ORH Newsletter Vol. MMVII Ed. IV
- Five Tips to Help Educate Your Hospital Board on Quality
- 340B Drug Pricing Program Findings
- Telemedicine and Telemonitoring: Its Role in Care Management
- New Web Tool Provides Samples of Report Cards on Health Care Quality
- NRHA Applauds Tom Dean's Appointment to MedPAC
- When Doctors, Patients Disagree, It Affects Survival
- HSU School of Nursing Names Associate Dean for Southern Region
- What's Happening!
- Coming Events
By Carrie Vaughan for HealthLeaders News
Published: May 16, 2007
Hospital board members are under increasing pressure to ensure their facilities meet--or better yet, exceed--quality and patient safety standards. Hospital comparison Web sites, quality ranking programs, and government initiatives linking performance on quality measures with pay are prompting hospital executives to make sure their board members have the tools they need to adequately monitor quality. This can be a challenging endeavor, however, since many board members are unfamiliar with medical lingo, the meaning of quality measurement data, and most importantly, what quality indicators they should be monitoring. Here are five tips to help get your board members up to speed on quality issues.
- Define the board's role
Board members need to know what their job is. "It is important for them to understand the distinction between making a judgment, inappropriately, about the care delivered and their understanding of where the process of care delivery failed," says Yosef D. Dlugacz, PhD, senior vice president and chief of clinical quality, education and research at the Krasnoff Quality Management Institute in Great Neck, NY. It is not the board's job to manage clinical care; their role is to understand the quality process, ask educated questions and help promote programs, he says.
- Explain that quality is more than regulations
Make sure the board understands that supporting quality is more than compliance with regulatory organizations. Even though maintaining government standards is a large component of quality management, board members should also understand how the quality process works. For instance, educate them on the methodologies used, how the measurement databases were developed and the communication process throughout the organization, says Dlugacz. He adds that it is also important for board members to know the driving forces behind quality, including external factors like the Institute for Healthcare Improvement and the Centers for Medicare & Medicaid Services, and internal factors like adverse events, patient complaints and malpractice suits.
- Find quality champions
Hospitals should consider recruiting a retired nurse or clinician to the board--someone who is an expert in patient safety and quality--says Todd C. Linden, president and CEO of 48-staffed-bed Grinnell (IA) Regional Medical Center. Hospital leaders should also encourage support for senior quality management staff. "Look for individuals who understand regulatory requirements, are good communicators, politically astute and who love to teach," says Dlugacz, adding that those individuals can help embed quality into the fabric of the organization.
- Incorporate quality in the mission
The board should play an active role in developing quality goals for the organization. They should have access to benchmarked data to measure the hospital's success toward these goals as well, says Linden. "Let the board take the lead in medical staff engagement," he advises. The medical staff leadership at our facility has focused all its meetings around the quality agenda, which has raised awareness and resulted in excellent physician engagement, Linden says. "The board's role in setting the vision for Grinnell to be a national leader in patient safety, quality and service excellence has driven the passion for this activity."
- Bring theory into reality
In the 20 years that Dlugacz has worked with board members, he has learned a lesson or two on what education strategies seem to be the most effective. "I find that highlighting incidents captures their attention. Everyone is justifiably outraged about a wrong site surgery or retained foreign body. They want to know how it could have happened, what went wrong, and most important, how to fix it," he says. In addition, hospitals should avoid presenting board members with raw data, like mortality rates. Not all deaths are comparable, says Dlugacz, "some are from technical errors, some from the progress of disease and inevitable, some unexpected and require further analysis."
Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at cvaughan@healthleadersmedia.com
NORC Walsh Center for Rural Health Analysis & NC Rural Health Research & Policy Analysis Center Releases Study on 340B Drug Pricing Program
There are substantial differences between participating and non-participating rural hospitals in the 340B Drug Pricing Program in terms of revenue and services offered. The proportion of rural hospitals participating in the program is twice as high among hospitals with more than $100 million in annual revenue versus those with less than $50 million in revenue each year. Participating hospitals also provide a much higher volume of outpatient services where the ability to offer reduced-price drugs might be advantageous, according to a report by the NORC Walsh Center for Rural Health Analysis and the North Carolina Rural Health Research & Policy Analysis Center.
The 340B Drug Pricing Program enables certain types of safety-net organizations to obtain medications at prices below the "best price" typically offered to Medicaid agencies. Historically, few rural hospitals qualified for the 340B program, but the Medicare Modernization Act of 2003 revised eligibility criteria, allowing many rural hospitals to participate. The study, "340B Drug Pricing Program Results of a Survey of Participating Hospitals," surveyed pharmacy directors at participating hospitals on the program in general, the financial impact of the program, and which specific program features presented barriers to its broader implementation. Selected results were compared to those from a separate companion survey of pharmacy directors at hospitals that were eligible but not participating in the 340B program.
Key findings include:
- The average monthly savings is approximately $19,700 on total outpatient drugs for participating rural hospitals; some hospitals reported saving an average of 24 percent of the pharmacy budget.
- About 96 percent of all respondents were satisfied with the discount they received. Savings from purchasing discounted outpatient drugs have been used to offset losses from providing pharmacy services (71 percent), increase and/or improve services at the hospital (51 percent), offset losses in other departments (41 percent), reduce medication prices to the patient (27 percent), and increase the quantity and/or variety of drugs available (16 percent).
- Maintaining separate records for inpatient and outpatient drugs was the biggest challenge in administering the program, according to pharmacy directors.
http://www.shepscenter.unc.edu/research_programs/rural_program/WP90.pdf
Marybeth Regan, Ph.D., for HealthLeaders News
For years, patients and physicians have sought solutions for several dilemmas in the healthcare delivery systems:
- How can patients in under served areas, both rural and urban, access primary care and specialty physicians, as well as other healthcare professionals when no physician is in their immediate area?
- How can treatment and medication compliance be improved for reduction of disease, risk factors, and management of chronically ill patients?
- Are there ways other than a visit to the physician's office or the emergency department for patients to receive health information, education, and decision support regarding care?
- Can homebound patients — such as the chronically ill, disabled, and hospice patients — be monitored and treated in ways that do not require as many visits to the physician's office, thereby improving convenience and reducing costs?
- Can quality of life be enhanced for patients with chronic conditions?
- Can telemedicine supplant traditional care?
Telemedicine is part of the enabling strategy that can answer these questions. Until now, there has not been feasible and cost-effective solutions to these problems. With the advent of the Internet, Web-enabled applications, and advances in telecommunications technology, a solution now exists: Connectivity — or some phase of telemedicine--can exist in the home and almost anywhere.
With part of its roots in medical research for military and space applications, telemedicine is expected to make it possible to link medical expertise with patients, regardless of location — providing clinicians with valuable new tools for remote monitoring, diagnosis, and intervention.
It is widely claimed and often assumed that innovation in healthcare technologies can contribute to increased access, improved quality of care, and reduced costs. Although telehealth technologies currently account for a small segment of all healthcare technologies, innovation in this area is stimulating significant improvements in productivity and quality of life. Today, after more than 30 years, the potential of telehealth has still not been fully realized due to costs, effectiveness, reimbursement and resistance to change. Telemedicine continues to expand, and pressure for policy development increases in the context of Federal Budget cuts and major changes in health services financing.
Rationale for Telemedicine
Despite these obstacles, the needs to overcome distance challenges, improve care management, and tackle chronic diseases have spurred telemedicine. Overcoming the distance factor was an early driver of telemedicine. Initially, the technology was defined as the use of telecommunications technology to provide healthcare services to persons who were at some distance from the provider. This typically occurs in two ways. Real-time examinations bear the closest resemblance to the typical face-to-face provider/patient interaction — both patient and physician are present at the same time and can provide instantaneous feedback to one another through video screens and audio. The second method used to transmit information in telemedicine, “store and forward,” is less synchronized. Data such as images and vital sign readings are stored and then transmitted to the medical expert for later examination. Image-oriented areas such as radiology and dermatology are especially suited for store-and-forward transmission, as are data for home telehealth care.
Care management is another driver of remote patient monitoring. Telemedicine has been utilized as an extension of the acute care setting for patient follow-up. Brigham and Women’s Hospital in in Boston, MA, discharges their mastectomy patients home with a laptop and camera. The first call with the physician is scheduled for the next day to review the incision and answer questions. The hospital determined that this was easier for the patient and provided the follow-up visit quickly after surgery. This solution provided benefits for both the physician and the patient.
In addition to addressing issues of distance and care management, telemedicine can be a disease management tool. Telehealth technology is now known to be effective for improving patient outcomes in many disease states, particularly chronic diseases such as diabetes and congestive heart failure. For some time, the general medical populace considered it too experimental.
Disease management companies that are paid by insurers to manage chronic care have managed patients telephonically for over 10 years. In their quest to use the newest technology, many created websites where patients can manage their own diseases. For example, an enrollee can submit clinical information using tools such as glucose monitoring logs to generate dosing and physician monitoring components. In addition, there are online courses and links to other relevant sites. Unfortunately, many patients do not have access to the technology. There are even remote monitoring devices that are used for weight (important for congestive heart failure), blood pressure and even daily vital signs.
Telemedicine’s great potential
In a context of tightened budgets, and increasing costs, telemedicine is emerging rapidly. It has the potential to affect health services delivery in many ways with rapid technological change and a volatile and changing healthcare system.
People with chronic diseases at home, for example, can take their multiple readings more frequently. Either the patient or the care support team can intervene when justified.
In addition, telemedicine, also known as telehealth or e-health, presents a chance to recognize and possibly prevent chronic conditions from worsening in patients, cutting healthcare costs through a reduction in hospital stays and outpatient clinic visits and providing better quality outcomes.
“That doesn’t mean that people don’t need to go into hospital,” says Adam Darkins, MD , chief consultant for care coordination at the U.S. Department of Veterans Affairs, which has spent $20 million for a program to install telehealth monitors in the homes of more than 16,000 patients across the country. “But if you get someone in for two days, stabilize them and get them home, rather than two weeks in an intensive care unit, it’s a win on both sides, “ says Benjamin Nagy, in Managed Healthcare Executive, Sept. 1, 2006.
Telemedicine can also foster collaborative decision making with patients. When patients access health information and obtain health education, they become informed participants in their own health decisions. The supported self-service tools of telemedicine empower patients with knowledge for the decision-making process. This sharing of accountability between providers and patients is a departure from the traditional relationship, in which accountability has resided primarily with the provider. As patients become more accountable, compliance often increases and outcomes are improved, according to Parmod Baur, PhD, president and CEO of Viterion TeleHealthcare, a telemedicine provider.
For example, home telemedicine applications for heart patients include condition monitoring, nutrition education, and meal planning. In some applications, patients are monitored on a 24-hour basis from their homes. A device worn by the patient detects potential cardiac events by tracking irregular heartbeats. The patient uses the telephone to transmit these data to a physician for evaluation and recommendations. The payoffs for monitoring cardiac patients this way are obvious: More accurate and expeditious diagnoses, fewer visits to the emergency department or the intensive care unit, and decreased costs.
In addition to interacting with a physician, patients can interact with others by participating in a home-based, on-line cardiac recovery program. Having to leave home can be highly problematic for many cardiac patients in rehabilitation. Sharing experiences in an on-line support group results in reduced anxiety and increased confidence, and often promotes physical activity. The program has resulted in an added benefit: many of these patients become friends.”
The new generation of telemedicine also brings “space age” technology into the fold. At the high-tech end of telemedicine, a robot that acts as a live-in nurse. The robot collects blood pressure, electrocardiogram, pulse, and temperature information, then transmits it back over the telephone line to a home nursing station. Nurses at the nursing station there monitor the patient’s condition and intervene when the data show that the patients needs to schedule an appointment or change the medication. One question remains: How much and what do you compromise by high tech versus high touch?
Telemedicine saves money, lives
Such difficult questions aside, what if the cost to treat patients — whether your organization is a health plan, employer, hospital or clinic — could be reduced without sacrificing care or patient satisfaction? What is the volume of clinic visits, hospital admissions, and emergency department visits could be reduced while maintaining or even improving clinical and human outcomes? Each of these is possible using advanced telephonic and web-enabled technology. Here are the examples of the financial impact of the financial impact of telemedicine on healthcare costs:
- Reduces hospitals days per thousand and physician visits for chronically ill patients. Using telephones to remind patients to take their medication or using a Web-based application to monitor glucose readings are two ways telemedicine keeps chronically ill patients healthier.
- Decreases costs of managing patients with chronic diseases. Continuous monitoring and education — which can be automated with telemedicine — reduce costs. Providers of integrated healthcare, disease management and Internet services, for example, demonstrated an average savings of $7.83 per patient for every dollar spent on one asthma management program. The program — which incorporates patient self-reports, medical records, and claims data — resulted in 52 percent fewer urgent physician visits, a 67 percent decrease in visits and a 36 percent reduction in healthcare costs compared with patient data from before the as noted in a 1998 press release by disease management company Patient Infosystems.
- Expands service area for providers using telecommunications technologies. Providers can efficiently and effectively manage more patients at lower cost per unit of care. This is important in fee-for service, discounted fee-for-service, and capitated environments.
A telemedicine cyber-revolution is providing solutions to many longstanding problems. Imagine an Internet-based technology that provides both transactional and analytical functions for receiving, transmitting, and managing clinical as well as financial data for patients. Increasingly, healthcare executives and providers are realizing the need to expand information management — one of the core competencies for success in the emerging healthcare delivery system. The transition to managing disease and promoting wellness using a new philosophy is clearly the wave of the future. Marybeth Regan, PhD, is an expert in disease and care management. She has written numerous articles on strategies for care and disease management. She may be reached at Drmarybethregan@aol.com.
With rising interest in information about the quality of care delivered by health care providers, HHS' Agency for Healthcare Research and Quality has developed a new Web tool demonstrating a variety of approaches for health quality report cards.
The new Health Care Report Card Compendium is a searchable directory of over 200 samples of report cards produced by a variety of organizations. The samples show formats and approaches for providing comparative information on the quality of health plans, hospitals, medical groups, individual physicians, nursing homes, and other providers of care. The Health Care Report Card Compendium can be found at http://www.talkingquality.gov/compendium/.
"Consumers and providers alike need better information if we're to get the highest quality and value from our health care system," said HHS Secretary Mike Leavitt. "We're still learning how to gather and present that information in the best ways, and we can learn from one another. The new AHRQ Web site will help with that learning."
"The demand for information about health care quality is rising rapidly, and it will be increasingly important for this information to be presented clearly and effectively," said AHRQ Director Carolyn M. Clancy, M.D. "Report card developers can use the examples from the Health Care Report Card Compendium to explore the scope and information they might want to cover, as well as various approaches to presenting their own organization's comparative data."
The purpose of the AHRQ Health Care Report Card Compendium is to inform and support the various organizations that develop health care quality reports, to provide easy access to examples of different approaches to content and presentation, and to meet the needs of health services researchers. It also provides related Web sites and sample pages where available.
AHRQ is providing this compilation of report card samples as a service to report developers, researchers, and other users. AHRQ makes no judgment concerning the effectiveness or value of reports in the compendium but offers them to users for their consideration. Inclusion of a report in the compendium does not constitute an endorsement of the report in its entirety, or of any element in the report, by AHRQ.
Public reporting regarding the performance of health care providers and plans is expanding as standards for measuring quality grow, and reports of the quality of health care providers and services are increasingly being made available to consumers. Public reporting about quality of care is also a central feature of Secretary Leavitt's Value-Driven Health Care Initiative.
Last August, President Bush committed federal health programs to make quality information available to all enrollees. Under Secretary Leavitt's initiative, other private and public employers are likewise committing to quality reporting for enrollees in their health plans, as well as to public reporting on the costs of care.
The compendium was developed as a resource for report sponsors to supplement guidance provided on AHRQ's TalkingQuality Web site at http://www.talkingquality.gov. TalkingQuality informs and supports current and potential sponsors of health care performance reports by sharing the lessons learned by researchers and experienced report developers.
This resource was developed by AHRQ's Consumer Assessment of Healthcare Providers and Systems User Network to give sponsors and researchers access to examples of quality reports and to enable them to locate and network with each other on related issues. More information about Secretary Leavitt's Initiative on Value-Driven Health Care is available at www.hhs.gov/transparency. For more information, please contact AHRQ: (301) 427-1244 or (301) 427-1862.
NRHA Concerned that MedPAC Still Lacks Full Rural Representation
Thomas M. Dean, MD, from Wessington Spring, South Dakota, has been appointed to the Medicare Payment Advisory Commission (MedPAC). David Walker, Comptroller General, made the announcement Monday.
MedPAC is an independent federal body that was established in 1997 to analyze access to care, quality of care and other issues affecting Medicare. MedPAC also advises Congress on payments to health plans participating in the Medicare Advantage program and to providers in Medicare's traditional fee-for-service programs. The Comptroller General is responsible for naming new commission members.
"We are thrilled that Dr. Dean was appointed to MedPAC," Alan Morgan, CEO of the NRHA, said. "Dr. Dean has been a tireless advocate of rural health and served our association well as its tenth president in 1990. Dr. Dean has extensive health care experience and understands the importance of representing rural beneficiaries' needs. We look forward to working with him to make sure that the views of rural Medicare beneficiaries and providers are heard on the commission."
For more than thirty years, Dr. Dean has served rural Americans in a variety of clinical settings. Nationally, Dr. Dean has been a leader in the quality movement in rural America. His research has explained the necessity of rural providers making changes at their facilities to improve patient care. He has served as the President of the NRHA and been honored by the National Health Service Corps for "for improving access to those most in need."
"Dr. Dean's experiences at a variety of facilities in South Dakota have uniquely prepared him to understand primary care, Community Health Centers, and large health systems. MedPAC will be well suited with a Commissioner that understands these issues and can help strengthen the care provided through these venues," Maggie Elehwany, Vice President of Government Affairs and Policy, said.
"We remain concerned; however, that MedPAC is not balanced towards rural members. Dr. Dean will become only the second rural voice on the seventeen member commission with any significant professional experience in rural America," Ms. Elehwany cautioned. "Federal law requires that MedPAC representation include 'a balance between urban and rural representatives.' Two out of seventeen still is far short of this. We must make sure that the twenty-seven percent of Medicare beneficiaries that live in rural America are given an equal voice on the commission."
The NRHA is a national nonprofit organization, with approximately 15,000 members that provides leadership on rural health issues. The Association's mission is to improve the health and wellbeing of rural Americans and to provide leadership on rural health issues through advocacy, communications, education and research. The NRHA membership is made up of a diverse collection of individuals and organizations, all of whom share the common bond of an interest in rural health.
Research will be presented at annual American Society of Clinical Oncologists meeting
A new study by Oregon Health & Science University Cancer Institute researchers show when a patient and physician disagree about physical well-being, the patient has a higher risk of dying.
The researchers found patients and their doctors disagree about the performance and the nutritional status more than half the time. Furthermore, the degree of disagreement is significant with physicians, who frequently rate their patients better than the patients rate themselves.
The implications are important in cancer patients because disagreement is associated with an increased death risk of death.
Ian Schnadig, M.D., principal investigator, a fellow in the Division of Hematology and Medical Oncology, OHSU Cancer Institute, OHSU School of Medicine, will present these findings Tuesday, June 5, at 8 a.m. (CDT) at the 43rd annual meeting of the American Society of Clinical Oncologists in Chicago.
“These findings are important because performance and nutritional status according to a physician is one of the most important measurements in clinical cancer research and care because it can be a major factor in deciding between two or more therapeutic approaches. So when doctors overestimate how the patients are doing, the patients may end up not getting the right cancer treatment or receive futile therapy,” said Schnadig.
Performance status is a simple assessment tool oncologists use to categorize the overall fitness, physical well-being and ability to carry out daily activities. In clinical practice, patients do not provide these assessments.
For performance status, disagreement is associated with an 11 percent increased risk of death; nutritional status disagreement is associated with a 38 percent increased risk.
This large study, 1,636 subjects with advanced colorectal or lung cancer - were included in an analysis with follow-up after seven years.
It was also found that when patients are unable to work prior to retirement, have less then a high school education or are depressed more than half the time, the disconnect with their physician is more likely.
“This information is important because armed with this information, physicians can redouble their effort to better understand how their patients are doing,” said Tomasz Beer, M.D., the senior author of the study; director of the Prostate Cancer Research program at the OHSU Cancer Institute; and associate professor of medicine (hematology/medical oncology), OHSU School of Medicine.
“Our study points out how important it is that patients and doctors communicate well. Clearly, we need to work to understand why this disconnect happens and how we can close the gap to give patients the best chance as they fight their cancer,” said Schnadig.
“We knew that patient-reported performance assessment commonly differs from physician-only assessment. However, the extent and the direction (i.e., whether physician or patient tended to rate patients better) of these differences have never been evaluated in such a large group of subjects with advanced cancer. Also, neither the predictors, nor the implications of such disagreement have been previously been defined.
“Most importantly, this research highlights that being wrong about performance status matters in the outcomes of these patients. We need to develop tools to bring the patient and physician into line with one another. One way to do so would be to systematically collect this data during regular patient visits and to routinely present this information, much the same way we do vital signs to the clinician,” Schnadig said.
He suggests further clinical trials to validate such an approach.
Jan Heineken Ph.D., R.N. has been appointed the new associate dean of the Oregon Health & Science University School of Nursing Southern Region.
Saundra L. Theis, Ph.D., R.N., interim dean of the OHSU School of Nursing announced Heineken's appointment today. Heineken begins her position at the School of Nursing in Ashland Sept. 4.
"Dr. Heineken will bring a fresh perspective on nursing and communications," Theis said. "We are thrilled she has agreed to join our faculty, and we know her active participation within the school and with students will have a lasting impact."
The School of Nursing Southern Region encompasses both Ashland and Klamath Falls. The Ashland program is located on the Southern Oregon University campus, and has 126 undergraduate students, eight graduate students, one doctoral student, and 25 faculty members. Klamath Falls is located on the Oregon Institute of Technology campus, and serves 54 undergraduate students, two graduate students, and 10 faculty members. Both programs have been operating under OHSU since 1993.
Heineken was formerly associate director and professor at the School of Nursing at San Diego State University. Prior to that position, she served as associate dean for the School of Nursing at the University of San Diego, assistant professor at the University of Colorado, and head nurse/clinical specialist at the Colorado Psychiatric Hospital.
Her teaching responsibilities have included undergraduate courses in gerontological nursing, health care systems, and leadership and management. Graduate courses she’s taught include nursing systems administration, personnel management, and others. Heineken is a graduate of San Diego State University, where she received her bachelor's degree in nursing. She continued her education at Washington University, where she was awarded a master's, and the University of Denver, where she completed her doctorate.
Oregon Health & Science University is the state’s only health and research university, and its only academic health center. OHSU is Portland’s largest employer and the fourth largest in Oregon (excluding government). OHSU serves more than 184,000 patients, and is a conduit for learning for more than 3,900 students and trainees statewide.
Nominations Solicited for the 2007 Oregon Rural Health Conference Awards (ORHCAs)
The ORHCAs honor individuals and organizations that demonstrate outstanding commitment to improving the quality and availability of health care in rural Oregon.
Many unique individuals devote their time and energy to ensuring the physical and mental health of the rural Oregon communities they serve. We all know at least one person or group that has demonstrated an extraordinary commitment to health care in our community. The ORHCAs were created to honor those efforts.
Think about nominating someone whose actions have had a notable positive impact on the health of the community or a successful program that has been implemented that other communities might want to replicate. How about a teacher or coach with a unique approach to educating students on health care risk prevention, or a health care provider, clinic or health department that has demonstrated a unique devotion to the populations they serve?
Nominate a deserving individual or group in your rural community today! Nomination forms are available below. Please contact the email address at the bottom of the page if you need any of the forms in a different format.
Nominations will be accepted through July 5, 2007.
For more information, please click here.
- 2 day Provider or 1 day Recertification ALCS Course
July 21 & 22, 2007
Harney General Hospital
Burns OR
For more information, click here.
- The Telehealth Alliance of Oregon (TAO ) in-service trainings for Critical Access Hospitals & Rural Health Clinics
August 3, 2007
6 Sites Statewide
For more information, click here.
- Rural Women’s Health Conference
August 13-15, 2007
Omni Shoreham Hotel, Washington DC
Registration and conference details, click here.
- 24th Annual Oregon Rural Health Conference
September 13th - 15th, 2007
Salem Conference Center
For more details, click here.
- The Telehealth Alliance of Oregon (TAO ) in-service trainings for Critical Access Hospitals & Rural Health Clinics
October 5, 2007
6 Sites Statewide
For more information, click here.
- 30th Annual Oregon Nurses Association's Nurse Practitioners of Oregon (NPO) Education Conference
November 2-4, 2007
Salishan Lodge on the Central Oregon coast
For more information, click here.
