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Executive Healthcare Management magazine. Issue 9. November 2009. Hidden enemies - Why the H1N1 pandemic is not the only serious health threat we're facing.
www.executivehm.com • Q4 2009
IN THE AIRHow The Joint Commission is leading the fight against
airborne infectious disease Page 38
LESSONS LEARNED Page 44 GETTING BETTER ALL THE TIME Page 80 PLANE AND SIMPLE Page 114
TOGETHERNESSWhy the Healthcare LeadershipCouncil encourages public andprivate collaboration Page 72
DATA DELIVERYThe vital role played by healthinformation exchanges in the futureof our health system Page 90
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When the WHO declaredthat H1N1 had reachedphase 6 on its scale ofpandemic alerts, theworld’s media went into
overdrive. While the predicted widespread panichas not yet materialized, fears are still runninghigh ahead of the full scale winter flu season.
Given this, it’s worth putting the pandemicthreat into context. H1N1 has killed more than6200 people worldwide since April, a figure thatappears high until you consider that according toCDC estimates, between 36,000 and 40,000 peo-ple are killed every year by garden-variety sea-sonal flu. Because seasonal flu – by definition –happens seasonally, and the people it kills tend tobe older and often have underlying health prob-lems, these deaths don’t make the headlines.
Among the other leaders on the list of unac-knowledged killers are hospital-acquired infec-
sarily those who respond well to an increase inadministrative procedures, or to having potentialerrors pointed out by junior staff members.
It’s clear that H1N1 is not the only majorhealth issue we have to worry about. While weshouldn’t discount its potential to become moredeadly, we should also not underestimate the se-rious nature of these other health challenges.They may not be as newsworthy, but their effectsare just as devastating for the victims and theirfamilies.
tions, often referred to as the ‘hidden epidemic’.According to the CDC again, HAIs kill nearly100,000 people each year, far more than any typeof flu. The most shocking thing about this figureis that the prevention of HAIs often comes downto something as simple as reminding hospitalstaff to wash their hands.
HAIs are not the only way to die unneces-sarily in hospital – surgical errors also claim anestimated 100,000 lives each year in the US. Itwould seem that the remedy is simply a matter ofhaving the correct checklists and procedures inplace and ensuring good communication amongOR staff. However, as Richard Karl, Founder andChairman of the Surgical Safety Institute, ex-plains in this issue, the reality is not so straight-forward.
Karl points out that the problem can beginas early as medical school, where the type of peo-ple attracted to a surgical career are not neces-
“Legislators should notassume that creating newknowledge about improvingquality and safetyautomatically translates intothe delivery of care” MarkChassin, President, The JointCommission (Page 38)
“We need to make changes inour healthcare system, butwe want to make sure thatwe don’t throw out the babywith the bathwater” MaryGrealy, President, HealthcareLeadership Council (Page 72)
“Global pandemics don’t occurevery few years. They occurwith periodicity that’sdetermined by the amount ofchange in the virus” DavidHooper, Chief, Infection ControlDivision, MGH (Page 66)
Hidden enemiesWhy the H1N1 pandemic is not the only serioushealth threat we’re facing.
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Lessons learnedSteve Gordon on why thechallenges of a pandemic meanchanges for the future
Coming togetherMary Grealy explains how publicand private collaboration is pavingthe way to a better healthcare system
Condition criticalMark Chassin faces the nation’s infection control issues
Nursing an ailing health systemColleen Conway-Welch outlines the role of nurses in the evolutionof healthcare
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INFECTION CONTROL51 Helping handsElaine Larson outlines the technique that aimsto limit the rate of H1N1 infection
56 Pathogen controlMichael Beach of the CDC examines thevarious aspects of waterborne pathogens
62 Gearing up for battleHow Novartis Vaccines is preparing forH1N1’s next assault
66 Ready for the next waveSteve Hooper explains how the currentpandemic is shaping future prevention
TECHNOLOGY80 Getting better all the timeThe technology challenges facing SeattleChildren’s Hospital
86 Well connected in IndianaMarc Overhage extols the benefits of astatewide health information exchange
Final word Operational excellence
78 Kevin Burton, Burton AssetManagement, Inc.132 Jim Causey, PhysicianRPO134 David Lei and Frank Lloyd, SMUCox School of Business
119 Operating room integration,with Jim Cloar of MedtronicNavigation and Olympus MedicalSystems Group’s Richard Harada
54 James Hosler, DRSS Global60 Brian Carpenter, Muvezi 84 Phil McVey, Kroll
ASK THE EXPERT
70 Michael Rumbin, RiverDiagnostics, Inc.94 Neal Flora, Fletcher-Flora HealthCare Inc.102 Jeanine Tome, Allscripts CareManagement126 Nancy Moureau, GreenvilleMemorial Hospital
CONTENTS_nov09 19/11/2009 11:41 Page 13
In the right veinGetting better all the time80
96 Evaluating the futureWhy medical technologies should be judgedon their actual value to patients, according toCharlie Whelan
PATIENT CARE108 Surgical innovationClaude Deschamps on Mayo Clinic’sminimally invasive and robotic surgery
114 Plane and simpleHow a few lessons from the aviation industrycould revolutionize patient safety duringsurgery
128 The best medicinePitney Bowes’ approach to employeewellbeing
136 Regional focus138 In review140 Events
122 In the right veinNadine Nakazawa on the current challengesin vascular access
IN THE BACK
142 Close up144 Final word withFrancesco Pompei
HEAD TO HEAD
90 Interoperability, with RaymondScott of Axolotl Corp andRelayHealth’s Jim Bodenbender
CONTENTS_nov09 18/11/2009 15:16 Page 14
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The bill was nearly broughtdown by last minute objections
from 64 pro-life Democratswho wanted to tighten
restrictions to ensurethat no federal fund-ing of abortions could
occur as a result ofthe reforms.
Obama and his allieson Capitol Hill still face a tough
battle for victory on his signaturedomestic issue. There is a signifi-
erupted as Nancy Pelosi, the HouseSpeaker, declared the victory.
The vote marked thefirst time a chamber ofCongress has votedto back such sweep-ing reform of theUS health industry.Pelosi compared it tothe passage of legislationcreating a state pension system in1935 and government health coverfor the elderly and poor in 1965.
vote “historic” and said he was ab-solutely confident that he wouldsign a health reform Bill by the endof the year.
Democrats have sought fordecades to provide universal healthcover. When the bill was passed by220 votes to 215 during a lateSaturday night session, cheers
A STEP FORWARD FORHEALTH REFORM
With a helping hand fromthe House of Representatives,President Obama has overcome ahurdle to get his $1.2 trillionhealthcare reform passed. In earlyNovember, the House ofRepresentatives narrowly passed areform bill to provide healthcare toall Americans. Obama called the
The bill would provide cover for an
UPFRONT EHM US9:25 June 18/11/09 15:29 Page 18
UPFRONTTHE BRIEF 19
cant risk that the debate will slideinto 2010, a mid-term electionyear when vulnerable Democratsin conservative and moderate dis-tricts might fail to back a final billbecause of its huge cost.
“Take this baton and bring thiseffort to the finish line,” Obamaurged senators in an appearance atthe White House, saying passage ofhealthcare reform would represent“their finest moment in public ser-vice,” according to Reuters.
The Senate must now comeup with its own version of ahealth reform bill. HarryReid, the Democraticleader, is underenormous pres-sure from theWhite House toget it through be-fore the end of theyear. Reid is strug-gling to find the 60 votes heneeds to overcome Republicanblocking tactics despite hisparty’s Senate majority.
If Reid succeeds in getting leg-islation out of the Senate, his bill –which will be slightly differentfrom the 1990-page, $1.2 trillionbehemoth passed by the House –will have to be reconciled into onepiece of legislation in negotiationswith the lower chamber.
Despite the obstacles ahead,the success of the House Bill was apowerful victory for Obama andprovided strong political momen-tum behind his drive for health re-form. “It provides coverage for 96percent of Americans. It offerseveryone, regardless of health or in-come, the peace of mind that comesfrom knowing they will have accessto affordable healthcare when theyneed it,” said John Dingell, aMichigan Democrat who has intro-duced universal health insurancelegislation in every Congress sincehis arrival in 1955.
The package will transformlarge parts of the health industry,which currently accounts for asixth of the US economy. Privateinsurers will no longer be able todeny cover to people with pre-ex-isting conditions, limit cover ordrop it altogether when peoplebecome ill.
The bill also contains agovernment-run health insur-ance option to provide compe-tition to private insurers,something bitterly opposed byRepublicans and an issue which
triggered heated protestsduring the summer.
Under theHouse Bill, mostindividuals will berequired to obtain
health insurance ifit is not provided by
their employer. All butthe smallest companies will
have to provide cover for theiremployees or face a fine as high aseight percent of their payroll.Overall, the bill would providecover for an additional 36 millionAmericans, leaving 18 millionwithout insurance by 2019,around a third of these being ille-gal immigrants.
The proposed package willbe paid for by increasing – bymore than five percent – the taxon individuals earning more than$500,000 a year, and on familieswith a combined income of morethan $1 million.
Senator Joe Lieberman, anindependent who caucuses withDemocrats, renewed his promiseon Sunday to help Republicansblock a final vote if the bill con-tains the government-run insur-ance option backed by Senateliberals. Republicans remain al-most unanimously opposed, crit-ical of its huge cost and the taxincreases needed to pay for it.
Patricia Steward holds her 11-month-old son Brayden as he receiveshis H1N1 pandemic vaccine from a nurse at the The East York CivicCentre clinic in Toronto, October 29, 2009
Hairdressers wearing masks to protect against swine flu at a salonin Lviv, Ukraine, November 2, 2009
NEWS IN PICTURES
First Lady Michelle Obamaduring an event at the WhiteHouse on women’s healthcare
Harry Reid, Christopher Doddand Max Baucus deliver remarksto the press on healthcare reform
A tax increase of more than
will be needed to payfor the proposed
UPFRONT EHM US9:25 June 19/11/09 11:21 Page 19
UPFRONTIN MY VIEW20
I have an outstanding scientific andphysician staff and ultimately itstarts there: if you have the bestpeople in the business then you atleast stand a chance of being hailedto be competitive, but you can haveall the best people in the world andif they’re not organized well thenyou’ve lost the benefit.
Lilly has created an environmentwhere our biologists working incancer and neurosciences are work-ing closely with our chemists andour toxicologists; and our folks whowork on ADME, PK/PD, experimen-tal medicine and medical work to-gether in a cluster concept ofactivity.
Genetics is absolutely important tohelp us understand which may bethe most important targets for drugdiscovery. One of our challenges isthat we need to be better at choos-ing these targets.
Even if we have the most innova-tive drug but our patients have noaccess to it, for whatever reason, be-cause they can’t afford it or govern-ments or third-party payers are notwilling to reimburse for it, then wereally haven’t done anything.
The FDA, as well as the EMEA, hasallowed us to be a part of the ap-proach that we can take in terms ofpersonalized medicine.
What we are trying to find out ishow can we share in knowledge,share in work, share in the risk ofprojects and hopefully, then, sharein the reward.
WILLIAM CHIN, VicePresident of DiscoveryResearch and ClinicalInvestigation at Eli Lillyand Company.
UPFRONT EHM US9:25 June 19/11/09 11:22 Page 20
UPFRONTCOMPANY NEWS 21
MAKE NO MISTAKE
Medical errors are the eighth leading cause of mor-tality in the United States. During the past decademuch has been written about how important patientidentification is to preventing deaths. Unfortunately,many hospitals still base patient ID purchase deci-sions on short-term considerations such as initialcost and convenience, while losing sight of criticalpatient safety implications.
Thermal printed wristbands offer a prime exam-ple of this lost focus. The most common thermal IDproducts offer the apparent convenience of compactprinters that print one wristband at a time. However,these wristbands suffer from the same issue: unpro-tected image areas that quickly degrade as vital patientdata is exposed to common hospital liquids. Eventhough single wristband printing seems convenientand inexpensive, in reality chart labels are often need-ed during a patient’s stay and must be printed sepa-rately, slowing workflow and adding cost.
To address these issues, the world’s leading laser
wristband company, LaserBand, has leveraged overa decade of laser-wristband research and real worldproduct usage to bring meaningful patient safety dri-ven innovation to thermal wristbands. Their newFusionBand thermal wristbands feature a patentedself-laminating design with a 100 percent film con-struction to form a water and alcohol resistant sealthat protects vital patient data for the duration of thepatient’s stay. In fact, FusionBand recently scored100 percent on readability and water resistance dur-ing an extensive trial at the Denver VA.
The FusionBand line features the world’s firstand only thermal wristband and chart label combi-nation form. For the first time hospital personnel canprint a thermal wristband and several chart labels onthe same form and in a single pass, improving work-flow and reducing costs.
FusionBand products are the leading patientidentification solution in the UK and other parts ofEurope and will be widely available in the US mid-year 2009.
For more information visit www.laserband.com
of drugs sold in the USare fakes
UPFRONT EHM US9:25 June 18/11/09 15:31 Page 21
CANCER CELL CURE
An Israeli research scientist hasaccidentally discovered a chemicalcompound that eradicates cancercells without harming normal cellsin the process. Professor MalkaCohen-Armon, a biochemist atTel Aviv University, explainedthat the compound is a compo-nent of a family of drugs devel-oped 10 years ago to preservenerve cells stressed by a stroke orinflammation, but on further ex-amination the drugs were foundto be inappropriate for their in-tended use, and they were releasedonly for research purposes.
Cohen-Armon and her teamof researchers set out to find anapplication for DNA repair, butfound a potentially huge discov-ery within cancer cells – the drugscreate a mechanism in cancercells that causes them to die with-in 48-72 hours, without harmingnormal tissue.
GET VACCINEThe European Union haswarned against complacencyover the spread of swine flu, urg-ing people to get vaccinated eventhough the virus has not hit ashard as it was first feared.
The World HealthOrganization (WHO) has con-firmed that at least 6250 peoplehave died from swine flu infec-tions since the virus was uncov-ered in April. Most deathsoccurred in the Americas region,where 4512 fatalities have beenreported. Some 678 people havedied from the infection in theAsia-Pacific region, while at least300 fatal cases have been record-ed in Europe.
EU Health CommissionerAndroulla Vassiliou also warnedthat while it was up to individualsto decide whether they should getvaccinated, it was probably betterto take precautions.
New research by a team based atthe Department of Epidemiologyand Public Health, UniversityCollege London, has shown thateating a diet high in processedfood increases the risk of depres-sion, and that those who ateplenty of vegetables, fruit andfish, actually had a lower risk ofdepression. The British Journalof Psychiatry said that data onthe diets among 3500 middle-aged civil servants was comparedwith depression five years later.
After accounting for factorssuch as gender, age, education,physical activity, smoking habitsand chronic diseases, they founda significant difference in futuredepression risk with the differentdiets. Those who had a diet highin processed food had a 58 per-cent higher risk of depressionthan those who ate very fewprocessed foods.
UPFRONT EHM US9:25 June 18/11/09 15:33 Page 22
A Canadian man has developeda strain of H1N1 that has provedresistant to the antiviral Tamiflu,after being given the drug to pre-vent the disease. So far, theWorld Health Organization hasrecorded 45 cases of resistance tothe drug, which is why the CDC,amongst others, is cautioningthose using Tamiflu who still re-main without symptoms.
It is reported that the man’sson was hospitalized with H1N1and so he was provided the vac-cine at a reduced dose to helpprevent him from getting thedisease. However, within a daythe man developed flu-likesymptoms and a test of his virusrevealed its resistance toTamiflu. The mutated strain ofH1N1 swine flu is also reportedto be susceptible to another an-tiviral, Relenza.
An international conference inMauritius has been set up in col-laboration with the WorldHealth Organization AfricanRegion to highlight the concernof the rapid growth of the dia-betes epidemic throughoutAfrica. The conference featuresthe Regional Director of WHOAfrica, health ministers from 46African countries, IDF expertsand other leading diabetes ex-perts, who will be discussing lat-est developments, practicalmanagement and prevention ofdiabetes and its complications.The aim of the conference is tobuild a strategic alliance amonghealth professionals that will pro-vide the momentum to imple-ment both the National DiabetesServices Framework and the UNResolution on Diabetes.
Africa will have the highestpercentage increase in the num-ber of people with diabetes in thenext 20 years because of rapidindustrialization and general im-provements in living standardsover the past five decades.
In protest at further expansion ofcigarette consumption in Asia,hundreds of Thais gathered out-side a tobacco industry congress.Angry at the tobacco industry forwhat they describe as usingThailand as a base from which toexpand the market within youngAsian men and women, thegroup gathered 86, 238 signaturesof those opposed to the congress.
The Thai government haswon praise from the World HealthOrganization for its campaignagainst cigarette smoking, whichhas included such measures ashigh taxes, gruesome pictures oncigarette packs depicting lung can-cer and throat cancer victims, andbans on cigarette ads and smokingin all public places. However, thereare still an estimated 14.3 milliontobacco users in Thailand, morethan a quarter of the adult popula-tion, according to recent researchconducted by the Global AdultsTobacco Survey.
UPFRONTINTERNATIONAL NEWS 23
UPFRONT EHM US9:25 June 19/11/09 11:30 Page 23
President Obama named Nancy-Ann MinDeParle as Director of the new White HouseOffice of Health Reform on March 2, 2009.Described by the President as serving as “healthreform Czar,” DeParle will work within the newgovernment entity, leading the change proposedby the new administration.
Becoming the first female president of the stu-dent body at the University of Tennessee, DeParleis familiar to asserting herself within new roles.After earning a JD from Harvard Law School,DeParle became a partner at a law firm beforeimmersing herself in politics, serving as commis-sioner of the Tennessee Department of HumanServices under Governor Ned McWherter.
Leaving government in 2000, DeParle took on nu-merous roles, becoming a fellow at the Instituteof Politics at Harvard’s John F. Kennedy School ofGovernment, a Senior Adviser to JP MorganPartners LLC, a Commissioner of the MedicarePayment Advisory Commission (MedPAC), and aSenior Fellow at the Wharton School of Businessof the University of Pennsylvania, just to name afew. Her time within the corporate private sectoris thought to bring her a unique industry perspec-tive on public healthcare.
Serving under the Clinton Administration in 1997,DeParle returned to politics. NamedAdministrator of the Healthcare FinancingAdministration (now called the Centers forMedicare and Medicaid Services). Responsible forthe running of Medicare, Medicaid and SCHIP –providing health insurance for 74 millionAmericans – DeParle was in charge of a fund ofmore than $600 billion, and became a key advi-sor to President Clinton.
DeParle has received criticism for her corporateconnections and the benefits they may havebrought her following her tenure within theClinton Administration. Msnbc.com reported herto be paid more then $6 million during this time,and with many of the companies she directedfacing federal investigations, she became regard-ed with suspicion. Many of these companies cur-rently hold a stake in the health reform that sheis leading.
UPFRONT EHM US9:25 June 18/11/09 15:38 Page 24
VACCINE SHORTAGEDespite the fact the regular flu seasonhas yet to start, the nation is alreadyfacing a severe shortage of seasonalflu vaccine. This comes atthe same time as ashortage of the swineflu vaccine.
Federal offi-cials and indepen-dent flu expertshave said the situa-tion was unavoidable,given that the global swineflu pandemic had raised demandfor all flu shots far beyond whatmanufacturers can make in a year,
the New York Times reports.Although the nation is experi-
encing this shortage, it does notmean there will be an
increase in seasonalflu deaths –
which averageabout 36,000per year. Thesame amount of
vaccine was madethis year as it was
last, so there is no reasonto believe that any of the threestrains of seasonal flu will be anyworse this winter.
In Q1 2009 of EHM, NANCY BROWN, CEO of the American HeartAssociation, explains her excitement at becoming the first femaleCEO at the organization, and the responsibility in educating thepeople of America to change their lifestyles.
Go to www.executivehm.com to browse ‘Past issues’ and click onIssue 7, March 2009 and read of Brown’s call for a new healthcaremodel, “a focus on prevention and finding a way to make ourhealthcare system economically viable.”
FROM THE VAULT
OBESITY LINKED WITH MS
A study by researchers fromHarvard School of Public Healthhas found that being obese as ateenager may be linked with anincreased risk of multiple sclero-sis as an adult. The researchersused data from nurses taking partin a large study on diet, lifestylefactors and health.
A 40-year study of 238,000women found that those whowere obese at 18 had twice therisk of developing MS com-pared to women who were slim-mer at that age. Yet body sizeduring childhood or adulthoodwas not found to be associatedwith MS risk, the US researchersreport in Neurology.
Over the length of the study,593 women were diagnosed with
MS, a condition caused by theloss of nerve fibres and their pro-tective myelin sheath in the brainand spinal cord, which causesneurological damage. The re-searchers compared the risk ofthe disease with body mass index(BMI) – a ratio of weight toheight – at age 18.
Those participating werealso asked to describe their bodysize, at the age of five, 10 and 20,using a series of diagrams. Thestudy showed that those with an‘obese’ BMI of 30 or larger at age18 had more than twice the riskof developing MS.
There was also a smaller in-creased risk in those who wereclassed as overweight. The resultswere also the same after account-
ing for smok-ing status
and physi-cal activ-
Seasonal flu deaths average
There are approximately
in the US with multiple sclerosis
UPFRONT EHM US9:25 June 19/11/09 11:35 Page 25
During my time as SVP at Memorial UniversityMedical Center, we opened a world-class cancer re-search center that went on to win the COC(Commission on Cancer) excellence award, placingthe center in the top six percent of institutions sur-veyed. We also implemented an in-depth quality ini-tiative program in the hospital and received accoladesfor patient outcomes, and the institution became oneof Fortune’s‘100 Best Places to Work’.
My experience at Memorialprovided me with theability to empathize with the needs of our customers –physicians and hospitals. With the ever-changinghealthcare environment, we are able to ensure thatwe address the needs of these stakeholders, such aspay-for-performance, bundled services and like trends.
Ingenious Med is my fifth such software venture.The processes learned and developed at these pre-vious companies are now being released and im-plemented at Ingenious Med, allowing us torapidly scale and grow. These process changes haveallowed Ingenious Med to double in size this yearin terms of revenue and resources, while improvingcustomer resources.
In order to be successful, you have to build theright team and then incorporate the right process-es in everything that you do. Proper processes
allow you to scale and give you efficiencies to com-pete and do well in ever-changing markets. Youalso have to go from servicing to truly delightingcustomers. You’ve got to go back to basics – such asa live voice for tech support and a bi-annual cus-tomer satisfaction survey, following up with rapidlyimplemented improvements.
There are a lot of exciting projects going on atIngenious Med. We are leaders in providing bedside,point-of-care data-capture, data-push and reportingservices, and we are continually developing our appli-cation to be available on today’s most popular de-vices, such as the Blackberry and iPhone. We arereleasing several revenue-enhancing solutions thatempower physicians and hospitals to appropriatelycode and remain compliant.
We are extending our quality module to address notonly PQRI, but hospital core measures and other qual-ity compliance areas as well. We will also soon be re-leasing some powerful new business intelligencesoftware that will take our current, industry-leadingreporting solutions to another level of usefulness forour clients. Stay tuned – these are exciting times forall of us at Ingenious Med, and all of us in the health-care industry.
For more information, please visit www.ingeniousmed.com
S. HART WILLIFORD,CEO, INGENIOUS MED
CANCER TEST NEEDEDAccording to the AmericanCancer Society, this year alone anestimated 40,170 women will losetheir lives to breast cancer.Meanwhile, it is estimated that4000 breast cancer deaths could beprevented just by increasing thepercentage of women who receivebreast cancer screenings – name-ly, mammograms – to 90 percent.
Mammograms lead to earli-er detection of breast cancer,which is why health insurancepays for them. But between 2003and 2005, mammography ratesdeclined, with a notable decreasefor Hispanic women, from 65percent to 59 percent, and inAfrican-American women, from70 percent to 65 percent. Notonly that, but it is estimated thatone in five women over 50 havenot received a mammogram inthe past two years, largely due toa lack of insurance.
FIVE MINUTE EXECTUTIVE
This year alone anestimated
women will lose theirlives to breast cancer
It is estimated that
women over 50 havenot recieved a
mammogram in thelast 2 years
1 in 5
breast cancer deathscould be prevented just
by increasing thepercentage of women
who recieve screenings
“We are releasing several revenue-enhancing solutions that empower physicians and hospitalsto appropriately codeand remain compliant”
UPFRONT EHM US9:25 June 18/11/09 15:40 Page 26
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Estimated US national prevalence of total diabetes by age, sex, race and insurance status (%) NHANES
6thleading cause ofdeath in the US
Deaths per 10,000 ranges from
in Arizona and Floridain West Virginiaand DC
Medical expenditures attributed to diabetes
$116 bnEstimated direct costs in 2007 at
$27 billion for care to directly treat diabetes
$58 billion to treat diabetes-related chronic complications$31 billion in excess general medical costs
NHANES. National Health and Nutrition Examination Survey
HORMONE MAY LOWER DIABETES RISK DIABETES IN THE US
The World Health Organizationestimates that at least 180 millionpeople have diabetes. Roughly 90percent have type 2, caused by thebody’s ineffective use of insulin.Researchers have focused in recentyears on a hormone derived from fatcells, called adiponectin, which isshown to lower the risk of diabetes.Scientists now hope this could im-prove the treatment of diabetes oreven prevent it altogether.
Obesity and physical inactivityare common conditions associatedwith type 2 diabetes. The WHOprojects that 330 million to 360 mil-lion people will be diagnosed as dia-betics by the year 2030. Doctorshave preached diet and exercise topatients for decades. Now re-searchers have noticed that high lev-els of one fat-producing hormone isnot such a bad thing, after all.
Scientists haveknown about thefat-producinghormoneadiponectin forsome time. ButRich Van Damand his colleagues atthe Harvard School ofPublic Health havelooked at studies of at least14,000 patients and confirmed
something interesting. They are notsure why, but patients with a lowerrisk of type 2 diabetes seem to havehigher levels of adiponectin.
“It actually has beneficial effectson the liver and on muscles and it in-creases insulin sensitivity, it seems,and it reduces inflammation,” saysVan Dam.
Van Dam says the link betweenadiponectin and a lower risk of thedisease is consistent, regardless of anindividual’s body mass index, genderor race. That, he says, raises hope forscreening and further treatment in-volving adiponectin, or in preven-tion of the disease itself.
“It’s an interesting finding be-cause we know that certain ethnicgroups, certain racial groups seemto be more sensitive to develop[ing]type 2 diabetes,” he explained.
of the medicines consumed in some developingcountries are counterfeit or substandard
Up to 25%
UPFRONT EHM US9:25 June 18/11/09 16:01 Page 28
8 10 12 14 16 18
Estimated prevalence of total diabetes, by sex and state (%)
Average cost for a hospital inpatient day due to diabetes
$1,853 - $2,281due to diabetes-related chronic complications, including neurological, peripheral vascular, cardiovascular, renal, metabolic, and ophthalmic complications
million days200724.3million days200216.9
Source: www.diabetes.org | www.pophealthmetrics.com
UPFRONTDIABETES INFOGRAPHIC 29
UPFRONT EHM US9:25 June 18/11/09 16:01 Page 29
nGage, a wireless RFIDquality compliance monitoring sys-
tem, allows hospitals to measure hand hygieneactivities and other events, whilst providing infor-mation for meaningful behavior modification at thepoint of care. Through nGage, hospitals no longerrely on spotty observational data to assess compli-ance with quality events. The system provides real-time information to increase compliance and tocreate operational efficiency.
nGage was developed by Proventix Systems, Inc.in response to increasing emphasis by CMS, JCAHOand other world health organizations on hand hygieneas means to prevent costly and deadly healthcare as-sociated infections (HAIs).
Its first goal is to measure 100 percent of the
HAND HYGIENE TECHNOLOGY
FUND FOR DISEASE FIGHT APPROVED
The Global Fund to Fight AIDS,Malaria and Tuberculosis has ap-proved grants worth $2.4 billion tofight the diseases during the nexttwo years. The amount representsa slight decrease in funding levels,though the three killer diseasesshow little sign of abatement.
The $2.4 billion figure ap-proved by the Global Fund to FightAIDS, Malaria and Tuberculosis is$350 million less than last year’samount, which was set before thefull effects of the world economicslump were known.
Fund Executive DirectorMichel Kazatchkine warned in anews release that even this reduced
funding level may not be sustainableunless wealthy countries and otherdonors increase their commitments.The amount was set during aFund board meeting inAddis Ababa.
The U.S.Global AIDS coor-dinator,Ambassador EricGoosby attendedthe Addis Ababameeting. He saysamong the hardest-to-reachvulnerable groups are those engagingin behaviors that in some countriesare illegal or socially unacceptable,such as homosexuality.
Goosby also said that whileEthiopia’s HIV infection rate isworrisome, it is far lower than in
the AIDS ravaged countriesof southern Africa.
“Looking at the 23million peoplein sub-SaharanAfrica who areinfected,
Ethiopia makesup about one
million of those,”says Goosby. “So it is not
the worst impacted countryin sub-Saharan Africa by along shot.”Source: www.voanews.com
people in Ethiopia are infected
hand hygieneopportunities andevents for healthcareworkers, patients andvisitors without any disruptionof workflow. The system is easilyintegrated into the hospital’s existingIT infrastructure.
“The key barrier to improving hand hygiene com-pliance lies in the ability to accurately track and mea-sure compliance rates across a healthcareorganization,” says Harvey Nix, CEO of ProventixSystems, Inc. “If you can add behavioral modificationat the point of care and create opportunities for effi-ciency you have something of great value.”
For more information visit www.proventix.com
One out of every 1500 intra-ab-dominal surgeries today results ina sponge being left behind in thepatient. A retained sponge causesinfection, requiring additionalsurgery, the risk of severe compli-cations and sometimes even death.
The Centers for Medicareand Medicaid Services, instituted aruling in October 2008 to refusepayment for this avoidable med-ical error, which they have dubbeda ‘never event’ because the medicalestablishment has determined itshould never happen. It remainsthe most frequent and costly surgi-cal ‘never event’. The culprit for itspersistent re-occurrence: humanerror due to reliance on manualcounting and detection measures.A new application of radio fre-quency identification (RFID) tech-nology allows hospitals to pursue azero tolerance goal for left-behindsponges. A device using the tech-nology, the SmartSponge Systemfrom ClearCount MedicalSolutions, Pittsburgh, Pa., allowsfor nurses to easily scan sponges‘in’ and ‘out’ of the surgical site.
Unlike other technologies,RFID allows the device to unique-ly identify the type as well as thenumber of sponges, for an exactview of the situation. As a finalsafety measure or in the case of anun-reconciled count, the doctor atsurgery’s close waves a reusableRFID wand over the patient to en-sure the body is sponge-free.ClearCount has received fundingfrom the US government to pur-sue applications that will preventretained surgical instruments aswell. At $20-30 per procedure, thisprevention approach may well bethe way for hospitals to put somemeaning behind the ‘never’ innever events.
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Corporate wellness initiatives have grown in im-portance, particularly within the past year, as em-ployers are expected to do more with less in anuncertain economic climate. Once considered ‘anice thing to do’, comprehensive wellness pro-grams are now recognized by senior managementas a legitimate and powerful driver for reducinghealthcare costs and improving productivity.However, goals and expectations have been set highas budgets are slashed and stress levels rise amonga leaner employee population. Proactive employersare rising to the challenge by learning to be morecreative with their benefit offerings and leveragingexisting resources already being paid for.
In reaction to the needs of their clients, nationalEAP and wellness provider, eni, created a dynamicsolution that is ‘doing more for less’ by integratingwellness services with the behavioral health servicesof their work/life employee assis-tance program (EAP).This new strategy alsoincludes an estab-lished referral
process between existing medical/health and dis-ability providers, delivering an integrated approachto total wellness.
Gene Raymondi, founder and continuing ChiefExecutive Officer of eni, advises benefit executives towork in partnership with their providers to create asynergy of cross referrals. “When vendors are flexi-ble and cooperative with the employer, as well asother providers, the results show increased partici-pation and engagement, as well as a positive and no-ticeable shift in the corporate culture towards thetotal health and well-being of employees and theirfamily members,” explains Raymondi.
eni has developed a shared data platform, posi-tioning their EAP as a central contact to coordinatereferrals. This new system has driven participationrates as high as 93 percent, and created a new, sus-tainable trend that provides employees better accessto and understanding of the resources available tothem. Participating providers are now able to effec-
tively target the root cause of eachindividual, leading to lasting
change for the employ-ee, as well as the cor-porate bottom-line.
WELLNESS THAT WORKS
eduTrax LLC, based outside of Atlanta, Georgia,since 2007 has been providing online healthcarecompliance-focused live and recorded courses,consolidated resources and documentation toolstargeting US hospitals’ regulatory and bottom linevulnerabilities. eduTrax has entered a collabora-tive agreement with a national accounting firm,Draffin Tucker LLP, to provide CPA CPE accred-ited course material through eduTrax’s portal ex-panding the online compliance library to eduTraxhospital subscribers.
The online library has expanded to greaterthan 82 courses, which bring vital information‘real-time’ into key hospital departments on adaily basis, maximizing time efficiency andknowledge transfer during the current tumul-
tuous regulatory and economic environment theUS healthcare industry now faces. eduTrax servesas the education ‘engine’ for RAC University,which is part of California based RACMonitor, anational online vehicle providing education andsupport to hospitals as the US Centers forMedicare and Medicaid Services’ (CMS) nation-al recover audit contractor (RAC) program com-menced in August 2009.
US Hospital CEOs and CFOs face daily chal-lenges to their organizations’ fiscal health, timemanagement, and knowledge transfer across alllevels from physicians to back office billing staff.Online education and training is on the forefrontproviding necessary resources and support at afraction of distance learning or ‘train the trainer’methods traditionally utilized over the years.For more information please visit www.myedutrax.com
The World Health Organizationsays antiviral medicines and antibi-otics used in a timely manner canhelp save the lives of people who aresick with the H1N1 influenza. TheWHO issued new guidelines in mid-November on the clinical treatmentof people who contract the swine flu.
With the start of the influenzaseason in the Northern Hemisphere,there has been an upsurge in influen-za across Europe and Asia. The WHOsays clinics in some countries areoverwhelmed with patients. It saysone way to save lives and ease the bur-den on clinics is to provide early treat-ment to prevent H1N1 fromdeveloping into a severe disease.
WHO Medical Officer in theClinical Aspects of Influenza, NikkiShindo, says the agency has con-vincing evidence that antiviral med-icines, such as Tamiflu, can preventsevere cases of H1N1. She says theWHO has three updated recom-mendations for countries where thevirus is circulating.
Annual earnings from the sales ofcounterfeit andsubstandardmedicines are over
globally $32 billion
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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
Burton Asset Management, Inc.
78, 79, OBC
CDC 51, 56
CDH Partners, Inc. 35, 110
ClearCount Medical Solutions 30, 117
Cleveland Clinic 44
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
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
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
Muvezi 60, 61
Nephros, Inc. 59
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
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
FASTING DEEMED UNNECESSARY FOR ACCURATE CHOLESTEROL TESTING
COMPANY INDEX Q4 2009
According to a group of New England re-searchers, your risk of developing coronaryheart disease and ischemic stroke can be as-sessed by measuring cholesterol levels withoutthe requirement of fasting. The full report canbe found in the Journal of the AmericanMedical Association.
John Danesh, of the Emerging Risk FactorsCollaboration Coordinating Center at theUniversity of Cambridge, and his colleagueshave found that methods to gauge blood cho-lesterol for the determination of vascular dis-ease risk can be simplified. Their studiesshowed that measuring high-density lipopro-tein (HDL) cholesterol, also called ‘good’ cho-lesterol, in combination with the measurementof high-density lipoprotein (LDL) cholesterol,or bad cholesterol, was just as revealing as test-ing for apolipoproteins AI and B.Apolipoproteins are proteins that bind to fats(lipids).
The researchers analyzed the data of302,430 people from 68 long-term prospectivestudies regarding the effect of major lipids andapolipoproteins on vascular risk. At the begin-
ning of the studies, the participants had no signof vascular disease. However, during the 2.79million person-years of follow-up, 8857 nonfa-tal heart attacks occurred, as well as 3928 deathsfrom coronary heart disease, 2534 ischemicstrokes, 513 hemorrhagic strokes, and 2536 un-classified strokes.
The research team found noassociation betweentriglyceride levelsand coro-nary
heart disease or ischemic stroke, even after ad-justing for several conventional risk factors.However, they did find that HDL cholesterolwas associated with a lower risk of vasculardisease, and that non-HDL cholesterol and di-rectly measured LDL cholesterol were associ-
ated with a higher risk.
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Chassin ed:26 June 18/11/09 15:29 Page 38
Like every other healthcare institution attempting to limit infec-tion, The Joint Commission understands the critical safety issuecurrently facing America’s hospitals. “Hospital-associated andhealthcare-associated infections are a huge problem, inpart because the landscape of infectious disease isconstantly changing, evolving and challenging
us,” explains Mark Chassin, President of the commission.With various approaches suggested as being the most effec-tive for control and protection, he notes the difficulty forhealthcare institutions in understanding and choosing theright prevention program in a climate where the goalpostsare constantly moving.
The Joint Commission has a variety of programs, ac-tivities and approaches to help healthcare organizations man-age these problems, most notably its accreditation standards,which are revised on an annual basis. “The beginning of this year sawsome substantial expansion of those requirements, which focus on the plan-ning and execution of comprehensive infection prevention and control plans,including some detailed requirements on instrument sterilization, disinfec-tion reprocessing, and specifically, what hospitals need to do to maintainstate-of-the-art infection control and prevention,” he says.
The commission also operates another group of requirements, theNational Patient Safety Goals, which function in a similar manner, and aimto highlight the most important and difficult areas of patient safety and qual-
ity. Many of the standards directly address infection control and pre-vention issues, including hand hygiene, bloodstream infections
and surgical site infection prevention. “We have also worked to focus our survey process on
various aspects of infection prevention and control,”explains Chassin. “We have performance measure-ment requirements under which all of our accredit-ed hospitals have to send data to us, and the one new
group that was introduced in 2005 has seen importantimprovement. It’s a group of measurement require-
ments that address one of the most critical parts of pre-venting surgical site infection: the proper application of
prophylactic antibiotics in a wide variety of surgical procedures. “We know from research that prophylactic antibiotics are a powerful pre-
ventative for surgical site infection. However, the first dose must be adminis-tered within an hour of the beginning of the surgical incision. As of the lastfull year of data from the thousands of hospitals that report to us, the US av-erage across the different procedures in that measurement group was 89 per-
The Joint Commission’s Mark Chassin tells Natalie Brandweiner about theinfection control issues facing the nation.
89%of first antibioticdoses were givenwithin the hour
Chassin ed:26 June 18/11/09 15:31 Page 39
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 theright antibiotic: It must be appropriate for the procedure, and there are clearguidelines on that. In 2007 across all of the different groups of procedures,from vascular to gynecology to orthopedic surgery and colon surgery, 95percent had selected the right antibiotics,” says Chassin.
The Joint Commission has taken a leadership role among all of theleading organizations in infection prevention and control, including theInfectious Disease Society of America, the Society of HospitalEpidemiologists and the National Foundation for Infectious Diseases,whom it catalyzed to undertake a comprehensive review in 2008, lookingat critical infection issues in hospitals. The result of this review was theCompendium of Strategies to Prevent Healthcare-Associated Infections inAcute Care Hospitals, which principally focuseson getting hospitals to make their programsworking more effectively. The Commission alsoproduces other resources to educate its members,such as educational conferences and consulting,as well as publishing various booklets andbrochures.
Clean handsDesignated by the World Health Organization
in 2005, The Joint Commission is the only worldcollaborating center for patient safety solutions.The WHO’s initiation of this global patient safetyinitiative took hand hygiene as its first challenge,which has been a National Patient Safety goal of thecommission for some time.
The continued prevalence of healthcare-asso-ciated infections and their prominence in thehealthcare debate has prompted the commission tostep up its operations, so for the first time it ispreparing to engage with healthcare organizationsto create interventions to improve safety and qual-ity. “We’ve created requirements for organizationsto improve their processes and outcomes, but in the past we haven’t engageddirectly with them in solving some of these critical problems,” explainsChassin.
“That’s what this new activity is focused on. We are launching a com-ponent of The Joint Commission called the Center for TransformingHealthcare; it is a separate component, like the Joint CommissionResources, but a subsidiary.
“We’re not for profit, so our focus is to use some of the newer tools ofprocess improvement, such as Lean Six Sigma and change acceleration, tobegin working with a group of 16 leading hospitals and health systems thathave themselves already made the investment in mastering these tools. Wecan use this systematic approach to solving problems to attack these crit-ical quality and safety problems that every organization has been strug-gling with.
“The first topic the participating hospitals chose for this effort, which waslaunched earlier this year, is hand hygiene failures. We’re talking about someof the leading hospital systems in the United States, from Hopkins and Mayo
to Inner Mountain in Utah, Partners in Boston, New York Presbyterian inNorth Shore in New York, Cedars, Stanford, Kaiser in California, Exemplarin Colorado, Memorial Herman in Texas. It’s a very impressive list. Theyidentified a number of their highest priority problems, and hand hygiene fail-ures got the most number one, high priority votes.
“For about 15 months, The Joint Commission has been undertaking avery aggressive program for our own internal process improvement of adopt-ing strategies and methods, the same tools of Lean Six Sigma and change ac-celeration. We have our own Lean Six Sigma experts whom we are bringingto this new center’s activities to work with these organizations. The hallmarkof what’s different about this approach is the systematic methodology to solvethese problems, which starts with an agreement on reliable and accurate mea-surement systems and hand hygiene.
“There currently aren’t any good, easy toapply, systematic measurement systems toknow what your performance is, and if youcan’t measure something reliably, you can’timprove it effectively. The second issue is,once you’ve got a good measurement ap-proach, to understand these tools with sys-tematic applications and figure out why theprocess isn’t working. That’s a step in theLean Six Sigma approach to solving prob-lems that is absolutely essential in these crit-ical quality and safety areas, where solutionshave remained elusive. This leads you to bevery precise about what the causes of thefailures are in where you’re trying to fix theproblem,” he explains.
Finding the causeChassin hopes this approach will pin-
point the major reason why hand hygienecompliance is so hard to achieve, and why thedistribution of the causes of noncompliancediffers from one place to another. He provides
an example of solving the problem of soap dispensers and their location out-side patient rooms, noting one surprising major cause of infection in a largenumber of hospitals is the number of healthcare staff approaching patientrooms with unclean hands.
Unless the process is carefully assessed and the reasons for failure un-derstood, it is impossible to target interventions that effectively manage thehigh impact causes, nor can improvements be made. Chassin believes this isthe key activity that differentiates the center from others pursuing thismethodology.
The second difference is that this methodology is now married with thereach of The Joint Commission. “Our job is to coordinate these projects, over-see them and make sure they’re done exactly the same way with fidelity to thismethod so that we can compile results across all of these organizations,” heexplains. “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 thelearnings from these initial projects into a knowledge database that we can
Chassin ed:26 June 18/11/09 15:31 Page 40
the need to refresh emergency preparedness guidelines and plans, coordinat-ing with other organizations in the community so that you’re not function-ing in isolation. We are very much engaged in the planning work, for ourorganization and our standards have been the most recognized items in thisarea,” 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 hospitalenvironment, and as Chassin points out, whenever times are hard, healthcareorganizations are tempted to reduce expenditures that aren’t directly involvedin the delivery of patient care.
“Fortunately for quality, the Joint Commission Accreditation process andrequirements don’t change,” he adds. “We don’t change the way we assesshospitals and other organizations, and we believe it is critical to attend to qual-ity programs even in difficult economic times, because backing off them canlead to adverse events and outbreaks of quality problems that can be costlynot only in adverse outcomes for the patients, but also for the resources of thehospitals and other organizations.
then take to the other 95 percent plus of hospitals that have not invested inLean Six Sigma process improvement. Then we view how they’re doing onthe programs and often find opportunities for improvement. We direct themwith very precise guidelines and instructions on how to measure the problem,how to assess what their causes are, and then give them specific interventionsdeveloped by the participating hospitals in the center project to tackle exact-ly the same cause in locations.
“The reach of The Joint Commission in pushing these very effective in-terventions out, along with this methodology, translated and jargon-free, soyou 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 enoughopportunities for improvement across the healthcare delivery system so thateverybody who wants to work in quality improvement should feel free to ex-pend their maximum effort. We don’t view this as competitive with or re-placing anything that’s out there: it’s complementary and additive.”
Flu focusThe Joint Commission has been very involved with H1N1 from the first
outbreak in spring and early summer, advising its healthcare organizationson the CDC’s most up-to-date recommendations. As a partner with the CDCand being present in its regular briefings, the commission can communicatethe latest information and guidelines directly to accredited organizations. Thecommission’s infection control and prevention standards cover the neededguidelines; specifically the recommendations of what hospitals need to do toprepare 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 ofhealthcare-associated infections andtheir prominence in the healthcaredebate has prompted the commissionto step up its operations”
Chassin ed:26 June 18/11/09 15:31 Page 41
“We’ve been pretty effective in making those arguments. There’s been an oc-casional organization here or there that is literally on the verge of bankruptcy thathas idiosyncratic problems, but we don’t see any significant retreat from the com-mitment or the safety and quality programs that are necessary.”
Implementing a standard performance measurement across the whole spec-trum of organizations is no easy feat. The Joint Commission was the first of itskind at the start of the 21st century to begin a national program of measuring qual-ity in hospitals, and met with huge resistance when attempting to collect the datafrom hospitals and publicly record it. Chassin explains that back then there werevery few measures that anybody could agree on, whereas now there hundreds ofmeasures available, both good and bad.
“Our program was picked up by the AmericanHospital Association, and hospitals were encouragedto voluntarily report in the middle part of the decade.Then Medicare CMS picked it up and required hos-pitals to report, but they wanted to get their full an-nual payment update, so a penalty for not reportingwas the Medicare approach. Now virtually every hos-pital that has appropriate patient services reports awhole panoply of core measure data to us and someof those measures have now reached levels of consis-tent excellence that are unparalleled anywhere in thehealthcare delivery systems.
“For example, some of the surgical site infectionmeasures that came in in the middle of this decadewere for heart attack. When that program started, itwasn’t uncommon to see 40 and 50 percent rates of performance on things likeaspirin and beta blockers. Now the national average for aspirin on arrival and betablocker on discharge is 97 percent,” he says.
The model operated by The Joint Commission demonstrates a good degreeof consistency, with the later measures of surgical site infection prevention hav-ing a standard level of accuracy. Chassin explains that this program has a lot ofstakeholders and therefore must continue to be worked on. The commissionworks with CMS on a weekly basis to ensure this, to be certain that the specifica-tions for these measures are identical between it and the government.
“The Joint Commission created the program, got the experts around thetable, did the evidence summaries, got them to agree on precise specifications withgreat fidelity to the clinical integrity of the measures,” he explains. “The clinicianswere all on board. The Joint Commission created the data collection infrastruc-ture to allow the data to be collected across the country in exactly the same way,with high levels of data quality, completeness and accuracy, by creating a networkof vendors that have to pass very rigorous tests that we administer. Every hospi-tal knows that the data in California are collected the same way as in New York,Illinois or Texas.”
Chassin notes that it was this infrastructure that allowed Medicare to ask forthe same data, which is now collected the same way for Medicare’s accreditationpurposes, with the same vendors; with the hospital’s agreement the vendor sendsthe same data to two different places. The Joint Commission works to maintainthat data collection infrastructure capacity by ensuring that the specifications areexactly the same.
He notes that this is not easy – data changes over time, and so does the sci-ence; for example, the information about who is an appropriate candidate for abeta blocker ace inhibitor and what is the appropriate antibiotic for preventing in-
fection in colon surgery. “All of that is maintained with great fidelity to the clini-cal integrity and the evidence, and to making this data collection infrastructurework so that it’s seamless for the hospitals that collect the data once,” says Chassin.
Obama’s Plan for America only vaguely alluded to initiating performancemeasures, says Chassin. There is discussion of using these measures to drive im-provement in a variety of ways, such as arranging new collaborations betweendoctors and hospitals. Quality will be judged through measuring performances,and the commission is focusing on making sure the measures are the very best.
Armed with the experience of conducting such measures for thousands oforganizations, The Joint Commission has been contributing knowledge, ensur-ing that it supports the creation of a quality improvement infrastructure. Chassin
points to the example of the Center for TransformingHealthcare, which can take information from the re-newed interest in comparative effectiveness researchand transform it into practice much more rapidlythan before.
“That’s part of our involvement in health reformlegislative debate – the legislators should not assumethat creating new knowledge about the best thing todo for improving quality and safety automaticallytranslates into the delivery of care. Often that takesmany years and we can’t afford those lengthy delaysany longer,” he says.
The Joint Commission is continuously engagedin processes to improve its own standards and the wayit conducts its surveys across all of its programs. “We
accredit over 4000 hospitals, but that’s less than a quarter of the 16,000 organiza-tions across all the delivery systems that we accredit or certify,” he explains. “Weactually accredit more home-care organizations now than hospitals.”
Internal standards“We are engaged in every kind of delivery organization that exists out there
and we developed standards for all of them. There are requirements for safety,which are focused on quality. The standards improvement initiative, which start-ed several years ago, was designed to review all of our requirements, to sharpen,clarify and remove ambiguity from the language, to make sure that the standardswere specific to the different programs – ambulatory care, behavior health pro-gram, home care – and make sure that we got rid of anything that was redundantor nonessential.
“That phase of our improvement initiative is coming to an end now with thesecond group of programs that are going into effect this year, but we’re not stop-ping there. Now we’re starting another round of improvement that will focus onunderstanding exactly what the evidence is behind our requirements, and mak-ing sure that we have the highest possible confidence, whether it’s really good ev-idence like the prophylactic antibiotics, preventing surgical site infection, or a verystrong rationale to have a good maintenance program for machinery like cardiacdefibrillators, to make sure the battery is there when you need it.
“The highest confidence results when we ask organizations to do the workof complying with National Patient Safety Goals, standards and performancemeasures. Health outcomes for patients will improve directly as a result of thatwork. Now we are engaged in that aspect of improving our standards and surveyprocess,” concludes Chassin. �
Mark Chassin is President of The Joint Commission.
The Joint CommissionAn independent, not-for-profitorganization, The Joint Commissionaccredits and certifies more than16,000 healthcare organizations andprograms in the United States. JointCommission accreditation andcertification is recognizednationwide as a symbol of qualitythat reflects an organization’scommitment to meeting certainperformance standards.
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one come in with unrecognized influenza, or healthcare workers workingwith unrecognized influenza.”
Cleveland Clinic has launched a campaign to prevent both seasonal fluand H1N1, and Gordon explains that the leadership of the clinic has been keyin supporting these efforts. The flu cart has just begun its seasonal vaccines,with between six and eight thousand employees receiving their vaccines with-in the first week, a much higher figure than in the past. Combining the sea-sonal vaccines with those of H1N1, will be a challenge – never before has theclinic had to give two vaccines in a season. Gordon notes that the vaccine islikely to be received soon, and is then to be distributed to the healthcare work-ers and high-risk patients.
The Healthcare Education Industry Partnership (HEIP), the advisorygroup to the CDC, has identified five high-risk groups that they’ve targeted,based upon the initial epidemiology from H1N1 and which encompass ap-proximately 159 million Americans. One of the groups incorporated withinthis is healthcare workers, another being pregnant women, as well as children
Infection control is not viewed simply as a challenge at ClevelandClinic, but also as an opportunity to become more focused on beingpatient-centric. With the colder months fast approaching, worriesabout H1N1 are increasing. Steve Gordon, Chairman of InfectiousDiseases at the clinic, describes the flu season as analogous to pre-
dicting 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 sea-son is that we’re entering it when we’re already in the midst of a pandemic,meaning there’s widespread transmission of H1N1 across communitiesworldwide. It has been estimated that there’s probably been a million cases ofH1N1 in the United States alone,” he adds.
“Most people don’t need to be tested or treated or seen, and it looks likeit’s been at least a relatively mild virus from that. That’s not to say that peoplehaven’t had severe illness, but it’s mostly been relatively mild. We monitor ourfree testing, but the biggest threat for us in a hospital would be having some-
Cleveland Clinic’s Steve Gordon discusses the paradigm shift ininfection control and patient safety, and why the current pandemicprovides opportunities for the future.
Gordon ED:26 June 18/11/09 15:35 Page 44
and young people between the ages of six and 24. It also includes adults belowthe age of 55 suffering from a chronic medical condition that is likely to putthem at a high risk of complications, as well as anyone who is taking care of achild six months old or younger.
“The good news is in terms of supplies: it looks like one dose of H1N1 ap-pears to be sufficient for healthy adults, meaning that it is unlikely we will haveto give a two shot administration protocol, which will then expend the avail-ability 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, andthe clinic’s current emphasis is to provide this shot, and produce H1N1 vaccinesin a second round when they become available. There are between 79 and 90 mil-lion doses of influenza vaccine each season, despite the fact that on paper 172 mil-lion Americans are targeted for seasonal influenza vaccine.
“We’re hoping that the H1N1 pandemic will get people thinking aboutprevention and looking to try to make seasonal vaccination a part of their pre-
ventive health every season, not just this season,” Gordon explains. “We liketo think that there is infection control behind every patient contact, even if it’snot seen.
“Hand hygiene should be up in the front, but, in terms of sterilization dis-infection, practice is about Foley catheter avoidance. For every kind of infec-tion there is control; sometimes it is up front in your face in every patientcontact, and sometimes not, and we think that’s important.
Patient safety“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’thave great antimicrobial therapy. Most of these are healthcare-associated typeof situations, not out in the community. Staphylococcus aureus is obviouslyone of those things, the acquired MRSA that most people are familiar with.The other issue is that of Clostridium difficile and that the association withantimicrobial use has spread. That is also high up on the list of infection con-trol practitioners’ concerns and challenges.”
The infections themselves are only one side of the coin, the other beingpatient safety and outcomes. “Whether we’re talking about healthcare-asso-ciated infections, falls, medication errors or patients who have had infections,the big paradigm shift, and it’s something our leadership has embraced, is de-veloping this culture of safety from the top radiating down, so from TobyCosgrove, the CEO, to Mark Harris in operations to Mike Henderson in theQuality and Patient Safety Institute is now embedded as a part of every activ-ity that we do,” explains Gordon.
He notes hand hygiene as an example of this; not being the responsibili-ty of the infection control practitioner but of every healthcare provider – amove reasserting the patient as the centre of clinical operations. “The otherside 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 improv-ing this. And then the third focus, is that we are talking primarily about badsystems, not bad people.
“So, for instance, it might be through the nurse that the wrong clini-cal dose was given, but instead of blaming the nurse, there is usually a sys-tems issue behind that. And our focus is to try to engineer good systemsin place to reduce the risk of adverse events occurring at the bedside,” heexplains.
Gordon notes the retaining importance of compliance and the natureof looking at the root cause, and not just in adverse events. Pointing to theInstitute of Medicine report in 1987 and the issue highlighted within it re-garding medication errors due to illegible handwriting, he notes the op-portunity for a translation error when dispensing the prescription. The
“We’re hoping that the H1N1pandemic will get peoplethinking about prevention”
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introduction of an order entry system would not necessarily eliminate allthe problems, but would be sure to attack and safeguard against a lot ofthem.
Cleveland Clinic embraced this, investing in computer physician orderentry (CPOE) technology, ensuring that now every order is done with fin-gerprint assurance for the medication, and providing the details of who wrotethe order. This does not guarantee that the right medication will be given, butit makes the chances of error slimmer regarding dosage and allows parame-ters for a much safer system of ordering and administering medications, aswell as lab tests.
Gordon also notes the important role of compliance in ensuring patientsafety. “If someone is in isolation for whatever disease that they may have orwe’re trying to rule out, it’s knowing if the health workers going into the roomof that patient should be wearing a gown or things of that nature. Again, usingan electronic information collector is important – having our infection con-trol practitioners actually put electronic notes in the chart so that if there arequestions, people know whom to ask, where it’s referenced in terms of whythey’re in that, and, also, of course, having the carts outside so that the ap-propriate protective equipment is there.
Gordon notes that the best patient is the most educated patient; beingasked about hand washing is not taken as an insult by the physicians, but en-couraged. “Hand hygiene is still the best thing one can do in terms of preven-tion 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; encourag-ing patients and their families to check that you are washing your hands, tobe able to go ahead and ask me and I won’t feel bad about that. We’d ratherhave that opportunity executed as opposed to not executed.”
Specialized controlAlthough it is a tertiary care center, Cleveland Clinic has specialized in
infection control. Gordon explains that the reason for this is for better effi-ciency, as well as the desire to create more knowledgeable care. “It became clearto us that with the growth and explosion of transplant infection control, of HIVand other sub-specialties, it’s very difficult for one person to keep up to speed onall of that. Now I have colleagues that can. It’s based on the concept of disease-based care, and this is becoming quite prevalent in the economy.
“An economist from Virginia recently talked of the different outcomesand what it really means. For instance, in transplant solid organism disease orbone marrow, we have aligned our groups so we have people who have a biginterest in that, and for some it’s all they do. They’re able to partner up withcolleagues in other specialty care that are delivering that. It becomes a veryteam-based approach of putting the patient in front, and there are colleagues
“There hasnever been a
better time to beinvolved inhealthcare”
Gordon ED:26 June 19/11/09 11:20 Page 47
that are really interested in this and are up tospeed in the latest developments as opposed tohaving a general person who may or may notknow a lot about one transplant patient, or allo-geneic bone marrow transplantation and thecomplications.
“We have eight services, and I could putnine services on at any one time, including abone marrow transplant ID service and a solidorgan transplant infection disease service. Wehave a bone and joint infection service, a cardiacdevice and endocarditis service, and an intensivecard ID service. All of this, again, is centered on the disease-based model ofdeveloping expertise and so we can hopefully put the patient first and pro-mote communication amongst other colleagues in other multidisciplinaryareas that are actually providing care. This helps in terms of patient care andeducation, as well as hopefully designing studies to look at the pain points indelivering clinical care in each of these different areas,” says Gordon.
The clinic also operates an infectious disease fellowship program – partof its mission is education. “Many of us are getting a little long in the toothand we want to make sure that the people taking care of us are also welltrained,’ he laughs. “It’s a legacy issue, too.”
The clinic currently offers a two-year program with three fellows andadds a special third year, which includes a microbiology degree for thosewanting to pursue that area. Starting next July, it will also have a special trans-plant infectious disease fellowship.
“The purpose of the fellowship is research, education, training and clin-ical practice, and we believe it makes us better as well to have younger peoplequestion what we do. It allows us to provide education, and hopefully to trainthe future leaders and practitioners of infectious disease,” he explains.
When asked about the future of infectious diseases and the possibility ofmore pandemics, Gordon is confident that a change of the current system willcreate a much more efficient system. From a global public health perspective,as well as what we do, there are going to be great opportunities. Developingmore vaccines for preventable illness, developing hopefully a universal flushot, 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 certainsevere 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 tothis therapy or that therapy?
“We review global health as a responsibility of infectious disease, andmuch of that has to do with poverty and education. Elimination of warfare isimportant – 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 causefor. There’s a huge area of looking for the next new emerging disease or po-tentially discovering illnesses that may be caused by infections, but we don’thave the pathogen for.
“The future is going to be extremely exciting. And on the other side ofthat are immune-based therapies that we give patients for rheumatologic con-ditions, or cancer conditions, which will always affect the immune system, andthen also lead to a potential increase in infections. We’d like to try to preventthose,” adds Gordon.
Rather than hide from challenges during such a time as this, ClevelandClinic is not only working its hardest to remain patient-centric in its ap-proach, but is enthusiastic about the developments that will result from theH1N1 pandemic. As Gordon concludes, “There has never been a better timeto be involved in healthcare.” �
A mission to healSteve Gordon on the goals of the Department of InfectiousDiseases, Cleveland Clinic:
“The primary mission in our department is to providethe most technologically advanced, compassionatemedical care for our patients. We are committed to a‘patients first’ orientation and maintaining our well-recognized excellence in patient care and medicaleducation. In addition, we want to capture the synergiesof existing and emerging opportunities in the areas ofclinical research and outcomes research to takeadvantage of the breadth of our clinical volume.
“We are aligning resources to establish newprograms in the areas of transplant infectious diseases,cardiothoracic infections, HIV/AIDS, healthcareepidemiology and prevention of healthcare-associatedinfections, and the development and evaluation ofinnovative infectious disease diagnostics by partneringwith 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, andinfectious Granuloma. Initiatives for 2008 will focus ontaking advantage of the CCF electronic health record andthe internet to improve productivity and service intaking care of our patients.
“Our department uses ‘My Chart’, allowing patientsto access portions of their clinical record via the internet.We will continue to enhance our website to facilitatedissemination of information and the access for referralsand appointments by clinicians and patients. We areviewing these challenges as opportunities for thecontinuing pursuit of excellence.”
Steve Gordon is Chairman of the Department of Infectious Diseases at Cleveland Clinic
Gordon ED:26 June 19/11/09 11:21 Page 48
BIO TECH MEDICS AD.indd 1BIO TECH MEDICS AD.indd 1 18/11/09 09:28:0918/11/09 09:28:09
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The H1N1 virus may not be featuring so prominently in the in-ternational news at the moment, but the maximum classificationof phase 6, which the World Health Organization designates asa pandemic, remains in place. With the main winter flu seasonrapidly 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 theMailman School of Public Health, Columbia University.Her work currently focuses on determining the lifes-pan of the H1N1 virus.
“Believe it or not, nobody actually knowshow long this virus lives on your hands orin the environment,” says Larson.“We are conducting a studyright now whereby we gointo the homes of peoplewho have the flu and
get them to cough into their hands, and then we culture their hands every fiveminutes 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 andtouch some of the objects they regularly come into contact with, such as cellphones and pillows.”
Through this study, Larson is hoping to shed some light on how H1N1is spreading in real life situations. She explains that there is already a lot of lit-erature on the topic, but most of the other studies have been done under testconditions where the infection is not natural. People are given the virus andthen tested, whereas Larson is recruiting people who are genuinely suffering
from the flu. She wants to be able to assess the risks involved for peopleliving in a household where someone is already infected.
The main problem Larson is facing with regards to herstudy is a current lack of participants. “We’d like to finish
the study as soon as possible but we need to find morepeople who are sick,” she says. We’re trying to
spread the word and get people to call us if theyhave flu-like symptoms, a fever and chills.”
The initial phase of Larson’s study co-incided with extremely reduced num-
bers of H1N1 cases in hospital
Helping handsEHM’s Stacey Sheppard talks to Elaine Larson about the handwashing researchaimed at reducing the H1N1 virus’ capacity to spread and limiting the rate of infection.
Larson:26 June 19/11/09 11:23 Page 51
By gaining a better understanding of the virus, Larson hopes to be ableto educate people as to what they need to clean in their homes and also whoshould be wearing masks and for how long. Unfortunately, too many ques-tions remain unanswered for her liking and the recommendations that arecoming from New York City and the Centers for Disease Control andPrevention (CDC) are different.
“For healthcare workers, the CDC is recommending N95 masks, whichhave a lot more filtration, and New York City is recommending just the reg-ular surgical mask. But for the general population any regular mask will do.There was a paper published in the Journal of the American MedicalAssociation in October that showed that the two types of mask are equivalentin terms of protection,” says Larson.
Larson’s work in the area of hand hygiene also extends to the recentlypublished WHO hand hygiene guidelines. “This has been tested now in 81countries around the world and we were involved in some of the testing tomake sure that it is practical. It’s one thing to recommend what needs to bedone in this country, but we have major resources compared to other coun-tries,” she says.
Larson has also worked on a number of smaller projects related to themeaning of hand hygiene in various religious groups and points out thatthe issues affecting Islamic cultures, for example, are somewhat differentfrom those affecting other cultures. “In Islam it is against many funda-mentalist Muslims to even touch alcohol – it’s a sin. There’s are lots ofthings that you don’t consider until you start talking with people aroundthe world Muslims,” she says. �
emergency rooms in comparison with the figures from last spring, and shebelieves this can be explained by immunity. “It appears that in the placesthat were hit hard in the spring, like New York City, we are not seeing itso much now. So, obviously there are some people who got it in thespring who are now immune,” she explains. In this case, people who havealready 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 residualimmunity. I think that in some ways those people who got it in spring areprobably lucky.”
At least for those people who may be infected this winter a vaccine is onits way, but this will only help if received in sufficient time before infectiontakes 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 yourbody developing enough antibodies. So if you got the vaccine and then got theflu the next day, you wouldn’t have much protection at all. That’s why it’s im-portant to get the vaccine out before people start getting sick,“ explainsLarson.
In the meantime, the main piece of advice that Larson can offer is towash your hands as much as possible to avoid the potential of furtherspreading the infection. But then the question arises as to what is the mosteffective means of washing your hands, and this is another area thatLarson is investigating. “We’re looking at the impact of different hand hy-giene soaps. If we can determine whether sanitizers or plain soap andwater is better, then we’ll know what to recommend that people to use,”she says.
“Wash your hands asmuch as possible to avoidthe potential of furtherspreading the infection”
Larson:26 June 18/11/09 15:40 Page 52
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Where do hospitals currently stand in their fightagainst hospital-acquired infections? James Hosler. Unfortunately, most hospitals are in an ex-tremely weak and vulnerable position. Bacteria such asMRSA and C.diff have grown stronger, while hand washingtechnologies have not. The industry is facing increasing in-fection rates, poor scores on JCAHO scorecards, and the fi-nancial burden of paying for treatment of infections acquiredby patients while under their care. That’s why it’s imperativefor hospitals to innovate and reduce the risk of HAIs.
Do you see any solutions that would help protect hospi-tals from these costly threats to their business?JH. Yes, our belief is that innovations in hand washing pro-tocols and products are key to a hospital’s financial successand ultimate survival. Hospitals must recognize the need toinnovate and fight HAIs differently, because current proto-cols are no longer effective and in reality, haven’t been forquite some time.
It’s this reality that led us to develop our new MicrodineHand Scrub product. It’s an innovation based on a very crucialneed recognized years ago by the renowned Nobel Laureate Dr.Joshua Lederberg, who correctly identified the need to addressalcohol’s ineffectiveness to control HAIs and improve hand-washing compliance. His suggestions inspired us to pursuepaths that led to remarkable innovations in antiseptics.
Both hand washing products and protocols need im-provement. Alcohol is effective at killing some germs, but notall. For example, certain C.diff spores are frequently resistantto destruction by alcohol. Furthermore, alcohol-based anti-septics routinely damage skin when used repetitively. Thishas the undesirable effect of reducing compliance. By com-parison, Microdine Hand Scrub kills 99.99 percent of germs,including MRSA and C.diff spores, and persists with antimi-crobial activity for six hours, yet remains gentle to the skin.Because it contains an active skin protectant (0.5 percentAllantoin), it actually promotes healthy skin growth.
It is important that we institute a protocol that ad-dresses the full threat that HAIs represent. If we can intro-duce a Category I hand antiseptic that provides apersistence effect and combine that with the current handwashing procedures, we can decrease the incidence ofHAIs while increasing compliance.
Has Microdine satisfied the FDA Tentative FinalMonograph for effectiveness testing of a surgicalhand scrub?JH. Yes. BioScience Labs independently tested and veri-fied that Microdine successfully meets the requirementsof that FDA monograph; the test results and final reportcan be viewed on the website. Microdine uses our patent-ed Nouristrat system to electrostatically bond a long-last-ing protective layer to the surface of the skin. It kills germsin compliance with the FDA’s highest standards, whichrequire Category I antiseptics to be fast acting, broad spec-trum and inhibit bacterial growth for six hours. At thesame time, it helps prevent cracked skin and promotes thegrowth of healthy skin. We like to think of it as a ‘win-
win-win’, because Microdine literally offers it all – persis-tent germ control, healthier skin and improved dailycompliance. It’s the Holy Grail of hand washing protocol– a product whose time has come.
As healthcare providers, we all share a common mis-sion to address the growing threat of HAIs.Our vision atDRSS Global is to change the way the world protects itselffrom contamination by bacteria, viruses and other germs.We believe our products make a meaningful contributionto this mission. �
Streamlining the prevention ofhospital-acquired infections
James Hosler discusses the huge threat that hospital-acquired infectionspose to the healthcare industry.
“It is important that weinstitute a protocol thataddresses the full threatthat HAIs represent”
For more information please visit www.microdine.com
James Hosler graduated from the University of Michigan MedicalSchool and engaged in private practice of GI medicine from July 1979to October 2008 in the Dallas-Fort Worth area. He was a member ofhis hospital’s Board of Directors from 1987-93, and is a Fellow of theAmerican College of Physicians.
Drs Solutions ed:16 nov 19/11/09 11:22 Page 54
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PathogencontrolMichael Beach of the CDC examines the various faces of waterborne pathogens and the need
for stricter regulation and greater awareness.
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able to judge the incorporation of this via the sales of the units. Th ere has been a recent surge in the sale of units and the number of them being installed, although the exact number, again, is vague. Th e CDC is ad-vocating 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, aft er 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 suff ered. “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 diff erences in how pools are main-tained and operated under a pool code. Th e 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.
“Th at 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 cur-rent 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. Th ey can become part of a national consortium to do that.”
Hospital-based infectionsRecreational 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. Th e state is heavily focusing on reduc-ing 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
In light of the current H1N1 pandemic and the ever-increasing public concern over HAIs, waterborne pathogens was tradition-ally an area oft en overlooked, surprisingly more so in Western societies than would be expected. Michael Beach, a CDC spe-cialist in waterborne pathogens, defi nes 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.”
Th e most common recreational water illness pathogen that is re-ported to the CDC is Cryptosporidium in its various species – it is cur-rently 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 eff ect in our home and public pools because it’s resistant to chlorine,” explains Beach.
Recreational illnessesTh e number of outbreaks in disinfected venues in the US, caused
by Cryptosporidium, has risen by 70 percent in recent years. As a devel-oped 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.
“Cryptosporidium is chlorine resistant,” he explains. “We’re advo-cating 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 aft er the fi lter system irradiates the water going through it, and so it’s a fl ow-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, instan-taneous 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 cur-rently operating this system across the US is poor. However, the CDC is
“Good hygiene, good health practices and understanding that chlorine doesn’t kill everything instantly is
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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 poten-tially contaminated water allowing pathogens to enter from any orifi ce, 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 practic-ing 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.
He adds that showering is oft en done when people get out of the pool, not before, which is vital for practicing good hygenie. He also notes the neces-sity 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 chlo-rine 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 de-manding 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.
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
such as Legionella or Mycobacterium avium complex. Dialysis machines and biofi lms can be impacted by water quality and contamination. Th e 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.
“Th ey 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. Th ese are currently really big issues in the US; how do you control biofi lms and Legionella levels that can be spread through an entire build-ing 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.”
AwarenessAwareness of hygiene and infection control is increasing, from drink-
ing water facilities to hospitals to recreational water facilities. Th ere 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 fi ve 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 diff erent model of waterborne disease – it’s not that it’s gone, it’s just taken on a diff erent face. We have to educate all risk reduc-tion specialists in the complexity of diff erent things that occur here, and so
“We’re trying to develop a national consortium and a model code at the national level with local and state partners”
Michael Beach is a specialist at the CDC in recreational waterborne illnesses.
Sprayground shut downThe 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 confi rmed 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.
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NEPHROS AD_NEW:mar09 18/11/09 10:22 Page 61
Please tell us about Muvezi Health ProjectsSociety’s ‘Africa helping Africa’ concept.Brian Carpenter. The facilitation of tradingShona stone sculptures for health has created a fi-nancially self-sustaining charity. Following a se-ries of coincidences about three years ago, I flewto meet Doug Dicker in Zimbabwe and, to makea long story short, Muvezi has bought approxi-mately 3000 sculptures, created a renaissance ofAfrican Shona art and sustained about 2000Africans financially every month for three years(a charity in its own right).
Muvezi Inc. was formed with my co-founderGreg Pendura to provide a steady stream of in-come to the charity, with 20 percent of the salesproceeds of every sculpture sold going toMHPS. Our Shona art can be viewed atwww.muvezi.com. We sell sculptures from gal-leries in Canada, Mexico and througheCommerce. Importantly, MHPS’s expenses areessentially zero, since Muvezi Inc. supplies of-fices, 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 largehealing center using only natural healing laws andnatural products. Over the last several years I haveprovided Guardian Silver Sol to thousands ofclients with just about every infectious conditionpossible. The results, without exaggeration, havebeen miraculous.
Since silver sol has cleared the malaria plas-modium from the bloodstream in five days in clin-ical trials and malaria kills a child every 30 seconds,MHPS had a perfect way to make a specific differ-ence through our African connections. Malaria wasour original focus, since results are fast, complianceproblems are minimal and verification of the effec-tiveness of the treatment is easily tested.
MHPS will have sent silver sol toZimbabwe, Senegal, Sierra Leone, Mexico, Nepaland more before the year’s end. Our charity ef-forts are also expanding, largely due to the broadspectrum antimicrobial results of silver sol, andour business model for the charity now includesmarketing silver sol worldwide througheCommerce. Silver sol is now shipped all overthe world. For every 10 bottles sold, two are sup-plied to charities free of charge.
It is our passion for it to result in a very largecharity. Rather than getting bogged down with
building a distribution infrastructure, MHPSsimply supplies pre-existing charities with thismiraculous antimicrobial, allowing our missionto grow quickly and with almost no costs.Volunteers and charity workers traveling tocountries with prevalent malaria, hepatitis, TBand so on shouldn’t leave home without silversol for personal protection against infection.
Further, why would any corporation have theirexecutives or employees leave home withoutsilver sol? Many corporations also have theirown charities, so there is a perfect fit.
How does another charity or corporation partnerwith Muvezi?BC.With the huge advantages of the internet, theysimply start by trying the silver sol. Quickly theywill start to trust the many antimicrobial, andsometimes life-saving, benefits. From there, theycan contact us directly via the website to allow thebenefits of resulting purchases to flow directly totheir charity of choice.
We need many leaders to join us. All readers ofthis interview have an invitation to help their fami-lies and friends fight infections with silver sol whilealso helping impoverished people around the worldthrough a charity of their choice. �
Trading art for health
For more information, please visitwww.muvezi.org
Brian Carpenter is Managing Director of Muvezi HealthProjects Society. In addition to managing a healing centerin Edmonton, Alberta, Carpenter is especially passionateabout sharing the health benefits of silver sol with asmany partner charities as possible.
Dr. Brian Carpenter with children in Zimbabwe
Brian Carpenter of Muvezi Health Projects Society explains the importance ofsilver sol in treating life-threatening infections in Africa.
“People traveling to countries with prevalent malaria,hepatitis and TB shouldn’t leave home without silver sol”
Guardian Silver ed:26 June 19/11/09 11:25 Page 60
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GUARDIAN SILVER_3RD.indd 63GUARDIAN SILVER_3RD.indd 63 12/11/09 09:16:5512/11/09 09:16:55
As the winter months draw near and seasonal infl u-enza begins to dominate headlines, Novartis Vac-cines 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 offi cials 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. Th at’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 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.
Gearing up for battle
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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 diff erent mutations in H1N1 in diff erent parts of the world”
Pandemic preparationTh e 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 al-ready 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 infl uenza 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) wild-type strain show the signifi cant time savings of cell-based production over the traditional egg-based manufacturing approach, confi rming 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 diff erence,” says Oswald.
Novartis Vaccine’s proprietary adjuvant, MF59, also plays a role in pandemic preparedness. MF59 is the fi rst oil-in-water infl uenza vaccine adjuvant to be approved for use and commercialized in com-bination with a seasonal infl uenza 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-
Oswald.indd Sec1:63Oswald.indd Sec1:63 18/11/09 15:17:0918/11/09 15:17:09
so there is a signifi cant window until a new tailored vaccine then becomes available. It is also very likely that we will see diff erent mutations in diff er-ent parts of the world; we see that with seasonal fl u as well. Th ere may be in the US one mutant that will start to spread and a diff erent 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? Th e avian fl u, for example, is not completely off the table, and a more severe pandemic can defi nitely 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 signifi cant 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 shift ed over towards that,” he says.
Oswald suggests that prevention could be enhanced by a more ef-fi cient production capacity, noting the current pressure of shipping vaccines to developing countries. If there’s not enough capacity for the countries that have invested and built this capacity, how can we expect it to be available for other countries that have not done so? His solution is to build a sustainable production system that can supply the entire world, adding, “Th at should not happen by forcing donations in a pandemic, but it should happen so that the capacity would be available.”
He also argues for bigger and better investments into new technolo-gies, again citing the shortfalls of egg-based production. “We need the
fi nancial incentives for companies to be attracted by that, because in the fl u business with a lower demand and prices in many countries for seasonal fl u, we simply cannot aff ord to aggressively invest into new technologies, so we have to think about how to address it and how to create the right incen-tives for innovation.
“Finally, from a patient point of view, there are still too many hurdles that stop us from being really quick. We have to think through with the diff erent authorities and regulators how in a real emergency one could make a vaccine available in two months. Th at’s possible, but we would have to cut out some of the hurdles if a pandemic were to be severe,” con-cludes Oswald.
With not much time left before the winter fl u season begins, it remains to be seen how the industry
will cope with the crisis. Novartis’ preparedness to the pandemic and its mutations means it is already one step ahead of the game.
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 cross-protection, 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 fl u 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 eff ective. 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 unno-ticed. Th e 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 specifi c 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.”
H1N1 mutationHowever, developing the vaccine for H1N1 is not so simple. Experts
have speculated that the virus is likely to mutate into a more virulent, deadly form when the winter fl u season starts, and Oswald agrees with this. “It will happen because fl u viruses do mutate,” he explains. “We see that with the seasonal fl u viruses as well. Th ey normally mutate when there is pressure for them to do so, which is at the time when a fair number of the population has already been infected; if the virus hits someone who already has some protective antibodies, then it is under pressure to mutate to survive and keep going. I would expect mutation to happen not in the fi rst wave but in the second wave of the pandemic, when maybe 20 to 30 percent of the population has already been infected and has some protection.
“We normally see the virus drift ing and making small mutations to become more virulent to survive. Th at doesn’t necessarily mean that the virus becomes more pathogenic or more severe; that is not necessarily the case. It’s just diff erent. Even if you’ve had the earlier form you could get it again, and of course the people that didn’t have it would still get it. It wouldn’t necessarily be more severe, but it’s a challenge to the vaccine because the mutations could make the vaccine somewhat less ef-fective. Hence, our belief that with an adjuvant one has a higher chance of vaccinating with something that would still protect if these small mutations actually happened.
“When these mutations happen we will develop a new vaccine, par-ticularly addressing that mutated virus, but that takes a couple of months
Andrin Oswald is CEO of Novartis Vaccines.
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MEDIC ACCESS AD.indd 67MEDIC ACCESS AD.indd 67 12/11/09 09:12:0512/11/09 09:12:05
Steve Hooper of Massachusetts GeneralHospital explains how the experiences of H1N1are shaping its preparation for the nextpandemic.
READY FOR THE
Hooper ED:26 June 19/11/09 11:32 Page 66
September saw an upsurge in the US in influenza activity; thedata from both the CDC and Massachusetts General Hospital(MGH) has shown this. David Hooper, Chief of the InfectionControl Division at MGH explains that most of these cases areattributable to the H1N1 pandemic strain, but remains unsureas to how the virus is likely to play out overall, looking at previ-
ous 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 H1N1virus in it,” he explains. “They saw around a fivefold increase in patients with in-fluenza-like illness and they saw patients in their intensive care units that werequite 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 thatwould be very unusual to see with seasonal influenza. So we anticipate on bothwhat we heard from the southern hemisphere and what we’re beginning to seenow-that this will be a very challenging flu season for us.”
H1N1 vaccineMGH is currently conducting an enormous amount of work at the hos-
pital level, preparing for a surge of patients and being able to manage thesepatients in an already busy tertiary care hospital. Hooper notesthat this is now taking up 70 percent of his time, focusing on thesepreparations and responses.
“You don’t need specific antiviral medications. You need sup-portive care – go home and you’ll get better in a few days.However, there are certain subgroups that are more likely to get amore severe form of the disease, pregnant women being one ofthose groups, young children being another and patients who areunusually obese, a group that’s newly being recognized. It wasn’tsomething that was recognized in seasonal influenza and so we’reseeing some of those patients in our ICUs.
“It’s not that H1N1 is necessarily worse but there’s just such a large pop-ulation of people who are susceptible to it. Even a small proportion of peoplewho have severe diseases can have a large impact on a hospital like ours whichis a tertiary referral center. The sickest people come to us and so that’s whatwe’re dealing with. Hospitals have to be doing preparation work but the mes-sage to most of the public is that it is a mild disease but particularly the high-risk groups should avail themselves to vaccine as it becomes available, as wellas the rest of the population, because broad vaccinations of population pro-tects not only the individual but damps down the spread within the popula-tion, thereby reducing the number of cases both primarily and secondarilywhen there’s enough vaccine distribution,” says Hooper.
For several weeks MGH has been receiving supplies of the vaccine, al-though 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 enoughvaccines for everyone. Currently, being at the start of flu season, priority vac-cinations are given to those patients with the highest risks vaccinated first –obstetrical patients, pediatric patients and then those other patients who haveunderlying risk factors such as chronic heart and lung conditions.
This is a situation most hospital institutions are finding themselves in: noone has all the vaccine that they want and need at this stage. Hooper adds thatdistribution 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 mytime is spent with people who aren’t quite in the front part of the line wanti-ng to know when they’re going to get their vaccine. What we thought early onwas that there was going to be some concern about it being a new vaccine andits safety, but this has turned into a problem of shortage. Everyone is clamor-ing, which in the end, ultimately, is a good thing because getting people vac-cinated is the most important public health activity.”
Infection controlThe media hype of H1N1 may be recent, but the challenges of infection
control are not new phenomena. Hooper explains the amount of work in-volved in education and staffing, and despite its size it, is never as large as thehospital would like it to be.
“At the hospital we are fortunate in that we have fairly good resources butwe could still use more and particularly in the context of surveillance activi-ty, 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 ratespublicly. All of this we’ve done to some level internally in the past but the extrapublic reporting and ensuring it’s standardized across the system has addedmore work. It’s a good thing, ultimately, because it’s caused a greater focus of
attention on infection control and that’s important. And certainly, that’s lever-age for advocating more resources going forward.
“For our hospital in particular, we devoted a lot of resources to improv-ing our hand hygiene clients’ rates, and over a number of years have beenable to get them to over 90 percent compliant. Healthcare workers wouldgenerally use alcohol-based hand gel or hand rub before patient contact andover 90 percent after patient contact. Temporally associated with that, we’veseen a 2.5 percent drop in our hospital-associated MRSA infection, andwe’ve sustained those levels of compliance with antigens. It’s a lot of workbut it’s possible to change the culture of hospitals’ standard of care andeverybody accepts it and does it with a high degree of consistency in thesame way that surgeons going into the operating room would always be ex-pected and would think it standard to do a surgical scrub before they go intothe operating room.”
Education of infection control has been an issue for many years, only com-ing to the forefront of the healthcare debate given the recent media focus. MGHhas been tackling it with observations of compliance, feedback of complianceand accountability for compliance, all of which has been given a huge amount ofattention from the hospital’s senior management. Hooper notes the example ofa hospital in Geneva that has pioneered the use of alcohol-based gels in reduc-ing hospital infections, having a similar experience of their MRSA infections de-creasing as their compliance with antigen improved over time.
“What has developed and will probably beeven more challenging is the global spreadof multiple antibiotic-resistant bacteria”
Hooper ED:26 June 18/11/09 15:39 Page 67
“The main difficulty that this cre-ates is that those genes are often onthese plasmas that have other resis-tance genes, other determinants sothat it links quinolone resistance withresistance to other antibiotics andtherefore multi-drug resistance, andthat’s become an increasing problemepidemiologically. We’re interestedin knowing how some of the proteinsencoded by these resistance genescause resistance. We know that someof the proteins interact with the quin-talone target enzymes and we’re try-ing to sort out exactly how theyinteract with those and the resistanceproteins interact with those enzymes.
“The other area that I look at, interms of bacterial resistance also has todo with multi-drug resistance but by adifferent mechanism and it’s focused on
gram-positive bacteria, particularly staphylococcus aureus, a very commonhuman pathogen. We are trying to understand the role of multi-drug effluxpumps in resistance, which are proteins that are in the bacterial cell membraneand can remove antibiotics from the cell. Where there are more of their levels ofexpression they can cause more resistance and many of them are, the pumps canactually pump out a number of different types of compounds and a number ofdifferent types of antibiotics, including quinolones,” he explains.
Hooper says that knowing the natural function of the normal makeupof these cells is an area of interest. Often it appears that their natural func-tion allows the organism to survive in different environments – staph au-reus is an example of this, commonly when it causes skin infections fromabscesses.
“We’ve looked at expression of these efflux pumps in abscesses and itturns out that in several of them their expression is increased when the bug isgrowing in the abscess as opposed to other growing conditions,” adds Hooper.
“We found that in fact that expression gives the bug fitness to survive inthe abscess environment, so this is where you have linking of a resistancemechanism with, in fact, an over-expression of a protein which also allows theorganism to survive in other environments. It’s something akin to linking fit-ness of the organism with resistance, which potentially has concerns becausethe organisms use these mechanisms to cause disease and now, you’re link-ing a disease mechanism or cause of disease mechanism with antibiotic resis-tance, which is the opposite of what’s often talked about where resistancemechanisms have a cost to the bacteria and therefore, they’re less fit. Thisworks just the other way around.”
The occurrence of pandemics every few decades seems unavoidable, butheightened education of infection control can improve the outcomes. Now atthe vaccination stage, there appear to be far bigger challenges ahead, withHooper’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. �
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 theglobal pandemics don’t occur every few years,” says Hooper. “They occur withperiodicity that’s determined by the amount of changes in the virus so that thepopulation then no longer has immunity and the usual change from year toyear are small enough that it’s not going to make the population fully suscep-tible or fully lacking in immunity. However every 20-to-40 years or so a bigchange occurs and that’s when the pandemics occur. Our last was in 1968 andso we were due, in a sense.
“I don’t think they’re necessarily going to occur more frequently than thatalthough I can’t tell you it’s going to be exactly 20 years from now. The virusdecides 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 evenmore challenging is some of the problems with the global spread of multipleantibiotic-resistant bacteria. That’s been documented in a number of in-stances and doesn’t seem to be abating.
“That’s going to continue going forward, not in a cataclysmic way but ina carefully progressive way, which is going to be a challenge for all of us be-cause in some cases, particularly for gram-negative bacteria, we see somestrains causing infections that are susceptible to almost none of the currentlyavailable antibodies. We get to the situation where you’re really challenged totreat a patient who has a severe infection adequately. In some cases this is par-ticularly typical in the hospital setting.”
Antibiotic-resistant bacteriaHooper’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 in-terested in resistance genes determinants that are on mobile genetic elements,plasmas usually, that have spread worldwide and contribute to low-levelquinolone resistance amongst a range of gram-negative bacteria and promoteselection of high levels of resistance.
“The occurrence of pandemicsevery few decades seemsunavoidable, but heightenededucation of infection control canimprove the outcomes”
David Hooper is Chief of the Infection Control Division at Massachusetts General Hospital.
Hooper ED:26 June 19/11/09 11:32 Page 68
PFM AD.indd 71PFM AD.indd 71 18/11/09 09:56:0518/11/09 09:56:05
Hospital-acquired infections (HAI)are among the most pressing prob-lems in healthcare today. Five to 10percent of all patients become in-
fected while hospitalized, with incidences up to 28percent reported in ICUs. In the United States,more people die from hospital infections thanfrom breast cancer and AIDS combined. Thecosts involved with hospital infections are stag-gering, estimated at $1.6 billion per year in theUK and $6 billion per year in the US, or approxi-mately $7000 annually per hospital bed. Once webelieved it was easier to treat HAIs than to pre-vent them. However, we now realize that theenormous scope of the problem argues in favor ofprevention.
There are two current lines of prevention.The first is to stop infections from entering thehospital. Rapid PCR-based tests screen for colo-nization of MRSA upon admittance to a hospital.Positive tests are followed by decolonization ofthe patient, with isolation from other patients.
Detecting transmission of infections withinthe hospital is the second. Rigorous and consis-tent maintenance of infection control measureshelp to prevent transmission of microorganisms.
These include hand hygiene, environmental de-contamination, personal protective equipmentand isolation/cohort nursing. However, withouta rapid tool to fingerprintpathogens found within the hos-pital, these efforts lose impor-tance and focus. Identifyingvectors of transmission and mon-itoring compliance are essentialto a rigorous program. With thedevelopment of the SpectraCellRA bacterial strain analyzer,available from River Diagnostics,active surveillance is now a reali-ty, providing actionable outbreakinformation within minutes fromculture.
Bacterial identification atstrain level can be compared totaking a fingerprint. It enablesprecise tracking of when andwhere a specific bacterial strainoccurred. Such surveillance iscritical to identifying sources ofinfection and to limiting the spread of an out-break. Tracking the occurrence of strains over
time and location enables early and automateddetection of transmissions of microorganismswithin the hospital.
Until now, hospitals have had limited meansto implement an active surveillance program todetect outbreaks in real-time and to determinepathways of transmission. The standard methodfor bacterial typing is slow, with hospitals gener-ally having to wait anywhere from three days to aslong as several weeks for results. Further, the test-ing is costly and labor intensive, requiring highlytrained personnel and special facilities. Moreover,conclusive identification of recurrence is difficult.As a consequence, this method is generally andbest limited to analysis only after an outbreak hasoccurred.
With SpectraCell, positive culture samplesfrom patients, staff and the hospital (hand-touchareas such as beds, doors, and faucets, diagnosticand therapeutic devices) are stored in aSpectraCell database. Information about the ori-gin of the sample (such as time and date of sam-ple collection, subject ID and location [object] ofsample collection) is stored in the same database.SpectraCell data of new samples can then be com-pared to the spectra already in the database.Criteria can be set for alerts to be generated bySpectraCell as matches are found between thedatabase and new spectra. Alerts and epidemio-logical data provide information enabling infec-
tion control specialists to taketargeted action.
While MRSA, VRE andC.diff are at the center of atten-tion, the list of species frequentlyencountered in HAI is muchlarger and contains both antibiot-ic resistant and susceptible mi-croorganisms. It is estimated that30 percent of HAIs can be pre-vented by means of targeted in-fection control measures enabledby bacterial fingerprinting (typ-ing) of organisms.
Prevention of an outbreak isthe most cost-effective measure tocurb the cost of HAIs. SpectraCellenables active surveillance of hos-pital bugs such as MSSA, MRSA,VRE, Acinetobacter and Klebsiella,providing actionable information
for targeted intervention by infection control teams,when a potential problem is signaled. �
IDENTIFYING MRSA VECTORS OF TRANSMISSIONMichael Rumbin examines solutions for HAI prevention.
Michael Rumbin is the VicePresident of Marketing andSales for River Diagnostics B.V.He has held numerouspositions in the industry,including VP of TechnologyManagement with the SiemensMicroScan Business Unit.Rumbin holds a Masters degreefrom Villanova University and isa graduate of the WhartonSchool of Business at theUniversity of Pennsylvania.
River Diagnostics ed:26 June 19/11/09 11:31 Page 70
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THE BIG INTERVIEW
GREALY_16 nov 18/11/2009 15:27 Page 72
Adiverse organization with the challenging task ofrepresenting the many sectors within healthcare,the Healthcare Leadership Council is comprisedof both publicly traded healthcare companies aswell as not-for-profit entities representing phar-maceuticals and health insurance plans. Unifyingthese various organizations is the desire toachieve a high quality, high value, cost efficient
healthcare system that’s accessible to everyone and as Grealy explains, thecouncil has spent a lot of time reaching a consensus among its members toform 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-profitand it’s even more remarkable that we are able to get hospitals, health plansand manufacturers around the table and they truly check their individualagendas (and also their weapons) at the door,” she laughs.
Grealy explains that this was no less of a surprise to her when she firsttook up the role over 10 years ago. Previously working at two trade hospitalsshe had plenty of experience seeing the hospital association fighting with thehealth insurance association and the AMA. However the council avoids thisproblem by electing individual CEOs as members, with each working togetherto find the common ground. “They understand that if the different sectorsdon’t work together, then you have a divide and conquer strategy and it’s notgood for the overall system,” she says.
Innovative reformA 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 asource of information for congressional staff conducting a great deal of Hillbriefings on particular issues. The fundamental goal of the council is change:canvassing healthcare reform.
Having a combination of a pharmaceutical company, a hospital CEO anda 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 ismuch 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 pricecontrols and that it inhibits innovation.
“We need to make changes in our healthcare system, but we want tomake sure that we don’t throw out the baby with the bathwater and that weprotect those things that are good about our healthcare system,” she says.“Innovation is one of the key principles that we feel very strongly about – wewant to ensure that whatever we do as part of healthcare reform that we pro-tect and foster innovation.
“That can be a big part of the solution in what we’re trying to achieve witha reformed healthcare system, and so as well as new products and services thatwill improve the quality and efficiency of healthcare. We’re also looking atbenefits design and how can we move our system from one that has beenabout treating sickness and move it more towards how we can prevent illnessin the first place and the innovative ways that we could be doing that.”
Patient careGrealy points to recent data that displays the progress the healthcare sys-
tem is making: longevity is now at an all time high as diseases continues to beovercome. She notes the advancement in breast cancer treatment and the re-turn on the investment of dollars that have been put into the disease by notonly an increase in the lengthening of life, but also in productivity. “Whenwe’re able to shorten the length of stay in a hospital, that means that that per-son is back to work and contributing to the economy.
“As we’re looking at the cost of medicines, or medical devices, we alsoneed to take into account what those things are doing. What we’re seeing isthat they’re not only producing longer lives, but also healthier lives. It’s beenremarkable looking at our aging population, but it’s a much more vibrantpopulation than we’ve had before.”
However, these are not new issues for the council. Grealy explains thaton 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 pro-vided them with the data to understand the problem and formulate a solu-tion. Knowing whom the uninsured comprised of was pivotal – the Counciltook five months to analyze information and resulted in the now commonlyknown statistic of eight out of 10 uninsured living in a household where at
Mary Grealy of the Healthcare Leadership Council explains how collaborationin the industry and the council’s lobbying efforts are bringing about change.
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be available and then after that, when the plans were finally available, actual-ly going out and helping people sign up and enroll in the program that wouldwork best for them.
“On a personal level it was one of the very few times I’ve had the experi-ence of working on legislation and then actually getting to meet the peoplethat would be helped by it, so it was a really gratifying project to work on. It’sbeen a phenomenal success; there’s a satisfaction rate of over 80 percent andI don’t think you find that in too many programs, so that was a big plus, andthe program actually wound up costing less than had been projected so thatwas another positive as well,” says Grealy.
Alongside the issue of health insurance cover is the council’s desire tochange the incentives within the current system. America is practicing evi-dence-based medicine; patients are becoming partners in their healthcare andbecoming involved in prevention and wellness. Grealy notes that 70 percentof healthcare expenditure is for chronic disease and if the American publiccan be persuaded to liver healthier lifestyles this could be reduced signifi-cantly. As well as this, Grealy advocated moving away from a system that paysonly for volume and moving towards one that pays based on outcomes andthe value of the work that is done.
Heading up patient safety and addressing another topical issue, is an ex-ecutive level taskforce with many of its members being leaders in the variousquality improvement initiatives. “One example would be Premier, an allianceof not-for-profit hospitals, which has participated in the center for Medicareand Medicaid services hospital quality improvement demonstration projects,”
least one person is employed. The population of the uninsured belongs toAmerica’s workforce, with nearly half of those offered health insurance bytheir employer refusing.
Cost is often a factor with many taking coverage for themselves but notfor their dependants, family coverage being more expensive. What emergedfrom the results was that the uninsured were a gap in the population, over-looked because of their mediocrity – Medicaid is provided for the very low in-come, state children’s health insurance programs for children, but nothing forthe employed population who cannot afford to pay.
The Healthcare Leadership Council has made this group a priority, aswell as investigating further into those who appear to be covered. “Nearly halfof those who are eligible for Medicaid or the children’s health insurance pro-
gram are not enrolled so we launched an initiative called Health AccessAmerica to help do outreach in different communities,” says Grealy.
“We did 10 pilot sites and we focused not just on those public programsbut also brought in private insurance brokers and had them help small busi-ness owners and individuals, looking at the products that are available andhow much they cost. We also had someone from the state that could helpsign someone up for the children’s health insurance program or for theMedicaid program and amazingly nearly half of those that attended theseprograms left with some type of coverage. So that’s the grassroots outreachwork that we’ve done.
“Then of course we’re also working with members of Congress, with oursolutions, which are pretty simple – making sure that those public programsare working well. We need to provide a helping hand to those that are unableto afford the insurance that’s being offered to them by their employer, andproviding some kind of premium subsidy to help them. We are also workingwith small business and helping them understand what’s available, how muchit costs, because they often don’t have a human resources person and so help-ing provide them information on how they can provide health insurance totheir employees.”
As well as its work for the uninsured, the Healthcare Leadership Councilhas been a very strong supporter of Medicare prescription drug benefits. Fora long period of time, private health plans provided prescription drug cover-age to the population under-65, ignoring that those with the greatest need forthose drugs are the over-65, the Medicare population. The council workednot only towards the commitment of passing the legislation but also ensuringthat people understand how to get the prescription drug plan that worked forthem, what would be most cost-effective and cover their needs.
To bring this about the council formed a coalition of over 400 nationaland local organizations, conducting thousands of events to educate people –all of which was done two years prior to them implementing it. “For the first18 months we were just educating people about what’s coming and what will
“It is much more powerful when youhave a hospital making the case on
behalf of a pharmaceutical company”
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says Grealy. “What they were able to demonstrate is improving quality can re-duce 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 demonstratewe can save money by not only rewarding the right behavior, but more im-portantly providing information, sharing best practices, sharing your resultscompared to other hospitals or physician group practices’ results.”
Electronic health recordsShe notes that the council’s members are supportive of the adoption
of electronic health records and the use of IT: a tool for practicing evi-dence-based medicine. “How do we develop the appropriate quality stan-dards and how do we start rewarding those that adopt those practices toreduce the disparity of treatment, both geographically and among popula-tions, by making sure people know quickly what are the best practicesrather than it taking something like 17 years for known good practices tobe disseminated widely?”
However, she’s not convinced that the exchange of information be-tween healthcare institutions is realistically viable, not soon anyway. “It’snot just the financial aspect, it’s also a big cultural change. “From what I’veseen among our members it takes the leadership of the organization beingengaged in this, making it clear that they believe it’s important and thatthey want everyone on board with it, that it is the right thing to do and it’snot easy but our members have done it. Many of our members did it with-out expecting to see a return on their investment. They thought, ‘We’regoing to make this huge investment; it’s going to provide better care for ourpatients,’ but they weren’t sure it would actually reduce their costs because
of that huge investment. They’ve been very pleasantly surprised that theyare seeing a return on the investment.
“There are some things that we can start with that are less of an in-vestment such as e-prescribing, and if we can reduce drug interactions andthe harmful side effects of that it’s an important first step. Right now ourmembers, such as McKesso – probably the largest health informationtechnology provider in the world – are working hard to develop the stan-dards and make these systems interoperable but in a way that still will pro-tect the need to innovate so you don’t develop a system and then stopprogressing.”
The number of those council members at the forefront of technologicalinnovation is multiple. Grealy points to the work of Mayo Clinic and BaylorHealth System, as well as the work of one of its smaller organizations,Northshore University Health System, a three-hospital not-for-profit systemwhich has won awards for being a leader in this field. “There was the leader-ship under CEO Mark Neaman, taking it all and making the commitmentthat you’re going to do it and then also involving their physician leaders in thedevelopment of that system.
“A great example of this is the issue of hospital-acquired infections, be-cause they have electronic records and they’re screening their patients as theycome in. They know immediately what they need to do and they’re able to actquickly – they have rapid testing, they have the results. It really is phenome-nal the improvements you can make in treatment as a result of having thatquickly and widely available
“Congress has sent a clear signal and probably the public is going to besending a clear signal that this has to be addressed and we have seen wherehospitals have taken this on. Again, it takes leadership, it takes the entire work-
Former President George W Bush signs the Genetic Information Nondiscrimination Act
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as we develop electronic health records and have access to much larger data-bases, emphasize that the information is anonymous but held by researchersto use and develop better treatments in the future.
“If we don’t assure patients and employees that we’re protecting it andthat it won’t be used against them, then we’re not going to get that infor-mation, so that’s our responsibility, as well as employers, health plan, hos-pitals and others to make sure that they protect that information. Thereare severe penalties for anyone who misuses that information but mybiggest fear is that there are interest groups out there that just want to shutdown all access to this information and that would be very bad for pa-tients,” she says.
Grealy’s passion and dedication to her work has brought her personalachievements, too. Women in Healthcare recently named her one of its top 25women in healthcare for her work in the council and Washington. On the im-portance of women representing healthcare issues she is firmly supportive oftheir role: “If you look at the statistics, the people that are making decisionsabout healthcare for their families are, by and large, women. And so they playa very important role in what treatments or coverage their family’s going toengage in.
“In terms of Washington, women are great problem solvers but more im-portantly they’re also great at collaborating and networking and working to-gether to find solutions, and so that’s another place that they can play animportant role, it’s is just a slightly different tone perhaps.”
Collaboration is most certainly Grealy’s skill, unifying different agendagroups for the sole purpose of bettering the healthcare system. It will still besome time before electronic health records are implemented and the unin-sured are fully covered, but there is no doubt that the Healthcare LeadershipCouncil will be canvassing patient causes every step of the way. n
force in the hospital as well as their affiliatedphysicians – everyone committed to reduc-ing those hospital-acquired infections. Oneof our concerns has been that we need to dothis in a positive way, not a punitive way.
“If we do it in a punitive way then youstart encouraging people, perhaps, to useantibiotics out of the box when maybethey’re not indicated, so there really has tobe a correct balance there; not penalizinghospitals in instances where perhaps thatpatient already had the infection whenthey entered the hospital, or they may de-velop it after they leave the hospital. Ourmembers are committed, obviously, tosolving this problem and there are ways todo it, but it’s important that it be done in acollaborative way between governmentand the private sector.”
Data protectionThe Healthcare Leadership Council’s
work with the government providing col-laborative insight into legislation has awarded them achievements, such as theGenetic Information Nondiscrimination Act. Grealy notes the work that thecouncil has done on the confidentiality of medical information, specializingin the genetic area.
“As a result of the human genome project, we are on the verge of beingable to diagnose and, more importantly, to individually target therapies forpeople,” she says. However, she is quick to point out the concerns with the po-tential opportunities for discrimination when using medical information – be
it employment or health insurance coverage – laying fault with healthcareproviders and researchers for not providing sufficient knowledge to the pub-lic as to how this will benefit them. Moreover how institutions will protect thatinformation.
“So how do we find that balance between the need to assure people theirinformation is protected and that they will not be discriminated against whilstmaking sure we have information available to provide them with the righttreatments at the right time whether we’re talking about drug interaction orthe right cancer therapy for them? And then how are we going to use that in-formation 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
“The people that are makingdecisions about healthcare for theirfamilies are by and large women”
Mary Grealy is President of the Healthcare Leadership Council.
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Hospital, urgent care and outpatientfacilities still face the challenge ofdelivering care during a disaster ormass causality event. And as H1N1
and healthcare reform in the US becomes a stresspoint for radical American views on revolutionand revolt, it is important to consider that these fa-cilities may be at higher risk than ever from a loneattacker or homegrown terror.
To say that the rhetoric around healthcare andH1N1 has reached a fever pitch in North America,and in some cases abroad, would be an understate-ment. A month ago, when I made the statement thatH1N1 was less dangerous than this ‘crazy conspira-cy’ around eugenics in North America, I receivedmultiple threats to my personal security.
We are a disaster recovery and business conti-nuity firm with employees who have deep intelli-gence and military backgrounds. However, I’venever been under such close guard since thosedeath threats occurred. My personal experienceas an executive who is working to help calm thefears of individuals regarding their care in the faceof H1N1 is that doing so, in some cases, is to putyour life at risk.
I cannot stress enough how important it is forhospitals, urgent care and outpatient facilities to
consider the risk their employees face and the po-tential for violence and civil unrest in their places ofbusiness as part of their overall business continuityand disaster recovery stance, given the times.
According to a recent pollpublished by CS Mott Children’sHospital, only 40 percent of USparents plan on giving their chil-dren the H1N1 flu shot. Thestudy suggests that parents sim-ply don’t believe that the virus isdeadly, despite the fact that it haskilled 40 children in the US sinceApril. The question not asked inthe survey, but hinted at largelyin non-mainstream media andon the internet, is that radicalizedviews of what swine flu is, whatthe shots are, and how both theUS and other governments areusing these shots as ‘kill shots,’ isnot being widely reported.
To be clear, this is no smallproblem for first responders and caregivers whomight find themselves between a fully agitatedand perhaps dangerous individual and the needto provide care to a minor. While most hospitals
have security, many are simply unprepared forthe type of potentials we are seeing now in ananti-government, anti-federalism movement.
The recent hanging of a census worker inKentucky is a clear signal that there are some whoare willing to kill to keep away from government (orcaregiver) assistance. While only a small portion ofyour community or patient base may harbor thesedestructive tendencies, getting in front of securityas it relates to business continuity and disaster re-covery is indeed an emerging best practice.Hospitals would be well advised to incorporate a fu-sion approach to their business continuity and dis-aster recovery planning as soon as possible.
A fusion approach includes health and safety,disaster recovery, business continuity and securityto assure that your hospital or organization has anintegrated view of the risk it is facing and an inte-grated plan for militating against that risk.
Like government fusion centers, this approachacts as a force multiplier in budgetefficiency, insights and opera-tional gains. Consider it a crashteam for your risk mitigation ef-forts. Rather than having all of thespecialists in different rooms, yousimply bring everyone in on therisk mitigation project so thatmultiple tests, multiple scenariosand multiple plans of action arereplaced with singular clarity anda one-time cost where once therewere many.
Organizations using this ap-proach are safer, more preparedand ready for disasters, securitybreaches and the unforeseen thanthose who continue to operate insilos. Given the current climate,
administrators and executives would be wise toconsider how fusing these risk management sys-tems can lower the strain on their budget and in-crease their readiness. �
Kevin Burton explains the importance of disaster recovery,business continuity and security in fully understanding risk.
PREPARING FOR THE WORST
Kevin D. Burton is CEO ofBurton Asset Management, Inc.Burton has a broad range ofexperience and has helpedclients address many issues toincrease their IT processefficiencies or to addressbusiness process needs, staffand governance issues, andbusiness-to-IT communication.
“Getting in front of securityas it relates to businesscontinuity and disasterrecovery is indeed anemerging best practice”
Burton Asset Management ed:26 June 18/11/09 15:28 Page 78
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President Obama’s plan to computerize all health records within fi ve 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 hos-pitals 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 fi ve years.
“Th ere are certainly a lot of folks who are somewhat skeptical that it can be done in fi ve years, but at the same time, there are many who believe that we can get a good start in that time. Getting started is prob-ably 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 health-care 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 signifi cantly 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 fi rst things fi rst: reform healthcare and then fi gure out how to automate the new healthcare pro-cesses. He says that the healthcare reform debate has shift ed from its origi-nal overarching form to now being largely about healthcare fi nance.
Wes Wright, the hospital’s CTO, points out that on a less grand scale, Seattle Children’s itself carries out continuous performance im-provement, or CPI, following Th e 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 effi ciency. With the overall healthcare reform, I’m
EHM spoke to Wes Wright and Drexel DeFord about using technology for continuous performance improvement at Seattle Children’s Hospital.
GETTING BETTER ALL THE TIME
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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, technol-ogy – we need to concentrate on the people and process before we con-centrate on the technology.”
Seattle Children’s has been using Lean for fi ve 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 eff orts that we try to continuously improve. Th at’s how we make changes in our healthcare delivery system.”
“It allows us to focus, too. It lays out the process fl ow so we can then very surgically implement a technology solution that we know will help a particular process become more effi cient. We don’t have to fi nd the solution and then be effi cient at it. We know that we’re effi cient and we just need help making it more effi cient. It’s really quite refreshing.”
Seattle Children’s has even taken teams of its staff to Japan to learn Lean from the masters. Th ey 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 fi ve 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 talkRegardless 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 Offi ce of the National Coordinator for Healthcare IT.
“Th e Offi ce of the National Coordinator, or ONC, has several proj-ects under way right now that include trying to standardize the language that would be used in electronic medical records,” says DeFord. “Th ey
are standardizing the protocols around the transition of data between diff erent systems to the certifi cation of electronic health records to make sure those records that are available on the market and available for pur-chase have at least minimal sets of capabilities.
“One of the big pieces they’re involved in is what would be the ulti-mate creation of a National Health Information Network, which would allow hospitals and doctors’ offi ces across the country to be able to ex-change patient information. Th at’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. Th at 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 be-tween healthcare organizations.”
Another ongoing challenge holding back the development of such a national system is the lack of a single patient identifi er. While some have tried to play down this issue, DeFord believes it could cause signifi cant dif-fi culties: “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 identifi es 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 oft en
gets lost in the fog is exactly how complicated health-care IT is. “When you talk about exchanging infor-mation 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 sys-tems to talk to other systems. It’s a much, much more complicated animal than one would think.”
Staying secureTh ere 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 certifi cation by its vendors. “In 2000-2001, medical equipment vendors were allowed to use Microsoft products to power their equipment,” he says. “Th ere were oft en proprietary operating sys-tems, and when a product went through FDA certifi cation, part of that certifi cation covered the operating system.
“Of course, operating systems have changed quite dramatically since 2000. And when Microsoft discovers a vulnerability – or even nowadays
“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 identifi es them for everything they do”Wes Wright, VP and CTO, Seattle Children’s Hospital
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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. Th ere are fi ve or six big vendors and then there are 500 small vendors. Each one of those vendors has a specifi c application; for example, in cardiology, they may have built it specifi cally 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 diffi cult 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 manage-ment 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 decid-ed to put them together. And they realized there were some big security vulnerabilities to that.
“Th ey started a program in 2007 called Project Bedrock, which essen-tially forklift s our old network infrastructure to a consciously designed infrastructure that has specifi c security zones. It will treat every client on
Seattle Children’s Hospital
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 secu-rity infrastructure, and having the machines talk to themselves better. For example, you could have one physician who could potentially be in fi ve or six diff erent 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 fi ve diff erent applications throughout the day.
“When we forklift ed the infrastructure, we de-signed 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. Th e physician now has one username and password for all the applications. Within the next six months, that physician or clini-cian will have a XyLoc badge, walk up to a computer, and the computer will recognize who that physician is and bring up their applications. Th ose 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
workfl ow perspective, that’s a major benefi t.”Wright points out that another great benefi t 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 at’s our biggest challenge. We’ve got our fi rst generation fl ight plans already accomplished aft er 18 months, and we’ll continue to look at and review those, but that then begins to drive a diff erent conversation around how much money are we going to invest and when are we going to invest it.”
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. “Th at is going to be a thorn in healthcare’s side for many, many years to come,” he says. “Th ey have to be more agile in their security patching and their use of new technologies. Th at is my main concern over the next two years.”
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 aheadAnother important aspect of the CIO’s and CTO’s work is the abil-
ity 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 archi-tecture 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 air-planes fl ying around, and we need to get them into some sort of order from an air traffi c control standpoint. Th en 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. Wes Wright is VP and CTO and Drexel DeFord is CIO, Seattle Children’s Hospital.
“We might rush to computerize patient records and it turns out that the processes we’ve just computerized change signifi cantly”Drexel DeFord, CIO, Seattle Children’s Hospital
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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 diff erent today is the staggering complexity the industry has to deal with. To date, a total of 48 states and territories have breach notifi -cation laws in place and every state mandates some form of background screening, but it’s not just maintaining compliance with existing regu-lations 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 informa-tion has been breached. And then we have an increase in the civil monetary penalty that can be levied due to HIPAA viola-tion. 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 in-dustry has indeed fi xated on the new laws and regulations, but it’s also true that com-pliance 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 oft en exists in numerous areas within the same facility, making it diffi cult to keep tabs on where it’s stored, who’s using it and how it can be exposed. Despite the diffi culty of doing so, it’s crucial for you to account for all the diff erent 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 eff ective 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 eff ort to identify and manage threats before they can actually aff ect your business or the quality of your care. Back-ground screening is an aff ordable, widely accepted and relatively simple
practice that’s easily integrated into any internal process. A successful screening program can help you avoid costly fi nes, reduce the risk of employee malfeasance such as data theft , and shore up public confi dence. I should also mention that screening is much more than just run-ning a baseline check on a prospective employee. Eff ective background screen-ing is ensuring you’re doing everything within your power – and your budget – to ensure that employees, vendors, volunteers and business partners aren’t presenting you with unnecessary risks.
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 ex-perience a data breach. Regardless of how good an organization’s se-curity 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. Imple-menting a breach preparedness program is about security awareness and training, not preventing a data breach. If an organization recog-nizes 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.
Risk managementPhil McVey tells EHM about the importance of keeping health information secure.
As President of the Background Screening division of Kroll, Phil McVey leads the company’s global pre-employment screening, identity management, data breach/fraud solutions and corporate integrity verifi cation businesses. Previously, McVey was President of the Commercial Services division of USIS, setting direction for and supporting the company’s mergers and acquisitions activity.
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Marc Overhage fi lls EHM in on the benefi ts of a statewide health information exchange.
Exchanging patient information across multiple pro-viders over a statewide area is an incredible chal-lenge on many levels. Marc Overhage, President and CEO of the Indiana Health Information Ex-change (IHIE), says one of the main initial issues for him was developing
the value proposition; in other words, demonstrating that people do move between providers. He explains that many people didn’t believe this actually happened when the IHIE was fi rst started in the 1990s.
“Th ey had this view that we’re a large health-care system and people come to our hospital and people come to our laboratory, and they don’t go elsewhere. So that was the fi rst challenge, at least demonstrating that there was a problem to be solved. Th e second was – not so much today but again in the 1990s – the technological chal-lenges. We were some of the fi rst folks to try and tackle the problems of patient matching, for example.
“Because we do not have a common patient identifi er, as people move between providers, you have to have a way to link together their information. Th e third challenge is provider matching, because doctors and providers in the United States also do not have a common identifi er. As a primary care provider in Indianapolis, I have 47 unique identifi ers, 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.
“Th e 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
Well connected in Indianaformat. In other words, every hospital, and every laboratory calls a serum sodium something diff erent. 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 adviceWhen asked what counsel he
would give to others contemplat-ing 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: “Th e second thing is that you have to build incrementally and be pa-tient. Th e only way you establish trust is by working out each use of the data in a very careful, thought-ful way, because the one thing you don’t want is for anybody to be surprised about how their pa-tient’s data ends up being used.
“Th at’s one of the key things, and related to that is being very patient, because healthcare
organizations are relatively slow-moving beasts and you have to let things
play out. Th ere’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 or-ganizations 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 noth-ing to operational in 18 months.
“Th ey were far down the road with trust, and they’d done a some-what 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.”
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Th e 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 diff erences that existed between the three organizations involved.
“Th e 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. Th at’s just the way healthcare works.
“But the most important thing is that this is the fi rst real live instan-tiation 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 goalTh ere has been a lot of buzz around the current administration’s
goal of computerizing all patient health records within fi ve 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 Offi ce 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. Th ere 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 physi-cians’ practices – for example, what your blood pressure was when you went to see your doctor – and then the other issue is that this informa-tion is all in separate silos. A patient’s data might live in six diff erent systems, with radiology data at three diff erent radiology centers, and he or she may have been to two diff erent hospitals. With pharmacies, obviously there are competing pharmacy chains that might be spread across 12 locations.
“So while all that data is structured elec-tronically, it’s not linked together. Th at’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. Th e 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.
“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 identityIn contrast to many others working in the fi eld, Overhage does not
believe that the lack of a single patient identifi er 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 iden-tifi ers, it hasn’t solved any of the fundamental problems,” he asserts. “Th ere are still data entry errors – roughly fi ve percent of the health data numbers that are recorded in general practitio-ners’ offi ces in the UK are wrong.
“And then you have the usual challenges of people who don’t have one. Th e utility or value of that identifi er is modest at best. Th ere 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 identifi er.
“Doing more could be a negative factor, because it confuses
everybody and they’re not sure
where to put their eff ort”
Marc Overhage on the Indiana Health
Information Exchange“The Indiana Health Information Exchange was
created fi ve 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 effi ciency 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.”
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“Th at’s not to say there’s no value in having an identifi er. Th ere 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 aheadIn 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. “Th ose 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-engi-neering and building in too much complexity. I be-lieve we can do what we need to in the next fi ve 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.
“In fact, doing more could be a negative factor, because it confuses everybody and they’re not sure where to put their eff ort and they don’t know if Beta-max 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.
“Th e 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 diff er-ent markets.
“Th e 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. Th e 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.
IHIE servicesThe 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 ineffi ciencies.
By bridging the gap between paper-based and electronic-based medical offi ces, 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, effi ciency 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.
“Healthcare organizations are relatively slow-moving beasts and you have to let things play out”
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Raymond Scott of Axolotl Corpand RelayHealth’s Jim
Bodenbender talk to EHM aboutinteroperability solutions.
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With only a year for hospitals to qualify for front-loaded stimulus dol-lars, how will they be able to demonstrate ‘meaningful use’ in such ashort time period? Raymond Scott. Hospitals need to evaluate their existing CPOE and EHR in-frastructure, determine where gaps exist and begin the work required to makethem interoperable with the systems used by the ambulatory care partners.The use of health information exchange (HIE) technology provides a fast andsimple mechanism to connect to third party EHRs and to receive orders fromthem. Hospitals should look to SaaS-based solutions, which will significantlyreduce the implementation time and eliminate application maintance foryour IT staff. Hospitals can be operational with HIE technology in as little astwo months – exchanging discrete data elements between existing HIS andambulatory EHR systems. Also, CCHIT-certified EHR Lite applications pro-vide a very affordable solution for ambulatory physicians that don’t alreadyhave an EHR, enabling a complete medical trading area to be fully connectedin the required timeframe. It is important to remember, however, that whileARRA’s goal is to remove cost as a barrier to adoption, changes to workflowwill require planned training.
Jim Bodenbender. First, according to McKesson’s interpretation of the tim-ing for receipt of federal incentive payments under the HITECH Act, we be-lieve a hospital would be eligible for full reimbursement if they demonstratemeaningful use of a certified EHR by the end of the government’s FY2013 andcontinue to meet subsequent phase criteria. However, the payments would bedelayed accordingly. So, unless things change before the requirements are fi-nalized, eligible hospitals can qualify as late as September 2013 and still receivemaximum stimulus incentive funding.
Hospitals planning for stimulus incentives during this period need tofocus on gaps between current capabilities and meaningful use criteria, de-
spite the criteria being in draft form. One likely gapfor many hospitals is interoperability. The HITPolicy Committee’s Information ExchangeWorkgroup estimated 45 percent of meaningful usecriteria are supported by health information ex-change. It is critical for hospitals to establish plans forconnectivity to physicians, patients and the commu-nity at large.
With the ONC’s focus on providing moneythrough state-designated entities and regionalextension centers, the establishment ofstatewide health information exchanges (HIE)has become important. What is your companydoing at state levels with regard to HIE? JB. RelayHealth and its parent company, McKesson,are actively involved at both the federal and state lev-els, providing guidance and real-world experience ontopics including meaningful use criteria, certificationstandards and interoperability approaches. For HIEspecifically, we are working with several states shap-ing strategic plans and driving strategies to enablesustainable connectivity in their communities.
Raymond Scott is CEO of AxolotlCorp., co-founding it in 1995 toprovide collaborative electronicworkflow solutions forcommunities of healthcareproviders. Scott has establishedAxolotl as a leader in healthinformation exchange (HIE),today providing the technologyand services to support manyfully functioning hospital,regional and state-wide HIEsacross the US.
Jim Bodenbender is a grouppresident of RelayHealth, adivision of McKesson. He hasresponsibility for the business’operational management andstrategic direction, which includesR&D, sales and channelmanagement, businessdevelopment, productmanagement, customer support,and account management.Bodenbender has more than 25years’ experience in healthcareinformation systems and services.
Technology RT:26 June 18/11/09 15:43 Page 91
tered model, providers can perform clinical and financial HIE activities withtheir patients and other providers.
As the nation expands clinical connectivity, we should look atRelayHealth’s established networks for financial and pharmacy transac-tions as an example. Over 95 percent of providers and 90 percent of re-tail pharmacies, providing ample lessons on interoperability, use theseexchanges. These levels of adoption enable RelayHealth to provide ser-vices such as a secure data feed on retail prescriptions every four hoursto the CDC to assist them in tracking viral outbreaks and other health-care emergencies.
How are your physician customers achieving interoperability in theirpractices, and how does that help them towards achieving mean-ingful use?JB. Currently, RelayHealth provides all the necessary functionality for our cus-tomers to demonstrate the current meaningful use interoperability require-ments for the 2011 phase, based on the draft meaningful use criteria. Ourcustomers are also already capable of demonstrating many of the other cur-rent meaningful use criteria for the 2013 and 2015 phases, including real-timepopulation of a patient’s personal health record and secure messaging be-tween patients and their providers.
Enrolled physicians on the RelayHealth network have access to its con-nectivity services either directly within their EMR workflow or online via abrowser using our modular, cloud-based applications. A key goal of mean-
ingful use is to drive care collaboration and this approach ensures all physi-cians can participate, including those not ready for an EMR. Furthermore,this low-cost, scalable and highly networked solution doesn’t require a costlyinfrastructure and assures providers a predictable cost structure, lower totalcost of ownership and a quick return on investment.
RS. Axolotl’s Elysium EHR Lite is the first fully interoperable solution on themarket – able to plug into a HIE and connect to all of its HIS and EHR sys-tems without point-to-point interfaces. Data from all sources is sent andreceived in a standard format with discrete data elements. As one of onlysix Gold Surescripts-certified vendors, our integrated eprescribing solu-tion provides complete medication lists and fully automated renewal pro-cessing. In addition, active, electronic reporting of quality measures canbe established and maintained with minimal physician or staff interven-tion. Axolotl anticipates that almost 25,000 physicians currently using theCCHIT-certified Elysium EHR Lite will be able to apply for full incentivepayments. �
One specific attribute historically lacking in state-level HIE initiatives isa sustainability model that enables the HIE program to continue and advancelong after the grant funding ends. RelayHealth’s approach to HIE incorpo-rates a long-term sustainability structure proven to yield tangible return oninvestment for hospitals, physicians and ancillary providers. Our patient-cen-tric SaaS design affords extended leveraging for broader state to interstate andultimately nationwide connectivity. The result is actionable health informa-tion when and wherever stakeholders need it, be it in local communitiesacross the state, regionally or throughout the nation.
RS. Axolotl is the statewide designated HIE vendor for Utah, Idaho andNebraska and has connected many regions within Indiana, New York,California, Washington, Texas, Ohio and Colorado, among others. TheseHIE customers are clinically networking hospitals, labs, public health, pay-ers and physician practices – the entire healthcare continuum with SaaSapplications. Patient information is securely shared and made availablewhen and where it is needed. A virtual health record provides authorizedusers with complete patient data, displayed from all connected facilities.In addition, Axolotl’s CCHIT-certified EMR Lite provides any physiciannot already using an electronic medical record with an affordable web-basedsolution to immediately connect the state’s HIE.
What is your view on the statement that full interoperability for hospi-tals and physician practices can only be achieved by connecting to ahealth information exchange? RS. Most physician practices use more than one hospital or lab, with dif-ferent internal information systems, to provide care for their patients.Hospitals and labs provide services to a variety of physicians, some ownedor affiliated and some independent, all potentially using different EHRs.Without a HIE, full interchange of clinical data between the partners in amedical trading area would require a large number of point-to-point in-terfaces between each hospital, lab and physician practice, which wouldbe prohibitively expensive to build and maintain. A HIE provides com-prehensive interchange of data between all the parties through a singleconnection to each.
JB. It is important to understand hospitals, physicians, pharmacists and otherstakeholders can perform the act of HIE without joining a formal health in-formation organization such as a RHIO. In fact, over 50 health systems andhospitals have contracted with RelayHealth to engage in HIE with limitedHIO formalization. One area that formal exchanges have poorly addressed ispatient engagement – because RelayHealth is fundamentally a patient-cen-
“Without a HIE, full interchange of clinicaldata between the partners in a medicaltrading area would require a large numberof point-to-point interfaces between eachhospital, lab and physician practice”
“It is important to understand hospitals,physicians, pharmacists and otherstakeholders can perform the act of HIEwithout joining a formal healthinformation organization such as a RHIO”
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The challenge of today’s laboratories is to do morewith less. Handling physician requests, deliveringpatient results, managing workflow, ensuringproper billing and meeting regulatory require-
ments all need to be accomplished in an efficient, secure andcost-effective manner.
Today’s technology can be divided into three general ar-chitectures, the first being a thick client. Each physical com-puter that provides information to the user contains all of thesoftware required to deliver data. This is an older technologysuited for small labs that do not require multiple users or de-livery of results outside their four walls. A client server is thesecond. The main software required runs on a single servermachine with individual user computers running proprietarysoftware called the ‘client’. Remote users must install propri-etary software to access data. Web-based is the third generalarchitecture. All software runs on the web server and each in-dividual user simply needs an industry standard browser, suchas 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 con-nectivity for billing. But when it comes to delivery of patientresults and handling physician requests in a secure efficientmanner, most people feel that the flexibility and portabilityof the web-based architecture provides the superior solution.
Managing patient data consists of receiving the orderfrom a physician either electronically or via a paper requisi-tion, receiving the sample or drawing the sample, perform-ing the testing either in-house, sending to a reference lab orboth, and delivering the results back to the physician. Themost efficient manner of ordering and receiving specimensin the lab is electronically. Web-based solutions such asFletcher-Flora’s FFlex eSuite LIS, allow orders to be receivedfrom an EMR system or through a lab outreach portal suchas FFlex ePortal, in a secure manner over the internet. Labelscan be printed locally where the sample is drawn, which pre-pares specimens for immediate handling once they arrive inthe lab. This not only helps organize orders and samples butalso eliminates costly and time-consuming re-labeling.
Today’s technology includes business rules that effi-ciently and automatically route samples based on insur-ance/payer, patient status, order priority (routine, stat, timeddraw, etc.) and the menu of in-house tests the lab is capableof performing. In many of today’s LIS offerings like Fletcher-
Flora’s FFlex eSuite, such business rules are built in to facili-tate efficient, cost-effective testing. Automatic routing ofsamples based upon these and other factors simplify themanagement of this workflow and ensure reimbursement forthe lab work performed.
The net product delivered by today’s laboratories is a pa-tient’s results. Efficient and secure delivery is essential for asuccessful laboratory. In addition, physicians want a com-plete consolidated result picture without having to refer tomultiple documents. Part of the efficient delivery of results isa consolidated report that also, for compliance reasons, clear-ly identifies the performing facility. Many of today’s solu-tions, including Fletcher-Flora’s FFlex eSuite, integratein-house and reference lab test results in a single consolidat-ed report. By far the most efficient and cost effective manner
for patient results delivery is the internet. With no paper tohandle, secure access and almost instantaneous delivery,FFlex ePortal ensures your patient results are delivered toyour customers with minimal or no intervention.
Today’s technology affords the clinical laboratory withsolutions to the many challenges they face. Features, includ-ing software business, rules that automate sample routing, re-flex testing, result interpretation and result verificationdramatically improve efficiency and streamline managementof patient data. Choosing web-based technology that can de-liver results securely and efficiently over the internet helpsthe laboratory compete and ensure that physicians haverapid and secure access to their patient results. n
Neal Flora explains the importance of streamliningpatient data.
Neal Flora is CEO of Fletcher-Flora Health Care Inc. and has over 30 yearsof healthcare IT experience focused on the clinical laboratory. Flora bringsknowledge and expertise gained from the early days of laboratoryautomation and computerization through the present state-of-the-artsystems, keeping the company ahead of the curve in technology.
“The most efficientmanner of ordering andreceiving specimens in thelab is electronically”
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“We saw a trend wherein clients were coming to us and wanting toassess not just the technical or clinical aspects of their technology, but alsothe economic benefit that it could bring to healthcare providers,” Whelansays. “We saw that as becoming increasingly important in the market-place, largely because of economic variables.
“It wasn’t that clinical needs are changing, it was more about certaineconomic decision-makers having more of an impact on the decisionsaround whether a product was adopted or not; so we wanted to look atthat a little more closely.”
The survey results showed that the variable of patient satisfaction has be-come increasingly important to hospitals for economic and competitive rea-
In April/May of 2009, Frost & Sullivan surveyed 70 hospital profes-sionals in six functional areas, asking them about the strategic chal-lenges facing their institutions and the process by which theyevaluated and adopted new technologies. In addition, Frost &Sullivan conducted extensive interviews with a physicians and hos-
pital 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 thecompany’s ongoing interest in marketplace trends within healthcare, aswell as his day-to-day work with clients who are developing new medicaltechnologies.
Evaluating the future
Frost & Sullivan’s Charlie Whelan looks at why medical technologies should bejudged on their actual value to patients.
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sons. “Obviously, hospitals have always wanted to keep their patients happy foraltruistic reasons,” Whelan underlines. “But here in the US, what’s happening isthat hospitals now have very clear economic drivers to secure higher patient sat-isfaction levels, because they get bonus payments from Medicare.”
Whelan says patient satisfaction has now become a lot more transparent.For many hospitals, patients can go online and see how hospitals score in differ-ent areas, then make a decision about which hospital to go to for their often elec-tive surgical procedures. Moving into the future, Whelan believes that thosetechnologies that offer higher patient satisfaction will be considered to be morevaluable than they were previously.
“In the past, hospitals and doctors may have looked at a device that claimedto provide better patient satisfaction and said, ‘That’s nice, but it cost too muchand it’s not really worth that expense,” Whelan says. “In the future, they’re goingto look at that and say, ‘Wow, that could help improve our patient satisfactionscores and that, in turn, can help generate greater reimbursement and greaterprofits for us and make us more competitive versus our other healthcareproviders locally.’”
Net benefitWhelan gives the example of a technology that costs $400 that is not re-
imbursed. The manufacturer claims it can get patients out of a hospitalone to two days earlier, depending on the type of surgery. Keeping a pa-tient in hospital after surgery can cost $1200 a day, and hospitals are in-creasingly being paid under bundle codes or DRG codes that incentivizethem to get patients out of the hospital as fast as possible, because it makesthem more profitable.
For these reasons, Whelan says it can make financial sense for hospitalsto consider such products, even when they are not reimbursed. “You need tolook at the technology and consider it because of the operational benefits itprovides,” he says. “It may cost $400 but you’re able to save $1200, which netsyou $800 in savings.
“You also add patient satisfaction and better outcomes. That type of cal-culation, at least based on the research that we did, is not fully appreciated by
Technology objectivesThe objectives of Frost & Sullivan’sweb survey into new technologyadoption by US healthcareproviders included the following:
• To show how forces in thehealthcare industry shouldchange the way hospitalsevaluate new technologiesbased on the actual value theydeliver
• To describe the processhospitals currently use in theevaluation and adoption of newtechnologies
• To describe how hospitalscurrently think about operatingcost management and value,particularly when evaluatingthe adoption of newtechnologies that might havean impact on patient outcomes
• To show how forward-thinkingproviders are changing the waythey act on this value equationto position themselves forsurvival in their markets
Frost & Sullivan’s picture of the future UShealthcare system
• 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 (hospitalvs surgery center); more competition on a global basis forelective procedures
• Greater collaboration and information sharing acrossvalue 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 orby GPOs
• More locked out accounts and a more competitive marketwith customers signing longer-term, exclusive contractsto enjoy lower prices
• More ‘generics’ – technologies providing same value atlower price, stripped down feature sets
• Greater focus on prevention and primary care
“When more informationbecomes available to people, theymake decisions differently, andbehavior changes”
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hospitals everywhere. Some leading-edge hospitals see that and they make theconnection, but a lot of hospitals are still not fully appreciative of it. I thinkthat’s going to change.”
Whelan points out that technology companies have historically focusedon clinicians and the fact that something has clinical value: it can help yourpatients get better faster. While that is important, he says that technologycompanies need to keep in mind the economic, operational and workflow im-pact that their technologies have.
“Many companies have appreciated this, but it’s still relatively new. Partof what precipitated the survey was the fact that a lot of medical device com-panies were coming to us and talking about strategies they had that were fo-cused on presenting the economic and operational benefits that theirtechnology brings and not the traditional sole focus on the clinical benefit.”
Expert adviceWhelan 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 technol-ogy is adopted, and whom it would impact. “For example,” he says, “It’s notgoing to impact just the doctors and nurses. It’s going to impact the biomateri-als managers and the OR managers and the purchasing managers and the CFOsand 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 onenew technology option can cause a complete paradigm shift, so you need tounderstand how your technology fits into the much larger context of whereit’s being used and how it’s being used.
Technology assessmantConclusions drawn from the Frost & Sullivan web survey, as out-lined in the white paper, The New Economics of Healthcare.
“Whether a hospital adopts new technologies or not isnot an option. Hospitals must constantly evaluate newtechnologies to improve patient outcomes, as well as tomaintain competitiveness and financial viability. Hospitalsshould institute multi-disciplinary technology evaluationcommittees aligned with the larger strategic objectives ofthe whole facility and system.
“These committees must have executive sponsorshipand broad influence over the entire facility to addressconflicting agendas and make decisions in the best interestof patients and the facility. Hospitals must ensure that theadoption of new technologies is aligned with the largerpriorities of the facility and its mission.
“Most hospitals have these committees to some degreealready, but administrators need to take a more proactiverole in bringing new technologies up for evaluation.Whether the technology passes clinical muster is crucial, butevery new idea deserves evaluation, regardless of wherethat idea may have originated.
“A holistic approach to technology assessment is crucialfor hospitals to fully appreciate the value of the technology.This approach includes a thorough review of the trueeconomics of a technology and the long-term outcomes itcan deliver. This process must be guided by more thansimply a narrow focus on reimbursement or the partisaninterests of particular departments.”
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“The other thing I would say is you need to develop some quantitativedata showing how it can demonstrate economic benefits and patient satisfac-tion. You also need to think about how your technology can measurably im-prove patient satisfaction scores.”
Whelan cites one OR manager he spoke to, who said she had adopted aparticular technology specifically because of its ability to improve patient sat-
isfaction scores. She had done a study internally comparing two populationsof patients who had had the same surgery; one group got this particular typeof pump and the other group didn’t. And she found that the pain scores forthe population with the pump were better.
The survey also predicts an increased reliance on healthcare information
technology, which Whelan believes will flatten healthcare delivery in manyways. Once data is captured and standardized in a patient record and is avail-able to individuals other than just the doctor, he says, this will change how de-livery is carried out.
“Much discussion on the growing importance has glossed over this,” heasserts. “A lot of things happen when information is made available to peo-
ple: look at what’s happened with the internet. When peo-ple have more information, they make decisionsdifferently and their behavior changes.
“What we’ll see is more healthcare information beingat the fingertips of case managers or nurses or hospital ad-ministrators, and they will start to make more decisionsand gain more power relative to physicians. We’ll alsostart to see more standardization of care.
“There will be continued emphasis on workflowoptimization and more technologies will develop thatand put that same information back into the hands of
patients so they can manage their own care. It’s going to facilitate greatercollaboration, too, not just between clinicians and clinicians but betweenclinicians and patients.” �
“Healthcare is so complex. It’s such amatrix-type organization that one newtechnology option can cause a completeparadigm shift”
Charlie Whelan is Director of Consulting, Healthcare and Life Sciences for Frost & Sullivan.
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We are embarking on a digital revolution in healthcare. Th e massive eff ort to transform healthcare began with the signifi cant action taken on February
17, 2009, with the signing of the American Recovery and Reinvestment Act. Contained within the bill is the health-care information technology component (HITECH). Th is legislation adds signifi cant fi nancial incentives for physi-cians and hospitals to join the digital revolution by adopt-ing 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 off ers incentive payments to hospitals and physi-cians to effi ciently utilize an EHR. Physicians have already begun electronic medication prescribing, and further in-centives from Medicare and Medicaid are in the bill.
Th e 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 recommen-dations will be fi nalized by CMS at the end of 2009. In the recommendations targeted for 2011, there are specifi c objectives to improve care coordination. Th is would be evidenced by the exchange of key clinical information among providers, and with the performance of medica-tion reconciliation at relevant encounters.
Additional outcome measures included in the rec-ommendations are reports of 30 day readmissions rates, demonstration of the ability to exchange health informa-tion with external clinical entities and measuring the per-cent 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. Th e case management process encompasses communication and facilitates care along a continuum through eff ective resource coordination (ACMA, 2002). Many decisions are made for safe home discharge, physician follow-up, post acute care and out-patient services. Care is planned, insurance coverage veri-fi ed 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 capa-bilities 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 set-tings 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 pre-ventable. Organizations have already begun to set targets to reduce the 30 day readmission rate. Th e inpatient case manager’s role will begin to stretch beyond the walls of the hospital, supported by technology to accomplish these targets. Th e result is anticipated to improve qual-ity of care, further insure patient safety and reduce costs during all transitions of care.
In outlining the Seven Top Trends for Case Manage-ment 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 workfl ow. Case managers will be continually learning how to apply newly integrat-ed technology to transform case management practice as EHR adoption moves forward. Let the digital revolution of meaningful use begin.
The digital revolution
“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 explains how meaningful use impacts case management.
Jeanine Tome is Chief Clinical Offi cer 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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Colleen Conway-Welch, Dean of Vanderbilt School of Nurs-ing, has some strong words for the way the Obama govern-ment 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 offi ce in Nashville, Tennessee. “Th e point that I was trying to make is that the infrastructure of the healthcare delivery system – where the diff erent health professions have to be educated together, have to work in teams, have to be able to have seamless handoff s between provider offi ces and surgery, step-down units and regular units, and hospice and home care – all of that is the healthcare delivery infrastructure.
“Th at 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 terrifi c, 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. Th at’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 diff erent forms for patients and physicians and provider offi ces to fi ll out. Why don’t we have one standardized form? Th at would save billions.
Colleen Conway-Welch tells Marie Shields about the role of nurses in
the evolution of healthcare.
Nursing an ailing health
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“Th ere 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 evolutionHer position as Dean has given Colleen Conway-Welch a unique
viewpoint on the evolution of American nursing, as well as the health-care 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.”
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.”
Vanderbilt School of NursingWith 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 fi rst fi ve 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 fi rst to launch a ‘bridge’ program in 1986, through which students who hold non-nursing 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, fi rst 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.
Another change Conway-Welch has seen in her career is the increas-ing 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 medi-cal 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 oft en? Th is costs $1100 a dose. Is there any other dose you want to think about?’ It’s almost interactive.
“Th e standardization and interactivity of IT is going to make a huge diff erence for nurses. Th e 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 diff erent 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 identifi ed data. Th at will make huge strides in terms of the responsive-ness 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 revolutionHealthcare IT is a hot topic at the moment, with the ambitious plans
coming out of Washington to make all health records available in elec-tronic format. When asked if she thinks this goal is achievable, Conway-Welch is fi rm. “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 access-ing 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, “Th e 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. Th e IOM committee will defi ne a clear agenda and blueprint for action, including changes in public and institutional policies at the national, state and local levels. Th e com-mittee’s recommendations will address a range of system changes, includ-ing 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. Th ere are also
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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. Re-thinking nursing, or rethinking medicine, or rethinking phar-macy, or rethinking physical therapy, are all worthwhile ef-forts. But until you get nursing, medicine, physical therapy and pharmacy at the table and have them rethink the health profes-sion’s education and the health profession’s preceptorships and heath profession’s residencies as one unit, with the understand-ing that everybody will have to give up something, you’re not going to be successful.
“I think it’s a wonderful ini-tiative, 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 ‘rethink-ing the health profession’s education’ or ‘rethinking health profession practice’ – that’s really the question that needs a lot of attention.”
Preparing for a pandemicColleen Conway-Welch on getting ready for swine fl u’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 fi ngernails, 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.
Another big issue within US healthcare is malpractice. According to Conway-Welch, malpractice has gotten completely out of hand, and part of the reason lies in the way trial lawyers are reimbursed. “Th ere are some patients that are harmed, and they should be responded to,” Conway-Welch says. “But we need to have a cap on frivolous lawsuits. We need to have a cap on pain and suff ering. And that’s a delicate balance so that people who truly are damaged have access. But people who fi le a $50 million dollar lawsuit for a very minor issue – that doesn’t make a lot of sense, and it ties up the court system.
“It adds enormous expense to the healthcare system, and it causes not only physician providers, but nurse practitioners and nurse midwives, to be very sensitive about practicing defensive medicine. Th ey will order extra tests so that they can say in a courtroom, ‘I didn’t think it was this, but I ordered these three tests to make sure that I was correct.’
Colleen Conway-Welch is Dean of Vanderbilt School of Nursing. Her long career as a mentor to aspiring nurses and her work to raise standards in nursing education, improve emergency preparedness and heighten HIV/AIDS awareness led to her being named to Modern Healthcare’s 2009 Top 25 Women in Healthcare list.
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personnel in the department as well as the patients. “We would not exist with-out patients; the mantra here is dedication to quality, safety and service,” saysDeschamps.
Embracing discovery, teaching and communication through its acade-mic excellence is also a layer to the strategic plan. Educating residents and al-lied health is essential, as is communication, which is needed to achieve this.Continuous discovery and the researching of new patents ensure that educa-tion is given priority.
Practice advancement is another. “That means innovation in process im-provement and new procedure, as well as supporting the recruitment of sur-geons that will be trained in new procedures,” he says. You have to have amore adventurous vision, which means leaving room for innovation, but youmust sometimes accept that there will be consequences when you start newinnovation. In a culture like ours it’s not always easy, having been used todoing things the same way for 100 years. Sometimes it’s disturbing for someof us to see how things will be done from now on and the change that is re-quired for the culture,” he says.
Based at Mayo Clinic’s biggest site in Rochester, MinnesotaClaude Deschamps has the hefty responsibility of overseeingand being accountable for 10 clinical research divisions, aswell as one research group within his department. His role asChair of the Department of Surgery entails the monitoringand steering of these different divisions in the right direction.
“I obtain resources for them from the institution and help enforce and writenew policies depending on the need,” explains Deschamps.
Cardiac, vascular, gastrointestinal and general surgery are just some ofthe many divisions Deschamps oversees. As a physician-led organization,Mayo Clinic is a consensus-driven hospital and the department has a strongrole within the overall institution.
Deschamps is responsible for the implementation of the clinic’s strategicplan. He describes the plan as having a multitude of layers – orientation, men-toring, satisfaction and performance being some of these. It is based on themembers of the department and its focus is in retaining, developing and at-tracting the best people. The basis of the plan is the people themselves – the
Mayo Clinic’s Claude Deschamps outlines the hospital’s pioneeringtechniques in minimally invasive and robotic surgery.
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cause of the material that needs to be used to do those surgeries. Before whenyou conducted a traditional open surgery, you had a large retractor that wasused every day, you didn’t use a special camera. With minimally invasivesurgery, you have ports, you have a camera, you have expensive staplers andfancy suturing material that is more expensive.
“It has shifted the cost of taking care of a patient so that even if the lengthof stay is shorter, it has increased the number of supplies. It has alsobrought a higher profile role for the industry that supplies material – thecamera, the screens, the staplers, all the ports – everything we use insurgery increases in applications because it’s increase in volume hasprompted a whole new world for the industry. All the companies thatserve the surgeons in the operating room have seen a huge increase intheir business over the last 18 years because of this.”
As a clinician, Deschamps is mainly involved in thoracic surgery, morespecifically either pulmonary and chest wall surgery or esophageal surgery,which he describes as his passion. This involves the repair of haital hernia, thetreatment of gastroesophageal reflux and the treatment of esophageal cancerby removing the esophagus.
Minimally invasiveMayo 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 askedthe patients on how they thought the operation would change their quality oflife, and would sometimes change operations based on what they would findthrough the patient’s information. Surgery is hugely important for the treat-ment of diseases, explains Deschamps, and the emergence of minimally in-vasive surgery has changed practices industry-wide.
“For the patient it has been a huge change. A smaller incision means lesspain post-op, a shorter length of stay and an earlier return to work. This is truenot only of Mayo but also worldwide and in countries that have seen the dif-ference between traditional and minimally invasive surgery. Of course, min-imally invasive surgery is not for everybody, not for every patient and not forevery procedure, but it has been a significant change.
“It also changes the economy of scale that we see in medicine. While ithas decreased the length of stay, it has increased the cost of the procedure be-
“Robotic surgery is another aspectof minimally invasive surgery thathas been seeing a lot of changes andimprovements”
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Deschamps adds that it has also brought innovation, as well as a biggervoice for the industry, which feeds the costs. Raising the bar of innovation,Deschamps recently performed the first single-incision total colectomy andexplains that this new single-port approach uses a special device that is ap-proximately 3.5 centimeters in size and compresses all of the traditional la-paroscopic trocar sites into one site.
“This means that rather than the four or five trocar sites and an extrac-tion site for a traditional laparoscopy total colectomy, this all goes down toone incision which collectively is about the same as the total of the others. Soinstead of having three of four trocar sites measuring one centimeter each,and a separate incision of four centimeters to get the specimen out, you haveone incision, one port about 3.5 centimeters,” says Deschamps.
“So this is just another tool in the spectrum of techniques for minimallyinvasive colectomies. Mayo and other centers are working with Intuitive, thecompany that produced the robot, to develop a similar tool. Robotic surgeryis another aspect of minimally invasive surgery that has been seeing a lot ofchanges and improvement. Anything that improves the number of minimaland excess colectomies is good for the patients in terms of pain, fewer com-plications, less time in the hospital and a faster return to work – the same ben-efits as for minimally invasive surgery. Unfortunately, currently only 15percent of colectomies are performed in the minimal access fashion; here atMayo about 60 percent are performed the minimally invasive way.”
Most of the departments within Mayo Clinic are involved with clinicaltrials, be it lung cancer, esophageal cancer, breast cancer, robotic surgery,colon cancer or transplant surgery. Key to each of these is the focus on re-duction: 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 qual-ity of surgery is done as when the robots are used. Can colon cancer be com-pletely removed with localized resection without having even to make anincision by going transanally?
He also explains that Mayo is currently focusing on transplant surgeryand widening the implication to bring in more patients who need it and canbenefit. “Right now there are millions of people worldwide on dialysis for kid-ney transplant and we can enlarge the donor pool by looking at rejection andassessing ways to overcome incompatibility. We’ve discovered that if you havea different blood group, by pre-treating some patients and doing certainchanges we can enlarge the pool of patients that can give their kidney,” saysDeschamps.
“By giving a substitute to blood in certain patients, you can save life fromthe get-go using preoperative rehabilitation before major surgery and thoracicsurgery. We are also using special sealants in lung surgery or gastric surgeryin 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 formorbid obesity and now we have discovered that there is a need for youngerpatients; unfortunately, there’s a shift now in society where obesity is presentin more younger patients, even teenagers. So we’re trying to see what type ofprocedure would be best. Would a ring around the upper stomach be betterthan doing major surgery on the stomach, which might have long-term effectsthat are worse than obesity itself? We’re trying to understand what’s best forour morbid obesity patients have. You can now find clinical trials in every sin-gle area of the department, and for that matter, of the major departments atthe clinic,” he says.
“A smaller incision meansless pain post-op, a shorterlength of stay and anearlier return to work”
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Infection controlPublic awareness of hospital-acquired infections during surgery is in-
creasing and hospitals across America, Mayo Clinic included, are now heav-ily addressing the issues of infection control and prevention. Deschamps notesthat the first thing Mayo is doing is assessing the universal aspects that theclinic is adhering to, such as maintenance of blood sugar within a certainrange before the surgery, the patient temperature during the surgery and soon. The clinic currently has a team that is dedicated to the countrywide ini-tiative ‘surgical care improvement project’ (SCIP) of which Mayo Clinic hasset itself the target of 95 percent compliance.
It is small measures that are regarded as making the big differences, suchas providing the right antibiotics at the right time and for the right time peri-od, which is within one hour of incision. SCIP is monitored during the hoursof surgery and is incorporated into several departments, such as vascular, or-thopedic, gynecologic and colorectal surgery. Each of these departments is au-
dited each month to ensure that at least 95 percent of the patients answer tothe right criteria. So SCIP is primarily focusing on the correct dosage of an-tibiotics that the government and the hospital have agreed on for the patient.
“You should not give an antibiotic for longer than 24 hours for electivesurgery. Also for some of our patients that are at high risk of infection weadded the pre-op showers, such as those undergoing cardiac surgery, coro-nary artery bypass, patients that are obese or have diabetes and are more atrisk. We have clinical protocol for those patients to reduce infection, but weare adding pre-op showers and special soaps before the surgery. The patientsare all admitted to the clinic the morning of the surgery, nobody’s admittedthe night before because we all know that spending more time in the hospitalincreases the risk of infection.
“Nowadays there’s almost no elective surgery done with the patient ad-mitted in the hospital. That’s another initiative. Of course, there is a hugehand-washing initiative that’s been in full swing and has been now for morethan two years – the physicians and surgeons are being audited and are notonly encouraged but also forced to wash their hands every time they come inand out of the room of a patient. This is an institutional measure.
“Another measure that has been in affect now for a number of yearsis that we have noted that shaving the patient before surgery causes injuryto the skin, so now we use clippers rather than razors before surgery, es-pecially minutes before the patients are operated because the razors arecausing microtrauma; they make the patient bleed and that increases therisk of infection.
“So there are initiatives at several levels that are all aligned during the op-eration. The big institutional initiative of trying to prevent infection and forc-ing isolation of patients that have communicable organisms is strictly
enforced. When a patient is isolated because they have a hospital-acquired in-fection, the personnel observe the isolation very strictly,” says Deschamps.
InnovationMayo Clinic is also pushing the boundaries of innovation with its natur-
al orifice transendoscopic surgery (NOTE). Dr. Bingener-Casey, a surgeon atthe hospital, is currently researching the area and is starting two new clinicalprotocols that will look at transvaginal hysterectomy, transvaginal cholecys-tectomy and transgastric cholecystectomy. Her collaborative work with Dr.Chris Gostout, a gastroenterologist, is described by Deschamps as one focusof innovation within the department.
“As well as this, we have two young vascular surgeons that are work-ing on branched endograft with vascular surgery hybrid procedure – wehave a minimally invasive incision where the vascular surgeon slips agraft inside the artery through the groin, and those grafts are severalbranches, more than the usual proximal and distal branches that arebranching into visceral branches like the renal artery and the digestivevisceral artery.
“We have the robotic incision in cardiac surgery. Our cardiac sur-geons are repairing the mitral valve with a robot with small incision, re-sulting in the patient going home in three days. You have surgeonsworking on an artificial liver as well as surgeons that are expanding theindication for solid organ transplant to a wider group of patients, such asa patient with cancer of the liver. Cholangiocarcinoma is a cancer that isusually localized but destroys the liver, and we have now transplantedseveral patients with cholangiocarcinoma, which is an active area of re-search, also the area of ABO incompatibility where we’ve been able to ex-pand the group of patients being transplanted.”
Deschamps explains that the department is attempting to expand thebrainiac surgical treatment to a wider group of patients, looking at the ge-nomic predicator of clinical outcome in lung cancer. There are currentlyonly a few institutions in the US that have the patient pool to understandthe epidemiology of lung cancer in terms of what type of genome or genecan tell the prognosis of a tumor.
However, he notes that the staging classification of the clinic is not pre-cise enough, especially not as medicine increasingly aligns with individual-ized medicine and it is now a requirement to be able to tell a single patient’sprognosis as precisely as possible. “Strengthening the original response totrauma, we are now part of a regional trauma center where we can provide abigger and a better response to the trauma patient,” says Deschamps.
“The final area of research that this department is involved with is qual-ity and safety. We have written several publications in recent months andyears about human factors and safety in the operating room environment, thequality provided and the changes needed in processes to improve the qualitythat is delivered to the patient in the operating room, such as communication.
“In relation to this, our involvement in the national database has increasedsignificantly, which is a reflection of our desire to understand more about ouroutcomes. And this is part of a new area of clinical outcomes,” he concludes.
Mayo Clinic is certainly embracing clinical research discoveries and rais-ing the bar on minimally invasive techniques, making following in its foot-steps a hard job to follow. �
“We would not exist without patients;the mantra here is dedication toquality, safety and service”
Claude Deschamps is Chair of the Department of Surgery at Mayo Clinic.
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PLANE AND SIMPLEThe Surgical Safety Institute’s Richard Karl tells Stacey
Sheppard how a few straightforward lessons from the aviation industry could revolutionize patient safety during surgery.
Everybody makes mistakes, and while some mistakes are inconsequential, others have the capacity to provoke catastrophic consequences. Th is is particularly true for people work-ing in industries such as healthcare and aviation, where lives are quite
literally on the line. Richard Karl is a nationally recognized cancer sur-
geon 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 coun-try. 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).
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Th e 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. Th e dramatic advances seen in commercial airline safety over the last 30 years convinced Karl that the successful lessons of the air-plane cockpit could translate to the operating theater.
“We had a diff erent 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-certifi cation.
“A lot of what they learned in the airlines was that even aft er the de-velopment of the jet engine, they were still fl ying 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 follow-ing the captain’s order out of this Geheimrat notion of what the hierarchy ought to be.”
Lessons learnedTh e issues with hierarchy have since been addressed by the airlines
and now, if you look at the criteria that many of them have for hiring – at least here in the States – decision-making with input for others and setting the tone of open communication are both high up on the list of priorities.
But, according to Karl, this has not been the case in medicine: “If somebody’s bright and they pass all their exams, they go to medical school. And if it’s a prestigious one, they oft en get hired without any assessment of their communication abilities.”
Th e SSI is keen to rectify this situation by training people to improve how they work together. “Th e relationship between surgeons, anesthesiolo-gists and nurses is quite isolated into separate silos and rarely do we work together as a team to get a safe outcome,” says Karl.
“In the States alone, it is estimated that there are 100,000 lives a year lost due to medical error. About half of those occur around an operation of one sort or another. And that doesn’t count the other things: operating on the wrong knee; surgi-cal site infection; retained surgical items that get left behind inside somebody – things that would just be unthinkable in aviation.
“Leaving a surgical implement behind is the equivalent of landing with the wheels up, but this never happens in the airlines. Yet in the United States alone we leave 1500 tools a year behind,” reveals Karl.
“And that is something that you can address, both technologically,
Richard Karl is Founder and Chairman of the Surgical Safety Institute.
by wanding and radio frequency, things that can detect a sponge, and by looking at human factors such as counting tools, knowing who is respon-sible 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 check-lists into eight hospitals around the world. Th e use of these checklists in
operations allegedly cut the mortality rate in half and the morbidity rate dropped by approximately 38 percent. Th is 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.
Falling behindIn comparison to industries like aviation or nuclear power submarine
services, which have transformed themselves over the last 30 years, Karl believes that medicine is severely lagging behind.
“Th ere are 6000 hospitals in the US and it is es-timated that there are 15 million incidents of harm per year in those hospitals. Th at’s 15 million patients getting the wrong knee operated on, getting a sponge left behind, getting the wrong drug or the wrong dosage. Th at’s a lot of mayhem, most of which can be avoided with some simple training and some crew resource management.”
But Karl is quick to point out that not everyone is keen to adopt new practices: “Physicians and sur-geons have always been trained to think that they are special and pretty terrifi c and the idea that they might make a mistake or that using this checklist would slow them down is really in the front of their intelligence. Th ey get their backs up and there is a fair amount of pushback.”
At this point Karl recounts a quote by Profes-sor James Reason, who is widely recognized as a world-leading expert on human error. During a 2003 conference at the Royal College of Physicians in the
UK Reason, said: “Aviation is predicated on the assumption that people screw up. You (healthcare professionals), on the other hand, are exten-sively educated to get it right and so you don’t have a culture where you really have a notion of error. It’s something of a big sea change.”
“Although we kill 100,000 people a year, this is over 6000 hospitals, which is sometimes known as the tyranny of small numbers”
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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.”
Th is, he says, is sometimes known as the “tyranny of small numbers” and is why Karl and the SSI believe that it is some-thing 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. Th e people who make the rules are well intentioned, but as he points out, it is sometimes diffi cult to get rules passed as they are merely viewed as hindrances that could potentially decrease the fl ow of patients through the system.
Bad habitsHe also identifi es 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 intelli-gence as well as their scientifi c 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 com-pletely 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 off er-ing consultations, training and support. When called into an institution
they fi rst 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 anesthesi-ologists, the SSI listens to their gripes and then trains them to identify problems, speak up when necessary and listen to others.
Th e 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 fl y 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 recur-
rent evaluations and come back, see where the hot spots are, what’s worked, what hasn’t and fre-quently 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
the perspective of others, to understand the roles of colleagues, to in-vestigate things when they don’t go well and to use near miss reporting to help you learn and avoid mistakes in the future.
Th e 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. Th at basically boils down to being will-ing 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 health-care 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. Th e 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.”
In the United States, 1500 tools
a year are left behind in patients following surgery
“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”
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Tighter financial constraints and growing staff shortages are makingit more difficult for hospitals to meet their operating room perfor-mance needs. What can they do to optimize operating room proce-dures?Jim Cloar. It really comes down to workflow and familiarity in the OR. Ateam’s protocols and how they work together can be aided or impinged bythe physical objects and information sources in that OR. Seamless integra-tion between equipment vendors is an absolute must, as is a centralized in-formation source so that everyone is on the same page and there is no needto examine multiple or divergent sources. An information hub that is up-dated frequently provides them with one less thing to have to worry aboutso that they can focus on the procedures and the patients at all times.Simplicity and familiarity with all the technologies enable any staff memberto carry out the protocol, even if they are a new or visiting team member.
Richard Harada. Systems integration, before anything, can help facilitiesmeet their operating room performance needs as well as generate potential
savings through improved efficiency, reducework hours, and enhance communicationand collaboration. Remote control of laparo-scopic instrumentation and the ability to viewand collaborate remotely in and out of theprocedure room will help lead the way.
What are the advantages of implementingan integrated operating room solution?RH. In implementing an integrated operatingroom solution, the possibilities in terms of ad-vantages are endless. Efficiencies and collab-oration are immediately improved. The
EHM talks to two industry expertsabout the benefits of integratedoperating room solutions. With Jim
Cloar of Medtronic Navigation andOlympus Medical Systems Group’sRichard Harada.
Jim Cloar was named Vice President andGeneral Manager of Medtronic Navigation inMay 2007. He leads the Louisville, Colorado-based company, which is the leadingprovider of integrated navigation and intra-operative imaging solutions in the world.Cloar has held a series of increasingly broad-reaching and strategic roles in the spinal andbiologics business, most recently as VicePresident and General Manager of theThoracolumbar Spine business line.
Richard Harada serves as the Director ofMarketing for Olympus Medical SystemsGroup’s Systems Integration business unit.He has over 25 years of experience inproduct development, marketing and salesmanagement in hospital informationsystems. Harada’s expertise lies in radiologyimage archive systems, data storage systemsand integration systems.
OPERATING RT_16 nov 18/11/2009 15:20 Page 119
surgeon and team are working with the besttechnology in doing what they do best –providing patient care. Educational oppor-tunities, with streaming video capabilities,are further enhanced in the form of broad-casting procedures to medical students whonow do not have to be in the room.Monitors and displays are everywhere, pre-venting any leaning over of the surgeon’sshoulder throughout procedures as well.The entire team enjoys an optimal view ofwhat is going on at all times. The OR envi-ronment also remains clutter free and with-out any troublesome cords throughout theroom that can only cause inefficienciesamongst the OR team.
JC. There are numerous advantages. Let’s take a neurosurgery suite as anexample. The surgeon must absorb so many disparate data points on thesame patient for a single procedure in order to be as precise as possiblewhen going in to operate on that patient’s brain. Having all that highlycomplex data come together for the surgeon in the OR in a single ‘map’enables precise surgeries and allows the OR staff to follow along withconfidence.
What specific equipment and technology can be used to enable sur-gical, clinical, engineering and IT staff members to reach their inte-gration goals?
JC. Taking again the example of a neurosurgery suite, we have a lot of ex-perience integrating both image-guided navigation and intra-operativeimaging to provide a seamless and dynamic information hub in the OR.The patient’s information can be updated live, while they are undergoingsurgery. 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 thetip of the iceberg in terms of what will still transpire with electronic healthrecords (EHR) and other digital information trends occurring in thehealthcare market.
Our StealthStation i7 is a fully boom-mounted navigation solution thatcan inter-operate with Medtronic intra-operative imaging solutions(PoleStar Surgical MRI system and O-arm 2D/3D Imaging system) as well
as other vendors’ scanners. Medtronic strives to be an openarchitecture firm in order to meet biomedical engineeringand hospital IT staff needs. We offer an iOR suite of solu-tions that provide additional services for integration, be-yond navigation and intra-operative imaging.
RH. The specific equipment and technology utilized by staff members inreaching integration goals will vary and be dependent on each facility’s spe-cific needs and potentially the capabilities of their current system in incor-porating those with the new technology. Some of the new technology to beconsidered would be wireless medical grade displays, long-term videoarchive server solution, and web browser-based viewing of procedures forthose in training, such as residents, interns and fellows.
How do you see the area of operating room integration developingwithin the next few years?RH. In the coming years, technology and innovation will continue to leadthe way within the operating room and systems integration will be the so-
lution to bring it all together in allow-ing facilities to stay competitive andcontinue providing the best patientcare possible. Going forward, some ofthe key areas that will play a majorrole are video streaming through net-works, multi-viewing displaysteamed with real-time information,RFID technology for tracking pa-tients and data, 3-D imaging displays,and the ability to archive video andstill images in an EMR system for
better handling and preparation of patient records.
JC. I think that operating room integration will continue in many differentgeographies around the world, and not only in the emerging markets. Dataconvergence and interconnectivity have hit the healthcare world, just asthey did in telecommunications over a decade ago. Integrating the OR suiteis just one more step to always having accessible data for the surgeon andthe surgical staff, with the ultimate goal of optimized patient care. In termsof the vendors, the key to their success will include their services deliverytrack record and their closed versus open architecture approach. I believethat a positive services track record and open architecture flexibility willdictate which integrated OR vendors remain at the top of the preferredpartner charts. n
“In implementing an integratedoperating room solution, thepossibilities in terms of advantagesare endless” Richard Harada
“Interconnectivity is a mustnow in our digital era,DICOM is just the tip of theiceberg” Jim Cloar
OPERATING RT_16 nov 19/11/2009 11:47 Page 120
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Nadine Nakazawa of the Association for Vascular Access talks to EHM about the
current challenges in the field.
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In 1985, Suzanne Herbst, a nurse working in home infusion, broughttogether a group of her colleagues with the aim of promoting con-sistency in vascular access care in the greater San Francisco Bayarea. The group, which came to be known as the Bay Area VascularAccess Network (BAVAN), quickly grew to include people from allover northern California and beyond. Now called the Association
for Vascular Access (AVA), it has become an international organization serv-ing 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 profes-sional focus as well: she started the peripherally inserted central catheter(PICC) program at Stanford Hospital in 1990. The Stanford PICC programhas grown from an initial placement of 20 PICC lines in the second half of thatyear to now placing more than 2000 PICC lines a year.
In her work, Nakazawa focuses primarily on central venous access de-vices, and within that, on central venous catheters, with about half of thesebeing acute care central venous catheters. She points out that the advantageof a central venous catheter is that it provides reliablevenous access.
“What happens in chronic illness, acute seriousillness, or prolonged need for IV therapy whether it’sacute or chronic, is that patients’ peripheral veinsquickly become damaged and diminished over pro-longed usage,” she explains. “It could be a matter ofdays or weeks, months or years. The damage tendsto be cumulative, particularly during the acute phasewhile patients are in the hospital getting multiplevenipunctures for repeated peripheral IV restarts.Often the sites have to be rotated more frequentlythan what the CDC recommends, which is no morethan every 72 hours to prevent infection, but the re-ality is that the drugs that we put in are very damag-ing to the peripheral veins.
“Peripherally, problems can be caused by any-thing that has a pH that’s less than five, which wouldmean very acidic; or greater than nine, which would mean very alkaline; orhas an osmolality greater than 450 milliosmoles per liter. That means the par-ticulate concentration of the chemical or the drug is greater than what can behandled by the peripheral vein walls. Some drugs, by their chemical design,are inherently irritating or they can cause tissue necrosis if they leak out intothe surrounding tissue.”
Nakazawa explains that this category of drugs is called vesicants. Theycan quickly cause damage to the peripheral veins, and the IV pump pressurescan 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 ofhospitalization or outpatient infusions or chemotherapy, or if they’re in thehospital for any extended period of time, and central venous access is essen-tial for proper delivery.
“Many of these medications cannot be interrupted; patients, for exam-ple, in the critical care setting may need to have medications that are infusedcontinuously at a certain prescribed rate to be able to support their blood pres-sure. They may require antibiotics, or antifungal or antiviral drugs. Becauseof 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 theright time is critical, taking into consideration their total IV therapy needswhile they’re acutely ill, but also their long-term and chronic IV therapyneeds.
“The correct insertion technique, both technically and in terms of pre-venting infection and other kinds of complications, is critical for the properfunctioning of these devices. And then the proper maintenance of these de-vices during the dwell time is also critical. The person who inserts the devicereleases it to the staff nurses to use it.
“We also teach patients and family members to take care of the devicesoutside of the hospital, because they need to maintain them in terms of func-tioning and preventing infection. They also need to protect the site where thecatheter exits out through the skin or access it through the skin if it’s an im-planted 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 in-fectious complications and thrombotic complications, plus a multitude of
others that, as Nakazawa points out, require someonein the healthcare organization to take responsibility foreducation and policies and procedures that are evi-dence-based. “There is a need to conform to nationalguidelines, and those competencies are based on thosepolicies and procedures. So somebody has to take re-sponsibility to ensure that the people who use these de-vices are competent according to a consistentmanner,” she underlines.
Making a choiceBecause vascular access arose from different, very
specific, areas of medicine, this can sometimes lead toconfusion as to which device to use in a particular cir-cumstance. For example, those working in dialysis areinterested in gaining access into the bloodstream forhemodialysis, so the science around dialysis cathetersfalls into the realm of nephrologists, vascular surgeons
and interventional radiologists, plus dialysis nurses. But Nakazawa notes therisk that people outside of dialysis may be tempted to use these devices, cre-ating a huge risk for patients.
Catheters used in the intensive care and critical care setting include acutecare central venous catheters placed for monitoring purposes, for the deliv-ery of multiple infusions and drips. These would be placed by surgeons or byanesthesiologists or intensivists.
In surgery, catheters are primarily placed by anesthesiologists, and some-times by vascular surgeons or general surgeons. The majority of peripheralIVs are placed by nurses. In oncology, long-term central venous catheters areplaced by surgeons or interventional radiologists. Most peripherally insertedcentral catheters are placed by specially trained registered nurses and the restare placed by other disciplines. The result is that, because most of these peo-ple are specialists in particular areas, they look at the patient’s immediaterather than long term needs.
This situation, in Nakazawa’s opinion, highlights the need for a vascularaccess specialist: someone whose specialty is around the science and promot-ing best practices in vascular access, and who takes both the short-term and
“The selectionof the right
device for theright patient at the right
time is critical”
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Nakazawa explains that such a patient would probably need four to sixweeks worth of IV antibiotics, along with support for blood pressure and painmanagement. There will be many infusions, and if he’s unable to eat he mayneed total parenteral nutrition so that he could be fed intravenously. He wouldalso have a lot of IV therapy needs, prompting the physican to order a pe-ripherally inserted central catheter, which can stay in place for weeks ormonths at a time.
However, a vascular access specialist, such as a PICC nurse, would lookat the patient’s history and his lab work, but she would also note that the pa-tient is approaching either renal failure or renal insufficiency, and that he hasevidence of chronic kidney disease.
If he’s young enough, Nakazawa says, in his 40s, 50s or 60s, the nurse maysay, “Is he going to progress to chronic renal failure, in which case we will needto preserve one arm for the surgical build of an arteriovenous fistula,” meaningthe artery is connected to the vein in either the forearm or in the upper arm forhemodialysis in the future, which is the safest device for hemodialysis.
“If you place a PICC line,” Nakazawa points out, “or you place an acutecare catheter in the subclavian vein on that side, the resultant scar tissue willpreclude the ability to build an AV fistula. You have to preserve the veins onone side, so it’s the vascular access specialists in hospitals that are going to alertphysicians to this, and develop a program around it.”
The problem can be finding such a vascular access specialist. Many areinterventional radiologists who consider themselves vascular access spe-cialists within their specialty. There are also, within interventional radiol-ogy departments, physician assistants or nurse practitioners whoseprimary focus is on a vascular access service within the interventional ra-diology department.
the long-term view of each individual patient. “They would also take into con-sideration the published evidence and best practice guidelines so that their se-lection of the device and technique in placing these devices is usually muchmore optimal,” says Nakazawa.
“For example, a patient comes in with an aneurysm in his aorta that’s dis-secting, and he ends up going for emergency surgery for repair. Either in the pre-operative area or in the emergency room, an anesthesiologist places an acute carecentral venous catheter to get the patient through this major surgery.
“The patient may be elderly. He may be obese. He may have other co-morbidities and end up going to the ICU; and now staff are having troubletaking the breathing tube out of the patient because of these other chronic un-derlying health problems that weren’t problematic before the surgery.
“Or the patient could have chronic underlying lung disease. Maybe he’sbeen a smoker. Maybe he’s diabetic. All of these confounding co-morbiditiescome into play and affect the patient’s ability to recover from this surgery. Thelonger the patient is intubated, the more he is at risk for other healthcare prob-lems such as post-operative and ventilator-associated pneumonia. Maybe alsowound 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 thiscritically ill patient who now has multiple medical problems that started fromsomething that was fairly catastrophic and had it not been treated he wouldhave died. Now he’s in the ICU, and he’s developing complications becauseof his underlying co-morbidities. Maybe he has a wound infection or he con-tracts an MRSA, and he needs prolonged antibiotics.”
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Specialists neededThese types of physicians and other specialists place longer term catheters
or dialysis catheters, as well as carrying out all of the complication manage-ment 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 vascu-lar surgeons or general surgeons who consider the specialty of vascular accessto be a very big part of their practice, and they may be the advocate in theirhospitals for best practices.
Amongst nurses, it could be an IV team or a vascular access team orPICC team. Nakazawa gives the example of Stanford, where there is a PICCteam of five people. All orders for PICC lines come through them, and theyplace all PICC lines. If they are not successful, they refer thepatient to interventional radiology for an alternate type ofvascular access device.
“If we deem a patient not to be a candidate for a PICCline,” Nakazawa says, “we would also be the ones to makethat evaluation and refer the patient to IR. For example, apatient may have cellulitis from a wound infection and needfour to six weeks worth of antibiotics. But when we look ather history, she may have had breast cancer and bilateralmastectomies and lymph node dissections. We would notwant to place a catheter in either arm. It’s contraindicated.We would be able to determine that by looking at the pa-tient’s history, talking to the patient, talking to the physician, or a combina-tion of all three.
“We would make the recommendation that the patient is not a can-didate for a PICC line, but she would be a candidate for a small-bore tun-neled catheter placed by the vascular access service in interventionalradiology. So we would call the physician and say, ‘Would you like me tomake that referral?’ And then we could take care of it. We could also doteaching with the patient as to why this is the recommended device forher.”
Keeping trackAnother issue in vascular access revolves around the difficulty of moni-
toring of patients with devices inserted once they are out in the community.“Most hospitals have a great deal of trouble tracking that kind of informationbecause 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 man-aged there, but it will be the home infusion company that will take responsi-bility. They may go to an ambulatory outpatient infusion center. They maygo to a doctor’s office for their infusions or they may go home and do theirown infusions through a home infusion company.
“It’s very, very difficult. Most hospitals are unable to track patients oncethey leave the hospital. One hospital that does a great job in tracking their pa-tients is the MD Anderson Cancer Center, but they have a huge IV vascularaccess team of about 65 clinicians; and they do track all 10,000 of their patientsper year, both inpatients and outpatients.
“It is not an easy thing. You have to have the manpower to do it. Youhave to have tremendous administrative support, and you have to have theability to maintain that kind of communication with patients. I’ve had patients
who have had PICC lines in for over a year and they may be treated in the can-cer center associated with Stanford, but they may also be going back home totheir communities, and maybe a nurse in a doctor’s office is also drawing labsor giving infusions there. It’s very hard to keep track of an individual patient’scontact points with every care provider along the trajectory of the dwell timeof their catheter.”
Future directionsIn terms of the future, Nakazawa says the AVA will focus on a couple of
key projects, including the development of a certification exam for cliniciansthat will test people’s knowledge and articulate the curriculum it expects ofusers and inserters of these devices.
“There is knowledge that we teach across the country,” she says. “We willbring experts together to define what that curriculum should look like. Peoplehave their own individual ideas and there is some consensus, but we need toarticulate that. That’s going to make a huge difference, because then we willbe able to go into hospitals that have no idea that vascular access is a special-ty, and say, ‘Here is this specialty knowledge. You have people who are in-serting devices who may or may not be adhering to already published nationalguidelines and to best practices.’
“We want to be the voice of vascular access to articulate what is best prac-tice; so we hope to create better consistency in both baseline education andadvanced education around vascular access. We also want to promote re-search around both the design and functioning of devices, as well as researchinto behavioral aspects.
“Our goal is certainly prevention of complications. But after articulatingbest practice, you then need to promote the education around it and then youneed to promulgate that widely.
“Those of us who consider ourselves to be experts in vascular access cer-tainly see many hospitals and healthcare organizations at which no one rec-ognizes 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, complicationscan 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, un-necessary thrombotic complications, and a much worsening vascular accesssituation for serious and chronically ill patients, because of the overall incon-sistent and often poor practices across the country. It’s a national issue, andan international issue.” �
“Complications can occur when people dothings because somebody taught them thatway, and it may not be based on anycumulative science or understanding”
Nadine Nakazawa is immediate Past President and Presidential Advisor for theAssociation for Vascular Access.
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With more than 3.8 million cen-tral venous catheters (CVCs),two million peripherally insert-ed central catheters (PICCs)
and 310 million peripheral intravenous devicessold yearly in the US, vascular access is clearly ahigh volume, high usage procedure for patients
receiving medical treatments. Getting the rightintravenous device placed early in the hospitalstay can speed treatment and patient dischargewhile minimizing expenditures.
Vessel health and preservation has becomean important issue, as patients now come to hos-pitals more acutely ill, living longer and often hav-ing chronic conditions. According to the Centersfor Disease Control (CDC), selection of the rightdevice inserted into the right location is para-mount to reducing complications, specifically in-fection.
In 2008, a multidisciplinary task force of vas-cular access experts created a conceptual modeldefining a vessel health and preservation proto-col. The protocol incorporates a systematicprocess driving selection and placement of theright line upon admission through end of care.
The steps for protocol implementation in-clude, firstly, right line selection. The vessel healthand preservation program is initiated through stand-ing orders, allowing line selection within 24 hours.Device selection is based on diagnosis, therapy andpharmaceuticals. The second step is right patient as-sessment. Once a device is selected, a patient assess-ment is performed, including admission riskassessment, critical factors/acuity and vein health as-
sessment. Final device selection is placed within 48hours using central line bundle with the central lineinsertion prevention (CLIP) checklist. The third isright line/right time daily review. Daily assessment isperformed during rounds to determine necessity andevaluate changes in acuity/medications. Central linebundle is applied to all care and maintenance proce-
dures. The fourth is outcome eval-uation. Prior to patient release,compliance to program is mea-sured to evaluate vessel health andcomplications and provide educa-tion to staff.
Selection processThe selection process in-
corporates multidisciplinary as-pects through selection of theright device, placement, anddaily assessment by the physi-cian, nurse and other teammembers. The goal is to proac-tively drive patient-specific de-vice placement within 24 to 48hours of admission.
National guidelines fromagencies such as the CDC andSociety for Healthcare Epidemiology (SHEA)/Infectious Disease Society of America (IDSA) 2008Compendium Strategies (SHEA 2008) are a part ofthe vessel health and preservation program, throughinsertion and daily assessment of the patient and de-vices chosen to administer treatment. The Institutefor Healthcare Improvement central line bundle in
the insertion process is evaluated through the CLIPchecklist, which measures compliance with the bun-dle and other infection prevention practices.Education is ongoing, with the vessel health andpreservation program providing preventative ed-ucation in keeping with the Joint CommissionNational Patient Safety Goal 07.04.01 require-ment for insertion, care and maintenance train-ing, patient education and a process forimplementing this education.
Fast, well-directed treatment following diag-nosis is the hallmark of efficiently managed hospi-tal systems. Costs are controlled when patientsreceive a vascular access plan that is immediatelyimplemented, assessed daily and adapted as need-ed, with evaluation at the end of the process.Using new technology in placement of safety
CVCs, such as the AcceleratedSeldinger technique, may re-duce delays in device access.Roadblocks occur when pa-tients fail to receive a vascularaccess plan. When peripheralveins for intravenous accessare exhausted or developcomplications, precious timeis lost identifying the rightperson and device for place-ment. Process flow is im-proved when a vessel healthand preservation program in-stitutes an intentional selec-tion and placement processwith indicators of daily suc-cessful function, which willspeed the patient to betterhealth and discharge.
A program built with a vessel health andpreservation clinical pathway ensures patients’right to safe and timely drug delivery, reinforc-ing the core message: the right line for the rightpatient at the right time. �
Preservation protocolNancy Moureau tells EHM of the proactive management of vessel health.
Nancy Moureau is a VascularAccess Consultant, educator, andper diem clinician at GreenvilleMemorial Hospital in Greenville,SC. She is the founder and CEOof PICC Excellence, Inc., acorporation established fortraining, education andconsulting on PICC lines.
For more information, please visitwww.piccexcellence.com
“The goal is to proactively drive patient-specific device placement within 24 to 48
hours of admission”
Teleflex ed:26 June 18/11/09 15:44 Page 126
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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.
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Prevention is better than cure. Th ough 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 insignifi cant element of a traditional treatment-focused healthcare off ering, well-ness programs are steadily gaining promi-
nence. 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 Offi cer Johnna Torsone, the benefi ts 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. Th e results show that a more proactive approach can reap big benefi ts. “Th at was the big thing that Pitney Bowes discovered,” says Torsone. “Now it’s everybody. Th ere are more and more companies that have recognized that. Th at 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 aff ect 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 signifi cantly 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 signifi cant complications from those diseases go down.”
Key to making wellness pay is bringing the workforce on board. Em-ployees 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 responsibil-ity 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 fi ve 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 eff ectively changing ingrained attitudes requires a great deal of persua-sion. “Th ere are some companies that have built penalties into their pro-gram, for failure to do some of these things,” she says. “Up to now we’ve taken a diff erent 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.
“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 un-derstand 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 effi cient use out of the system, not just us. We’re asking them to
“I would say it’s a combination of education, plan design, actual provision of services and subsidizing things like wellness visits, vaccinations and screenings”
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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 out-side business. “It requires us to begin to educate our populace on a sub-stantial 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 benefi t of it. Th at’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.”
Torsone and her peers will be observing the ongoing healthcare wran-gling 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 diffi cult 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 off ers a viable model for a new national strategy. “I hope that any program, whether it’s public 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 effi ciently designed nor struc-tured 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 effi cient focus that we do on health. If we don’t do it, whatever system it is, I don’t see it being sustainable.”
be a partner with us in this, and I think that’s the most important ele-ment of what is missing in the public discussion of healthcare. Th ere’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. Th ere are things you can do to help make that happen, but ultimately there’s a joint responsibility here.”
Taking it to the topHealthcare 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 diffi cult in the public arena is it’s hard to prove how much will they save and when bills are submitted, the congressional budget offi ce 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.
“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”
Johnna Torsone is Executive Vice President and Chief Human Resources Offi cer at Pitney Bowes Inc.
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Physician recruitment is a function within health-care organizations that keep the ‘C’ suite folksawake at night. Yes, it’s a necessary process thatfeeds the livelihood of your facility. One would
think that it’s pretty straightforward without much variationin the process, right? In reality many healthcare executivessee physician recruiting as frustrating, difficult to manageand very costly with questionable control over success.
Until recently hospitals, medical groups and practiceshave had only two options for the recruitment of physicians– they could build their own internal system or outsource theprocess to various firms and manage the process internally.It was only a short time ago that it was proposed that facili-ties start doing what they do with payroll and HR manage-ment and outsource the process.
In 2004 leadership from the Human Resources andOperations department of a large multi-specialty clinic in cen-tral Massachusetts sought to establish an on-site physician andadvanced practitioner recruitment program exclusive to theclinic. The clinic elected to outsource to a third party vendorrather than develop an internal recruiting department becauseincorporating the expertise of a professional firm offered thebenefit of a faster start and shortened learning curve, providedthe professional firm could replicate their service in an on-sitemodel and adapt to the clinic’s culture.
The clinic chose a national physician-recruiting firm tobe the backbone of what eventually became a beta model insimilar design of a recruitment process outsourcing (RPO)service. Professional RPO services have become widely ac-cepted for recruitment in commercial industry sectors andare described by the RPO Association as, “Providing the en-tire recruiting process including management, staff, tech-nology, job validation, metric reporting and presentation offinal candidates. A properly managed RPO will improve anorganization’s time to hire, increase the quality of candidatesand reduce cost.”
During the first two years the third-party firm suppliedthe sourcing expertise and the HR support to provide ongo-ing recruiting while assisting the clinic staff in the develop-ment of a system to manage the numerous and diverseoperational components of provider recruiting. Midwaythrough the five-year process, the clinic recognized that theinitial vision was the correct path to pursue based on resultsat that point. In order to move the model to the next level of
performance, leadership elected to distribute an RFP to ad-ditional vendors in an effort to seek a more palatable busi-ness 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-the-art physician sourcing data and management system to thou-sands of in-house physician recruiters. The new vendor wasable to capitalize on the progress made in the previous de-velopment of the clinic’s leadership vision. Following the ad-dition of the more sophisticated data and managementsystem, the critical sourcing component was improved.
You might be wondering where I’m going with this, andhere it is – after the conclusion ofthe five-year process the clinicreduced their costs of physicianrecruitment by 40 percent whileincreasing their results by 44percent. The clinic created a cul-ture of recruitment at the facilitythat involved existing physiciansin the process of recruiting newproviders, helping raise their rateof retention and increase thesupport services available for new physicians.
Much like the commercial RPO services, the beta pro-gram validated the absolute need for key elements of a re-cruitment process, such as a reliable and consistent flow ofcandidate sourcing, milestone based monitoring of everyaspect of the process from A to Z, a driving philosophy ofmatching professional and personal requirements, seniorlevel involvement by the organization and vendor, and themost important factor – an onsite concierge style coordi-nator, task focused and not bifurcated by non-relatedtasks. Simply through the beta outsourcing model theclinic was able to under spend their last annual recruitingbudget by $1 million. �
The future of recruitment outsourcing
Jim Causey tells EHM of the benefits of outsourcingpractitioner recruitment.
Jim Causey is Vice President of Marketing andDevelopment at PhysicianRPO. He has over 30years of experience in business and productdevelopment, physician practice mergers and
acquisitions. Causey pioneered theoutsourced physician-recruiting conceptand now directs the initiative forhospitals, systems and medical groups.
“The clinic reducedtheir costs ofphysician recruitmentby 40 percent”
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areas such as infection to bolster prevention and control eff orts.
Building operational leverage through asset leanness is the fourth step . A big invest-ment in hard assets can become an albatross when demand dissipates. However, many fi rms have already begun investing smarter, not bigger, to become more fl exible in the face of volatile demand. Pharmaceutical fi rms are outsourcing quality control to enable 100 per-
cent sampling and turning production over to contract manufacturing organi-zations. Outsourcing can benefi t health-care providers as well. For instance, the use of Pyxis to provide end-to-end safety and automatic replenishment in delivering prescription drugs within the hospital can dramatically reduce administrative and clinical errors.
Th e fi nal step is to invest in neigh-boring markets. Retrenchment is the mantra that accompanies a recession. Wise companies, however, are planting growth seeds in new businesses adjacent to their core. Healthcare providers have similar opportunities in collaboration with employers and insurers. For ex-ample, some forward-looking insurers
are working with clients on prevention pro-grams that target risk factors for obesity. Th ey believe that if the healthcare system cannot respond eff ectively to the epidemic of obesity, it will drown in the expense of related health problems. Hospitals that work with them can contribute understanding of the science behind this syndrome to maximize the eff ectiveness of prevention programs.
Adopting business strategies for the ‘new reality’ will help healthcare providers improve the quality and effi ciency of the care they de-liver. Quality improvements will drive prefer-ential treatment from employers and insurers, boosting revenue.
The consensus is that the economy has bottomed out and is starting to strength-en. Yet healthcare providers continue to face unrelenting turbulence. While the ulti-
mate transformation of US healthcare is as hard to predict as the shape of the economic recov-ery, there are some strategic steps that providers can adopt from business to build resiliency for an uncertain new reality.
Th e fi rst step is to empower em-ployees to engage in lifetime learning. Companies now realize the meaning of the long held belief that people are their most important assets. Highly moti-vated directors, physicians, nurses and staff are the only assets that bring other assets into play. Even more important, adaptability is the key to meeting the unrelenting and accelerating series of challenges ahead.
Th us, the smartest organizations are those that recognize the need to cul-tivate life-long learning in their people. Dallas’ Baylor Health Care System, for example, has adopted this strategy and invested thousands of hours in develop-ing leadership, communication, fi nance and strategic planning skills among its physician, nurse and administrative leaders, with the payoff of improved quality and effi ciency, and the capability for continued improvement.
Th e second step is to manage working capital to ensure liquidity. Tomorrow’s business winners will be those who have ready reserves of cash today. Freeing up cash can be diffi cult for healthcare providers that are squeezed between reduced reimbursement rates and lowered billing rates. However, hospitals can continue to wrench effi ciencies from their operations by eliminating medical errors and slicing ad-ministrative waste. For example, Mayo Clinic
recently transitioned to all electronic records to speed communication between physicians in diff erent departments and improve accuracy of diagnosis and treatment. Generally, hospitals are burdened with manually archived records and non-standardized procedures that make data storage and retrieval diffi cult. As both patient and information volume escalate, these become even more burdensome, leading to even greater administrative and clinical waste.
Using your customers to design and promote your product is the third step. Many companies have asked their customers to share in the recession’s pain, but the smarter ones look to harness them as co-creators of the next breakthroughs. How can healthcare providers benefi t from this strategy? New information technologies enable physicians and hospitals to capture a wider range of patient data, such as adherence to treatment regimens to personalize care. Greater use of biomarkers enables provid-ers to accelerate the discovery of new treatment regimens – compressing multi-year clinical testing protocols. Th e use of new data mining techniques can help hospitals spot trends in
Five steps to building a resilient organization
Frank Lloyd is Associate Dean, Executive Education, Southern Methodist University Cox School of Business.
David T. Lei, PhD, is Associate Professor in the Strategy and Entrepreneurship Department, Southern Methodist University Cox School of Business.
David Lei and Frank Lloyd explain the key strategic business moves for the healthcare economy.
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Recently thrown into the spotlight fol-lowing Obama’s move toward a more state-based healthcare system, the UK is a publicly funded healthcare coun-try with free services provided to all of the 60,000 UK residents. Introduced aft er 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.”
Th e public system, the National Health Service (NHS), is funded via countrywide taxation and includes primary care, in-patient care, long-term healthcare, ophthalmology and
With a devolved public healthcare system, the UK offers a democratic approach.
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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. Th e government’s budget portioned the Department of Health £98.6 billion for the fi scal year 2008-09, with the majority of that being spent on the NHS. Th e private healthcare oper-ates 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.
Th e responsibility of healthcare is a devolved matter to the jurisdictions of the UK – Eng-land, Scotland, Wales and Northern Ireland – and with each system implementing diff erent sets of policies and programs they each take a diff erent approach. Th e UK Government is expanding the role of the private sector within England whereas the Scottish govern-ment is aiming to reduce the infl uence 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 oft en subjected to severe criticism by the national newspapers.
Emergency medical servicesIn 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 fi rms are being awarded contracts and money is being diverted away from the trusts. The government measures the performance of every Ambulance Trust.
Travel focusLondon 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 fi nancial 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.
Th e NHS employs more
than 1.3 million people
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Uncertain Suffering: Racial Health Care Disparities and Sickle Cell DiseaseBy Carolyn Moxley Rouse
Carolyn Moxley Rouse examines the higher mortality rate and lower life expectancy of black Ameri-cans as compared to white Americans, and what this means for healthcare in the US through the lens of sickle cell anemia – a disease that primarily aff ects 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 suff ering.
The Healing of America: A Global Quest for Better, Cheaper and Fairer Health CareBy 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 NeededBy Robert Levine
Off ering an easily understandable diagnosis of the problems plaguing our current health care infra-structure, 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 ap-proach and off ers practical solutions.
On the shelfEHM rounds up the latest healthcare books.
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From the people you hire to the products you sell, if you’re in business, we’ve got it covered...
Your World. COVERED
Find out more: www.executivehm.com
Executive Healthcare ManagementThe healthcare industry is changing. Understanding how to improve clinical processes, meet industry standards and merge the maze of disparate systems is vital. EHM combines unbiased industry news with thought leadership from the most respected executives in healthcare, providing a platform for strategy and learning.
Next Generation PharmaceuticalApproximately 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
Find out more: www.ngpharma.com
Business ManagementWhat 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
Oil & GasCollaboration between government and multinationals is essential to ensure the energy supply is developing on two fronts. O&G is the defi nitive publication for stakeholders and service companies to read about the regional projects, technologies and strategies affecting their group.Available for: MENA, US, Russia
Find out more: www.ngoilgas.com
InfrastructureInfrastructure 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
tegy and learning.
Previous US Edition
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Healthcare for the Elderly Jan. 18 – Jan. 19, 2010Toronto, ON, Canadawww.insightinfo.com/healthcarefortheelderly
3rd International Conference on Health InformaticsJan. 20 – Jan. 23, 2010Valencia, Spainwww.healthinf.biostec.org/
Healthcare Market and Emerging Consumers Jan. 21 – Jan. 23, 2010Manipal, Karnataka, Indiawww.mim.ac.in
2010 National Health Policy Conference Feb. 8 – Feb. 9, 2010Washington, DC, United Stateswww.academyhealth.org/nhpc
Connecting Healthcare 2010 Feb. 9 – Feb. 10, 2010Sydney, NSW, Australiawww.connectinghealthcare.com.au/
Obs-Gyne Middle East 2010 Feb. 14 – Feb. 16, 2010Dubai, United Arab Emirateswww.obs-gyne.com
Manipal, Karnataka Washington Toronto
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5th Decennial International Conference on Healthcare-Associated Infections Mar. 18 – Mar. 22, 2010Atlanta, Georgiawww.decennial2010.com/
16th ISHEID - International Symposium on HIV & Emerging Infectious Diseases Mar. 24 – Mar. 26, 2010Marseille, Francewww.isheid.com
Healthcare Tourism Congress 2010 Apr. 12 – April. 13, 2010Kuala Lumpur, Malaysiawww.htcongress.com
Biomed Europe 2010 Conference and Exhibition Apr. 19 – April. 21, 2010Budapest, Hungarywww.biomedeurope.com
Dubai Marseille Kuala Lumpur
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Androulla 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 fi eld 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 Aff airs Com-mittee 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 Women’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 interna-tional and regional conferences, especially in the fi eld of human rights.
Androulla Vassiliou, European
Commissioner for Health
Androulla Vassiliou at the EU Headquarters in Luxembourg
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On June 11, 2009, Dr. Margaret Chan, Director General of the World Health Organization, raised the level of infl uenza pandemic alert from phase 5 to phase 6, and declared: “Th e world is now at the start of the 2009 in-fl uenza pandemic.” Th e US Centers for Disease Control
and Prevention (CDC) reported on November 12, 2009, that H1N1 had in-fected 22 million Americans, hospitalized 100,000 of them and resulted in 4000 deaths. Th ere is scientifi c evidence that H1N1 is a genetic successor to the virus of the 1918 infl uenza pandemic, which killed 50 mil-lion people, about three per-cent of the world’s population. Th ere 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, particu-larly aft er SARS in 2003, important elements of pandemic preparedness have been a focus of attention on many levels, including businesses pre-paring for large numbers of absent workers, schools establishing closure policies, medical institutions preparing for dramatic increases in patient load, public health offi cials 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 eff ectiveness
of the vaccine is not yet well understood. Th at leaves us with isolation: preventing symptomatic individuals from infecting asymptomatic indi-viduals. Since fever is by far the most important and most effi cient 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. Th e 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 effi cient mass screening.
Effective screeningInfrared imaging cameras have been prominent in newscasts show-
ing screening at airports and other travel centers, primarily overseas. Re-cently, 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 regard-ing 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 eff ec-tive 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 im-agers or infrared thermometer guns can be qualifi ed for clinically accurate fever detection, due to limitations of physics and physiology, a well-known
fact amongst knowl-edgeable scientists.
Suitable qualifi ed clinical methods must be fast and non-invasive, as well as accurate. One example is temporal artery thermometers, now used in most medi-cal institutions in the US. Th ey have been selected worldwide by
major companies, pandemic and bioterrorism response teams, govern-ment health departments, and hospitals to mass screen individuals enter-ing 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.
H1N1 and mass screening for feverBy Francesco Pompei
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.
“Unfortunately, only a fraction of the US and world population will be vaccinated against H1N1, and the eff ectiveness of the vaccine is not yet well understood”
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