HCPro.com - Health Governance Report

Predictive modeling options to cut preventable admissions

Fri, 01 Jun 2012 04:00:00 GMT

Predictive modeling options to cut preventable admissions

by Karen Minich-Pourshadi

With the looming threat of reimbursement losses for preventable 30-day readmissions, healthcare organizations nationwide are analyzing care transitions in an effort to achieve better outcomes and keep patients from returning to their facilities unnecessarily. While transition programs show promise in helping hospitals reduce their readmission rates, predictive models are also being used successfully in tandem with these programs. Three early adopters of these models are achieving positive results thanks to tactics and technology that identify at-risk patients from the outset of care and influence treatment approaches and the required level of transitional care.

Parkland Health & Hospital System, Dallas: Data algorithm and readmission rates

Since December 2009, Parkland Health & Hospital System in Dallas has been using what it calls the e-Model, one of the first electronic readmission predictive models of its kind. The organization's Center for Clinical Innovation began development on the model in 2007 with an eye toward real-time identification of heart failure patients at high risk for hospital readmission or death. Since then, it has expanded the program to include all causes of readmission.

"The challenge is: How can we turn this [model] into data that can help clinicians make real-time decisions that affect outcomes? We're taking information from various sources, and based on it we can say with high probability that [the clinicians] may want to suggest a different course of treatment," says John Dragovits, executive vice president and chief financial officer at the $1.1-billion-net-revenue Parkland Health & Hospital System.

The Center for Clinical Innovation at Parkland received grants from several sources to support its work on the model, which combines 29 data points extracted from its EMR. The data includes physiologic, laboratory, demographic, and utilization variables that can be pulled from a patient's EMR within 24 hours of hospital admission. The comprehensive algorithm has proven to be accurate at predicting readmission or death, says Ruben Amarasingham, MD, director of Parkland's Center for Clinical Innovation and assistant professor of medicine at UT Southwestern in Dallas. Preliminary results show 33% reduction in readmission of Medicare heart failure patients and 20% reduction in readmission of all heart failure patients.

Parkland's predictive model compiles a daily report of all admitted patients; it essentially profiles patients and places them into risk categories. Clinicians and case managers are then notified which patients are at highest risk for complications so those patients can be treated accordingly, explains Amarasingham. "There's a lot of value in doing this [modeling] because we have an enormous amount of clinical need and a fixed amount of resources."

Based on Parkland's preliminary success with this algorithmic approach to preventable readmissions, it received a grant from The Commonwealth Fund to expand the model to all conditions and across several hospitals. The goal is to build the first electronic readmission model that can be applied to any patient in any hospital where EMRs are available and reduce readmission rates.

Amarasingham, who started the predictive modeling project with a team of four and now has 15 people working on the project, says the use of predictive modeling has been well received by many clinicians. However, while many see the value in having this data in the system, not everyone was keen to follow the algorithm's advice.

"It's a culture change," he says. "We need to see how this model changes care and what the human-to-computer interface in clinical decision-making will be, because it's becoming increasingly impossible for clinicians to keep track of the level of detail-both clinical and social-that's needed in order to arrive at a risk level assessment. Eventually, I believe physicians will demand this type of predictive modeling technology."

Mount Sinai Medical Center, New York City: Admissions data and readmission rates

For nearly two years, Maria Basso Lipani, LCSW, coordinator of the preventable admissions care team (PACT) at Mount Sinai Medical Center in New York City, and Jill Kalman, MD, director of the cardiomyopathy program, associate professor of medicine at Mount Sinai's Cardiovascular Institute, and the PACT medical director, have been using admission history data to identify patients at high risk for readmission.

PACT, which consists of both a social work-led transitional program and a nurse practitioner-led medical clinic, enrolls patients based upon data collected from Mount Sinai's existing EMR. A physician from the IT department creates a daily list that identifies hospitalized patients who had at least one admission within the past 30 days or two admissions within the past six months, says Basso Lipani.

Kalman explains that the 1,171-licensed-bed Mount Sinai launched PACT to reduce exposure to federal readmission penalties and to improve health outcomes through better care transitions. "We wanted to ensure that the program is truly reaching those who are most likely to benefit from the intervention," she says.

To do that, Mount Sinai's health evidence and policy team developed a risk prediction model for readmission within 30 days using logistic regression. "The higher the score, the higher the risk of readmission," Kalman says.

Last summer, the predictive model was applied to patients enrolled in the PACT program to determine how many of them were at high risk for 30-day readmission. "Ninety-five percent of PACT enrollees had a risk score greater than 3, meaning that their readmission rate was between 19% and 29%," Kalman says.

Mount Sinai is showing early success with its model. The PACT program has decreased its 30-day readmission rate from 30% to 12% and its ED visits by 63% (over three-plus months), and it has a 90% primary care show rate at seven to 10 days post-discharge for patients enrolled in the program.

Basso Lipani says the core of the transitional program's success is the engagement of patients and families in a discussion of what uniquely drives readmissions for them. "We've learned that patients with the highest medical utilization, at highest risk for readmission, and with the most fragmented care can be reached and their readmission risk can be reduced through our intervention," she says.

Mount Sinai hopes to integrate the risk score into the EMR and use it in conjunction with the transitional social worker's assessment to develop a tiered approach to intervention. "Patients at low risk for readmission may do best with a single follow-up call post-discharge, while a moderate-risk patient may need several calls. This is one way in which the predictive model could have a direct impact on the allocation of resources," Basso Lipani says.

"We wondered if modeling readmissions was going to require us to use more data and create a complex score, but we're validating that a simple [admission history] approach works, and we believe it can be set up easily, regardless of where [an organization] is located, its size, or the level of IT support," says Kalman.

Cincinnati Children's Hospital Medical Center: Proactive care and readmission rates

Given the young average age of the patients at Cincinnati Children's Hospital Medical Center (CCHMC), the decision to create a predictive model program wasn't primarily directed at reducing readmissions, explains Frederick C. Ryckman, MD, senior vice president for medical operations and professor of surgery at CCHMC. Rather, it was directed at changing the hospital's approach to care from reactive to proactive.

"[Predictive modeling] leads to better communication, better coordination of care, and better outcomes-it's the key to preventable admissions," he says. "Our hypothesis is that a lot of healthcare is very predictable, and if you're able to predict at-risk situations, you can preempt them by building robust mitigation strategies. You can deliver better care, improve [patient] safety, use your capacity and space more efficiently, and create a better patient experience overall."

Several years ago, the organization decided to take a more proactive approach to care, and Ryckman explains that data was essential to that approach. "We wanted to understand when an event might occur so we could plan for how to react when an adverse event actually happened," he says.

After gathering three years' worth of data, a team created a model that looked at inpatient units for general pediatrics based on pediatric early-warning assessments and created scores using behavior, cardiovascular, and respiratory results. Scores of 3 or above linked to clear action and bedside examination by nurses or physicians, and scores of 7 or above linked to an automatic medical response team call.

For example, the 523-licensed-bed CCHMC uses pediatric early-warning scores in the predictive metric within its Epic system to look at comorbidity, previous history, and risk, and then couples that information with the clinician's knowledge to assess the patient's risk level and put contingency plans in place should the worst-case scenarios develop.

"We have achieved a systemwide approach to using at-risk predictions," says Ryckman, who notes that CCHMC also uses the predictive model to determine the level of care coordination needed at discharge.

While patients could be admitted to the hospital with a wide variety of problems, the model showed there were common potential problems associated with each scenario; for instance, respiratory disease and pneumonia could be complicated by asthma. It would take the clinical staff's input to assess the likelihood of a complication taking place, and that information would be included in the data to help decide the risk level of the patient.

To aid in assessing the patients, the clinical team on each floor of the hospital meets three times daily (during shift changes) to gauge the severity of patients' illnesses. The morning assessment looks at capacity and the potential for any patient to need intensive care. The staff also does a safety call for all the units that alerts the team to potential problems-for instance, if the pharmacy is low on a particular drug. "We decided to use technology in a supportive role for the clinical staff, rather than as the solution. I believe other organizations could even run this exact approach in a hospital that has no EMR," says Ryckman.

No additional staff were needed to run the predictive model program or coordinate the daily floor meetings, he notes. "Having these huddles isn't a hugely time-consuming process, and what comes out of it produces a good ROI."

The main goal of the program was to predict when children may show signs of progressive deterioration in their clinical condition and flag the patients who may need escalated care early on. "By using this approach, we've seen the length of stay decrease in ICU, as has the number of critical care codes outside ICU," Ryckman says. The number of overall codes outside critical care previously averaged 20 events per 1,000 hospital days, with a single-quarter high reached in 2007 of over 40 events per 1,000 hospital days. It now hovers near 10. "I'd say sending kids home sooner, with a shorter length of stay and not having complications, has an impact on our revenue stream, but the goal is to deliver better outcomes for better overall value of care," Ryckman explains.

While for the most part predictive models require an organization to put some financial investment toward technology, it's not new technology-rather, it's an investment in the EMRs the organization is required to have anyway. "The ROI with predictive modeling is difficult to characterize and analyze, but if you're preventing multiple admissions, then you're making beds available for other patients," Kalman says.

Adapted from HealthLeaders magazine, April 2012.

10 things we don't know about looming readmission penalties

Fri, 01 Jun 2012 04:00:00 GMT

10 things we don't know about looming readmission penalties

by Cheryl Clark

The second, and some say the most anxiously anticipated, document setting forth how hospitals with excessive 30-day readmission rates are to be fined will soon be released-and a lot of money is at stake for some hospitals.

Beginning October 1, the Affordable Care Act (ACA) calls for penalties up to 1% of a hospital's entire base Medicare diagnosis-related group (DRG) payments in the first year, up to 2% the following year, and up to 3% every year after that.

CMS released the first installment of this new program's details in August 2011 with the final rules by which it would pay hospitals in FY 2012. In that inpatient prospective payment system (IPPS) document, CMS promised further clarification in the FY 2013 IPPS rule, expected in April 2012.

But precisely how these new rules will be implemented for three conditions that represent 16% of overall readmissions-heart failure, pneumonia, and acute myocardial infarction (AMI)-remains unclear. Hospital officials are scratching their heads over how CMS will define, weigh, adjust, exclude, and compare hospitals, and how much money will be taken away. Here are the most pressing issues hospital leaders hope CMS will answer soon:

1. How will hospitals be compared? Hospitals with greater-than-expected risk-adjusted readmission rates between July 1, 2008, and June 30, 2011, will be penalized in the first round. But what groups of hospitals would constitute a fair comparison? Those within a similar region or state? Those of similar size? Those with similar patient populations, such as safety net or rural hospitals? Or will each hospital be measured with all others across the country?

The answer is important because there are vast regional differences in readmission rates across the country, according to CMS' Medicare Hospital Quality Chartbook for 2011. CMS has indicated it intends to compare every hospital's readmission rates with the rest of the nation's, but some hospital officials hope for reconsideration.

2. Will CMS adjust for hospital size or socioeconomic status? The risk adjustment formula to date adjusts for some disease comorbidities, such as age, but does not correct for hospitals with patients who are more likely to be low-income, poorly educated, or have little access to primary care physicians, pharmacies, or healthy food. It also does not take race into account. Some hospital leaders have argued vociferously that the formula is therefore biased against hospitals grappling with tougher populations.

In its FY 2012 rule last August, CMS explained it would not adjust for such factors as English language proficiency or socioeconomic status, saying that poorer scores could be due to "differences in the quality of healthcare received by groups of patients with varying race/language and socioeconomic status." If there were such a correction, poor-quality care for patients in "certain racial and ethnic groups may be obscured," the agency said, and "may suggest that hospitals with a high proportion of minority patients are held to a different standard of quality than hospitals treating fewer minority patients."

Nancy Foster, vice president for quality and patient safety policy for the American Hospital Association, says many hospitals strongly disagree. "What we're assessing here is supposed to be the performance of the hospital in doing what it can to prevent readmissions. And when you confound that by not adjusting for community factors, then what you end up doing is penalizing hospitals for things that are clearly outside their control," she says. "I would agree that if we were assessing the impact of low socioeconomic status or communities without adequate primary care physicians, we want to hold that up and make sure that our measures doesn't adjust for that, but that's not what we're assessing here. We are supposed to simply be assessing hospital performance."

CMS promises to keep an open mind and "will monitor" whether the program "has a disparate impact on hospitals that care for large numbers of disadvantaged patients. If such an impact is found, we will consider whether additional program modifications would be appropriate."

3. What is the "index hospitalization"? What is the definition of the index hospitalization that starts the 30-day clock ticking?

"Is it the first one you come across in a year?" Foster asks. "Or is it an admission to a critical access hospital that then warrants further admission to a general acute care hospital? Those are the sorts of questions we hope they'll answer."

4. What unrelated readmissions might be excluded? In general, CMS will impose a penalty if a hospital has greater-than-expected risk-adjusted readmissions, regardless of the reason for the readmissions. If a heart attack patient falls at home after discharge and must be readmitted, perhaps the hospital might have first inspected the home for a fall risk.

However, some readmissions could be justifiably unrelated, and even typically required as a standard of care. So far, CMS has noted it would not count as a readmission the case of a heart attack patient who is subsequently scheduled for a heart bypass procedure within 30 days, since such a procedure would be a typical occurrence. CMS has not named any "typically scheduled" exclusions for pneumonia or heart failure-but neither has it closed the door on the possibility.

5. How much will Medicare save? The law will result in gradually increasing savings to the Medicare program, totaling $7.1 billion over the next seven years, according to the Congressional Budget Office. But will penalized hospitals lose the maximum 1% of base DRG, or will there be thresholds-for example, 0.5%?

So far, Foster interprets the penalty as one that includes the hospital's number of risk-adjusted readmissions factored with its expected number and the hospital's base payment for that diagnosis, calculated with a complex formula set forth by the ACA. However, CMS still must clarify terms in the formula, such as base operating DRG, ratio, and floor adjustment factors.

6. How will each condition be weighted? Will readmission rates for each condition be weighted equally? The answer could be pivotal because heart attack patients are much less likely to be readmitted than patients with heart failure or pneumonia, and they incur readmission care costs that are one-fourth of what is spent to treat heart failure or pneumonia readmissions, according to a 2007 Medicare Payment Advisory Commission (MedPAC) report. CMS intends to clarify its definition of "aggregate payments for excess readmissions."

7. What is an "applicable hospital"? CMS intends to define this term. For example, might an admission that results in a readmission to a cancer hospital be excluded?

8. What is the appeal process? CMS is considering what aspects of readmission rates sent to hospitals for review prior to public release might be correctable, and will clarify its review and process.

9. What future conditions will be added? Four additional diagnoses account for 11.7% of all preventable readmissions-about 133,000 per year, according to a 2007 MedPAC report. They are:

Chronic obstructive pulmonary disease
Coronary artery bypass grafts
Percutaneous coronary angioplasties
"Other" vascular surgeries

The ACA specifies that these four categories and others the HHS secretary deems appropriate may be added by FY 2015. CMS is expected to signal which ones top its list.

10. How will CMS prevent hospitals from gaming the system? CMS acknowledges the possibility that some hospitals might try various tactics to avoid excess readmission penalties, such as changing diagnostic codes to avoid identifying patients with AMI, heart failure, or pneumonia; "systematic shifting, diversion or delays in care"; or putting pressure on emergency room staff not to admit patients within the 30-day window.

And although CMS has promised to monitor such practices to "minimize any unintended consequences," it has not explained how frequently or with what tools it intends to do so.

Preventing hospital readmissions takes a village

Fri, 01 Jun 2012 04:00:00 GMT

Preventing hospital readmissions takes a village

by Cheryl Clark

Remember the African proverb "it takes a village to raise a child"? Maybe it takes a village to prevent hospital readmissions, too. From Rockport to Yakima and from Detroit to El Paso, 30 community-based organizations (CBO) are joining hands with hospitals, finally, in a communal effort to do just that, all funded by $500 million authorized by the Affordable Care Act for five years.

These CBOs are social support groups and Area Agencies on Aging, the type of quasi-governmental entities and nonprofits historically known for home-delivered meals, transportation services, support, and counseling for seniors and the disabled. Now, these regional collaboratives are embarking on a variety of experiments to pick up patient care where hospital discharge planners leave off.

In October 2011, prospects looked grim for the Community-Based Care Transitions Program. Projects were supposed to have started January 1, 2011, but by fall none had been picked and few hospitals seemed interested. HHS officials lamented the paucity of applications, and hospital officials complained they didn't even know who their senior services organizations were or what they did because they lived in different worlds. After more than a year's delay, federal officials picked the first seven groups last fall and another 23 in March 2012. As of spring 2012, the 30 groups were just getting programs started.

These CBOs have challenging tasks. They must have already partnered with a hospital, preferably one grappling with readmission rates in the top quartile within each state, to identify the Medicare patients at highest risk for readmissions. These projects must also achieve a 20% reduction in the number of 30-day readmissions to their partner hospitals within the first two years to be eligible for further funding.

But CBOs can't follow every discharged patient, and only Medicare FFS patients are eligible. So to capture enough reductions, the hospital must direct the CBOs to those patients at highest risk: those who live alone, who are elderly or disabled, or who have high-risk conditions such as pneumonia or congestive heart failure or multiple comorbidities.

While the details of each program vary, in general, the CBO workers meet these patients at the hospital bedside, talk with the providers familiar with their care, and earn the patients' and families' trust. After hospital discharge, the CBOs track the patients in their homes or long-term care facilities with face-to-face visits to assess any environmental or cultural barriers that impede their safe recovery.

CBO workers try to anticipate avoidable complications, such as malnutrition, falls, or medication misuse because the patient didn't understand his or her dosage. If problems do arise, there are follow-up calls and referrals to coordinate additional services that hospitals rarely have enough staff to perform.

"Sometimes it really does take looking into someone's fridge to see, do they have food when they get home from the hospital?" says Cathie Berger, director of the Atlanta Area Agency on Aging, one of the first seven collaboratives approved.

People don't always understand what their needs are until they get home, says Robert Mapes, manager of community and agency relations at AgeOptions, a collaborative approved to work with six Chicago-area hospitals. "They may find that their bed at home is a lot lower than their hospital bed and it's tougher to get in and out of and they need help."

CMS pays the CBOs directly. Rates vary, but one organization indicated the rate was $200-$300 per discharge, or more depending on the scope of work. CMS officials wouldn't comment, saying it separately negotiates all rates.

Funds bypass hospitals

One of the sore points for hospitals, however, is that they are precluded from receiving any of the $500 million for helping with the discharge planning, since that's within their normal scope of patient work. "These functions are already required by discharge planners; now they just have an additional resource for referral," says Juliana Tiongson, CMS' social science research analyst, who is familiar with the program.

Tiongson says more CBOs have now applied, and she expects to announce more agreements soon. "We've reached a little over 50% capacity for the program, based on the $500 million over five years," she says.

But she doesn't know which programs will pay off in the long run. "It's a little bit early to tell what ultimately is going to work," Tiongson says. The programs are encouraged to join learning collaboratives "to rapidly disseminate what's working in some of the communities."

One particularly ambitious effort is the Merrimack Valley Care Transitions project, which intends to track 8,000-10,000 patients discharged from five suburban Boston and southern New Hampshire hospitals in its first year. Merrimack's executive director, Rosanne DiStefano, says a root cause analysis identified environmental factors-not patient illnesses-as the greatest reason for readmissions. For example, the patients may have literacy or language challenges or be living with a spouse who also has health issues.

"Say they're being discharged to home, but they have a third-floor walkup, and they're in no shape to do that. Or they suffer from cardiovascular problems or COPD, and their apartment has no ventilation. These are problems waiting to happen," DiStefano says.

Readmissions battle gets help from tech

Fri, 01 Jun 2012 04:00:00 GMT

Readmissions battle gets help from tech

by Scott Mace

There are many technologies in the world today that make other industries look good but have yet to really impact healthcare. In the travel and leisure industry, for example, there is a cornucopia of online choice and scheduling to make vacation planning a breeze-a far cry from the days when travel agents made vacation planning tedious at best and woefully misinformed excursions at worst.

Nurses and others involved in the hospital discharge process are still acting as healthcare's travel agents today, toiling to find care for patients being discharged. The process is labor-intensive, taking nurses away from the care they need to provide and instead chaining them to telephones and fax machines as they request patient transfers to this long-term care facility or that nursing home.

Worse, if the facilities the nurses choose turn out to be poor fits for their patients, those choices could be reflected in the hospital's readmission rates. It's a shame to think that after all that non-nursing skilled labor, nurses could be inadvertently contributing to readmissions.

What if, instead, hospitals were able to borrow a best practice from the travel industry? Well, some case management directors say they've found a service provider that does just that. Massachusetts-based Curaspan Health Group provides software-as-a-service that takes care of transmitting patient records and clinical documentation and sending them to the next provider in the chain of care. That eliminates the labor of phone calls and faxes and speeds the process of getting a referral request on its way.

Here's the travel industry tie-in: Because it's an online service, the solution enables providers to search a database of care facilities, and hospitals benefit from reports detailing which facilities were referred to most often, and which ones declined or delayed care and for what reason, such as insurance denials.

The software-as-a-service also enables discharge personnel to communicate with and share documents with transport companies and payers, traditional sources of phone and fax labor. The following are other ways software-as-a-service solutions could curb readmissions:

Identifying the highest readmission rates by postacute care provider, diagnosis, and time of day. That way, hospitals can zero in on the problem providers and particular caregiver issues, and troubleshoot getting the right care to the right patients at the right time to reduce readmissions.
Looking at how postacute providers processed referrals. Did they review them in a timely manner? Did the information provided lead to better matches between hospitals and postacute facilities? That type of evaluation could reduce readmissions.
Time- and date-stamping all online activities by personnel at all facilities, creating an automatically generated audit trail that can improve accountability at facilities, enhance treatment, and reduce readmissions.

Think about how the travel industry exploits the information it now has about travelers to maximize its profits and simultaneously pamper its customers. This is the mind-set that healthcare needs to adopt.

Data-driven technology is the linchpin to making this happen in hospitals. Think of how those in the travel and tourism business have been freed from the drudgery of manual tasks in order to spend more time with their customers. That should be happening across the board in healthcare too. The move to accountable care organizations will pull in the stragglers, but it's clear many providers aren't waiting for accountable care in order to fix their broken and costly processes.

There's also increased federal funding for making programs like this happen. In March 2012, CMS announced a second set of sites for its Community-Based Care Transitions Program. The program provides funding to community-based organizations to test models that improve care transitions for high-risk Medicare patients.

Hospital readmission penalties set to start

Fri, 01 Jun 2012 04:00:00 GMT

Hospital readmission penalties set to start

by Karen Minich-Pourshadi

Although experts disagree on how many readmissions are actually preventable, the Medicare Payment Advisory Commission (MedPAC) reported in a 2007 study that about 40% of rehospitalizations are avoidable and cost the industry billions per year.

The MedPAC data helped drive the Patient Protection and Affordable Care Act's goal of reducing readmissions by tying them to reimbursements. For FY 2013, Medicare payment rates are scheduled to be reduced by a maximum of 1% based on a hospital's ratio of actual to expected readmissions. For FY 2014 the maximum payment reduction is 2%, then the reduction caps at 3% for FY 2015 and beyond. Commercial payers are expected to follow suit and adopt similar payment reductions for providers in the coming years.

When the preventable admissions policy takes effect, CMS will be watching three measures:

1.Acute myocardial infarction

2.Heart failure

3.Pneumonia

Then in 2015, the policy will expand to include chronic obstructive pulmonary disease, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and other vascular areas.

Hospitals and health systems will be required to submit this information to CMS, which will calculate hospital-specific all-payer readmission rates that will be posted publicly on Hospital Compare.

Health Governance Report, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Predictive modeling options to cut preventable admissions

by Karen Minich-Pourshadi

Parkland Health & Hospital System, Dallas: Data algorithm and readmission rates

Mount Sinai Medical Center, New York City: Admissions data and readmission rates

Cincinnati Children's Hospital Medical Center: Proactive care and readmission rates

Adapted from HealthLeaders magazine, April 2012.

10 things we don't know about looming readmission penalties

by Cheryl Clark

3. What is the "index hospitalization"? What is the definition of the index hospitalization that starts the 30-day clock ticking?

7. What is an "applicable hospital"? CMS intends to define this term. For example, might an admission that results in a readmission to a cancer hospital be excluded?

9. What future conditions will be added? Four additional diagnoses account for 11.7% of all preventable readmissions-about 133,000 per year, according to a 2007 MedPAC report. They are:

Chronic obstructive pulmonary disease
Coronary artery bypass grafts
Percutaneous coronary angioplasties
"Other" vascular surgeries

The ACA specifies that these four categories and others the HHS secretary deems appropriate may be added by FY 2015. CMS is expected to signal which ones top its list.

And although CMS has promised to monitor such practices to "minimize any unintended consequences," it has not explained how frequently or with what tools it intends to do so.

Preventing hospital readmissions takes a village

by Cheryl Clark

Funds bypass hospitals

Readmissions battle gets help from tech

by Scott Mace

Identifying the highest readmission rates by postacute care provider, diagnosis, and time of day. That way, hospitals can zero in on the problem providers and particular caregiver issues, and troubleshoot getting the right care to the right patients at the right time to reduce readmissions.
Looking at how postacute providers processed referrals. Did they review them in a timely manner? Did the information provided lead to better matches between hospitals and postacute facilities? That type of evaluation could reduce readmissions.
Time- and date-stamping all online activities by personnel at all facilities, creating an automatically generated audit trail that can improve accountability at facilities, enhance treatment, and reduce readmissions.

Data-driven technology is the linchpin to making this happen in hospitals. Think of how those in the travel and tourism business have been freed

A new look at imaging

Tue, 01 May 2012 04:00:00 GMT

A new look at imaging

by John Commins

Within the next five years, experts believe that patients will have-or will come to expect-near-immediate Internet access to medical imaging as part of their personal medical records.

That push toward more access to imaging has caused some trepidation within healthcare circles as primary care physicians, radiologists, and administrative staff try to determine how it will alter the physician-patient relationship and impact the use of expensive medical imaging.

David S. Mendelson, MD, FACR, chief of clinical informatics at The Mount Sinai Medical Center in New York City, says improving patient access to imaging is something that all physicians-including radiologists-should embrace.

"The intent is to push for more appropriate imaging," says Mendelson. "You need the right information available when you're evaluating a patient. One reason there is inappropriate imaging is lack of access to prior exams," he says.

Mendelson is also the principal investigator for the Radiological Society of North America Image Share network, which offers patients Internet access to their medical imaging through a secure portal. The pilot project has enrolled patients at The Mount Sinai Medical Center, the University of California San Francisco, and the University of Maryland Medical Center in Baltimore. Mayo Clinic in Rochester, MN, and the University of Chicago Medical Center will soon enroll patients.

Image Share all but eliminates the need for patients (or medical professionals) to travel to their physicians' offices to retrieve CDs containing their medical imaging-which is the standard method of delivery at most healthcare facilities right now.

"The patients who have embraced Image Share are very positive about the expediency of using the Internet to replace a whole set of manual processes," Mendelson says.

Nagging doubts

Mendelson says there is growing support for improving patient access to all medical records, including imaging. However, he and other healthcare leaders concede that there are issues remaining to be solved.

A paper about a survey released in December 2011 for the OpenNotes medical record pilot project, initiated by Beth Israel Deaconess Medical Center in Boston, found that patients were overwhelmingly interested in accessing their doctors' notes, but physicians were less receptive.

"First of all, physicians are worried about their patients-that they are not going to understand what they read, or they'll get confused and worry unnecessarily," says Jan Walker, RN, MBA, an instructor in medicine at Harvard Medical School, on staff at Beth Israel Deaconess, and lead author of the paper.

Physicians are also worried about the impact on their time, Walker says. "Physicians are so busy they don't have time for one more thing. The last thing they can imagine is having 100 phone calls from patients asking them to explain something to them," she says.

There are also concerns about utilization. Will giving patients access to their medical records increase their demand for more services, including costly CT scans, MRIs, and other imaging that may not otherwise be warranted?

"That is the question of the hour, and it remains to be seen," Walker says. "Certainly knowledge is power in other arenas, so you could argue it either way. I can't deny the possibility, but I hope the preponderance of evidence will be that people use this information well."

Steven P. Cohen, MD, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, has studied the overuse of medical imaging in spine care, which he says often adds little value while significantly increasing costs. "The use of imaging does not seem to affect decision-making or improve outcomes in the large majority of individuals," Cohen says. "So while I think that patients have a right to know the results of tests done on them, I don't think they should be the ones who decide on whether they are indicated-unless they are paying for them."

Ted Eytan, MD, MS, MPH, a director for the Permanente Federation at Kaiser Permanente, says facilitating patient access to medical imaging will help to educate patients and demystify the technology. "They will start to understand the limits of imaging," Eytan says. "Sometimes these imaging reports come back and do not reduce the uncertainty that the patient has, and the patient thinks, 'Why did I spend two hours in a box if this was not a justifiable expense that didn't change the condition?' "

Cost-shifting will make for more discriminating patients, says Walker. "The incentives are going to be different, so it seems like a well-informed patient could spend money more wisely as patients are spending more out of pocket."

It also makes sense to involve patients in their care so that they can catch potential errors early on, Walker says. "[Patient acccess to imaging] would provide opportunities for patients to say, 'I don't need a test. I already had it, and here are the test results right here.' "

Image maker makeover

Increasing patients' access to medical imaging will also raise the profiles of radiologists-many of whom now have little if any contact with patients. "This will raise awareness of the profession to the general patient community," says Mendelson. "One of the pushes of our professional societies over the last few years is to let the patients know who we are. A lot of patients are not fully aware of who radiologists are or that we are even physicians."

That higher profile will also carry some new responsibilities, Mendelson says, including "making yourself available and spending time that you don't spend today more directly encountering the patients."

Eytan says that increased direct contact with patients will make radiologists better physicians. "Radiology is a service profession. In this new era they may not yet realize how valuable their service will be to the actual patient," he says. "In the past they were serving other doctors, but I think they understand quite well what the future is."

Eytan compares increasing patient access to imaging to that of opening laboratory records to patient review. Similar concerns were raised when lab records were opened, but that access is now standard operating procedure at most healthcare systems and has helped patients appreciate the value of pathology and other laboratory services.

"I would tell radiologists that this is going to help the people you serve understand just how much you contribute to their care," Eytan says. "And the second thing is if you never do it, you'll never know how much better your care can be because you'll keep talking in this arcane language, things will keep falling through the cracks, and you won't learn how to be a better radiologist."

Confusing data

Mendelson is not overly concerned that patient access will prompt radiologists to alter the imaging case notes they provide for EMRs.

"We believe patients are entitled to see their reports, but it will be a balancing act," he says, adding that in the long run, the process will improve communication and efficiency.

"As more patients leverage seeing their results, will there be a feedback loop? Where will radiologists get more demand on their time to deal with patients? Will they find ways to rephrase things to generate fewer questions? That may well happen. But I wouldn't call it 'dumb down' as much as finding the appropriate phrasing."

As an additional safeguard-at least initially-the Image Share network has a 72-hour delay on releasing new medical images to the patient until the results and images can be communicated to the referring physicians. The delay was designed, in part, to protect patients from potentially devastating or confusing news without a ready interpretation of the data.

Mendelson notes that the program designers knew such a delay would be controversial. "When we set this up initially we knew that we couldn't do everything in one fell swoop perfectly. We had to set priorities," he says. "The 72 hours was something that we recognized would require further refinement. We wanted to get the programming right for moving images around first. Now we can come back and revisit things that need to be a little more granular."

For Eytan, patient access to medical imaging is inevitable and part of the greater move toward access and transparency in healthcare delivery. Rather than debating the pros and cons of patient access, Eytan says physicians should spend their time trying to make it work.

"It's not the if, it's the how," he says. "This should be done, and the how, I have learned, is everyone needs to be involved. The subspecialty of radiology is very important, so this should not be done without their involvement. If we allow them to be involved, they will do a great job with primary care doctors to make this happen."

Well-meaning health IT efforts

Tue, 01 May 2012 04:00:00 GMT

Well-meaning health IT efforts

by John Commins

In HealthLeaders Media's January 2011 Intelligence Report, E-Health Systems: Opportunities and Obstacles, most healthcare leaders (51%) said a realistic time frame to see industrywide quality of care improve as a result of meaningful use regulations was two to five years away, but a significant number (44%) said six years or more is more realistic. We asked our survey respondents, "What do you see as the major obstacles to a robust electronic health record (EHR), and what can industry leaders do to achieve meaningful use sooner rather than later?"

Virgil Bourne, administratorThe Family Physicians, Iola, KS

We have been documenting care in certain slots in the medical record, but we found that when we ran reports, that was not where the meaningful use software pulled the results. We had to adjust where we were documenting. It requires some additional time in doing the documentation. Productivity is reduced because providers are responsible for entering documentation, which requires them to enter various fields in the EMR to input data.

But overall, EHR is going about as fast as it can. It is a very expensive proposition. There is money set aside to help with startups. We did it without that initiative because we felt it was the best thing to do with multiple locations. It allowed us to have immediate access from any location regardless of where the patient was being seen, even the emergency room.

It is something that is the right thing to do. The financial incentives are great, but they aren't going to cover the costs. If somebody goes into it thinking it is going to cover all the costs, they are shortsighted. It is expensive with all the computers and file servers and cabling and software packaging and continual software updates and other modules like patient portals and e-prescribing and other additional expenses.

Kim Sharkey, chief nursing officerSaint Joseph's Hospital of Atlanta

We have been spending the past two years on some issues with financial decline due to changing patient patterns of admissions and referrals. We had been focusing our attention on forming a strategic alliance with another healthcare system in Atlanta. We had several hospitals and health systems we were looking at.

During that time, we did not have the financial reserves to invest in our technology infrastructure. I would imagine that this is not unique to anyone. Now we are finding, as we have to meet the deadlines for ICD-10 compliance and meaningful use, at least at stage 1, we are having to very frantically with our new partner come up with the money and the resources to completely overhaul our clinical IT structure by this fall, with everything done by 2015.

The biggest challenge is, where are you going to find the financial resources? Then, once you get that, where do you get the human resources to integrate something as quickly as we are having to with the deadlines coming up?

James L. Holly, MD, CEO

Southeast Texas Medical Associates, Beaumont, TX

The intimidating ramp-up: There is a potential hazard for discouraging people because they have not started [adopting meaningful use criteria]. It could have been much easier. The first two years could have been a lower threshold with a rapid ramp-up in the third, fourth, and fifth years-as opposed to what it presently is: a fairly significant first-year ramp-up.

Building patient engagement: Those who want to turn meaningful use into a marketable product are going to have to deal with some of the more complex issues-such as plans of care and transitions of care-that require documents to be delivered to the patient that are patient-centric and specific to the individual patient. We have to have a means for transferring responsibility of care to the patient. When you establish a continuum of care, that is when meaningful use becomes meaningful to the patient.

Incremental steps to improvement: Our goal is to be better next year than this year. Meaningful use creates somewhat of a competition, but it should not deter people from getting started. If they can't meet meaningful use to gain the financial benefit, they should start nonetheless because ultimately it is the future and they are going to have to do it. The only option is to stop practicing medicine, which for most of us is part of our DNA. Get started. That is the first thing. I've started lots of things that I've never finished, but I never finished anything I didn't start.

Jeetu Nanda, MD, Medical Director-Informatics

SSM Health Care, St. Louis

Have we met the meaningful use criteria? Yes. But we have met meaningful use criteria by the letter of the word, not in its essence. The idea behind meaningful use is that patient care and safety will be better and we-all healthcare providers-would be on the same page.

But there is a lot of pushback because when EHRs were developed from the ground up, they probably did not involve end users as much as they should have. They don't follow the work flow that people were used to in the paper world. Now we are trying to tweak them by going around certain things, and that makes them cumbersome. That is the stumbling block-going back and trying to fix something that wasn't built the way it should have been-and that is making it more cumbersome on the front end for providers to use.

One of the pushbacks I'm hearing is that Yahoo! or Google refresh when we write an e-mail, but you can't do that with EHR. Physicians are not willing to keep refreshing and doing those little things because those are additional clicks. We healthcare providers are more interested in caring for the patient. This is deemed administrative work, which was done before by nonmedical people. Now we have to do it as physicians.

Impact of postponing the ICD-10 deadline

Tue, 01 May 2012 04:00:00 GMT

Impact of postponing the ICD-10 deadline

by John Commins

HHS Secretary Kathleen Sebelius announced in February that the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system.

In a media release, Sebelius said federal officials were acting on providers' concerns "about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system."

ICD-10, which has been widely used in many other countries for years, was scheduled to replace ICD-9 in October 2011. During the 2008 public comment period, providers asked for, and got, a delay in ICD-10 implementation until October 1, 2013.

For the past several months, the AMA and other provider groups have pressed the Obama administration and Congress for another delay.

But Sue Bowman, director of coding policy and compliance at the American Health Information Management Association, says that postponing the ICD-10 implementation raises concerns.

"The need to replace ICD-9 and go to a better coding system is still out there and hasn't gone away," she says. "The need for high-quality healthcare data has gotten bigger now with meaningful use and payment reform and value-based purchasing and [accountable care organizations (ACO)] and all the other initiatives."

Delaying implementation of ICD-10 will delay all of the other benefits of better healthcare data, Bowman says. "Until we have a better coding system, we can't really have a better healthcare system and achieve the goals of all of these other initiatives."

Implementing ICD-10 alongside other looming initiatives such as bundled payments, EMRs, and ACOs makes sense because the initiatives are all related to one another, explains Bowman.

"The [initiatives] all link together and are interrelated in a way to promote value for healthcare, both to improve the quality and costs," she says. "I don't think we are going to see the anticipated benefits of all of the other initiatives unless we move to a better coding system."

Tim Stettheimer, a Birmingham, AL-based regional CIO for Ascension Health, says that HHS' earlier decision to delay the implementation of the 5010 HIPAA transaction standards by 90 days signaled that federal officials understand the burdens hospitals face.

Many of CMS' fiscal intermediaries are not ready for 5010, Stettheimer notes. "We have seen the impact on hospital cash because of delays and payers being unable to accept those federally mandated transaction standards. If we would have kept that ICD-10 implementation date in October, it would have been considerably worse."

Stettheimer says payers also are having problems with the ICD-10 deadline. "If you change the codes, you impact the whole reimbursement cycle within healthcare. It's not that the healthcare providers are standing alone and not being ready. It is the payers, all the insurance companies, the fiscal intermediaries that handle the transactions for CMS, all of these organizations-most of them aren't ready."

ICD-10 implementation is further complicated, he says, because there is no way to ease into the new system. "It is a little bit like a light switch. You go from ICD-9 to ICD-10 in a day," he says. "We can't put just one hospital or unit up on ICD-10 and see how it goes."

Bowman says the "too much on our plate" excuse has been used before by providers to justify delays. "There is never going to be a year when we don't have a lot on our plates," she says. "It is unfortunate that ICD-10 didn't get initiated several years ago ahead of these other things to set the foundation and the groundwork for these other initiatives."

Bowman says providers should use their extended deadline to continue preparations for ICD-10. "This is a delay. It is not a stoppage of ICD-10," she says. "Our message is, 'Don't stop the work you are doing.' "

Four social media strategies to build patient loyalty

Tue, 01 May 2012 04:00:00 GMT

Four social media strategies to build patient loyalty

by Carrie Vaughan

In order to build relationships and truly connect with members of your community through social media sites, such as Facebook®, Twitter™, and YouTube, hospitals are learning that it takes more than simply pushing out a weekly bit of health advice.

Social media can be a great tool for patient education and brand messaging. But to really build loyalty-and possibly even grow market share-hospitals need to engage consumers in two-way conversations. Photographs, contests, and links to interesting stories can be a great way to get those conversations started.

St. Peter's Hospital in Helena, MT, is a relative newcomer to social media, having just launched its Facebook page in April 2011. "At first, we were using the page mainly to promote community events. We added monthly health tips and usual hospital news, but struggled to obtain friends," says Peggy Stebbins, director of PR and marketing. After roughly nine months, the 123-bed hospital had only about 80 friends-many of whom were employees.

"The only increase in activity we saw was when we posted photos of a special women's event we held featuring Patty Duke," says Stebbins. So St. Peter's decided to join the growing number of hospitals conducting cute baby contests online.

The nonprofit hospital launched its own contest with media coverage of the first baby of the new year. And just like that, St. Peter's number of Facebook friends increased to 1,153-it gained more than 1,000 friends from the contest.

"Because of the success of the baby contest, we decided to continue with contests to increase activity," says Stebbins. "Our hospital holds numerous successful community events, and Go Red for Women was the next event scheduled. With our sponsorship partner, we devised the best red outfit photo contest."

St. Peter's wanted to attract more friends and also give more women a reason to attend the event, says Stebbins. While "Go Red for Women" only generated about 10 new friends, St. Peter's did receive 18 photo submissions, and 96 people voted for their favorite red outfit.

Michelle Kustra, marketing coordinator at Sherman Health, a 255-bed hospital in Elgin, IL, admits that, like St. Peter's, her organization started out simply posting information on social media sites as well. However, for the past few years, Sherman Health's social media goal has been to start discussions with the community.

Kustra says that the Illinois hospital uses all the tools at its disposal-including Facebook, Twitter, blogs, YouTube, and e-blasts. "We are no longer talking to the community, but talking with them and connecting to them and helping [the community] to connect with us on a personal level," Kustra says.

Healthcare organizations whose strategy is to simply post healthcare information are missing out on the true essence of what social media is all about-having "two-way communication and getting people to connect with you interactively," says Kustra.

The following are four strategies to keep in mind when trying to improve consumer engagement and patient loyalty:

1. Incorporate humor. Many healthcare issues are life-or-death topics that have a very serious tone or message. When it comes to social media, however, organizations should splice in some health-related topics that focus on the lighter side of healthcare. Otherwise, people may stop reading your posts.

When Sherman Health started using humor, its numbers began to climb, says Kustra. "We are up to 5,000 Twitter followers and a couple of thousand Facebook fans."

It's important to have your social media presence mimic the ups and downs of your patients' lives-meaning you should cover both serious and fun events, says Charles Falls, president and owner of DC Interactive Group, the agency Sherman Health has partnered with for social media. "We don't want to cross lines, so we try to keep fun events that everyone would find fun and interesting. We are not looking for controversy," Falls says.

One of Sherman Health's successful forays in using humor to disseminate health information was its Movember mustache contest that took place in November 2011. "It was men's health month, so we were trying to think of creative ways to engage the community and remind them that there are a lot of men's health issues out there, and the big one is prostate cancer," says Kustra.

Sherman Health's marketing team meets with DC Interactive Group on a monthly basis to develop a social media plan for the next one to two months. During its brainstorming session, the idea of tying a men's health campaign to Movember, a global initiative to raise awareness and funds for men's health issues, was formed.

In addition to asking people to send in mustache photos, the hospital had blog posts on famous mustaches over the years, ranging from real-life celebrities all the way to Ned Flanders from the television series The Simpsons. "We had to talk about what we were doing, but also had to talk about the things that were interesting to people to draw them in and connect them back to the contest," explains Falls. The blog posts also included information on the importance of having prostate screenings and eating healthy.

The mustache contest far exceeded Sherman Health's goals of 15 photo submissions and 1,500 unique page views. The hospital received more than 40 submissions and had more than 2,500 unique views for its Movember-related posts. In addition, the mustache contest also engaged employees at Sherman Health, many of whom were telling their family and friends about it, says Kustra. "It was a really fun experience all around."

2. Integrate your social media channels. For any contest or marketing campaign using social media, organizations should include as many channels as possible, says Falls. For Movember, Sherman Health used Facebook applications to run the contest, but its blog helped connect all of the social media channels. For example, its Twitter posts would drive people back to the blog where they could connect to Facebook and look at photos, he explains. The blog allowed people to read about the contest without having to get onto Facebook and like the page. "While we like having 'likes,' we are trying to build up our e-lists by having people sign up for e-mail communication so we can directly communicate with people," Falls says.

3. Keep the budget low. Sherman Health had a $500 budget for its Movember contest, and it plans to stick to that same budget for future contests, says Kustra. "Since we already have a lot of [blog] pages built and e-blasts in place, we spent that money mostly on prizes." For Movember, the grand prize was Blackhawks hockey tickets that were donated, the second-place prize was a Kindle Fire, and the third-place prize was a Norelco™ razor system.

Based on her experience with the baby photo contest, Stebbins cautions hospitals about offering too big a prize. The prize for St. Peter's contest was an overnight hotel stay, lunch, and dinner, a total value of about $200. "People were amazingly competitive," she says. "One of the mothers had a relative who specialized in social media and sent the contest to one million friends. Obviously, this baby won with over 3,000 votes, the next nearest being about 200 votes."

Unfortunately, this activity resulted in people writing negative comments accusing the contest of being rigged-and some people wrote mean comments about the other babies, Stebbins notes. "We never anticipated this activity, and our webmaster spent nearly two days monitoring and deleting the nasty comments. We met our goal of increasing friends, but I'm not sure we'll keep them."

Still, Stebbins says she would do another baby photo contest, but with a more modest prize. She adds that she would probably use third-party software to administer the contest and offer a prize tailored to a more mature audience, such as a dinner with wine (which would require entrants to be at least 21 years old).

4. Tie social media to service lines. Ideally you want to connect social media campaigns to something that you are trying to promote, says Falls. "That ties [the campaign] into the business purpose for doing it and makes it easier for the C-suite to understand that there is a goal here, that you can identify it and see if you are meeting it."

Kustra says that based on the success of Movember, Sherman Health is trying to come up with an event each month that relates to a healthcare topic. For example, for February, it linked its cardiovascular services with a "What Do You Heart?" contest in which people submitted a photo of what they loved.

Stebbins says the "Go Red for Women" event and Facebook contest were part of St. Peter's overall strategy to promote its cardiologists, cardiology clinic, and services. St. Peter's will probably do about six contests during the year, all of which will align with its community events, she says.

Falls advises healthcare organizations that are new to social media or looking to improve their consumer engagement to pay attention to what other people are doing. "Don't be afraid of putting together a contest and not having it be all you'd hope it would be," he says. "The important thing is to be out there."

Meaningful use Stage 2 proposed rules released

Tue, 01 May 2012 04:00:00 GMT

Meaningful use Stage 2 proposed rules released

by Margaret Dick Tocknell, with additional reporting by Cheryl Clark

The long-anticipated proposed rules for Stage 2 meaningful use were released in February by HHS.

In a press conference at the annual meeting for the Healthcare Information and Management Systems Society (HIMSS), Farzad Mostashari, head of the Office of the National Coordinator for Health IT, characterized the proposed rules as "reducing the regulatory burden" for providers. He noted that the proposed rules are consistent with recommendations by the Health IT Policy and Health IT Standards committees. Mostashari highlighted the following aspects of the proposed rule:

It continues the core and menu objectives of Stage 1.
Regardless of when they start, everyone would have two years in Stage 1, two years in Stage 2, and two years in Stage 3.
A 90-day reporting period would be retained for the first year.
The rule allows medical groups to report quality measures as a group instead of on an individual basis. In a practice with 20 doctors, for example, there would be no need to individually specify which provider had which quality measure.
HHS is seeking comments on whether group reporting should be extended to functional measures such as prescribing measures.
By default, vendors would enable encryption on end- user devices.

When asked to put meaningful use in perspective with regard to healthcare reform efforts, Mostashari noted that providers now care about how they do on quality and patient satisfaction measures, and how well they coordinate care. "There are such a number of payment changes happening. It's almost as if Medicare unplugged a dam and there's just an explosion of new initiatives. It's really, really good because it provides, finally, a business case for the coordination of care that we need and, frankly, which health IT enables."

The 455-page document released by HHS also includes these points:

Stage 1 of meaningful use would be extended to fiscal year 2014, and eligible providers would have two full years to participate in Stage 2
There would be two new menu objectives: electronic reporting to registries and viewing images through electronic health records (EHR)
Eligible providers must meet 17 core objectives and three of five menu objectives
Hospitals must meet 16 core objectives and two of four menu objectives
Hospitals and physicians would have to use computerized physician order entry for more than 60% of medication, laboratory, and radiology orders
Providers would be required to enable patients to view, download, and transmit their medical records online
Specialists could qualify for meaningful use by using EHRs that are certified to meet the needs of their specialties
Stage 2 regulations would require the alignment of clinical quality measures and reporting across accountable care organizations and patient-centered medical homes

Comments will be accepted for 60 days after the proposed rules are published in the Federal Register.

Health Governance Report, May 2012

Tue, 01 May 2012 04:00:00 GMT

A new look at imaging

by John Commins

Within the next five years, experts believe that patients will have-or will come to expect-near-immediate Internet access to medical imaging as part of their personal medical records.

"The patients who have embraced Image Share are very positive about the expediency of using the Internet to replace a whole set of manual processes," Mendelson says.

Nagging doubts

Image maker makeover

Confusing data

Mendelson is not overly concerned that patient access will prompt radiologists to alter the imaging case notes they provide for EMRs.

"We believe patients are entitled to see their reports, but it will be a balancing act," he says, adding that in the long run, the process will improve communication and efficiency.

Well-meaning health IT efforts

by John Commins

Virgil Bourne, administratorThe Family Physicians, Iola, KS

Kim Sharkey, chief nursing officerSaint Joseph's Hospital of Atlanta

James L. Holly, MD, CEO

Southeast Texas Medical Associates, Beaumont, TX

Jeetu Nanda, MD, Medical Director-Informatics

SSM Health Care, St. Louis

Impact of postponing the ICD-10 deadline

by John Commins

HHS Secretary Kathleen Sebelius announced in February that the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system.

For the past several months, the AMA and other provider groups have pressed the Obama administration and Congress for another delay.

But Sue Bowman, director of coding policy and compliance at the American Health Information Management Association, says that postponing the ICD-10 implementation raises concerns.

Implementing ICD-10 alongside other looming initiatives such as bundled payments, EMRs, and ACOs makes sense because the initiatives are all related to one another, explains Bowman.

Four social media strategies to build patient loyalty

by Carrie Vaughan

The following are four strategies to keep in mind when trying to improve consumer engagement and patient loyalty:

When Sherman Health started using humor, its numbers began to climb, says Kustra. "We are up to 5,000 Twitter followers and a couple of thousand Facebook fans."

Meaningful use Stage 2 proposed rules released

by Margaret Dick Tocknell, with additional reporting by Cheryl Clark

The long-anticipated proposed rules for Stage 2 meaningful use were released in February by HHS.

In a press conference at the annual meeting for the Healthcare Information and Management Systems Society (HIMSS), Farzad Mostashari, head of the Office of the National Coordinator f

Putting data in nurses' hands

Sun, 01 Apr 2012 04:00:00 GMT

Putting data in nurses' hands

by Gienna Shaw

Although the title of chief nursing informatics officer (CNIO) or nurse informaticist isn't exactly commonplace, data is increasingly becoming a part of nurses' day-to-day working lives. Typically the largest employee population, nurses also have the most frequent direct contact with patients, so getting data into their hands can have a big impact on patient care.

"We have always collected data and information. So we need to understand the data that's at our fingertips. It's something that every staff nurse should be able to do," says Toni Hebda, PhD, RN, BSN, MNEd, MSIS, a professor in the master of science nursing degree program at Chamberlain College of Nursing, which has campuses in seven states and is headquartered in Downers Grove, IL.

Still, some say adding a CNIO to the executive team is another example of C-suite bloat. While Hebda agrees that not every department needs a chief informatics officer, she says it's a mistake to think that informatics should be solely the domain of doctors.

That attitude isn't an issue at the 330-licensed-bed Catholic Medical Center (CMC) in Manchester, NH, says Mercedes Fleming, the organization's manager of nursing systems and support.

"My experience is that at community hospitals the nurse has tremendous autonomy," she says. "The doctors here are actually accustomed to nursing taking a leadership role in caring for the patient. I'm not saying we operate outside our scope of practice, but we do keep a pretty close watch over what is going on with our patients."

Resources and responsibilities

CMC started its nursing informatics work in 2007 with a clinical documentation system-a knowledge-based charting program that merges evidence-based practice and clinical practice guidelines. "It dramatically improved the quality of the documentation and put all nurses on the same page in terms of caring for the patients," Fleming says.

The program, a product by Grand Rapids, MI-based software firm Elsevier CPM, measures patient outcomes by asking nurses to determine the patient's condition-whether it is improving, declining, or stable.

After adopting the documentation program, the hospital decided to make its nurses experts in a number of different systems, starting with computerized physician order entry (CPOE). "We don't own most of our medical staff. And being community-based, we had to come up with a different strategy [for CPOE]. We thought that if all of our nurses became experts in the system first, then they would support the medical staff," Fleming says.

Jennifer Torosian, RN, MSN, NE-BC, administrative director of nursing services at CMC, agrees that there's a huge benefit to giving nurses this kind of responsibility. At CMC, when nurses have a concern, they don't hesitate to take it to the administration, in part because "they really believe we're going to do something about it," she says.

In some cases, the hospital was doing the right thing, such as removing catheters on time, but just wasn't proving it. Now the organization can run a report to calculate catheter days with an insertion date and a removal date. "I can go on at any time and print out and see how many patients in-house have catheters, the date they were inserted, and the date they were removed. And I can also see if one of the nurses hasn't documented an insertion date," Torosian says.

Having the ability to deliver close to real-time feedback is a good starting point, but determining who will monitor and run those reports is essential, says Torosian. "We've done a great job in empowering the department coordinators to do that," she says. As a result, CMC has seen a significant decrease in the number of missing insertion dates. "Previously, on any given day we would have on average six patients on the report with no insertion date; we are down to an average of two," Torosian says.

Order reconciliation is another area where informatics has made dramatic improvements, says Fleming. "Medication reconciliation has always been a challenge, but now the nurses are entering historical medications with the expectations that they are accurate, allowing the attending provider to convert it to an inpatient order."

On paper, the nurse or provider could leave key prescribing information blank on the home medications list, but with electronic medication entry, the nurse is guided to complete all elements of a historical medication order, she explains. "The nurses are now routinely following up with PCP offices and home pharmacies to determine the correct and complete home medication information."

CMC reports that the improvements are leading to better quality. For example, CMC's key performance indicator (KPI) scores have exceeded expectations, with 44 excellent and 28 notable scores. CMC also achieved best practice thresholds in 72 KPI categories. What's more, improving clinical documentation has had a positive financial impact. By decreasing lost billable charges, the organization's ED increased revenue by 48% in the first six months, and it continues to see appreciable monthly increases in expected revenue capture. The total overall charge capture for fiscal year 2011 showed an average monthly increase of 33%.

Unlocking the data

Oklahoma Heart Hospital bills itself as one of the nation's first all-digital hospitals. But like many organizations that are early adopters of EMRs, the organization's leaders were struggling to figure out how to make better use of the technology.

"We had this great EMR that had all this data that we couldn't get out very easily," says CIO Steve Miller. So the 145-staffed-bed Oklahoma City organization, which encompasses two campuses and 60 affiliated clinics, started investigating how to use technology to unlock that data, make it actionable, and get it into nurses' and physicians' hands.

"Most hospitals have a centralized monitoring room where you'll have dozens and dozens and dozens of monitors and a 24/7 staff who are just sitting there staring at the monitors waiting for critical alerts," Miller says.

Instead, Oklahoma Heart Hospital sends near-real-time critical alerts from hardwired heart and vital sign monitors directly to nurses' smartphones using an integration engine from Boulder, CO-based Connexall USA.

The mobile alerts include an image of the patient's heart rhythm so the nurse can evaluate the severity of the alert. Of course, monitors still give alerts in patients' rooms and at nursing stations. "But in our facility, nurses could be in another room taking care of patients. So the idea was to give them the best possible way to know as quickly as possible that there's an alert," Miller says.

The system allows nurses to not only spend more time at the bedside, but also respond to patients more quickly, says Janet Fundaro, APRN-CNP, Oklahoma Heart Hospital's CNO. And integration with the organization's EMR is another important piece of the alerting system.

"Inside our EMR, we have multiple alerts that are designed to really help stay ahead of all the factors that may contribute to the overall care of that patient," Miller says. Alerts automatically generated from EMR data include risk for infections, falls, and out-of-range lab values.

Assessing acuity

At the 624-staffed-bed Mission Hospital in Asheville, NC, nurses use informatics to classify the acuity of every patient on every unit every day. That data tells them how many hours of care each patient will need so that they can deploy staff accordingly.

"The nurse on the unit providing the care to the patient that day goes in and does what we call a classification of her patients," explains Brenda Shuford, RN, Mission Hospital's management systems coordinator. The assessment takes about 20 seconds per patient when conducted by a nurse who is familiar with the system and its indicators. "Once they get all the patients on that unit classified, they're able to run a report and see what kind of staffing recommendations they're going to need for the next shift," she says.

When Shuford was a nurse manager in the pediatric ICU, she instinctively knew that although the number of patients in any given unit didn't change dramatically over time, the severity of illness did. "And the staffing-hiring and change of mix-had not kept current to the patient changes," she adds.

But when Shuford asked for more RNs and a change in skill mix on the units, the answer was no. Budgets were created based on patient days, and because the historic data on patient days hadn't changed, neither would the nursing staff configuration or budget.

Using an acuity system developed by Reston, VA-based QuadraMed, Shuford and her team tracked patient data for two years and ultimately convinced finance leaders to create parallel budgets-one based on acuity system data and one based on historical data. It turned out the two budgets weren't so different; the former would save the organization just one half of a full-time equivalent position. But although staff levels stayed more or less the same under the acuity-based budget, nurses are now deployed where they are most needed each day.

Acuity data has led to significant staffing changes in several Mission Hospital departments. The surgical unit, for example, used work flow data to make the case for a dedicated discharge nurse who would work peak discharge hours: Monday through Friday from 8 a.m. to 4 p.m. That position allows other nurses to focus on caring for new admissions, Shuford says, and "reduces the chance of error from interruptions."

In the ED, acuity data was used to make the case for staggered shifts with overlap at peaks in volume. Prior to using the acuity data, the ED provided staffing within the target range for only 12.5% of the hours of the day. Since implementation of staggered staffing based on acuity data by hour of day and day of week, it is now providing staffing within the target range for 54% of the hours of the day, Shuford says.

Putting data in plain view

The ability to view alerts and other clinical data in dashboard format also makes it easier for nurses to respond quickly "in a way that we were never able to do in the past," says Miller. The MPages Web-based platform from Kansas City, MO-based Cerner helps keep track of data such as vaccines, stroke indicators, aspirin on arrival, rehabilitation references, venous thromboembolism, and dietary needs, arranging the information for nurses in an easy-to-read format.

"Most of the data is near real-time in that it is information about patients who are currently in the hospital. It's information about actions that we either have performed or need to perform on those patients," Miller says.

The organization also uses its EMR reports and dashboards to track progress toward goals such as meaningful use readiness.

"We really needed a way to track our percentages and look at that information in much greater detail to ensure we were really meeting the meaningful use standards," Miller says. "That's why we started this process, but it really led us to this whole better way to consume information that is, we think, really going to revolutionize our area."

Having the ability to build dashboards and present data in more than just a list format, such as dials and other graphics, and being able to put that data on a traditional interface as well as on an iPhone® or iPad® device is changing the business of healthcare, he says. "We're really focused on making information more useable."

And that applies to both clinical and business information. "Being able to use that [information] more effectively to run our business is going to be very core to the future," Miller says. "The challenges of healthcare are so large ... the ability to use data and information to help us chart the way and become more efficient, to find out ways to improve the cost or the value that we're delivering to that patient, is absolutely paramount."

Nurses key to care coordination

Sun, 01 Apr 2012 04:00:00 GMT

Nurses key to care coordination

by John Commins

The role of nurse advocate and care coordinator will only grow in coming years as the practice of medicine gets more complex and the medical care team approach becomes more entrenched. One could argue that experienced and well-trained nurses at the bedside are as big a factor in determining healthy patient outcomes as any other component in healthcare delivery. Someone will have to lead the care team, and nurses are the obvious choice.

These commonsense findings in a January study by the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative (INQRI) underscore the importance of nurses' critical thinking skills as the key component in reducing errors and improving outcomes.

The study appeared in the January issue of Qualitative Health Research, and it details the following clinical reasoning practices and processes that 50 nurses at 10 hospitals have identified to prevent medication errors:

Educating patients about their medication
Considering all factors related to the patient
Advocating for patients with the pharmacy department
Coordinating care with physicians
Independently reconciling medications with patients' records
Verifying medications and doses with colleagues
Coping with interruptions and distractions
Interpreting physicians' orders
Documenting near misses
Communicating openly with physicians, pharmacists, and other team members

These findings are not breaking news. Everything on that list would prompt a knowing nod from nurses. However, the findings also give those who aren't nurses a better idea of the challenges that nurses face every day and the skills they need to do their jobs effectively. Imagine the sum total of these 10 focus points for each patient, multiply it by the number of patients under a nurse's care at just about any time and on any given floor, and you might have a better idea of the time pressures that are placed on nurses during an 8- or 12-hour shift.

Among the most serious problems nurses continually face are missing medications and the timeliness of medication delivery, the study found. Administering medication might seem simple enough-until the pressures and distractions that nurses routinely face are factored in.

For example, medication delivery schedules at hospital pharmacies may not fit with nurses' work schedules. Or a patient may be scheduled for tests that coincide or interfere with medication times. The INQRI study found that effective strategies to ensure medication compliance included nurses making repeated calls to the pharmacy to check on the status of medications, marking drugs that are to be given immediately, and often picking up the medications themselves.

Coauthor Linda Flynn, RN, professor and associate dean for graduate nursing education at Rutgers University in New Jersey, says the study "identified communication with doctors, pharmacists, and other nurses as an indispensable part of preventing medication errors and ensuring patient safety.

"That means that nurses also [should] take responsibility for developing good relationships with all members of the healthcare team so that when they have to locate missing medication, double-check doses, or ask questions about new medications, they get the answers they need when they need them," Flynn says.

The study recommends tapping into nurses' clinical reasoning as a foundation for reducing medication errors in the care team environment. Such a program would push nurses to move beyond the "five rights" of medication administration (right patient, right route, right dose, right time, right medication) and to use clinical reasoning to protect their patients from harm.

The study also calls for retooling provider education to promote the team care approach. Elements of that education should include basic errors theory and team-centered clinical problem-solving exercises.

The study makes it clear that nurses will face a variety of new challenges in the coming years as they are asked to play a greater role in patient care coordination. Everyone else in the healthcare delivery system must understand that role and must be willing to provide nurses with the support and resources they need to do their many jobs.

Designing a hospital? Ask nurses first

Sun, 01 Apr 2012 04:00:00 GMT

Designing a hospital? Ask nurses first

by Alexandra Wilson Pecci

When the nurses at Cass Regional Medical Center in Harrisonville, MO, were asked to pitch in their ideas on the design of their new hospital, they weren't just concerned with the color of the walls.

"They got very excited. They really wanted to look it from a perspective of, ‘How is it going to help the patients and families?' " explains Twila Buckner, BSN, MBA, NE-BC, Cass Regional's CNO. The nurses wanted to know, "What [was] going to help them do their jobs easier and faster and better?"

A growing number of hospitals are involving nurses in the design of their facilities, consulting with them about everything from the size of patient rooms to the art that hangs on the walls. Doing so not only helps improve patient care, it can also improve morale and employee satisfaction.

That was the case at Cass Regional, which opened a new facility in September 2009. According to Buckner, the staff worked with the architects in designing the new building and had a say in everything-from what patient and treatment rooms would look like, to the functionality of the showers, to how the patients would flow through the hospital.

"The CEO took a really big approach and decided to really involve nursing and those at the bedside in the design because he really felt like the employees were closer to the patients and would better know how to design the hospital," Buckner says.

Involving the bedside staff in the design of a facility is a smart move. According to a research brief from the Robert Wood Johnson Foundation, "nurses at all levels and in every setting have a critical role to play on multidisciplinary teams charged with assessing, planning, and designing new and replacement facilities."

The paper discusses the importance of nurse involvement in hospital design using case studies from U.S. hospitals. For example, nurses at St. Mary's Medical Center North in Powell, TN, "advocated for wider doorways to facilitate patient handling, nonslip floors to prevent falls, and supply servers with pass-through doors," the research brief stated.

Similarly, rooms at Cass Regional are large and provide ample room for equipment and transporting patients, as well as allowing the nurses to move around easily. Showers compliant with the Americans with Disabilities Act allow nurses to simply wheel patients directly into the shower if needed, Buckner says.

In addition to contributing to a work environment that's more conducive to healing and patient care, Buckner says the nurses at Cass Regional are happier in their jobs. She adds that giving the nurses a say in the design has "absolutely" helped boost morale. "People are happier coming to work because of the ownership piece. Our employee engagement scores really show that the staff are more engaged in the facility, and I think a lot of that comes from them being allowed to have quite a bit of input into the design."

Real value of seeking credentialing lies in the journey

Sun, 01 Apr 2012 04:00:00 GMT

Real value of seeking credentialing lies in the journey

by Alexandra Wilson Pecci

How much does designation as an American Nurses Credentialing Center (ANCC) Magnet Recognition Program® (MRP) hospital matter? The results of a recent study call into question the value of attaining credentials from the ANCC, a division of the American Nurses Association.

A study published in December 2011 in the Journal of Nursing Administration has found worse patient outcomes at hospitals with MRP accreditation than at non-MRP facilities. According to the study, "Non-[MRP] hospitals had better patient outcomes than [MRP] hospitals. [MRP] hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in [MRP] hospitals."

So is the designation worth the time, effort, and money it takes to reach? After all, it can take years and tens of thousands of dollars, if not more, to achieve the coveted designation. For two nurse leaders at Catholic Medical Center (CMC) in Manchester, NH, the answer is still a resounding "yes"-and they haven't even achieved their goal yet.

"The biggest thing we've learned on our [MRP] journey is that it's about the journey itself," says Emily Sheff, MS, RN, CMSRN, FNP-BC, CMC's nursing practice and standards coordinator. "We've learned and restructured and grown so much just from the parts we've been able to look at thus far."

CMC is about a year and a half into the MRP process, and it has already established shared decision-making and developed a professional practice model. It's also in the process of promoting leadership, certification, and professional development among its nurses, says Jennifer Torosian, RN, MSN, NE-BC, administrative director of nursing services.

"Whether we achieve the [MRP] certification or not, the components of [MRP] set a really good foundation for the profession of nursing," Torosian says.

For example, because MRP emphasizes professional certifications, the hospital started reimbursing nurses for obtaining certification, which the hospital thought would remove "98% of the barriers," Sheff says.

But when reimbursement alone didn't boost certifications the way nurse leaders expected, more subtle barriers came to light. The hospital found that nurses were afraid they wouldn't have enough time to study; that they were unsure about what they wanted to become certified in; and that some didn't know how to become certified in the first place.

"We're now looking at the potential of offering on-site courses," Sheff says.

When considering the MRP journey, it's important to realize that if a hospital invests in its nurses, they will likely experience increased job satisfaction. "There's evidence out there that if your staff is happy, your patients are going to be happier and your care is going to be better," Torosian says.

For example, a separate study in the Journal of Nursing Administration found that "[MRP] hospital nurses were 18% less likely to be dissatisfied with their job and 13% less likely to report high burnout." Of course, simply pointing to happier nurses doesn't really answer the questions raised in the patient outcomes study. But Sheff counters that the outcomes measured in the study don't just depend on nursing.

"Those are outcomes in terms of things that nursing itself doesn't have total control over," she says. For example, there are a lot of factors that go into whether a patient develops postoperative sepsis, such as race, age, hospital size and location, and patient income.

In response to that point, Colleen J. Goode, PhD, RN, FAAN, NEA-BC, lead author of the study and professor at the College of Nursing in Denver's University of Colorado, says "sepsis and the others we used have been shown in the past to be influenced by nurse staffing. They are called ‘nursing-sensitive indicators.' " Goode adds, "by doing the multivariate analyses, we controlled for hospital characteristics such as the average severity of patients at each hospital. The outcome measures we used adjusted for risk from patient characteristics that are often associated with the development of each of the outcomes."

But even in light of her findings, Goode says she "absolutely" believes that hospitals should pursue the certification, especially since MRP is increasingly focused on patient outcomes. "I am a big believer in [MRP]," she says.

And for Sheff and Torosian, the study doesn't sway their choice to pursue MRP certification. "It's so empowering, so wonderful to be able to give the bedside nurse that voice," Sheff says.

The challenge to collaborate

Sun, 01 Apr 2012 04:00:00 GMT

The challenge to collaborate

by Bob Wertz

Until you identify the source of a problem, you are not likely to develop a solution. A common theme that runs through the results of the 2012 HealthLeaders Media Industry Survey is collaboration-the need for it and, too often, the lack of it.

This fourth annual offering-through survey data and analysis of that data by healthcare leaders themselves-reveals the targeted priorities and concerns from within the industry's C-suite, including the following results:

A significant majority, 59% of healthcare leaders, cited "too much self-interest among the different stakeholders" as the reason the healthcare industry cannot solve its own problems. The next-highest response (14%) was "lack of incentive to innovate or deliver value."
No single actor or group is going to be the one to save the healthcare industry, according to our survey-the single greatest response to the question of who the industry's savior will be was "other" (31%), and the written comments reveal that most believe it will take a collaborative effort among all elements of the industry to fix things.
It may come as little surprise that the single biggest culprit for the healthcare industry's mess is the government, cited by 40% of respondents. Health plans get the blame from 22% of respondents, but an equal share (22%) chose "other," and the written comments reveal that all stakeholders must share the blame.

Coordination strategies

The absence of and the need for collaboration is seen in questions that explore not just the business of healthcare, but its clinical aspects as well. Check out the following:

Care coordination and continuum of care represents the single greatest strategic challenge for clinical quality improvement, selected as top choice by 25%. Second choice (at 21%) is improving patient experience, including patient flow.
Only 14% of leaders say their organization's care coordination is "very strong." Yes, 45% rate it as being "strong," but one-quarter (24%) can muster only a "neutral" rating.
More than half of respondents see accountable care organizations (ACO) as worth pursuing, with 53% saying that their organization will be part of an ACO within the next three to five years.

Internal imperatives

Perhaps ACOs can help reduce some of the tension that exists between payers and providers. But providers still have some challenges within their own ranks that suggest a need for greater collaboration.

We asked both physician and nurse leaders to assess the pervasiveness of physician abuse or disrespect of nurses at their organizations. There is a clear disconnect in their perceptions. While just 13% of physician leaders say those conditions are common, more than three times that number of nurse leaders (42%) see it that way.

Despite the industry's enormous challenges and demands, bright and dedicated people continue to devote their careers to healing and helping, and 81% of the survey respondents say that, overall, they are satisfied or very satisfied in their job.

Clearly, individuals should feel positive about the work that they do, but they also need to feel good about their profession. The survey suggests room for improvement in the area of collaboration. Given the complexity of clinical care, achieving that cohesion will not be easy-but no one enters healthcare because it's easy. As one nurse leader puts it, "We will only fix this when we stop blaming and decide to collaborate as a system."

Insurer trains nurse care coordinators

Sun, 01 Apr 2012 04:00:00 GMT

Insurer trains nurse care coordinators

by John Commins

At an accelerating pace, the nation's health insurance companies are embracing the latest trend in care delivery: An ounce of prevention is worth a pound of cure.

In January, WellPoint, Inc., said it would increase payments to physicians who transition to patient-centered medical homes (PCMH). The plan calls for care management fees for primary care physicians (PCP), who could see fee increases of about 10% with incentives that could improve payments by as much as 50%.

And in another sign that the landscape is shifting, Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) announced in February that it would fund a collaborative to train 200 nurses in the Garden State over the next two years as "population care coordinators."

Horizon Healthcare Innovations, a subsidiary of Horizon BCBSNJ, said the "first-of-its-kind initiative" is designed for nurses who work in PCPs' offices. The program uses curricula developed in collaboration with Duke University School of Nursing and Rutgers College of Nursing.

The nurses who graduate from the 12-week program will work with PCPs, other care team members, and the patients themselves to coordinate follow-up care and create individualized health plans that empower and engage patients.

"Through this collaborative partnership we are working to shift care delivery from an illness model to one of keeping our citizens healthy, using nurses as the linchpin to analyzing data on high-risk patients and developing coordinated plans of care," Edna Cadmus, project director and clinical professor at Rutgers College of Nursing, said in a media release announcing the project.

The first class of 37 population care coordinators began their studies in January. Most of the courses are delivered online and are supplemented by three face-to-face sessions on the Duke and Rutgers campuses. The nurses will also take part in a residency program that integrates their course work and skills to provide a real-world experience for their new roles as care coordinators.

The Horizon project courses will focus on the following skill sets:

Case management of patients with complex health conditions
Communication strategies with patients
Using databases, which will include disease registries and EMRs
Coordinating care of "frequent flyer" patients and discharged patients from care facilities
Implementing and managing change in healthcare organizations
Operations of a PCMH
Role of care coordinators in improving patient care and patient experience in a PCMH

The announcements from WellPoint and Horizon should be welcomed by anyone who cares about healthcare reform and the move toward the PCMH model. If the commercial plans aren't on board, it's not going to work.

The initiatives also show that payers clearly understand that there is no going back to the old FFS model-it is simply too wasteful and too unaffordable. The plans are planting a stake on the future of healthcare, and they're betting that PCPs and nurses will lead the way.

Health Governance Report, April 2012

Sun, 01 Apr 2012 04:00:00 GMT

Putting data in nurses' hands

by Gienna Shaw

That attitude isn't an issue at the 330-licensed-bed Catholic Medical Center (CMC) in Manchester, NH, says Mercedes Fleming, the organization's manager of nursing systems and support.

Resources and responsibilities

Unlocking the data

Assessing acuity

Putting data in plain view

The organization also uses its EMR reports and dashboards to track progress toward goals such as meaningful use readiness.

Nurses key to care coordination

by John Commins

Educating patients about their medication
Considering all factors related to the patient
Advocating for patients with the pharmacy department
Coordinating care with physicians
Independently reconciling medications with patients' records
Verifying medications and doses with colleagues
Coping with interruptions and distractions
Interpreting physicians' orders
Documenting near misses
Communicating openly with physicians, pharmacists, and other team members

Designing a hospital? Ask nurses first

by Alexandra Wilson Pecci

When the nurses at Cass Regional Medical Center in Harrisonville, MO, were asked to pitch in their ideas on the design of their new hospital, they weren't just concerned with the color of the walls.

Real value of seeking credentialing lies in the journey

by Alexandra Wilson Pecci

"Whether we achieve the [MRP] certification or not, the components of [MRP] set a really good foundation for the profession of nursing," Torosian says.

"We're now looking at the potential of offering on-site courses," Sheff says.

And for Sheff and Torosian, the study doesn't sway their choice to pursue MRP certification. "It's so empowering, so wonderful to be able to give the bedside nurse that voice," Sheff says.

The challenge to collaborate

by Bob Wertz

A significant majority, 59% of healthcare leaders, cited "too much self-interest among the different stakeholders" as the reason the healthcare industry cannot solve its own problems. The next-highest response (14%) was "lack of incentive to innovate or deliver value."
No single actor or group is going to be the one to save the healthcare industry, according to our survey-the single greatest response to the question of who the industry's savior will be was "other" (31%), and the written comments reveal that most believe it will take a collaborative effort among all elements of the industry to fix things.
It may come as little surprise that the single biggest culprit for the healthcare industry's mess is the government, cited by 40% of respondents. Health plans get the blame from 22% of respondents, but an equal share (22%) chose "other," and the written comments reveal that all stakeholders must share the blame.

Coordination strategies

The absence of and the need for collaboration is seen in questions that explore not just the business of healthcare, but its clinical aspects as well. Check out the following:

Care coordination and continuum of care represents the single greatest strategic challenge for clinical quality improvement, selected as top choice by 25%. Second choice (at 21%) is improving patient experience, including patient flow.
Only 14% of leaders say their organization's care coordination is "very strong." Yes, 45% rate it as being "strong," but one-quarter (24%) can muster only a "neutral" rating.
More than half of respondents see accountable care organizations (ACO) as worth pursuing, with 53% saying that their organization will be part of an ACO within the next three to five years.

Internal imperatives

Insurer trains nurse care coordinators

by John Commins

At an accelerating pace, the nation's health insurance companies are embracing the latest trend in care delivery: An ounce of prevention is worth a pound of cure.

And in another sign that the landscape is shifting, Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) announced in February that it would fund a collaborative to trai

How big, how soon?

Thu, 01 Mar 2012 04:00:00 GMT

How big, how soon?

by Philip Betbeze

Hospitals and health systems are rapidly transitioning their businesses to deal with some of the known truths about healthcare reform. For one, reimbursement is declining, so they'll be looking to do more with less. Second, the acute care hospital will not be the engine of growth; outpatient services will. But amid these generally accepted facts, perhaps the greatest unknown is service capacity. Will hospitals be ready for an influx of patients as more people become insured?

Hospital leaders can make educated guesses about what services and facilities the newly insured may need, but committing real dollars to building them requires insight and practicality. Further, reimbursement for these patients is expected to rival Medicaid levels, not commercial payer levels, so caution is required when allocating capital to deal with the expected influx.

In a recent HealthLeaders Media Intelligence Report, Better Care and the Bottom Line, some 69% of healthcare leaders surveyed said that they are ready to handle the projected addition of millions of insured patients into their healthcare systems over the next two decades. But how can they be so sure when even experts can't predict the scope of the patient surge or in what setting they will likely present? Many of the advisors in the report, hospital executives themselves, expressed skepticism that their peers could be so confident about their readiness.

Regardless, capital investment is by nature long term, so hospitals and health systems are struggling with how best to invest that capital to ensure not only that they're providing the best care for their community, but that they are positioned to take advantage of the best possible reimbursement when providing that care, which will increasingly shift to outpatient facilities.

Volume estimates, shifts

For decades, hospitals invested in inpatient care. Since it yielded the highest reimbursement, much more work was centered there. More recently, however, as more complex procedures are being effectively moved out of the hospital to lower-acuity settings, hospital leaders have invested in outpatient care. Many hospitals have simply followed the revenue that moved out of the hospital setting by expanding their network to include more ambulatory surgery centers, imaging, and lab work. But the shift has been haphazard and tailored to existing patients.

New patient volume growth is expected to occur most rapidly among the portion of the population that was previously uninsured. Many of these patients received much of their care in the emergency room, the only place they previously were guaranteed care because of federal requirements that prevented hospitals from refusing treatment there to the uninsured. As more patients move to health insurance exchanges between now and 2014, hospitals, for a variety of reasons, are working to encourage such patients to pursue strong primary care relationships.

"We expect to see significant increases in primary care volume," says Frank J. Cracolici, president and CEO of St. Luke's-Roosevelt Hospital Center, a 1,076-licensed-bed hospital that's part of New York's Continuum Health Partners. To deal with those increases, St. Luke's-Roosevelt is investing in physician talent and new outpatient facilities, and is developing contracts with existing providers in many cases, rather than owning other pieces of the care continuum.

"We're developing a very strong primary care network," Cracolici says. "Rather than patients visiting the ED, they can go to primary care networks that will give them more consistent and less episodic care."

In 2011, St. Luke's-Roosevelt completed construction of a primary care site in Central Harlem, St. Luke's Medical Group, with five physicians, as a method of encouraging people to stay in their community for care and avoid the emergency room. Other hospitals are in the planning stages, but all rest on the presumption that what most of these patients need is primary care.

"In Manhattan, the cultural transformation we need to go through is immense," says Cracolici. "There are thousands of patients who have an inability to pay who don't have a primary care physician."

The developing network of primary care sites is one way to address that problem, but St. Luke's-Roosevelt has also partnered with two major federally qualified health centers (FQHC), which the Patient Protection and Affordable Care Act makes possible. Such facilities are reimbursed at a higher rate than hospital clinics, which is one big reason for the partnership.

"We've made a decision to move the clinics out of the hospital, shut them down, and shift the workforce to the FQHC partnership," Cracolici says. "Those centers get higher reimbursement, and the downstream positive for care is that they can expand hours, maintain quality of care and improve patient access, and provide it in a more appropriate setting than a hospital."

St. Luke's-Roosevelt physicians staff the FQHCs, so patients still feel as though they receive as good or better-quality care than at the hospital, Cracolici says. "When they go to the William F. Ryan Community [Health] Center, which has four locations, they will see a doctor with a lab coat that says St. Luke's-Roosevelt."

"Admission avoidance" is a term Cracolici likes to use when talking about the capital spending St. Luke's-Roosevelt is planning for and executing now. He says the most important aspect of dealing with this patient demographic is the prevention focus on diseases that "go with the territory," such as obesity, diabetes, hypertension, and cardiac disease.

"We're working on admission avoidance because there will be fiscal penalties associated with readmission," he says. "We're not eliminating services, but moving toward those that surround wellness and prevention."

IT investment becomes the top priority

Meanwhile, in California, Laurie Eberst is working diligently on the IT side of capital allocation. As CEO of the Catholic Healthcare West (CHW) Ventura County service area and St. John's Regional Medical Center, Eberst is expecting another million patients in her community to move into the health insurance exchanges mandated in the healthcare reform act.

That translates to extremely high volume in the ED unless changes are made, she says. Those changes begin with the ability to exchange health information among providers that currently don't use the same systems. Moving to compatible systems enhances the goal of influencing patients proactively in a much more unified and holistic way. That can't be done without extensive investment in IT infrastructure, Eberst says.

"Investment in IT absolutely has to exceed bricks and mortar," she says. "We also have to spread the footprint of the hospital in the community. The best way to do that is through physician clinics that are affiliated with your hospital or health system."

Those independent physician clinics won't want to affiliate if their lives can't be improved through that interaction, Eberst says. One way their lives can be improved is through IT investment that physicians know they have to make, but that they can't necessarily afford.

"It's important to build the infrastructure that allows the patients to be assigned to primary care physicians in your community so that he or she becomes the gatekeeper who manages those health needs," she explains.

That's tough to do when you don't employ your physicians, which is difficult in California because of state law that theoretically prevents Eberst and the two hospitals she leads, 265-licensed-bed St. John's Regional Medical Center in Oxnard and 181-licensed-bed St. John's Pleasant Valley Hospital in Camarillo, from hiring doctors. But St. John's has a foundation model, a way of circumventing the state's ban.

"We're expanding that foundation, with the goal of having at least 40 physicians in there in the next four years," Eberst says. In addition, St. John's is working on a clinical integration model for physicians who are not interested in employment, "but who also understand the future is in working closely with the hospital," she says.

"We're looking at different IT systems that can pull demographic data from our communities, data on diagnoses to evaluate the health of the community and the risk of disease," says Eberst.

Like many others, the St. John's management infrastructure focuses on service lines. The twist is that the service line directors are responsible not only for acute care, but also for prevention and rehab. "That way our entire hospital focuses on those risk factors," she says.

But from a capital standpoint, bricks and mortar for new clinics doesn't appear to be as necessary as the IT solutions required to tie together all of these facilities working outside the hospital, both clinically and financially.

"Capital is getting tighter and tighter as reimbursement per patient is going down," Eberst says. "We realize that Medicare and Medi-Cal, California's version of Medicaid, is going down. In the future when these patients roll into the exchange, reimbursement for them will be similar to the Medi-Cal population."

With declining reimbursement as the backdrop, the biggest change in the entire CHW system, she says, is related to population management. "We're investing in ways to work on the front end with people in the community to keep them healthy, offer preventive treatments, incentivizing for healthy lifestyles. On the long-term side, we're coordinating the type of care they receive after discharge, skilled nursing, at home. The idea is to stay out of the hospital. But, if one is needed, it should be one that is integrated with the patient's physicians and offers efficient high-quality care."