventilator. We're starting to use ing to that patient's VAP. From that a mortality rate of 20 % to 33 % that at NorthShore ourselves." you can fi nd out whether it was a lack of oral hygiene or the bed head Silver lining being less than a 30 degree angle, In addition to such innovative for example, and use that inforVAP increases patient time in the ICU by 4 to 6 days practices, a number of other methods mation to interact with the care are becoming more widely used in the providers in order to work on the fight to reduce the incidence of VAP. problem area." One such method involves taking a plasated to generate P is estim Each incidence of VA tic endotracheal tube and lining it with Treatment to $40,000 a cost of $20,000 a free silver alloy that is already used in Flipping the metaphorical other anti-infective devices. This significoin, once a patient has contracted cantly reduces the likelihood of organisms being able to VAP, a completely new set of perspectives needs to be admigrate down the tube and into the patient's lungs. opted in order to prevent further complications. From the "Silver-coated endotracheal tubes may be used in bedside aid of physicians and nurses, the responsibility at some of the high-risk patients," says Gajic. "These highthis stage is passed on to the microbiology laboratories at risk patients, who are deemed to require prolonged meNorthShore and Mayo Clinic, with the intention of turn- VAP STATISTICS INFECTION CONTROL | EHM 47 "When we shove a tube past all the cilia that we have along our trachea, we're basically opening up the `autobahn' to organisms. That's the first problem: You're doing something that your body doesn't want to" ing around a susceptibility profile; essentially finding out which antibiotics work well for a particular bug. As time is critical, a susceptibility profile can often be produced at the same time that the necessary organism is detailed to the necessary staff. "Timely and appropriate antibiotics are the main therapy for patients with VAP," says Gajic. "The pneumonia that caused respiratory failure (and the need for ventilator care) and the new infection are likely to be resistant to some of the first line antibiotics, so the appropriate choice of antibiotics to cover possible microbes is very important, and it's largely hospital-dependent." This point is echoed by Wright, who stresses that NorthShore's microbiology laboratories are alert to the dangers posed by incorrect antibiotic administration. "Sometimes, you might actually start antibiotics before you get the results back," he admits. "You start the patient on antibiotics for what you think might be causing the pneumonia. Then when you get the results back, you tailor your therapy to be more specific to that organism and complete the therapy. At the same time, you don't want to give up on trying to get that patient off the ventilator. While VAP is a relatively infrequent occurrence, it's not unheard of for a patient to have pneumonia, recover and still be on the vent and get another pneumonia, so you need to go after it as aggressively as possible." One would naturally assume that starting a course of antibiotics before the known organism is released could have a detrimental effect on the patient, but as Wright points out, that is very rarely the case. "It will undoubtedly vary from organism to organism and antibiotic to antibiotic, but generally that isn't the case because what we're talking about with empiric antibiotic therapy is usually a single dose or a single day of doses. The bad things that could happen to a VAP patient are the same that can happen to any patient on any antibiotic. "They might have an allergic reaction or it might adversely affect their kidney function � all those things that you could have with many antibiotics. But the consequences of not starting that treatment early enough are even worse. Hypothetically speaking, if I woke up and had pneumonia while my doctor is waiting 24 to 48 hours to get a result back, I would be well on my way out the door literally before the end of the day. "Anyone entering a hospital at any time has the possibility of acquiring any sort of HAI. There are drug-resistant bacteria such as MRSA and VRE. There are bacteria that are incredibly smart too. For example, if you come in with a bacterial infection in your lungs and you get placed on antibiotics, you may very well develop what's called C. diffwhich is an enteric pathogen in as much as it gives you horrible diarrhea � but it only exposes itself once the patient is put on antibiotics as the antibiotics kills everything else." 48 EHM | INFECTION CONTROL Other HAIs relative to VAP include urinary tract infections, which can be yet another source of trouble. If a patient enters the hospital environment to be placed on a ventilator, there is a very good chance that they will have a Foley catheter put in place to aid the patient's functioning and bowel movements. In addition, and for the same reason, an intravenous line would almost always be present to feed the patient the necessary antibiotics, because swallowing pills is obviously not an option. "Hospitalized patients placed on ventilators are at risk of bloodstream and urinary tract infections because they almost always have arterial, central venous and urinary cuts," says Gajic. "These insertions are sometimes unavoidable, and they do increase a patient's risk of contracting a bloodstream infection. Again, these infections are partly preventable as long as adherences to strict infection control measures are put into place. We have come a long way in decreasing the risks by proactively thinking, `When can I take the device out?' rather than having it stay unnecessarily for longer periods and become the cause of infection." Difficult elimination With a seemingly infinite number of potential infection routes for a ventilated patient to contract VAP, hospitals have a colossal job on their hands in attempting to prevent both HAIs and VAP. It is here that Wright is clear about the task ahead for the healthcare industry � and it seems that perhaps the term `prevention' may be more accurate than `elimination'. "I realize there are many publications out there that talk about how one hospital or another hospital got to zero ventilator-associated pneumonias," says Wright. "I think that a lot of that has to do with the subjectivity of determining who has a VAP. That being said, we don't have a very good measure in infection control to assess an individual patient's risk. If you can imagine the gentleman that comes in, has to have cardiac surgery and so goes into the operating room. They intubate him, but he's relatively healthy. The next morning they take his ventilator out. Now, there's no reason why he should ever get a VAP as he's relatively healthy and intubated for a very short period of time. "Compare that to someone who has been a quadriplegic for 20-25 years and has been chronically trached; it's going to be very difficult to prevent a pneumonia from ever happening in that individual. Say they have multiple health conditions aside from their paralysis � being on a ventilator for that period of time and never experiencing an acute lung infection? I think it's difficult, if not approaching outside the realm of possibility. "I firmly believe that it's completely possible, plausible and fully achievable to eliminate VAP in our low-risk population and probably even in our moderate-risk patient population � someone who's on a ventilator for a couple of days or even a week. But for those who are chronically receiving artificial ventilation? Never say never, but I think unfortunately it's highly unlikely that it will ever be fully eliminated. The pathogenesis of VAP is very multi-factorial. Even if you have all the bells, whistles, silver tubes, perfect air and the perfect oral hygiene, all you need is that one loving daughter to come in and not wash her hands who wants to give daddy a kiss. There are just far too many options for this to be completely preventable." On this issue, Gajic is equally skeptical. "Strict prevention protocols and infection control measures can mitigate, but probably not completely eliminate, the causes and complications [associated with VAP] because sometimes the original condition requires the presence of these foreign devices for a lengthy period of time, and it is simply impossible to avoid all of these infections. Foreign bodies in an organism do, obviously, break the natural defenses, they break barriers, and they cause infections." While Wright jokingly suggests that the best way to avoid an HAI is to not become hospitalized, his quip does carry a serious message for the progression of fighting VAP: complete elimination is just not plausible. Instead, VAP should be fought by preventative methods that are backed up by a solid and efficient system, which functions instinctively when the unfortunate event of a VAP does occur. "Consistent efforts on VAP prevention will lead to reductions in the incidents of this complication and the associated burden," concludes Gajic. "So it can be greatly limited but will never, unfortunately, be completely eliminated." Marc-Oliver Wright is Director of Infection Control at NorthShore University HealthSystem. Ognjen Gajic is Associate Professor of Medicine at the College of Medicine, Mayo Clinic. 50 EHM | EXECUTIVE INTERVIEW The advantage of motion Leslie Swadener-Culpepper passes on her tips for implementing CLRT in the ICU. What were the changes that sparked your interest in using continuous lateral rotation therapy in your intensive care unit? Leslie Swadener-Culpepper. I've long had an interest in mobility as a process to keep lungs clear. With a critically ill patient who has tubes, wires, IVs and ventilators attached to them, mobility is a challenge. I wanted to fi nd out what kind of mobility was best for the patient, when it should be implemented, how it should be implemented and for how long. In a study we carried out between 2002 and 2004, we compared lateral rotation for early versus late implementation. The study found that if you apply lateral rotation for at least 18 hours per day in a patient that meets the criteria very early on, within 48 hours, then they have much better outcomes than waiting, or obviously not applying the therapy at all. Please tell us about some of the protocols and processes have you created to achieve successful CLRT outcomes. LC. We have a clinical practice guideline in place that is nurse-driven. We believe that it is a nursing function to assess the patient's need for lateral rotation to prevent pulmonary complications just as much as it is to assess for skin complications. You turn a patient every two hours for skin care; if you assess that the patient meets the criteria for needing to rotate for pulmonary care, we believe that's just as much a nursing and allied health responsibility, so we've empowered our nursing and respiratory staff based on inclusion and exclusion criteria. If the patient meets the criteria, then we can place them on lateral rotation without obtaining an additional physician order; our protocol provides a standard that allows us to do that. What are some of the barriers that could hinder CLRT implementation? What solutions would you pass on to those thinking of implementing CLRT in their ICU? LC. CLRT has always had its barriers. We call patients' hemodynamic status in general. If a patient is unstable and their blood pressure has dropped or their oxygen saturation level has dropped because of their degree of illness, and they're on lateral rotation therapy, the fi rst thing that the staff want to blame is the rotation, and stop the therapy. We've had to do a lot of education in supporting nurses to show them how to manage the patient's volume status, pressure status and oxygenation status, and show them ways to alter the lateral rotation therapy so that the therapy can continue without destabilizing the patients' hemodynamic status. Leslie Swadener-Culpepper, RN, MSN, CCRN, CCNS is a clinical nurse specialist for critical care at the Medical Center of Central Georgia in Macon, Georgia. A critical care nurse for 27 years, and a CNS for 15, her practice has included clinical practice, education, process improvement and leadership roles. "We've had to do a lot of education in supporting nurses to show them how to manage the patient's volume status, pressure status and oxygenation status and show them ways to alter the lateral rotation therapy so that the therapy can continue without destabilizing the patients' hemodynamic status" them `hassle factors'; the things that get in the way of the nurse implementing the therapy. Nurses for example, want to make their patients look good. If their patients are on a continuously moving bed, sometimes the patient isn't as neat as nurses would like them to be and they don't like that. Another big thing that hinders implementation in CLRT in the clinical setting is How do you measure the success of CLRT therapy in your unit? LC. We have a variety of ways to measure it. We evaluate compliance to our CLRT protocol as part of our process standards, and our process standards are evaluated with the other elements of the VAP bundle. Respiratory therapy assists with this evaluation. We look to see, on a regular basis, of the patients that meet criteria, how many of them are on CLRT, how many aren't, how many of them have their head elevated to 30 degrees, how many of them have `evac' endotracheal tubes, for example, So we look at our standards and we implement changes in order to increase compliance and to make sure that those numbers stay at an acceptable level; we look to see that `evac' endotracheal tubes are used on all of our intubated patients and that CLRT is implemented within 24 hours of meeting the criteria. Having beds with CLRT capability in the unit makes it a lot easier. Nurses don't have to wait to call for a rental bed, get a bed in, transfer the patient over, which is another big problem for a lot of nurses moving a patient from one bed to another when they've got multiple tubes and lines; if they were to become dislodged during transfer to the specialty rental bed, that would be detrimental to the patient. 52 EHM | EXECUTIVE INTERVIEW Helping patients breathe easier EHM talks to Douglas Hansell about the latest advances in ventilation and microaspiration. tion � a term that refers to the dangerous seepage of foreign material past the tracheal cuff and into the respiratory tract. Tell us about the latest advances in the area your product serves. DH. Microaspiration � the movement of secretions into the respiratory tract � is widely viewed as a cause of specific post-intubation pulmonary complications, including postoperative and ventilator-associated pneumonias. The overwhelming majority of such microaspiration cases stem from inadequately designed tracheal cuffs that fail to seal the tracheal passageway. The current standard endotracheal tube, which has a barrel-shaped high volume, lowpressure cuff, was originally introduced in the mid-1970s as a redesign of the original red rubber tube. Though the gold standard for over 30 years, the barrel-shaped cuff provided an adequate air seal but did not adequately seal the patient's tracheal passageway. This allowed secretions to potentially migrate through folds in the cuff. Although these air seal gaps are very small � micro in size � they can allow gastric laden secretions or virulent secretions associated with pneumonia to enter into and be dispersed throughout the lungs. The new Mallinckrodt TaperGuard line of endotracheal tubes reduce microaspiration by an average of 90 percent compared to conventional high volume low pressure cuffed endotracheal tubes. When used in surgical procedures and critical care applications, TaperGuard endotracheal tubes will substantially reduce specific and severe risks related to the movement of secretions beyond the tube's sealing cuff, most notably from pneumonia. In addition to microaspiration reduction, the Mallinckrodt TaperGuard Evac endotracheal tube has been shown to reduce significantly VAP. As a further example of the value of Covidien's integrated respiratory product portfolio, when the TaperGuard Evac endotracheal tube is used in conjunction with a Puritan BennettTM 840 ventilator, clinicians can further reduce the risk of infection because of the ventilator's inspiratory and expiratory filters. These filters prevent the ventilators from becoming either inspiratory or expiratory transmission vectors for viral and bacterial agents. Discuss the educational services you offer for use of your product. DH. Covidien offers an exceptional level of service and technical support, including onsite and real-time training for clinicians. This hands-on service is complemented by a comprehensive array of clinical education resources, including a wide variety of free, accredited continuing education courses for registered nurses and respiratory therapists. Available through Covidien's Center for Clinical Excellence website, these self-paced courses can be accessed 24/7 and offer convenient post-testing, plus the ability to earn a Certificate of Completion that may be used to meet or accumulate contact hour requirements for re-licensure. What new technology do you see as having the greatest impact on your area of expertise? DH. Technology gains with miniaturization are likely to have the greatest impact in the area of portable ventilation. The ability to produce smaller ventilators addresses a key healthcare concern facing clinicians and patients today: How do we make a significant improvement in a ventilation-dependent patient's quality of life and health outcome? The answer in part depends on the size of the ventilator. Covidien offers the Puritan Bennett 540 ventilator that weighs less than 10 pounds and provide up to 10 hours of portable operation. These improvements potentially provide ventilation-dependent patients � including adult and pediatric patients � the chance to live much less restrictive lives than would be possible with larger and more cumbersome equipment. Douglas M. Hansell, MD, MPH, is Medical Director for Covidien. A Harvard-based physician, Hansell has over 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. Could you please describe your products and their unique features. Douglas Hansell. Covidien, a leading global healthcare products company and recognized innovator in mechanical ventilation and respiratory care devices, delivers reliable, indispensable respiratory care products for use in hospitals, healthcare facilities and homes. The company's integrated portfolio of respiratory and monitoring products spans broadly across pulse oximetry, airway and temperature management, critical care accessories, acute care and home ventilators and hospital soft ware solutions. In the pulse oximetry category, Covidien created the first commercially viable pulse oximeter more than 20 years ago; we continue to lead the way in R&D today with the Nellcor OxiMax n-600x pulse oximeter with Alarm Management System, which helps clinicians more effectively and monitors a broad range of patients. Launched in late 2009, Covidien's Mallinckrodt TaperGuard line of endotracheal tubes introduced a revolutionary, tapered-cuff design that significantly reduces microaspira- ROUNDTABLE | EHM 55 sterile lower respiratory tract, which means VAP could be referred to as intubation-associated pneumonia. Stefano Nava. The incidence of VAP within US hospital varies according to the type of environment, the geographical location and also the prevention measures adopted by each specific hospital. Nationwide, a large retrospective survey was conducted in the late 1990s. According to that study, of the 9080 patients meeting study entry criteria, VAP developed in 842 patients (9.3 percent). The mean interval between intubation, admission to the ICU, hospital admission, and the identification of VAP was 3.3 days, 4.5 days, and 5.4 days, respectively. Risk factors for VAP were also examined using crude and adjusted odds ratios. Identified independent risk factors for the development of VAP were: male gender, trauma admission and intermediate deciles of underlying illness severity (on admission). Quite surprisingly, hospital mortality did not differ significantly between cases and matched control subjects, Nevertheless, patients with VAP had a significantly longer duration of mechanical ventilation and hospital stay. Other single-center or multicenter studies have also shown an association between VAP and mortality rate. Preventing VAP Three industry experts give us their views on the fight to eliminate ventilator-associated pneumonia from the US healthcare system. Ernest Waaser, President, Teleflex Medical, has over 20 years of experience in the medical device industry, leading multinational businesses, including as President/CEO of Hill-Rom, President of Agfa Medical Imaging and COO of Sterling Diagnostic Imaging. He holds a BS degree in Nuclear Engineering from Mississippi State University and an ME degree in Mechanical Engineering from the University of South Carolina. How common is ventilator-associated pneumonia within US hospitals? What are the circumstances that would result in a patient contracting VAP? Ed Coombs. VAP is a leading cause of death associated with hospital-acquired infections. It is exceeding the rate of death due to central line infections, severe sepsis and What are some of the strategies that hospitals can respiratory tract infections in the non-intubated patient. employ to prevent the occurrence of this type of Perhaps the most concerning aspect of VAP is the high pneumonia? What technologies are available to help associated mortality rate. Hospital mortality of ventilated achieve this? patients who develop VAP is 46 percent compared to 32 EW. According to SHEA, strategies to prevent VAP in percent for ventilated patients who do not develop VAP. hospitals focus on controlling the main causes: aspiration In addition, VAP prolongs time spent on the ventilaof secretions into the lungs, colonization of bacteria in the tor, length of ICU stay and length of hosaerodigestive tract and use of contami"While VAP appears pital stay after discharge from the ICU. nated equipment. Many hospitals adopt to be an impossible VAP adds an estimated cost of $40,000 a VAP bundle approach. Simple steps of challenge to eliminate, hand washing, head-of-bed elevation and to a typical hospital admission. the history of routine oral care, combined with the use of medicine shows that Ernest Waaser. The CDC and the innovative medical devices and caregiver many healthcare Society for Healthcare Epidemiology education, have also been effective. Recbreakthroughs have (SHEA) cite VAP as the second most ognizing the value of this comprehensive solved even greater common hospital acquired infection in approach, we at Teleflex Medical offer a problems" the United States. VAP is estimated to suite of ventilation management products occur in 10 percent to 20 percent of meand programs designed to reduce the risk -Ernest Waaser chanically assisted ventilated patients. of VAP. Many potentially harmful pathogens exist throughout One promising technology is our ISIS HVT, the inthe hospital, especially in ICUs. ICU patients tend to have dustry's first convertible endotracheal tube, which allows compromised immune systems and are highly susceptible for subglottic secretion suctioning on demand with a to infection through contact transmission from caregivers separate suction line. Often, the endotracheal tube chosen or equipment. Ventilated patients are at high risk for VAP for initial intubation doesn't allow for easy access for this because natural respiratory defenses are compromised valuable practice, which helps prevent aspiration of secreand are often breached through the use of an indwelling tions into the lungs. The ISIS HVT solves that challenge. device, like an endotracheal tube. Endotracheal tubes The Teleflex Gibeck Humid-Flo Passive Humidificacan act like superhighways for bacterial invasion into the tion Kit is an integrated system that promotes best practic- ROUNDTABLE | EHM 57 es for VAP risk reduction. This product has been validated to remain in-line during the first 72 hours of mechanical ventilation, which minimizes ventilator circuit breaks and the resulting patient exposure to inadvertent contact transmission of harmful bacteria. Teleflex's OSMO allows for maintenance-free water removal from the expiratory limb of the breathing circuit; providing protection to the patient through reduced circuit manipulation and cross-contamination potential. OSMO further assists institutions with compliance to infection-risk reduction strategies such as SHEA's recommendation to keep ventilator circuits closed during condensate removal. We also offer a variety of non-invasive ventilation (NIV) products to help manage a patient's respiratory requirements without endotracheal intubation, including the ConchaTherm Neptune heated humidifier and the ResMed NIV masks. Education is also critically important, and Teleflex sponsors several caregiver educational initiatives focused on improving patient outcomes and facilitating VAP risk reduction as well. From the Clinical Foundations Newsletter (www.clinicalfoundations.org) to the Advances in Respiratory Care speaker series, we are proud to partner with leading respiratory care clinicians to deliver world-class education. We also sponsor www.firstdonoharm.com, a website dedicated to helping healthcare practitioners and executives reduce the human and financial toll exacted by hospital-acquired conditions. SN. There are several clinician-developed guidelines for avoiding the occurrence of VAP that are based on the criteria of evidence-based medicine. Obviously, the single best way to prevent VAP is to limit the amount of time a patient is on mechanical ventilation. The guidelines call for using noninvasive positivepressure ventilation instead of intubation whenever possible. If this is not possible, remove a patient's ET tube as soon as possible and avoid re-intubation. The use of a particular type of ET tube with an additional lumen that ends with an evacuation port just above the cuff � making it possible to remove secretions from above the cuff � may also be employed. Orotracheal rather than nasotracheal intubation is recommended, together with proper patient positioning (i.e. elevation of 30-40 degrees) to avoid gastric reflux. Tubing and other disposables changes are advised only when the equipment is visibly soiled or malfunctioning. Oral care (i.e. chlorhexidine gluconate (0.12 percent) oral rinse) should also be performed, especially in postsurgical patients. Finally, avoiding cross-contamination (i.e. preventing the transmission of microorganisms from healthcare workers to patients) through proper personal hygiene is probably the oldest but most effective preventive measure one can take. EC. Reducing mortality due to ventilator-associated pneumonia requires an organized process that ensures early recognition of pneumonia and consistent application of the best evidence-based practices. A multi-disciplinary approach involving all bedside caregivers is essential to reducing the incidence of VAP. The Institute for Health Care Improvement's `Ventilator Bundle' is a series of interventions related to ventilator care that, when implemented together, should achieve significantly better outcomes than when implemented individually. The key components of the Ventilator Bundle include elevation of the head of the bed. While it is not immediately clear whether this intervention facilitates the prevention of ventilator-associated pneumonia by decreasing the risk of aspiration of gastrointestinal contents or oropharyngeal and nasopharyngeal secretions, this was the ostensible reason for the initial recommendation. Another reason that the intervention was suggested was to improve patients' ventilation. For example, patients in the supine position will have lower spontaneous tidal volumes on pressure support ventilation than those seated in an upright position. Although a variety of ventilator strategies may be applied, the improvement in patient positioning may aid ventilatory efforts and minimize risk of atelectasis. Daily `sedation vacations' and assessment of readiness to extubate are also key components of the Bundle. It appears that lightening sedation decreases the amount of time spent on mechanical ventilation and therefore the risk of ventilator-acquired pneumonia. In addition, weaning patients from ventilators becomes easier when patients are able to assist themselves at extubation with coughing and control of secretions. Sedation vacations are not without risks, however. Patients who are not sedated as deeply have an increased potential for self-extubation. Therefore, the maneuver must be conducted in a careful manner. In addition, there may be an increased potential for pain and anxiety associated with light sedation. Lastly, decreased muscle tone and poor synchrony with the ventilator during the maneuver may risk episodes of desaturation. The final two components are peptic ulcer disease prophylaxis and deep venous thrombosis prophylaxis. With peptic ulcer disease prophylaxis, critically ill intubated patients lack the ability to defend their airway. Esophageal reflux and aspiration of gastric contents along the endotracheal tube may lead to endobronchial colonization and pneumonia or may precipitate pneumonia due to the decreased bacterial killing in the low-acid environment. "The guidelines call for using noninvasive positivepressure ventilation instead of intubation whenever possible" Stefano Nava Stefano Nava is the Chief of the Respiratory Critical Care unit at the Istituto Scientifico di Pavia in Italy and a specialist in respiratory medicine and intensive care medicine. He has published over 120 papers in peer-reviewed journals. Nava was elected Chairman of the Intensive Care assembly at the European Respiratory Society. 58 EHM | ROUNDTABLE Applying deep venous thrombosis prophylaxis is an appropriate intervention in all patients who are sedentary; however, the higher incidence of deep venous thrombosis in critical illness justifies greater vigilance. The risk of venous thromboembolism is reduced if prophylaxis is consistently applied. In addition to the IHI's ventilator bundle, new technologies in mechanical ventilation employ closed-loop systems to automate weaning protocols such as Draeger's SmartCare/PS which is available on the Evita XL and Evita Infinity V500. SmartCare/PS utilizes patient values such as ETCO2, tidal volume and respiratory rate to evaluate and automate weaning through knowledgebased guidelines. How does VAP fit into the broader issue of post-operative pulmonary complications? SN. Independent of surgical complications, such as infections and bleeding, there are three major types of medical risks that accompany major surgery. These include: cardiac risks, the formation of blood clots and pulmonary complications. The closer the surgery is to the diaphragm � any thoracic, upper abdominal, gallbladder or aortic surgery for example � the greater the risk of complications. Additionally, emergency surgery or surgery lasting more than three hours also increases the likelihood that patients will develop postoperative pneumonia. Patients at risk are mainly those with advanced age (patients over 70 have a four-fold to six-fold increased risk of developing pneumonia), pre-existing COPD, functional dependence (patients' inability to care for themselves), congestive heart failure, obstructive sleep apnea (OSA), pulmonary hypertension and a history of smoking. The incidence of pulmonary complications (2.7 percent) is highly comparable to that of cardiac complications (2.5 percent). The development of post-operative respiratory failure (often defined as the need for ventilation for more than 48 hours after surgery) is an extremely morbid event, since it carries a mortality rate of greater than 25 percent. EC. Post-operative ventilator care in the recovery room or ICU can range from short-term to long-term use of mechanical ventilation, depending on the nature of the illness or injury and duration of anesthesia. In both cases, it is essential to maintain proper airway care and utilize a protective ventilation strategy to reduce the risks of ventilator-induced lung injury. Reduction of ventilation time is paramount in the prevention of post-operative pulmonary complications. EW. VAP significantly increases morbidity, mortality and healthcare costs in post-operative patients, and research Ed Coombs is Regional Director of Marketing � Respiratory Care Systems, Draeger-North America. Coombs is a graduate of SUNY Upstate Medical Center in Syracuse New York, earning his respiratory care credentials. He has served as a respiratory therapist, shift supervisor and clinical instructor for Stony Brook University Hospital and other Long Island community hospitals for approximately 18 years, prior to becoming involved in the medical device industry. shows VAP is the most frequent ICU-acquired infection among patients receiving mechanical ventilation. Continuous aspiration of subglottic secretions, as facilitated by the Teleflex ISIS HVT, has been identified as a VAP-preventive measure. Other measures include limiting breathing circuit changes, spontaneous breathing trials and implementation of VAP bundles. Lung expansion intervention post-extubation may also decrease post-operative pulmonary complications. Teleflex's ventilator disposables with extended change-out protocols and incentive breathing spirometers support these strategies. What is the likelihood of VAP being eliminated from the US hospital system in the future? EW. While VAP appears to be an impossible challenge to eliminate, the history of medicine shows that many healthcare breakthroughs have solved even greater problems. The elimination of VAP is an ambitious and oftendebated goal that the healthcare community, including its industry partners, must continue to strive to achieve. Education, increasing caregiver and public scrutiny and ongoing innovation are the tools that will help us meet that goal. SN. This is a very difficult question to answer. Several studies have shown a significant and sustained reduction in VAP rates after the implementation of protocols aimed at preventive measures. However, most of these measures (e.g. hygiene, positioning, oral ET) are not related to any direct improvements in technology. Therefore, there remains a need for new technologies to help the clinicians avoid the development of VAP. Right now, the only `space' I see is for improving and expanding the use of NIV and ET tube with an additional lumen. NIV has been shown to significantly reduce the rate of VAP compared to ETI, so much so that some authors have suggested the name be changed from ventilator-associated pneumonia to intubation-associated pneumonia. Clinicians, however, should be aware of any absolute or relative contra-indications for NIV. EC. While VAP may not be completely eliminated from mechanically ventilated patients, many facilities have been successful in significantly reducing or eliminating VAP through evidence-based practices. The Institute for Health Care Improvement (www.ihi.org) website is a powerful resource. The IHI model has been used very successfully by hundreds of healthcare organizations in the US and many countries to improve many different health care processes, resulting in improved outcomes. The Model for Improvement has been combined with the concept of `bundles of changes' to simplify the very complex processes of the care of critically ill patients. "Reducing mortality due to ventilatorassociated pneumonia requires an organized process that ensures early recognition of pneumonia" Ed Coombs 60 EHM | ASK THE EXPERT Physics, physiology and serendipity of temporal artery thermometry By Francesco Pompei ith temporal artery thermometers now used in more than half of US hospitals nearly a billion times per year, and millions of consumers using them for care of their families, it is sensible to more closely examine what makes temporal artery thermometers work, and why they have become popular. Temporal artery (TA) thermometry was originally developed in response to pediatricians requesting a replacement for ear thermometry due to inaccuracy, and rectal thermometry due to parents' and clinicians' growing disdain for rectal thermometers. The technology development spans some 20 years, borrowing heavily from methods originally invented for industrial processes and medical research in thermoregulation. Although the forehead has been used since antiquity to detect fever, accuracy had always been questionable due to poorly understood physiological artifacts. It wasn't until these artifacts were identified, quantified and mathematically modeled has it been possible to measure clinically accurate body temperatures entirely non-invasively from the skin, with just a gentle scan of the forehead. After 10 years and 35 published studies, it is now settled science that TA thermometry is more accurate than ear thermometers, and comparable in accuracy to rectal and oral thermometers. The physics are relatively straightforward, but the physiological requirements are not. Physiological artifacts can cause errors of more than 4 0F in conventional non-invasive thermometry at the skin and needed to be reduced by an order of magnitude to provide medically useful temperatures. The technology in more than 10 US patents is employed to overcome the errors. Two unexpected major benefits for TA thermometry resulted from the technological development: a cost reduction of 90 percent compared to the standard thermometry methods, and the reintroduction into clinical medicine of what everyone appreciates from a caregiver when they are in need of care � a gentle reassuring touch to the forehead. W What is the central idea of temporal artery thermometry? Measuring the temperature inside, from the outside � with medically accurate results equivalent to invasive methods. Conventional thermometry technology requires invasiveness more or less proportional to the accuracy desired. Starting with the most invasive/ most accurate and ending with the least invasive/least accurate, conventional thermometry can be ordered as (a) pulmonary artery catheter, (b) esophageal catheter, (c) rectal thermometer, (d) oral thermometer, (e) ear thermometer, (f) axilla thermometer, (g) skin thermometer. The central idea of TA thermometry is to have the non-invasiveness of a skin thermometer, but with the accuracy of an invasive thermometer such as a catheter or rectal thermometer. What physics are employed to do this? It starts with skin temperature. Naturally emitted infrared radiation can provide a thermal signal to measure temperature in a fast accurate manner. Radiation detectors are available that can detect this, but there is the problem of emissivity to contend with, which is the characteristic of skin to emit different amounts of radiation at a given temperature. Borrowing a technique originally developed for industrial use, TA thermometry employs an emissivity-correcting reflective cup within the scanning head. Th is corrects the emissivity automatically and eliminates all emission errors due to skin surface properties. For this to work, the scanning head of the TA thermometer must be close to, or preferably lightly touching, the skin. Isn't skin temperature inaccurate? Yes, that is the reason there needed to be much more physiological insight for TA thermometry to work. In a normal environment, skin temperature will always be significantly lower than body temperature. Th is happens because metabolic heat is generated inside the body and has to flow outside the body to the cooler ambient temperature, which it does so at the skin. If we knew the physiology of how heat is flowing from inside the core to the outside through the skin, and we knew the ambient temperature, we could determine the inside temperature. This determination is automatically performed by the arterial heat balance system (AHB) algorithm programmed into the TA thermometer. TA thermometer scanning across the superficial temporal artery Infrared image of the superficial temporal artery ASK THE EXPERT | EHM 61 Can you measure anywhere on the skin instead of just at the temporal artery? No. Further physiology is required. The skin temperature is heavily influenced by the local blood perfusion, which can vary hugely due to thermoregulation. The AHB algorithms require high and relatively stable skin perfusion to produce medically accurate body temperature. Research led to the superficial temporal artery (STA), which was found to lack arteriovenous anastomoses, an unusual property for a skin artery, effectively lacking valves which vary the skin perfusion. Th is meant that perfusion at the STA was essentially constant, and thus the AHB algorithms could produce medically accurate results. That an accessible part of the STA was located on both sides of the forehead above each eyebrow was especially convenient. There are some specific circumstances that produce high and stable skin perfusion that allow measurements in other locations, and users are instructed to use them when appropriate. The superficial temporal artery is usually not visible. How do you find and measure it? The STA is in a somewhat different location on each individual, which is the reason that TA thermometry employs a distinctive `scan' of the forehead. The infrared detection system performs about 1000 measurements per second during the scan in a line across the forehead. Since the STA always traverses the forehead in a generally vertical direction, include labor time savings � reported at 87 percent of nursing time by a recent independent study � or the cost of disposal of several tons of waste per year. Further, since there is no small probe to be inserted into a body cavity, the TA thermometer can be designed to be far more robust than conventional thermometers, and can carry a lifetime warranty. Th is 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 TA thermometry have essentially eliminated the cost of patient temperature as a vital sign. How about the effect on caregiver-patient interaction? Th is serendipitous benefit was captured perfectly in a recent episode of the popular TV program Grey's Anatomy, depicting a physician gently scanning the patient with his personal TA thermometer, while checking the patient's chart and joking amiably about his discharge (see www.exergen.com for the clip). Th is interaction captures something unexpected and quite important � that the gentle touch of scanning the patient's TA thermometer scanning a patient The idea of arterial heat balance (AHB) the scan across the forehead will always intersect the STA and detect the temperature of the skin over the STA. Of the several thousand readings in a scan, the AHB algorithm selects the peak reading, which is the most accurate, discarding the rest. Since STA at the forehead is always located between the skull and the skin, it is always very close to the skin surface, and a reliable temperature measurement can be made from newborns to seniors, allowing a single device to be medically accurate for all patients. How is cost reduced by 90 percent? Th is was one of the serendipitous benefits. Other medical thermometry systems require a probe to be inserted into a body cavity, which requires robust protection from contamination with a single-use disposable cover. TA thermometry lightly scans the intact skin of the forehead, placing it in the same category as a stethoscope � simply clean between patients. The reduced use of disposable probe covers turns out to be a major benefit from TA thermometry, eliminating approximately 90 percent of the direct cost of providing this vital sign. Th is savings figure does not forehead with a TA thermometer evokes an emotional response of care given, and care accepted, from the caregiver and patient � the same as a mother's touch to the forehead of a sick child. Th is very much enhances the patient-caregiver experience, and is a significant reason why patients and caregivers are such strong supporters of TA thermometry. TA thermometry every year eliminates nearly a billion probe insertions into patients' body cavities, replacing each one with a gentle touch of the forehead. Th is converts a billion unpleasant experiences for patients and caregivers to a billion very positive experiences for both � a major contribution to everyone's sense of wellbeing. Hopefully, soon the other five billion or so thermometry probe insertions per year will be converted as well. Francesco Pompei is Founder and CEO of Exergen Corporation, and holds 60 US patents in non-invasive thermometry for medical and industrial applications. Earning BS and MS degrees from MIT, and SM and PhD from Harvard, Pompei also holds an appointment as Research Scholar in the Dept. of Physics at Harvard in cancer research. 62 EHM | INFECTION CONTROL Staying one step ahead of infection Duane Newton plans a strategic offensive against the agents of infection in the healthcare setting. INFECTION CONTROL | EHM 63 he hospital setting is a double-edged sword when it comes to infectious diseases and infection control; the weak enter to leave healthy, yet what they bring with them in terms of bacteria and infective organisms can often introduce complications. Multiply that by the number of patients within any given hospital, and what you're left with is a bubble of infection waiting to explode, given the opportunity. Fortunately for those in need of treatment, a team dedicated to controlling infections, diagnosing infectious diseases and preventing the spread of bacteria within the hospital setting is always on hand, relentlessly at battle to ensure the best possible environment for their patients. A hospital that takes just as much pride in its team as it does with its success record is the University of Michigan's Hospitals and Health Centers (UM). Duane Newton, Director of Microbiology and Virology labs at UM Hospital, makes sure he has everything at his disposal to give patients entering the hospital the best possible chance of leaving without encountering anything infectious; and if they do, his presence allows the turnaround of results quick enough to minimize the risk of other patients becoming infected. Newton has a passion for what he does that is rarely appreciated by those outside the `lab world'� and it certainly shows in his track record. "We have been doing active surveillance for MRSA for about two years now," says Newton. "It initially started in our neonatal intensive care unit (ICU) and later included our surgical ICU; then over the course of a summer we expanded that to include all of our ICUs and our bone marrow transplant unit as a high-risk patient population. There are probably seven or eight units in the hospital that are participating in this now, and it was based on all the information that's been going around and our recognition of the potential clinical and epidemiologic impact of carriage and infection." T Primary sites Duane Newton is raised dramatically through nasal colonization. It then becomes clear why Newton notes the anterior nares as the primary site of choice. The world of infection control is littered with challenges, of which swab site selection is the mere tip of the iceberg. "There are two things I see as most problematic," offers Newton. "The first is deciding who to include in the surveillance population and how wide a net to cast as it changes from institution to institution. The main thing to think about is how you're using this information. Are you putting patients into contact precautions at admission and then waiting until the test results are back to decide whether to keep the precautions or remove them? Alternatively, are you doing it the other way round; are you sampling them and only putting them under precautions once they are deemed to be positive? Both approaches have different logistical challenges associated with them. "Putting patients into precautions at admission is just too difficult to maintain and many hospitals don't have the luxury of that. The challenge on the other hand is to provide the results in a timely enough fashion that you don't have positive patients sitting around the hospital needing to go into precautions, but it's taken you five days to get that information to the provider. That's the first "We weren't doing it broadly, and we expanded it to be more broad," Newton continues. "The practical desire is to eventually have nasal swabs collected upon admission to any of those units � weekly while the patient is on the unit and then upon discharge from that unit." The nasal cavity may seem like just another swab site, but it is in fact the primary anatomic site for colonization. Past studies have also concluded that if nasal swabs are used in conjunction with other body sites, a significant increase in detection rates is noticed. However, Newton is quick to point out that they haven't chosen any other sites to swab for MRSA. And while published work has dedicated itself to the detection of colonization in other body sites, there has been very little clinical correlation with regard to the risk of infection based on the colonization of those body sites. On top of this, the probability of transmission to others "Putting patients into precautions at admission is just too difficult to maintain and many hospitals don't have the luxury of that" INFECTION CONTROL | EHM 65 thing that contributes to this process. The second, within our institution, is that we don't have 100 percent compliance with the sampling schedule that's required, so the data that we're collecting with regards to our colonization and acquisition rates are suboptimal. "That's unfortunate because this is quality assurance; it's a patient care and patient safety issue in the context of a large quality assurance program that needs to have feedback, continuous monitoring, improvement and responses. If your data stink because they are incomplete, then the conclusions that you're drawing up are going to be inappropriate. We know that we're not capturing all the samples, and it comes down to the patient's bedside standpoint and the inability of healthcare providers to do this in the context of everything else that they're trying to do." Progressing technology On top of this is the additional struggle of costs. Putting someone in precautions is far more expensive than the majority of people would like to believe, but when you trade off the issue of cost against another patient becoming infected, you begin to see where the struggle kicks in. To counteract this, UM and various other hospitals have begun employing specific tools and technologies to make the surveillance process more efficient. "The traditional methods of culturing the organism have improved significantly," explains Newton. "In the old days, what we would do is get a nasal swab, set it up for culture, identify Staphylococcus aureus and then conduct tests to determine whether it was MRSA � that may take a couple of days to get to that endpoint. On the culture side, there are several vendors that have made media that are selective and differential for MRSA, so they allow you to specifically and selectively identify just MRSA from that sample. "Those media are referred to as chromogenic because when you culture MRSA on the plate, it turns a specific color that's unique for whatever vendor's formulation. Companies like Bio-Rad, Becton-Dickinson, Thermo Fisher Remel and bioM�rieux all have these types of selective media." There are, perhaps unsurprisingly, more sophisticated methods that utilize molecular techniques such as PCR; Newton points out that there are also commercially available assays that are relatively simple and straightforward to use, whereby you take a swab, perform an amplification test and then potentially have a turnaround time to results of about two hours. There are assays from Cepheid that utilize the GeneXpert platform, in which the swab is put in a cartridge, then that cartridge is plugged into a machine. An hour-and-a-half later, the result is ready. Besides these, there are other assays that remain slightly more manual and are considered `real-time' PCR assays � but these require a fast extraction of the swab upfront. What some institutions have chosen to do, according to Newton, is utilize those types of technologies on a more rolling or potentially random-access basis � allowing specimens to enter the lab and be tested to provide the results in real time. From this, the scenario that Newton describes of having everyone in precautions and only being taken out based on the results becomes more accessible � albeit from a testing standpoint. Unfortunately, the reality of the situation always returns full circle to money; fi nding out how the information is being used and at what cost seems to underlie the majority of decisions in testing and infectious disease diagnostics, regardless of hospital facilities. Evanston Northwestern Hospital in Chicago, for example, tests multiple times a day, but the luxury of having single patient rooms allows them to accommodate infection control management with less difficulty than UM. The only way other hospitals can compete is by utilizing different detection methods to make up for the lack of single patient rooms. Newton says that having evaluated several of the chromogenic media and one of the PCR assays, he found no analytical difference in the ability to detect MRSA from the swabs. When compared to molecular methods, he would also suggest a tie, but at higher price tag. "One reason we chose culture is that we're handling MRSA in the same way that we handle VRE � vancomycin-resistant enterococci � by conducting active surveillance Betsy Foxman is Professor of Epidemiology and Director at the Center for Molecular and Clinical Epidemiology of Infectious Diseases at the University of Michigan Hospitals and Health Centers. She offers her take on MRSA prevention and infection control. On swab sites ven though MRSA and Staph aureus colonize in multiple body sites, the focus is on the nose. Nasal colonization is associated with auto-infection of other sites, leading to wound infections and medical device infections. I don't know how soon, but I can envision a day when we will have the technology so that someone with very little laboratory expertise can take a swab, put it in a machine and detect pathogens. That will be terrific, but what I want to emphasize is that detection methods cannot replace good infection control. E 66 EHM | INFECTION CONTROL Betsy Foxman on hospital populations There are two different sources of infection in the hospital: pathogens that the patient comes in with and pathogens circulating in the hospital. Screening patients on entry lowers their risk of getting a wound infection from a pathogen they are already carrying and prevents the introduction of new pathogens to the hospital. The rates of MRSA carriage in the community are increasing � the National Health and Examination Survey (NHANES) found that about 32 percent of the general population carry Staph aureus in their nose and about one percent carry MRSA. Among those over 65 years of age, eight percent carry MRSA in their nose. It's a different problem to keep pathogens from continuously circulating within the hospital, than preventing new ones from coming in. The hospital population is a very dynamic one. People go in and out rapidly. Virtually all patients are treated with antibiotics, which selects for resistant bacteria. The combination of a dynamic population and high antibiotic use selects for bacteria that are easily transmitted and are resistant to antibiotics. Hospital personnel have much higher carriage rates for Staph aureus than the general population: specifically, about 40 percent. MRSA rates are higher too, approaching 10 percent for some types of hospital personnel. Even clerical staff have higher rates than the general population. for that organism, which is abnormal in the healthcare world. But patients that are MRSA or VRE colonized are put into precautions." T Precautions Although UM isn't currently doing active surveillance for C. difficile, if patients are also found to be positive for that organism then they are put into contact precautions. In total, Newton hazards a turnaround time of about 24 hours to get these more comprehensive results. "It didn't make a whole lot of sense for us if we were going to handle all three of them in the same way," confi rms Newton. "We could pay a lot of money for MRSA but we still had to wait for VRE and C. difficile. It didn't make a lot of sense managing those patients � so we decided we could do everything in 24 hours and that was adequate. "Now the technology and assay availability is changing and we're seeing more molecular availability for other targets like VRE and C. difficile, so that's something that we could potentially readdress as an institution. But it's a challenge because MRSA is not the only drug-resistant organism that we have to pay attention to. Undoubtedly, it's had the most attention, but especially in a large institution like ours, there are multi drug-resistant organisms that are gram-positive and gram-negative that we are challenged to identify." Inherent within this comes the simple truth: Infection control is the fundamental building block for hospital control levels. Washing hands, making sure equipment is sterile and that sterile techniques are employed should "About 32 percent of the general population carry Staph aureus in their nose" INFECTION CONTROL | EHM 67 be standard � and there is no substitution for that. All the technology in the world will never replace the need for these disciplines. "It all goes back to what I was saying about the quality of our data," confirms Newton. "We're implementing multiple things at the same time, which include more robust contact precaution through programs and more attention to hand washing in addition to our active surveillance. "It's really difficult to figure out what is having the most impact � or even if it's having any impact at all. From the lab point of view I recognize where the limitations are from the testing side and I want to make sure that all the resources we're putting into it are worthwhile. If testing doesn't have anything to do with it and it's actually hand washing, and that's all you need to focus on, then that's where you need to put your resources." As if that weren't enough, exchanges between hospitals and long-term care facilities in terms of introducing resistant bugs back and forth in those settings add further potential problems. To ensure this is regulated, UM monitors who � and more importantly what � comes into the hospital. The hospital staff concern themselves with immediately fi nding out what a patient has been admitted for, not only so they can be treated and given more efficient individual care, but also to decrease the risk of infection to other patients in the hospital. With home-care and long-term care facilities and hospitals all sharing a much closer space, the future of infectious disease diagnostics and the wider picture of infection control seems to be the cementing and progressing of present principles. "On the technical side," offers Newton, "the direction I see things heading in the shortterm is the existence of more platforms where you have integrated sample processing and target detection all in one box, so they're not separate entities. They're simplified to a level where you don't have to be a hardcore molecular biology technologist in order to understand how to run the system. "Also, the footprints are getting smaller, so it doesn't take up as much room in the laboratory. The menus on those platforms are expanding, so they can do more than just one thing. All those factors, from a management and administrative standpoint, are important in deciding to bring a new technology into the lab because we can't afford to have a lab full of one-trick ponies. We just don't have the space for that. "What you're seeing when you go to the trade shows now is a greater awareness of this. Technology is moving in the same direction too. Some of them are amplification-based technologies and some of them are arraybased. But the biggest challenge for them is to figure out how they want to make their panel. How many different tests or targets do you want to test for at the same time? You know when you get a room full of people like me and they ask us a question, we all have different answers, so it's very difficult from the vendors' perspective to come up with something that's going to be marketable." And yet the world of in vitro infectious disease diagnostics fi nds itself being introduced to new technologies and methodologies that are being pushed to work in accordance with technologists and the greater laboratory mind. There will never be a true `ground zero' in eliminating infectious diseases and hospital-acquired infections, but perhaps that isn't the point. With people like Newton continuing to identify and tackle increasingly resistant infectious bacteria, it won't be long before the human and technological elements collide to evolve the world of infection prevention to do precisely that � prevent. Betsy Foxman on cost aboratory tests are just one piece of information and if you want a decrease in infections, testing has to be part of an overall system of infection control. The problem is that infection control costs are not going to go down. Procedures can be made more efficient; the use of checklists has been effective in reducing hospital-acquired infections. You have to get everyone to buy in; they have to use the checklist and there has to be intervention and evaluation after breakdowns are detected. The increasing use of electronic monitoring is exciting. Making electronic checklists facilitates rapid detection of breakdowns in the system; this can be linked to laboratory data. That's great, but someone has to analyze the data and implement appropriate interventions. Good infection control saves money in the long term. Infection control procedures prevent all types of infections, not just those due to MRSA. If we want to decrease antibiotic resistance � and limit the emergence of those due to MRSA � we have to think about alternative strategies for treatment and prevention of bacterial infections so we don't find ourselves continuously chasing the next drug. L 68 EHM | ASK THE EXPERT Effective MRSA screening to improve patient safety and reduce costs Mary Jo Deal analyzes the financial impact of laboratory test performance. ethicillin-resistant Staphylococcus Ultimately, the incorrect screening result leads to a much aureus (MRSA) is a problematic greater financial burden and risk to the patient as well as pathogen and a leading cause of the healthcare provider. By selecting a screening test with a healthcare-associated infections high PPV, hospitals can correctly detect patients colonized (HAI). To combat the spread of with MRSA, execute appropriate isolation protocols, and MRSA, active surveillance is often part of a multidisciimplement contact precautions to aid in the prevention and plinary infection prevention program. This approach is control of MRSA. aimed at reducing the associated morbidity, mortality Thermo Fisher Scientific offers a chromogenic media and systemic costs of HAIs. A closer look into the active for the detection of MRSA colonization, Remel Spectra surveillance tests can illustrate how effective laboratory MRSA, which offers the highest PPV currently on the testing can impact patient safety and finanmarket. With many different products cial outcomes. available, it can be a daunting task to "A closer look Clinicians have been trained to look determine the best solution for your into the active for high sensitivity and specificity as key institution. surveillance tests performance indicators of laboratory tests. In order to better understand While these indicators are important, an the systemic financial implications of can illustrate how additional parameter to performance is the MRSA screening and the costs for isolaeffective laboratory predictive value of a laboratory test, spetion, an independent health economist testing can impact cifically positive predictive value (PPV) and has developed the MRSA Screening patient safety negative predictive value (NPV). Predictive Cost Analyzer to review all commercial and financial value is essential because it is a measure of chromogenic media and PCR methods outcomes" the likelihood that a positive test result infor detecting MRSA nasal colonization. dicates disease, or a negative test result may The MRSA Screening Cost Analyzer rule out disease. Low PPV translates into more false positakes into account specific parameters of different screentive results, while low NPV translates into more false negaing populations, MRSA colonization rate, isolation costs, tive results. Both affect the proper treatment and handling and the screening test costs. Additionally, the MRSA of a patient. Clinicians, and those working in infection preScreening Cost Analyzer is the first of its kind to look at vention and administration, want to know, given a specific unnecessary isolation costs and their deleterious effect on test result, the probability of disease, or in this case, MRSA the hospital system. A demonstration of this tool can be colonization. This relates to the predictive value of the test. seen at www.remel.com/hai, and a demonstration with Depending on a hospital's patient isolation strategy to your specific hospital data can be performed by a Remel prevent the spread of MRSA, an MRSA screening test may Technical Sales Representative. result in a patient being moved in to or out of isolation. So The mission of Thermo Fisher Scientific is to enable what happens if a patient is falsely categorized as MRSAcustomers to make the world healthier, cleaner and safer. colonized? They may be unnecessarily placed in isolation In today's healthcare environment, every decision involves with contact precautions, utilizing precious resources a calculated risk to ensure patient safety with appropriwithout reducing transmission of the infectious agent. ate financial outcomes. The best decision is made when Often, the positive MRSA colonization result is captured epidemiological data and hospital costs are involved to deon medical records and is a red flag upon patient readtermine how your institution's goals and objectives can be mission to the hospital, causing another chain of costly achieved. Only then can the human and financial impact events for treating negative patients as MRSA-colonized. be appropriately managed. M Mary Jo Deal is Vice President and General Manager for Thermo Fisher Scientific, Microbiology Americas. She has held numerous positions in the IVD industry, including Senior VP Marketing and Sales for Hycor Biomedical, as well as positions with Dade International (now Siemens Healthcare Diagnostics) and Abbott Diagnostics. She holds a BS in Chemistry and a PhD in Biochemistry. VASCULAR ACCESS | EHM 71 Maximizing vessel health EHM talks to Nancy Moureau about the current challenges in vascular access. What are the different types of vascular access devices used in chronic and acute illness? 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. Then there are tunneled central venous catheters and non-tunneled. 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. What role do these devices play in delivering appropriate therapy across the chronic disease spectrum? NM. In this day and age, central venous catheters are needed for almost all treatment plans. Every patient that is receiving some sort of treatment for their illness almost always has an intravenous medication ordered � whether they're cancer patients, patients with infection, or various types of problems � it is most common to have intravenous medications ordered, at least in the beginning, for acute and for chronic illness. Without reliable vascular access, patients are not able to receive their medications, experience delays, more trauma with multiple accesses and medication is wasted- all contributing to greater cost. Choosing the right device, for the individual patient and treatment plan, is key to getting the treatment job done and using money efficiently in healthcare. There are chronic illnesses like Crohn's disease that require infusions of nutritional substances over a long period of time and the type of device that's chosen for these patients is somewhat dependent on the patient's preference, but also on the level of risk that the device would carry. The choice is a balance between the device that will work for their treatment, the duration of time that it's needed, the preference of the patient and the level of risk that the device would carry, choosing the lowest risk, of course. 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 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. The Vessel Health and Preservation Program was an effort to make sense out of the selection process for all medical professionals to create a standardized process for selection, placement, assessment and then discontinuation of the device. The way that we approached these issues was to bring a group of experts together, work on the process, work on creating a program that is evidence based, develop the program and the tools that were necessary for the program, and then work with individual hospitals on customizing and implementing the program. That's what we're doing now. 72 EHM | VASCULAR ACCESS The VHP protocol is not just for selection; it also applies best practices to selection, insertion, daily assessment, discontinuation of the device and even continued in alternate care if needed. Th is is the fi rst time I have seen a group work together to create a standardized approach to vascular access and one where the company is making the process available to all in a way that they can customize it to fit their facility. I have been working on clinical pathways for vascular access for quite some time and it is much more than just an algorithm or decision tree, taking into account the whole patient, individual risk factors, treatment plan and conditions. Medical professionals should choose the right device with a selection process within 24 hours of patient admission to acute care, placement within 48 hours if a CVC is needed and assessment each and every day as to whether it is still the right device. 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 device is 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. What are the other current top-of-mind issues in vascular access? NM. In terms of vascular access, one of the most important things is communication between healthcare professionals. Working together and recognizing particular areas of expertise with the vascular access specialists that are growing in the hospital and with the physicians to really determine the best way or the best device for the patient is most important. Applying best practices in the development of vascular access teams that work within acute care and help to manage the transition into alternate care is also very important. We've seen from research that enhancing communication between medical professionals improves the outcomes for patients. That's what we're trying to focus on with Vessel Health and Preservation in addition to establishing a true process. Nancy Moureau is President and CEO of PICC Excellence, Inc. Diagnostic criteria for PICCs Use of diagnostic criteria for PICCs can guide the way to early device selection and placement promoting vein preservation. Admission of patients with this short list of diagnoses should trigger a referral to the vascular access specialists for assessment of the best device. � Burns of more than 30% of body � Cellulitis � Ulcerative Colitis/Malabsorption � Complicated Pneumonia � Crohn's Disease � Infection/Septicemia � Lyme Disease � Bacterial Meningitis � Osteomyelitis � Pancreatitis Source: Indications for inclusion and exclusion of PICCs and CVCs, PICC Excellence, Inc., March 1, 2010 Exclusion criteria for CVCs Central venous-catheters, both percutaneous and tunneled are used for situations where immediate access, high volume fluid delivery, or long term access is needed. While generally CVCs can provide a reliable form of vascular access, there are some contraindications and exclusion criteria for limiting their insertion. The list below includes some of the known exclusions and is not considered comprehensive. Limiting Factor Elevated INR or low platelets Deep Vein Thrombosis Critical status of patient exceeds risk benefit ratio Ventilated or tracheostomy pt Existing dialysis catheter Or elevated Creatinine >2.0 Infection risk, use peripheral access Use Dialysis catheter with CVC port Rationale/Recommendation Consider PICC or PIV if indicated Thrombosis prevents placement, use PIV Evidence/Guidelines General prevention strategy General prevention strategy General prevention strategy General prevention strategy ASDIN Guidelines Source: Indications for inclusion and exclusion of PICCs and CVCs, PICC Excellence, Inc., March 1, 2010 74 EHM | THE BIG INTERVIEW How David Blumenthal is helping healthcare organizations make meaningful use of EHR. I n March of last year, the Department of Health and Human Services announced the selection of David Blumenthal as the Obama Administration's choice for National Coordinator for Health Information Technology. In a statement accompanying the announcement, Blumenthal was charged with leading the implementation of a nationwide interoperable, privacy-protected health information technology infrastructure, as called for in the American Recovery and Reinvestment Act. Part of the motivation behind the appointment, and indeed for the emphasis being placed on the Office of the National Coordinator, is the desire to show that President Obama and his team are serious about pushing through the electronic revolution. "President Obama believes we must take serious steps to modernize our healthcare system in order to improve the health of all Americans, bring down costs and ensure sustained long-term economic growth. Health information technology is a critical part of the President's strategy to reform our healthcare system and as one of the nation's leading health THE BIG INTERVIEW | EHM 75 "We want to get doctors and hospitals on the escalator towards the adoption and meaningful use of electronic health records. We don't want them to trip and break their necks on the first step because it's so high, but we also don't want them to just be able to walk on it and never ascend" information technology experts, Dr. Blumenthal has the experience and the vision to help make this effort a reality," said HHS spokeswoman Jenny Backus at the time of the announcement. A big role to fill, and one that will be frequently in the spotlight, making it even more ironic that the man chosen to lead the nation's healthcare sector in its pursuit of the digitization of health records does not come from an IT background. Far from it, in fact � Blumenthal started his working life as a primary care physician. As he himself admits, "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. That tickled my antennae as a researcher, because one of the things that researchers try to do is decide what hypotheses are important and which trends are going to matter, then get ahead of the curve and try to identify them sooner than their colleagues do and write the grants and begin the work that will have a real impact." While the development of electronic health records (EHR) piqued Blumenthal's interest, he says he never envisaged himself ending up where he is now. "As a health services researcher, I could see the importance of this technology � I could see it as something that was going to change medicine, and so I put my research skills to work tracking it. I didn't think of myself as someone who was going to be working on it as a public official; I was just being a researcher. "But I did have this other life of being involved in the public sector through advising campaigns, and when I was involved in the Obama campaign and we were putting together his plan, he was extremely receptive to the idea that technology could be a big influence on care and make it more cost effective. "A lot of people around him shared that point of view, so it became a piece of Obama's campaign platform, a distinctive piece, and then one that carried over into legislation shortly after he took office. And then, of course, this office � the Office of the National Coordinator � suddenly became an interesting place to be." While Blumenthal says he wasn't expecting to be appointed to the National Coordinator role, he says that he is "grateful to have it," calling the position "a very unusual and important opportunity, especially after the stimulus legislation passed and made this a new office authorized by law, with significant potential to affect the way the healthcare system develops, using electronic health systems." Certification ful use, one of the things In addition to its focus on meaning tor is working hardest the Office of the National Coordina process. Because it has on now is creating a certification as being capable of to certify electronic health records has had to create from meaning ful use, that has meant it ronic health records, scratch a process of certifying elect complicated. which has turned out to be fairly est challenges we're working on is "One of the bigg ronic health records," how to evaluate the usability of elect out that there isn't a says David Blumenthal. "It turns ing with the National good science there, so we're work s and Technology, NIST, which is the Institute for Standard dards, such as setting organization that creates public stan units of measure the nation's clocks and determining al setting of standards around critic and monitoring the to working with them infrastruc ture capabilities. We're lable usability that we could make avai create metrics for e point, be even at som for consumers to use, and that may y, we could use to certify electronic when they 're read health records. t. My goal would be "Usability is really, really importan look forward to using to make it possible for providers to use it works so well and their electronic record system, beca as easy as the iPhone so it's easy to use. Having something it, if we could get doctors that you always want to play with electronic records we and nurses to feel that way about n the pace at which would have accomplished a lot. Give , if we create a vibrant technology changes and improves d happen very fast." market with good measures it coul 76 EHM | THE BIG INTERVIEW Achieving the goal Blumenthal's overriding goal as National Coordinator will be to lead the effort to modernize the US healthcare system by catalyzing the adoption of interoperable health information technology by 2014. The Obama government hopes this will reduce health costs for the federal government by an estimated $12 billion over 10 years. Blumenthal believes his office needs 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," he says. "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, and that will create standards around the packaging of information so that it can be exchanged. That is a whole set of regulatory activities, and that's the core of them, but there are others that are more complicated and less of a new departure. "The other thing we're doing is creating support structures for doctors and hospitals to become meaning- "Usability is really, really important. My goal would be to make it possible for providers to look forward to using their electronic record system, because it works so well and it's easy to use" ful users. The foremost of those is our program of Regional Extension Centers, which have now all been funded; there are 60 of them 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 have already brought in all the leaders of these new centers and we are working with them around the clock, trying to get them ready to help people in the field." These Regional Extension Centers are interesting in that they are modeled on a program for farmers called the Agriculture Extension Program, which was designed to get the most modern techniques from the laboratory out to family farms at the beginning of the last century. Extension agents were based in an office of the Department of Agriculture and traveled between a school of agriculture and farms in rural states, bringing information about the latest seeds, fertilizers and irrigation techniques. In Blumenthal's words, "They were very influential in increasing the productivity of American farming in the 20th century." "The Congress decided that perhaps getting the best information about the use of health information systems out to family doctors could be done the same way," Blumenthal continues. "We are creating multidisciplinary teams in 60 locations 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 THE BIG INTERVIEW | EHM 77 practices and hospitals, developing whatever resources are needed to make those physicians and hospitals successful in adopting and using electronic health records. "Those teams will be doing a variety of things, including helping physicians and hospitals pick the right record system, helping them buy it or buy those systems as groups so they get better prices, helping them install the systems, helping them set the systems up and use them so that they can be effective users, and then helping them adapt their office processes and their work design to the new technology." The reasoning behind having the extension center program target smaller offices and institutions is that big hospitals and group practices will be able to hire large `integrator' companies to help them with their IT installations. "For the amount of money that we're making available, those larger organizations are going to be able to afford those services, and the larger companies will be happy to go to work with the larger organizations, because there are economies of scale," Blumenthal points out. "But for your average four- or five-person family physician or primary care practice, it's just not worth it to most of these big companies to have a contract; or if they do, if you're trying to get to some far-away small-town practice, and it's not worth sending your technician out there, or if you do, he or she is not going to get back there very often." Beacon communities HHS Secretary Kathleen Sebelius and Dr. David Blumenthal, HHS' National Coordinator for Health Information Technology, announced in December last year plans to make available $235 million to support a Beacon Community Program. The awards will help 15 communities around the country become beacon communities for the meaningful use of electronic health records. "What we specifically focused on was helping them to use electronic health systems to improve health and efficiency in their population areas for their populations," Blumenthal says. The specific communities were named in May, after which Blumenthal and Sebelius visited one in Indianapolis. "It was a very interesting place." Blumenthal recalls. "The community has made a long-term investment in electronic health systems, and the result is that they are able to set pretty ambitious goals for this beacon program, and that was what attracted us to that setting. "In Indianapolis we saw a demonstration of how their information exchange program works and how they can locate all the information on a patient within their geographic location and ways in which that enables them to reduce duplicate tests and avoid unnecessary drugs and understand drug/drug interactions and all those things that are critical for care. That was a very encouraging demonstration for myself and for the Secretary. "The Secretary has now visited a lot of hospitals and practices and she always comes back to what she sees in her experience as someone who has been for years an elected official, who is very much in touch with the views of average citizens and people who are at the front lines. What gives her a lot of assurance that we're on the right track is that whenever she talks to a doctor or hospital they may find some problems with their systems, but none of them ever want to go back to paper." Challenges ahead In his keynote address at the HIMSS10 Annual Conference & Exhibition in March, Blumenthal outlined the challenges faced by his office in the following manner: "No one in the history of healthcare or any other sector has tried to do something as complicated and difficult in such a large, heterogeneous, diverse country with the kind of independence of spirit and commitment to local autonomy and professional autonomy that we have in the United States." When asked about the challenges that will result from this "diversity" and "independence of spirit", Blumenthal says that while it's still early days, the Office has in place a set of programs appropriate to the challenges and is rolling them out. "One of the biggest challenges that we have is the great variety of healthcare providers in this country, and their physical distance from one another, and therefore the challenge of meeting them where they are, both in terms of their level of adoption and their capability of adoption and use, and their physical location. "In the former case, the tool we have for that is the definition of meaningful use and trying to find a set of performance requirements that are reachable, but not necessarily easily reached. I use the analogy of an escalator; we want to get doctors and hospitals on the escalator towards the adoption and meaningful use of electronic health records. We don't want them to trip and break their necks on the first step because it's so high, but we also don't want them to just be able to walk on it and never ascend. Getting that balance right has been a tough challenge. "We've had lots of comments from the public about the original proposal we made; a proposal that we're in the midst of modifying right now. The goal is to challenge the profession and challenge hospitals, but make it possible for most of them initially to become meaningful users. And that's a tricky job, given the variety of institutions out there and the variety of practices." Another potential challenge facing the introduction of electronic records is resistance from prospective users. While it would be wrong to subscribe to stereotypes, data compiled by the Office of the National Coordinator show that older doctors are less likely to be users of EHR. COMPLY WITH HIPAA & WE'LL HELP SUBSIDIZE YOUR INVESTMENT By 2015, HIPAA requires that all healthcare organizations standardize the interchange of electronic data for specified administrative and financial transactions in order to protect the confidentiality of their patients' electronic health information. Making the switch to Electronic Health Records (EHR) can be a long and expensive process, but penalties for non-compliance are substantial with fines as high as $50,000 per incident and may include jail time! Don't navigate through HIPAA requirements alone � PAETEC is here to help. You can draw on the expertise of a true communications partner to design and implement a plan for EHR that allows your organization to protect sensitive medical records with personalized network security solutions. Plus, with our Equipment for Services and Software for Services programs, PAETEC allows you to use a portion of the money you spend on our network services to subsidize the purchase of your EHR systems. SAVE MONEY, PROTECT PATIENT INFORMATION & STAY COMPLIANT WITH PAETEC. DOWNLOAD OUR FREE WHITEPAPER: WWW.EXECUTIVEHM.COM/EHR-SUBSIDY � PAETEC - 1585695 www.paetec.com THE BIG INTERVIEW | EHM 79 "I do understand that some doctors out there may decide that it's too much trouble," Blumenthal says. "We'll try to help them the best we can, but there will be an agerelated trend towards more rapid adoption among younger physicians." He knows whereof he speaks, with a daughter and son and a daughter-in-law who are young physicians or physicians-in-training, and who have grown up using computers, are being trained on electronic records and will never use anything else. But Blumenthal also points to himself as an example of someone of a slightly older generation who has obviously become very comfortable using electronic systems. "This transition between old and young is inevitable," he says. "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." Information exchange As has been pointed out previously in this magazine, even if every healthcare organization in the country implemented an EHR system, that does not necessarily mean these systems would be able to talk to each other. "There are challenges, and we're working on them," Blumenthal agrees. "We're trying multiple tactics. First, we're incenting doctors to exchange information and hospitals to exchange information using the incentives under the meaningful use regulation. "Second, we are developing standards that will be part of certified electronic health records that will facilitate communication among different systems. Third, we are giving the states funding to promote health information exchange. And fourth, we are developing systems that can be used by states and institutions that can be used to create private and secure exchange over the internet. "We're doing all these things. The one thing we can't do is sit down with every doctor and every nurse every moment of the day to make it possible for them to use the resources we're creating. At some point they have to take over and make this happen. We're just trying to make that as easy as we can." Another oft-cited potential snag is the lack of a single patient identifier. Harking back to his comment about the "independence of spirit" that prevails within the US, Blumenthal feels that a personal identifier is unlikely to be introduced any time in the near future. "We have to solve this problem without it. There are technologies for establishing patient identity and matching patient identity, and they work reasonably well in particular health systems that use them right now. We don't need to wait until the time that we have such an identifier, if ever. We can do this without it and we are going to have to just get on with it. "The personal identifier is not perfect either as a matcher. Those countries that use an identifier will tell you that there are mistakes, people enter the wrong digits; there HIT could reduce health costs by $12 billion over the next 10 years 60 Regional Extension Centers are being created, each looking after 1500 physicians is a need, even with a personal identifier, to use identification protocol. So we're going to rely more on those identification protocols than would be true in other countries." There are those who feel that data stored electronically are less secure than they would have been under the old, paper-based system, but Blumenthal is quick to refute this. "Paper was neither perfectly secure against any sort of breach, nor was it physically secure. It's very interesting that our Surgeon General, Regina Benjamin, told me that she had adopted electronic health records when she ran a very small practice in the Mississippi Delta. She said that after two hurricanes in two years, losing all her patients' records both times from flooding, she decided it was time to have an electronic health record system, where she could store her patient's records off-site on a secure server. Certainly she wasn't going to have to worry any more about floods destroying all her patients' records. That's one way in which records get more secure. "And the other is that you can track who has had access to your records. I remember when I was a hospital administrator we had a famous person hospitalized at one point. And a member of the press put on hospital scrubs and found their way to the nurse's station and got a hold of the record. That breach of security we couldn't track. If it hadn't been someone who'd wrote about it, we never would have known about it." Despite the concerns, the case made by Blumenthal shows that the benefits of digitization outweigh the challenges. Healthcare organizations � especially the smaller physician practices and hospitals � need to take that first step on to the EHR escalator, or risk being left behind. 80 EHM | INDUSTRY INSIGHT Delivering early HIE value By Raymond Scott T oday, healthcare information is fragmented among disparate healthcare systems and providers. Professionals recognize that this leads to ineffective, costly care; medical errors; and unnecessary repetition of diagnostic tests. Professionals also recognize that health information exchange (HIE) holds the promise of a cure for those who participate. The major barrier to successful implementation of an HIE is the lack of EMR adoption by physicians, particularly those in the smaller practices. A recent study by AC Group found that only about 10 percent of physicians in small practices (one to 10 physicians) have installed EMRs to date. These small practices represent 50 percent of all ambulatory practices in the nation � so this lack of EMR adoption can seriously impact the ability of any HIE to deliver on its promise, delaying the benefits to the patients, the community, the stakeholders and to the physicians themselves. "An EMR lite is an easy to use, easy to deploy EMR that provides physicians who are not already electronic with the ability to receive, view, manage and act on clinical data" Unfortunately, increasing physician adoption is not merely a matter of reducing the cost. Other key barriers are inherent in the independent and entrepreneurial nature of the private healthcare sector, affecting private practices, hospitals and other providers. With HIEs, we are moving into an era where individual and institutional providers will be sharing data. While participants value the data they capture and the relationships they have developed, the basis for competition will be the service they offer, not the data themselves. The undeniable reality is that clinical data now need to be shared at the point of care � the key to quickly improving the quality and significantly lowering the cost of care. To achieve it, all participants must have the ability to elec- tronically review and manage data from multiple sources. Yet, there remains a need to avoid permanent comingling of data from competing entities. In summary, there are three interrelated requirements that must be addressed for early HIE success: the network effect � the more providers connected to an HIE, the more valuable the HIE; the automation effect � all connected physicians must be able to review and manage data electronically or institutional providers will not get benefit; the separation effect � institutional providers must be able to keep their data separate so they can exercise control over broader HIE participation and access. The cost of EMR adoption to physicians has been partially addressed by the availability of federal ARRA stimulus incentives. Many of the remaining barriers to physician adoption, particularly those involving ease of use and changes in practice workflow, can be addressed by well-designed EMRs. The remaining dilemma, then, is how to reconcile the equally vital requirements of sharing patient data and preserving data ownership. The debate on this issue has been polarizing in both the private and public healthcare sectors. Fortunately, the power to resolve it exists in the fundamental technology of today's HIEs, the two principal components being an `EMR lite' and hybrid-federated repositories. An EMR lite is an easy to use, easy to deploy (browser-based) EMR that provides physicians who are not already electronic with the ability to receive, view, manage and act on clinical data. It immediately connects a small practice to an HIE without the need to purchase new equipment or undergo major workflow changes. Hybrid-federated repositories are a database solution that allows hospitals and labs to keep their data separate and secure while allowing for appropriate searching and selective sharing at the point of care. A hybrid-federated approach works with existing information systems and provides complete data-sharing flexibility. Any hospital, RHIO or statewide system developing its HIE plans should insist on a hybrid-federated solution and give serious consideration to an EMR lite option. Each can be a significant factor in achieving early `critical mass', the result necessary for a successful and sustainable HIE that delivers real value to all its stakeholders. Raymond W. Scott co-founded Axolotl Corp. in 1995 to provide collaborative electronic workflow solutions for communities of healthcare providers. He was instrumental in creating the concepts around clinical messaging, turning electronic medical record communication into a reality, and establishing it as a necessary requirement for successful health information exchanges and Regional Health information organizations. With a strong supporting management team, Scott has established Axolotl as a market leader in electronic connectivity and collaboration, today providing the technology and services to power most of the full functioning HIEs across the US. 82 EHM | INDUSTRY INSIGHT How information is connecting all types of healthcare data to make a difference By Bill Thornburg and Paul Lagasse ealth information exchange (HIE) promises to reduce healthcare costs, improve efficiency, and enhance quality of care, yet few organizations have been able to achieve long-term sustainability. To deliver on those promises, HIEs need a business model that can demonstrate a solid return on investment and financial stability. Advanced Analytics models can be the linchpin to defining an HIE value proposition centered on improved patient outcomes. With Advanced Analytics Solutions, HIEs can help all stakeholders take better care of patients and reduce costs � by providing the evidence-based medicine (EBM) insights necessary to develop intervention programs, do community outreach, measure performance and compare providers. The Ingenix HIE Gateway Model enables HIEs with administrative transactions exchange capabilities to capture the revenue typically associated with administrative exchange into a funding stream for the HIE to support the build-out of the clinical exchange infrastructure. The HIE Gateway Model supports sustainability because it eliminates redundant data exchange services for administrative transaction services and reduces fees paid by physicians. The HIE Gateway Model yields solid returns to fund HIE operations by supporting administrative transactions. However, to fund, grow and achieve sustainability, HIEs will need to provide value beyond basic exchange. By offering Advanced Analytics services as a value-add service in addition to administrative transaction exchange services, HIEs can transform existing electronic information into useful, actionable data to improve outcomes and provide physicians with the tools needed to care for their patients within that HIE community. Advanced Analytics Solutions capture raw data from disparate sources and databases and transform those data into information and insight that can be used to assist the clinical team in making informed choices at the point of care. "Advanced Analytics services can provide information to physicians about recommended tests, or if the patient is current on tests, and compliant with their medi- H cation," explains Paul Lagasse, Senior Director, Solution Architecture, Ingenix. Advanced Analytics provides care management professionals with transparent predictive modeling, EBM and tailored clinical and business rules to identify, stratify and assess patients' health status. This information and insight enables physicians and clinical teams to identify gaps in care, support and design new programs, initiate new interventions, understand patients' comprehensive use of healthcare resources, and assess physician care delivery within a network. Using Advanced Analytics to help render HIEs sustainable is a win-win situation because in providing stakeholders with actionable information that improves care, HIEs are creating a service that has distinct market value. For example, in our recently published white paper, Formula for Long-term HIE Sustainability, Better Healthcare. The HIE Gateway Model, Part II: Return Model for HIE Value-Add Advanced Analytics Solutions, we look at three common chronic conditions and show that for diabetes alone, the total potential saved if all gaps in care are closed could mean upwards of $12 million in savings for the community in the model. By knowing which diabetics are not conforming to EBM guidelines, physicians can help bring a patient into compliance, savings millions and improving long-term health. This model demonstrates value and provides a basis for cost coverage necessary for an HIE to deliver value-add services. Advanced Analytics Solutions can help providers demonstrate that they have achieved "meaningful use" of healthcare technology, compare outcomes and develop performance-based programs, identify public health concerns to contain and stop the spread of contagious disease, and develop concrete data as a source for discussion regarding cost variations for specific treatments. Ingenix provides industry-leading EBM-based tools and episodic groupers that enable analytical insight. The Ingenix Advanced Analytics "tool box" includes proven, sophisticated analytics tools that allow HIEs to deliver valuable information to employers, hospitals and payers that leads to improved outcomes and lower costs � the keys to sustainability. Bill Thornburg is Vice President, Product Management, Health Management Solutions for Ingenix. Thornburg leads the product development for the Health Management Solutions business at Ingenix. He has over 20 years of experience in software product development, management and marketing. Paul Lagasse is Senior Director, Solution Architecture for Ingenix. Lagasse is a subject matter expert in the Ingenix Health Management Solutions group. Using a variety of analytic tools to collect, analyze, assess and report on data from multiple sources, he helps clients develop comprehensive solutions to identify actionable opportunities for improvement in both quality and utilization. Learn more about the HIE Gateway Model at www. ingenix.com/hie. 84 EHM | TECHNOLOGY Sink or swim With EMRs flooding into hospitals nationwide, it's time for CIOs to take the plunge and face a new era of medical records. A s the fi ngertips of healthcare begin to run through the waters of binary, CIOs and technology officers are fi nding themselves at a sink-or-swim point. Keeping up with the constant influx of new patients and medical records is a challenge at the best of times, but with health reform now pushing for a complete EMR overhaul within the next four years, hospitals are having to compete with their own systems to ensure they stay afloat. Flying the flag for Norton Healthcare, Steve Heilman, Vice President and CMIO, knows what lies ahead. His experience in the industry has witnessed the emergence of new technologies, a new generation of IT savvy staff and the call for EMRs to succeed � but his belief in computerizing all health records within the next four years is still uncertain. TECHNOLOGY | EHM 85 "It's going to be very difficult to get everyone to where they need to be," admits Heilman. "Smaller hospitals can't afford to make the changes that are expected to be fully compliant with EMRs. There are enough resources with all the current vendors to get the implementations in place. It's the right thing to do and I think it's a great plan to get everybody on a platform where we can share information amongst institutions and that patients are enabled to have an electronic record that's moveable with them. "It's good in theory, but the problem is the timescale. It's great that they've offered the carrot of reimbursement money if you can get EMRs in place quick enough, but they also have a penalty coming in very quickly in 2015 where all of a sudden Medicare payments get cut back if you haven't hit your target. Those cuts in Medicare are going to be a huge problem to hospitals." Joel Vengco, Chief Applications Officer and Director of IT at Boston Medical Center, couldn't agree more. Having already implemented 11 EMRs in the local community, and a further three within Boston Medical Center itself, Vengco reckons that it will come down to a combination of resources and knowledge. "There's assumed to be a 50,000 person workers gap for health IT, so that's a significant gap in terms of resources," says Vengco. "That's exactly what you need to be able to implement and maintain these EMRs nationally. "In many ways it's primarily a resource gap, but then it moves into the process of implementation and the standardization of vendors. There are so many vendors out there that it's going to be complicated for those with no IT knowledge to be able to select the right products and implement them." respect to discoverability and use of data that you have with paper records. What's important is interoperability: connectivity between your peers that you're affi liated with as a provider, as well as report ability and consumption or usability of the information." All of these clearly add up to a more than just EMR implementation. Healthcare IT (HIT) undoubtedly works in different ways for different hospitals, which makes interoperability a difficult thing to come by, and a call for standardization is being heard right across the board. "Th is is a very interesting juncture in HIT," confi rms Vengco, "because we now have a federal government that it pushing for IT standards, particularly with regards to content terminologies � they're not just pushing messaging standards, but also content standards � which is critical." Continuing this sentiment, Heilman sees things more from the patient side of things. "We focus so much on the core systems in hospitals and how they operate," he says. "Personal health records, patient portals, the sharing of information; all of a sudden everybody has more power to help control their own healthcare. Patients are far more fluent with disease processes and diagnoses now than they ever have been. The sharing of information and opening up of the internet is changing the way we practice medicine, and getting connected and closing the loop on care will have a big impact." But it won't be the only area feeling an impact. With the sharing of information becoming far more open, the role of security will have to tighten up exponentially. Indeed, the Technology Act has already said plenty on the subject, and PHI will become more important the further down the EMR line hospitals get. Back in the `old days' of locally held information, security was relatively uncomplicated � secure that area and make sure nothing leaves unless it's meant to was the bottom line. However, with today's information being more of a disseminated entity, it's becoming a larger issue to plug the security gaps � meaning it's becoming harder to identify where to place blame. "If you incorrectly push the wrong patient data, potential fi nes are getting worse not better," admits Heilman. "They're increasing your risk by making you push for more information, and yet they're going to penalize you more if you mess up. But it's the right thing to do. You want to make sure that you're keeping things secure, but I wouldn't have thought they would try to defi ne who's responsible in terms of the rules of that information. If I partner with a third-party vendor to say we're going to open up an HIE or sharing of information portal, am I still responsible if I give it to you and you lose it? That's one of the questions around security that hasn't been worked out 100 percent yet." Steve Heilman is the Chief Medical Information Officer for Norton Healthcare. He joined the organization in 2008 and is responsible for the system-wide implementation of an integrated electronic medical record. His duties also include facilitating the integration of new technologies into clinical practice and acting as a liaison between physicians in the organization and the Information Services Department. The bigger picture Despite this, both Heilman and Vengco agree that the current government is right to put such emphasis on EMR implementation, especially in terms of their intended objectives � the only worries are the speed and lack of seeming completeness that the intentions have taken. "We do need to face healthcare," continues Heilman. "Part of it is EMRs and freeing up that information to be able to get it to move around, but there are other things that need to be hit on too. We need to look at liability issues, for example. It's great that we're able to focus attention and get some momentum behind things, I'm just afraid we're doing so much so fast that we might hit a roadblock and the whole thing will fall apart." Continuing Heilman's sentiment, Vengco offers another view of the same problem. "Digitization of the paper record is not enough. Just putting an EMR out there is not going to solve anything as you're basically creating the same type of problem that you have with "We do need to face healthcare. Part of it is EMRs and freeing up that information to be able to get it to move around, but there are other things that need to be hit on too" -Steve Heilman 86 EHM | TECHNOLOGY Wants and needs And with specific security issues being unique to the holes that need `plugging' relative to each hospital, the IT challenges faced will also differ; Heilman and Vengco are no different. Where one wants to complete system adoption, the other is scouting for interoperability. "We have a very high adoption rate in our community," affi rms Vengco. "What has been an issue is an ability to exchange data. We share patients and providers to a certain degree. Those providers become the integrators at the computer screen. We shouldn't have them opening five to six different EMRs to try and aggregate a story for a patient. At the end of the day, that patient is only there for 20 minutes at best, so spending time fi nding facts and aggregating different data could create a very low patient effectiveness in terms of treatment. "Interoperability was our largest problem. I like to call the first eight to 10 years of our existence implementation because we just digitized records, but now we've realized that we have to integrate, interoperate and be able to utilize that data � so now we fi nd ourselves in the realization phase. In a further eight to 10 years, I predict that in my environment, our data will be standardized so that they are interoperable between our organizations, which they are already is today, but we need to be able to continue to do before we fully get there." For Heilman, the challenge is taking on a new system and being able to understand, develop and integrate it to work specifically for Norton Healthcare. "In the past we never did anything with the data, it was all just locked up in charts," admits Heilman. "Now it's going to a database somewhere. The challenge is: what do we do with it? How do we take all that information and improve the care of the patients in our institution now? We tried to make our web presence a little more prominent, so patients are getting more access to scheduling things online, being able to access our facilities, to know what services we have that are available. The goal is to be able to say in the future you'll be able to make your schedule completely online." Joel Vengco is the Director and Chief Applications Officer at Boston Medical Center. In this role, he oversees various enterprise HIT applications and technologies that include the primary point-of-care applications such as the EMR, ancillary applications and associated devices, integration technologies, and diagnostic modalities. He is the architect of BMC and Boston HealthNet's Community Information Exchange that has established information sharing and interoperability between BMC and its partnering community health centers. Make it personal With the intention of EMRs to do precisely that, it could be assumed that the effect they will have will also cross over into the world of pharmaceuticals and personalized medicine. "Right now, we're trying to get into the personalized medicine realm," says Heilman, "and trying to get genetics into an EMR; if patients are willing to have testing done, can we fi le it and what effect will it have? That will have a huge impact. Right now we're taught that we know certain medications will treat certain genders and races in specific ways and these are the first-line drugs. If those don't work, try the second-line drugs. What may work on one race may not work as well on another. "We're already getting a lot of information, and trying to figure out what story that information is telling us is the challenge right now for physicians" - Joel Vengco "But it's obviously going to get more personal than that. If we can fi nd those roadmaps that can say things like `this is going to be the best chemotherapy for this cancer' or `as soon as you gain a further 30 pounds you know you're going to become a diabetic'; if you can start hammering that education down in people's minds when you can make a difference about it, it will change the way you practice medicine. "People always ask, `So you found out I'm going to get breast cancer'. Some people don't want to know that. They would prefer not to. Nothing in life is 100 percent; even if you have a breast cancer gene, I can't tell you that there are 100 percent odds you're going to get breast cancer. If we do get to the point where we can, with positive conviction, say that from a genetic report that this is going to happen to you, maybe we can at least educate you about what to look for as things are coming online, or prevent it from even occurring." Heilman's notion of EMRs working within the realms outside of healthcare is certainly echoed by Vengco � but his belief sits around the five to eight year mark. "I say that, because that's going to provide even more insight to providers about what a patient should be provided for better care," declares Vengco. "It's going to come down to work flow, integration and utilization of information and how it integrates with the information that's already resident in the EMR. "The problem we're facing is outside of interoperability. We're already getting a lot of information, and trying to figure out what story that information is telling us is the challenge right now for physicians. There are studies out there that show that if you give too much information, you create confusion and hindrance. But all that aside, there's no question that EMR over the next 10 years will drive personalized patient care and medicine and should be at the fi ngertips of every patient in their EMR. When a provider sees a patient, they should be able to look at genetic or genomic information and say what they are predisposed to having, if anything, or preempt conditions based on genetic issues." For healthcare institutions and hospitals such as Norton Healthcare and Boston Medical, the answer to EMR implementation has only been partly revealed. Educated assumptions and experience will serve them well up to a point but � as with most things in life � the real challenges will only expose themselves during the process. However, what is glaringly obvious is that in order for the industry as a whole to achieve this milestone and overcome the challenges awaiting it, it must see the bigger picture and work sympathetically with smaller establishments to impart knowledge and experience once it is comfortable with its own EMR implementation. Only then will the Obama administration's goal be fully realized and begin to evolve. 88 EHM | PATIENT FLOW Healthcare and traffic management How ensuring patients move through your hospital in an efficient manner can increase staff satisfaction, patient safety, and even your bottom line, according to Eugene Litvak. What's the link between the following two statements? ugene Litvak, President and CEO of the Institute for Healthcare Optimization, points out that the problems of overcrowding and long wait times in hospitals are not unique to the US. "One may speculate about why that happened � because of an increase in the demand from the baby boomers, for example � but the bottom line is that the demand now exceeds capacity in many countries," he says. "Here in the US, the situation is even deeper. Because of the healthcare bill, we are going to add another 30 million people to the demand." The issue of simple overcrowding is compounded by the problem of uneven patient flow. Because patient demand at most hospitals fluctuates significantly from day to day, medical staff become stressed, which in turn is one of the main causes of medical errors and lapses in patient safety. "When we have a peak in patient demand, that doesn't just impact the throughput of waiting time. It also affects patient safety and nurse satisfaction. What happens when we have a peak? We don't have enough nurses, because no hospital staffs to the peak 24 hours a day every week. They staff somewhere below the peak, probably to the average level. "When there is a peak, you don't have a sufficient number of nurses. We call in oncall nurses, travel nurses, etc., but they do not arrive immediately. It takes time, and during this time, patients are in danger. Nurses are also stressed because when we have a valley, we cannot save those nursing resources to use for tomorrow's peak, so they are gone. Day after day, they alternate different types of stress. One day you have a valley, you have stress; another day you have a peak, you have stress. That's how all hospitals work." E At first glance, it appears that `nothing' would be the correct answer. However, the truth is that the second is partly to blame for the first. Read on to find out why. PATIENT FLOW | EHM 89 The second solution is to challenge the nature of those peaks by drilling deeper and finding out how to get rid of them. "Demand currently exceeds capacity, given the way that capacity is being managed. To state it even more boldly, demand exceeds mismanaged capacity" Practicalities According to the IHO, achieving breakthrough levels of improvement in patient flow requires work in three areas: within-day variability, between-day variability, and lengthening the chain. Litvak explains lengthening the chain this way: "What does it mean when the patient is ready to be discharged, but there is no other facility? Suppose the patient needs some rehabilitation care, but there are no rehabilitation beds or rehabilitation facilities available. Patients then get rehabilitation care in the acute facility, when in fact they should be somewhere else. They would then needlessly occupy beds in their acute hospital, which prevents other people from entering. That's why it's important to make sure that the patients who are ready to be discharged are being discharged; that we don't give them longer than we should. "In terms of variability, there are several types. There is seasonal variability: the demand, for example, when people have flu clearly is greater in the winter than in the summer, so there is variability between different seasons. Th is variability is not dangerous; it is relatively easy to adjust to because in the winter we anticipate these cases, so we make sure that we provide sufficient resources." The second type of variability is variability between days � the peaks and valleys. In order to discover the root cause of this variability, Litvak says it's important to look at why elective procedures are scheduled the way they are. "If we schedule elective admissions, what would prevent us from scheduling them evenly? If the average number of surgeries that the hospital performs is 50 surgeries a day, what would prevent us from scheduling somewhere between 47 and 53 surgeries? Nothing, and yet at a hospital with that average, one day we may have 20 surgeries, and another day 75. "That's what puts hospital under stress, and this variability is much greater than the variability caused by the person who broke her leg and came to the emergency room. It is literally easier for us to predict when somebody will their break leg and come to the emergency room than when elective scheduled surgery will take place." Th is seems counterintuitive, but Litvak explains that the cause is historical. "Until relatively recently, hospitals have been cost-plus reimbursed. If I have as much money as I want, I will not look at what is on the sale in the supermarket." "I will just buy whatever looks good to me. Hospitals used to have excess capacity, so when we had those peaks, we didn't feel anything, because we had plenty of open beds. Not anymore. So now all of a sudden we feel these peaks and valleys. There has traditionally been a strong belief that these peaks and valleys are patient driven, which leads to a sense of powerlessness. As Litvak puts it, "Even if we say it's not good when the hospital has rest and then stress, what can we do if it's patient driven and we don't have resources to staff through the peak because we don't have enough money?" The bad/good news is that, according to Litvak, many of these peaks are not patient driven. "When I say that the demand exceeds capacity, I usually reformulate it. Demand currently exceeds capacity, given the way that capacity is being managed. To state it even more boldly, demand exceeds mismanaged capacity. That's why patient flow is becoming extremely important � how to manage capacity to meet the demand. "Another thing is that when you have those peaks, your emergency departments become overcrowded. In the UK, for example, there is a four-hour limit on waiting time in emergency departments. In the US, we don't have this rule, and our waiting time could be 10 hours or more. "Even in the UK where the limit is four hours, after that the patient should be put on the floor, but if there is no space, if there is a peak that day, the only solution then for the hospital administration would be to discharge patients to free up beds. Patients are then being discharged prematurely. Th is all has consequences on quality of care. Those peaks and valleys probably are the worst enemies today in healthcare." Litvak says there are only two ways of addressing this issue. The first is to go to the government and say, "Give us more money so we can staff through the peak." This is not always a feasible solution, and especially with the current situation in the US. PATIENT FLOW | EHM 93 income by an even greater amount. While medical staff at the hospital were initially wary, they have come to appreciate the new system. It has also made doctors and nurses happy, because schedules became more predictable. And hospital officials say the changes have also made their hospital safer by reducing the times when nurses and doctors are under extreme stress. "They were planning to build additional beds to deal with the peaks," Litvak says. "Once they figured out that they could keep the number of beds they have, their avoided capital cost was $100 million. I am not aware of any project in healthcare, in any country, that an individual hospital would get this return on investment." Another hospital, Boston Medical Center, significantly increased its throughput thanks to the IHO's intervention. Compared to the previous year, the number of ambulances diverted to other hospitals fell by 12 percent. Take it back four years, and the difference is even more astounding � diversions were down by 40 percent. "They used to have 700 cancelled or postponed surgeries a year," Litvak continues. "After implementing our concepts, their number of surgical postponements or cancellations in the last three years was 16. That's more than 100 times less. "Once we discovered the cause, we started working on how to change it. Our methodology includes the following factors. First, operations management model- ing: we do very deep and rigorous analysis. An equally important component is data collection and cleaning. Hospitals have never been concerned about their capacity and scheduling, so many of the data we need for the analysis are simply not being collected. "When we start with a hospital, we ask them to collect the data and then we help them to clean the data and put them on the right track, because the variability methodology, is 99 percent, 100 percent data driven. If you don't have reliable data from individual hospitals, there is no way we can provide a reliable solution." Litvak believes this situation will improve with the introduction of radio frequency (RFID) technology, which should provide a dramatic improvement in the ability to obtain accurate data, and avoid the need for extensive data cleaning. Education There is another component in the effort to improve the efficiency of patient flow: education and organizational behavior. "I've never come to a hospital and had the surgeons cry on our shoulders and say, `Oh, we were waiting for you,'" Litvaks laughs. "That's not the case. The case is for them is to push back. Then what we do, once we have data, is to start educating them about the concept and explaining that they're going to do more surgeries, not less. Then we tell them another benefit for surgeons: they are going to go home not at 11 p.m., but at 5 p.m., and yet still do more surgeries. Th eir overtime is reduced significantly. That's a very, very big attraction." To make the transition easier, Litvak shows them results from other hospitals his team is working with. Once they have implemented phase one of their plan at a hospital, they send a questionnaire to surgeons. Then when the team goes into a new hospital, they show the surgeons there how their colleagues at the other hospital felt. "Second, we show them their own data," Litvak says, "and explain to the individual surgical subspecialties how they're going to benefit from that in terms of the number of cases and reduced overtime. 94 EHM | PATIENT FLOW "There is another parameter for surgeons that they're very sensitive to � they call it turnover, the time needed to clean the room between two cases. If you're a surgeon, for you it's a waste of time, because you don't do anything, you just sit and wait. Surgeons want to reduce this time. If you come to any surgical department and ask them, `Give me one thing that you want to change,' they will tell you turnover, and it doesn't matter whether turnover is good or bad. They want to reduce it anyway. For them the ideal scenario would be zero. "What happens today in terms of turnover? Suppose that you convince nurses that they should work harder and do it faster, and they do it. During the day they have, let's say, four or five surgeries and instead of having a turnover of let's say 40 minutes they make it 20 minutes. So these four or five cases, 20 minutes reduction in turnover each � you will get 100 minutes out of it. "What would the consequence of that be? If they work hard and save this 100 minutes, they would be rewarded with another case. `Oh, you fi nished early? Good. We can do another project.' That's exactly how it works today." What Litvak does instead is guarantee that everybody � surgeons, nurses, anesthetists � will leave the hospital at a certain time every day, usually at 4 p.m. or 5 p.m. Th is provides a better incentive for the nurses � they work faster because they know that once they're done, they can leave. Variability methodology and operations management; data collection and verification; organizational behavior; clinical � Litvak calls these elements of improved patient flow the `four-legged stool'. If you ignore or take away one leg, the whole stool will fail. Organizational behavior means explaining to people how they personally would benefit. "If I come to a surgeon and say, `Your hospital will benefit on your back,' they would not be happy with that," Litvak rightly says. "We explain to the doctors how they benefit, to the nurses how they benefit, to the anesthetists how they benefit. "Finally the fourth leg of this stool after organizational behavior is the clinical part. We show that we significantly reduce waiting time for emergency and urgent surgeries. "Another part of the clinical leg is this: Surgeons, when they have a broken schedule, it's not because they're mean-spirited people. They are very devoted people. They just have a lot of other responsibilities: office hours, clinics, etc. They do the surgeries, they do their best to save patients, and then the patient is being placed in the wrong bed because the right bed is being occupied because they had a peak today in admissions, so they get inadequate healthcare. "Th is inadequate nursing care affects the outcomes. So how should surgeons feel about putting their whole energy and passion into the surgery if after that somebody is going to diminish it? They feel very, very bad. I know surgeons who will stay at the hospital overnight if they know that their patients are put in the wrong bed. That's a big stress. That's why we tell them that as a result of our methods, their patients will be in the right beds." Litvak says he is convinced that with the current state of the US hospital system, there is absolutely no choice but to optimize patient flow in this way. When asked about timescale, he is less defi nite. "We are working with different organizations on how to develop a plan that would make this available as widely as possible. We have to bring in education. We cannot roll it out to hospitals one by one, that would take too long. What we're doing now is exploring group collaborative training of several hospitals." Despite facing such a daunting task, Litvak is upbeat. He says it's exciting that hospitals are fi nally listening. "Our demand already exceeds our capacity; that's why we started changing the model. What is interesting that although we were are less sophisticated in our work years ago, our message was the same, and yet at that point nobody listened. The situation has changed now. Hospitals are already under stress and they understand that stress levels will only increase with the new healthcare bill. So they are much, much more amenable. It's like a different world. "It reminds me of what Mark Twain said about how when he was 14, his father was stupid, but when he got to be 21, he was surprised at how much his father had learned. Now all of a sudden, in healthcare, the father has become smarter." PATIENT FLOW | EHM 91 "Let me give an example: If you look at someone who is buying a car for a teenage son or a daughter, what kind of car would these parents be looking for? Short of the cost � everybody wants cheap � what would be the most important parameters for such parents? Probably making sure that the car is safe: That the car has a big bumper, that the car looks like a tank. Why? Because they know that this car is going to be subjected to frequent stresses. "What has happened to our fi nancial bumper in healthcare? We used to have a tank and a very thick bumper on our healthcare car, but now our fi nancial bumper is getting thinner and thinner. We've started feeling more and more of those stresses. That's why it is more important today than yesterday, and as long as our healthcare cost is being controlled, we will feel more and more of those peaks." Scheduling There's also the question of variability during the day. Most US hospitals discharge more patients in the afternoons. As Litvak points out, if a patient's disease is driven by their healthcare status � if their stay at the hospital is driven by their condition � why would they suddenly become healthier in the afternoons? "As much as we have to reduce peaks and valleys in our admission, we have to reduce peaks and valleys in our discharging," Litvak says. "What happens is that most surgeons, when asked to choose the times of their surgeries, will choose morning hours. Their minds are fresh, they feel good, and they want to finish the job as soon as possible and go and do something else. So what you see frequently is that in the morning, especially on The `four-legged stool' of patient flow Monday and Tuesday, there is a peak in patient surgeries. In the afternoon, you have a valley. When you have a peak in patient admissions in the morning and the patients are still not being discharged, you immediately have a peak in bed occupancy, then it drops in the afternoon. "First of all, we should understand that discharging patients comes second after admissions. Artificial variability in patient admissions � the peaks and valleys that are being created by us � must be eliminated. We simply cannot afford them any more. "We are no longer cost-plus reimbursed. We shouldn't have nurses under stress, or have somebody's emergency surgery delayed because everything is scheduled based on individual people's convenience. It's no longer just about money; it's about patient mortality and patient safety." Litvak explains that while hospitals have their internal teams to help patients when the patient deteriorates, patients often deteriorate because they are put in the wrong beds. "Why are they put in the wrong beds? Suppose we have an average surgical case volume at a particular hospital of about 50, and suppose that today they have 80. It means that 30 more beds will be taken away from patients that are coming for example from emergency rooms. Nurses, instead of taking care of 50 patients, would be taking care of 80 patients. Clearly that would diminish quality of care and patient safety." To counter this, when Litvak and his team are advising a hospital, they recommend the following: if the average is 50 surgeries a day, that hospital should never do more than 55. "That should be more than sufficient for them to get all their patients through because that's based on their average. We would not allow them to have 60 surgeries a day, and certainly not 70 or 80. I know hospitals where the increase in those peaks could be 50 percent above the average as well as 50 percent below, so the difference in elective scheduled hospital admissions between two neighboring days could be 100 percent. The hospitals cannot tolerate it any more." "Variability methodology and operations management; data collection and verification; organizational behavior; clinical: these elements of improved patient flow are like a fourlegged stool. If you ignore or take away one leg, the whole stool will fail" Progress Litvak and the IHO are working with several hospitals to improve this crucial aspect of patient flow, including the well-known Cincinnati Children's Hospital. To explain the changes made there, Litvak uses the following analogy: "Suppose you have a road between point A and point B and you want to send as many cars between them as possible. You could send your cars in uneven clusters, such as 10 cars then 70 then 0 then 50 then 100; or you could send your cars in a steady flow. Under which scenario will you send more cars?" The correct answer is that using the steady flow allows you to send more cars. The peaks fi ll up the valleys, and overall throughput increases. In a hospital scenario, this allows more patients to be processed in the same amount of time. Over the past seven years, Litvak has worked with Cincinnati Children's to streamline patient flow between the emergency department and post-surgical recovery areas. The changes made have allowed hospital physicians to look after more patients in less time more efficiently and with fewer logistical issues. According to the hospital administration, improvements in efficiency have given it a boost in capacity equivalent to a $100-million, 100-bed expansion, and have raised its Variability methodology Data collection Organizational behavior Clinical iStrategy USA Chicago, Il 15-16 September 2010 The Hotel Allegro Transforming the Enterprise with Digital Expertise Participation in Social Media and Interactive Marketing is no longer revolutionary. it's crucial. � The top 10 most important factors in your social media strategy � How to measure your social capital and monetize your efforts � Hot buttons to bring people to your web store front � How to find your best fit in integrating email and social media � How to deliver a response-driven, relevant message The simple truth is that there is no magic one-sizefits-all marketing mix. iStrategy will arm you with the deep understanding of aligning social media and digital strategy according to your organization's processes and operations to achieve the objectives you're after. 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Mobile: + 44 (0) 7798 820 711 96 EHM | EXECUTIVE INTERVIEW Keeping a steady flow Sid Mandel explains how technology can help ensure patients move efficiently � and happily � through the waiting room. Sid Mandel is the Director for Qnomy Inc. in North America. He is responsible for sales, marketing, operations and oversight of Qnomy's existing clients and distributors. Mandel brings over 25 years of experience working with software solutions for the healthcare industry. What are the challenges in dealing with this type of patient flow, and how can they be dealt with? SM. The first challenge is creating a system that handles all these cases, and can decide at any given moment who � of all waiting patients � should be called next, weighing in all the different priorities and factors. Second, this complex logic needs to be made transparent, so that each patient feels he or she is treated fairly and provided good care. A simple numbering system is not enough to tackle these challenges, and any attempt to force such a system into complex scenarios would usually result in angry patients, frustrated doctors and total disorder. Instead, a specialized system of patient flow management needs to be implemented. What type of patient flow management system would you recommend? SM. Systems such as Q-nomy's Q-Flow software can automatically handle all common cases by applying business rules, which on one hand assign a priority to each case, and on the other hand set clear limits for maximum waiting that prevent lower priority cases from being overtaken again and again and never getting called. Such a system would also allow very particular algorithms to be rapidly programmed to support the requirements of any site � such as the ophthalmologist's clinic. Specialized systems like Q-Flow also provide appropriate presentation tools, which can be used to provide patients with clear indication of their priority and when they are going to be called. What are the basic tools used in such a system? SM. The basic tools are LCD screen displays (replacing the old LED signs that only show the `next in line' number). LCD displays pro- "A simple numbering system is not enough to tackle these challenges, and any attempt to force such a system into complex scenarios would usually result in angry patients, frustrated doctors and total disorder" vide enough room to show a number of different queues (such as appointments, walk-ins, returning patients, and so on) and to show more than one patient per queue. All patients can see where they are on the display, and can feel relaxed knowing there's a consistent method at work. For patients who will need to experience a long wait, more advanced options can be offered � for instance, to wait at a nearby cafeteria and be notified using SMS when they need to get back to the waiting room. The bottom line is, clinic patient flow is one complex challenge where good automated technology can make people (patients and doctors alike) more happy and relaxed than any human intervention � as well intended as it may be � ever could. How would you describe the behavior of patient flow in a physician's waiting room? Sid Mandel. Patient flow in the doctor's waiting room behaves less like an orderly queue and more like a cloud, from which patients need to be called according to complex logic. Th is cloud is made up of different types of cases, including people admitted based on first-come-first-served; patients with appointments who take priority, assuming they arrived on time; patients who are too late for their appointment (and whose priority might somehow still precede random walk-ins); patients who walk in and got prioritized based on level of urgency (possibly by a triage nurse); patients who previously visited the doctor, got sent to a series of lab tests, and now come back with results; and so on. Specific clinics often have other particular types of cases with unique behavior. For instance, patients visiting an ophthalmologist might be asked to wait 20 minutes for dilation to take effect, and then be called to the doctors according to their original order of arrival. 98 EHM | COVER STORY TECHNOLOGY With President Obama's goal of computerizing all health records by 2014 now in place, Kevin Williams tells Nick Pryke about the reality of the situation and its implications for hospitals nationwide. TECHNOLOGY | EHM COVER STORY 99 H ealth reform. Technological innovation. predict what will be available on the market within the next 18 months, An increasing healthcare population. The let alone the next four years; it seems as though the assimilation of techworld's brightest minds applied to creativity. nology was missed by the sweeping hands of health reform. Add them all together and divide by limiting "To give physicians, nurses and their providers the ability to asfunds, and you have yourself the current state similate that kind of information and technology in a country as large of affairs within the majority of hospitals and as the US is not feasible within the next four years," asserts Williams. healthcare organizations across the US. And "If you look deep into the legislation, EMR funding is stated as being for with President Obama confirming that all US health records are indeed hospitals between 100 and 500 beds. That would get you Middle America, to become computerized, potentially within the next four years, CIOs and but it's like doing any kind of computer program application � the last 20 chief technology officers are frantically scouting the market for technology percent of the job is going to take 80 percent of the time." that can bring them up to scratch with where they need to be. Another kink in the health reform super-plan is that, in the grand One of the people doing precisely that is Kevin Williams, former scheme of things, Williams believes that far too much emphasis has been CIO and Vice President of Information Systems for Triumph Healthcare placed on EMRs. "My main disagreement with it," continues Williams, in Houston, Texas. With an attitude that never fails to inspire and moti"is that there are too many players that have their own economic needs vate, Williams understands the reality of converting an endless stack of to take into consideration, so there are problems in two areas � the public paper into what is becoming commonly known as the electronic medical health system and the individuals. You have to remember that we're obvirecord (EMR). However, with so much inherent change, is the timescale ously still a capitalistic system, so it's difficult in the role of a CIO, CMIO truly viable? or VP of information systems to go to the management and say, `We need "It's close to being feasible," offers Williams, "but it's wrought with to spend $5 million and it will benefit the public health sector'." some complexities that did not make their way into the legislative thinkFor Williams and his former organization � a long-term acute care ing. Th is would have been a great idea 25 or 30 years ago when the popu(LTAC) and rehabilitation hospital � the biggest obstacle attached to this lation was not quite as mobile as it is now. For example, if your hospital is point is trying to fi nd vendors that can satisfy a large majority of their up in Boston and has a nice EMR, but you get hurt in Dallas, you've got specialist needs. Unlike areas such as OBGYN, where predictions can to go to a hospital there � so that EMR isn't going to do anything for the be made within certain parameters, LTAC deals with patients who have patient. Perhaps a competing idea would have been something like what multiple diagnoses, so diagnostics are irrelevant as the patient's problem I call a `personal medical record', whereby the individual is the literal is already understood. The job of those in LTAC is to ultimately get the owner of the information. patient back to their former glory. "When we go to a hospital or to see a physician, we allow them to write test results and diagnoses into that record. That way, the next time we go somewhere we can grant another physician or hospital access to that information. That n the subject of risk, security has taken a leading role in recent discussions on satisfies a couple of requirements. The fi rst is that EMR, and indeed is on the lips of CIOs nationwide. People want to be able to it gives us a true EMR; the second is that it allows access data from a mobility standpoint; the bottom line remains that they it to become more logical and less physical. If you Security look at the way that it's proposed under health information technology (HIT) standards, the record will be physically housed at a particular hospital � but if the patient isn't there then it doesn't do any good." O Oversights While other companies and industry experts are already half way down the acceptance road with EMRs, Williams' alternate perspective sheds new light on the matter, offering logical solutions that would undoubtedly solve more problems in the long term. However, the `rules of reform' have already been cast, leaving little room for maneuverability. The main problem Williams envisions with trying to tackle the issue in such a strict timescale is that technology is moving with such speed that it is impossible to want to be mobile, and they have to be mobile. However, nurses, physicians and healthcare staff in general have a very different relationship with technology than an accountant or administrative member might have. "Rightfully so," affirms Williams. "Whenever there's need for some intervention, a clinician's going to drop everything. It's all about the patient at that point in time, so when they come back to what they were doing, they'll be thinking, `Where did I put my iPhone?' The other thing, which doesn't come out as much, would be something like someone leaving a laptop in public; it's completely innocent, but potentially dangerous in the wrong hands. "I'll give you an example that we've run into before. It's not unique to LTAC, but it gets exacerbated there. A patient comes into a hospital and fills out all their admission paperwork. Once we get all that in, we know we've got their work history, social security number, address and next of kin. Basically, what we have now is everything you need to apply for a credit card. You've got to make sure that that information doesn't fall into the wrong hands. One thing that's also unique about LTAC, and is a big potential problem, is that our patients are in hospital for 35 to 45 days. Those people are not going to be going to their mailbox any time soon, so all you need to do is get your hands on some of that information and go to apply for a credit card. 100 EHM | TECHNOLOGY "The issue that you run into is that, let's say a patient broke their ensures that the automation process is fulfi lled; in doing so, you have leg and was in an acute care hospital and then went for physical therapy to know whether the process makes any sense, because it's easy to take afterwards that involved some minor movement. If that patient also has a computer and "do something stupid faster", as Williams puts it. The some cardiac conditions and perhaps some respiratory ones as well, you second considers the time value of information; knowledge or informacan't say, `We want you to go over here and do a mile on the treadmill,' tion known and data disseminated at any given time is pivotally imporbecause it's just not going to happen. You have to build those interdiscitant to comprehend. The fi nal principle concerns itself with the velocity plinary teams and there isn't any one HIT vendor out there that is willing of information. If a business' information is flowing slowly, then good to take that approach. decisions can't be made quickly; you have to match the decision-making "Part of the reason is that that specialized aspect of the healthcare process up with the velocity of that information. continuum of care, where you're going to have really intensive care, doesn't represent enough EMR funding is stated as being The human element money to make it worthwhile for a vendor to go for hospitals between 100 and For all the downfalls that Williams points out, out and take the risk and develop a product. They'd 500 beds. That would get you if these three principles can become standardized, have to sell it to everybody in the market, which is Middle America, but it's like then the future of EMRs could be better than first not going to happen." doing any kind of computer predicted. "One of the things that an EMR will program application � the last do that is very difficult to do in the situation as Communication 20 percent of the job is going it exists right now is with the data � you can then Williams cites one of the biggest challenges to take 80 percent of the time. look at the trends. That's one of the problems we faced by his former company as being the speed have right now. When a patient comes in, we can at which it could get information into the hands sit down. We can do an EKG. We could run lab of clinicians � not an easy task when you have and blood tests to fi nd out what the patient's hospitals spread across different time zones condition is right now. But if you had an EMR with everybody needing information as early where you had some historical pieces, you could in the morning as possible. What then hapcheck if there were any trends: How has their pens is the window to access and obtain the blood pressure been over the years, for example. necessary information from the computer "On the fl ipside of that, one of the biggest narrows very quickly. Understanding how potential dangers will be where people will try to keep a system running 24 hours a day while to make predictions and forecasts based on releasing secure information without driving your historical data. If you see someone's blood presstaff into the ground is therefore pivotal. The answer? Getting the sure going up, then quite possibly it could be that you may have some "talent" as Williams refers to it. cardiac issues. Alternatively, if you don't know enough about how that "It seems that you can get IT people, but IT people don't generally person lives, you could also just have someone who has been in a stressful relate well to the users. To avoid this, we used a technique that, for lack situation, so that forecast wouldn't be valid." The biggest fear continues of a better term, I'll call `selective handholding'. I had an IT group that to be that, with all this accumulated data, an EMR could end up contook care of most of the hardware, networking and security. I took care of taining more personal information than patients even consciously know the information systems people and paired them up with the users based about themselves. on some common experiences that they had. I had one person that un"Those things are going to come up three or four years down the derstood the intake process, so he worked with the intake Vice President road, as we start to implement these things," adds Williams. "The other of Marketing on referrals, as he was a programmer and a soft ware guy. thing that concerns me is that we'll start to raise a whole generation "I had another soft ware guy that took care of the accounting side under these circumstances, so we've got their information all the way of the house, as he could talk to the accountants and relate to them. I from birth. But what happens if a child's parents divorce? The mother worked with the operators because I understood the operations of the wants things one way, the father another, and you've got all this historical hospital. Th is was my idea, but it was borrowed from other industries. data. What happens is that you start to get a lot of other mixed opinions For one, I noticed how Black & Decker had to rebuild itself to get back into the data, and that can create problems. into some market share it had lost. One of the things I remember hearing "We see that a lot in on the LTAC side already, not so much with chilthe CEO say was that nobody wants to buy a drill � they just want a hole dren, but more with the geriatric population. Then, for security purposes, in the wall. we get into a child being `granted custody' to one parent. Who now has "When you start getting physicians and members of medical execucustody of that child's medical record? There's plenty of little legal things tive committees thinking like that � `Did you want a coffee maker or did that that are bound to emerge. A lot of the time marriages break up due you want a cup of coffee?' � then you can offer them a better underto philosophical differences � when you throw a medical record into the standing of the situation relative to IT systems. " mix, you're sure to end up with plenty of court settlements." Williams also took a concept of three main principles that he wanted Kevin Williams was formerly Vice President and CIO for Information Systems at Triumph all information systems and IT people to understand fully. The fi rst Healthcare. NEXT BIG THING | EHM 101 PathXchange: A global online pathology community Facebook, LinkedIn, Twitter and YouTube are social media sites that have changed the way we look at our professional and social networks. The pathology industry is no different; technology is revolutionizing the field. In the past decade, the industry has transitioned into the digital age, allowing pathologists to view, manage, manipulate, analyze, report and collaborate using digital slides. echnology is revolutionizing the art and science of pathology and the methods used to disseminate information generated by these developments. The move to a digital format has increased the need for pathologists to stay connected with the professional network and keep up to date with the latest advances in the field. PathXchange.org (PX) is a not-for-profit professional networking portal for the global pathology community. This brings the field of pathology into the digital age with Web 2.0 features designed to promote exchange of pathological cases, ideas, knowledge, information, products and services. Cases and information can originate from anywhere, from any platform, and be shared with the sub-groups of users' choice. Traditionally, community pathology practices are geographically fragmented and small. Social networks, however, can allow a bridging of collaboration and consultation regardless of physical location. Pathologists can digitally T to browse and search for cases, archive cases in their own library and develop a URL for each case for use in websites, papers and journals. In addition, case reviews allow case review committee members to review member cases and publish the `case of the month'. A `virtual tumor board' affords members access to PX as a platform for conducting tumor boards virtually, without having to be physically present, while `peer reviews/second opinion' options allow members to selectively submit a case and seek an informal peer review or a formal second opinion from experts through their professional network. The `Pro Bono' reviews service from PX sees members being able to review cases from developing areas such as Africa and India, where currently they may not exist. Finally, scan glass slides and upload them to PX. PathX`e-learning' allows the site to combine several change fosters e-learning, digital elements, including course case sharing and archival, and galleries, self-assessments telepathology, bringing together and interactive teaching the eyes and minds of geographitools to promote commucally distributed pathologists. nity based learning, conThe site allows members to coltinued medical education, laborate on cases and view slides knowledge sharing and together in synchronized mode. professional networking, while alerts allow members Social tools to stay informed of new Dubbed "Facebook for Padevelopments through Robert Monroe is board certified by the American Board of thologists", PX not only allows community feeds. Pathology in cytopathology, anatomic pathology and clinical pathologists to stay connected The PathXchange pathology. He received his with their professional network, community has grown degrees in medicine and genetics from Harvard Medical School. but also provides access to a to include 4500 members He subsequently completed residency training in pathology number of tools designed to supfrom 60 countries in nine at Stanford University and the port the exchange of knowledge months since its inception UCLA Medical Center followed by a fellowship in cytopathology and ideas, including a case galand has become the largat UCLA. He has published numerous articles for peerlery, where members can share est global online pathology reviewed journals and has shared cases online by creating their community with the larghis expertise through various lectures and presentations locally own photo gallery of case slides. est user contributed digital and nationally. The gallery also allows members case library. 102 EHM | ASK THE EXPERT Strong leaders required During an era of rapid transformation for the healthcare sector, which strategies will be most effective in helping organizations strengthen their leadership teams? Samantha Carey and Tom Koch examine the issues. uilding the right leadership team is a significant challenge for today's healthcare organizations, regardless of their industry niche or size. Strong forces are pushing this sector in the direction of major change and, increasingly, we'll see many businesses struggling to keep up. US healthcare reform will be an important part of this process, but there are many other forces of change at work including an aging population and shift ing investor interest, demonstrated in particular by much more attention from the private equity community. With these various trends all combining to encourage � in fact, to necessitate � a movement by healthcare companies to become more cost efficient, technologically savvy, strategically focused, and, above all, competitively nimble, the same-old, same-old approach to management just won't work. Whether the business is a chain of hospitals, a provider of home healthcare services, an imaging company, or another type of business within this sector, there is a fundamental need to assess the skills and experiences of the leadership team, especially as these relate to the corporation's short- and longer-term challenges and opportunities. For many companies, there is great potential; however, where there are talent gaps, these must be addressed. And where there is a lack of clarity or direction at the top, this also cannot be ignored without great cost. For the healthcare sector, this is an era in which marketplace dynamics demand leadership and vision like never before. A well-qualified and active board of directors can play an invaluable role in setting the agenda and helping the company achieve its key priorities. But in order for this to happen, the board cannot consist simply of a group of wealthy benefactors and corporate insiders. For companies that are committed to building the right leadership team, this must begin in the boardroom, with a B "A strong board of directors, top quality executive team, and the right advisors will help organizations better pursue and achieve their goals" group of top-quality directors who will bring tangible operating and functional experience to the table, as well as a commitment to asking the tough questions. Impactful, healthcare boards will need to be proactive and extremely capable of helping their companies think in new ways and chart out new courses, in order to help them deliver value. If the board is doing its job well, it will also focus on succession planning and talent bench-building, since both are essential to achieving sustainable, profitable growth in this turbulent marketplace. In a sector like this one, with high demand and a limited supply of top talent, healthcare executives should not only be open to hiring great talent � they need to be prepared to act decisively, acquiring valuable talent as it becomes available. The right hires will be men and women who possess `turnkey' skills, contacts and experiences that could result in an immediate impact for the business. Great talent won't necessarily fit into traditional capacities, roles or functions. A `general athlete' can take on a strategy role, identifying areas of need and opportunity, and then set himself or herself, along with the organization, on the path to solutions. These days, there may be pressing talent needs that companies simply cannot fi ll, at least in the short run. In such cases, a company should try to identify key advisors to help it bridge those critical requirements. Th is strategy is also effective in situations in which there are areas of expertise that will be most valuable to the organization immediately and in the short term � during this period of quick, intense, transformative change and development � rather than over the longer term, when different executive skills will be required. Th is period will not be easy for the healthcare sector. But the potential rewards are great. A strong board of directors, top quality executive team, and the right advisors will help organizations better pursue and achieve their goals. Tom Koch is a Partner in the Life Science and Healthcare Practice at CTPartners based in California. He can be reached at firstname.lastname@example.org. Samantha Carey is a Partner in the Life Science and Healthcare Practice at CTPartners based in New York. She can be reached at email@example.com The Great Search Identifying, retaining, and placing the world's leading healthcare executives with experience and vision to meet your specific challenge www.ctnet.com CTPartners Redefining executive searc h 104 EHM | INDUSTRY INSIGHT The return of the war for talent Talent management is more critical then ever � ignore it at your peril, says Sharon Moses he economic recovery, albeit slow, appears to be happening. Healthcare reform legislation has passed. These issues and their impact on healthcare organizations are complex and hard to predict, but a few things can be stated with certainty. Competition for talent will rebound. While the fall of the economy has temporarily decreased recruiting and retention challenges, these will rebound as the economy picks up and retirement rates return to pre-downturn levels. Increased insurance coverage and an aging population will strain staffi ng levels. As more people become insured, it will become even more critical to have enough staff and the right staff in place to meet the increased demand. Pressure will increase to provide cost-effective care. The cost side of healthcare is escalating at unsustainable levels as costs for prescription drugs and new medical technologies rise, and as big waves of baby boomers qualify for Medicare. In addition, reimbursement methodologies are shift ing from volume-based to value-based, so it is critical now more than ever to provide cost-effective high-quality care. Efficient and effective staffi ng is a big part of that equation. All these challenges are driving an even greater need for sound talent management practices. The ability to hire the right people, to schedule them where they are needed most, to develop and retain them and provide a succession plan for key organizational leaders has never been more important. If you haven't asked yourself the following questions, you should. How well are you positioned for the war for talent to re-emerge? As the economy recovers, the need to attract and hire top talent will re-emerge. Th is is of course very positive overall, but it also means the workforce shortage, particularly for nurses, will also return. Additionally, as confidence in the economy returns and personal fi nances look better, the baby boomer wave of retirements will pick up once again, which will further the strain on existing workers and increase the need for effective recruiting processes. Do you maintain a pipeline of potential candidates? Do you have processes honed to reduce time-to-fi ll? Do you have systems in place that help managers staff to volume fluctuations to lessen premium pay? T "As more people become insured, it will become even more critical to have enough staff and the right staff in place to meet the increased demand" Are you at risk of top talent leaving your organization? The economic recovery will mean more and better opportunities for healthcare workers. Your highly talented staff that has hunkered down weathering the current economic storm will have new and exciting options to consider. Employees that stay will be those that are engaged with their organizations, and feel that their career prospects are positive and that their organizations are investing in their professional development. All this points to the importance of career planning, and learning and development strategies and tools. What kind of bench strength do you have? As the competition for top talent heats up and baby boomers retire, particularly in the leadership ranks, it will be critical to know where your new leaders will come from. The ability to identify potential gaps in leadership and put plans in place to develop emerging leaders in an organization is critical. While succession planning used to be a nice-to-have strategy in healthcare, ignoring it now could compromise your organization's ability to meet both its fi nancial goals and mission. Are you a leader or a follower in talent management? As the economy recovers and healthcare reform initiatives begin, hospitals and healthcare organizations need to thoughtfully examine their talent management strategies. What are you doing to attract and retain employees, how are you engaging and retaining existing staff, and how are you identifying and developing the next generation of leaders in your organization? Being a leader and not a follower where talent management strategies are concerned is critical. Not only can it help differentiate your organization from the competition, it can also have an immediate and direct impact on cost and patient safety � inarguably two of the most critical operational issues facing healthcare organizations today. Those who fail to recognize this need and fail to put in processes and systems to manage their talent may fall behind. Sharon Moses is the Healthcare Human Capital Strategy Director for Lawson Healthcare. She was a principal at VasTech, a leading healthcare nurse scheduling vendor, before it was acquired by Lawson in 2008. Moses has focused on healthcare solutions for her entire 18-year career, with experience in solutions designed to meet the needs of hospitals, physician practices and payers. Visit www.lawson.com/talent for valuable information on talent management in healthcare. 106 EHM | RECRUITMENT Joelle Lofaso, Director of Talent Management, Staffing and Recruitment at Cleveland Clinic, gives us her thoughts on the issues currently facing healthcare recruitment. What are the main recruitment challenges currently facing the US healthcare sector? Joelle Lofaso. The main challenges for nursing recruitment are to ensure a balance of experienced nursing staff along with the new nurses and to be equipped with experienced staff when the seasoned nurses start to retire. The projections show there are not enough new nurses in the nation's pipeline to replace our seasoned staff that may be leaving the workforce in the next 10-15 years. Nursing recruitment was particularly hit by the recession, with new graduates often fi nding it hard to fi nd the jobs they wanted last year. What is the current situation at Cleveland Clinic with regard to recruiting nurses? Cleveland Clinic is continuing to hire nursing staff as needed for patient care. We have had an increased focus on hiring experienced nurses for many areas to ensure we have the right balance of seasoned staff for our high acuity patients. We also have positions for new graduates once they obtain licensure. Because of the number of new graduates applying, managers are able to interview a number of candidates to select the highest caliber new graduate. How much of a challenge is it to find more experienced nurses, who may have been unwilling to switch jobs during difficult economic times? JL. At times it has been challenging, but we have developed some creative approaches to this. We have been using social media more: we have a specialist on our team who focuses on utilizing social media channels to recruit. We are also using video job advertising which gives us a different way to market our positions on the web and on cable TV. These have positioned us to be successful in fi lling positions in needed areas such as ambulatory nursing and cardiothoracic surgery. How much emphasis do healthcare organizations place on developing staff internally rather than hiring externally? Has this changed due to the recent economic conditions? JL. Cleveland Clinic has always had a strong emphasis on developing our internal staff and hiring from within. We continue to support our internal staff by providing strong tuition reimbursement for those returning to school. For both employees we develop from within or Staffing appropriately in challenging times "The main challenges for nursing recruitment are to ensure a balance of experienced nursing staff along with the new nurses and to be equipped with experienced staff when the seasoned nurses start to retire" bring in externally, we offer a variety of benefits including flexible working arrangements for our nurses and a generous tuition reimbursement program, and we pay for nurses' certifications. What do you see as the future direction of recruitment within the healthcare industry? JL. Organizations will need to stay on top of looking at the mix of hiring experienced nurses and new graduates. Hospitals and other healthcare organizations will need to look at workforce planning as the economy turns around and as the average age of nurses increases to be certain they are poised with trained staff when seasoned staff begin to change status or retire. "We bring the world of medical occupation to your doorstep" Welcome Assurgent Medical Solutions is committed to being the most thorough, wellrespected, and successful healthcare staffing firm in the industry. Our Firm provides both permanent placement and locum tenens staffing solutions of physicians, allied professionals and nurses. We are determined to attract the most highly regarded professionals in the industry, to utilize the most innovative techniques, and dedicated to setting the standard in client satisfaction, all in an effort to improve healthcare throughout the world. Our success rate is unmatched and we bring to the table some of the best references you will find. We have had success in every facet of healthcare recruitment, and even the most difficult, sub-specialized search projects have been completed repeatedly by our team of professionals. Contact us: Assurgent Medical Solutions 3355 Lenox Road, Suite 825 Atlanta, GA 30326 (Office) 877-842-6833 firstname.lastname@example.org www.assurgentmedical.com 108 EHM | WORKFORCE MANAGEMENT PART ONE From staff-mix to skill-mix and beyond Towards a systemic approach to health workforce management. By Carl-Ardy Dubois and Debbie Singh T hroughout the world, countries are experiencing shortages of healthcare workers. Policy-makers and system managers have developed a range of methods and initiatives to optimize the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimization in healthcare. We conclude that in order to use human resources most effectively, healthcare organizations must consider a more systemic approach � one that accounts for factors beyond narrowly defined human resources management practices and includes organizational and institutional conditions. Healthcare systems' ability to provide safe, high-quality, effective and patient-centred services depends on sufficient, well-motivated and appropriately skilled personnel operating within service delivery models that optimize their performance. However, both develop- ing and developed countries are experiencing shortages in healthcare human resources. Two recent major reports have estimated the global shortage at more than four million workers. Sub-Saharan countries, for example, must nearly triple their current number of workers if they are to progress towards achieving the health Millennium Development Goals. Meanwhile, analysts project that the shortage of registered nurses in the United States could reach as high as 500,000 by 2025, with a projected deficit of 200,000 physicians by 2020. Th is looming and global human resources crisis is the culmination of shortages of physicians, nurses, allied professionals, support workers and administrators. It is also affected by factors such as societal trends towards reduced work hours, workforce ageing, and early retirement (particularly in industrialized countries). The policies and methods used to manage HR are at the core of any sustainable solution to healthcare system performance and can constrain or facilitate healthcare sector reform. In developing countries, workforce imbalances have been identified as one of the main bottlenecks that compromise population health development. In developed countries, those imbalances are manifest amidst other concerns such as waiting lists, crowded emergency departments, understaffed wards and a lack of time to provide patient-centred care. These difficulties arise from quantitative imbalances and from inadequate approaches to HR management that may result in overusing, underusing or misusing available healthcare personnel. Healthcare organizations worldwide have been exploring innovative ways to deploy their workforces. There has been a focus on staff-mix, i.e. achieving a specific mix of different types of personnel, with an increasing interest in evidence about the value and contributions of different staff-mixes to patient, personnel and organizational outcomes. Current evidence suggests that staff-mix cannot be considered in isolation from the contexts in which people work. In order to optimize HR, managers must extend beyond simple staff-mix modifications to address organizational and system factors. To support planners, policy-makers and workforce planners, this article reviews the main approaches to and limitations of conventional healthcare personnel deployment. WORKFORCE MANAGEMENT | EHM 109 We contend that the current staff-mix focus is both restrictive and static, and that it fails to account for staff members' skills and their effective utilization. The second part of the article examines several options that offer a more dynamic solution that introduces the notion of skill management, referring to the mechanisms used by an organization to optimize the utilization of its workforce. These options emphasize enabling healthcare providers to practise to the full extent of their education, training, skills, knowledge, experience, and competence. We conclude by discussing levers that healthcare organizations and systems must mobilize to ensure that available personnel are used to their fullest potential. Although our selection of articles was clearly focused on human resources in healthcare, we had to extend our investigation to a wider range of literature in order to fi ll some gaps of evidence, gain insight from other areas and elaborate the emerging analysis. We particularly draw on theoretical perspectives and empirical work in sociology, economics, management, industrial and labour relations, and psychology that address different aspects of the domain of human resource management. Those works account for 20 percent of the 250 selected papers. The selection of articles, the extraction and the analysis therefore involved a constant dialectic and iterative process conducted concurrently with theory generation. been used as a resourcing strategy to address shortage problems. On the demand side, those changes have been implemented as a means to enlarging the scope of services, fi ll previously unmet health needs and improve patient care. While many regard adequate staff and skill mix to be prerequisites for meeting patients' needs for high-quality care, HR adequacy is, in reality, hard to assess because it relates to many different parameters, including needs, preferences, availability, cost and quality. In this regard, recent reviews have highlighted the diversity of ways in which personnel deployment across teams and organizations is conceptualized. Reviews suggest that although the concepts of staff-mix and skill mix are often used interchangeably, the four most prevalent conceptualizations are closer to the notion of staff-mix. We discuss these conceptualizations below. Number of personnel Th is conceptualization focuses on the total number of workers in defi ned occupational groups. It takes into account the volume of work assigned to a given staff member or the amount of direct patient contact a worker experiences over a defi ned period of time. Common measurements are the number of hours of professional care per patient, per day; and the number of full-time equivalent workers per patient, per day. For pharmacists, the ratio has been defi ned as the number of prescription orders fi lled per day. For some physicians, the Literature review O Personnel deployment Managing human resources in healthcare involves organizing groups of workers with different professional backgrounds, skills, grades, qualifications, expertise and experience in order to achieve optimal patient care. Th is distinctive feature of healthcare has become more prominent during recent decades with the emergence of numerous new professions, specialties and occupations. These developments have drawn considerable attention to the concepts of staff-mix and skill-mix as policy tools for developing the best combinations of skills across professions and organizations, as well as at the individual level. Increased interest in achieving optimal staff-mix also results from pressures arising from both the supply and demand sides of healthcare. On the supply side, changing the mix of healthcare staff has often ur findings are based on a structured review of published literature, including articles, reviews, comparative studies, observational studies and dissertations identified through a range of electronic databases: Medline, PubMed, Embase, Current Contents, CINAHL and Google Scholar. Other relevant materials (research reports, administrative reports and articles) were collected through website searching, reference chaining and contacting experts in the field. The search focused on the literature between 1995 and 2008. However, some key literature prior to 1995 has been included when it was considered to be of particular relevance. The following key words uncovered many hundreds of hits: staff-mix, skill-mix, human resource management, human resource optimization, workforce performance, human capital, skill management, human resources for health, performance management. All references were reviewed by title and abstract to determine their potential relevance to the review. Letters, comments and editorials were systematically excluded. References that related directly to the subject matter in either the title or the abstract were selected for a more in depth review. In total, we examined full copies of 250 selected studies more thoroughly. The evaluations of the studies and the data extraction were performed manually by the two investigators. Papers were first sorted into two categories: conceptual papers and empirical papers. Conceptual papers were evaluated and sorted according to their theoretical foundations, their comprehensiveness, their relevance and their contribution to subsequent work in the field. Empirical papers were evaluated and classed based on their relevance to the review objective and appropriate criteria of validity (research design, sampling and methods of analysis). We used the technique of interpretative synthesis to collate the findings. This approach involved building a general interpretation grounded in the findings of separate studies and then integrating evidence from across the studies into a coherent theoretical framework comprising a network of constructs and the relationships between them. As for the search strategy, the analysis focused first on evidence and theoretical perspectives drawn from the healthcare sector; however, as we advanced in the analysis, it has become evident that human resource management is a topic with diffuse boundaries that overlaps with several other fields. WORKFORCE MANAGEMENT | EHM 111 "While many regard adequate staff- and skill-mix to be prerequisites for meeting patients' needs for high-quality care, HR adequacy is, in reality, hard to assess because it relates to many different parameters, including needs, preferences, availability, cost and quality" number of certain procedures performed per year is measured. Research on personnel numbers has focused largely on nurses, and is based on the hypothesis that a lower nurse-to-patient ratio results in a greater workload and poorer quality of care due to time pressures that affect a person's ability to implement best-practice standards. Several empirical studies and systematic reviews support this hypothesis and indicate that the numbers of nurses in a unit and the number of nurses per patient affect patient outcomes, including adverse events, readmissions and mortality. One study found that each additional patient in a typical nursing workload situation resulted in an average seven percent increase in failure-to-rescue. In another study, hospitals in which nurses cared for an average of eight patients each had risk-adjusted mortality rates following common inpatient surgical procedures that were 31 percent higher than hospitals in which nurses cared for four patients each. Such findings have prompted legislation on safe staffi ng ratios for nurses in two jurisdictions: California and the state of Victoria in Australia. Yet, there is currently no clear-cut evidence of the effectiveness of such legislated ratios, which may prevent managers from making local decisions about appropriate staffi ng and are insensitive to many contextual factors (e.g., changes in patient dependency, presence of ancillary personnel or non-nurse providers, technology). In contrast to nursing research, studies of physician resources are based on the premise that higher volumes, rather than hindering the ability to meet patients' needs, lead to improved experience and high-level technical skills. Evidence from recent systematic reviews and observational studies suggests that higher volumes are, for physicians, associated with lower error rates and lower patient mortality rates. Another study that used hospitals as the unit of aggregation showed that facilities with higher case volumes experienced lower complication rates. Such positive fi ndings are, however, balanced by some contradictory evidence. In controlling for institutional factors, some studies have failed to fi nd that physicians who performed high rates of technical procedures experienced lower rates of adverse outcomes, suggesting that improved results reported in other studies may have been due to institutional rather than physician-specific factors. Mixing qualifications Th is conceptualization focuses on the proportion of highly qualified staff members in the overall pool of professional resources. As yet, there is no indication of the appropriate ratio for any grade on the healthcare team, although several observational studies support the view that a rich mix of qualified personnel with ad- The shortage of registered nurses in the United States could reach as high as 500,000 by 2025, with a projected deficit of 200,000 physicians by 2020. vanced degrees or specialty certifications is associated with better clinical outcomes. Blegen et al suggest that having a nursing team that is richer in registered nurses contributes to lower patient mortality rates. In a landmark study, Aiken et al found an inverse relationship between the proportion of registered nurses holding undergraduate degrees and patient mortality rates within 30 days of admission: a 10 percent increase in the proportion of nurses with undergraduate degrees was associated with a five percent decrease in the likelihood of patients dying. Another study found that people cared for in the community by undergraduate degree-level nurses required fewer home visits and had better knowledge and health behaviors than those cared for by nurses without such degrees. Again, it is important to keep in mind that current evidence only suggests some trends; it does not offer clear direction on the most effective skill mix for nurses. Those studies that have found positive associations have reported wide-ranging registered nurse proportions: from a low of 46 percent to a high of 96 percent. A number of studies have examined the added value of specialty certification among physicians. Evidence suggests that physicians with specialty training have lower rates of adverse outcomes for certain procedures and medical conditions. Researchers have found a significant association between greater prior training by physicians on certain surgical procedures and better results in performing those procedures. Similarly, patients with acute myocardial infarction tend to have lower risk-adjusted mortality rates when cared for by cardiologists. In pharmacies, meanwhile, the evidence points in the opposite direction. Studies comparing pharmacists to pharmacy technicians have found similar error rates between the two groups. Balancing junior and senior staff Th is staff-mix conceptualization draws attention to the proportion of experienced staff members on healthcare teams. This proportion is usually measured by the number of years an individual has worked in a particular grade or job category. The most common WORKFORCE MANAGEMENT | EHM 113 hypothesis is that longer experience is associated with better patient outcomes. However the evidence is scarce and confl icting. Several observational studies have concluded that more years of surgical experience are not associated with lower rates of post-operative complications. Similarly, studies suggest no relationship between years of experience as a registered nurse and patient mortality rates. Conversely, others report that for each additional year of nurse experience on a clinical unit there were four to six fewer deaths for every 1000 acute medical patients discharged (depending on hospital type). Another study demonstrated that registered nurses' duration of practice was inversely related to rates of medication errors and patient falls. Mixing disciplines Th is conceptualization involves gathering together individuals from different pro- on the effectiveness of multidisciplinary teams compared to care provided by a single group of professionals. A review of 14 systematic reviews and 33 additional randomized trials found that the impact of multidisciplinary teams on quality of life and clinical outcomes varied considerably amongst the studies. Other research indicates that, although multidisciplinary outpatient teams or teams of primary and secondary care personnel working together can improve patient outcomes; this result may vary according to the initiatives undertaken and patients' conditions. A systematic review focusing on people with rheumatoid arthritis found that multidisciplinary outpatient teams may improve functional outcomes more than usual care. Other trials involving elderly people and those who had suffered strokes, however, found no impact on health outcomes. Physician-nurse collaboration has particularly attracted researchers' attention. Some studies suggest that a high degree of collabo- A 10 percent increase in the proportion of nurses with undergraduate degrees was associated with a five percent decrease in the likelihood of patients dying "Healthcare organizations have a range of options for ensuring a richer staff-mix, including increasing the number of personnel, higher ratios of qualified workers, higher ratios of senior staff members and multidisciplinary teams" What can we conclude about optimal staff-mix? Healthcare organizations have a range of options for ensuring a richer staff-mix, including increasing the number of personnel, higher ratios of qualified workers, higher ratios of senior staff members and multidisciplinary teams. Despite conflicting findings and the need for further research, a number of studies and systematic reviews suggest that a richer staffmix 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. fessions and specialties in order to provide well-rounded care. Multidisciplinary teams are commonly used in hospitals or outpatient services. These primary care teams comprise nurses and physicians, and sometimes include specialists. Collaboration is increasing between mental health and primary care workers, and pharmacists are increasingly integrated into primary care teams. Increased interest in a `whole system' approach to care has also contributed to the inclusion of social service staff, community workers and volunteers on primary care teams. There is an extensive body of literature focusing on the potential benefits of multidisciplinary teams and, more broadly, of collaboration amongst professionals from different disciplines as a way to address fragmentation, discontinuity and lack of receptiveness. In reality, however, the evidence is inconsistent ration is associated with lower mortality and complication rates and with increased patient satisfaction in adult intensive care units (ICUs). Findings about the value of general practitioner and nurse collaboration in primary care are often less clear. While some studies have found improved clinical outcomes and satisfaction, others have discovered no significant improvement over usual care approaches. In addition to the confl icting fi ndings, it is difficult to draw clear conclusions from these studies because most multidisciplinary interventions contain several other variables, such as increased follow-up and medication reviews. It is therefore unclear whether multidisciplinary team composition, additional contacts with staff members, or other factors influence outcomes. Similarly, it is uncertain which specific staff members may be more or less useful within multidisciplinary teams. See the Q4 2010 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. Carl-Ardy Dubois, Faculty of Nursing Sciences, University of Montreal, Quebec, Canada. Debbie Singh, Health Services Management Centre, University of Birmingham, Birmingham, UK. 114 EHM | INDUSTRY INSIGHT Optimizing healthcare staffing Graham Barnes explains how to improve your bottom line and quality of life for your staff. abor expenses comprise as much as 70 percent of the typical hospital's operating budget, and the degree to which staffi ng and workflow challenges can negatively affect a hospital's bottom line cannot be overstated. In the July/August 2009 Health Affairs, Dr. Peter Buerhaus and coauthors found that, despite the current easing of the nursing shortage due to the recession, the US nursing shortage is projected to grow to 260,000 registered nurses by 2025. A shortage of this magnitude would be twice as large as any nursing shortage experienced in this country since the mid-1960s. Hospitals are continually challenged to fi nd and retain good nurses. Not surprisingly, more than half of hospital labor costs are in nursing � a cost center rife with challenges that affect workflow efficiency, flexible staffi ng levels, job satisfaction and nurse retention. Daily issues associated with over and understaffi ng, variable patient census and acuity, and staff mix tend to feed and perpetuate each other, leading to decreased quality of life for nurses and increased labor costs for the typical hospital. So, how does a hospital tackle these kinds of challenges? While there are a number of links in the causal chain, one vital element for many hospitals lies in a sustainable workforce management system that motivates and engages staff, optimizes efficiency, and drives employee satisfaction, while it simultaneously improves labor costs. Internet-delivered workforce management systems allow hospitals to manage scheduling, open shift management, and patient acuity/assignment scheduling while raising quality of life factors such as home access, job satisfaction, fairness and career development for nurses. In particular, staffi ng and scheduling options that give employees freedom to choose when and where they work have been shown to keep them happier and more productive, making the process of planning each week's schedule more engaging for nurses and leading to significant labor cost savings for hospitals. Employers are fi nding that providing flexible options for employees is central to attracting new Gen Y nurses and retaining quality staff. For example, hospitals are seeing unprecedented benefits in the use of open L "Healthcare staffing is complex, and intrinsically linked to quality, safety, staff and patient satisfaction, and financial performance" shift management technology, where a hospital's open shift s are posted online and all nurses have simultaneous access from anywhere at any time to request to work available shift s at their hospital. By heightening awareness of staffi ng needs, organizations move from unit-based awareness to organization-wide awareness of work opportunities, and employees can become active participants in the solution. Many Concerro hospitals are seeing between 20 to 60 percent of their nurses volunteering to work on non-home units or hospitals within a health system. Workforce management systems should also promote continuity of care by fi lling shifts where possible with existing nurses who are already familiar with hospital policies and procedures. Th is alone can have a profound effect on patient outcomes and safety. Empowering qualified nurses with control and flexibility around their schedules makes them happier overall, while simultaneously serving as a sustainable optimization tool for hospitals. Nurses are given the opportunity to work on new units where they are qualified, which helps them gain valuable experience and encourages nurses to expand their education and accreditation to further their careers. Providing career development support and opportunities to advance their skill sets through unit cross-training increases quality of life, boosts retention and maximizes human resource management for the hospital. Optimizing the staffi ng function will require flexibility, technology and innovation. With the right staffi ng infrastructure, your organization will have a framework to make optimal human capital decisions while improving the quality of life for your staff. Leveraging your existing workforce translates into staffi ng continuity and quality of care for patients. There is no question that a happier staff is more loyal, performs better, lowers costs and improves patient care. Graham Barnes is the CEO of Concerro Inc., and has over 25 years of experience in high tech services. He received a BSc (Hons) in Engineering from Imperial College, University of London, and an MBA (Beta Gamma Sigma) from Santa Clara University. For more information, visit www.concerro.com 116 EHM | ASK THE EXPERT Battling to attract and retain the best Chadd Dehn walks us through the four core components of attracting and retaining top talent. "Our employees are our most valuable resource." We constantly hear these words from organizational leaders across every industry, but mostly in the healthcare and life sciences fields where employees make decisions that not only impact a `customer service score', but at times, patients' lives. Yet many healthcare executives are concerned that their attraction and retention strategies are not getting the necessary attention for talent to become their competitive advantage. The aging US population is creating increased demand for healthcare services and people to provide these services. Even during our recent economic crisis, in a month where 85,000 jobs were shed across the country, hospitals, long-term care facilities and ambulatory clinics added 21,000 new positions. In the nursing profession alone, the demand for clinicians is expected to grow by 22 percent through 2018, creating 581,500 new RN positions. Organizations that make a strategic decision to reposition their approach to attracting and retaining top talent will develop a formidable competitive advantage into the future. costs associated with vacancy rates are simply too high in some business segments � or they negatively impact patient care, staffi ng budgets and employee satisfaction � often creating additional turnover and more vacancies. In addition, the quality of new hires improves as organizations hire the best candidate instead of the best candidate available. Secondly, the recruitment process must be designed with the ultimate customer in mind � the candidate. Having a `candidatecentric' recruitment process is imperative in this highly competitive field. Many healthcare organizations have developed great systems to measure the quality of care and service they provide, yet have failed to establish similar systems to measure the experience of their future employees. Organizations need to be mindful that a good candidate is also interviewing them as a prospective employer. The third requirement is to create a focus on selling rather than selection, which often means fi ltering out candidates. In today's world � especially for skill sets in high demand � organizations must balance their focus between selection and selling. Whether candidates actually come out and say it, they want to know `what's in it for me?' Recruitment marketing materials and hiring managers should articulate the organization's value proposition to prospective employees. The fi nal element is training. HR business partners, along with talent acquisition specialists, need to collaborate on training hiring managers and others interfacing with potential candidates on proper interviewing techniques. Interview guides should be developed that promote and perpetuate best practices. Managers should be ambassadors of the company who "The costs associated with vacancy rates are simply too high in some business segments � or they negatively impact patient care, staffing budgets and employee satisfaction � often creating additional turnover and more vacancies" are able to articulate the benefits of joining the team. A training program should also attempt to reinforce a culture of ongoing recruitment by establishing a `candidate-centric' philosophy, and providing hiring managers with the tools and information necessary for them to effectively sell both the job and the company to a prospective employee. Organizations that consistently attract and retain the best employees share these philosophies and more. They instill commitment to continuous recruitment within their organizations. They keep the needs of the candidate in mind when making decisions regarding their hiring and employment practices. High performing recruitment organizations know how to sell the employee value proposition and recognize the importance of training their managers on these philosophies. In doing so, talent acquisition is viewed as an enabler to organizational success instead of an obstacle. The function becomes a competitive advantage to help a company differentiate itself from its competitors and attract the best talent. The four core components The fi rst step is to create a philosophy of `continuous recruitment'. Instead of being driven by requisitions, companies must be constantly recruiting and building a pipeline of talent, especially for critical skills sets. Organizations need to build talent communities, promote themselves via different social media outlets, create realistic job previews and employee testimonials, leverage technology to enhance the candidate experience, and constantly seek innovative ways to promote their organization and career opportunities. The As Healthcare/Life Science Practice Director at Adecco, Chadd Dehn is responsible for growing and managing his accounts. Dehn works with his leadership team to design effective recruitment processes, integrate proprietary recruitment technologies, and create systems to analyze results. Dehn earned his MBA from the University of Toledo and is a Certified Personnel Consultant. 118 EHM | ASK THE EXPERT The 21st century healthcare executive Envisioning the future leadership of an accountable care organization. J ust after the turn of the century, we published Creating the Healthy Hospital, a white paper on physician leadership co-authored with William J. Fulkerson Jr., MD, who is now Senior Vice President for clinical affairs of Duke University Health System. Dr. Fulkerson's prior position as the top leader of his hospital, and his transition from `hospital' to `system' leadership, says everything about what has changed � and what will continue to evolve � in the delivery of healthcare. Then, our focus was `technology and clinical connectivity'. Today, our focus for the 21st century healthcare executive is on how those two concepts have set the stage for `accountable care' � the linchpin of healthcare reform that will engender a new level of `system-ness'. In such a revolutionary time, identifying and cultivating candidates for leadership � including physician and nurse leaders � who fit well and will drive the success of your organization remains paramount. Several fundamental requirements can guide you in this process. Ability to integrate teams and align incentives. As articulated by the American Medical Group Association, accountable care organizations (ACOs) "are clinically accountable to the communities they serve, coordinate care, have invested in use of electronic health records, and embody ideas of continuous quality improvement". Such systems, in which accountability, risks and rewards are shared, must be built on the foundation of credibility and trust. The industry's maturation toward accountable care creates the absolute necessity for leaders with the track record and reputation that prove their skills in integrating teams and aligning incentives. Leadership of diverse management teams. As healthcare organizations succeed in developing more diverse management teams, the most senior executives will need to be effective at leading diverse groups and using each member's expertise to advance the organization toward becoming an ACO. Beyond racial, cultural and gender diversity, tomorrow's healthcare management teams also will include members with very different professional and Deedra Hartung is Executive Vice President and Managing Principal of Cejka Executive Search, a nationally recognized executive search firm, placing leaders for hospitals, health systems, medical groups and academic medical centers. Hartung is a frequent speaker and author on topics related to leadership. educational backgrounds, forms of expertise and knowledge bases. The richer the diversity of viewpoints, the more effective the idea generation process will be, with better outcomes the likely result. It takes courage, open-mindedness and competence for a leader to hire senior managers who are not in the leader's image. It will be increasingly critical to the success of an organization, however, not only to hire such people but to listen to them. ACOs will approach management decisions from multiple perspectives. Fostering of innovative thinking and problemsolving. The ACO leader must encourage a culture of innovation throughout the organization. The culture must begin with the leadership team and flow through the entire organization. Leaders set the direction for innovation by first identifying a vision for the organization that reflects a true marketplace assessment and the support of its important stakeholders. As buy-in to the organizational vision evolves, the leader can then encourage development of solutions and ideas that will help support the vision. Creation of a culture in which people feel that their ideas will be valued will result in effective, often creative problem-solving and innovations that can make an organization more competitive and cutting-edge. Developing a strong pool of leadership talent within today's healthcare management ranks is a critical need of the industry as a whole. As a healthcare executive leading your organization toward a system of accountable care, ask yourself questions such as: Does the leadership team need an infusion of new talent with different skills or capabilities? Do current leaders need to undergo intensive assessments to identify their skill and knowledge gaps in delivering accountable care? How can training resources best be utilized to maximize the potential of mid-level managers and build bench strength within the organization? 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 our team? Whatever the answers to these questions, addressing them proactively will help you build the leadership team of an ACO. Your World. COVERED From the people you hire to the products you sell, if you're in business, we've got it covered... Executive Healthcare Management The healthcare industry is changing. Understanding how to improve clinical processes, meet industry standards and merge the maze of disparate systems is vital. EHM combines unbiased industry news with thought leadership from the most respected executives in healthcare, providing a platform for strategy and learning. Prev US ious Edit ion Find out more: www.executivehm.com Next Generation Pharmaceutical Approximately 50 percent of new drug development fails in the late stages of phase ||| � while the cost of getting a drug to market continues to rise. NGP features interviews with pharmaceutical experts from the discovery, technology, business, outsourcing and manufacturing sectors. It is committed to providing information for every step of the pharmaceutical development path. Available for: US, EU Business Management What business processes work? What are the proven, successful strategies for taking advantage of domestic and international markets? Business Management is about real, daily management challenges. It is a targeted blend of leadership and learning for key decision-makers in government and private enterprise. Available for: US, EU, MENA Find out more: www.busmanagement.com Find out more: www.ngpharma.com Oil & Gas Collaboration between government and multinationals is essential to ensure the energy supply is developing on two fronts. O&G is the definitive publication for stakeholders and service companies to read about the regional projects, technologies and strategies affecting their group. 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 Travel I Gadgets I Books I Leisure I Money Details Heading down under With some of the best beaches and sunshine available anywhere in the world, Australia is a hot spot for holidays and potentially the longest `business trips' known to man. 124 BOOK REVIEW The Decision Tree by Thomas Goetz 126 WELLNESS Top tips to fight burnout 128 PHOTO FINISH Yoga in Times Square 122 EHM | DETAILS TRAVEL Regardless of whether you're looking for run-of-the-mill activities and sightseeing opportunities or a truly life-affirming experience, Australia's six states have everything you could ever ask for. To give you a slightly less pamphlet view of the land down under, EHM has decided to show you around some of Australia's better-kept secrets. Yes the Sydney Opera House is beautiful, and of course the Great Barrier Reef has to be seen to be believed � but we all know that. Instead, dig below the surface and let us show you what can be found if you have a nose for sniffing out adventure. Or wine for that matter. 2 2 Bungle Bungle National Park: Western Australia Known to the locals as `Purnululu', you'll probably get less awkward stares calling this one Bungle Bungle, even though it's an area within the Purnululus. A World Heritagelisted national park, Bungle Bungle is without doubt one of the most spectacular geological wonders this fine planet has to offer. Unknown to many apart from the locals, the remote park is only accessible by four-wheel drive. To give you a taste of what you're likely to come across at Bungle Bungle, have you ever seen mystical beehive mounds that rise yards into the air? Didn't think so. To be honest, trying to describe what you'll see is irrelevant as the visit is untouched in terms of the Mother Nature experience; travel along the Gibb River Road on the way there and leave a new person. As a side note for movie buffs out there, Bungle Bungle is where Baz Luhrmann fi lmed sections of his fi lm, Australia. So you can tick that box too. 1 1 Ningaloo Reef: West Coast A literal stone's throw away from the beach and with far fewer visitors and warmer water than its big brother the Great Barrier Reef, Ningaloo Reef gives its visitors the opportunity to do something that can't be done anywhere else in Australia: swim with whale sharks. Usually, this kind of tourism would be severely frowned upon, but with such a strong conservation scheme in place, Ningaloo Reef has complete control of the amount of visitors coming into contact with its whale population. Even if you miss the sharks � who are the furthest thing away from Jaws imaginable � you've still got a good chance of seeing manta rays, turtles and humpback whales. If that isn't your thing, count yourself extremely lucky that you can kick back in the idyllic lagoon in Coral Bay and watch the world go by. DETAILS | EHM 123 3 Fraser Island: Okay, so we had to put something in here that had done the tourist rounds � but it's too good to miss out on. Believed to be the largest sand island in the world and spreading across 695 square miles, Fraser Island is a must. Pure and simple. Which is actually also a good way of describing the island. Starting at Hervey Bay on the mainland, the tour commences with being given your very own four-wheel drive before getting the ferry to the island. Once there, you usually have two to three days to drive around, take in the scenes and generally avoid crashing as you check out mesmerizing spots such as the famous Champagne Pool, which is great to lie in and soak up the rays, or the Wreck of Maheno; sounds ominous, but is rather enchanting. However, a little tip if you do get yourself out there � don't worry about the dingos. While they get themselves around camps with ninja precision, the old adage of `they're more scared of you than you are of them' holds more true than when you were a kid. Talking of kids, Fraser Island is the perfect place to unleash your little monster's imaginations and sense of adventure. Alternatively, get you and your loved one out for a couple of secluded days away. 3 5 4 The Barossa Located roughly 27 miles northeast of Adelaide, the Barossa has a food and wine culture that you can't escape from. With its premium wine production, abundant seasonal produce and unique smoked and cured meats, the Barossa is the perfect place for those with a hunger for the finer things in life � and an even bigger thirst. Listed by the world's largest online travel community, TripAdvisor, as one of the world's top 10 wine destinations, leaving there without a smile on your face would be verging on the criminal. Still unsure? Well, these seven words could make all the difference: Reisling, Semillion, Chardonnay, Shiraz, Grenache and Cabernet Sauvignon � all served in their respective vineyards. You can't ask for more than that. 6 5 Andaluz Bar and Tapas, Perth What is a tapas bar doing on here you might be asking? Well, to put it bluntly, if you have any respect for your taste buds you'll take our word for it and book a table as soon as you land. Offering up a selection of contemporary Spanish tapas menus with exquisite interior design, it's far from traditional. But what it lacks in history, it certainly makes up for in experience and imagination. Indeed, the Andaluz bar team is well-versed in the art of cocktail flaring and tasting, and is sure to help you on your way to getting to know the area that little bit better. Just remember not to mix your drinks, especially when you're sat on antiquated chesterfield seats by the fireplace. Some things just can't be unseen. 4 6 Aussie rules football While not exactly a geographical attraction, no trip to Australia is complete without a visit to an `aussie rules' football stadium. You've seen rugby in England, know what American football looks like � but have you ever seen a game of Aussie rules? Truly unlike anything you've seen before, it could be loosely described as containing the aggression of ice hockey and the speed of lacrosse; and if you think they could kick in American football, just wait until you're ducking in the stands to avoid getting hit. As if that wasn't enticing enough, every bar throughout almost every venue is dedicated to having a live screening of the match, so you don't need to worry about missing out on a single second of the game as you slurp down yet another freezing cold beverage. It might take you a while to acquaint yourself with the rules, but once you do, you'll be hard pushed to take it off ESPN when you get home. 124 EHM | DETAILS BOOK REVIEW Fresh off the press EHM takes an in-depth look one of this quarter's most important healthcare books. The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine By Thomas Goetz R "The Decision tree is a gamechanger. A brilliant synthesis of science, public health and practical advice that puts each of us at the center of our own healthcare revolution. The best decision you can make? Read this important book" �Dr. David Kessler, former commissioner of the FDA egardless of who we are or what we do, we all get the same feeling when we visit the doctor. It begins innocently enough, with a sit down and a chat, before the inevitable click of the mouse sends you into a state of inquisitive paranoia about what's just come up on the computer screen. Sure, you know it's your medical record � but what does it say? What information does the doctor have that you don't? And why does he stare for an unnerving amount of time at the screen before discretely minimizing it and `moving swift ly on'? Well, in Thomas Goetz' new book, The Decision Tree, he not only encourages you to take charge of your inquisitive nature and medical records, he shows you how and why you should do precisely that. When it comes to our health, too many of us get confused and overwhelmed about how to take charge of it, so instead we let insurance companies and doctors take charge in the hope that they'll know what to do with it. Which is true, but it's only half the truth. The reality is that the era of personalized medicine is upon us � and it's time to take responsibility for our health and future living. When we start engaging with our health, every decision matters, every choice becomes an opportunity to improve our heath. Line these choices up in a sequence � from prevention, to diagnosis, to treatment � and it takes the form of what Goetz refers to as a `decision tree'. As the Executive Editor of Wired magazine, Goetz offers a bold new vision of healthcare, where something as simple as a list of pros and cons can allow patients to make sense of their options and figure out the best possible path to better health. The book is written, as you would expect, with the clarity and knowledge of a Wired editor. Regardless of whether you're in the healthcare industry or just someone wanting to take control of their health and medical lifestyle, Goetz explains everything with an eloquence that keeps you enthralled and engaged without losing sight of the lesson at hand. He explains that personalized medicine isn't just about tailor-made drugs � it's about our personal data. And with the prevalence of technology, especially within the last decade, each and every one of us should be able to track and interpret our medical data with surprising simplicity. Standing aside from the usual plethora of data heavy healthcare books, The Decision Tree not only deals with Goetz' opinions, but those of people living and breathing what he's talking about. Personal discussions with people in with chronic and life-threatening conditions go a long way to exemplifying the points Goetz tries to explain, and it certainly leaves you thinking you should be doing more about your own situation. Both the book and author offer you a way out of presumptive thinking and encourage you to engage with your `medical self' in order to understand more about not only yourself, but about the life choices you make. At the end of the day, if it leaves you with nothing less than a healthier lifestyle and peace of mind � what's the problem? If you can balance your mortgage and calculate bills, why not give it a go with your health and lifestyle. Make your own decision tree, as Goetz would put it. REGISTER NOW 126 EHM | DETAILS A winning idea As the country emerges from recession, burnout again becomes a reality for many. However, the implementation of wellness programs is having a huge impact. E xecutives are facing the toughest economic situation since the Great Depression. The after-effects of the recession � growing demands on services, a staffi ng squeeze, salary freezes and shrinking budgets � are all adding up to a huge amount of stress, so is it any wonder that employees are feeling the burn? We all deal with stress in our lives, it is part of everyday life; however, working long hours for sustained periods of time under pressure leads to mental and physical exhaustion � a century ago Robert Yerkes and John Dodson definitively showed that there is a tipping point where stress detracts from performance. It is vital to recognize the symptoms before this exhaustion leads to breakdown or burnout, with early signs including insomnia and depression, extreme tiredness and fatigue, heart palpitations, inability to focus and migraines. Burnout takes a heft y toll on job satisfaction, performance and retention, as well as health and wellbeing. Indeed, stress has long been linked with DETAILS | EHM 127 many ailments, including heart attacks, high blood pressure, hypertension, allergies and skin disorders. In fact, 75-90 percent of employee visits to hospitals are for stress-related symptoms. And as excessive workloads and unrealistic targets come off the back of the current working environment, it is par for course that the average employee is dealing with above-average stress. 81% of American businesses with 50 or more employees have some form of health promotion program Stress management By learning the skills you need to perform under pressure, you can help deal with stress and anxiety, as well as improve your employees' wellbeing. Firstly, managing workload is key. Th is can be fought on three levels: over-commitment, resource issues and focus problems. Over-commitment often stems from an inability to draw boundaries and say no to unrealistic requests. By concentrating on resource issues you can delegate work to others and make sure you are effectively using the tools that are available. It is imperative to focus correctly. Perhaps you are simply responding to emails coming in rather than managing your time according to priorities, or procrastinating on things that are difficult. The second weapon against burnout centers around embracing renewal. There is no doubt that hard work is critical to success, but it is just as vital to renew, restore and rejuvenate your body and mind. Short-term, look at building quiet time into each day; just 15 minutes a day of meditation or listening to soft music will work wonders. Long-term, take vacation time and enjoy yourself; look at fi lling in time with adventure and rest. The key is to stay healthy � eat light, nutritious meals, exercise and make sure you are getting enough sleep. Th irdly, evaluate your work/life balance and ensure you are doing the right work for you. Bob Burford, business leader and best-selling author, talks about a "smoldering discontent" that many workers feel after realizing that they have spent decades building lives of success but not significance. Find ways to work everyday that serve your family, workplace community or cause, and choose a role within an organization that has a mission or culture that fits to you. Top 10 tips to beat burnout 1. Learn to delegate 2. Learn to say no 3. Work in a physically comfortable environment 4. Plan your day 5. Take a 15minute power break each day 6. Avoid caffeine 7. Take regular exercise 8. Keep your sense of humor 9. Introduce monthly stressbuster meetings 10. Remember your staff are your best asset Bottom line benefits A healthy team is a happy team. Companies that invest in the psychological health and wellbeing of their staff will undoubtedly see the benefits of increased productivity and employee retention. It has been proved that stress-free staff will perform better, work harder and are generally happier in their working environment than those that feel undervalued and overworked. And this can all impact an organization's bottom line � if employees are out sick for an extended period of time, productivity can suffer, particularly if other workers have to pick up the slack � according to the Cornell University Institute for Health and Productivity Studies, employers can save between $300-$450 annually per employee as a result of reduced health expenditures due to annual wellness investment of $100-$150 per employee. Implementing wellness initiatives through a quality wellness program is key to encouraging a stress-free work/life balance, which can make a huge difference to the business. Today, more than 81 percent of American businesses with 50 or more employees have some form of health promotion program. Simply including a nosmoking policy, an exercise program or an annual health checkup can help, with an increasing number of workplaces incorporating gyms and even personal trainers and fitness instructors. Incentivizing employees with an extra paid day off if they have no claims within 12 months is becoming a common trait in wellness programs, and likewise, tying in the notion of wellness in the community at large, many companies, such as KPMG, also offer employees paid time off when they do volunteer work in the community. There is no doubt that workplace wellness programs benefit both employees and employers and may be just the cure for companies struggling with rapidly rising healthcare costs. 128 EHM | DETAILS PHOTO FINISH ith the balance of a healthy mind and body slowly but surely sinking its roots into our consciousness, a day-long, mass yoga session was organized in Times Square, New York, on June 21, 2010, to mark the summer solstice. Free public sessions and advice from health professionals enticed out hundreds of hardened yoga masters and novices to take part in the rather unusual setting for such a peaceful practice. As our daily lives become potentially more stressful, yoga can provide a profound benefit in stress reduction and addresses the balancing of the body between strength and flexibility � both of which Westerners could certainly do with. And while you might be thinking that the practice involves standing on your head and being tied in a knot, the truth is that there is something for everyone to "quiet the mind", from intermediate stretches to reduce back ache, to positions that encourage a sense of wellbeing and relaxation that you're sure to have never felt before. Male or female, young to old � there are no exceptions to the rule. Apart from maybe not trying to do it in Times Square on your own. W