Christina's Considerations

PHR School of Hard Knocks

The Healthcare Blog has a great post from one of my old RHIO connections, Missy Krasner.  She shares her thoughts about personal health records given her role with Google Health prior to its demise last week.  I really do agree with her view, especially the part about consumer interest being relative to their health situation.  It is the same for health related social networking.

Medication Error and Two Deaths Later

Not long ago, I recognized Seattle Children's Hospital for their use of Facebook for transparency related to the death of a child (possibly) from a medication error.  I just learned that the nurse who made and reported the error had been fired, and later committed suicide.  

I can't know the details of this case nor can I can attest to whether the decision to fire the nurse was right or wrong.  However, I think that this story is one that does highlight the complexity of healthcare and the challenges faced by those who enter caring professions.

As we establish healthcare policy, we do need to push for improved healthcare... but we also need to remember that medicine is not an exact science --- yet. 

Sepsis: A Challenge for Patients and Hospitals

I thought I'd carry through on Infection Control again this week and share some new data I recently came across on Septicemia, commonly known in the hospital as, Sepsis.  This topic has been on my mind ever since I had a conversation with a new friend. (Yes, I met him through the wonders of social media.)

He is Dr. Herb Rogove, an Intensivist, who's virtual medical group provides remote presence specialty care to hospitals, clinics and other providers using telemedicine technologies.  We were speaking about stroke and he mentioned that sepsis is another high volume condition (approximately 800,000 per year) with great risk for disability, high costs and/or mortality.

This new brief from the CDC is based upon data from the National Hospital Discharge Survey for 2008.  Key findings include

• The number and rate of hospitalizations for septicemia or sepsis more than doubled from 2000 through 2008
• The hospital rates in 2008 were similar for males and females, and with increased age
• Patients under age 65 and aged 65 and over who were hospitalized for septicemia or sepsis in 2008 were sicker and stayed longer than those hospitalized for other conditions.
• The proportion of hospitalized patients who were discharged to other short-stay hospitals or long-term care institutions was higher for those with septicemia or sepsis (36%) than for those with other conditions (14%).  
• The proportion of hospitalizations that ended in death were higher for those with septicemia or sepsis (17%) than for others (2%).

This is really consistent with the information shared with me by Dr. Rogove and my experience walking the units of the hospital.  According to Dr. Rogove, time really is of the essence with regard to selecting the right antibiotic and getting it started to help reduce the lenght of stay and risk of unwanted outcomes.

If you have additional data to share, please leave a comment.

Bacteria and Mobile Devices

I really see us moving beyond COWs (computers-on-wheels) and an explosion in use of mobile devices (smartphones, tablets, etc) in healthcare environments.  But, I would be remiss if the Environment of Care  professional in me didn't speak up on the subject of bacteria and mobile devices.

Our healthcare organizations have made progress with nosocomial infections, but we also now have MRSA infections.  Over the years we have swabbed COWs, door handles, elevator buttons and stair railings to demonstrate just how bacteria can move around the facility by staff, visitors and patients.  

We now have to up our efforts for preventing the spread of infection by addressing all of those personal devices being used by physicians and staff (to access the organization's EHR or resources), patients, and visitors in healthcare environments.  So, cleaning devices needs to be added to protocols along with handwashing, wearing gloves and other precautions.

Read Fierce Mobile Healthcare's recent article on the subject for additional information and some great resources.

 

Satisfying Your Customers with Social Media

Did you see my article in Healthcare Executive on Satisfying your Customers with Social Media?  It focused on a healthcare organization's patients, consumers and community.  In the Fall, a follow-up article will focus on satisfying your physicians and employees (customers) with social media.  

If you have any great examples to share, just get in touch with me.

Cost of Caring for Aging Parents

The results of MetLife's study of  Caregiving Costs to Working Caregivers: Double Jeopardy for Baby Boomers Caring for Their Parents have been released and present data we can all use.  The part about curtailing working careers especially speaks to me, so I appreciate having actual cost numbers assigned.

I truly believe some of the new technologies will help alleviate some of the challenges and help families manage the costs.  In particular, I believe they will be helpful for the caregivers so they no longer have to report that their health is fair or poor.

Heart Attacks & Hospitalization in CA

A report released by OSHPD on heart attacks & hospitalization in CA reviews trends over 20 years. Some of the highlights (mostly related to the hospitalizations) for me include:

• State populations increased by 35% during same time period.
• Number of hospitalizations for acute heart attack increased by 15%, but the rate per 1000 people declined by 15%
• Hospitalization rate declined for people under age 70
• Hospitalizations increased 27% for females and 7% for males, but rates per 1000 people decreased by 6% and 20%,respectively (need to work on the ladies)
• % of patients with another condition, such as diabetes or high blood pressure, doubled from 20% to 40% (this is a big and increasing problem)
• In-hospital mortality rate was 15% in 1988, but fell by 2008 to 13%.  Overall in-hospital mortality rate is 2%. (the opportunity for improvement continues)
• In-hospital mortality rate increased for patients in the 60s and younger. (this isn't good and I think is linked to the increase in other conditions and obesity)
• Increase in admissions through the ER from 66% to 74% (importance of cardiology call coverage increases)

OSHPD reports that about half of the decline may be due to improvements in "revascularization" and new medications to lower blood pressure and cholesterol levels  Another 40% is attributed to decreases in risk behaviors, such as smoking.  However, half of the benefit from decreases in risk behavior is being offset by rising rates  of obesity and diabetes.

Part I: Trends in Utilization and Resources and Part II: Trends in Heart Attack Hospitalizations 

It is frustrating to see improvements in one area being wiped out by something else.  I really think it comes down to educating young people on the importance of healthy behaviors and reducing obesity.

HIT Exchange: The Cost of Healthcare Data Breaches

My latest article was in a bit of a new direction for me.  I put my risk manager hat back on and explore data breaches from the perspective of an administrator who needs to balance several influences. 

HIT Exchange: The Cost of Healthcare Data Breaches

Let me know what you think?  Did I miss anything?

A new tool for surviving an OCR/HHS privacy investigation might also be helpful.

CMS Proposed Rule: An Opportunity for Remote Monitoring

FierceHealth IT has a great editorial on the proposed payment changes and I have to agree that this presents an opportunity for remote monitoring and other forms of telehealth.  CMS will begin placing 1 percent of hospital Medicare payments at risk once the value-based purchasing (VBP) program is implemented in Oct 2012.

• Hospitals that score high enough on quality and patient satisfaction goals, it will get some portion of that money back.
• Hospitals will also be judged on their performance in reducing hospital-acquired conditions and other safety goals in 2013
• Hospitals with excessive readmissions will be penalized.

Remote monitoring will be one of the tools used to help with each of these goals.  I agree hospitals will need to find new ways to work with non-hospital providers and engage patients to improve post-discharge care to avoid readmissions.  It gets back to my post on community partnerships.

CMS Reports on Provider Performance

The next step in the process of releasing more information about the performance of hospitals and physicians (as noted previously) has been taken by CMS.  And, it will identify hospitals and information on their quality and cost of care to help employers and patients make better decisions about their care.

CMS' proposed rule really shouldn't be a surprise to anyone.  By the way, did you see the news about how patients can look at the safety of a provider from the www.HealthCare.gov/compare site?  I just compared the three largest hospitals that are closest to me on several items and the results are interesting - especially on cost.

The Value of Experienced Hospital Administrators

This is an issue really close to home for two reasons. First, this facility is truly in my neighborhood and second because I did some work for this agency in the mid 1990s. Over the last several years they have had their challenges, but this one is central to my realm of expertise. So, I will comment and hopefully shed light on this subject for others in similar situations.

One of our local social news sites, Noozhawk, has two articles about a recent CMS visit to the SB County Psychiatric Health Facility and followup on lax drug controls. I first have to say that I'm shocked the DADMHS administrators were surprised by a visit from CMS. Note to self - if you accept any Medicaid (MediCal), Medicare or other CMS funds for treatment of patients, you should be prepared for a visit at any time. It is really just that simple!

Yes, it is true that CMS over the last many years has delegated their survey/audit visits to the states, but they can and still will come out themselves to confirm state findings (its is part of their own due diligence). This can also occur when they receive a complaint (staff, patients, families or anyone else), they get word of other problems (such as billing or other agency sanctions) or because they happen to be in the area. It doesn't matter how big or small you are, if you accept their money you agree to comply with their minimum standards for the facility and patient care.

And, the CMS surveyors have a reputation for being the most strict. So, if you don't have a copy of the manual (regulations) and you have responsibility for any licensed acute care facility, get a copy and start reading. It is thick and you can't wait to do this when they are sitting in your waiting room.

My observations (and advice for others who may be new to their responsibilities) include:

• How often did the PHF's administration conduct a safety and quality walkthrough of the Contractor's kitchen? How often did they conduct a walkthrough of the PHF and audit compliance themselves?
• The technology is available to have more responsive pharmacy services and timely availability of medications for these patients. And, just because you have a contractor, you don't delegate responsibility for oversight.
• The hospital administrator is responsible for ensuring the presence of an effective quality improvement program (including safety, patients rights, quality, etc). And, the Governing Body is responsible for oversight and ensuring that the administration is fully performing their responsibilities. (Hospital Administion 101)
• The State Department of Mental Health is also an important inspection, however, their emphasis is usually a little different. CMS comes first from the general hospital world and that is the approach they take.
• A hospital must have its own governance structure clearly delineated and followed. There are ways to address more system wide issues, but the hospital can't get lost in the system. Acute facilities (because of the higher needs of patients) are held to a higher standard and this should always be in the forefront. The County Board of Supervisors can delegate responsibility to department heads, but they can't delegate their responsibility for oversight. In Ventura County, the Board Of Supervisors has appointed two of its members to serve on an Oversight Committee with hospital leadership. This seems to work well and might be a good model for Santa Barbara County to follow or explore some of the other governance models of CA public hospitals.
• There should also be a clearly written policy identifying the hospital administrator and who is responsible in his or her absence. This is also hospital administration 101 and if the other agencies weren't checking this, then that is a problem.

I'm sorry I have to be so blunt, but feel that the situation warrants it. At some point, people need to step up to the plate and make the decisions necessary to fulfill their responsibilities to the patients and our community. Being responsible for an acute care facility (no matter how small) is a big job and it must be taken seriously -- because the lives of our patients truly depend upon it.

 

 

ONC's Direct Project

The ONC's Direct Project comes down to nationwide accessibility and a simple way to connect each little practice's EHR with other EHRs, registeries and software.  It will/could facilitate:

• HIEs connecting with individual practices
• practices connecting with practices
• practices connecting with agencies for reporting
• HIEs connecting with other HIEs
• HIEs connecting to agencies for reporting
• connecting with portals, labs, pharmacies, remote monitoring devices, telehealth and others
• connections across the continuim of care to link long-term, home and other care sites
• PHRs linking to provider EHRs.

The Direct Project Wiki includes recordings of overview presentations, information from the Direct Bootcamp and resources.  Basically, it involves:

• providers to request an account; being authenticated as a provider and then being given an address.
• They can connect with others who have been given an address (think back to Fax machines when we needed our referral sources to have Faxes too before we could send anything to them).
• EHR vendors are helping with the establishment and updating of directories and sets a trigger point to send information.
• Pushes information out when trigger point is reached (based upon the patients pre-established consent for sharing information)
• a message using simple mail transfer protocol (SMTP) and attachments that are multipurpose Internet mail extensions (MIME)
• The message is discrete data that can move into the receiving provider's EHR.

We will start seeing this technology used more and more to facilitate connections and ultimately longitudinal health.  It is an especially useful tool for rural communities and small networks and also presents opportunities for exploring applications with telemedicine.

For the very latest update, visit the CAeHC webinar archive.