COVER EHM9 v1_nov09 18/11/2009 15:47 Page 1
TOGETHERNESS Why the Healthcare Leadership Council encourages public and private collaboration Page 72
DATA DELIVERY www.executivehm.com • Q4 2009
The vital role played by health information exchanges in the future of our health system Page 90
R I A E H T IN
ainst g a t h g ﬁ e h leading t is n io s is m int Com Page 38 How The Jo e s a e is d s u ectio airborne inf
LESSONS LEARNED Page 44 GETTING BETTER ALL THE TIME Page 80 PLANE AND SIMPLE Page 114
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EDITOR’S NOTE 7
Hidden enemies Why the H1N1 pandemic is not the only serious health threat we’re facing.
hen the WHO declared that H1N1 had reached phase 6 on its scale of pandemic alerts, the world’s media went into overdrive. While the predicted widespread panic has not yet materialized, fears are still running high ahead of the full scale winter flu season. Given this, it’s worth putting the pandemic threat into context. H1N1 has killed more than 6200 people worldwide since April, a figure that appears high until you consider that according to CDC estimates, between 36,000 and 40,000 people are killed every year by garden-variety seasonal flu. Because seasonal flu – by definition – happens seasonally, and the people it kills tend to be older and often have underlying health problems, these deaths don’t make the headlines. Among the other leaders on the list of unacknowledged killers are hospital-acquired infec-
“Legislators should not assume that creating new knowledge about improving quality and safety automatically translates into the delivery of care” Mark Chassin, President, The Joint Commission (Page 38)
tions, often referred to as the ‘hidden epidemic’. According to the CDC again, HAIs kill nearly 100,000 people each year, far more than any type of flu. The most shocking thing about this figure is that the prevention of HAIs often comes down to something as simple as reminding hospital staff to wash their hands. HAIs are not the only way to die unnecessarily in hospital – surgical errors also claim an estimated 100,000 lives each year in the US. It would seem that the remedy is simply a matter of having the correct checklists and procedures in place and ensuring good communication among OR staff. However, as Richard Karl, Founder and Chairman of the Surgical Safety Institute, explains in this issue, the reality is not so straightforward. Karl points out that the problem can begin as early as medical school, where the type of people attracted to a surgical career are not neces-
“Global pandemics don’t occur every few years. They occur with periodicity that’s determined by the amount of change in the virus” David Hooper, Chief, Infection Control Division, MGH (Page 66)
sarily those who respond well to an increase in administrative procedures, or to having potential errors pointed out by junior staff members. It’s clear that H1N1 is not the only major health issue we have to worry about. While we shouldn’t discount its potential to become more deadly, we should also not underestimate the serious nature of these other health challenges. They may not be as newsworthy, but their effects are just as devastating for the victims and their families.
Marie Shields Editor
“We need to make changes in our healthcare system, but we want to make sure that we don’t throw out the baby with the bathwater” Mary Grealy, President, Healthcare Leadership Council (Page 72)
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CONTENTS_nov09 18/11/2009 15:16 Page 11
72 Coming together
Nursing an ailing health system
Mary Grealy explains how public and private collaboration is paving the way to a better healthcare system
Colleen Conway-Welch outlines the role of nurses in the evolution of healthcare
44 Lessons learned Steve Gordon on why the challenges of a pandemic mean changes for the future
Condition critical Mark Chassin faces the nationâ€™s infection control issues
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CONTENTS_nov09 19/11/2009 11:41 Page 13
119 ASK THE EXPERT 70 Michael Rumbin, River Diagnostics, Inc. 94 Neal Flora, Fletcher-Flora Health Care Inc. 102 Jeanine Tome, Allscripts Care Management 126 Nancy Moureau, Greenville Memorial Hospital
EXECUTIVE INTERVIEW 54 James Hosler, DRSS Global 60 Brian Carpenter, Muvezi 84 Phil McVey, Kroll
51 Helping hands Elaine Larson outlines the technique that aims to limit the rate of H1N1 infection
56 Pathogen control Michael Beach of the CDC examines the various aspects of waterborne pathogens
62 Gearing up for battle How Novartis Vaccines is preparing for H1N1’s next assault
66 Ready for the next wave Steve Hooper explains how the current pandemic is shaping future prevention
ROUNDTABLE 119 Operating room integration, with Jim Cloar of Medtronic Navigation and Olympus Medical Systems Group’s Richard Harada
INDUSTRY INSIGHT 78 Kevin Burton, Burton Asset Management, Inc. 132 Jim Causey, PhysicianRPO 134 David Lei and Frank Lloyd, SMU Cox School of Business
80 Getting better all the time
86 Well connected in Indiana
The technology challenges facing Seattle Children’s Hospital
Marc Overhage extols the benefits of a statewide health information exchange
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HEAD TO HEAD
IN THE BACK
90 Interoperability, with Raymond Scott of Axolotl Corp and RelayHealth’s Jim Bodenbender
136 Regional focus 138 In review 140 Events
142 Close up 144 Final word with Francesco Pompei
96 Evaluating the future Why medical technologies should be judged on their actual value to patients, according to Charlie Whelan PATIENT CARE
108 Surgical innovation Claude Deschamps on Mayo Clinic’s minimally invasive and robotic surgery
114 Plane and simple How a few lessons from the aviation industry could revolutionize patient safety during surgery
122 In the right vein
128 The best medicine
Nadine Nakazawa on the current challenges in vascular access
Pitney Bowes’ approach to employee wellbeing
Getting better all the time
In the right vein
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UPFRONT EHM US9:25 June
UPFRONT THE BRIEF
A STEP FORWARD FOR HEALTH REFORM With a helping hand from the House of Representatives, President Obama has overcome a hurdle to get his $1.2 trillion healthcare reform passed. In early November, the House of Representatives narrowly passed a reform bill to provide healthcare to all Americans. Obama called the
vote â€œhistoricâ€? and said he was absolutely confident that he would sign a health reform Bill by the end of the year. Democrats have sought for decades to provide universal health cover. When the bill was passed by 220 votes to 215 during a late Saturday night session, cheers
erupted as Nancy Pelosi, the House The bill was nearly brought Speaker, declared the victory. down by last minute objections The vote marked the from 64 pro-life Democrats first time a chamber of who wanted to tighten The bill would Congress has voted restrictions to ensure provide cover for an to back such sweepthat no federal fundadditional ing reform of the ing of abortions could US health industry. occur as a result of Americans Pelosi compared it to the reforms. the passage of legislation Obama and his allies creating a state pension system in on Capitol Hill still face a tough 1935 and government health cover battle for victory on his signature for the elderly and poor in 1965. domestic issue. There is a signifi-
UPFRONT EHM US9:25 June
cant risk that the debate will slide The package will transform into 2010, a mid-term election large parts of the health industry, year when vulnerable Democrats which currently accounts for a in conservative and moderate dissixth of the US economy. Private tricts might fail to back a final bill insurers will no longer be able to because of its huge cost. deny cover to people with pre-ex“Take this baton and bring this isting conditions, limit cover or effort to the finish line,” Obama drop it altogether when people urged senators in an appearance at become ill. the White House, saying passage of The bill also contains a healthcare reform would represent government-run health insur“their finest moment in public serance option to provide compevice,” according to Reuters. tition to private insurers, The Senate must now come something bitterly opposed by up with its own version of a Republicans and an issue which health reform bill. Harry triggered heated protests Reid, the Democratic during the summer. leader, is under Under the A tax increase of more than enormous presHouse Bill, most sure from the individuals will be White House to required to obtain will be needed to pay get it through behealth insurance if for the proposed package fore the end of the it is not provided by year. Reid is strugtheir employer. All but gling to find the 60 votes he the smallest companies will needs to overcome Republican have to provide cover for their blocking tactics despite his employees or face a fine as high as party’s Senate majority. eight percent of their payroll. If Reid succeeds in getting legOverall, the bill would provide islation out of the Senate, his bill – cover for an additional 36 million which will be slightly different Americans, leaving 18 million from the 1990-page, $1.2 trillion without insurance by 2019, behemoth passed by the House – around a third of these being illewill have to be reconciled into one gal immigrants. piece of legislation in negotiations The proposed package will with the lower chamber. be paid for by increasing – by Despite the obstacles ahead, more than five percent – the tax the success of the House Bill was a on individuals earning more than powerful victory for Obama and $500,000 a year, and on families provided strong political momenwith a combined income of more tum behind his drive for health rethan $1 million. form. “It provides coverage for 96 Senator Joe Lieberman, an percent of Americans. It offers independent who caucuses with everyone, regardless of health or inDemocrats, renewed his promise come, the peace of mind that comes on Sunday to help Republicans from knowing they will have access block a final vote if the bill conto affordable healthcare when they tains the government-run insurneed it,” said John Dingell, a ance option backed by Senate Michigan Democrat who has introliberals. Republicans remain alduced universal health insurance most unanimously opposed, critlegislation in every Congress since ical of its huge cost and the tax his arrival in 1955. increases needed to pay for it.
NEWS IN PICTURES
Patricia Steward holds her 11-month-old son Brayden as he receives his H1N1 pandemic vaccine from a nurse at the The East York Civic Centre clinic in Toronto, October 29, 2009
First Lady Michelle Obama during an event at the White House on women’s healthcare
Harry Reid, Christopher Dodd and Max Baucus deliver remarks to the press on healthcare reform
Hairdressers wearing masks to protect against swine ﬂu at a salon in Lviv, Ukraine, November 2, 2009
UPFRONT EHM US9:25 June
UPFRONT IN MY VIEW
20 WILLIAM CHIN, Vice President of Discovery Research and Clinical Investigation at Eli Lilly and Company. I have an outstanding scientific and physician staff and ultimately it starts there: if you have the best people in the business then you at least stand a chance of being hailed to be competitive, but you can have all the best people in the world and if they’re not organized well then you’ve lost the benefit. Lilly has created an environment where our biologists working in cancer and neurosciences are working closely with our chemists and our toxicologists; and our folks who work on ADME, PK/PD, experimental medicine and medical work together in a cluster concept of activity. Genetics is absolutely important to help us understand which may be the most important targets for drug discovery. One of our challenges is that we need to be better at choosing these targets. Even if we have the most innovative drug but our patients have no access to it, for whatever reason, because they can’t afford it or governments or third-party payers are not willing to reimburse for it, then we really haven’t done anything. The FDA, as well as the EMEA, has allowed us to be a part of the approach that we can take in terms of personalized medicine. What we are trying to find out is how can we share in knowledge, share in work, share in the risk of projects and hopefully, then, share in the reward.
UPFRONT EHM US9:25 June
COMPANY NEWS MAKE NO MISTAKE Medical errors are the eighth leading cause of mortality in the United States. During the past decade much has been written about how important patient identification is to preventing deaths. Unfortunately, many hospitals still base patient ID purchase decisions on short-term considerations such as initial cost and convenience, while losing sight of critical patient safety implications. Thermal printed wristbands offer a prime example of this lost focus. The most common thermal ID products offer the apparent convenience of compact printers that print one wristband at a time. However, these wristbands suffer from the same issue: unprotected image areas that quickly degrade as vital patient data is exposed to common hospital liquids. Even though single wristband printing seems convenient and inexpensive, in reality chart labels are often needed during a patient’s stay and must be printed separately, slowing workflow and adding cost. To address these issues, the world’s leading laser
wristband company, LaserBand, has leveraged over a decade of laser-wristband research and real world product usage to bring meaningful patient safety driven innovation to thermal wristbands. Their new FusionBand thermal wristbands feature a patented self-laminating design with a 100 percent film construction to form a water and alcohol resistant seal that protects vital patient data for the duration of the patient’s stay. In fact, FusionBand recently scored 100 percent on readability and water resistance during an extensive trial at the Denver VA. The FusionBand line features the world’s first and only thermal wristband and chart label combination form. For the first time hospital personnel can print a thermal wristband and several chart labels on the same form and in a single pass, improving workflow and reducing costs. FusionBand products are the leading patient identification solution in the UK and other parts of Europe and will be widely available in the US midyear 2009. For more information visit www.laserband.com
10% of drugs sold in the US are fakes
UPFRONT EHM US9:25 June
UPFRONT INTERNATIONAL NEWS
CANCER CELL CURE
New research by a team based at the Department of Epidemiology and Public Health, University College London, has shown that eating a diet high in processed food increases the risk of depression, and that those who ate plenty of vegetables, fruit and fish, actually had a lower risk of depression. The British Journal of Psychiatry said that data on the diets among 3500 middleaged civil servants was compared with depression five years later. After accounting for factors such as gender, age, education, physical activity, smoking habits and chronic diseases, they found a significant difference in future depression risk with the different diets. Those who had a diet high in processed food had a 58 percent higher risk of depression than those who ate very few processed foods.
The European Union has warned against complacency over the spread of swine flu, urging people to get vaccinated even though the virus has not hit as hard as it was first feared. The World Health Organization (WHO) has confirmed that at least 6250 people have died from swine flu infections since the virus was uncovered in April. Most deaths occurred in the Americas region, where 4512 fatalities have been reported. Some 678 people have died from the infection in the Asia-Pacific region, while at least 300 fatal cases have been recorded in Europe. EU Health Commissioner Androulla Vassiliou also warned that while it was up to individuals to decide whether they should get vaccinated, it was probably better to take precautions.
An Israeli research scientist has accidentally discovered a chemical compound that eradicates cancer cells without harming normal cells in the process. Professor Malka Cohen-Armon, a biochemist at Tel Aviv University, explained that the compound is a component of a family of drugs developed 10 years ago to preserve nerve cells stressed by a stroke or inflammation, but on further examination the drugs were found to be inappropriate for their intended use, and they were released only for research purposes. Cohen-Armon and her team of researchers set out to find an application for DNA repair, but found a potentially huge discovery within cancer cells â€“ the drugs create a mechanism in cancer cells that causes them to die within 48-72 hours, without harming normal tissue.
UPFRONT EHM US9:25 June
A Canadian man has developed a strain of H1N1 that has proved resistant to the antiviral Tamiflu, after being given the drug to prevent the disease. So far, the World Health Organization has recorded 45 cases of resistance to the drug, which is why the CDC, amongst others, is cautioning those using Tamiflu who still remain without symptoms. It is reported that the manâ€™s son was hospitalized with H1N1 and so he was provided the vaccine at a reduced dose to help prevent him from getting the disease. However, within a day the man developed flu-like symptoms and a test of his virus revealed its resistance to Tamiflu. The mutated strain of H1N1 swine flu is also reported to be susceptible to another antiviral, Relenza.
In protest at further expansion of cigarette consumption in Asia, hundreds of Thais gathered outside a tobacco industry congress. Angry at the tobacco industry for what they describe as using Thailand as a base from which to expand the market within young Asian men and women, the group gathered 86, 238 signatures of those opposed to the congress. The Thai government has won praise from the World Health Organization for its campaign against cigarette smoking, which has included such measures as high taxes, gruesome pictures on cigarette packs depicting lung cancer and throat cancer victims, and bans on cigarette ads and smoking in all public places. However, there are still an estimated 14.3 million tobacco users in Thailand, more than a quarter of the adult population, according to recent research conducted by the Global Adults Tobacco Survey.
An international conference in Mauritius has been set up in collaboration with the World Health Organization African Region to highlight the concern of the rapid growth of the diabetes epidemic throughout Africa. The conference features the Regional Director of WHO Africa, health ministers from 46 African countries, IDF experts and other leading diabetes experts, who will be discussing latest developments, practical management and prevention of diabetes and its complications. The aim of the conference is to build a strategic alliance among health professionals that will provide the momentum to implement both the National Diabetes Services Framework and the UN Resolution on Diabetes. Africa will have the highest percentage increase in the number of people with diabetes in the next 20 years because of rapid industrialization and general improvements in living standards over the past five decades.
UPFRONT EHM US9:25 June
24 NANCY-ANN DEPARLE President Obama named Nancy-Ann Min DeParle as Director of the new White House Ofﬁce of Health Reform on March 2, 2009. Described by the President as serving as “health reform Czar,” DeParle will work within the new government entity, leading the change proposed by the new administration. Becoming the ﬁrst female president of the student body at the University of Tennessee, DeParle is familiar to asserting herself within new roles. After earning a JD from Harvard Law School, DeParle became a partner at a law ﬁrm before immersing herself in politics, serving as commissioner of the Tennessee Department of Human Services under Governor Ned McWherter. Leaving government in 2000, DeParle took on numerous roles, becoming a fellow at the Institute of Politics at Harvard’s John F. Kennedy School of Government, a Senior Adviser to JP Morgan Partners LLC, a Commissioner of the Medicare Payment Advisory Commission (MedPAC), and a Senior Fellow at the Wharton School of Business of the University of Pennsylvania, just to name a few. Her time within the corporate private sector is thought to bring her a unique industry perspective on public healthcare. Serving under the Clinton Administration in 1997, DeParle returned to politics. Named Administrator of the Healthcare Financing Administration (now called the Centers for Medicare and Medicaid Services). Responsible for the running of Medicare, Medicaid and SCHIP – providing health insurance for 74 million Americans – DeParle was in charge of a fund of more than $600 billion, and became a key advisor to President Clinton. DeParle has received criticism for her corporate connections and the beneﬁts they may have brought her following her tenure within the Clinton Administration. Msnbc.com reported her to be paid more then $6 million during this time, and with many of the companies she directed facing federal investigations, she became regarded with suspicion. Many of these companies currently hold a stake in the health reform that she is leading.
UPFRONT EHM US9:25 June
There are approximately
350,000 people in the US with multiple sclerosis
OBESITY LINKED WITH MS A study by researchers from Harvard School of Public Health has found that being obese as a teenager may be linked with an increased risk of multiple sclerosis as an adult. The researchers used data from nurses taking part in a large study on diet, lifestyle factors and health. A 40-year study of 238,000 women found that those who were obese at 18 had twice the risk of developing MS compared to women who were slimmer at that age. Yet body size during childhood or adulthood was not found to be associated with MS risk, the US researchers report in Neurology. Over the length of the study, 593 women were diagnosed with
MS, a condition caused by the loss of nerve fibres and their protective myelin sheath in the brain and spinal cord, which causes neurological damage. The researchers compared the risk of the disease with body mass index (BMI) – a ratio of weight to height – at age 18. Those participating were also asked to describe their body size, at the age of five, 10 and 20, using a series of diagrams. The study showed that those with an ‘obese’ BMI of 30 or larger at age 18 had more than twice the risk of developing MS. There was also a smaller increased risk in those who were classed as overweight. The results were also the same after accounting for smoking status and physical activity level.
FROM THE VAULT In Q1 2009 of EHM, NANCY BROWN, CEO of the American Heart Association, explains her excitement at becoming the first female CEO at the organization, and the responsibility in educating the people of America to change their lifestyles. Go to www.executivehm.com to browse ‘Past issues’ and click on Issue 7, March 2009 and read of Brown’s call for a new healthcare model, “a focus on prevention and finding a way to make our healthcare system economically viable.”
VACCINE SHORTAGE Despite the fact the regular flu season the New York Times reports. has yet to start, the nation is already Although the nation is experifacing a severe shortage of seasonal encing this shortage, it does not flu vaccine. This comes at mean there will be an the same time as a increase in seasonal shortage of the swine flu deaths – Seasonal flu vaccine. which average ﬂu deaths average Federal offiabout 36,000 about cials and indepenper year. The dent flu experts same amount of per year have said the situavaccine was made tion was unavoidable, this year as it was given that the global swine last, so there is no reason flu pandemic had raised demand to believe that any of the three for all flu shots far beyond what strains of seasonal flu will be any manufacturers can make in a year, worse this winter.
UPFRONT EHM US9:25 June
FIVE MINUTE EXECTUTIVE
CANCER TEST NEEDED
“We are releasing several revenueenhancing solutions that empower physicians and hospitals to appropriately code and remain compliant”
S. HART WILLIFORD, CEO, INGENIOUS MED During my time as SVP at Memorial University Medical Center, we opened a world-class cancer research center that went on to win the COC (Commission on Cancer) excellence award, placing the center in the top six percent of institutions surveyed. We also implemented an in-depth quality initiative program in the hospital and received accolades for patient outcomes, and the institution became one of Fortune’s‘100 Best Places to Work’.
allow you to scale and give you efﬁciencies to compete and do well in ever-changing markets. You also have to go from servicing to truly delighting customers. You’ve got to go back to basics – such as a live voice for tech support and a bi-annual customer satisfaction survey, following up with rapidly implemented improvements.
There are a lot of exciting projects going on at Ingenious Med.We are leaders in providing bedside, point-of-care data-capture, data-push and reporting My experience at Memorialprovided me with the ability to empathize with the needs of our customers – services, and we are continually developing our application to be available on today’s most popular dephysicians and hospitals.With the ever-changing vices, such as the Blackberry and iPhone.We are healthcare environment, we are able to ensure that releasing several revenue-enhancing solutions that we address the needs of these stakeholders, such as pay-for-performance, bundled services and like trends. empower physicians and hospitals to appropriately code and remain compliant. Ingenious Med is my ﬁfth such software venture. The processes learned and developed at these previous companies are now being released and implemented at Ingenious Med, allowing us to rapidly scale and grow. These process changes have allowed Ingenious Med to double in size this year in terms of revenue and resources, while improving customer resources. In order to be successful, you have to build the right team and then incorporate the right processes in everything that you do. Proper processes
We are extending our quality module to address not only PQRI, but hospital core measures and other quality compliance areas as well.We will also soon be releasing some powerful new business intelligence software that will take our current, industry-leading reporting solutions to another level of usefulness for our clients. Stay tuned – these are exciting times for all of us at Ingenious Med, and all of us in the healthcare industry. For more information, please visit www.ingeniousmed.com
According to the American Cancer Society, this year alone an estimated 40,170 women will lose their lives to breast cancer. Meanwhile, it is estimated that 4000 breast cancer deaths could be prevented just by increasing the percentage of women who receive breast cancer screenings – namely, mammograms – to 90 percent. Mammograms lead to earlier detection of breast cancer, which is why health insurance pays for them. But between 2003 and 2005, mammography rates declined, with a notable decrease for Hispanic women, from 65 percent to 59 percent, and in African-American women, from 70 percent to 65 percent. Not only that, but it is estimated that one in five women over 50 have not received a mammogram in the past two years, largely due to a lack of insurance.
This year alone an estimated
40,170 women will lose their lives to breast cancer
4000 breast cancer deaths could be prevented just by increasing the percentage of women who recieve screenings It is estimated that
1 in 5
women over 50 have not recieved a mammogram in the last 2 years
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UPFRONT EHM US9:25 June
UPFRONT DIABETES INFOGRAPHIC
HORMONE MAY LOWER DIABETES RISK The World Health Organization estimates that at least 180 million people have diabetes. Roughly 90 percent have type 2, caused by the body’s ineffective use of insulin. Researchers have focused in recent years on a hormone derived from fat cells, called adiponectin, which is shown to lower the risk of diabetes. Scientists now hope this could improve the treatment of diabetes or even prevent it altogether. Obesity and physical inactivity are common conditions associated with type 2 diabetes. The WHO projects that 330 million to 360 million people will be diagnosed as diabetics by the year 2030. Doctors have preached diet and exercise to patients for decades. Now researchers have noticed that high levels of one fat-producing hormone is not such a bad thing, after all. Scientists have known about the fat-producing hormone adiponectin for some time. But Rich Van Dam and his colleagues at the Harvard School of Public Health have looked at studies of at least 14,000 patients and confirmed
something interesting. They are not sure why, but patients with a lower risk of type 2 diabetes seem to have higher levels of adiponectin. “It actually has beneficial effects on the liver and on muscles and it increases insulin sensitivity, it seems, and it reduces inflammation,” says Van Dam. Van Dam says the link between adiponectin and a lower risk of the disease is consistent, regardless of an individual’s body mass index, gender or race. That, he says, raises hope for screening and further treatment involving adiponectin, or in prevention of the disease itself. “It’s an interesting finding because we know that certain ethnic groups, certain racial groups seem to be more sensitive to develop[ing] type 2 diabetes,” he explained. Source: www.voanews.com
DIABETES IN THE US
Estimated US national prevalence of total diabetes by age, sex, race and insurance status (%) NHANES
deaths annually cause of death in the US 6thleading
Deaths per 10,000 ranges from
in Arizona and Florida in West Virginia and DC
Medical expenditures attributed to diabetes Estimated direct costs in 2007 at
$27 billion for care to directly treat diabetes
Up to 25% of the medicines consumed in some developing countries are counterfeit or substandard
$58 billion to treat diabetesrelated chronic complications $31 billion in excess general medical costs NHANES. National Health and Nutrition Examination Survey
UPFRONT EHM US9:25 June
Estimated prevalence of total diabetes, by sex and state (%)
Black Hispanic Other
11.4% 18.3% 16.7% 11.1%
Average cost for a hospital inpatient day due to diabetes
13.3% 9.2% Diabetes-related hospitalizations
$1,853 - $2,281 due to diabetes-related chronic complications, including neurological, peripheral vascular, cardiovascular, renal, metabolic, and ophthalmic complications
million days 2007 million days 2002
Source: www.diabetes.org | www.pophealthmetrics.com
UPFRONT EHM US9:25 June
UPFRONT COMPANY NEWS
FUND FOR DISEASE FIGHT APPROVED
One out of every 1500 intra-abdominal surgeries today results in a sponge being left behind in the patient. A retained sponge causes infection, requiring additional surgery, the risk of severe complications and sometimes even death. The Centers for Medicare and Medicaid Services, instituted a ruling in October 2008 to refuse payment for this avoidable medical error, which they have dubbed a ‘never event’ because the medical establishment has determined it should never happen. It remains the most frequent and costly surgical ‘never event’. The culprit for its persistent re-occurrence: human error due to reliance on manual counting and detection measures. A new application of radio frequency identification (RFID) technology allows hospitals to pursue a zero tolerance goal for left-behind sponges. A device using the technology, the SmartSponge System from ClearCount Medical Solutions, Pittsburgh, Pa., allows for nurses to easily scan sponges ‘in’ and ‘out’ of the surgical site. Unlike other technologies, RFID allows the device to uniquely identify the type as well as the number of sponges, for an exact view of the situation. As a final safety measure or in the case of an un-reconciled count, the doctor at surgery’s close waves a reusable RFID wand over the patient to ensure the body is sponge-free. ClearCount has received funding from the US government to pursue applications that will prevent retained surgical instruments as well. At $20-30 per procedure, this prevention approach may well be the way for hospitals to put some meaning behind the ‘never’ in never events.
The Global Fund to Fight AIDS, Malaria and Tuberculosis has approved grants worth $2.4 billion to fight the diseases during the next two years. The amount represents a slight decrease in funding levels, though the three killer diseases show little sign of abatement. The $2.4 billion figure approved by the Global Fund to Fight AIDS, Malaria and Tuberculosis is $350 million less than last year’s amount, which was set before the full effects of the world economic slump were known. Fund Executive Director Michel Kazatchkine warned in a news release that even this reduced
funding level may not be sustainable Goosby also said that while unless wealthy countries and other Ethiopia’s HIV infection rate is donors increase their commitments. worrisome, it is far lower than in The amount was set during a the AIDS ravaged countries Fund board meeting in of southern Africa. Addis Ababa. “Looking at the 23 The U.S. million people Global AIDS coorin sub-Saharan dinator, Africa who are people in Ethiopia Ambassador Eric infected, are infected Goosby attended Ethiopia makes with HIV the Addis Ababa up about one meeting. He says million of those,” among the hardest-to-reach says Goosby. “So it is not vulnerable groups are those engaging the worst impacted country in behaviors that in some countries in sub-Saharan Africa by a are illegal or socially unacceptable, long shot.” such as homosexuality. Source: www.voanews.com
HAND HYGIENE TECHNOLOGY
nGage, a wireless RFID quality compliance monitoring system, allows hospitals to measure hand hygiene activities and other events, whilst providing information for meaningful behavior modification at the point of care. Through nGage, hospitals no longer rely on spotty observational data to assess compliance with quality events. The system provides realtime information to increase compliance and to create operational efficiency. nGage was developed by Proventix Systems, Inc. in response to increasing emphasis by CMS, JCAHO and other world health organizations on hand hygiene as means to prevent costly and deadly healthcare associated infections (HAIs). Its first goal is to measure 100 percent of the
hand hygiene opportunities and events for healthcare workers, patients and visitors without any disruption of workflow. The system is easily integrated into the hospital’s existing IT infrastructure. “The key barrier to improving hand hygiene compliance lies in the ability to accurately track and measure compliance rates across a healthcare organization,” says Harvey Nix, CEO of Proventix Systems, Inc. “If you can add behavioral modification at the point of care and create opportunities for efficiency you have something of great value.” For more information visit www.proventix.com
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UPFRONT COMPANY NEWS
WELLNESS THAT WORKS Corporate wellness initiatives have grown in importance, particularly within the past year, as employers are expected to do more with less in an uncertain economic climate. Once considered ‘a nice thing to do’, comprehensive wellness programs are now recognized by senior management as a legitimate and powerful driver for reducing healthcare costs and improving productivity. However, goals and expectations have been set high as budgets are slashed and stress levels rise among a leaner employee population. Proactive employers are rising to the challenge by learning to be more creative with their benefit offerings and leveraging existing resources already being paid for. In reaction to the needs of their clients, national EAP and wellness provider, eni, created a dynamic solution that is ‘doing more for less’ by integrating wellness services with the behavioral health services of their work/life employee assistance program (EAP). This new strategy also includes an established referral
process between existing medical/health and disability providers, delivering an integrated approach to total wellness. Gene Raymondi, founder and continuing Chief Executive Officer of eni, advises benefit executives to work in partnership with their providers to create a synergy of cross referrals. “When vendors are flexible and cooperative with the employer, as well as other providers, the results show increased participation and engagement, as well as a positive and noticeable shift in the corporate culture towards the total health and well-being of employees and their family members,” explains Raymondi. eni has developed a shared data platform, positioning their EAP as a central contact to coordinate referrals. This new system has driven participation rates as high as 93 percent, and created a new, sustainable trend that provides employees better access to and understanding of the resources available to them. Participating providers are now able to effectively target the root cause of each individual, leading to lasting change for the employee, as well as the corporate bottom-line.
SAVING LIVES? The World Health Organization says antiviral medicines and antibiotics used in a timely manner can help save the lives of people who are sick with the H1N1 influenza. The WHO issued new guidelines in midNovember on the clinical treatment of people who contract the swine flu. With the start of the influenza season in the Northern Hemisphere, there has been an upsurge in influenza across Europe and Asia. The WHO says clinics in some countries are overwhelmed with patients. It says one way to save lives and ease the burden on clinics is to provide early treatment to prevent H1N1 from developing into a severe disease. WHO Medical Officer in the Clinical Aspects of Influenza, Nikki Shindo, says the agency has convincing evidence that antiviral medicines, such as Tamiflu, can prevent severe cases of H1N1. She says the WHO has three updated recommendations for countries where the virus is circulating. Source: www.voanews.com
FAST FACT ONLINE COMPLIANCE eduTrax LLC, based outside of Atlanta, Georgia, since 2007 has been providing online healthcare compliance-focused live and recorded courses, consolidated resources and documentation tools targeting US hospitals’ regulatory and bottom line vulnerabilities. eduTrax has entered a collaborative agreement with a national accounting firm, Draffin Tucker LLP, to provide CPA CPE accredited course material through eduTrax’s portal expanding the online compliance library to eduTrax hospital subscribers. The online library has expanded to greater than 82 courses, which bring vital information ‘real-time’ into key hospital departments on a daily basis, maximizing time efficiency and knowledge transfer during the current tumul-
tuous regulatory and economic environment the US healthcare industry now faces. eduTrax serves as the education ‘engine’ for RAC University, which is part of California based RACMonitor, a national online vehicle providing education and support to hospitals as the US Centers for Medicare and Medicaid Services’ (CMS) national recover audit contractor (RAC) program commenced in August 2009. US Hospital CEOs and CFOs face daily challenges to their organizations’ fiscal health, time management, and knowledge transfer across all levels from physicians to back office billing staff. Online education and training is on the forefront providing necessary resources and support at a fraction of distance learning or ‘train the trainer’ methods traditionally utilized over the years. For more information please visit www.myedutrax.com
Annual earnings from the sales of counterfeit and substandard medicines are over
$32 billion globally
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UPFRONT EHM US9:25 June
UPFRONT COMPANY INDEX
FASTING DEEMED UNNECESSARY FOR ACCURATE CHOLESTEROL TESTING According to a group of New England researchers, your risk of developing coronary heart disease and ischemic stroke can be assessed by measuring cholesterol levels without the requirement of fasting. The full report can be found in the Journal of the American Medical Association. John Danesh, of the Emerging Risk Factors Collaboration Coordinating Center at the University of Cambridge, and his colleagues have found that methods to gauge blood cholesterol for the determination of vascular disease risk can be simplified. Their studies showed that measuring high-density lipoprotein (HDL) cholesterol, also called ‘good’ cholesterol, in combination with the measurement of high-density lipoprotein (LDL) cholesterol, or bad cholesterol, was just as revealing as testing for apolipoproteins AI and B. Apolipoproteins are proteins that bind to fats (lipids). The researchers analyzed the data of 302,430 people from 68 long-term prospective studies regarding the effect of major lipids and apolipoproteins on vascular risk. At the begin-
ning of the studies, the participants had no sign of vascular disease. However, during the 2.79 million person-years of follow-up, 8857 nonfatal heart attacks occurred, as well as 3928 deaths from coronary heart disease, 2534 ischemic strokes, 513 hemorrhagic strokes, and 2536 unclassified strokes. The research team found no association between triglyceride levels and coronary
heart disease or ischemic stroke, even after adjusting for several conventional risk factors. However, they did find that HDL cholesterol was associated with a lower risk of vascular disease, and that non-HDL cholesterol and directly measured LDL cholesterol were associated with a higher risk. Source: www.healthnews.com
COMPANY INDEX Q4 2009 Companies in this issue are indexed to the ﬁrst page of the article in which each is mentioned. Allscripts Care Management 102, 103 Association for Vascular Access 122 Axolotl Corp. 4, 90 B. David Company 46 BioTech Medics, Inc. 49 Bracco 36 Burton Asset Management, Inc. 78, 79, OBC CDC 51, 56 CDH Partners, Inc. 35, 110 ClearCount Medical Solutions 30, 117 Cleveland Clinic 44 Coremotive 101 DRSS Global, LLC IFC, 54, 55 Dynamic Clinical Systems, Inc. 98 e-Health Data Solutions 89
eduTrax LLC 32, 33 eni 32, 131 Exergen 17, 107, 144, IBC Fletcher-Flora Healthcare Systems Inc. 12, 94, 95 Frost & Sullivan 96 GE Healthcare 6 Greenville Memorial Hospital 126 Gremed, Inc. 53 HandGiene, Corp. 15, 43 Healthcare Leadership Council 72 Indiana Health Information Exchange 86 Ingenious Med 26, 27 J&A Companies 50 Kroll 84, 85
LaserBand 21, 83 Massachusetts General Hospital 66 Mayo Clinic 108 Medic Acces 65 Medtronic Navigation 77, 118, 119 MeettheBoss 121 Muvezi 60, 61 Nephros, Inc. 59 Novaces 143 Novartis 62 Olympus America Inc. 2, 118 pfm Medical, Inc. 69 Pitney Bowes 128 PhysicianRPO 132, 133 Proventix Systems, Inc 30, 31 RelayHealth 90, 93
River Diagnostics, Inc. 70, 71 Seattle Children’s Hospital 80 Skytron 113 Sword & Shield Enterprise Security, Inc. 100 SMU Cox School of Business 10, 134, 135 Surgical Safety Institute 114 Teleflex Medical 127 The Joint Commission 38 Vanderbilt School of Nursing 104 Xoft, Inc. 8
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Chassin ed:26 June
Chassin ed:26 June
The Joint Commission’s Mark Chassin tells Natalie Brandweiner about the infection control issues facing the nation.
ike every other healthcare institution attempting to limit infecThe commission also operates another group of requirements, the tion, The Joint Commission understands the critical safety issue National Patient Safety Goals, which function in a similar manner, and aim currently facing America’s hospitals. “Hospital-associated and to highlight the most important and difficult areas of patient safety and qualhealthcare-associated infections are a huge problem, in ity. Many of the standards directly address infection control and prepart because the landscape of infectious disease is vention issues, including hand hygiene, bloodstream infections constantly changing, evolving and challenging and surgical site infection prevention. us,” explains Mark Chassin, President of the commission. “We have also worked to focus our survey process on With various approaches suggested as being the most effecvarious aspects of infection prevention and control,” tive for control and protection, he notes the difficulty for explains Chassin. “We have performance measureof ﬁrst antibiotic healthcare institutions in understanding and choosing the ment requirements under which all of our accreditdoses were given right prevention program in a climate where the goalposts ed hospitals have to send data to us, and the one new within the hour are constantly moving. group that was introduced in 2005 has seen important The Joint Commission has a variety of programs, acimprovement. It’s a group of measurement requiretivities and approaches to help healthcare organizations manments that address one of the most critical parts of preage these problems, most notably its accreditation standards, venting surgical site infection: the proper application of which are revised on an annual basis. “The beginning of this year saw prophylactic antibiotics in a wide variety of surgical procedures. some substantial expansion of those requirements, which focus on the plan“We know from research that prophylactic antibiotics are a powerful prening and execution of comprehensive infection prevention and control plans, ventative for surgical site infection. However, the first dose must be adminisincluding some detailed requirements on instrument sterilization, disinfectered within an hour of the beginning of the surgical incision. As of the last tion reprocessing, and specifically, what hospitals need to do to maintain full year of data from the thousands of hospitals that report to us, the US avstate-of-the-art infection control and prevention,” he says. erage across the different procedures in that measurement group was 89 per-
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cent of first doses within an hour, and 86 percent stopped within 24 hours, which is the other component of the measurement. Then you have to pick the right antibiotic: It must be appropriate for the procedure, and there are clear guidelines on that. In 2007 across all of the different groups of procedures, from vascular to gynecology to orthopedic surgery and colon surgery, 95 percent had selected the right antibiotics,” says Chassin. The Joint Commission has taken a leadership role among all of the leading organizations in infection prevention and control, including the Infectious Disease Society of America, the Society of Hospital Epidemiologists and the National Foundation for Infectious Diseases, whom it catalyzed to undertake a comprehensive review in 2008, looking at critical infection issues in hospitals. The result of this review was the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, which principally focuses on getting hospitals to make their programs working more effectively. The Commission also produces other resources to educate its members, such as educational conferences and consulting, as well as publishing various booklets and brochures.
Clean hands Designated by the World Health Organization in 2005, The Joint Commission is the only world collaborating center for patient safety solutions. The WHO’s initiation of this global patient safety initiative took hand hygiene as its first challenge, which has been a National Patient Safety goal of the commission for some time. The continued prevalence of healthcare-associated infections and their prominence in the healthcare debate has prompted the commission to step up its operations, so for the first time it is preparing to engage with healthcare organizations Mark Chassin to create interventions to improve safety and quality. “We’ve created requirements for organizations to improve their processes and outcomes, but in the past we haven’t engaged directly with them in solving some of these critical problems,” explains Chassin. “That’s what this new activity is focused on. We are launching a component of The Joint Commission called the Center for Transforming Healthcare; it is a separate component, like the Joint Commission Resources, but a subsidiary. “We’re not for profit, so our focus is to use some of the newer tools of process improvement, such as Lean Six Sigma and change acceleration, to begin working with a group of 16 leading hospitals and health systems that have themselves already made the investment in mastering these tools. We can use this systematic approach to solving problems to attack these critical quality and safety problems that every organization has been struggling with. “The first topic the participating hospitals chose for this effort, which was launched earlier this year, is hand hygiene failures. We’re talking about some of the leading hospital systems in the United States, from Hopkins and Mayo
to Inner Mountain in Utah, Partners in Boston, New York Presbyterian in North Shore in New York, Cedars, Stanford, Kaiser in California, Exemplar in Colorado, Memorial Herman in Texas. It’s a very impressive list. They identified a number of their highest priority problems, and hand hygiene failures got the most number one, high priority votes. “For about 15 months, The Joint Commission has been undertaking a very aggressive program for our own internal process improvement of adopting strategies and methods, the same tools of Lean Six Sigma and change acceleration. We have our own Lean Six Sigma experts whom we are bringing to this new center’s activities to work with these organizations. The hallmark of what’s different about this approach is the systematic methodology to solve these problems, which starts with an agreement on reliable and accurate measurement systems and hand hygiene. “There currently aren’t any good, easy to apply, systematic measurement systems to know what your performance is, and if you can’t measure something reliably, you can’t improve it effectively. The second issue is, once you’ve got a good measurement approach, to understand these tools with systematic applications and figure out why the process isn’t working. That’s a step in the Lean Six Sigma approach to solving problems that is absolutely essential in these critical quality and safety areas, where solutions have remained elusive. This leads you to be very precise about what the causes of the failures are in where you’re trying to fix the problem,” he explains.
Finding the cause Chassin hopes this approach will pinpoint the major reason why hand hygiene compliance is so hard to achieve, and why the distribution of the causes of noncompliance differs from one place to another. He provides an example of solving the problem of soap dispensers and their location outside patient rooms, noting one surprising major cause of infection in a large number of hospitals is the number of healthcare staff approaching patient rooms with unclean hands. Unless the process is carefully assessed and the reasons for failure understood, it is impossible to target interventions that effectively manage the high impact causes, nor can improvements be made. Chassin believes this is the key activity that differentiates the center from others pursuing this methodology. The second difference is that this methodology is now married with the reach of The Joint Commission. “Our job is to coordinate these projects, oversee them and make sure they’re done exactly the same way with fidelity to this method so that we can compile results across all of these organizations,” he explains. “Eight of the 16 are participating in this first project of hand hygiene, and the remaining eight are just starting the second project. “Every hospital is worried about hand hygiene. Our job is to put the learnings from these initial projects into a knowledge database that we can
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then take to the other 95 percent plus of hospitals that have not invested in Lean Six Sigma process improvement. Then we view how they’re doing on the programs and often find opportunities for improvement. We direct them with very precise guidelines and instructions on how to measure the problem, how to assess what their causes are, and then give them specific interventions developed by the participating hospitals in the center project to tackle exactly the same cause in locations. “The reach of The Joint Commission in pushing these very effective interventions out, along with this methodology, translated and jargon-free, so you don’t have to do the painstaking, difficult process of learning this stuff: that’s the other component of what’s different. Obviously there are enough opportunities for improvement across the healthcare delivery system so that everybody who wants to work in quality improvement should feel free to expend their maximum effort. We don’t view this as competitive with or replacing anything that’s out there: it’s complementary and additive.”
Flu focus The Joint Commission has been very involved with H1N1 from the first outbreak in spring and early summer, advising its healthcare organizations on the CDC’s most up-to-date recommendations. As a partner with the CDC and being present in its regular briefings, the commission can communicate the latest information and guidelines directly to accredited organizations. The commission’s infection control and prevention standards cover the needed guidelines; specifically the recommendations of what hospitals need to do to prepare for a large increase in the number of potentially infectious patients. “We’ve been among the leaders in preparing hospitals for emergencies, including pandemics. And that’s been recognized in a lot of different places:
“The continued prevalence of healthcare-associated infections and their prominence in the healthcare debate has prompted the commission to step up its operations” the need to refresh emergency preparedness guidelines and plans, coordinating with other organizations in the community so that you’re not functioning in isolation. We are very much engaged in the planning work, for our organization and our standards have been the most recognized items in this area,” says Chassin. H1N1 is not the only difficult issue that the industry is currently facing. The economic recession has had a notable impact on safety within a hospital environment, and as Chassin points out, whenever times are hard, healthcare organizations are tempted to reduce expenditures that aren’t directly involved in the delivery of patient care. “Fortunately for quality, the Joint Commission Accreditation process and requirements don’t change,” he adds. “We don’t change the way we assess hospitals and other organizations, and we believe it is critical to attend to quality programs even in difficult economic times, because backing off them can lead to adverse events and outbreaks of quality problems that can be costly not only in adverse outcomes for the patients, but also for the resources of the hospitals and other organizations.
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“We’ve been pretty effective in making those arguments. There’s been an ocfection in colon surgery. “All of that is maintained with great fidelity to the clinicasional organization here or there that is literally on the verge of bankruptcy that cal integrity and the evidence, and to making this data collection infrastructure has idiosyncratic problems, but we don’t see any significant retreat from the comwork so that it’s seamless for the hospitals that collect the data once,” says Chassin. mitment or the safety and quality programs that are necessary.” Obama’s Plan for America only vaguely alluded to initiating performance Implementing a standard performance measurement across the whole specmeasures, says Chassin. There is discussion of using these measures to drive imtrum of organizations is no easy feat. The Joint Commission was the first of its provement in a variety of ways, such as arranging new collaborations between kind at the start of the 21st century to begin a national program of measuring qualdoctors and hospitals. Quality will be judged through measuring performances, ity in hospitals, and met with huge resistance when attempting to collect the data and the commission is focusing on making sure the measures are the very best. from hospitals and publicly record it. Chassin explains that back then there were Armed with the experience of conducting such measures for thousands of very few measures that anybody could agree on, whereas now there hundreds of organizations, The Joint Commission has been contributing knowledge, ensurmeasures available, both good and bad. ing that it supports the creation of a quality improvement infrastructure. Chassin “Our program was picked up by the American points to the example of the Center for Transforming Hospital Association, and hospitals were encouraged Healthcare, which can take information from the reThe Joint Commission to voluntarily report in the middle part of the decade. newed interest in comparative effectiveness research An independent, not-for-proﬁt Then Medicare CMS picked it up and required hosand transform it into practice much more rapidly organization, The Joint Commission pitals to report, but they wanted to get their full anthan before. accredits and certiﬁes more than nual payment update, so a penalty for not reporting “That’s part of our involvement in health reform 16,000 healthcare organizations and was the Medicare approach. Now virtually every hoslegislative debate – the legislators should not assume programs in the United States. Joint pital that has appropriate patient services reports a that creating new knowledge about the best thing to Commission accreditation and whole panoply of core measure data to us and some do for improving quality and safety automatically certiﬁcation is recognized of those measures have now reached levels of consistranslates into the delivery of care. Often that takes nationwide as a symbol of quality tent excellence that are unparalleled anywhere in the many years and we can’t afford those lengthy delays that reﬂects an organization’s healthcare delivery systems. any longer,” he says. commitment to meeting certain “For example, some of the surgical site infection The Joint Commission is continuously engaged performance standards. measures that came in in the middle of this decade in processes to improve its own standards and the way were for heart attack. When that program started, it it conducts its surveys across all of its programs. “We wasn’t uncommon to see 40 and 50 percent rates of performance on things like accredit over 4000 hospitals, but that’s less than a quarter of the 16,000 organizaaspirin and beta blockers. Now the national average for aspirin on arrival and beta tions across all the delivery systems that we accredit or certify,” he explains. “We blocker on discharge is 97 percent,” he says. actually accredit more home-care organizations now than hospitals.” The model operated by The Joint Commission demonstrates a good degree of consistency, with the later measures of surgical site infection prevention havInternal standards ing a standard level of accuracy. Chassin explains that this program has a lot of “We are engaged in every kind of delivery organization that exists out there stakeholders and therefore must continue to be worked on. The commission and we developed standards for all of them. There are requirements for safety, works with CMS on a weekly basis to ensure this, to be certain that the specificawhich are focused on quality. The standards improvement initiative, which starttions for these measures are identical between it and the government. ed several years ago, was designed to review all of our requirements, to sharpen, “The Joint Commission created the program, got the experts around the clarify and remove ambiguity from the language, to make sure that the standards table, did the evidence summaries, got them to agree on precise specifications with were specific to the different programs – ambulatory care, behavior health progreat fidelity to the clinical integrity of the measures,” he explains. “The clinicians gram, home care – and make sure that we got rid of anything that was redundant were all on board. The Joint Commission created the data collection infrastrucor nonessential. ture to allow the data to be collected across the country in exactly the same way, “That phase of our improvement initiative is coming to an end now with the with high levels of data quality, completeness and accuracy, by creating a network second group of programs that are going into effect this year, but we’re not stopof vendors that have to pass very rigorous tests that we administer. Every hospiping there. Now we’re starting another round of improvement that will focus on tal knows that the data in California are collected the same way as in New York, understanding exactly what the evidence is behind our requirements, and makIllinois or Texas.” ing sure that we have the highest possible confidence, whether it’s really good evChassin notes that it was this infrastructure that allowed Medicare to ask for idence like the prophylactic antibiotics, preventing surgical site infection, or a very the same data, which is now collected the same way for Medicare’s accreditation strong rationale to have a good maintenance program for machinery like cardiac purposes, with the same vendors; with the hospital’s agreement the vendor sends defibrillators, to make sure the battery is there when you need it. the same data to two different places. The Joint Commission works to maintain “The highest confidence results when we ask organizations to do the work that data collection infrastructure capacity by ensuring that the specifications are of complying with National Patient Safety Goals, standards and performance exactly the same. measures. Health outcomes for patients will improve directly as a result of that He notes that this is not easy – data changes over time, and so does the sciwork. Now we are engaged in that aspect of improving our standards and survey ence; for example, the information about who is an appropriate candidate for a process,” concludes Chassin. beta blocker ace inhibitor and what is the appropriate antibiotic for preventing inMark Chassin is President of The Joint Commission.
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s n o s s e L learned Cleveland Clinic’s Steve Gordon discusses the paradigm shift in infection control and patient safety, and why the current pandemic provides opportunities for the future.
nfection control is not viewed simply as a challenge at Cleveland Clinic, but also as an opportunity to become more focused on being patient-centric. With the colder months fast approaching, worries about H1N1 are increasing. Steve Gordon, Chairman of Infectious Diseases at the clinic, describes the flu season as analogous to predicting the weather, as well as reiterating the uncertainty of the outcome. However, the subject of swine flu is not completely ambiguous: we have been in a pandemic state for months. “The unusual situation about this season is that we’re entering it when we’re already in the midst of a pandemic, meaning there’s widespread transmission of H1N1 across communities worldwide. It has been estimated that there’s probably been a million cases of H1N1 in the United States alone,” he adds. “Most people don’t need to be tested or treated or seen, and it looks like it’s been at least a relatively mild virus from that. That’s not to say that people haven’t had severe illness, but it’s mostly been relatively mild. We monitor our free testing, but the biggest threat for us in a hospital would be having some-
one come in with unrecognized influenza, or healthcare workers working with unrecognized influenza.” Cleveland Clinic has launched a campaign to prevent both seasonal flu and H1N1, and Gordon explains that the leadership of the clinic has been key in supporting these efforts. The flu cart has just begun its seasonal vaccines, with between six and eight thousand employees receiving their vaccines within the first week, a much higher figure than in the past. Combining the seasonal vaccines with those of H1N1, will be a challenge – never before has the clinic had to give two vaccines in a season. Gordon notes that the vaccine is likely to be received soon, and is then to be distributed to the healthcare workers and high-risk patients. The Healthcare Education Industry Partnership (HEIP), the advisory group to the CDC, has identified five high-risk groups that they’ve targeted, based upon the initial epidemiology from H1N1 and which encompass approximately 159 million Americans. One of the groups incorporated within this is healthcare workers, another being pregnant women, as well as children
Gordon ED:26 June
ventive health every season, not just this season,” Gordon explains. “We like to think that there is infection control behind every patient contact, even if it’s not seen. “Hand hygiene should be up in the front, but, in terms of sterilization disinfection, practice is about Foley catheter avoidance. For every kind of infection there is control; sometimes it is up front in your face in every patient contact, and sometimes not, and we think that’s important.
“We’re hoping that the H1N1 pandemic will get people thinking about prevention”
and young people between the ages of six and 24. It also includes adults below the age of 55 suffering from a chronic medical condition that is likely to put them at a high risk of complications, as well as anyone who is taking care of a child six months old or younger. “The good news is in terms of supplies: it looks like one dose of H1N1 appears to be sufficient for healthy adults, meaning that it is unlikely we will have to give a two shot administration protocol, which will then expend the availability of vaccine,” says Gordon. Depending on supply, the targeted groups are to receive the vaccines first. He explains that there is a plentiful amount of vaccines for seasonal influenza, and the clinic’s current emphasis is to provide this shot, and produce H1N1 vaccines in a second round when they become available. There are between 79 and 90 million doses of influenza vaccine each season, despite the fact that on paper 172 million Americans are targeted for seasonal influenza vaccine. “We’re hoping that the H1N1 pandemic will get people thinking about prevention and looking to try to make seasonal vaccination a part of their pre-
“Some of the other issues, have been in gram negative bacteria, in what we’d say are the multi-germ organisms, and for some of these things we don’t have great antimicrobial therapy. Most of these are healthcare-associated type of situations, not out in the community. Staphylococcus aureus is obviously one of those things, the acquired MRSA that most people are familiar with. The other issue is that of Clostridium difficile and that the association with antimicrobial use has spread. That is also high up on the list of infection control practitioners’ concerns and challenges.” The infections themselves are only one side of the coin, the other being patient safety and outcomes. “Whether we’re talking about healthcare-associated infections, falls, medication errors or patients who have had infections, the big paradigm shift, and it’s something our leadership has embraced, is developing this culture of safety from the top radiating down, so from Toby Cosgrove, the CEO, to Mark Harris in operations to Mike Henderson in the Quality and Patient Safety Institute is now embedded as a part of every activity that we do,” explains Gordon. He notes hand hygiene as an example of this; not being the responsibility of the infection control practitioner but of every healthcare provider – a move reasserting the patient as the centre of clinical operations. “The other side of that story is that not every death or adverse outcome is preventable. The focus is that many of these are, and that we should be looking at improving this. And then the third focus, is that we are talking primarily about bad systems, not bad people. “So, for instance, it might be through the nurse that the wrong clinical dose was given, but instead of blaming the nurse, there is usually a systems issue behind that. And our focus is to try to engineer good systems in place to reduce the risk of adverse events occurring at the bedside,” he explains. Gordon notes the retaining importance of compliance and the nature of looking at the root cause, and not just in adverse events. Pointing to the Institute of Medicine report in 1987 and the issue highlighted within it regarding medication errors due to illegible handwriting, he notes the opportunity for a translation error when dispensing the prescription. The
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introduction of an order entry system would not necessarily eliminate all the problems, but would be sure to attack and safeguard against a lot of them. Cleveland Clinic embraced this, investing in computer physician order entry (CPOE) technology, ensuring that now every order is done with fingerprint assurance for the medication, and providing the details of who wrote the order. This does not guarantee that the right medication will be given, but it makes the chances of error slimmer regarding dosage and allows parameters for a much safer system of ordering and administering medications, as well as lab tests. Gordon also notes the important role of compliance in ensuring patient safety. “If someone is in isolation for whatever disease that they may have or we’re trying to rule out, it’s knowing if the health workers going into the room of that patient should be wearing a gown or things of that nature. Again, using an electronic information collector is important – having our infection control practitioners actually put electronic notes in the chart so that if there are questions, people know whom to ask, where it’s referenced in terms of why they’re in that, and, also, of course, having the carts outside so that the appropriate protective equipment is there. Gordon notes that the best patient is the most educated patient; being asked about hand washing is not taken as an insult by the physicians, but encouraged. “Hand hygiene is still the best thing one can do in terms of prevention of transmission of many types of infections in and out of the hospital. Again, you do it because it’s the right thing to do for patient safety; encouraging patients and their families to check that you are washing your hands, to be able to go ahead and ask me and I won’t feel bad about that. We’d rather have that opportunity executed as opposed to not executed.”
Specialized control Although it is a tertiary care center, Cleveland Clinic has specialized in infection control. Gordon explains that the reason for this is for better efficiency, as well as the desire to create more knowledgeable care. “It became clear to us that with the growth and explosion of transplant infection control, of HIV and other sub-specialties, it’s very difficult for one person to keep up to speed on all of that. Now I have colleagues that can. It’s based on the concept of diseasebased care, and this is becoming quite prevalent in the economy.
“There has never been a better time to be involved in healthcare” Steve Gordon “An economist from Virginia recently talked of the different outcomes and what it really means. For instance, in transplant solid organism disease or bone marrow, we have aligned our groups so we have people who have a big interest in that, and for some it’s all they do. They’re able to partner up with colleagues in other specialty care that are delivering that. It becomes a very team-based approach of putting the patient in front, and there are colleagues
Gordon ED:26 June
that are really interested in this and are up to speed in the latest developments as opposed to having a general person who may or may not know a lot about one transplant patient, or allogeneic bone marrow transplantation and the complications. “We have eight services, and I could put nine services on at any one time, including a bone marrow transplant ID service and a solid organ transplant infection disease service. We have a bone and joint infection service, a cardiac device and endocarditis service, and an intensive card ID service. All of this, again, is centered on the disease-based model of developing expertise and so we can hopefully put the patient first and promote communication amongst other colleagues in other multidisciplinary areas that are actually providing care. This helps in terms of patient care and education, as well as hopefully designing studies to look at the pain points in delivering clinical care in each of these different areas,” says Gordon. The clinic also operates an infectious disease fellowship program – part of its mission is education. “Many of us are getting a little long in the tooth and we want to make sure that the people taking care of us are also well trained,’ he laughs. “It’s a legacy issue, too.” The clinic currently offers a two-year program with three fellows and adds a special third year, which includes a microbiology degree for those wanting to pursue that area. Starting next July, it will also have a special transplant infectious disease fellowship. “The purpose of the fellowship is research, education, training and clinical practice, and we believe it makes us better as well to have younger people question what we do. It allows us to provide education, and hopefully to train the future leaders and practitioners of infectious disease,” he explains. When asked about the future of infectious diseases and the possibility of more pandemics, Gordon is confident that a change of the current system will create a much more efficient system. From a global public health perspective, as well as what we do, there are going to be great opportunities. Developing more vaccines for preventable illness, developing hopefully a universal flu shot, or the Holy Grail of an HIV vaccine, or other vaccines for Hepatitis C. “Diagnostics will improve in the whole concept of pharmacogenetics, whereby we’ll be able to potentially predict who might be at risk for certain severe diseases or infections, and also who might respond better to treatments, similar to what you’re seeing in cancer. What type of tumors will respond to this therapy or that therapy? “We review global health as a responsibility of infectious disease, and much of that has to do with poverty and education. Elimination of warfare is important – situations where disease could spread. We have disease hunters; there’s a lot of disease that exists that we probably still don’t know the cause for. There’s a huge area of looking for the next new emerging disease or potentially discovering illnesses that may be caused by infections, but we don’t have the pathogen for. “The future is going to be extremely exciting. And on the other side of that are immune-based therapies that we give patients for rheumatologic conditions, or cancer conditions, which will always affect the immune system, and then also lead to a potential increase in infections. We’d like to try to prevent those,” adds Gordon.
A mission to heal Steve Gordon on the goals of the Department of Infectious Diseases, Cleveland Clinic: “The primary mission in our department is to provide the most technologically advanced, compassionate medical care for our patients. We are committed to a ‘patients first’ orientation and maintaining our wellrecognized excellence in patient care and medical education. In addition, we want to capture the synergies of existing and emerging opportunities in the areas of clinical research and outcomes research to take advantage of the breadth of our clinical volume. “We are aligning resources to establish new programs in the areas of transplant infectious diseases, cardiothoracic infections, HIV/AIDS, healthcare epidemiology and prevention of healthcare-associated infections, and the development and evaluation of innovative infectious disease diagnostics by partnering with colleagues from within and outside the institution. “In addition to our general infectious disease clinics, HIV/AIDS clinics, and international travel health clinics, we offer the following additional sub-specialty clinics: transplant infectious disease, infective endocarditis, and infectious Granuloma. Initiatives for 2008 will focus on taking advantage of the CCF electronic health record and the internet to improve productivity and service in taking care of our patients. “Our department uses ‘My Chart’, allowing patients to access portions of their clinical record via the internet. We will continue to enhance our website to facilitate dissemination of information and the access for referrals and appointments by clinicians and patients. We are viewing these challenges as opportunities for the continuing pursuit of excellence.”
Rather than hide from challenges during such a time as this, Cleveland Clinic is not only working its hardest to remain patient-centric in its approach, but is enthusiastic about the developments that will result from the H1N1 pandemic. As Gordon concludes, “There has never been a better time to be involved in healthcare.” . Steve Gordon is Chairman of the Department of Infectious Diseases at Cleveland Clinic
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Helping hands EHM’s Stacey Sheppard talks to Elaine Larson about the handwashing research aimed at reducing the H1N1 virus’ capacity to spread and limiting the rate of infection.
he H1N1 virus may not be featuring so prominently in the international news at the moment, but the maximum classification of phase 6, which the World Health Organization designates as a pandemic, remains in place. With the main winter flu season rapidly approaching in many parts of the world, attention has now turned to how future outbreaks can be prevented and the effects mitigated. Elaine Larson is Professor of Epidemiology and Director at the Center for Interdisciplinary Research on Antimicrobial Resistance at the Mailman School of Public Health, Columbia University. Her work currently focuses on determining the lifespan of the H1N1 virus. “Believe it or not, nobody actually knows how long this virus lives on your hands or in the environment,” says Larson. “We are conducting a study right now whereby we go into the homes of people who have the flu and
get them to cough into their hands, and then we culture their hands every five minutes for 30 minutes. We’re getting them to cough into a handkerchief, which we culture as well. We’re also asking them to cough into their hand and touch some of the objects they regularly come into contact with, such as cell phones and pillows.” Through this study, Larson is hoping to shed some light on how H1N1 is spreading in real life situations. She explains that there is already a lot of literature on the topic, but most of the other studies have been done under test conditions where the infection is not natural. People are given the virus and then tested, whereas Larson is recruiting people who are genuinely suffering from the flu. She wants to be able to assess the risks involved for people living in a household where someone is already infected. The main problem Larson is facing with regards to her study is a current lack of participants. “We’d like to finish the study as soon as possible but we need to find more people who are sick,” she says. We’re trying to spread the word and get people to call us if they have flu-like symptoms, a fever and chills.” The initial phase of Larson’s study coincided with extremely reduced numbers of H1N1 cases in hospital
“Wash your hands as much as possible to avoid the potential of further spreading the infection”
emergency rooms in comparison with the figures from last spring, and she believes this can be explained by immunity. “It appears that in the places that were hit hard in the spring, like New York City, we are not seeing it so much now. So, obviously there are some people who got it in the spring who are now immune,” she explains. In this case, people who have already fallen victim to H1N1 may not be infected a second time around. “Even if it mutates it’s extremely likely that there will be a lot of residual immunity. I think that in some ways those people who got it in spring are probably lucky.” At least for those people who may be infected this winter a vaccine is on its way, but this will only help if received in sufficient time before infection takes hold. “It’s terrific that the H1N1 vaccine is going to be available soon. But it takes about two weeks between the time you get the vaccine and your body developing enough antibodies. So if you got the vaccine and then got the flu the next day, you wouldn’t have much protection at all. That’s why it’s important to get the vaccine out before people start getting sick,“ explains Larson. In the meantime, the main piece of advice that Larson can offer is to wash your hands as much as possible to avoid the potential of further spreading the infection. But then the question arises as to what is the most effective means of washing your hands, and this is another area that Larson is investigating. “We’re looking at the impact of different hand hygiene soaps. If we can determine whether sanitizers or plain soap and water is better, then we’ll know what to recommend that people to use,” she says.
By gaining a better understanding of the virus, Larson hopes to be able to educate people as to what they need to clean in their homes and also who should be wearing masks and for how long. Unfortunately, too many questions remain unanswered for her liking and the recommendations that are coming from New York City and the Centers for Disease Control and Prevention (CDC) are different. “For healthcare workers, the CDC is recommending N95 masks, which have a lot more filtration, and New York City is recommending just the regular surgical mask. But for the general population any regular mask will do. There was a paper published in the Journal of the American Medical Association in October that showed that the two types of mask are equivalent in terms of protection,” says Larson. Larson’s work in the area of hand hygiene also extends to the recently published WHO hand hygiene guidelines. “This has been tested now in 81 countries around the world and we were involved in some of the testing to make sure that it is practical. It’s one thing to recommend what needs to be done in this country, but we have major resources compared to other countries,” she says. Larson has also worked on a number of smaller projects related to the meaning of hand hygiene in various religious groups and points out that the issues affecting Islamic cultures, for example, are somewhat different from those affecting other cultures. “In Islam it is against many fundamentalist Muslims to even touch alcohol – it’s a sin. There’s are lots of things that you don’t consider until you start talking with people around the world Muslims,” she says.
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Drs Solutions ed:16 nov
Streamlining the prevention of hospital-acquired infections James Hosler discusses the huge threat that hospital-acquired infections pose to the healthcare industry. Where do hospitals currently stand in their fight against hospital-acquired infections? James Hosler. Unfortunately, most hospitals are in an extremely weak and vulnerable position. Bacteria such as MRSA and C.diff have grown stronger, while hand washing technologies have not. The industry is facing increasing infection rates, poor scores on JCAHO scorecards, and the financial burden of paying for treatment of infections acquired by patients while under their care. That’s why it’s imperative for hospitals to innovate and reduce the risk of HAIs. Do you see any solutions that would help protect hospitals from these costly threats to their business? JH. Yes, our belief is that innovations in hand washing protocols and products are key to a hospital’s financial success and ultimate survival. Hospitals must recognize the need to innovate and fight HAIs differently, because current protocols are no longer effective and in reality, haven’t been for quite some time. It’s this reality that led us to develop our new Microdine Hand Scrub product. It’s an innovation based on a very crucial need recognized years ago by the renowned Nobel Laureate Dr. Joshua Lederberg, who correctly identified the need to address alcohol’s ineffectiveness to control HAIs and improve handwashing compliance. His suggestions inspired us to pursue paths that led to remarkable innovations in antiseptics. Both hand washing products and protocols need improvement. Alcohol is effective at killing some germs, but not all. For example, certain C.diff spores are frequently resistant to destruction by alcohol. Furthermore, alcohol-based antiseptics routinely damage skin when used repetitively. This has the undesirable effect of reducing compliance. By comparison, Microdine Hand Scrub kills 99.99 percent of germs, including MRSA and C.diff spores, and persists with antimicrobial activity for six hours, yet remains gentle to the skin. Because it contains an active skin protectant (0.5 percent Allantoin), it actually promotes healthy skin growth. It is important that we institute a protocol that addresses the full threat that HAIs represent. If we can introduce a Category I hand antiseptic that provides a persistence effect and combine that with the current hand washing procedures, we can decrease the incidence of HAIs while increasing compliance.
Has Microdine satisfied the FDA Tentative Final Monograph for effectiveness testing of a surgical hand scrub? JH. Yes. BioScience Labs independently tested and verified that Microdine successfully meets the requirements of that FDA monograph; the test results and final report can be viewed on the website. Microdine uses our patented Nouristrat system to electrostatically bond a long-lasting protective layer to the surface of the skin. It kills germs in compliance with the FDA’s highest standards, which require Category I antiseptics to be fast acting, broad spectrum and inhibit bacterial growth for six hours. At the same time, it helps prevent cracked skin and promotes the growth of healthy skin. We like to think of it as a ‘win-
“It is important that we institute a protocol that addresses the full threat that HAIs represent” James Hosler
win-win’, because Microdine literally offers it all – persistent germ control, healthier skin and improved daily compliance. It’s the Holy Grail of hand washing protocol – a product whose time has come. As healthcare providers, we all share a common mission to address the growing threat of HAIs.Our vision at DRSS Global is to change the way the world protects itself from contamination by bacteria, viruses and other germs. We believe our products make a meaningful contribution to this mission. For more information please visit www.microdine.com James Hosler graduated from the University of Michigan Medical School and engaged in private practice of GI medicine from July 1979 to October 2008 in the Dallas-Fort Worth area. He was a member of his hospital’s Board of Directors from 1987-93, and is a Fellow of the American College of Physicians.
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Pathogen control Michael Beach of the CDC examines the various faces of waterborne pathogens and the need for stricter regulation and greater awareness. 56 www.executivehm.com
n light of the current H1N1 pandemic and the ever-increasing public concern over HAIs, waterborne pathogens was traditionally an area often overlooked, surprisingly more so in Western societies than would be expected. Michael Beach, a CDC specialist in waterborne pathogens, defines the illnesses as “those that are spread by having contact with, ingesting, breathing aerosols from substances contaminated by water from either a chlorinated type of aquatic venue, freshwater lakes and rivers, or the oceans.” The most common recreational water illness pathogen that is reported to the CDC is Cryptosporidium in its various species – it is currently the major cause of diarrheal illness related to recreational water – and is reported to be an even larger player in treated aquatic illnesses. “It’s a chlorine-resistant parasite and so it bypasses the major barrier that’s in effect in our home and public pools because it’s resistant to chlorine,” explains Beach.
Recreational illnesses The number of outbreaks in disinfected venues in the US, caused by Cryptosporidium, has risen by 70 percent in recent years. As a developed country operating a vast number of swimming pools, the US sees a minimum of 360 million visits to recreational waters a year in the US. Beach adds that the statistic of recorded visits is much lower than the number of actual visits.
“Good hygiene, good health practices and understanding that chlorine doesn’t kill everything instantly is paramount” “Cryptosporidium is chlorine resistant,” he explains. “We’re advocating for the expansion of the paradigm of pool water treatment. For decades we’ve relied solely on fi ltration and chlorination, now we need to move towards supplementary disinfection as well. UV light and ozone can inactivate the Cryptosporidium quite well, and so we’d like to see those added routinely as part of swimming pool construction. “A bank of UV lights go in usually after the fi lter system irradiates the water going through it, and so it’s a flow-dependent technology – you’ve got to pass all the water out in the pool back through this. It’s not an instantaneous disinfection system such as chlorination, instantaneous meaning that there’s chlorine throughout the entire water. With UV you do have to rely on how long it takes to circulate all that water back through the system, which is why it can only be a supplementary disinfection system because it doesn’t leave a residual in the water that would keep on disinfecting.” Beach explains that the data for knowing how many pools are currently operating this system across the US is poor. However, the CDC is
able to judge the incorporation of this via the sales of the units. There has been a recent surge in the sale of units and the number of them being installed, although the exact number, again, is vague. The CDC is advocating the installation of these units to be compulsory and built into pool codes. He notes the progression of New York State – following the outbreak at Sprayground, a recreational area, this has now been written into their regulations for splash parks. Currently in the US there are no federal regulations; swimming pools are regulated at the state or local government level, and that is where the CDC is aiming to begin driving its enforcement protocols. Waterborne diseases, after a long period of being overlooked, are beginning to receive recognition, from both the state and America’s public. Beach notes that despite seeing cuts in many areas of healthcare, research into waterborne pathogens has not suffered. “People are starting to recognize that this is a poorly understood, under-recognized area that is actually bigger than we think it is, at least in the United States,” says Beach “Regulation at the state and local level means you can walk from one state to another and see dramatic differences in how pools are maintained and operated under a pool code. The CDC being a non-regulatory function, we’re trying to develop a national consortium and a model code at the national level with local and state partners. It doesn’t have regulatory authority because there is no such authority, but it’s a model that’s data-based, knowledge-driven and can change over time with new data that becomes available. “That will then allow state and local health departments to look at that, pull what they want and then put that into pool code, rather than the current system of every group sitting down and reinventing the wheel every time. We’d like to see that a code is data-driven. Some things may make good sense, but over time we’d also like to have the data behind them. If there’s a model there that’s renewed and updated on a regular basis with new data-based recommendations, that’s what the state and local health departments need so that they don’t have to go in and redo this themselves alone. They can become part of a national consortium to do that.”
Hospital-based infections Recreational pools are not the only arena in which waterborne pathogens are present. Beach argues that again, this is an area in which better documentation is needed. The state is heavily focusing on reducing the number of hospital-acquired infections, but water can impact a hospital setting in a variety of ways: this may be through direct contact, or via hydrotherapy tanks in pools that can spread many of the same diseases that are present in a recreational water setting. Also, if drinking water is contaminated, ingestion can produce disease. It is essential for medical equipment to be cleaned and sterilized but waterborne diseases may threaten this in the form of biofi lms. Beach explains that biofi lms are a complex microbial population that live in the slime layer on surfaces with water running over them. Biofi lms are likely to harbor many organisms, including pathogens, which they tend to protect from disinfection, and so currently there is much analysis
being done to understand more as to what a biofi lm community is. “If you put your hand inside just about anything where you’ve got water – the scum on your teeth, the dog’s dish – all of that’s a biofi lm which is a microbial community, and so that’s an area which is being explored more,” explains Beach. “Clearly, what we see is an inhalation of aerosols from showerheads and cooling towers and other sorts of things that can contain pathogens
“We’re trying to develop a national consortium and a model code at the national level with local and state partners” such as Legionella or Mycobacterium avium complex. Dialysis machines and biofi lms can be impacted by water quality and contamination. The major issue is that a hospital essentially houses a very sentinel population that is more likely to have severe illness and more prone to becoming infected when they become infected with some of these pathogens, so you tend to pick it up more readily in such a setting. “They could be wound infections, GI illnesses, respiratory infections and so on, so we routinely document Legionnaire’s disease outbreaks in healthcare facilities. Part of that is due to vulnerable populations of elderly and weakened immune system – the sorts of individuals where you’re likely to have a severe pneumonia, which has a mortality rate associated with it as well. These are currently really big issues in the US; how do you control biofilms and Legionella levels that can be spread through an entire building or hospital via water distribution system? You can cover the gamut of disease from respiratory, contact, GI illness, wounds and so on, depending on how that potentially contaminated water is entering the body. “It’s a whole universe of exposures that can potentially occur, as they do in many other places. Premise plumbing is certainly an issue from the water-borne disease standpoint, and that could be the plumbing inside a hospital just as well as it can be the plumbing within a building.”
Awareness Awareness of hygiene and infection control is increasing, from drinking water facilities to hospitals to recreational water facilities. There is still huge room for improvement, explains Beach; especially in educating the American public that waterborne does not necessarily mean just drinking water. Over the past five years, the CDC has been collecting more data, trying to improve surveillance and tracking outbreaks. Although drinking water outbreaks have declined over the decades within the US, recreational water outbreaks have been doing the reverse. “In the developed world we don’t see typhoid and cholera anymore, many of those diseases have disappeared, what we see now are pathogens that are exploiting manmade habitats, like Mycobacterium and Legionella. We see chemicals in other personal care products, in water, disinfection byproducts, breakdowns in premise plumbing and other systems that lead to outbreaks. It’s a different model of waterborne disease – it’s not that it’s gone, it’s just taken on a different face. We have to educate all risk reduction specialists in the complexity of different things that occur here, and so
we tend to do a lot of focus out at the local level on food-borne disease. “We need to integrate waterborne disease prevention into their thinking at the same time because many of the same pathogens are transmitted by both food and water and we want people to understand that it’s not just about enteric GI illness here. It’s about respiratory pathogens, neurologic pathogens, wound infections, respiratory and so on. In a recreational setting we need to think about the human body, that you’re putting this human body with many openings into a potentially contaminated water allowing pathogens to enter from any orifice, and so let’s think about how we protect people and protect the water. Clearly much of this is also about behavioral issues: we are not practicing good common sense hygiene practices when we go to the pool.” Beach compares our recreational water habits to the Europen term bathing, believing this to be a view that Americans should learn to adopt.
Sprayground shut down The New York State Health Department shut down Sprayground, a recreational water area, on August 15, 2005 following information that the water holding tanks, which were used to recycle water, were contaminated with Cryptosporidium. 415 cases were conﬁrmed to be the effect of the pathogen, with 33 of those being hospitalized. The plaintiffs alleged the State of New York was negligent and therefore responsible for the illnesses.
He adds that showering is often done when people get out of the pool, not before, which is vital for practicing good hygenie. He also notes the necessity in not taking a child sick with diarrhea to the pool, which although sounds like common sense, the amount of parents that do this is the cause of the outbreaks continuously seen when analyzing contaminated water. “Good hygiene, good health practices and understanding that chlorine doesn’t kill everything instantly is paramount to us combating this,” he says. “It has to be multi-factorial, we cannot do this without the public becoming more aware and starting to change practices. Part of this is about operation, as well as behavior. We also want to see consumers demanding good operation of public pools, there is no reason that you walk up to a pool and it’s not operated properly,” concludes Beach. Waterborne pathogens are as much the responsibility of local health departments as they are that of the American public. As Beach notes, there is still a long way to go in improving the rate of infections, but until they become a thing of the past the CDC continues to raise awareness. Michael Beach is a specialist at the CDC in recreational waterborne illnesses.
Guardian Silver ed:26 June
Trading art for health Brian Carpenter of Muvezi Health Projects Society explains the importance of silver sol in treating life-threatening infections in Africa. Please tell us about Muvezi Health Projects Society’s ‘Africa helping Africa’ concept. Brian Carpenter. The facilitation of trading Shona stone sculptures for health has created a financially self-sustaining charity. Following a series of coincidences about three years ago, I flew to meet Doug Dicker in Zimbabwe and, to make a long story short, Muvezi has bought approximately 3000 sculptures, created a renaissance of African Shona art and sustained about 2000 Africans financially every month for three years (a charity in its own right). Muvezi Inc. was formed with my co-founder Greg Pendura to provide a steady stream of income to the charity, with 20 percent of the sales proceeds of every sculpture sold going to MHPS. Our Shona art can be viewed at www.muvezi.com. We sell sculptures from galleries in Canada, Mexico and through eCommerce. Importantly, MHPS’s expenses are essentially zero, since Muvezi Inc. supplies offices, management and so on at no cost. How does the health part of the trade work? BC. For over 20 years, I have managed a large healing center using only natural healing laws and natural products. Over the last several years I have provided Guardian Silver Sol to thousands of clients with just about every infectious condition possible. The results, without exaggeration, have been miraculous.
Dr. Brian Carpenter with children in Zimbabwe
MHPS will have sent silver sol to Zimbabwe, Senegal, Sierra Leone, Mexico, Nepal and more before the year’s end. Our charity efforts are also expanding, largely due to the broad spectrum antimicrobial results of silver sol, and our business model for the charity now includes marketing silver sol worldwide through eCommerce. Silver sol is now shipped all over the world. For every 10 bottles sold, two are supplied to charities free of charge. It is our passion for it to result in a very large charity. Rather than getting bogged down with
“People traveling to countries with prevalent malaria, hepatitis and TB shouldn’t leave home without silver sol” Since silver sol has cleared the malaria plasmodium from the bloodstream in five days in clinical trials and malaria kills a child every 30 seconds, MHPS had a perfect way to make a specific difference through our African connections. Malaria was our original focus, since results are fast, compliance problems are minimal and verification of the effectiveness of the treatment is easily tested.
building a distribution infrastructure, MHPS simply supplies pre-existing charities with this miraculous antimicrobial, allowing our mission to grow quickly and with almost no costs. Volunteers and charity workers traveling to countries with prevalent malaria, hepatitis, TB and so on shouldn’t leave home without silver sol for personal protection against infection.
Further, why would any corporation have their executives or employees leave home without silver sol? Many corporations also have their own charities, so there is a perfect fit. How does another charity or corporation partner with Muvezi? BC.With the huge advantages of the internet, they simply start by trying the silver sol. Quickly they will start to trust the many antimicrobial, and sometimes life-saving, benefits. From there, they can contact us directly via the website to allow the benefits of resulting purchases to flow directly to their charity of choice. We need many leaders to join us. All readers of this interview have an invitation to help their families and friends fight infections with silver sol while also helping impoverished people around the world through a charity of their choice.
For more information, please visit www.muvezi.org Brian Carpenter is Managing Director of Muvezi Health Projects Society. In addition to managing a healing center in Edmonton, Alberta, Carpenter is especially passionate about sharing the health beneﬁts of silver sol with as many partner charities as possible.
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BEYOND THE LAB: CLINICAL APPLICATION • Leaders are already using silver sol clinically with outstanding results • Internal and topical application permit use on a broad range of infectious conditions • A video discussing 2 years’ clinical use with Dr. Cynthia Eaton is available here: www.SilverSolHealth.com • Silver sol clinical applications include a wide variety of infections • YOU are invited to investigate silver sol further at www.SilverSolHealth.com
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VISIT WWW.SILVERSOLHEALTH.COM GUARDIAN SILVER_3RD.indd 63
Gearing up for battle Novartis Vaccines’ Andrin Oswald tells EHM how the company is preparing for the next wave of H1N1 mutations, and why a new manufacturing process is needed to provide faster vaccinations.
s the winter months draw near and seasonal influenza begins to dominate headlines, Novartis Vaccines began the process of shipping its vaccine to US healthcare facilities several weeks ahead of schedule. Andrin Oswald, CEO of Novartis Vaccines, explains the company’s desire to provide the opportunity for early vaccination. “Since we did not know whether healthcare officials would want to vaccinate seasonal and H1N1 together or separately, it was clear to us that if we ship seasonal quickly, we could get this one out of the way before the H1N1 vaccination would have to start,” he explains. Novartis provides approximately 30 million doses to the US each year, and intends to provide the same amount as last year. “When we started H1N1 vaccine production, we decided that since we didn’t know exactly how the pandemic would play out, it would be responsible to produce the same amount as was needed last year. That’s what we did, and then we switched to H1N1.” Providing a H1N1 vaccine was always going to be essential, but it was still uncertain whether this would be combined with a seasonal vaccine or if it was to be given separately with a three-week interval. Oswald explains that the ambiguity surrounding the H1N1 vaccine has brought forward seasonal vaccines. “Once the H1N1 vaccine becomes available in October, you don’t want to have to wait another three weeks because you’re still vaccinating seasonal. So in principle, seasonal now could be vaccinated ahead of H1N1, and when H1N1 becomes available, we could immediately start that program as well.”
Novartis’ clinical trial for the vaccine began in July, and since then, Oswald explains, the fi rst set of data has become available, which was published in the New England Journal of Medicine in September. He notes that the fi rst data from other clinical trials is also now available, and although they have not yet been published, they have been communicated to the respective health authorities in order for them to make the appropriate decision
“It is very likely that we will see different mutations in H1N1 in different parts of the world” Pandemic preparation The vaccine was created at a fairly rapid pace, thanks to a system that already exists to prepare for a pandemic as much as possible. Oswald notes that in Europe the company has a pandemic vaccine already fi led and approved under a mock-up fi le, so in principle when a new virus comes available, the fi le can be approved immediately once the pandemic is declared. “We also have technologies that allow us to operate as quickly as possible, in particular in our cell-based manufacturing system, by which one could gain a couple of weeks of speed over the traditional
Cell culture manufacturing Novartis Vaccines is currently the only company that has a licensed cell culture-based technology to produce inﬂuenza vaccine antigen. Since many viral strains cannot replicate in chicken eggs, cultivating viruses using a cell line offers the possibility of a more robust virus production and seed strain development that more closely matches circulating viruses, which could potentially translate into a more immunogenic and effective response. The use of cell-based manufacturing enabled Novartis to cut weeks off the time required to begin H1N1 vaccine production. First results achieved with the A(H1N1) wildtype strain show the signiﬁcant time savings of cell-based production over the traditional egg-based manufacturing approach, conﬁrming the value of cell-based production in pandemic situations.
egg-based manufacturing and by that make a new vaccine available somewhat earlier. In the case of a severe pandemic, a few weeks can make a big difference,” says Oswald. Novartis Vaccine’s proprietary adjuvant, MF59, also plays a role in pandemic preparedness. MF59 is the fi rst oil-in-water influenza vaccine adjuvant to be approved for use and commercialized in combination with a seasonal influenza virus vaccine. It works in two ways: by recruiting immune cells to the injection site, which increases the immune response to the vaccine; and by promoting the uptake of anti-
gen into the relevant immune cells, thus boosting the immune response to the vaccine “It boosts immune response,” says Oswald. “You can produce more because normally the antigen production is the limiting factor for the volume we can produce, and with the adjuvant you can probably stretch that by a factor of four. It also helps to boost supply, but that’s not the only reason we use the adjuvant. We also use it because it allows for better crossprotection, especially in a situation where one doesn’t know when and how the virus will mutate. Having an immune response that gives you some protection even against mutated forms of the virus is very valuable. “For flu vaccines some adjuvants – such as aluminum – don’t work well, so there was a need for a new adjuvant; this new class of adjuvants, called squalene-based adjuvants, are very effective. Our adjuvant has been on the market in Europe for 12 years with more than 45 million people vaccinated, so we have by far the longest safety history and from that point of view can clearly say that the adjuvant is unique,” he underlines. Novartis’ work in vaccine development has certainly not gone unnoticed. The company has been awarded two contracts by the US government for the future purchase of H1N1 bulk vaccines and is expecting several other orders to follow. Oswald explains that in September, the company is already sold out beyond the end of 2009. “We are not giving the exact data on the specific orders because we leave it up to the respective governments to be in charge of communication, but we expect that we can produce by the end of the year 80 to 100 million doses, and for the time being we have more demand than we can deliver.”
so there is a significant window until a new tailored vaccine then becomes available. It is also very likely that we will see different mutations in different parts of the world; we see that with seasonal flu as well. There may be in the US one mutant that will start to spread and a different one in Europe and a third one somewhere in South America, and given that we cannot develop tailored vaccines for each of these regions, the adjuvant allows you to give some broader protection.
“We would have to cut out some of the hurdles if a pandemic were to be severe”
“We are now responding to this pandemic as well as we can, but we will have to ask ourselves the question of how do we prepare better for future pandemics? The avian flu, for example, is not completely off the table, and a more severe pandemic can definitely hit us more or less anytime. It’s not about creating panic, that’s not what we want. What we want is to make sure we’re so well-protected that there is no need to panic. “Our systems today have significant shortfalls in terms of us being able to protect the world population against a severe pandemic. We should learn from the current exercise and be able to quickly come up with as many better solutions that are needed for the future. I would love to see more of the debate shifted over towards that,” he says. Oswald suggests that prevention could be enhanced by a more efficient production capacity, noting the current pressure of shipping H1N1 mutation vaccines to developing countries. If there’s not enough capacity for the However, developing the vaccine for H1N1 is not so simple. Experts countries that have invested and built this capacity, how can we expect it have speculated that the virus is likely to mutate into a more virulent, deadly to be available for other countries that have not done so? His solution is form when the winter flu season starts, and Oswald agrees with this. “It will to build a sustainable production system that can supply the entire world, happen because flu viruses do mutate,” he explains. “We see that with the adding, “That should not happen by forcing donations in a pandemic, but seasonal flu viruses as well. They normally mutate when there is pressure it should happen so that the capacity would be available.” for them to do so, which is at the time when a fair number of the population He also argues for bigger and better investments into new technolohas already been infected; if the virus hits someone who already has some gies, again citing the shortfalls of egg-based production. “We need the protective antibodies, then it is under pressure to mutate financial incentives for companies to be attracted to survive and keep going. I would expect mutation to by that, because in the flu business with a lower happen not in the first wave but in the second wave of the demand and prices in many countries for seasonal pandemic, when maybe 20 to 30 percent of the population flu, we simply cannot afford to aggressively invest has already been infected and has some protection. into new technologies, so we have to think about “We normally see the virus drifting and making how to address it and how to create the right incensmall mutations to become more virulent to survive. tives for innovation. That doesn’t necessarily mean that the virus becomes “Finally, from a patient point of view, there are more pathogenic or more severe; that is not necessarily still too many hurdles that stop us from being really the case. It’s just different. Even if you’ve had the earlier quick. We have to think through with the different form you could get it again, and of course the people that authorities and regulators how in a real emergency didn’t have it would still get it. It wouldn’t necessarily be one could make a vaccine available in two months. more severe, but it’s a challenge to the vaccine because That’s possible, but we would have to cut out some the mutations could make the vaccine somewhat less efof the hurdles if a pandemic were to be severe,” confective. Hence, our belief that with an adjuvant one has a cludes Oswald. Andrin Oswald is CEO of Novartis Vaccines. higher chance of vaccinating with something that would With not much time left before the winter flu still protect if these small mutations actually happened. season begins, it remains to be seen how the industry “When these mutations happen we will develop a new vaccine, parwill cope with the crisis. Novartis’ preparedness to the pandemic and its ticularly addressing that mutated virus, but that takes a couple of months mutations means it is already one step ahead of the game.
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Hooper ED:26 June
READY FOR THE NEXT WAVE Steve Hooper of Massachusetts General Hospital explains how the experiences of H1N1 are shaping its preparation for the next pandemic.
Hooper ED:26 June
eptember saw an upsurge in the US in influenza activity; the data from both the CDC and Massachusetts General Hospital (MGH) has shown this. David Hooper, Chief of the Infection Control Division at MGH explains that most of these cases are attributable to the H1N1 pandemic strain, but remains unsure as to how the virus is likely to play out overall, looking at previous activity for guidelines. “We are holding from our experience in the southern hemisphere, in Australia in particular, where they’ve already had their flu season with the H1N1 virus in it,” he explains. “They saw around a fivefold increase in patients with influenza-like illness and they saw patients in their intensive care units that were quite ill with it. We have begun to see patients who were quite ill in our ICUs – relatively small numbers, three or four at this stage – but this is something that would be very unusual to see with seasonal influenza. So we anticipate on both what we heard from the southern hemisphere and what we’re beginning to see now-that this will be a very challenging flu season for us.”
H1N1 vaccine MGH is currently conducting an enormous amount of work at the hospital level, preparing for a surge of patients and being able to manage these patients in an already busy tertiary care hospital. Hooper notes that this is now taking up 70 percent of his time, focusing on these preparations and responses. “You don’t need specific antiviral medications. You need supportive care – go home and you’ll get better in a few days. However, there are certain subgroups that are more likely to get a more severe form of the disease, pregnant women being one of those groups, young children being another and patients who are unusually obese, a group that’s newly being recognized. It wasn’t something that was recognized in seasonal influenza and so we’re seeing some of those patients in our ICUs. “It’s not that H1N1 is necessarily worse but there’s just such a large population of people who are susceptible to it. Even a small proportion of people who have severe diseases can have a large impact on a hospital like ours which is a tertiary referral center. The sickest people come to us and so that’s what we’re dealing with. Hospitals have to be doing preparation work but the message to most of the public is that it is a mild disease but particularly the highrisk groups should avail themselves to vaccine as it becomes available, as well as the rest of the population, because broad vaccinations of population protects not only the individual but damps down the spread within the population, thereby reducing the number of cases both primarily and secondarily when there’s enough vaccine distribution,” says Hooper. For several weeks MGH has been receiving supplies of the vaccine, although at a very slow rate and are having to prioritize who will be first in line. The hospital is remaining optimistic that at one point they will have enough vaccines for everyone. Currently, being at the start of flu season, priority vaccinations are given to those patients with the highest risks vaccinated first – obstetrical patients, pediatric patients and then those other patients who have underlying risk factors such as chronic heart and lung conditions. This is a situation most hospital institutions are finding themselves in: no one has all the vaccine that they want and need at this stage. Hooper adds that distribution has been done on a week-by-week basis at MGH as they come in, not knowing how much they will receive.
“It’s dynamic and challenging in that context,” he explains. “Part of my time is spent with people who aren’t quite in the front part of the line wanting to know when they’re going to get their vaccine. What we thought early on was that there was going to be some concern about it being a new vaccine and its safety, but this has turned into a problem of shortage. Everyone is clamoring, which in the end, ultimately, is a good thing because getting people vaccinated is the most important public health activity.”
Infection control The media hype of H1N1 may be recent, but the challenges of infection control are not new phenomena. Hooper explains the amount of work involved in education and staffing, and despite its size it, is never as large as the hospital would like it to be. “At the hospital we are fortunate in that we have fairly good resources but we could still use more and particularly in the context of surveillance activity, which is now required to be reported to public health authorities,” he says. “We’re getting the report of particular categories of surgical site infection rates publicly. All of this we’ve done to some level internally in the past but the extra public reporting and ensuring it’s standardized across the system has added more work. It’s a good thing, ultimately, because it’s caused a greater focus of
“What has developed and will probably be even more challenging is the global spread of multiple antibiotic-resistant bacteria”
attention on infection control and that’s important. And certainly, that’s leverage for advocating more resources going forward. “For our hospital in particular, we devoted a lot of resources to improving our hand hygiene clients’ rates, and over a number of years have been able to get them to over 90 percent compliant. Healthcare workers would generally use alcohol-based hand gel or hand rub before patient contact and over 90 percent after patient contact. Temporally associated with that, we’ve seen a 2.5 percent drop in our hospital-associated MRSA infection, and we’ve sustained those levels of compliance with antigens. It’s a lot of work but it’s possible to change the culture of hospitals’ standard of care and everybody accepts it and does it with a high degree of consistency in the same way that surgeons going into the operating room would always be expected and would think it standard to do a surgical scrub before they go into the operating room.” Education of infection control has been an issue for many years, only coming to the forefront of the healthcare debate given the recent media focus. MGH has been tackling it with observations of compliance, feedback of compliance and accountability for compliance, all of which has been given a huge amount of attention from the hospital’s senior management. Hooper notes the example of a hospital in Geneva that has pioneered the use of alcohol-based gels in reducing hospital infections, having a similar experience of their MRSA infections decreasing as their compliance with antigen improved over time.
Hooper ED:26 June
“The occurrence of pandemics every few decades seems unavoidable, but heightened education of infection control can improve the outcomes” He adds that this situation is not common – global pandemics are a rarity. “We have a lot of historical data on influence and what it tells us is that the global pandemics don’t occur every few years,” says Hooper. “They occur with periodicity that’s determined by the amount of changes in the virus so that the population then no longer has immunity and the usual change from year to year are small enough that it’s not going to make the population fully susceptible or fully lacking in immunity. However every 20-to-40 years or so a big change occurs and that’s when the pandemics occur. Our last was in 1968 and so we were due, in a sense. “I don’t think they’re necessarily going to occur more frequently than that although I can’t tell you it’s going to be exactly 20 years from now. The virus decides that but that’s been a pretty steady pattern over more than a century. My guess is that’ll change. What has developed and will probably be even more challenging is some of the problems with the global spread of multiple antibiotic-resistant bacteria. That’s been documented in a number of instances and doesn’t seem to be abating. “That’s going to continue going forward, not in a cataclysmic way but in a carefully progressive way, which is going to be a challenge for all of us because in some cases, particularly for gram-negative bacteria, we see some strains causing infections that are susceptible to almost none of the currently available antibodies. We get to the situation where you’re really challenged to treat a patient who has a severe infection adequately. In some cases this is particularly typical in the hospital setting.”
Antibiotic-resistant bacteria Hooper’s principle work is that of mechanisms of resistance to a class of antibiotics named quinolones. He notes that this is conducted in two areas – gram-negative bacteria and bacterial resistance. “We’ve been particularly interested in resistance genes determinants that are on mobile genetic elements, plasmas usually, that have spread worldwide and contribute to low-level quinolone resistance amongst a range of gram-negative bacteria and promote selection of high levels of resistance.
“The main difficulty that this creates is that those genes are often on these plasmas that have other resistance genes, other determinants so that it links quinolone resistance with resistance to other antibiotics and therefore multi-drug resistance, and that’s become an increasing problem epidemiologically. We’re interested in knowing how some of the proteins encoded by these resistance genes cause resistance. We know that some of the proteins interact with the quintalone target enzymes and we’re trying to sort out exactly how they interact with those and the resistance proteins interact with those enzymes. “The other area that I look at, in terms of bacterial resistance also has to do with multi-drug resistance but by a different mechanism and it’s focused on gram-positive bacteria, particularly staphylococcus aureus, a very common human pathogen. We are trying to understand the role of multi-drug efflux pumps in resistance, which are proteins that are in the bacterial cell membrane and can remove antibiotics from the cell. Where there are more of their levels of expression they can cause more resistance and many of them are, the pumps can actually pump out a number of different types of compounds and a number of different types of antibiotics, including quinolones,” he explains. Hooper says that knowing the natural function of the normal makeup of these cells is an area of interest. Often it appears that their natural function allows the organism to survive in different environments – staph aureus is an example of this, commonly when it causes skin infections from abscesses. “We’ve looked at expression of these efflux pumps in abscesses and it turns out that in several of them their expression is increased when the bug is growing in the abscess as opposed to other growing conditions,” adds Hooper. “We found that in fact that expression gives the bug fitness to survive in the abscess environment, so this is where you have linking of a resistance mechanism with, in fact, an over-expression of a protein which also allows the organism to survive in other environments. It’s something akin to linking fitness of the organism with resistance, which potentially has concerns because the organisms use these mechanisms to cause disease and now, you’re linking a disease mechanism or cause of disease mechanism with antibiotic resistance, which is the opposite of what’s often talked about where resistance mechanisms have a cost to the bacteria and therefore, they’re less fit. This works just the other way around.” The occurrence of pandemics every few decades seems unavoidable, but heightened education of infection control can improve the outcomes. Now at the vaccination stage, there appear to be far bigger challenges ahead, with Hooper’s team already working on the challenge of antibiotic-resistant bacteria, but whether it becomes a problem as big as H1N1 remains to be seen. David Hooper is Chief of the Infection Control Division at Massachusetts General Hospital.
PFM AD.indd 71
River Diagnostics ed:26 June
ASK THE EXPERT
time and location enables early and automated detection of transmissions of microorganisms within the hospital. Until now, hospitals have had limited means to implement an active surveillance program to detect outbreaks in real-time and to determine pathways of transmission. The standard method for bacterial typing is slow, with hospitals generally having to wait anywhere from three days to as long as several weeks for results. Further, the testing is costly and labor intensive, requiring highly trained personnel and special facilities. Moreover, conclusive identification of recurrence is difficult. As a consequence, this method is generally and best limited to analysis only after an outbreak has occurred. With SpectraCell, positive culture samples from patients, staff and the hospital (hand-touch areas such as beds, doors, and faucets, diagnostic and therapeutic devices) are stored in a SpectraCell database. Information about the origin of the sample (such as time and date of sample collection, subject ID and location [object] of sample collection) is stored in the same database. SpectraCell data of new samples can then be compared to the spectra already in the database. Michael Rumbin examines solutions for HAI prevention. Criteria can be set for alerts to be generated by ospital-acquired infections (HAI) These include hand hygiene, environmental deSpectraCell as matches are found between the are among the most pressing probcontamination, personal protective equipment database and new spectra. Alerts and epidemiolems in healthcare today. Five to 10 and isolation/cohort nursing. However, without logical data provide information enabling infecpercent of all patients become ina rapid tool to fingerprint tion control specialists to take fected while hospitalized, with incidences up to 28 pathogens found within the hostargeted action. percent reported in ICUs. In the United States, pital, these efforts lose imporWhile MRSA, VRE and more people die from hospital infections than tance and focus. Identifying C.diff are at the center of attenfrom breast cancer and AIDS combined. The vectors of transmission and montion, the list of species frequently costs involved with hospital infections are stagitoring compliance are essential encountered in HAI is much gering, estimated at $1.6 billion per year in the to a rigorous program. With the larger and contains both antibiotUK and $6 billion per year in the US, or approxidevelopment of the SpectraCell ic resistant and susceptible mimately $7000 annually per hospital bed. Once we RA bacterial strain analyzer, croorganisms. It is estimated that believed it was easier to treat HAIs than to preavailable from River Diagnostics, 30 percent of HAIs can be prevent them. However, we now realize that the active surveillance is now a realivented by means of targeted inenormous scope of the problem argues in favor of ty, providing actionable outbreak fection control measures enabled Michael Rumbin is the Vice President of Marketing and prevention. information within minutes from by bacterial fingerprinting (typSales for River Diagnostics B.V. There are two current lines of prevention. culture. ing) of organisms. He has held numerous positions in the industry, The first is to stop infections from entering the Bacterial identification at Prevention of an outbreak is including VP of Technology Management with the Siemens hospital. Rapid PCR-based tests screen for colostrain level can be compared to the most cost-effective measure to MicroScan Business Unit. nization of MRSA upon admittance to a hospital. taking a fingerprint. It enables curb the cost of HAIs. SpectraCell Rumbin holds a Masters degree from Villanova University and is Positive tests are followed by decolonization of precise tracking of when and enables active surveillance of hosa graduate of the Wharton School of Business at the the patient, with isolation from other patients. where a specific bacterial strain pital bugs such as MSSA, MRSA, University of Pennsylvania. Detecting transmission of infections within occurred. Such surveillance is VRE, Acinetobacter and Klebsiella, the hospital is the second. Rigorous and consiscritical to identifying sources of providing actionable information tent maintenance of infection control measures infection and to limiting the spread of an outfor targeted intervention by infection control teams, help to prevent transmission of microorganisms. break. Tracking the occurrence of strains over when a potential problem is signaled.
IDENTIFYING MRSA VECTORS OF TRANSMISSION
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THE BIG INTERVIEW
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Coming together Mary Grealy of the Healthcare Leadership Council explains how collaboration in the industry and the council’s lobbying efforts are bringing about change.
diverse organization with the challenging task of representing the many sectors within healthcare, the Healthcare Leadership Council is comprised of both publicly traded healthcare companies as well as not-for-profit entities representing pharmaceuticals and health insurance plans. Unifying these various organizations is the desire to achieve a high quality, high value, cost efficient healthcare system that’s accessible to everyone and as Grealy explains, the council has spent a lot of time reaching a consensus among its members to form this, emphasizing the issue of the uninsured as well as patient safety, quality and payment system reform. “I have not seen any dispute between the for-profit versus not-for-profit and it’s even more remarkable that we are able to get hospitals, health plans and manufacturers around the table and they truly check their individual agendas (and also their weapons) at the door,” she laughs. Grealy explains that this was no less of a surprise to her when she first took up the role over 10 years ago. Previously working at two trade hospitals she had plenty of experience seeing the hospital association fighting with the health insurance association and the AMA. However the council avoids this problem by electing individual CEOs as members, with each working together to find the common ground. “They understand that if the different sectors don’t work together, then you have a divide and conquer strategy and it’s not good for the overall system,” she says.
Innovative reform A primary function of the council is to lobby, be it members of Congress or the administration and its various agencies, but the council also serves as a source of information for congressional staff conducting a great deal of Hill briefings on particular issues. The fundamental goal of the council is change: canvassing healthcare reform. Having a combination of a pharmaceutical company, a hospital CEO and a health plan all campaign for the same issues is a great tactic for change – often putting a member of Congress a little off center, explains Grealy. “It is much more powerful when you have a hospital making the case on behalf of
a pharmaceutical company and they are all talking about the dangers of price controls and that it inhibits innovation. “We need to make changes in our healthcare system, but we want to make sure that we don’t throw out the baby with the bathwater and that we protect those things that are good about our healthcare system,” she says. “Innovation is one of the key principles that we feel very strongly about – we want to ensure that whatever we do as part of healthcare reform that we protect and foster innovation. “That can be a big part of the solution in what we’re trying to achieve with a reformed healthcare system, and so as well as new products and services that will improve the quality and efficiency of healthcare. We’re also looking at benefits design and how can we move our system from one that has been about treating sickness and move it more towards how we can prevent illness in the first place and the innovative ways that we could be doing that.”
Patient care Grealy points to recent data that displays the progress the healthcare system is making: longevity is now at an all time high as diseases continues to be overcome. She notes the advancement in breast cancer treatment and the return on the investment of dollars that have been put into the disease by not only an increase in the lengthening of life, but also in productivity. “When we’re able to shorten the length of stay in a hospital, that means that that person is back to work and contributing to the economy. “As we’re looking at the cost of medicines, or medical devices, we also need to take into account what those things are doing. What we’re seeing is that they’re not only producing longer lives, but also healthier lives. It’s been remarkable looking at our aging population, but it’s a much more vibrant population than we’ve had before.” However, these are not new issues for the council. Grealy explains that on appointment to her position the uninsured was to be its number one issue. The readiness of the CEOs of various institutions to operate on metrics provided them with the data to understand the problem and formulate a solution. Knowing whom the uninsured comprised of was pivotal – the Council took five months to analyze information and resulted in the now commonly known statistic of eight out of 10 uninsured living in a household where at
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least one person is employed. The population of the uninsured belongs to America’s workforce, with nearly half of those offered health insurance by their employer refusing. Cost is often a factor with many taking coverage for themselves but not for their dependants, family coverage being more expensive. What emerged from the results was that the uninsured were a gap in the population, overlooked because of their mediocrity – Medicaid is provided for the very low income, state children’s health insurance programs for children, but nothing for the employed population who cannot afford to pay. The Healthcare Leadership Council has made this group a priority, as well as investigating further into those who appear to be covered. “Nearly half of those who are eligible for Medicaid or the children’s health insurance pro-
“It is much more powerful when you have a hospital making the case on behalf of a pharmaceutical company”
gram are not enrolled so we launched an initiative called Health Access America to help do outreach in different communities,” says Grealy. “We did 10 pilot sites and we focused not just on those public programs but also brought in private insurance brokers and had them help small business owners and individuals, looking at the products that are available and how much they cost. We also had someone from the state that could help sign someone up for the children’s health insurance program or for the Medicaid program and amazingly nearly half of those that attended these programs left with some type of coverage. So that’s the grassroots outreach work that we’ve done. “Then of course we’re also working with members of Congress, with our solutions, which are pretty simple – making sure that those public programs are working well. We need to provide a helping hand to those that are unable to afford the insurance that’s being offered to them by their employer, and providing some kind of premium subsidy to help them. We are also working with small business and helping them understand what’s available, how much it costs, because they often don’t have a human resources person and so helping provide them information on how they can provide health insurance to their employees.” As well as its work for the uninsured, the Healthcare Leadership Council has been a very strong supporter of Medicare prescription drug benefits. For a long period of time, private health plans provided prescription drug coverage to the population under-65, ignoring that those with the greatest need for those drugs are the over-65, the Medicare population. The council worked not only towards the commitment of passing the legislation but also ensuring that people understand how to get the prescription drug plan that worked for them, what would be most cost-effective and cover their needs. To bring this about the council formed a coalition of over 400 national and local organizations, conducting thousands of events to educate people – all of which was done two years prior to them implementing it. “For the first 18 months we were just educating people about what’s coming and what will
be available and then after that, when the plans were finally available, actually going out and helping people sign up and enroll in the program that would work best for them. “On a personal level it was one of the very few times I’ve had the experience of working on legislation and then actually getting to meet the people that would be helped by it, so it was a really gratifying project to work on. It’s been a phenomenal success; there’s a satisfaction rate of over 80 percent and I don’t think you find that in too many programs, so that was a big plus, and the program actually wound up costing less than had been projected so that was another positive as well,” says Grealy. Alongside the issue of health insurance cover is the council’s desire to change the incentives within the current system. America is practicing evidence-based medicine; patients are becoming partners in their healthcare and becoming involved in prevention and wellness. Grealy notes that 70 percent of healthcare expenditure is for chronic disease and if the American public can be persuaded to liver healthier lifestyles this could be reduced significantly. As well as this, Grealy advocated moving away from a system that pays only for volume and moving towards one that pays based on outcomes and the value of the work that is done. Heading up patient safety and addressing another topical issue, is an executive level taskforce with many of its members being leaders in the various quality improvement initiatives. “One example would be Premier, an alliance of not-for-profit hospitals, which has participated in the center for Medicare and Medicaid services hospital quality improvement demonstration projects,”
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Former President George W Bush signs the Genetic Information Nondiscrimination Act says Grealy. “What they were able to demonstrate is improving quality can reduce costs. It improves outcomes but it also reduces costs. “There’s also a physician group practice demonstration project going on. Marshfield Clinic is participating in that and again, being able to demonstrate we can save money by not only rewarding the right behavior, but more importantly providing information, sharing best practices, sharing your results compared to other hospitals or physician group practices’ results.”
Electronic health records She notes that the council’s members are supportive of the adoption of electronic health records and the use of IT: a tool for practicing evidence-based medicine. “How do we develop the appropriate quality standards and how do we start rewarding those that adopt those practices to reduce the disparity of treatment, both geographically and among populations, by making sure people know quickly what are the best practices rather than it taking something like 17 years for known good practices to be disseminated widely?” However, she’s not convinced that the exchange of information between healthcare institutions is realistically viable, not soon anyway. “It’s not just the financial aspect, it’s also a big cultural change. “From what I’ve seen among our members it takes the leadership of the organization being engaged in this, making it clear that they believe it’s important and that they want everyone on board with it, that it is the right thing to do and it’s not easy but our members have done it. Many of our members did it without expecting to see a return on their investment. They thought, ‘We’re going to make this huge investment; it’s going to provide better care for our patients,’ but they weren’t sure it would actually reduce their costs because
of that huge investment. They’ve been very pleasantly surprised that they are seeing a return on the investment. “There are some things that we can start with that are less of an investment such as e-prescribing, and if we can reduce drug interactions and the harmful side effects of that it’s an important first step. Right now our members, such as McKesso – probably the largest health information technology provider in the world – are working hard to develop the standards and make these systems interoperable but in a way that still will protect the need to innovate so you don’t develop a system and then stop progressing.” The number of those council members at the forefront of technological innovation is multiple. Grealy points to the work of Mayo Clinic and Baylor Health System, as well as the work of one of its smaller organizations, Northshore University Health System, a three-hospital not-for-profit system which has won awards for being a leader in this field. “There was the leadership under CEO Mark Neaman, taking it all and making the commitment that you’re going to do it and then also involving their physician leaders in the development of that system. “A great example of this is the issue of hospital-acquired infections, because they have electronic records and they’re screening their patients as they come in. They know immediately what they need to do and they’re able to act quickly – they have rapid testing, they have the results. It really is phenomenal the improvements you can make in treatment as a result of having that quickly and widely available “Congress has sent a clear signal and probably the public is going to be sending a clear signal that this has to be addressed and we have seen where hospitals have taken this on. Again, it takes leadership, it takes the entire work-
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force in the hospital as well as their affiliated physicians – everyone committed to reducing those hospital-acquired infections. One of our concerns has been that we need to do this in a positive way, not a punitive way. “If we do it in a punitive way then you start encouraging people, perhaps, to use antibiotics out of the box when maybe they’re not indicated, so there really has to be a correct balance there; not penalizing hospitals in instances where perhaps that patient already had the infection when they entered the hospital, or they may develop it after they leave the hospital. Our members are committed, obviously, to solving this problem and there are ways to do it, but it’s important that it be done in a collaborative way between government and the private sector.”
Data protection The Healthcare Leadership Council’s work with the government providing collaborative insight into legislation has awarded them achievements, such as the Genetic Information Nondiscrimination Act. Grealy notes the work that the council has done on the confidentiality of medical information, specializing in the genetic area. “As a result of the human genome project, we are on the verge of being able to diagnose and, more importantly, to individually target therapies for people,” she says. However, she is quick to point out the concerns with the potential opportunities for discrimination when using medical information – be
“The people that are making decisions about healthcare for their families are by and large women” it employment or health insurance coverage – laying fault with healthcare providers and researchers for not providing sufficient knowledge to the public as to how this will benefit them. Moreover how institutions will protect that information. “So how do we find that balance between the need to assure people their information is protected and that they will not be discriminated against whilst making sure we have information available to provide them with the right treatments at the right time whether we’re talking about drug interaction or the right cancer therapy for them? And then how are we going to use that information to also develop new treatments and new drugs? “So we agree it’s very important that people not be discriminated against, the information be protected, but what you also want to make sure of is that
Senator Max Baucus and Mary Grealy as we develop electronic health records and have access to much larger databases, emphasize that the information is anonymous but held by researchers to use and develop better treatments in the future. “If we don’t assure patients and employees that we’re protecting it and that it won’t be used against them, then we’re not going to get that information, so that’s our responsibility, as well as employers, health plan, hospitals and others to make sure that they protect that information. There are severe penalties for anyone who misuses that information but my biggest fear is that there are interest groups out there that just want to shut down all access to this information and that would be very bad for patients,” she says. Grealy’s passion and dedication to her work has brought her personal achievements, too. Women in Healthcare recently named her one of its top 25 women in healthcare for her work in the council and Washington. On the importance of women representing healthcare issues she is firmly supportive of their role: “If you look at the statistics, the people that are making decisions about healthcare for their families are, by and large, women. And so they play a very important role in what treatments or coverage their family’s going to engage in. “In terms of Washington, women are great problem solvers but more importantly they’re also great at collaborating and networking and working together to find solutions, and so that’s another place that they can play an important role, it’s is just a slightly different tone perhaps.” Collaboration is most certainly Grealy’s skill, unifying different agenda groups for the sole purpose of bettering the healthcare system. It will still be some time before electronic health records are implemented and the uninsured are fully covered, but there is no doubt that the Healthcare Leadership Council will be canvassing patient causes every step of the way. n Mary Grealy is President of the Healthcare Leadership Council.
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have security, many are simply unprepared for the type of potentials we are seeing now in an anti-government, anti-federalism movement.
“Getting in front of security as it relates to business continuity and disaster recovery is indeed an emerging best practice” The recent hanging of a census worker in Kentucky is a clear signal that there are some who are willing to kill to keep away from government (or caregiver) assistance. While only a small portion of your community or patient base may harbor these destructive tendencies, getting in front of security as it relates to business continuity and disaster recovery is indeed an emerging best practice. Hospitals would be well advised to incorporate a fusion approach to their business continuity and disaster recovery planning as soon as possible. Kevin Burton explains the importance of disaster recovery, A fusion approach includes health and safety, business continuity and security in fully understanding risk. disaster recovery, business continuity and security ospital, urgent care and outpatient consider the risk their employees face and the poto assure that your hospital or organization has an facilities still face the challenge of tential for violence and civil unrest in their places of integrated view of the risk it is facing and an intedelivering care during a disaster or business as part of their overall business continuity grated plan for militating against that risk. mass causality event. And as H1N1 and disaster recovery stance, given the times. Like government fusion centers, this approach and healthcare reform in the US becomes a stress According to a recent poll acts as a force multiplier in budget point for radical American views on revolution published by CS Mott Children’s efficiency, insights and operaand revolt, it is important to consider that these faHospital, only 40 percent of US tional gains. Consider it a crash cilities may be at higher risk than ever from a lone parents plan on giving their chilteam for your risk mitigation efattacker or homegrown terror. dren the H1N1 flu shot. The forts. Rather than having all of the To say that the rhetoric around healthcare and study suggests that parents simspecialists in different rooms, you H1N1 has reached a fever pitch in North America, ply don’t believe that the virus is simply bring everyone in on the and in some cases abroad, would be an understatedeadly, despite the fact that it has risk mitigation project so that ment. A month ago, when I made the statement that killed 40 children in the US since multiple tests, multiple scenarios H1N1 was less dangerous than this ‘crazy conspiraApril. The question not asked in and multiple plans of action are cy’ around eugenics in North America, I received the survey, but hinted at largely replaced with singular clarity and Kevin D. Burton is CEO of multiple threats to my personal security. in non-mainstream media and a one-time cost where once there Burton Asset Management, Inc. Burton has a broad range of We are a disaster recovery and business contion the internet, is that radicalized were many. experience and has helped nuity firm with employees who have deep intelliviews of what swine flu is, what Organizations using this apclients address many issues to increase their IT process gence and military backgrounds. However, I’ve the shots are, and how both the proach are safer, more prepared efﬁciencies or to address business process needs, staff never been under such close guard since those US and other governments are and ready for disasters, security and governance issues, and death threats occurred. My personal experience using these shots as ‘kill shots,’ is breaches and the unforeseen than business-to-IT communication. as an executive who is working to help calm the not being widely reported. those who continue to operate in fears of individuals regarding their care in the face To be clear, this is no small silos. Given the current climate, of H1N1 is that doing so, in some cases, is to put problem for first responders and caregivers who administrators and executives would be wise to your life at risk. might find themselves between a fully agitated consider how fusing these risk management sysI cannot stress enough how important it is for and perhaps dangerous individual and the need tems can lower the strain on their budget and inhospitals, urgent care and outpatient facilities to to provide care to a minor. While most hospitals crease their readiness.
PREPARING FOR THE WORST
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GETTING BETTER ALL THE TIME
EHM spoke to Wes Wright and Drexel DeFord about using technology for continuous performance improvement at Seattle Children’s Hospital.
resident Obama’s plan to computerize all health records within five years is obviously posing a big challenge to health institutions across the country. Drexel DeFord, CIO of Seattle Children’s Hospital, points out that while this is a loft y goal, many hospitals and other organizations already have a head start. “A lot of work has gone into computerizing patient records in civilian healthcare, in the Department of Defense, and in Veterans Administration, and much of it has been going on for a lot longer than five years. “There are certainly a lot of folks who are somewhat skeptical that it can be done in five years, but at the same time, there are many who believe that we can get a good start in that time. Getting started is probably the important part. One of the concerns we have in general as we watch this rush to implement computerized patient records is that at the same time, there’s a very large debate going on in the US on healthcare reform.
“We might rush to computerize patient records, and then as part of the healthcare reform debate, it turns out that the processes we’ve just computerized change significantly and therefore we have to go back and either re-spend a lot of that money or re-engineer many of the systems we created. All of this causes folks who are familiar with our business to have some concern about how fast this seems to be going.” DeFord feels that we need to follow the logic of first things first: reform healthcare and then figure out how to automate the new healthcare processes. He says that the healthcare reform debate has shifted from its original overarching form to now being largely about healthcare finance. Wes Wright, the hospital’s CTO, points out that on a less grand scale, Seattle Children’s itself carries out continuous performance improvement, or CPI, following The Toyota Lean methodology. “One of the commitments the executive staff has made is that before we implement a piece of new technology within our hospital, we will CPI that process,” he says. “We then have a good standard by which we can automate the process and gain that efficiency. With the overall healthcare reform, I’m
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afraid what will happen is we’ll rush through some bad processes and then we’ll have to undo all that spending and all that work to get the processes properly aligned.” Wright believes the current healthcare reform process does not follow Lean principles: “It’s the triumvirate of people, process, technology – we need to concentrate on the people and process before we concentrate on the technology.”
“Another big issue that US healthcare will have to deal with is the refusal of Americans to accept some loss of privacy to have one number that identifies them for everything they do” Wes Wright, VP and CTO, Seattle Children’s Hospital
Seattle Children’s has been using Lean for five years, starting out for small implementations and evolving to the point at which it is used as a major change management philosophy. As Wright explains, “Any time we’re going to change or improve major processes, we do that using continuous performance improvement. We’ve built value streams for our major clinical processes, along with some support processes, and all of those generate individual projects or efforts that we try to continuously improve. That’s how we make changes in our healthcare delivery system.” “It allows us to focus, too. It lays out the process flow so we can then very surgically implement a technology solution that we know will help a particular process become more efficient. We don’t have to find the solution and then be efficient at it. Wes Wright We know that we’re efficient and we just need help making it more efficient. It’s really quite refreshing.” Seattle Children’s has even taken teams of its staff to Japan to learn Lean from the masters. They spend time with Toyota and several other companies deeply engaged in Lean processes. Wright says that from the point of view of an institution that has been doing Lean for only five years, it is interesting to see a company like Toyota that has been doing it for 50 years, and how much work it still has to do.
We need to talk Regardless of how Lean the processes are, and even if every record system across the country is computerized, that doesn’t necessarily mean that individual institutions will be able to exchange information. As DeFord points out, the Obama Administration has recognized this issue, and as part of the American Recovery and Reinvestment Act has formalized the Office of the National Coordinator for Healthcare IT. “The Office of the National Coordinator, or ONC, has several projects under way right now that include trying to standardize the language that would be used in electronic medical records,” says DeFord. “They
are standardizing the protocols around the transition of data between different systems to the certification of electronic health records to make sure those records that are available on the market and available for purchase have at least minimal sets of capabilities. “One of the big pieces they’re involved in is what would be the ultimate creation of a National Health Information Network, which would allow hospitals and doctors’ offices across the country to be able to exchange patient information. That’s a lot of work and there’s a lot going on at the local and state level all across the country, building regional health information organizations or health information exchanges that are beginning to create the foundation to allow for the exchange of data between doctors and hospitals, or between doctors, or between hospitals. That work’s really just started. I believe the national health information network is a long-term goal, but it’s the kind of work that has to occur before we can get to the point where we’re exchanging patient data between healthcare organizations.” Another ongoing challenge holding back the development of such a national system is the lack of a single patient identifier. While some have tried to play down this issue, DeFord believes it could cause significant difficulties: “I think it’s a big deal. It’s another issue that is part of the national health information infrastructure and is going to have to be dealt with. “Even today, in many large healthcare organizations, patient records can be confused. A master patient index certainly helps resolve some of those challenges, but you can imagine how much more complicated that becomes when you’re talking about not just one health system, but the whole country. “Another big issue that US healthcare will have to deal with is the refusal of Americans to accept some loss of privacy to have one number that identifies them for everything they do. So it’s a social and political problem on top of technically being a challenge.” Wes Wright points out that one thing that often gets lost in the fog is exactly how complicated healthcare IT is. “When you talk about exchanging information nationally, there are many organizations – and I count ourselves amongst them – that have systems that don’t even talk to their internal systems. Most organizations are still struggling with getting their internal systems to all talk to each other, and now we have to make that leap to getting our systems to talk to other systems. It’s a much, much more complicated animal than one would think.”
Staying secure There are plenty of challenges in managing technical operations in just one hospital, let alone the entire country. Wright points out that one big challenge for Seattle Children’s is FDA certification by its vendors. “In 2000-2001, medical equipment vendors were allowed to use Microsoft products to power their equipment,” he says. “There were often proprietary operating systems, and when a product went through FDA certification, part of that certification covered the operating system. “Of course, operating systems have changed quite dramatically since 2000. And when Microsoft discovers a vulnerability – or even nowadays
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when Apple discovers a vulnerability – it has to be patched, and a lot of our vendors have a hard time keeping up with that. From a total domain strategy, it makes it hard for me to keep those pieces of equipment on the network and keep my network protected the way I need to. “In the medical world, there’s not one big vendor. There are five or six big vendors and then there are 500 small vendors. Each one of those vendors has a specific application; for example, in cardiology, they may have built it specifically Drexel DeFord for a very niche cardiac procedure that I have to run in my hospital. It may have been built on Windows 2003 and hasn’t been patched in six years, which makes it very difficult to run a secure network. My vendors don’t always move as fast as the technology moves, so I’m always behind.” “Keeping the network secure can also cause headaches in a large healthcare organization. Our board of directors and executive management team realized that much like all healthcare organizations, our IT infrastructure had grown organically,” Wright continues. “A piece grew here and a piece grew there and then they decided to put them together. And they realized there were some big security vulnerabilities to that. “They started a program in 2007 called Project Bedrock, which essentially forklifts our old network infrastructure to a consciously designed infrastructure that has specific security zones. It will treat every client on
the network as a non-trusted client that will have to go through security hoops to get to the applications. “Some of the things we’re doing will help through redoing the security infrastructure, and having the machines talk to themselves better. For example, you could have one physician who could potentially be in five or six different applications throughout the day, and before Bedrock came about, those physicians or clinicians would have a username and password and have to sign in to those five different applications throughout the day. “When we forklifted the infrastructure, we designed it such that the major applications a clinician will have to be in all know who that clinician is via what’s called LDAP integration. The physician now has one username and password for all the applications. Within the next six months, that physician or clinician will have a XyLoc badge, walk up to a computer, and the computer will recognize who that physician is and bring up their applications. Those applications will follow that clinician throughout the hospital or throughout the clinic they’re working in. “Just by doing that, we’ve eliminated about 40 minutes a day in basic log on, log off. From a clinical workflow perspective, that’s a major benefit.” Wright points out that another great benefit comes from the fact that when they built the infrastructure, they wanted to maintain it and not start experiencing organic growth again, so they we established an architectural intake process that every application has to go through.
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Th is process consists of checklists and standard work back to the CPI philosophy, but can also be run on the network and can talk to other servers and other people can talk to it. By establishing this process, they have set themselves up for conscious design.
Looking ahead Another important aspect of the CIO’s and CTO’s work is the ability to look ahead and plan for future challenges. For DeFord, one of the biggest upcoming challenges in the healthcare sector will be the decisions that need to be made and the strategies that need to be built around the long-term investments needed for applications, for enterprise architecture and ultimately, for business intelligence. “We’ve approached that by setting up a governance structure that is driven largely by our internal hospital customers, to help us identify requirements for clinical systems or business systems or enterprise architecture needs or business intelligence,” he says. “By doing that, we’ve been able to build what are essentially road maps – although we call them fl ight plans, because in my mind these requirements are like a lot of little airplanes flying around, and we need to get them into some sort of order from an air traffic control standpoint. Then we need to decide from a healthcare standpoint what applications or what underlying architecture to land in what order, to make sure we can continue to be productive and head in the right direction to support our clinical and research needs into the future.
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“That’s our biggest challenge. We’ve got our first generation flight plans already accomplished after 18 months, and we’ll continue to look at and review those, but that then begins to drive a different conversation around how much money are we going to invest and when are we going to invest it.”
“We might rush to computerize patient records and it turns out that the processes we’ve just computerized change significantly” Drexel DeFord, CIO, Seattle Children’s Hospital From Wright’s perspective as CTO, the biggest technology challenge he faces within the next two years is ensuring his vendors are compliant with security standards and getting them caught up with technology. “That is going to be a thorn in healthcare’s side for many, many years to come,” he says. “They have to be more agile in their security patching and their use of new technologies. That is my main concern over the next two years.” Wes Wright is VP and CTO and Drexel DeFord is CIO, Seattle Children’s Hospital.
Risk management Phil McVey tells EHM about the importance of keeping health information secure.
What issue or topic do you see as most important to the healthcare industry today? Phil McVey. We see the greatest level of interest by far in understanding regulatory compliance. Th is has always been an area of concern, but what’s different today is the staggering complexity the industry has to deal with. To date, a total of 48 states and territories have breach notification laws in place and every state mandates some form of background screening, but it’s not just maintaining compliance with existing regulations that’s of concern; organizations also have to keep their eye on what’s on the horizon. Of course, right now everyone’s talking about the upcoming enforcement of the FTC’s Red Flag Rules as of November 1. But there’s also the HITECH act that will require covered entities to notify individuals within 60 days that their unsecured personal health information has been breached. And then we have an increase in the civil monetary penalty that can be levied due to HIPAA violation. Clearly, healthcare organizations are going to have to spend considerable time and resources just preparing to meet these new requirements. Certainly compliance is important, but what are some other focus areas for healthcare organizations? PM. With good reason, the healthcare industry has indeed fi xated on the new laws and regulations, but it’s also true that compliance doesn’t necessarily equate risk mitigation. Under fear of penalty, many organizations point resources toward compliance with state and federal law, resulting in bare measures that aren’t necessarily focused on minimizing the risk of a catastrophic event like a data breach. It can be a tricky balance for larger providers – you’re typically responsible for very sensitive and valuable health information that often exists in numerous areas within the same facility, making it difficult to keep tabs on where it’s stored, who’s using it and how it can be exposed. Despite the difficulty of doing so, it’s crucial for you to account for all the different areas of risk in maintaining this information. And one major area of risk management is to know who in your organization is accessing this data – that’s why we stress the importance of workforce screening. To minimize impact on
your resources, it will be increasingly important to work with a trusted risk management partner that can not only build a compliant incident response program, but also help you implement an effective screening program. You’ve mentioned background screening a couple of times. Why do you consider it such a crucial practice for the healthcare industry? PM. I see background screening as a fundamental step in protecting any healthcare organization from risk. It’s pretty elemental – you want to know as much as possible about the people working for you and should make every reasonable effort to identify and manage threats before they can actually affect your business or the quality of your care. Background screening is an affordable, widely accepted and relatively simple practice that’s easily integrated into any internal process. A successful screening As President of the program can help you avoid costly fi nes, Background Screening division of Kroll, Phil reduce the risk of employee malfeasance McVey leads the company’s global such as data theft , and shore up public pre-employment confidence. I should also mention that screening, identity management, screening is much more than just rundata breach/ fraud solutions ning a baseline check on a prospective and corporate employee. Effective background screenintegrity veriﬁcation businesses. Previously, ing is ensuring you’re doing everything McVey was President of the Commercial within your power – and your budget Services division of – to ensure that employees, vendors, USIS, setting direction for and supporting the volunteers and business partners aren’t company’s mergers and acquisitions presenting you with unnecessary risks. activity.
Does a healthcare organization really need a breach preparedness program? PM. Absolutely. Despite loft y claims from some within our industry, there simply is no way to guarantee that an organization will not experience a data breach. Regardless of how good an organization’s security program is, there is always the possibility of a breach, because the threats are so diverse. Rogue workers, hackers, recently terminated employees and even the absentminded can lead to a data breach. Implementing a breach preparedness program is about security awareness and training, not preventing a data breach. If an organization recognizes the importance of having a plan in place before an event occurs, not only does it lessen risk, it also minimizes downtime and confusion should an event occur.
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Well connected in Indiana Marc Overhage ﬁlls EHM in on the beneﬁts of a statewide health information exchange.
xchanging patient information across multiple providers over a statewide area is an incredible challenge on many levels. Marc Overhage, President and CEO of the Indiana Health Information Exchange (IHIE), says one of the main initial issues for him m was developing developing the value proposition; in other her words, word ds, demonstrating that people do move movve lains th hat between providers. He explains that actu ually many people didn’t believe this actually happened when the IHIE was fi rst started in the 1990s. “They had this view that we’re a large healthcare system and people come to our hospital and people come to our laboratory, and they he fi rst don’t go elsewhere. So thatt was th the ating that there challenge, at least demonstrating seccond was a problem to be solved. The second in was – not so much today butt again in cal chalchallthe 1990s – the technological l ks lenges. We were some of the fi rst fol folks ems of patient patient to try and tackle the problems matching, for example. “Because we do not have a common patient identifier, as people move between providers, you have to have a way to link together their information. The third challenge is provider matching, because doctors and providers in the United States also do not have a common identifier. As a primary care provider in Indianapolis, I have 47 unique identifiers, all of which need to be matched if you want to bring information together for quality improvement or simply to get a result delivered to a provider. “The next thing on the list is privacy and security, and there we did a number of things, including technological approaches, but more importantly process and trust building. “At the phase that we’re in now, the challenges are around creating value. It is costly to bring this information together in a standardized
format. In other words, every hospital, and every laboratory calls a serum sodium something different. You have to normalize that in order to make the data truly useful. In order to support that, you need to fi nd, in our view anyway, a variety of ways to help drive value out of that data and so create those sustainable business models, which is our big current challenge.”
Good advice When asked what counsel he would give to others contemplating setting up a statewide health information exchange network, Overhage’s fi rst response is to tell them not to build it from scratch if they have a choice. He continues: “The second thing is that you have to build incrementally and be patient. The only way you establish trust is by working out each use of the data in a very careful, thoughtful way, because the one thing you don’t want is for anybody to be surprised about how their patient’s data ends up being used. “That’s one of the key things, and related to that is being very patient, because healthcare organizations are relatively slowmoving beasts and you have to let things play out. There’s just no quick way to move that down the road, as much as you’d like to.” Despite the slow speed at which things can move in the healthcare sector, there have been cases where organizations have managed to set up a health information exchange fairly quickly. Overhage gives as an example the MidSouth eHealth Alliance in Memphis, Tennessee, which took some of IHIE’s agreements and technological approaches and went from nothing to operational in 18 months. “They were far down the road with trust, and they’d done a somewhat limited set of things to start with,” Overhage explains. “So it can be relatively fast. However, even for established organizations it could take years, not because it’s technologically challenging but because there are a lot of other things on their lists of tasks to get done and they’ve got other priorities, and maybe leadership turns over and it’s not a quick process.”
The IHIE recently joined with HealthLINC in Bloomington and HealthBridge in Cincinnati to form the nation’s fi rst live, multi-region clinical information exchange. According to Overhage, one of the main challenges in this project was dealing with the technological differences that existed between the three organizations involved. “The second thing is the fact that while we have focused on the state of Indiana and HealthBridge has focused on Cincinnati, there’s still a big overlap of several hundred thousand people in the southwestern part of the state who may go to Cincinnati to see a specialist even though they live in Indiana. That’s just the way healthcare works. “But the most important thing is that this is the fi rst real live instantiation of the vision of a nationwide health information network: when a patient is receiving care in one market and has data in another market, the data move with the patient. Th is is for real, with real patients getting real care; not a demonstration project, not a show and tell.”
National goal There has been a lot of buzz around the current administration’s goal of computerizing all patient health records within five years. Overhage, however, is quick to point out that this was an idea originally instituted by the Bush government as long ago as April 2004, when the Office of the National Coordinator was created and subsequently set a goal for the majority of Americans to have an interoperable electronic heath record by 2014. Regardless of its origin, questions have been raised in some quarters about the feasibility of this goal. Overhage believes it depends on how you defi ne ‘electronic health record’: “If you look at where most patients information is generated, it comes from laboratories, pharmacies and hospitals. There are transcription systems where a physician dictates a note and it is turned into a document. A great proportion of patients’ data is already computerized. “What’s lacking is, number one, structured data from many physicians’ practices – for example, what your blood pressure was when you went to see your doctor – and then the other issue is that this information is all in separate silos. A patient’s data might live in six different systems, with radiology data at three different radiology centers, and he or she may have been to two different hospitals. With pharmacies, obviously there are competing pharmacy chains that might be spread across 12 locations. “So while all that data is structured electronically, it’s not linked together. That’s why I think health information exchange is so critical, because it’s how you pull those silos together, and in fact that’s what we do. The vast majority of citizens in the state of Indiana already have an electronic health record that’s fairly complete; there are things that are missing that you’d like to have, but it’s starting to be pretty useful when you have lab, radiology, medications, hospital records and physician notes. It’s not perfect, but I can do a much better job of taking care of the patient with that record in hand.
Marc Overhage on the Indiana Health Information Exchange “The Indiana Health Information Exchange was created ﬁve years ago as a response to the Regenstreif Institute, a research organization that had been developing software and evaluating the value of health information exchange for about 10 years. We realized that we needed to create a vehicle for sustaining that effort, not as a research project but as a service that folks could rely on and build on. “Our mission is the usual ‘motherhood and apple pie’: to improve the quality, safety, and efﬁciency of care, to be a model that others can look at, and then to facilitate research into the areas of healthcare informatics. “The coalition is a fairly broad one. There are representations of providers, including physicians, hospitals and public health. Payers are represented. Business entities are represented. Research and medical education are represented.”
“In terms of the national goal, if it means every physician is going to be using an EMR by 2014, I don’t believe that will happen. But if you say every citizen will have an electronic health record, that is feasible if we focus our energy right.”
True identity In contrast to many others working in the field, Overhage does not believe that the lack of a single patient identifier is a hindrance to the development of a national electronic health record system. In fact, he goes so far as to say that even if one existed, it wouldn’t help. “In countries like the United Kingdom and New Zealand, where most people do have identifiers, it hasn’t solved any of the fundamental problems,” he asserts. “There are still data entry errors – roughly five percent of the health data numbers that are recorded in general practitioners’ offices in the UK are wrong. “And then you have the usual challenges of people who don’t have one. The utility or value of that identifier is modest at best. There are very good statistical solutions. In other words, if I know your name and your date of birth and your gender and your Social Security number and where you lived last month, I can do a very good job of matching up your health data over time. In fact I can do that at the 99th percentile level and make sure I don’t incorrectly match anything, and that’s all without a common identifier.
“Doing more could be a negative factor, because it confuses everybody and they’re not sure where to put their effort”
IHIE services The Indiana Health Information Exchange (IHIE), based in Indianapolis, provides an interoperable, standards-based health information infrastructure to directly address the lack of access and coordination of clinical information that can result in errors, misdiagnoses, patient safety issues and cost inefﬁciencies. By bridging the gap between paper-based and electronic-based medical ofﬁces, IHIE has created a secure network that can be used by physicians who have IT systems and those who do not have IT systems. This provides reach to even the small or rural physician practices – the setting where over 80 percent of care is delivered and the places least likely to have adopted an electronic medical records system. By delivering clinical information at the most critical time, the point of care, IHIE’s goal is to align transparency, efﬁciency and quality to improve patient health.
DOCS4DOCS IHIE’s DOCS4DOCS service provides health information in near real time, where and when it needs to be for patient care (to emergency departments, outpatient centers and ambulatory practices). Since 2004, more 50 million test results and other clinical information have been delivered to physicians.
Quality Health First The Quality Health First program is made possible through IHIE’s partnership with the Regenstrief Institute, Inc., through the Indiana Network for Patient Care (INPC), which powers the data used in the QHF program reports. The goal of the QHF program is that patients will experience fewer health complications and physicians will see better adherence to evidence-based medical practices.
“That’s not to say there’s no value in having an identifier. There is value, but there are also costs and risks associated with that. I would say it’s absolutely not essential and is not an impediment.”
Looking ahead In terms of the future for healthcare information technology, Overhage admits there is still a lot of work to do. He cites the need to build interfaces and normalize data, while pointing out that these are not technological challenges. “Those are things we’ve got to do and we know how to do them. We just have to get them done. “I do think we have to guard against over-engineering and building in too much complexity. I believe we can do what we need to in the next five or 10 years with our existing standards, with our existing technology platforms and knowledge base. We don’t need new technology. We don’t need new standards. We need to take what we have and do the hard work to make them real.
“Healthcare organizations are relatively slow-moving beasts and you have to let things play out” “In fact, doing more could be a negative factor, because it confuses everybody and they’re not sure where to put their effort and they don’t know if Betamax or VHS is going to win. So they either sit on their hands or they lobby for one or the other and we get all this noise and confusion when we could be getting real work done that helps patients. “The most important thing we need to do is connect local healthcare: the hospitals and labs and pharmacies within a market or region. In my mind, the value of a nationwide health information network is in dealing with the national overlays. It’s the care systems like Kaiser Permanente or the VA or the national laboratories or the national pharmacy chains that need a common way to connect to different markets. “The last mile part that we’re missing today is market by market, whether it’s Cincinnati or the state of Indiana or the city of Chicago. The need to have the various healthcare enterprises connected is really where the work and the focus needs to be.” Marc Overhage is President and CEO of the Indiana Health Information Exchange.
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HEAD TO HEAD
HEALTH INFORMATION EXCHANGE Raymond Scott of Axolotl Corp and RelayHealthâ€™s Jim Bodenbender talk to EHM about interoperability solutions.
Technology RT:26 June
With only a year for hospitals to qualify for front-loaded stimulus dollars, how will they be able to demonstrate ‘meaningful use’ in such a short time period? Raymond Scott. Hospitals need to evaluate their existing CPOE and EHR infrastructure, determine where gaps exist and begin the work required to make them interoperable with the systems used by the ambulatory care partners. The use of health information exchange (HIE) technology provides a fast and simple mechanism to connect to third party EHRs and to receive orders from them. Hospitals should look to SaaS-based solutions, which will significantly reduce the implementation time and eliminate application maintance for your IT staff. Hospitals can be operational with HIE technology in as little as two months – exchanging discrete data elements between existing HIS and ambulatory EHR systems. Also, CCHIT-certified EHR Lite applications provide a very affordable solution for ambulatory physicians that don’t already have an EHR, enabling a complete medical trading area to be fully connected in the required timeframe. It is important to remember, however, that while ARRA’s goal is to remove cost as a barrier to adoption, changes to workflow will require planned training. Jim Bodenbender. First, according to McKesson’s interpretation of the timing for receipt of federal incentive payments under the HITECH Act, we believe a hospital would be eligible for full reimbursement if they demonstrate meaningful use of a certified EHR by the end of the government’s FY2013 and continue to meet subsequent phase criteria. However, the payments would be delayed accordingly. So, unless things change before the requirements are finalized, eligible hospitals can qualify as late as September 2013 and still receive maximum stimulus incentive funding. Hospitals planning for stimulus incentives during this period need to focus on gaps between current capabilities and meaningful use criteria, despite the criteria being in draft form. One likely gap for many hospitals is interoperability. The HIT Policy Committee’s Information Exchange Workgroup estimated 45 percent of meaningful use Raymond Scott is CEO of Axolotl Corp., co-founding it in 1995 to criteria are supported by health information exprovide collaborative electronic workﬂow solutions for change. It is critical for hospitals to establish plans for communities of healthcare connectivity to physicians, patients and the commuproviders. Scott has established Axolotl as a leader in health nity at large. information exchange (HIE), today providing the technology and services to support many fully functioning hospital, regional and state-wide HIEs across the US.
Jim Bodenbender is a group president of RelayHealth, a division of McKesson. He has responsibility for the business’ operational management and strategic direction, which includes R&D, sales and channel management, business development, product management, customer support, and account management. Bodenbender has more than 25 years’ experience in healthcare information systems and services.
With the ONC’s focus on providing money through state-designated entities and regional extension centers, the establishment of statewide health information exchanges (HIE) has become important. What is your company doing at state levels with regard to HIE? JB. RelayHealth and its parent company, McKesson, are actively involved at both the federal and state levels, providing guidance and real-world experience on topics including meaningful use criteria, certification standards and interoperability approaches. For HIE specifically, we are working with several states shaping strategic plans and driving strategies to enable sustainable connectivity in their communities.
Technology RT:26 June
One specific attribute historically lacking in state-level HIE initiatives is a sustainability model that enables the HIE program to continue and advance long after the grant funding ends. RelayHealth’s approach to HIE incorporates a long-term sustainability structure proven to yield tangible return on investment for hospitals, physicians and ancillary providers. Our patient-centric SaaS design affords extended leveraging for broader state to interstate and ultimately nationwide connectivity. The result is actionable health information when and wherever stakeholders need it, be it in local communities across the state, regionally or throughout the nation.
“Without a HIE, full interchange of clinical data between the partners in a medical trading area would require a large number of point-to-point interfaces between each hospital, lab and physician practice” Raymond Scott
RS. Axolotl is the statewide designated HIE vendor for Utah, Idaho and Nebraska and has connected many regions within Indiana, New York, California, Washington, Texas, Ohio and Colorado, among others. These HIE customers are clinically networking hospitals, labs, public health, payers and physician practices – the entire healthcare continuum with SaaS applications. Patient information is securely shared and made available when and where it is needed. A virtual health record provides authorized users with complete patient data, displayed from all connected facilities. In addition, Axolotl’s CCHIT-certified EMR Lite provides any physician not already using an electronic medical record with an affordable web-based solution to immediately connect the state’s HIE. What is your view on the statement that full interoperability for hospitals and physician practices can only be achieved by connecting to a health information exchange? RS. Most physician practices use more than one hospital or lab, with different internal information systems, to provide care for their patients. Hospitals and labs provide services to a variety of physicians, some owned or affiliated and some independent, all potentially using different EHRs. Without a HIE, full interchange of clinical data between the partners in a medical trading area would require a large number of point-to-point interfaces between each hospital, lab and physician practice, which would be prohibitively expensive to build and maintain. A HIE provides comprehensive interchange of data between all the parties through a single connection to each. JB. It is important to understand hospitals, physicians, pharmacists and other stakeholders can perform the act of HIE without joining a formal health information organization such as a RHIO. In fact, over 50 health systems and hospitals have contracted with RelayHealth to engage in HIE with limited HIO formalization. One area that formal exchanges have poorly addressed is patient engagement – because RelayHealth is fundamentally a patient-cen-
tered model, providers can perform clinical and financial HIE activities with their patients and other providers. As the nation expands clinical connectivity, we should look at RelayHealth’s established networks for financial and pharmacy transactions as an example. Over 95 percent of providers and 90 percent of retail pharmacies, providing ample lessons on interoperability, use these exchanges. These levels of adoption enable RelayHealth to provide services such as a secure data feed on retail prescriptions every four hours to the CDC to assist them in tracking viral outbreaks and other healthcare emergencies. How are your physician customers achieving interoperability in their practices, and how does that help them towards achieving meaningful use? JB. Currently, RelayHealth provides all the necessary functionality for our customers to demonstrate the current meaningful use interoperability requirements for the 2011 phase, based on the draft meaningful use criteria. Our customers are also already capable of demonstrating many of the other current meaningful use criteria for the 2013 and 2015 phases, including real-time population of a patient’s personal health record and secure messaging between patients and their providers. Enrolled physicians on the RelayHealth network have access to its connectivity services either directly within their EMR workflow or online via a browser using our modular, cloud-based applications. A key goal of mean-
“It is important to understand hospitals, physicians, pharmacists and other stakeholders can perform the act of HIE without joining a formal health information organization such as a RHIO” Jim Bodenbender
ingful use is to drive care collaboration and this approach ensures all physicians can participate, including those not ready for an EMR. Furthermore, this low-cost, scalable and highly networked solution doesn’t require a costly infrastructure and assures providers a predictable cost structure, lower total cost of ownership and a quick return on investment. RS. Axolotl’s Elysium EHR Lite is the first fully interoperable solution on the market – able to plug into a HIE and connect to all of its HIS and EHR systems without point-to-point interfaces. Data from all sources is sent and received in a standard format with discrete data elements. As one of only six Gold Surescripts-certified vendors, our integrated eprescribing solution provides complete medication lists and fully automated renewal processing. In addition, active, electronic reporting of quality measures can be established and maintained with minimal physician or staff intervention. Axolotl anticipates that almost 25,000 physicians currently using the CCHIT-certified Elysium EHR Lite will be able to apply for full incentive payments.
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ASK THE EXPERT
Web-based results Neal Flora explains the importance of streamlining patient data.
he challenge of today’s laboratories is to do more with less. Handling physician requests, delivering patient results, managing workflow, ensuring proper billing and meeting regulatory requirements all need to be accomplished in an efficient, secure and cost-effective manner. Today’s technology can be divided into three general architectures, the first being a thick client. Each physical computer that provides information to the user contains all of the software required to deliver data. This is an older technology suited for small labs that do not require multiple users or delivery of results outside their four walls. A client server is the second. The main software required runs on a single server machine with individual user computers running proprietary software called the ‘client’. Remote users must install proprietary software to access data. Web-based is the third general architecture. All software runs on the web server and each individual user simply needs an industry standard browser, such as Microsoft’s Internet Explorer, and log in to access data. All three technologies can manage workflow in the lab, assist in meeting regulatory requirements, and provide connectivity for billing. But when it comes to delivery of patient results and handling physician requests in a secure efficient manner, most people feel that the flexibility and portability of the web-based architecture provides the superior solution. Managing patient data consists of receiving the order from a physician either electronically or via a paper requisition, receiving the sample or drawing the sample, performing the testing either in-house, sending to a reference lab or both, and delivering the results back to the physician. The most efficient manner of ordering and receiving specimens in the lab is electronically. Web-based solutions such as Fletcher-Flora’s FFlex eSuite LIS, allow orders to be received from an EMR system or through a lab outreach portal such as FFlex ePortal, in a secure manner over the internet. Labels can be printed locally where the sample is drawn, which prepares specimens for immediate handling once they arrive in the lab. This not only helps organize orders and samples but also eliminates costly and time-consuming re-labeling. Today’s technology includes business rules that efficiently and automatically route samples based on insurance/payer, patient status, order priority (routine, stat, timed draw, etc.) and the menu of in-house tests the lab is capable of performing. In many of today’s LIS offerings like Fletcher-
Flora’s FFlex eSuite, such business rules are built in to facilitate efficient, cost-effective testing. Automatic routing of samples based upon these and other factors simplify the management of this workflow and ensure reimbursement for the lab work performed. The net product delivered by today’s laboratories is a patient’s results. Efficient and secure delivery is essential for a successful laboratory. In addition, physicians want a complete consolidated result picture without having to refer to multiple documents. Part of the efficient delivery of results is a consolidated report that also, for compliance reasons, clearly identifies the performing facility. Many of today’s solutions, including Fletcher-Flora’s FFlex eSuite, integrate in-house and reference lab test results in a single consolidated report. By far the most efficient and cost effective manner
“The most efficient manner of ordering and receiving specimens in the lab is electronically”
for patient results delivery is the internet. With no paper to handle, secure access and almost instantaneous delivery, FFlex ePortal ensures your patient results are delivered to your customers with minimal or no intervention. Today’s technology affords the clinical laboratory with solutions to the many challenges they face. Features, including software business, rules that automate sample routing, reflex testing, result interpretation and result verification dramatically improve efficiency and streamline management of patient data. Choosing web-based technology that can deliver results securely and efficiently over the internet helps the laboratory compete and ensure that physicians have rapid and secure access to their patient results. n Neal Flora is CEO of Fletcher-Flora Health Care Inc. and has over 30 years of healthcare IT experience focused on the clinical laboratory. Flora brings knowledge and expertise gained from the early days of laboratory automation and computerization through the present state-of-the-art systems, keeping the company ahead of the curve in technology.
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Whelan ed:16 nov
Evaluating the future Frost & Sullivan’s Charlie Whelan looks at why medical technologies should be judged on their actual value to patients.
n April/May of 2009, Frost & Sullivan surveyed 70 hospital professionals in six functional areas, asking them about the strategic challenges facing their institutions and the process by which they evaluated and adopted new technologies. In addition, Frost & Sullivan conducted extensive interviews with a physicians and hospital professionals in a variety of roles. Charlie Whelan, Frost & Sullivan’s Director of Consulting, Healthcare and Life Sciences, explains that the impetus for the survey came from the company’s ongoing interest in marketplace trends within healthcare, as well as his day-to-day work with clients who are developing new medical technologies.
“We saw a trend wherein clients were coming to us and wanting to assess not just the technical or clinical aspects of their technology, but also the economic benefit that it could bring to healthcare providers,” Whelan says. “We saw that as becoming increasingly important in the marketplace, largely because of economic variables. “It wasn’t that clinical needs are changing, it was more about certain economic decision-makers having more of an impact on the decisions around whether a product was adopted or not; so we wanted to look at that a little more closely.” The survey results showed that the variable of patient satisfaction has become increasingly important to hospitals for economic and competitive rea-
Whelan ed:16 nov
sons. “Obviously, hospitals have always wanted to keep their patients happy for altruistic reasons,” Whelan underlines. “But here in the US, what’s happening is that hospitals now have very clear economic drivers to secure higher patient satisfaction levels, because they get bonus payments from Medicare.”
“When more information becomes available to people, they make decisions differently, and behavior changes” Whelan says patient satisfaction has now become a lot more transparent. For many hospitals, patients can go online and see how hospitals score in different areas, then make a decision about which hospital to go to for their often elective surgical procedures. Moving into the future, Whelan believes that those technologies that offer higher patient satisfaction will be considered to be more valuable than they were previously.
Frost & Sullivan’s picture of the future US healthcare system • • • • •
• • • • • •
Technology objectives The objectives of Frost & Sullivan’s web survey into new technology adoption by US healthcare providers included the following: • To show how forces in the healthcare industry should change the way hospitals evaluate new technologies based on the actual value they deliver • To describe the process hospitals currently use in the evaluation and adoption of new technologies • To describe how hospitals currently think about operating cost management and value, particularly when evaluating the adoption of new technologies that might have an impact on patient outcomes • To show how forward-thinking providers are changing the way they act on this value equation to position themselves for survival in their markets
Greater focus on economics Healthcare becomes more like other service industries Increased attention to patients as healthcare consumers Increased reliance on healthcare information technology Higher competition among healthcare providers both horizontally (hospital vs hospital) and vertically (hospital vs surgery center); more competition on a global basis for elective procedures Greater collaboration and information sharing across value chain Greater transparency of prices/costs and outcomes Increased development of standards of care and incentives to adopt Increasingly challenging market for new technologies Longer time to market for new technologies More decision making on purchasing occurring at higher levels within a customer organization, at system-levels or by GPOs More locked out accounts and a more competitive market with customers signing longer-term, exclusive contracts to enjoy lower prices More ‘generics’ – technologies providing same value at lower price, stripped down feature sets Greater focus on prevention and primary care
“In the past, hospitals and doctors may have looked at a device that claimed to provide better patient satisfaction and said, ‘That’s nice, but it cost too much and it’s not really worth that expense,” Whelan says. “In the future, they’re going to look at that and say, ‘Wow, that could help improve our patient satisfaction scores and that, in turn, can help generate greater reimbursement and greater profits for us and make us more competitive versus our other healthcare providers locally.’”
Net beneﬁt Whelan gives the example of a technology that costs $400 that is not reimbursed. The manufacturer claims it can get patients out of a hospital one to two days earlier, depending on the type of surgery. Keeping a patient in hospital after surgery can cost $1200 a day, and hospitals are increasingly being paid under bundle codes or DRG codes that incentivize them to get patients out of the hospital as fast as possible, because it makes them more profitable. For these reasons, Whelan says it can make financial sense for hospitals to consider such products, even when they are not reimbursed. “You need to look at the technology and consider it because of the operational benefits it provides,” he says. “It may cost $400 but you’re able to save $1200, which nets you $800 in savings. “You also add patient satisfaction and better outcomes. That type of calculation, at least based on the research that we did, is not fully appreciated by
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Technology assessmant Conclusions drawn from the Frost & Sullivan web survey, as outlined in the white paper, The New Economics of Healthcare. “Whether a hospital adopts new technologies or not is not an option. Hospitals must constantly evaluate new technologies to improve patient outcomes, as well as to maintain competitiveness and ﬁnancial viability. Hospitals should institute multi-disciplinary technology evaluation committees aligned with the larger strategic objectives of the whole facility and system. “These committees must have executive sponsorship and broad inﬂuence over the entire facility to address conﬂicting agendas and make decisions in the best interest of patients and the facility. Hospitals must ensure that the adoption of new technologies is aligned with the larger priorities of the facility and its mission. “Most hospitals have these committees to some degree already, but administrators need to take a more proactive role in bringing new technologies up for evaluation. Whether the technology passes clinical muster is crucial, but every new idea deserves evaluation, regardless of where that idea may have originated. “A holistic approach to technology assessment is crucial for hospitals to fully appreciate the value of the technology. This approach includes a thorough review of the true economics of a technology and the long-term outcomes it can deliver. This process must be guided by more than simply a narrow focus on reimbursement or the partisan interests of particular departments.”
hospitals everywhere. Some leading-edge hospitals see that and they make the connection, but a lot of hospitals are still not fully appreciative of it. I think that’s going to change.” Whelan points out that technology companies have historically focused on clinicians and the fact that something has clinical value: it can help your patients get better faster. While that is important, he says that technology companies need to keep in mind the economic, operational and workflow impact that their technologies have. “Many companies have appreciated this, but it’s still relatively new. Part of what precipitated the survey was the fact that a lot of medical device companies were coming to us and talking about strategies they had that were focused on presenting the economic and operational benefits that their technology brings and not the traditional sole focus on the clinical benefit.”
Expert advice Whelan advises technology companies to be sure they understand all of the relevant impact that their technology would have on the healthcare provider. This includes playing out the scenario of what would happen when the technology is adopted, and whom it would impact. “For example,” he says, “It’s not going to impact just the doctors and nurses. It’s going to impact the biomaterials managers and the OR managers and the purchasing managers and the CFOs and the case managers, all on down the line. It has a ripple effect. “Healthcare is so complex. It’s such a matrix-type organization that one new technology option can cause a complete paradigm shift, so you need to understand how your technology fits into the much larger context of where it’s being used and how it’s being used.
Whelan ed:16 nov
“The other thing I would say is you need to develop some quantitative data showing how it can demonstrate economic benefits and patient satisfaction. You also need to think about how your technology can measurably improve patient satisfaction scores.” Whelan cites one OR manager he spoke to, who said she had adopted a particular technology specifically because of its ability to improve patient sat-
technology, which Whelan believes will flatten healthcare delivery in many ways. Once data is captured and standardized in a patient record and is available to individuals other than just the doctor, he says, this will change how delivery is carried out. “Much discussion on the growing importance has glossed over this,” he asserts. “A lot of things happen when information is made available to people: look at what’s happened with the internet. When people have more information, they make decisions differently and their behavior changes. “What we’ll see is more healthcare information being at the fingertips of case managers or nurses or hospital administrators, and they will start to make more decisions and gain more power relative to physicians. We’ll also start to see more standardization of care. “There will be continued emphasis on workflow optimization and more technologies will develop that and put that same information back into the hands of patients so they can manage their own care. It’s going to facilitate greater collaboration, too, not just between clinicians and clinicians but between clinicians and patients.”
“Healthcare is so complex. It’s such a matrix-type organization that one new technology option can cause a complete paradigm shift” isfaction scores. She had done a study internally comparing two populations of patients who had had the same surgery; one group got this particular type of pump and the other group didn’t. And she found that the pain scores for the population with the pump were better. The survey also predicts an increased reliance on healthcare information
Charlie Whelan is Director of Consulting, Healthcare and Life Sciences for Frost & Sullivan.
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ASK THE EXPERT
The digital revolution Jeanine Tome explains how meaningful use impacts case management.
e are embarking on a digital revolution in healthcare. The massive effort to transform healthcare began with the significant action taken on February 17, 2009, with the signing of the American Recovery and Reinvestment Act. Contained within the bill is the healthcare information technology component (HITECH). This legislation adds significant financial incentives for physicians and hospitals to join the digital revolution by adopting electronic health records (EHR). By appropriating a net of $19.5 billion to modernize healthcare, the commitment has been made to support the adoption and meaningful use of electronic health records. HITECH offers incentive payments to hospitals and physicians to efficiently utilize an EHR. Physicians have already begun electronic medication prescribing, and further incentives from Medicare and Medicaid are in the bill. The most important impact of HITECH on case management practice is in the draft recommendations put forth by the Meaningful Use workgroup of the Health IT Policy Committee. It is anticipated these recommendations will be finalized by CMS at the end of 2009. In the recommendations targeted for 2011, there are specific objectives to improve care coordination. Th is would be evidenced by the exchange of key clinical information among providers, and with the performance of medication reconciliation at relevant encounters. Additional outcome measures included in the recommendations are reports of 30 day readmissions rates, demonstration of the ability to exchange health information with external clinical entities and measuring the percent of transitions of care where a summary care record is shared. Leadership needs to understand the important impact HITECH will have on case management practice in their organization. The case management process encompasses communication and facilitates care along a continuum through effective resource coordination (ACMA, 2002). Many decisions are made for safe home discharge, physician follow-up, post acute care and outpatient services. Care is planned, insurance coverage verified and options discussed with patients while managing length of stay. How this planning and communication occurs will be changing and will add to the organization’s ability to demonstrate meaningful use. By using the expanded capabilities of accessing information in an EHR, sharing infor-
mation electronically between clinical entities will become much more commonplace. Interoperability will allow more options for the exchange of information between settings without error. As this data is interpreted, a more clear and complete picture of the patient and family needs will emerge. Better decisions about the use of resources should be enabled in the coordination of care across settings with improvement in hand-off communication. Preventing unnecessary readmissions to acute care will also be tracked. MedPAC in 2008 showed that the Medicare acute care 30 readmission rate was 18 percent. Attention was focused on the determination that 13 percent of these readmissions were preventable. Organizations have already begun to set targets to reduce the 30 day readmission rate. The inpatient case manager’s role will begin to stretch beyond the walls of the hospital, supported by technology to accomplish these targets. The result is anticipated to improve quality of care, further insure patient safety and reduce costs during all transitions of care. In outlining the Seven Top Trends for Case Management Practice, Stanton (2008) reported that integrating informatics into practice was one of the top seven trends. Automation for current case management practice is a good starting point for helping case managers to see technology in their everyday workflow. Case managers will be continually learning how to apply newly integrated technology to transform case management practice as EHR adoption moves forward. Let the digital revolution of meaningful use begin.
“Preventing unnecessary readmissions to acute care will also be tracked. MedPAC in 2008 showed that the Medicare acute care 30 readmission rate was 18 percent”
Jeanine Tome is Chief Clinical Ofﬁcer for Allscripts Care Management, with a focus on bringing technology innovation to the care management practices. Tome has 33 years of experience with inpatient clinical operations leadership in care management, nursing administration, quality improvement and patient safety.
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Nursing an ailing health system
olleen Conway-Welch, Dean of Vanderbilt School of Nursing, has some strong words for the way the Obama government is handling the health reform debate. In one of her recent posts on the Washington Post’s online Health Care Rx forum, she criticized the administration for allowing the debate to center on cost, rather than care. “We’re not using the right words,” she tells me from her office in Nashville, Tennessee. “The point that I was trying to make is that the infrastructure of the healthcare delivery system – where the different health professions have to be educated together, have to work in teams, have to be able to have seamless handoffs between provider offices and surgery, step-down units and regular units, and hospice and home care – all of that is the healthcare delivery infrastructure. “That is what needs to be fi xed – tort reform, the insurance industry and the Emergency Medical Treatment and Active Labor Act and the Employee Retirement Income Security Act, which are fi nancial vehicles. People say that Medicare is terrific, but it’s going bankrupt. All of that is part of the infrastructure. All the current reform legislation is doing is talking about health cost reform, not healthcare reform. And with health cost reform, we’re rearranging the deck chairs on the Titanic. We’re taking money from one pocket and trying to shove it into another.” Another way of looking at it is that if healthcare were an illness, we’d be addressing the symptoms and not the cause. Conway-Welch believes that until we start examining the root of the problem, we’re just “playing a shell game with very few dollars.” Getting to the bottom of the issues may be easier said than done, however. “I wish I had the power to do it,” says Conway-Welch. “Changing the tort system would be a good start, because we currently practice so much defensive medicine. Insurance companies, for example, cannot cross state lines in the United States. That’s ridiculous, because you might be able to get a better deal in another state. Why not do that? Every insurance company and every state has hundreds of different forms for patients and physicians and provider offices to fi ll out. Why don’t we have one standardized form? That would save billions.
Colleen Conway-Welch tells Marie Shields about the role of nurses in the evolution of healthcare.
“There are probably 50 examples of those kinds of things that could be tweaked – maybe not fi xed, but tweaked – related to administrative costs in healthcare. Some of this is not rocket science. Common sense could go a long way in healthcare reform, but common sense is not really involved in health cost reform.”
Nursing evolution Her position as Dean has given Colleen Conway-Welch a unique viewpoint on the evolution of American nursing, as well as the healthcare system as a whole. As she explains, a few things have changed since she began her nursing career nearly 45 years ago: “I got my baccalaureate in 1965 in nursing, but it was very rare then. Now nursing has come into higher education, and as nurses accelerate on the educational ladder, they can bring more assistance to their patients and more complementarity to other healthcare workers, including physicians.”
Vanderbilt School of Nursing With a history dating back to 1909, Vanderbilt University School of Nursing has a long-standing reputation for excellence in nursing teaching, practice and research. As one of the ﬁrst ﬁve schools to receive Rockefeller funding to implement the Goldmark Report of 1923, the School of Nursing was a leader in altering the nature of nursing education and moving it into institutions of higher learning. The School began offering the Master of Science in Nursing (MSN) in 1955, and was one of the ﬁrst to launch a ‘bridge’ program in 1986, through which students who hold nonnursing degrees can enter the MSN program without repeating undergraduate classes – thereby permitting an accelerated path to the master’s degree. Vanderbilt’s Bachelor of Science in Nursing degree, ﬁrst conferred in 1935, was restructured into the bridge program as one of several entry options. In 1993, Vanderbilt School of Nursing established the PhD in Nursing Science program, leading to nursing research and scholarly activity that has positively impacted health care delivery in a variety of areas.
Conway-Welch points out that nurses have always enjoyed a high level of trust from patients, something she puts down to their commitment to patient advocacy. “It’s also the fact that they are there 24/7. And then there is the issue of ‘never’ events – events that should never happen in a hospital. Part of that is failure to rescue. And nurses have this seventh sense, if you will, that something is going to go wrong. Experienced nurses will tell you over and over and over again that they have this sense. We can have all the machinery and technology in the world, but they can walk into a room and look at a patient and know that something is not right. It’s something that comes with education and experience, and that is part of the trust level that patients and families have in nurses.”
Another change Conway-Welch has seen in her career is the increasing use of technology and the fact that nurses have been very involved in that evolution. “Here at Vanderbilt, we have what I call an electronic medical record on steroids,” she says, laughing. “Lots of people have EMRs, but ours is pretty unique because it also builds in decisioning. It carries on a conversation with you: ‘Are you sure you want to prescribe this drug? Are you sure you want to do this this often? This costs $1100 a dose. Is there any other dose you want to think about?’ It’s almost interactive. “The standardization and interactivity of IT is going to make a huge difference for nurses. The other interesting thing is that it is going to allow us to have datasets that we can look at internationally for research purposes, because a research question here in the US may have a different answer than in Europe or Asia. “If you want to know how many of your diabetic patients, for example, are compliant with foot care, we now have the capability to dial that up in the identified data. That will make huge strides in terms of the responsiveness of the healthcare system to individual consumers.” It’s a case of making an investment in the short term for long-term results, although as Conway-Welch points out, the bigger the scale, the harder it will be. “If you think we’ve got trouble getting standardization in the US,” she says, “start thinking about what the next steps would be to standardize our healthcare relationships with countries like the UK, New Zealand, Australia and South Africa. But it will happen.”
Technology revolution Healthcare IT is a hot topic at the moment, with the ambitious plans coming out of Washington to make all health records available in electronic format. When asked if she thinks this goal is achievable, ConwayWelch is firm. “Oh, yes. I don’t think there’s any doubt. Look at it this way: 20 years ago, if you had said everybody would have a cellular phone, people would have thought you were crazy. And now we’re all on computers, and so standardization in health IT and being able to communicate across cities and regions is only a matter of time. “In fact, Vanderbilt’s been very involved with a physician named Mark Frisse in Tennessee to knit together all the safety net hospitals in the state so they are all on the same IT system and have the same way of accessing data, which is a tremendous project and very exciting. And this will migrate across the country.” Conway-Welch is involved in the Initiative on the Future of Nursing, established by the Institute of Medicine in collaboration with the Robert Wood Johnson Foundation. According to the Institute’s website, “The future of healthcare is closely tied to the future of nursing, and it is critical to ensure that the nursing workforce has the capacity in numbers and skill competencies to meet present and future needs. The IOM committee will define a clear agenda and blueprint for action, including changes in public and institutional policies at the national, state and local levels. The committee’s recommendations will address a range of system changes, including innovative ways to improve healthcare quality and address the nursing shortage in the United States.” Despite her involvement, Conway-Welch has some concerns about the initiative’s aims. “In 1996, there was another initiative on the nursing workforce, and it was a well done commission with important thoughtful people, and their report sat on a shelf and collected dust. There are also
thoughtful, well-meaning, bright people on this 2009 commission, but it’s focused on nursing, and you can’t rethink nursing unless you rethink the entire delivery system. “Nurses, frankly, already know what to do to fi x it; we just don’t have the power to do it. Rethinking nursing, or rethinking medicine, or rethinking pharmacy, or rethinking physical therapy, are all worthwhile efforts. But until you get nursing, medicine, physical therapy and pharmacy at the table and have them rethink the health profession’s education and the health Colleen Conway-Welch is Dean of profession’s preceptorships and Vanderbilt School of Nursing. Her long career as a mentor to aspiring nurses heath profession’s residencies as and her work to raise standards in nursing education, improve emergency one unit, with the understandpreparedness and heighten HIV/AIDS ing that everybody will have to awareness led to her being named to Modern Healthcare’s 2009 Top 25 give up something, you’re not Women in Healthcare list. going to be successful. “I think it’s a wonderful initiative, but I don’t hold out a lot of hope that it will have an enormous amount of impact, because you don’t have all the other people at the table. Maybe this is the beginning of getting everyone involved, but rethinking nursing doesn’t do it for me. If you were to say ‘rethinking the health profession’s education’ or ‘rethinking health profession practice’ – that’s really the question that needs a lot of attention.”
Preparing for a pandemic Colleen Conway-Welch on getting ready for swine ﬂu’s second wave We already know that one of the most routine mechanisms to protect against H1N1 virus is to wash your hands for two minutes, and one of the things we teach our students is to sing Happy Birthday to yourself twice while you’re washing your hands. And also get under your ﬁngernails, because a lot of people don’t do that when they’re washing their hands. Simple things like that. Move the wastebasket close to the door handle of the bathroom so that you can open the door with your paper towel and throw it in the wastebasket and get out without recontaminating yourself. We’re looking right now at Vanderbilt about how we’re going to deal with the next wave of H1N1. If it hits badly, how are we going to keep teaching? We’re very computerized, and we can do a lot with technology over the internet. But we’re thinking ahead in terms of how that’s going to work. I think the vaccine is important, and I hope they role it out as fast as they can. But we’re going to have problems, there’s no question.
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SURGICAL INNOVATION Mayo Clinic’s Claude Deschamps outlines the hospital’s pioneering techniques in minimally invasive and robotic surgery. ased at Mayo Clinic’s biggest site in Rochester, Minnesota
Claude Deschamps has the hefty responsibility of overseeing and being accountable for 10 clinical research divisions, as well as one research group within his department. His role as Chair of the Department of Surgery entails the monitoring and steering of these different divisions in the right direction. “I obtain resources for them from the institution and help enforce and write new policies depending on the need,” explains Deschamps. Cardiac, vascular, gastrointestinal and general surgery are just some of the many divisions Deschamps oversees. As a physician-led organization, Mayo Clinic is a consensus-driven hospital and the department has a strong role within the overall institution. Deschamps is responsible for the implementation of the clinic’s strategic plan. He describes the plan as having a multitude of layers – orientation, mentoring, satisfaction and performance being some of these. It is based on the members of the department and its focus is in retaining, developing and attracting the best people. The basis of the plan is the people themselves – the
personnel in the department as well as the patients. “We would not exist without patients; the mantra here is dedication to quality, safety and service,” says Deschamps. Embracing discovery, teaching and communication through its academic excellence is also a layer to the strategic plan. Educating residents and allied health is essential, as is communication, which is needed to achieve this. Continuous discovery and the researching of new patents ensure that education is given priority. Practice advancement is another. “That means innovation in process improvement and new procedure, as well as supporting the recruitment of surgeons that will be trained in new procedures,” he says. You have to have a more adventurous vision, which means leaving room for innovation, but you must sometimes accept that there will be consequences when you start new innovation. In a culture like ours it’s not always easy, having been used to doing things the same way for 100 years. Sometimes it’s disturbing for some of us to see how things will be done from now on and the change that is required for the culture,” he says.
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As a clinician, Deschamps is mainly involved in thoracic surgery, more specifically either pulmonary and chest wall surgery or esophageal surgery, which he describes as his passion. This involves the repair of haital hernia, the treatment of gastroesophageal reflux and the treatment of esophageal cancer by removing the esophagus.
Minimally invasive Mayo Clinic was one of the first institutions in North America to write about quality of life and to study it within their patients. The practice asked the patients on how they thought the operation would change their quality of life, and would sometimes change operations based on what they would find through the patient’s information. Surgery is hugely important for the treatment of diseases, explains Deschamps, and the emergence of minimally invasive surgery has changed practices industry-wide. “For the patient it has been a huge change. A smaller incision means less pain post-op, a shorter length of stay and an earlier return to work. This is true not only of Mayo but also worldwide and in countries that have seen the difference between traditional and minimally invasive surgery. Of course, minimally invasive surgery is not for everybody, not for every patient and not for every procedure, but it has been a significant change. “It also changes the economy of scale that we see in medicine. While it has decreased the length of stay, it has increased the cost of the procedure be-
cause of the material that needs to be used to do those surgeries. Before when you conducted a traditional open surgery, you had a large retractor that was used every day, you didn’t use a special camera. With minimally invasive surgery, you have ports, you have a camera, you have expensive staplers and fancy suturing material that is more expensive.
“Robotic surgery is another aspect of minimally invasive surgery that has been seeing a lot of changes and improvements” “It has shifted the cost of taking care of a patient so that even if the length of stay is shorter, it has increased the number of supplies. It has also brought a higher profile role for the industry that supplies material – the camera, the screens, the staplers, all the ports – everything we use in surgery increases in applications because it’s increase in volume has prompted a whole new world for the industry. All the companies that serve the surgeons in the operating room have seen a huge increase in their business over the last 18 years because of this.”
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Deschamps adds that it has also brought innovation, as well as a bigger voice for the industry, which feeds the costs. Raising the bar of innovation, Deschamps recently performed the first single-incision total colectomy and explains that this new single-port approach uses a special device that is approximately 3.5 centimeters in size and compresses all of the traditional laparoscopic trocar sites into one site. “This means that rather than the four or five trocar sites and an extraction site for a traditional laparoscopy total colectomy, this all goes down to one incision which collectively is about the same as the total of the others. So instead of having three of four trocar sites measuring one centimeter each, and a separate incision of four centimeters to get the specimen out, you have one incision, one port about 3.5 centimeters,” says Deschamps. “So this is just another tool in the spectrum of techniques for minimally invasive colectomies. Mayo and other centers are working with Intuitive, the company that produced the robot, to develop a similar tool. Robotic surgery is another aspect of minimally invasive surgery that has been seeing a lot of changes and improvement. Anything that improves the number of minimal and excess colectomies is good for the patients in terms of pain, fewer complications, less time in the hospital and a faster return to work – the same benefits as for minimally invasive surgery. Unfortunately, currently only 15 percent of colectomies are performed in the minimal access fashion; here at Mayo about 60 percent are performed the minimally invasive way.” Most of the departments within Mayo Clinic are involved with clinical trials, be it lung cancer, esophageal cancer, breast cancer, robotic surgery, colon cancer or transplant surgery. Key to each of these is the focus on reduction: in the use of blood in trauma surgery, in lymphedema after mastec-
tomy in breast cancer and so on. Deschamps also questions if the same quality of surgery is done as when the robots are used. Can colon cancer be completely removed with localized resection without having even to make an incision by going transanally? He also explains that Mayo is currently focusing on transplant surgery and widening the implication to bring in more patients who need it and can benefit. “Right now there are millions of people worldwide on dialysis for kidney transplant and we can enlarge the donor pool by looking at rejection and assessing ways to overcome incompatibility. We’ve discovered that if you have a different blood group, by pre-treating some patients and doing certain changes we can enlarge the pool of patients that can give their kidney,” says Deschamps. “By giving a substitute to blood in certain patients, you can save life from the get-go using preoperative rehabilitation before major surgery and thoracic surgery. We are also using special sealants in lung surgery or gastric surgery in a bid to decrease the number of leakages. And it’s all down the line. “We have more and more patients that are having bariatric surgery for morbid obesity and now we have discovered that there is a need for younger patients; unfortunately, there’s a shift now in society where obesity is present in more younger patients, even teenagers. So we’re trying to see what type of procedure would be best. Would a ring around the upper stomach be better than doing major surgery on the stomach, which might have long-term effects that are worse than obesity itself? We’re trying to understand what’s best for our morbid obesity patients have. You can now find clinical trials in every single area of the department, and for that matter, of the major departments at the clinic,” he says.
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Infection control Public awareness of hospital-acquired infections during surgery is increasing and hospitals across America, Mayo Clinic included, are now heavily addressing the issues of infection control and prevention. Deschamps notes that the first thing Mayo is doing is assessing the universal aspects that the clinic is adhering to, such as maintenance of blood sugar within a certain range before the surgery, the patient temperature during the surgery and so on. The clinic currently has a team that is dedicated to the countrywide initiative ‘surgical care improvement project’ (SCIP) of which Mayo Clinic has set itself the target of 95 percent compliance. It is small measures that are regarded as making the big differences, such as providing the right antibiotics at the right time and for the right time period, which is within one hour of incision. SCIP is monitored during the hours of surgery and is incorporated into several departments, such as vascular, orthopedic, gynecologic and colorectal surgery. Each of these departments is au-
“We would not exist without patients; the mantra here is dedication to quality, safety and service”
dited each month to ensure that at least 95 percent of the patients answer to the right criteria. So SCIP is primarily focusing on the correct dosage of antibiotics that the government and the hospital have agreed on for the patient. “You should not give an antibiotic for longer than 24 hours for elective surgery. Also for some of our patients that are at high risk of infection we added the pre-op showers, such as those undergoing cardiac surgery, coronary artery bypass, patients that are obese or have diabetes and are more at risk. We have clinical protocol for those patients to reduce infection, but we are adding pre-op showers and special soaps before the surgery. The patients are all admitted to the clinic the morning of the surgery, nobody’s admitted the night before because we all know that spending more time in the hospital increases the risk of infection. “Nowadays there’s almost no elective surgery done with the patient admitted in the hospital. That’s another initiative. Of course, there is a huge hand-washing initiative that’s been in full swing and has been now for more than two years – the physicians and surgeons are being audited and are not only encouraged but also forced to wash their hands every time they come in and out of the room of a patient. This is an institutional measure. “Another measure that has been in affect now for a number of years is that we have noted that shaving the patient before surgery causes injury to the skin, so now we use clippers rather than razors before surgery, especially minutes before the patients are operated because the razors are causing microtrauma; they make the patient bleed and that increases the risk of infection. “So there are initiatives at several levels that are all aligned during the operation. The big institutional initiative of trying to prevent infection and forcing isolation of patients that have communicable organisms is strictly
enforced. When a patient is isolated because they have a hospital-acquired infection, the personnel observe the isolation very strictly,” says Deschamps.
Innovation Mayo Clinic is also pushing the boundaries of innovation with its natural orifice transendoscopic surgery (NOTE). Dr. Bingener-Casey, a surgeon at the hospital, is currently researching the area and is starting two new clinical protocols that will look at transvaginal hysterectomy, transvaginal cholecystectomy and transgastric cholecystectomy. Her collaborative work with Dr. Chris Gostout, a gastroenterologist, is described by Deschamps as one focus of innovation within the department. “As well as this, we have two young vascular surgeons that are working on branched endograft with vascular surgery hybrid procedure – we have a minimally invasive incision where the vascular surgeon slips a graft inside the artery through the groin, and those grafts are several branches, more than the usual proximal and distal branches that are branching into visceral branches like the renal artery and the digestive visceral artery. “We have the robotic incision in cardiac surgery. Our cardiac surgeons are repairing the mitral valve with a robot with small incision, resulting in the patient going home in three days. You have surgeons working on an artificial liver as well as surgeons that are expanding the indication for solid organ transplant to a wider group of patients, such as a patient with cancer of the liver. Cholangiocarcinoma is a cancer that is usually localized but destroys the liver, and we have now transplanted several patients with cholangiocarcinoma, which is an active area of research, also the area of ABO incompatibility where we’ve been able to expand the group of patients being transplanted.” Deschamps explains that the department is attempting to expand the brainiac surgical treatment to a wider group of patients, looking at the genomic predicator of clinical outcome in lung cancer. There are currently only a few institutions in the US that have the patient pool to understand the epidemiology of lung cancer in terms of what type of genome or gene can tell the prognosis of a tumor. However, he notes that the staging classification of the clinic is not precise enough, especially not as medicine increasingly aligns with individualized medicine and it is now a requirement to be able to tell a single patient’s prognosis as precisely as possible. “Strengthening the original response to trauma, we are now part of a regional trauma center where we can provide a bigger and a better response to the trauma patient,” says Deschamps. “The final area of research that this department is involved with is quality and safety. We have written several publications in recent months and years about human factors and safety in the operating room environment, the quality provided and the changes needed in processes to improve the quality that is delivered to the patient in the operating room, such as communication. “In relation to this, our involvement in the national database has increased significantly, which is a reflection of our desire to understand more about our outcomes. And this is part of a new area of clinical outcomes,” he concludes. Mayo Clinic is certainly embracing clinical research discoveries and raising the bar on minimally invasive techniques, making following in its footsteps a hard job to follow. Claude Deschamps is Chair of the Department of Surgery at Mayo Clinic.
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PLANE AND SIMPLE The Surgical Safety Instituteâ€™s Richard Karl tells Stacey Sheppard how a few straightforward lessons from the aviation industry could revolutionize patient safety during surgery.
verybody makes mistakes, and while some mistakes are inconsequential, others have the capacity to provoke catastrophic consequences. Th is is particularly true for people working in industries such as healthcare and aviation, where lives are quite
literally on the line. Richard Karl is a nationally recognized cancer surgeon and 737-type rated pilot who, in 2004, decided to use his unique insight into the aviation industry to help bring improved safety to operating rooms across the country. Inspired by the success of aviation safety techniques and knowing that the same methods could be applied to surgery, Karl pulled together a team of nurses, aviation experts, physicians and computer programmers and founded the Surgical Safety Institute (SSI).
The US airline fatality rate has declined continuously since the Federal Aviation Administration (FAA) mandated, in 1979, that all commercial airlines implement crew resource management – a system of intense, focused communication, teamwork training and operations designed to increase safety. The dramatic advances seen in commercial airline safety over the last 30 years convinced Karl that the successful lessons of the airplane cockpit could translate to the operating theater. “We had a different way of looking at things in aviation than we did in medicine and in surgery in particular, so it seemed pretty obvious that we ought to be able to improve safety by using some of these techniques that have been around in aviation for 30 or 40 years,” says Karl. Modeled on Flight Safety International – an organization that undertakes the bulk of the training worldwide for those working in aviation – Karl founded the Surgical Safety Institute and was able to take training to smaller institutions that might not have had the in-house resources to develop safety techniques, training and re-certification. “A lot of what they learned in the airlines was that even after the development of the jet engine, they were still flying perfectly good airplanes into mountains,” explains Karl. “Even though the co-pilot might have known there was a problem, the hierarchy in the cockpit between the captain and the other crew members was so steep that they were following the captain’s order out of this Geheimrat notion of what the hierarchy ought to be.”
by wanding and radio frequency, things that can detect a sponge, and by looking at human factors such as counting tools, knowing who is responsible for them and improving how teams work together so that they don’t leave anything behind.” Karl cites a recently published article about the introduction of checklists into eight hospitals around the world. The use of these checklists in
“Although we kill 100,000 people a year, this is over 6000 hospitals, which is sometimes known as the tyranny of small numbers” operations allegedly cut the mortality rate in half and the morbidity rate dropped by approximately 38 percent. This is one of the lessons that they have taken from the aviation industry. Another is the decision support tree that aviators use – the quick reference handbook. Th is outlines what to do if a generator stops or if an engine quits and until now this was not something that was available in medicine, despite the fact that it is relatively easy to put together. “It just seems like there is so much to borrow from submariners, nuclear power and aviation. It doesn’t cost much. You don’t have to discover a gene. Its all simple stuff,” says Karl.
Lessons learned The issues with hierarchy have since been addressed by the airlines Falling behind and now, if you look at the criteria that many of them have for hiring – at In comparison to industries like aviation or nuclear power submarine least here in the States – decision-making with input for others and setting services, which have transformed themselves over the last 30 years, Karl the tone of open communication are both high up on the list of priorities. believes that medicine is severely lagging behind. But, according to Karl, this has not been the “There are 6000 hospitals in the US and it is escase in medicine: “If somebody’s bright and they timated that there are 15 million incidents of harm pass all their exams, they go to medical school. per year in those hospitals. Th at’s 15 million patients And if it’s a prestigious one, they often get hired getting the wrong knee operated on, getting a sponge without any assessment of their communication left behind, getting the wrong drug or the wrong abilities.” dosage. That’s a lot of mayhem, most of which can The SSI is keen to rectify this situation by be avoided with some simple training and some crew training people to improve how they work together. resource management.” “The relationship between surgeons, anesthesioloBut Karl is quick to point out that not everyone gists and nurses is quite isolated into separate silos is keen to adopt new practices: “Physicians and surand rarely do we work together as a team to get a geons have always been trained to think that they safe outcome,” says Karl. are special and pretty terrific and the idea that they “In the States alone, it is estimated that there might make a mistake or that using this checklist are 100,000 lives a year lost due to medical error. would slow them down is really in the front of their About half of those occur around an operation of intelligence. They get their backs up and there is a one sort or another. And that doesn’t count the fair amount of pushback.” other things: operating on the wrong knee; surgiAt this point Karl recounts a quote by ProfesRichard Karl is Founder and Chairman of the cal site infection; retained surgical items that get sor James Reason, who is widely recognized as a Surgical Safety Institute. left behind inside somebody – things that would world-leading expert on human error. During a 2003 just be unthinkable in aviation. conference at the Royal College of Physicians in the “Leaving a surgical implement behind is the equivalent of landing UK Reason, said: “Aviation is predicated on the assumption that people with the wheels up, but this never happens in the airlines. Yet in the screw up. You (healthcare professionals), on the other hand, are extenUnited States alone we leave 1500 tools a year behind,” reveals Karl. sively educated to get it right and so you don’t have a culture where you “And that is something that you can address, both technologically, really have a notion of error. It’s something of a big sea change.”
So the obvious question is why, if the aviation industry addressed this problem 30 years ago, has the healthcare industry failed to follow suit? For Karl, one of the main explanations is the fact that those in healthcare are largely unaware of how much trouble they cause. “In any one institution the number of times that the workers in that institution would be aware of the fact that a sponge got left behind or that the wrong ear was operated on, is relatively small. So although we kill 100,000 people a year, this is over 6000 hospitals and it might be in the dialysis unit or the surgical area and not elsewhere in the hospital.” This, he says, is sometimes known as the “tyranny of small numbers” and is why Karl and the SSI believe that it is something we need to draw attention to, because the size of the problem is not immediately obvious. As he points out, if a jumbo jet were to crash and kill 300 people, it would be all over the newspapers. So airlines and pilots are highly motivated to avoid that. But even if people were more aware of the enormity of this issue in healthcare, there is still the problem of implementing change. As Karl sees it, the main obstacle to this is the fact that in the US there is no over-arching national health service that can mandate it. The people who make the rules are well intentioned, but as he points out, it is sometimes difficult to get rules passed as they are merely viewed as hindrances that could potentially decrease the flow of patients through the system.
they first do an assessment, set up focus groups and examine the policies and procedures in place. Once this has been done, training is conducted and if there is discordance between the nurses, surgeons and anesthesiologists, the SSI listens to their gripes and then trains them to identify problems, speak up when necessary and listen to others. The most important part however, is sustainability. “Recurrent training and re-emphasis are an absolute essential part of aviation,” says Karl. “Captains are back every six months for a check to see how they fly the simulator and whether they know about the near miss that occurred at Heathrow two weeks ago, why it might have happened and what we’re going to do about it. We share errors frequently in aviation, across all airlines, all across the world. “So we try to do that in healthcare with recurrent evaluations and come back, see where the hot spots are, what’s worked, what hasn’t and frequently there will be three or four early adapters who get it and they become useful in spreading the word,” he says. Communication, for Karl, is where it all begins. “If you look at the number one criteria by which captains at most airlines are evaluated, it’s not landing the plane. It’s not taking off. It’s promoting an environment that solicits communication. So that’s the key and that involves cultural change.” In healthcare, Karl believes, there is a need to learn how to respect
“We need to have training programs in medical schools that make students aware of the incidents of error and what the human price is. In the States, $50 billion worth of expense is incurred just by these errors”
In the United States, 1500 tools a year are left behind in patients following surgery
He also identifies what he refers to as latent factors as being part of the problem. Th is is where the institution allows habitual violations of the rules or it fails to acknowledge that a surgeon has made a mistake and act accordingly. “Until institutions are willing to discipline that sort of thing, until there is an over-arching body in medicine, which is going to make sure that this kind of training takes place, it’s really about trying to appeal to people’s better interest and sometimes that’s a hard sell to busy people,” says Karl. So in the absence of such a body, how do we go about bringing healthcare into line with other industries? Well, one way of doing this, according to Karl, is to catch healthcare professionals early on in their education and training. “We need to think about how we even accept people into medical school programs based on their ability to work well with others, not just their ability to pass an exam or know a lot about physics or mimic back to us what we think are the criteria for good doctors,” explains Karl. “We really need to start thinking about their emotional intelligence as well as their scientific intelligence. We need to have training programs in medical schools that make students aware of the incidents of error and what the human price is. In the US, $50 billion worth of expense is incurred just by these errors,” he says. However, it is perhaps unrealistic to think that errors can be completely eradicated, although they can be managed, and this is where the SSI comes in. It is tackling the problem on a case-by-case basis, by offering consultations, training and support. When called into an institution
the perspective of others, to understand the roles of colleagues, to investigate things when they don’t go well and to use near miss reporting to help you learn and avoid mistakes in the future. The hardest part of this, as Karl sees it, is the will to see it through. “You have to have the institutional will and commitment in order to make these changes take place. That basically boils down to being willing to back-up the people who see it in the new way and to commit to sustainability training and recon training.” But as we strive towards the utopian vision of an error-free healthcare industry, Karl does fi nd the situation somewhat frustrating: “If you went to a major research or drug company with a pill that could cure breast cancer – a disease that accounts for 42,000 deaths a year in the United States – you’d make a ton. And you’d be well received by the FDA and the Institute of Health. The fact is that by doing these simple things, if we cut the number of needless deaths in half, it’s the public health equivalent of curing breast cancer.”
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Operational excellence EHM talks to two industry experts about the beneﬁts of integrated operating room solutions. With Jim Cloar of Medtronic Navigation and Olympus Medical Systems Group’s Richard Harada.
Tighter financial constraints and growing staff shortages are making it more difficult for hospitals to meet their operating room performance needs. What can they do to optimize operating room procedures? Jim Cloar. It really comes down to workflow and familiarity in the OR. A team’s protocols and how they work together can be aided or impinged by the physical objects and information sources in that OR. Seamless integration between equipment vendors is an absolute must, as is a centralized information source so that everyone is on the same page and there is no need to examine multiple or divergent sources. An information hub that is updated frequently provides them with one less thing to have to worry about so that they can focus on the procedures and the patients at all times. Simplicity and familiarity with all the technologies enable any staff member to carry out the protocol, even if they are a new or visiting team member. Richard Harada. Systems integration, before anything, can help facilities meet their operating room performance needs as well as generate potential savings through improved efficiency, reduce work hours, and enhance communication and collaboration. Remote control of laparoscopic instrumentation and the ability to view and collaborate remotely in and out of the procedure room will help lead the way. What are the advantages of implementing an integrated operating room solution? RH. In implementing an integrated operating room solution, the possibilities in terms of advantages are endless. Efficiencies and collaboration are immediately improved. The
Jim Cloar was named Vice President and General Manager of Medtronic Navigation in May 2007. He leads the Louisville, Coloradobased company, which is the leading provider of integrated navigation and intraoperative imaging solutions in the world. Cloar has held a series of increasingly broadreaching and strategic roles in the spinal and biologics business, most recently as Vice President and General Manager of the Thoracolumbar Spine business line. Richard Harada serves as the Director of Marketing for Olympus Medical Systems Group’s Systems Integration business unit. He has over 25 years of experience in product development, marketing and sales management in hospital information systems. Harada’s expertise lies in radiology image archive systems, data storage systems and integration systems.
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surgeon and team are working with the best technology in doing what they do best – providing patient care. Educational opportunities, with streaming video capabilities, are further enhanced in the form of broadcasting procedures to medical students who now do not have to be in the room. Monitors and displays are everywhere, preventing any leaning over of the surgeon’s shoulder throughout procedures as well. The entire team enjoys an optimal view of what is going on at all times. The OR environment also remains clutter free and without any troublesome cords throughout the room that can only cause inefficiencies amongst the OR team. JC. There are numerous advantages. Let’s take a neurosurgery suite as an example. The surgeon must absorb so many disparate data points on the same patient for a single procedure in order to be as precise as possible when going in to operate on that patient’s brain. Having all that highly complex data come together for the surgeon in the OR in a single ‘map’ enables precise surgeries and allows the OR staff to follow along with confidence. What specific equipment and technology can be used to enable surgical, clinical, engineering and IT staff members to reach their integration goals?
“Interconnectivity is a must now in our digital era, DICOM is just the tip of the iceberg” Jim Cloar as other vendors’ scanners. Medtronic strives to be an open architecture firm in order to meet biomedical engineering and hospital IT staff needs. We offer an iOR suite of solutions that provide additional services for integration, beyond navigation and intra-operative imaging. RH. The specific equipment and technology utilized by staff members in reaching integration goals will vary and be dependent on each facility’s specific needs and potentially the capabilities of their current system in incorporating those with the new technology. Some of the new technology to be considered would be wireless medical grade displays, long-term video archive server solution, and web browser-based viewing of procedures for those in training, such as residents, interns and fellows. How do you see the area of operating room integration developing within the next few years? RH. In the coming years, technology and innovation will continue to lead the way within the operating room and systems integration will be the solution to bring it all together in allowing facilities to stay competitive and continue providing the best patient care possible. Going forward, some of the key areas that will play a major role are video streaming through networks, multi-viewing displays teamed with real-time information, RFID technology for tracking patients and data, 3-D imaging displays, and the ability to archive video and still images in an EMR system for better handling and preparation of patient records.
“In implementing an integrated operating room solution, the possibilities in terms of advantages are endless” Richard Harada
JC. Taking again the example of a neurosurgery suite, we have a lot of experience integrating both image-guided navigation and intra-operative imaging to provide a seamless and dynamic information hub in the OR. The patient’s information can be updated live, while they are undergoing surgery. Surgeons and surgical staff enjoy the benefits of a more ergonomic, information-rich OR in which to work. Interconnectivity is a must now in our digital era. DICOM is just the tip of the iceberg in terms of what will still transpire with electronic health records (EHR) and other digital information trends occurring in the healthcare market. Our StealthStation i7 is a fully boom-mounted navigation solution that can inter-operate with Medtronic intra-operative imaging solutions (PoleStar Surgical MRI system and O-arm 2D/3D Imaging system) as well
JC. I think that operating room integration will continue in many different geographies around the world, and not only in the emerging markets. Data convergence and interconnectivity have hit the healthcare world, just as they did in telecommunications over a decade ago. Integrating the OR suite is just one more step to always having accessible data for the surgeon and the surgical staff, with the ultimate goal of optimized patient care. In terms of the vendors, the key to their success will include their services delivery track record and their closed versus open architecture approach. I believe that a positive services track record and open architecture flexibility will dictate which integrated OR vendors remain at the top of the preferred partner charts. n
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Nakazawa ed:16 nov
RIGHT VEIN Nadine Nakazawa of the Association for Vascular Access talks to EHM about the current challenges in the ďŹ eld.
Nakazawa ed:16 nov
n 1985, Suzanne Herbst, a nurse working in home infusion, brought together a group of her colleagues with the aim of promoting consistency in vascular access care in the greater San Francisco Bay area. The group, which came to be known as the Bay Area Vascular Access Network (BAVAN), quickly grew to include people from all over northern California and beyond. Now called the Association for Vascular Access (AVA), it has become an international organization serving members around the globe. Nadine Nakazawa has been involved with AVA from the very beginning, and recently served as President. Vascular access became Nakazawa’s professional focus as well: she started the peripherally inserted central catheter (PICC) program at Stanford Hospital in 1990. The Stanford PICC program has grown from an initial placement of 20 PICC lines in the second half of that year to now placing more than 2000 PICC lines a year. In her work, Nakazawa focuses primarily on central venous access devices, and within that, on central venous catheters, with about half of these being acute care central venous catheters. She points out that the advantage of a central venous catheter is that it provides reliable venous access. “What happens in chronic illness, acute serious illness, or prolonged need for IV therapy whether it’s acute or chronic, is that patients’ peripheral veins quickly become damaged and diminished over prolonged usage,” she explains. “It could be a matter of days or weeks, months or years. The damage tends to be cumulative, particularly during the acute phase while patients are in the hospital getting multiple venipunctures for repeated peripheral IV restarts. Often the sites have to be rotated more frequently than what the CDC recommends, which is no more than every 72 hours to prevent infection, but the reality is that the drugs that we put in are very damaging to the peripheral veins. “Peripherally, problems can be caused by anything that has a pH that’s less than five, which would mean very acidic; or greater than nine, which would mean very alkaline; or has an osmolality greater than 450 milliosmoles per liter. That means the particulate concentration of the chemical or the drug is greater than what can be handled by the peripheral vein walls. Some drugs, by their chemical design, are inherently irritating or they can cause tissue necrosis if they leak out into the surrounding tissue.” Nakazawa explains that this category of drugs is called vesicants. They can quickly cause damage to the peripheral veins, and the IV pump pressures can also damage the very small veins in the lower arm and hand. “As a result,” says Nakazawa, “patients end up getting poked repeatedly over a course of hospitalization or outpatient infusions or chemotherapy, or if they’re in the hospital for any extended period of time, and central venous access is essential for proper delivery. “Many of these medications cannot be interrupted; patients, for example, in the critical care setting may need to have medications that are infused continuously at a certain prescribed rate to be able to support their blood pressure. They may require antibiotics, or antifungal or antiviral drugs. Because of their complex IV therapy needs, we need to find a reliable way to deliver
that IV therapy. The selection of the right device for the right patient at the right time is critical, taking into consideration their total IV therapy needs while they’re acutely ill, but also their long-term and chronic IV therapy needs. “The correct insertion technique, both technically and in terms of preventing infection and other kinds of complications, is critical for the proper functioning of these devices. And then the proper maintenance of these devices during the dwell time is also critical. The person who inserts the device releases it to the staff nurses to use it. “We also teach patients and family members to take care of the devices outside of the hospital, because they need to maintain them in terms of functioning and preventing infection. They also need to protect the site where the catheter exits out through the skin or access it through the skin if it’s an implanted port, as well as access it for lab draws and infusions through the ports, to prevent complications for the patient.” Complications caused by improperly inserted devices could include infectious complications and thrombotic complications, plus a multitude of others that, as Nakazawa points out, require someone in the healthcare organization to take responsibility for education and policies and procedures that are evidence-based. “There is a need to conform to national guidelines, and those competencies are based on those policies and procedures. So somebody has to take responsibility to ensure that the people who use these devices are competent according to a consistent manner,” she underlines.
“The selection of the right device for the right patient at the right time is critical”
Making a choice
Because vascular access arose from different, very specific, areas of medicine, this can sometimes lead to confusion as to which device to use in a particular circumstance. For example, those working in dialysis are interested in gaining access into the bloodstream for hemodialysis, so the science around dialysis catheters falls into the realm of nephrologists, vascular surgeons and interventional radiologists, plus dialysis nurses. But Nakazawa notes the risk that people outside of dialysis may be tempted to use these devices, creating a huge risk for patients. Catheters used in the intensive care and critical care setting include acute care central venous catheters placed for monitoring purposes, for the delivery of multiple infusions and drips. These would be placed by surgeons or by anesthesiologists or intensivists. In surgery, catheters are primarily placed by anesthesiologists, and sometimes by vascular surgeons or general surgeons. The majority of peripheral IVs are placed by nurses. In oncology, long-term central venous catheters are placed by surgeons or interventional radiologists. Most peripherally inserted central catheters are placed by specially trained registered nurses and the rest are placed by other disciplines. The result is that, because most of these people are specialists in particular areas, they look at the patient’s immediate rather than long term needs. This situation, in Nakazawa’s opinion, highlights the need for a vascular access specialist: someone whose specialty is around the science and promoting best practices in vascular access, and who takes both the short-term and
Nakazawa ed:16 nov
the long-term view of each individual patient. “They would also take into consideration the published evidence and best practice guidelines so that their selection of the device and technique in placing these devices is usually much more optimal,” says Nakazawa. “For example, a patient comes in with an aneurysm in his aorta that’s dissecting, and he ends up going for emergency surgery for repair. Either in the preoperative area or in the emergency room, an anesthesiologist places an acute care central venous catheter to get the patient through this major surgery. “The patient may be elderly. He may be obese. He may have other comorbidities and end up going to the ICU; and now staff are having trouble taking the breathing tube out of the patient because of these other chronic underlying health problems that weren’t problematic before the surgery. “Or the patient could have chronic underlying lung disease. Maybe he’s been a smoker. Maybe he’s diabetic. All of these confounding co-morbidities come into play and affect the patient’s ability to recover from this surgery. The longer the patient is intubated, the more he is at risk for other healthcare problems such as post-operative and ventilator-associated pneumonia. Maybe also wound infection if he has poor wound healing and he’s diabetic.”
Big picture “Most clinicians look at the immediate need,” Nakazawa continues, “but if you take just one step back and look at the overall situation, you may see this critically ill patient who now has multiple medical problems that started from something that was fairly catastrophic and had it not been treated he would have died. Now he’s in the ICU, and he’s developing complications because of his underlying co-morbidities. Maybe he has a wound infection or he contracts an MRSA, and he needs prolonged antibiotics.”
Nakazawa explains that such a patient would probably need four to six weeks worth of IV antibiotics, along with support for blood pressure and pain management. There will be many infusions, and if he’s unable to eat he may need total parenteral nutrition so that he could be fed intravenously. He would also have a lot of IV therapy needs, prompting the physican to order a peripherally inserted central catheter, which can stay in place for weeks or months at a time. However, a vascular access specialist, such as a PICC nurse, would look at the patient’s history and his lab work, but she would also note that the patient is approaching either renal failure or renal insufficiency, and that he has evidence of chronic kidney disease. If he’s young enough, Nakazawa says, in his 40s, 50s or 60s, the nurse may say, “Is he going to progress to chronic renal failure, in which case we will need to preserve one arm for the surgical build of an arteriovenous fistula,” meaning the artery is connected to the vein in either the forearm or in the upper arm for hemodialysis in the future, which is the safest device for hemodialysis. “If you place a PICC line,” Nakazawa points out, “or you place an acute care catheter in the subclavian vein on that side, the resultant scar tissue will preclude the ability to build an AV fistula. You have to preserve the veins on one side, so it’s the vascular access specialists in hospitals that are going to alert physicians to this, and develop a program around it.” The problem can be finding such a vascular access specialist. Many are interventional radiologists who consider themselves vascular access specialists within their specialty. There are also, within interventional radiology departments, physician assistants or nurse practitioners whose primary focus is on a vascular access service within the interventional radiology department.
Nakazawa ed:16 nov
Specialists needed These types of physicians and other specialists place longer term catheters or dialysis catheters, as well as carrying out all of the complication management and diagnosis or treatments of complications related to vascular access. They may also place peripherally inserted central catheters. Outside of the interventional radiology department, there may be vascular surgeons or general surgeons who consider the specialty of vascular access to be a very big part of their practice, and they may be the advocate in their hospitals for best practices. Amongst nurses, it could be an IV team or a vascular access team or PICC team. Nakazawa gives the example of Stanford, where there is a PICC team of five people. All orders for PICC lines come through them, and they place all PICC lines. If they are not successful, they refer the patient to interventional radiology for an alternate type of vascular access device. “If we deem a patient not to be a candidate for a PICC line,” Nakazawa says, “we would also be the ones to make that evaluation and refer the patient to IR. For example, a patient may have cellulitis from a wound infection and need four to six weeks worth of antibiotics. But when we look at her history, she may have had breast cancer and bilateral mastectomies and lymph node dissections. We would not want to place a catheter in either arm. It’s contraindicated. We would be able to determine that by looking at the patient’s history, talking to the patient, talking to the physician, or a combination of all three. “We would make the recommendation that the patient is not a candidate for a PICC line, but she would be a candidate for a small-bore tunneled catheter placed by the vascular access service in interventional radiology. So we would call the physician and say, ‘Would you like me to make that referral?’ And then we could take care of it. We could also do teaching with the patient as to why this is the recommended device for her.”
who have had PICC lines in for over a year and they may be treated in the cancer center associated with Stanford, but they may also be going back home to their communities, and maybe a nurse in a doctor’s office is also drawing labs or giving infusions there. It’s very hard to keep track of an individual patient’s contact points with every care provider along the trajectory of the dwell time of their catheter.”
Future directions In terms of the future, Nakazawa says the AVA will focus on a couple of key projects, including the development of a certification exam for clinicians that will test people’s knowledge and articulate the curriculum it expects of users and inserters of these devices.
“Complications can occur when people do things because somebody taught them that way, and it may not be based on any cumulative science or understanding”
Keeping track Another issue in vascular access revolves around the difficulty of monitoring of patients with devices inserted once they are out in the community. “Most hospitals have a great deal of trouble tracking that kind of information because patients do go from setting to setting once they leave the hospital,” Nakazawa concurs. “They may go to a skilled nursing facility and have the infusions managed there, but it will be the home infusion company that will take responsibility. They may go to an ambulatory outpatient infusion center. They may go to a doctor’s office for their infusions or they may go home and do their own infusions through a home infusion company. “It’s very, very difficult. Most hospitals are unable to track patients once they leave the hospital. One hospital that does a great job in tracking their patients is the MD Anderson Cancer Center, but they have a huge IV vascular access team of about 65 clinicians; and they do track all 10,000 of their patients per year, both inpatients and outpatients. “It is not an easy thing. You have to have the manpower to do it. You have to have tremendous administrative support, and you have to have the ability to maintain that kind of communication with patients. I’ve had patients
“There is knowledge that we teach across the country,” she says. “We will bring experts together to define what that curriculum should look like. People have their own individual ideas and there is some consensus, but we need to articulate that. That’s going to make a huge difference, because then we will be able to go into hospitals that have no idea that vascular access is a specialty, and say, ‘Here is this specialty knowledge. You have people who are inserting devices who may or may not be adhering to already published national guidelines and to best practices.’ “We want to be the voice of vascular access to articulate what is best practice; so we hope to create better consistency in both baseline education and advanced education around vascular access. We also want to promote research around both the design and functioning of devices, as well as research into behavioral aspects. “Our goal is certainly prevention of complications. But after articulating best practice, you then need to promote the education around it and then you need to promulgate that widely. “Those of us who consider ourselves to be experts in vascular access certainly see many hospitals and healthcare organizations at which no one recognizes that this is a specialty; they look at it as a device and its care as a task. If they don’t understand the bigger picture of vascular access, complications can occur when people do things because somebody taught them that way, and it may not be based on any cumulative science or understanding. “That’s why we have a national problem with unnecessary infections, unnecessary thrombotic complications, and a much worsening vascular access situation for serious and chronically ill patients, because of the overall inconsistent and often poor practices across the country. It’s a national issue, and an international issue.” Nadine Nakazawa is immediate Past President and Presidential Advisor for the Association for Vascular Access.
Teleflex ed:26 June
ASK THE EXPERT
Preservation protocol Nancy Moureau tells EHM of the proactive management of vessel health.
ith more than 3.8 million central venous catheters (CVCs), two million peripherally inserted central catheters (PICCs) and 310 million peripheral intravenous devices sold yearly in the US, vascular access is clearly a high volume, high usage procedure for patients
sessment. Final device selection is placed within 48 hours using central line bundle with the central line insertion prevention (CLIP) checklist. The third is right line/right time daily review. Daily assessment is performed during rounds to determine necessity and evaluate changes in acuity/medications. Central line bundle is applied to all care and maintenance proce-
ing, patient education and a process for implementing this education. Fast, well-directed treatment following diagnosis is the hallmark of efficiently managed hospital systems. Costs are controlled when patients receive a vascular access plan that is immediately implemented, assessed daily and adapted as needed, with evaluation at the end of the process. Using new technology in placement of safety dures. The fourth is outcome evalCVCs, such as the Accelerated uation. Prior to patient release, Seldinger technique, may recompliance to program is meaduce delays in device access. sured to evaluate vessel health and Roadblocks occur when pacomplications and provide educatients fail to receive a vascular tion to staff. access plan. When peripheral veins for intravenous access Selection process are exhausted or develop The selection process incomplications, precious time corporates multidisciplinary asis lost identifying the right pects through selection of the person and device for placeright device, placement, and ment. Process flow is imdaily assessment by the physiproved when a vessel health Nancy Moureau is a Vascular Access Consultant, educator, and cian, nurse and other team and preservation program inper diem clinician at Greenville members. The goal is to proacstitutes an intentional selecMemorial Hospital in Greenville, SC. She is the founder and CEO tively drive patient-specific detion and placement process of PICC Excellence, Inc., a corporation established for vice placement within 24 to 48 with indicators of daily suctraining, education and hours of admission. cessful function, which will consulting on PICC lines. National guidelines from speed the patient to better agencies such as the CDC and health and discharge. Society for Healthcare Epidemiology (SHEA)/ A program built with a vessel health and Infectious Disease Society of America (IDSA) 2008 preservation clinical pathway ensures patientsâ€™ Compendium Strategies (SHEA 2008) are a part of right to safe and timely drug delivery, reinforcthe vessel health and preservation program, through ing the core message: the right line for the right insertion and daily assessment of the patient and depatient at the right time. vices chosen to administer treatment. The Institute For more information, please visit for Healthcare Improvement central line bundle in www.piccexcellence.com ,
â€œThe goal is to proactively drive patientspecific device placement within 24 to 48 hours of admissionâ€? receiving medical treatments. Getting the right intravenous device placed early in the hospital stay can speed treatment and patient discharge while minimizing expenditures. Vessel health and preservation has become an important issue, as patients now come to hospitals more acutely ill, living longer and often having chronic conditions. According to the Centers for Disease Control (CDC), selection of the right device inserted into the right location is paramount to reducing complications, specifically infection. In 2008, a multidisciplinary task force of vascular access experts created a conceptual model defining a vessel health and preservation protocol. The protocol incorporates a systematic process driving selection and placement of the right line upon admission through end of care. The steps for protocol implementation include, firstly, right line selection. The vessel health and preservation program is initiated through standing orders, allowing line selection within 24 hours. Device selection is based on diagnosis, therapy and pharmaceuticals. The second step is right patient assessment. Once a device is selected, a patient assessment is performed, including admission risk assessment, critical factors/acuity and vein health as-
the insertion process is evaluated through the CLIP checklist, which measures compliance with the bundle and other infection prevention practices. Education is ongoing, with the vessel health and preservation program providing preventative education in keeping with the Joint Commission National Patient Safety Goal 07.04.01 requirement for insertion, care and maintenance train-
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Pitney Bowes’ Johnna Torsone explains how the company’s approach to employee wellbeing could offer a solution to the nation’s big healthcare question.
revention is better than cure. Though such a sentiment may appear to be self evident, it has taken quite a while for business to catch on. However, spurred by the rising costs of healthcare, organizations are now starting to take notice. Once looked upon as little more than an insignificant element of a traditional treatment-focused healthcare offering, wellness programs are steadily gaining prominence. Even President Obama is examining how wellness can be used to address the nation’s mounting healthcare woes. But for Pitney Bowes’ EVP and Chief HR Officer Johnna Torsone, the benefits that wellness can bring come as no surprise. For nearly a decade, the company has been refi ning its approach to employee healthcare, with every step taking it further from the old reactive model. The results show that a more proactive approach can reap big benefits. “That was the big thing that Pitney Bowes discovered,” says Torsone. “Now it’s everybody. There are more and more companies that have recognized that. That was the ‘aha moment’ that Pitney Bowes came to in the early part of the century; we recognized that we needed to educate people. We needed to design our plans so that people would engage and be incentivized to engage in the healthy maintenance of those chronic diseases and undertake behaviors that would help them not get into those chronic diseases in the fi rst place.” At the heart of Pitney Bowes’ plan is a targeted response to the most commonly occurring, and therefore most costly, illnesses that affect the workforce. “One of the chronic diseases that we saw drove our cost was diabetes,” continues Torsone. “We knew that if people maintain themselves appropriately then the cost at the back end from complications from failing to keep their insulin levels at the required amount would be significantly higher. What we’ve done is we’ve tried to remove the barriers around cost to drugs and from procedures that help them maintain themselves on chronic diseases like diabetes and
asthma and high blood pressure. We’ve made it easier for them to stay on the appropriate medication to do that. As a result of that we’ve seen our cost for emergency room visits and significant complications from those diseases go down.” Key to making wellness pay is bringing the workforce on board. Employees need to know what value these programs can bring. “I would say it’s a combination of education, plan design, actual provision of services and subsidizing things like wellness visits, vaccinations and screenings,” says Torsone. “We keep designing our plans to help discover problems before they become major issues so that employees can take responsibility for trying to stay healthier and trying to remove barriers around the utilization of tools and medications that will keep them productive and well as opposed to allowing it to get much more severe. Having them end up in emergency rooms when it’s unnecessary and not having them be as productive as employees as they could be.” Torsone tells us about Healthcare University, a branded program designed to steer people down the path to better health. Employees agree to focus on four or five key points, such as smoking cessation, weight reduction or even just promising to wear a seatbelt when driving. Perhaps most importantly, all this self-improvement is supported by a monetary incentive. You might think that being helped towards better health would be reward enough for participants, but Torsone argues that effectively changing ingrained attitudes requires a great deal of persuasion. “There are some companies that have built penalties into their program, for failure to do some of these things,” she says. “Up to now we’ve taken a different approach to that. We’ve made it much more of a carrot as opposed to a stick.” But even with these incentives, making the shift to wellness is a slow process.
“I would say it’s a combination of education, plan design, actual provision of services and subsidizing things like wellness visits, vaccinations and screenings” “None of these things, by the way, are things that work in a very short period of time,” she continues. “It takes time to build up to what we call a culture of health. It’s a relationship with employees over a period of time where they come to recognize that what you’re doing is designed to help them, not just the company. We’ve seen that in those instances where people have engaged in this and seen the results of it, the connection to the company is just astounding.” Building this sense of connection is vital. Moving away from the old ‘take a pill and feel better’ approach requires employees to understand the role they have to play. “Up until now we’ve believed that education, incentive and legitimate cost sharing, is the best way to go,” says Torsone. “When employees can understand what actually is the cost of things they can take responsibility for making sure they get the most efficient use out of the system, not just us. We’re asking them to
Taking it to the top Healthcare is currently a major political issue and the search is on for new solutions. Pitney Bowes CEO Murray Martin recently met with President Obama to offer the business perspective. Johnna Torsone. Our CEO was accompanied by representatives of four other companies that have been doing similar types of things to Pitney Bowes. The President and his staff wanted to understand whether wellness and prevention actions that the company had been taking had actually been able to bring the cost curve down of our healthcare. He said we should incorporate these same types of approaches into the federal programs and hopefully into healthcare reform; and we, of course, believe very much in that. We do think that the ability to bend this cost curve requires some of the principles that we’ve embedded in our programs at Pitney Bowes, such as education, appropriate plan design, appropriate sharing, appropriate screening, appropriate provision of the types of incentives and reduction of cost barriers for those things that we know will then ultimately drive the cost of disease management down and increase the ability for people to stay healthy. It’s not just at Pitney Bowes. More and more the companies now have the wherewithal to analyze things the way we do and to work with their employees the way we do. We believe those principles should be applicable to any system, and it’s only these types of principles which will ultimately bring down the cost curve. What’s difﬁcult in the public arena is it’s hard to prove how much will they save and when bills are submitted, the congressional budget ofﬁce has to score well. Because there’s not a long history of entities doing the kind of things that Pitney Bowes and other companies have done, there’s not enough data out there to prove what we all inherently know; that if you do these things, the cost curve will go down. In a microcosm we’ve seen that at Pitney Bowes. We can document that there’s a substantial decrease in the cost of that management of that disease by way of elimination of emergency room visits, of lost time to work, and so on. We know that in our world these things have made a difference because we know that if you look at the compound growth rate of our healthcare costs, even though they’ve gone up, they’ve gone up at a much lower rate than our benchmarks.
be a partner with us in this, and I think that’s the most important element of what is missing in the public discussion of healthcare. There’s only so much that those of us that are subsidizing healthcare can do to bring the cost down if individuals don’t cooperate with us. There are things you can do to help make that happen, but ultimately there’s a joint responsibility here.”
Torsone is hopeful that the elevated profi le of the healthcare debate will have a big impact on the perception of wellness both inside and outside business. “It requires us to begin to educate our populace on a substantial scale about the kinds of things I’m talking about and really build their willingness to take part in that agenda,” she says. “Over time, our employees have learned this. As we bring new employees in, they come into this culture of health; and we hope that these are principles that will be embedded in them whether they stay at Pitney Bowes or they leave. We think that ultimately these principles have to be embedded in other parts of the system. Otherwise unless you keep people here for the long term, you don’t get the benefit of it. That’s why we’re so evangelical about this. Because if they come into our workforce not having been in similar structures, well then we’re starting from ground zero with them.”
“It takes time to build up to what we call a culture of health. It’s a relationship with employees over a period of time, where they recognize what you’re doing is helping them” Torsone and her peers will be observing the ongoing healthcare wrangling with interest. At the time of writing the outcome of the debate is not yet known, but any new bill will have a big impact on how private business approaches healthcare. “We keep watching it because what happens in the public arena, will either make it easier or harder for us to maintain what we’re doing,” says Torsone. “Depending on how the healthcare bill comes out and how it is structured, it could make it more difficult for us to maintain the things we’re doing. On the other hand, it could make things easier, but so far what I’ve seen is that it is not necessarily going make it easier for us to maintain this focus.” However, Torsone is strong in her conviction that the wellness-based approach to healthcare being pioneered by companies like Pitney Bowes offers a viable model for a new national strategy. “I hope that Johnna Torsone is Executive Vice President and Chief Human Resources any program, whether it’s public Ofﬁcer at Pitney Bowes Inc. or private, should be following some of the principles that we’ve laid out,” she says. “In some of the cases where we have some very, very high cost healthcare plans, which are not efficiently designed nor structured to the type of incentives we’re talking about, they need to change because I don’t think they’re sustainable. I don’t think we can continue to not have the kind of efficient focus that we do on health. If we don’t do it, whatever system it is, I don’t see it being sustainable.”
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The future of recruitment outsourcing Jim Causey tells EHM of the benefits of outsourcing practitioner recruitment.
hysician recruitment is a function within healthcare organizations that keep the ‘C’ suite folks awake at night. Yes, it’s a necessary process that feeds the livelihood of your facility. One would think that it’s pretty straightforward without much variation in the process, right? In reality many healthcare executives see physician recruiting as frustrating, difficult to manage and very costly with questionable control over success. Until recently hospitals, medical groups and practices have had only two options for the recruitment of physicians – they could build their own internal system or outsource the process to various firms and manage the process internally. It was only a short time ago that it was proposed that facilities start doing what they do with payroll and HR management and outsource the process. In 2004 leadership from the Human Resources and Operations department of a large multi-specialty clinic in central Massachusetts sought to establish an on-site physician and advanced practitioner recruitment program exclusive to the clinic. The clinic elected to outsource to a third party vendor rather than develop an internal recruiting department because incorporating the expertise of a professional firm offered the benefit of a faster start and shortened learning curve, provided the professional firm could replicate their service in an on-site model and adapt to the clinic’s culture. The clinic chose a national physician-recruiting firm to be the backbone of what eventually became a beta model in similar design of a recruitment process outsourcing (RPO) service. Professional RPO services have become widely accepted for recruitment in commercial industry sectors and are described by the RPO Association as, “Providing the entire recruiting process including management, staff, technology, job validation, metric reporting and presentation of final candidates. A properly managed RPO will improve an organization’s time to hire, increase the quality of candidates and reduce cost.” During the first two years the third-party firm supplied the sourcing expertise and the HR support to provide ongoing recruiting while assisting the clinic staff in the development of a system to manage the numerous and diverse operational components of provider recruiting. Midway through the five-year process, the clinic recognized that the initial vision was the correct path to pursue based on results at that point. In order to move the model to the next level of
performance, leadership elected to distribute an RFP to additional vendors in an effort to seek a more palatable business model, higher results and an additional cost reduction. The new vendor, a physician data management firm, specialized in the collecting and marketing of a state-of-theart physician sourcing data and management system to thousands of in-house physician recruiters. The new vendor was able to capitalize on the progress made in the previous development of the clinic’s leadership vision. Following the addition of the more sophisticated data and management system, the critical sourcing component was improved. You might be wondering where I’m going with this, and here it is – after the conclusion of the five-year process the clinic reduced their costs of physician recruitment by 40 percent while increasing their results by 44 percent. The clinic created a culture of recruitment at the facility that involved existing physicians in the process of recruiting new providers, helping raise their rate of retention and increase the support services available for new physicians. Much like the commercial RPO services, the beta program validated the absolute need for key elements of a recruitment process, such as a reliable and consistent flow of candidate sourcing, milestone based monitoring of every aspect of the process from A to Z, a driving philosophy of matching professional and personal requirements, senior level involvement by the organization and vendor, and the most important factor – an onsite concierge style coordinator, task focused and not bifurcated by non-related tasks. Simply through the beta outsourcing model the clinic was able to under spend their last annual recruiting budget by $1 million.
“The clinic reduced their costs of physician recruitment by 40 percent”
Jim Causey is Vice President of Marketing and Development at PhysicianRPO. He has over 30 years of experience in business and product development, physician practice mergers and acquisitions. Causey pioneered the outsourced physician-recruiting concept and now directs the initiative for hospitals, systems and medical groups.
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Five steps to building a resilient organization David Lei and Frank Lloyd explain the key strategic business moves for the healthcare economy.
he consensus is that the recently transitioned to all electronic records areas such as infection to bolster prevention and economy has bottomed out to speed communication between physicians control efforts. and is starting to strengthin different departments and improve accuracy Building operational leverage through en. Yet healthcare providers of diagnosis and treatment. Generally, hospitals asset leanness is the fourth step . A big investcontinue to face unrelenting are burdened with manually archived records ment in hard assets can become an albatross turbulence. While the ultiand non-standardized procedures that make when demand dissipates. However, many mate transformation of US healthcare is as hard data storage and retrieval difficult. As both firms have already begun investing smarter, to predict as the shape of the economic recovpatient and information volume escalate, these not bigger, to become more flexible in the face ery, there are some strategic steps that providers become even more burdensome, leading to even of volatile demand. Pharmaceutical fi rms are can adopt from business to build resiliency for greater administrative and clinical waste. outsourcing quality control to enable 100 peran uncertain new reality. cent sampling and turning production The fi rst step is to empower emover to contract manufacturing organiployees to engage in lifetime learning. zations. Outsourcing can benefit healthCompanies now realize the meaning of care providers as well. For instance, the long held belief that people are their the use of Pyxis to provide end-to-end most important assets. Highly motisafety and automatic replenishment in vated directors, physicians, nurses and delivering prescription drugs within staff are the only assets that bring other the hospital can dramatically reduce assets into play. Even more important, administrative and clinical errors. adaptability is the key to meeting the The final step is to invest in neighunrelenting and accelerating series of boring markets. Retrenchment is the challenges ahead. mantra that accompanies a recession. Thus, the smartest organizations Wise companies, however, are planting are those that recognize the need to culgrowth seeds in new businesses adjacent David T. Lei, PhD, is Associate Frank Lloyd is Associate Dean, Professor in the Strategy and Executive Education, Southern tivate life-long learning in their people. to their core. Healthcare providers have Entrepreneurship Department, Methodist University Cox School of Southern Methodist University Cox Business. Dallas’ Baylor Health Care System, for similar opportunities in collaboration School of Business. example, has adopted this strategy and with employers and insurers. For exinvested thousands of hours in developample, some forward-looking insurers ing leadership, communication, finance and Using your customers to design and are working with clients on prevention prostrategic planning skills among its physician, promote your product is the third step. Many grams that target risk factors for obesity. They nurse and administrative leaders, with the companies have asked their customers to share believe that if the healthcare system cannot payoff of improved quality and efficiency, and in the recession’s pain, but the smarter ones respond effectively to the epidemic of obesity, the capability for continued improvement. look to harness them as co-creators of the next it will drown in the expense of related health The second step is to manage working breakthroughs. How can healthcare providers problems. Hospitals that work with them can capital to ensure liquidity. Tomorrow’s business benefit from this strategy? New information contribute understanding of the science behind winners will be those who have ready reserves of technologies enable physicians and hospitals to this syndrome to maximize the effectiveness of cash today. Freeing up cash can be difficult for capture a wider range of patient data, such as prevention programs. healthcare providers that are squeezed between adherence to treatment regimens to personalize Adopting business strategies for the ‘new reduced reimbursement rates and lowered care. Greater use of biomarkers enables providreality’ will help healthcare providers improve billing rates. However, hospitals can continue ers to accelerate the discovery of new treatment the quality and efficiency of the care they deto wrench efficiencies from their operations regimens – compressing multi-year clinical liver. Quality improvements will drive preferby eliminating medical errors and slicing adtesting protocols. The use of new data mining ential treatment from employers and insurers, ministrative waste. For example, Mayo Clinic techniques can help hospitals spot trends in boosting revenue.
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BRITISH HEALTHCARE With a devolved public healthcare system, the UK offers a democratic approach.
ecently thrown into the spotlight following Obama’s move toward a more state-based healthcare system, the UK is a publicly funded healthcare country with free services provided to all of the 60,000 UK residents. Introduced after the Second World War, Prime Minister Winston Churchill wanted a system that cared for all classes of society throughout all times of life, “from the cradle to the grave.” The public system, the National Health Service (NHS), is funded via countrywide taxation and includes primary care, in-patient care, long-term healthcare, ophthalmology and
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dentistry; there are charges for services such as eye tests, dental care and prescriptions. It is one of the largest cohesive organizations in the world, employing over 1.3 million people. The government’s budget portioned the Department of Health £98.6 billion for the fiscal year 2008-09, with the majority of that being spent on the NHS. The private healthcare operates on a parallel level to the NHS and it paid for by private insurance, which currently is used by less than eight percent of the population. To cope with the current strain on public resources, the public sector has been used to increase NHS capacity. The responsibility of healthcare is a devolved matter to the jurisdictions of the UK – England, Scotland, Wales and Northern Ireland – and with each system implementing different sets of policies and programs they each take a different approach. The UK Government is expanding the role of the private sector within England whereas the Scottish government is aiming to reduce the influence of the private sector within the NHS, and is even drawing up legislation that is aimed to prevent the possibility of private companies running GP practices. Although the NHS has a fairly high level of public support from the country’s citizens, it is often subjected to severe criticism by the national newspapers.
Emergency medical services In order to provide immediate care to those with acute illness or injury across the UK ambulatory services are deployed. Required by law, they must assist when requested. However, this is an area in which private ﬁrms are being awarded contracts and money is being diverted away from the trusts. The government measures the performance of every Ambulance Trust.
The NHS employs more than 1.3 million people
Travel focus London is the city’s capital and attracts millions of tourists into its metropolis each year. It is due to be hosting the Summer Olympics in 2012 and the capital is gearing up to accommodate the many more millions of tourists the event is due to bring. With its own mayor and assembly, London is a prominent city and one of the world’s largest ﬁnancial districts; central London incorporates more than half of the UK’s top 100 grossing UK companies. It also holds Europe’s longest shopping street, Oxford Street, which stretches a mile long. Ruled by a monarch and with Queen Elizabeth’s stately home, Buckingham Palace, situated in Central London, the city is teeming with historical builds. Westminster Abbey, the Tower of London and the Palace of Westminster were all built to accommodate the Royal Family.
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On the shelf EHM rounds up the latest healthcare books.
The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care By T. R. Reid
Writing on the current controversial issue of universal healthcare, the Washington Post correspondent explores varying healthcare systems across the world in a bid to understand why America remains the only nation unwilling to provide universal healthcare for its citizens. His results show that not only does the US spend more money on healthcare than any other country, but an astonishing 22,000 Americans die each year from easily treated diseases. EHM SAYS: a succinct account of the uninsured dilemma, with fi rsthand details of other healthcare systems to compare, and of which America should take note.
Shock Therapy for the American Health Care System: Why Comprehensive Reform Is Needed By Robert Levine
Offering an easily understandable diagnosis of the problems plaguing our current health care infrastructure, Robert Levine discusses the roles of various stakeholders, such as insurance companies, big pharma, hospitals, healthcare providers and patients. He provides a comprehensive plan, addressing everything from bloated bureaucracies to unnecessary procedures to the handling of negligence and malpractice lawsuits/claims. EHM SAYS: a great insider view from a veteran physician. Robert Levine takes a transparent approach and offers practical solutions.
Uncertain Suffering: Racial Health Care Disparities and Sickle Cell Disease By Carolyn Moxley Rouse
Carolyn Moxley Rouse examines the higher mortality rate and lower life expectancy of black Americans as compared to white Americans, and what this means for healthcare in the US through the lens of sickle cell anemia â€“ a disease that primarily affects blacks. Assessing individual patient cases as well as the compassionate yet distanced professionalism of healthcare specialists, Moxley Rouse uncovers the cultural assumptions that shape the quality and delivery of care for sickle cell patients. EHM SAYS: a thorough examination of how the politics of racism shapes attitudes towards pain and suffering.
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Your World. COVERED is
From the people you hire to the products you sell, if you’re in business, we’ve got it covered...
Executive Healthcare Managementt 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 st respected executives in healthcare, providing a platform for strategy tegy and learning.
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: EU, US
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: MENA, US, Russia
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
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Healthcare for the Elderly
2010 National Health Policy Conference
Jan. 18 – Jan. 19, 2010 Toronto, ON, Canada
Feb. 8 – Feb. 9, 2010 Washington, DC, United States
3rd International Conference on Health Informatics
Connecting Healthcare 2010
Jan. 20 – Jan. 23, 2010 Valencia, Spain
Feb. 9 – Feb. 10, 2010 Sydney, NSW, Australia
Healthcare Market and Emerging Consumers
Obs-Gyne Middle East 2010
Jan. 21 – Jan. 23, 2010 Manipal, Karnataka, India
Feb. 14 – Feb. 16, 2010 Dubai, United Arab Emirates
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5th Decennial International Conference on Healthcare-Associated Infections
Mar. 18 – Mar. 22, 2010 Atlanta, Georgia
Healthcare Tourism Congress 2010
Apr. 12 – April. 13, 2010 Kuala Lumpur, Malaysia www.htcongress.com
16th ISHEID - International Symposium on HIV & Emerging Infectious Diseases
Mar. 24 – Mar. 26, 2010 Marseille, France
Biomed Europe 2010 Conference and Exhibition
Apr. 19 – April. 21, 2010 Budapest, Hungary www.biomedeurope.com
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Androulla Vassiliou at the EU Headquarters in Luxembourg
Androulla Vassiliou, European Commissioner for Health
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ndroulla Vasiliou is a Cypriot and European politician and the European Commissioner for Health, confi rmed by the European Council on 3 March 2008. Previously a legal advisor, she moved into the field of politics following the election of her husband, George Vassiliou, to President of Cyprus. Vassiliou was elected to the House of Representatives of Cyprus in 1996, for the Movement of United Democrats, and re-elected in 2001 until 2006. During this time she served on the European Affairs Committee and the Joint Parliamentary Committee of Cyprus. She was also an Alternate Representative of Cyprus to the European Convention, which drew up the European Constitution. She was Vice President of the European Liberal Democrat and Reform Party between 2001 and 2006 as well as the chairperson of the European Liberal Womenâ€™s Network. In February 2008 Vassiliou was nominated to succeed Markos Kyprianou as European Commissioner for Health. On 3 March 2008 she took over from him in the European Commission and faced a hearing before the European Parliament in early April 2008; she was approved on 9 April 2008 by 446 to seven with 29 abstentions. She was elected President of the World Federation of United Nations Associations in 1991 and re-elected for two terms before being made an honorary president. Within this role she participated in many international and regional conferences, especially in the field of human rights. Â„
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of the vaccine is not yet well understood. That leaves us with isolation: preventing symptomatic individuals from infecting asymptomatic individuals. Since fever is by far the most important and most efficient way to identify symptomatic persons, there has been much attention on how to screen masses of people for the purpose of detaining them, at least temporarily, while further tests are performed to determine if they should be quarantined in some way. The problem is how to accurately identify the one percent or so febrile persons in the general population conducting their normal activities without bringing those activities to a grinding halt; hence the need for fast efficient mass screening.
H1N1 and mass screening for fever By Francesco Pompei
n June 11, 2009, Dr. Margaret Chan, Director General of the World Health Organization, raised the level of influenza pandemic alert from phase 5 to phase 6, and declared: “The world is now at the start of the 2009 influenza pandemic.” The US Centers for Disease Control and Prevention (CDC) reported on November 12, 2009, that H1N1 had infected 22 million Americans, hospitalized 100,000 of them and resulted in 4000 deaths. There is scientific evidence that H1N1 is a genetic successor to the virus of the 1918 influenza pandemic, which killed 50 million people, about three percent of the world’s population. There is additional evidence that what we have seen so far may very well be the prologue to much larger numbers of people being infected, and far greater mortality, in the next few years. In recent years, particularly after SARS in 2003, important elements of pandemic preparedness have been a focus of attention on many levels, including businesses preparing for large numbers of absent workers, schools establishing closure policies, medical institutions preparing for dramatic increases in patient load, public health officials obtaining new authority to respond to public health emergencies, and new vaccines to immunize those at risk. All of the preparedness activities ultimately reduce to two strategies: immunization and isolation. Unfortunately, only a fraction of the US and world population will be vaccinated against H1N1, and the effectiveness
Infrared imaging cameras have been prominent in newscasts showing screening at airports and other travel centers, primarily overseas. Recently, it has become common in some countries for inspectors to board airplanes before the passengers disembark, point a pistol-shaped device with a laser at each passenger’s forehead, and pull the trigger. Although only an infrared thermometer, the message is particularly clear regarding the consequences of attempting to enter the country with a fever that might indicate the presence of H1N1. An important lesson that emerged from SARS and is being used today is that individuals will self-quarantine at home when ill, if they believe they might be quarantined by force if caught in public. Whether the method of fever detection actually detects fevers is secondary. Although very effective in this way, there is still the possibility that some individuals will risk the mass screening, or be knowledgeable enough to disguise their thermal profi le to prevent detection. Clinically reliable fever detection is still the most desirable mass screening technique. Unfortunately, no infrared imagers or infrared thermometer guns can be qualified for clinically accurate fever detection, due to limitations of physics and physiology, a well-known fact amongst knowledgeable scientists. Suitable qualified clinical methods must be fast and non-invasive, as well as accurate. One example is temporal artery thermometers, now used in most medical institutions in the US. They have been selected worldwide by major companies, pandemic and bioterrorism response teams, government health departments, and hospitals to mass screen individuals entering their premises. One user can scan about 600 people per hour, thus making this a practical mass screening technique where and when such screening is necessary.
“Unfortunately, only a fraction of the US and world population will be vaccinated against H1N1, and the effectiveness of the vaccine is not yet well understood”
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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 an SM and a PhD from Harvard, Pompei also holds an appointment as Research Scholar in the Department of Physics at Harvard, in cancer research.
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