Healthcare Challenge: To Heal or Die

Fewer hospitals are dealing with more patients, more diseases, more costs, and bigger headaches. The good news is that we have answers! We can save costs while saving lives.

John Shoemaker is President of Shipcom Wireless and has focused on delivering hybrid data capture, RFID, and data management solutions across several industries, including transportation, aviation, government, and, most recently, healthcare with an important contract with the Air Force to create a technology showcase for a major medical center. Formerly VP of Amtech/Subsidiary of Intermec, Executive VP of TransCore, and Senior VP of Matrics and Symbol Technologies, he has extensive experience in the Middle East and Asia. Mr. Shoemaker is also a U.S. Army combat infantry veteran and is committed to leveraging technology to bring improved healthcare for active and retired military personnel. E-Mail: jshoemaker@shipcomwireless.com

Charles Olmeda is a Sr. Project Manager for Shipcom Healthcare Solutions focusing on delivering Automatic Identification Technology solutions to the healthcare industry, most recently as the Project Manager for a contract with a major Air Force Medical Center. Formerly an IBM Systems Engineer, Shared Medical Systems (now Siemens) Healthcare Systems Consultant and First Consulting Group Integration Manager. Before joining Shipcom Mr. Olmeda provided independent healthcare consulting and project management to various healthcare organizations, he has over twenty years in Healthcare Information Technology.E-Mail: colmeda@shipcomwireless.com

From the TV show, “House”, the irascible but brilliant Doctor House tells a class of med students that they will make mistakes and they will lose lives and that they better get used to it or either find another job or become a teacher. The silence in the room was deafening.  Tough words, but unfortunately they are very true.  And the likelihood of making more mistakes that cost lives increases with the rapid introduction of millions of baby boomers as they enter their sixties and seventies. All of this is coming at a time of increasing healthcare costs, fewer numbers of hospitals as consolidation continues from the past decade, lack of an agreed upon national healthcare strategy, the crunch on Social Security and government medical programs like Medicare and Medicaid, and the overall economic malaise we find ourselves experiencing today.

Answers are needed as at the statistics show that as healthcare needs increase, so do the errors, deaths, and lawsuits. DOA has succumbed all too often to DIH or died in hospital. Reports show 90,000 people had avoidable deaths in hospitals last year in the U.S.

Yet, there are answers.  Healthcare beckons innovation.

There is one potential hero that could come to the rescue at a time of great need for the healthcare industry: Hybrid AIDC Technologies for Real Time Visibility (RTV). This is quite a mouthful.

Although most of us are familiar with bar codes (UPC or uniform product codes) and routinely manage them at the supermarket with coupons, or purchases in retail stores or self service POS (point of sale) in places like Home Depot and airline check-in kiosks. Interestingly, hospitals have yet to exploit what is known as automatic identification and data collection (AIDC) and one of its related technologies, RFID (radio frequency identification) which now have electronic product codes, formerly EPC, now GS1 or one global standard for the world.

As a result and one example, President Obama has repeatedly called for a national effort to convert paper documents to secure digital form (EMR or EHR: electronic medical or health records) that will allow uses not currently available in the health care industry, but is routine in other industries.

Bar codes can be used to track items in hospitals, especially medical supplies or pharmaceuticals in inventories, but even that is not commonly used. Just as many third world countries have bypassed the use of wired communications or landlines and have implemented wireless/cell phone technologies; hospitals now have the chance not to necessarily bypass bar codes, but to complement their use where it makes sense while exploiting the wireless world with RFID.

Not all RFID is the same. There is active, battery powered RF; there is passive, non-battery or backscatter RF; and RF used with different frequencies – all dependent on the application. In simple terms, RF Active is used when long range is needed and passive use is best when very low cost tags are needed. Then there is RTLS (real time locating system) that wirelessly transmits signals to read a tag, obtains an ID and then calculates (using triangulation) the location of the tag.  But the list of applications is long, especially when including sensors for temperature, humidity, motion, or chemical presence.

So, for hospitals, we can deploy RFID, Bar Code and other sensor technologies to provide RTV for many specific medical applications. The first priority is to tag the items/people/assets that move or can move that can influence operational decisions.  We have lots of opportunities to leverage these hybrid technologies to a hospital’s operational and financial advantage. Hospitals are bleeding, but they may not know how badly, where or for how long.

Let’s take a look at some specific examples of target applications…

1. 
   
   General Asset Management of Medical and IT Equipment 
   Hospitals across the nation are faced with an equipment financing and management squeeze. The expense of constantly buying new equipment can annually strain the finances of even the best managed healthcare organizations. Medical equipment that is essential to maintaining a high standard of patient care and competitive advantage also involves high cost and the complexity of maintaining and managing equipment that may affect the hospital operations and could divert valuable facility resources away from the core mission of patient care. A hospital, by using RFID or other sensor technologies, could enable the automated collection of asset information including location, maintenance status, and more without a person needing direct line of sight or contact with that asset. Once the sensor technology gathers data, the information is passed to the organization's enterprise or asset management application. As a result, the system may trigger an alert, release a work order, update inventory, conduct inspections, create an invoice or locate an asset.  Hospitals could experience improvements in productivity, reduce costs by implementing automated maintenance schedules rather than an arbitrary calendar-based schedule, increase revenue by accurately valuing assets being used, and increase equipment longevity by identifying usage patterns.
   
   


2. 
   
   Patient Tracking/Flow 
   As the evolution of RFID moves forward, most hospitals are still waiting for continued technology development and for prices to perhaps inch downward. Experts in the industry estimate that only about 200 hospitals out of over 5,600 in the US are using automatic identification technology. Very few have implemented the technology for patient tracking to optimize  patient flows, reduce wait times in waiting rooms and improve patient satisfaction.  A small RFID tag on a patient wristband emits a radio wave that is detected by a network of receivers around the hospital. The system graphically displays the locations on a virtual map of the facility, or in a table view or into a hospital information system (HIMS).  In the few situations where RFID has been implemented, it has mainly been for emergency departments, operating rooms or small pilot programs on a single floor. RFID technology for patient tracking improves and streamlines patient care processes by coordinating crucial events from patient admission to discharge processes, all while improving patient safety by giving hospital staff the real-time data and task coordination tools required to improve patient care.
   
   


3. 
   
   Inventory Control 
   RFID technology has great potential in healthcare to significantly reduce cost, while improving materials management and inventory operations. Cost-conscious industries like retail and manufacturing traditionally have focused on using RFID systems to enhance the efficiency in supply management and logistics processes, including inventory control. Effective inventory management affects costs that can range 45-90% of total expenses. If the use of automatic identification technology can save just a percentage of that cost, the cost saving is real and drives to the bottom line profitability of the hospital. Use of RFID for managing and controlling inventory can provide more control over uses of capital that affects all departments. After all, why buy inventory when it is not needed. Overstocking is expensive. Also, having the right stock available at the right time is critical. A lack of RTV data on stock levels means that stocks often run low or even run out altogether, causing unnecessary disruption to operations. Additionally, staff normally must fill in paper-based forms so that supplies can be distributed to the wards or departments. This can waste valuable staff time and reduce hospital efficiency. RFID can provide real-time data on inventory logistics as items move from storage cabinets in the hospital and out to the wards and individual users, and back to storage if necessary.
   
   


4. 
   
   Bedside Services 
   The escalation of healthcare costs has created market pressure to increase the efficiency of patient care while continuing to increase quality. One means of addressing that challenge has been the advancement of computing solutions in various digital health initiatives. RFID introduces a new approach involving proximity-detection and association of the patient to assets, items, caregivers and other points of concern with automatic detection and presentment.  This approach enables a new generation of patient identification solutions for the healthcare industry that is going “digital”. An integrated patient-identification solution addresses the inefficiencies and potential for human error associated with traditional patient identification. Increased accuracy helps to avoid hospital liabilities associated with bedside services mistakes. While many hospitals are considering technology for patient identification, most hospitals have not considered automated patient association to create an audit trail with automated tracking and tracing and with a system of alarms/alerts when mistakes are anticipated or in progress.
   
   


5. 
   
   Surgical Trays and Instruments, Track & Trace 
   Surgical instrument storage and sterilization systems include surgical instrument trays and kits which typically consist of trays or boxes that hold a variety of general purpose and or specific surgical instruments such as forceps, scissors, clamps, retractors, scalpels, etc. These pre-prepared, surgery-specific instrument trays are brought into the operating room (OR) when preparing for surgery and are used as a means to organize and store surgical instruments. These trays are used to transport medical instruments within a hospital or even in and out of medical facilities. Advances in medical technology have created an enormous increase on the number and type of surgical instruments now in use.  It has become necessary to manage and track these instrument trays more quickly and efficiently to ensure they are properly cleaned and sterilized (autoclave) and that the kit is complete and accurate.  Use of RFID technology is effective for tracking surgical trays and managing the number of instruments within a tray or surgical kit to ensure “right instrument, right kit”.
   
   


6. 
   
   Medication Administration 
   One of the most difficult areas for technology to address is the medication administration process.  This is due to complex staff workflows and procedures - and in many cases, mandate compliance. A fundamental set of requirements that nurses must satisfy on a daily basis is embodied in the 'five rights': getting the right medication, in the right dose, using the right methodology, to the right patient at the right time. Errors in administering medication can have grave impacts on a patient's health.  There are the challenges for nurses of maintaining accuracy on long shifts while juggling multiple patients. Despite the importance of accuracy in meeting this set of requirements, nurses and other caregivers too often must rely upon hand-written orders from doctors, matched up to hand-written or printed ink patient wristbands. Those wristbands may be partially illegible, and the manual transcription of data when they are made can introduce errors. Mismatching patients to the proper care can result in consequences such as incorrect medications or missed doses, use of the incorrect blood type, mixed-up pathology samples and incorrect surgical procedures (e.g., wrong parts of the body operated on or removed). Automatic identification technology complements and may eliminate the use of manual patient identification using somewhat unreliable wristbands, which can reduce the prevalence of errors and improve efficiency. It involves tracking the patient at every stage of their treatment, using a digital means of automatic identification that is machine-read and allows matching the actual patient to their medical chart and physician's orders, plus non-medical aspects of their care such as meals and billing.
   
   

We have presented six areas of opportunity for hospitals to re-examine how they operate and offer more effective and efficient solutions to save costs and lives. Hospitals need to manage multiple business processes, just like any other business. This includes management of medical equipment, medication administration, tracking of blood and specimen and tracking patients from admission to discharge to optimize the patient flow.

We need to make these opportunities visible to hospital management, not only to smooth process flows, but to verify each process step and help prevent problems before they occur. It all starts with collecting relevant, real time information that allows you to analyze what is happening: identify errors, determine what and who are causing errors and then adjusting or modifying processes to resolve these issues.  Hopefully we can assist the medical community with our expertise in providing real time visibility to operational and clinical processes and improve Patient Safety and quality of care and at the same time reduce   costs and errors. We want to heal both the patient and the hospital and keep them both healthy.

Obama gives GOP 6-week deadline to get on board with healthcare package

WASHINGTON – At a White House healthcare summit held Thursday, President Barack Obama urged Republican congressional leaders to consider working on several areas of common interest in the healthcare reform package, giving them a rough 6-week deadline before Democrats may consider using alternative measures to pass the plan.

Obama named health insurance reform, the purchase of health insurance across state lines and medical liability reform among the top three areas where agreement could possibly be reached.

Republicans argued they wanted to scrap all proposals on the table and rework a set of smaller steps to reform healthcare.

For Democrats, starting over is not an option they said, because of the dire situation many Americans face.

According to Sen. Chris Dodd (D-Conn.), 14,000 Americans lose their healthcare daily, while six to eight Americans die per day because of no health insurance.

Democrats said healthcare reform is interconnected and cannot be tackled one step at a time. "We can't handle healthcare incrementally," Dodd said. "It has to be dealt with holistically. You can't get to quality and affordability, if you don't deal with coverage."

Much of the day's debate focused on coverage and whether or not it could be expanded without including more people in the insurance pool.

Sen. Tom Harkin (D-Iowa) said, "If you don't bring more people in together, the only people who get a break are the people who are healthy. People who are sick pay more. Is that what we want in this country?"

Republicans at the summit backed a health reform plan proposed by House Minority Leader John Beohner of Ohio, which would expand healthcare to some 3 million uninsured Americans.

The Democrat House and Senate bills, passed last year, would extend coverage to 30 million.

Sen. John McCain (R-Ariz.) said the unspoken issue overriding the entire summit was the threat of Democrats using an alternative measure to pass a bill with a simple majority, rather than the 60 that would be normally required in the Senate.

The special mechanism, called "reconciliation," was never meant to be used for issues that involve 17 percent of the Gross Domestic Product, as healthcare does, McCain said.

President Obama and Speaker of the House Nancy Pelosi (D-Calif.) would not guarantee that they would not use the method to pass a healthcare reform bill, when asked directly by several Republicans during the summit.

Obama said, "We cannot have another year-long debate about this."

"So the question that I'm going to ask myself and I ask of all of you is, is there enough serious effort that in a month's time or a few weeks' time or six weeks' time, we could actually resolve something," Obama said. "And if we can't, then I think we've got to go ahead and make some decisions and then that's what elections are for."

"We have honest disagreements about the vision for the country and we'll go ahead and test those out over the next several months till November," he said.

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Obama releases his own plan for healthcare reform

WASHINGTON – As Congressional leaders prepare for Thursday's White House summit on healthcare reform, President Barack Obama has released his own version of a healthcare reform plan.

Obama said his plan would put American families and small business owners in control of their own healthcare and build on legislation passed by the House and Senate last year, with a focus on providing health insurance reform "that lowers costs, guarantees choices and enhances quality healthcare for all Americans."

A White House statement on Monday said, "The president has long said he is open to any good ideas for reforming our healthcare system, and he looks forward to discussing ideas for further improvements from Republicans and Democrats at an open, bipartisan meeting on Thursday."

According to the White House, the Obama proposal would make healthcare more affordable, make health insurers more accountable, expand health coverage to all Americans and make the health system sustainable, stabilizing family budgets, the Federal budget and the economy.

"It makes insurance more affordable by providing the largest middle class tax cut for healthcare in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today," according to the White House. "This helps over 31 million Americans afford healthcare who do not get it today – and makes coverage more affordable for many more."

The White House said the Obama plan would also:

• set up a new competitive health insurance market, giving tens of millions of Americans the same insurance choices that members of Congress will have;


• bring greater accountability to healthcare by laying out so-called "rules of the road" to keep premiums down and prevent insurance industry abuses and denial of care;


• end discrimination against Americans with pre-existing conditions; and


• put the budget and economy on a more stable path by reducing the deficit by $100 billion over the next 10 years – and about $1 trillion over the second decade – by cutting government overspending and reining in waste, fraud and abuse.

The plan would also provide significant additional financing to all states for the expansion of Medicaid, eliminating any promised favoritism in bills proposed by Congress.

Data warehousing in healthcare: what is it and why do it?

In its 1996 Data Warehouse Roadmap, the Data Warehouse Institute outlines a number factors which help justify investment in a data warehouse. The Institute envisions these factors as only a starting block and maintains, logically, that every organization needs to review, at greater depth, the benefits of such an investment in its own unique business environment. With this in mind, following is a look at the benefits of data warehousing, using these factors as a framework. But first, what is a data warehouse and how does it differ from a transactional database.?Data Warehouse Defined

A data warehouse is essentially a large-scale central database loaded with information from multiple operating databases, for the express purpose of easy end-user access and decision support. It consolidates disparate data sources, making available the resources to support information generation critical to making strategic business decisions.

A data warehouse differs from a transactional system in that the data it contains is static and updated in a scheduled manner in massive loads. Data from multiple and disparate operational systems is brought into a data warehouse and "normalized." In this new environment, previously prohibitive data formats are stripped away, leaving a virtually limitless, user-friendly, uniform data format. In other words, a data warehouse readies inaccessible, disparate data for transformation into usable business information. This fact alone spawns the majority of the benefits of data warehousing. These benefits include, but are not limited to, the following:

Newly Enabled Workers
Historically, employees in need of strategic information have chosen from a limited number of reports available through MIS, submitted a request, and waited for as long as 30 days to get results. In addition, most healthcare organizations have been burdened by a multitude of disjointed sources of information. With a data warehouse, all of this disparate data can be pulled together and put into the hands of users. A data warehouse is specifically developed to give users the ability to explore data in an unlimited number of ways, accommodating essentially any query a manager could dream up, and providing access to the data sources which are behind the results. A data warehouse affords this ability to an increased number of employees, reduces the MIS report load and provides improved response time.

The user-driven nature of a data warehouse allows for exploration by users with a wide range of computer literacy, providing ready views for less experienced users and drill down and open query capabilities for those with more advanced skills. This benefit is particularly relevant considering the widespread decrease in the numbers of middle managers, who historically played the role of preparing and summarizing data for upper management.

Exposure to New Business Opportunities/Improved Cost Control
There are endless ways management can utilize a data warehouse for business gain. One is user-defined investigative querying. A manager, for example, can investigate resource utilization by a particular group of doctors or for a healthplan's different lines of business. In addition, a data warehouse performs a second, and very valuable, function by examining data for trends and abnormalities which users may not know to look for. In this way, the system can lead users toward hidden business opportunities and cost centers. For example, a data warehouse could assist healthcare organizations in detecting erroneous or fraudulent billing, identify patient or provider trends or uncover seemingly insignificant pockets of loss which, over extended periods, could become significant.

Improved Customer Bond
In addition to the constant pressure to reduce costs, healthcare organizations are increasingly confronted with demands to improve the quality, of care. As is often the case, knowledge is one key to improving the quality of care and thereby improving customer satisfaction. A data warehouse can help healthcare organizations watch trends in patient care and physician practices, utilize quality care measurements, and apply this knowledge for improved customer satisfaction.
For a healthcare organization, however, the patient is only one of many customers. Others include employers, providers, and the government. A data warehouse can help an organization meet the needs of these customers as well through decreased response time and improved reporting. Whether "customers" means patients, providers or whomever, an organization stands to benefit greatly by knowing its customers better.
Precise Marketing Tools
In addition to serving customers better, the knowledge gleaned through a data warehouse can improve a healthcare organization's reach to potential customers. Data warehouse reports can provide solid proof of the benefits the plan can offer, including indications of quality and efficiency of care. These "bragging rights" can help a healthcare organization differentiate itself from its competition. A data warehouse can aid in detecting geographic or demographic segments of the marketplace which remain untapped and help show the best way to reach out to these potential members. In addition, a data warehouse can help managers anticipate changes on the business horizon and assist them in altering their marketing plan accordingly. Finally, managers can utilize a data warehouse to measure the effectiveness of a particular marketing campaign, helping further maximize marketing dollars.

The obvious result of effective marketing and improved customer satisfaction is increased revenue. By engaging in more precise marketing tactics and more effectively meeting the needs of existing customers, an organization can increase its awareness and draw in business, thereby increasing its revenue intake. Also affecting revenue is the decision to enter new markets or offer new products or services.

A data warehouse can bolster revenue in more subtle ways as well. For example, information gleaned from a data warehouse can assist a managed care plan in deciding which type of contract to offer a potential member group. After simulating costs and profitability with different contract options, a healthplan can develop a more targeted proposal for a potential client, not to mention delivering a convincing sales presentation, complete with solid evidence of the plan's merits.

Ability to Respond More Rapidly to Key Business Events
It is important to think of a data warehouse as a strategic business tool. While the warehouse system itself may fall under the heading of information technology, the purpose of, benefits of, and responsibility for a data warehouse fall to management. A data warehouse is only as good as its ability to guide management in making strategic business decisions for the organization. Rapid reporting response and unlimited access to information translate into improved ability to anticipate, guide and respond to changes in a dynamic business atmosphere.

Ability to Respond More Rapially to Market and Technology Trends
By being aware of the marketplace and future trends, a healthcare organization can take advantage of the "first mover" principle, creating ownership of new offerings in the minds of consumers by coming to market first. A data warehouse can also help a healthcare organization forecast the potential profitability of new products and services and extend the life cycles of existing ones by adapting them appropriately. This is, once again, a result of knowing the customer and the marketplace.

Conclusion
While data warehousing is a significant task to undertake, the potential benefits are tremendous. The bottom line, however, is that it can help an organization succeed financially.

Ideally, warehousing should be viewed as an ongoing activity, wherein it is essential for managers to be intricately involved in planning, to reprogram the way they do business, and to make the warehouse an indispensible advisor. By incoporating the technology fully into business practices and by seeking to further apply the information available, a healthcare organization can assure that it is realizing maximum return on its investment in data warehousing.

Data Warehousing:
What's In It For You?
* Newly Enabled Workers
* Exposure to New Business Opportunities/Improved Cost Control
* Improved Customer Bond
* Precise Marketing Tools
* Increased Revenue
* Ability to Respond More Rapidly to Key Business Events
* Ability to Respond More Rapidly to Market and Technology Trends

New Jersey announces multi-payer portal to connect doctors with insurers

TRENTON, NJ – In a development that was compared for its convenience and usefulness to banks' establishment of ATM networks, NaviNet, the country's largest real-time healthcare communications network, announced Thursday it would partner with major health insurers in New Jersey to build a multi-payer portal as a "one-stop shop" for physicians to communicate directly with an array of health plans.

Developed in concert with two insurance trade groups – America’s Health Insurance Plans and the Blue Cross Blue Shield Association – NaviNet's Insurer Connect will offer providers easy communication with five of New Jersey's largest insurers: Aetna, AmeriHealth New Jersey, Cigna, Horizon Blue Cross Blue Shield of New Jersey, and United Healthcare.

"We absolutely believe that our coming together to use the NaviNet provider portal will be making better use of doctors' times and their staffs' times, will streamline services to our members and ultimately will improve quality and reduce costs," said Christy Bell, senior vice president of healthcare management for Horizon Blue Cross Blue Shield of New Jersey, on a conference call.

Doctors in New Jersey spend an average of $68,000 annually simply checking referrals and benefit eligibility, and ensuring their patients are enrolled in the correct plans, it was noted. Such expensive, "time-intensive, redundant administrative tasks add no value to the healthcare system, and [are of] no direct benefit to patients," said Sal Bernardo, MD, of the New Jersey Academy of Family Physicians, who uses the portal. "It's an "excessive amount of time on paperwork that could otherwise be spent on direct patient care."

Working to obviate that administrative burden of all those phone calls and faxes is the aim, said NaviNet president and CEO Brad Waugh. "We’ve seen positive feedback and results from the more than 50,000 New Jersey providers that already use NaviNet on behalf of 95 percent of the state’s commercially insured population, so we’re confident that this initiative will improve efficiencies as well as deliver a foundation for a comprehensive national health information exchange.”

"Over the years," noted Bell, "healthcare has become very complex, with inherent tensions built into the system, and that's eroded trust between the parties that really do need to work together. [There are] many different carriers doctors have to deal with, different coverages they have to deal with, and these different coverages may have different rules….  This collaboration will reduce that complexity and improve interactions and relationships."

“In order to ensure our patients receive the best possible care in a timely manner, family physicians are always eager to find a more uniform, efficient and cost effective manner in which to exchange patient information with health plans," said Stephen Nurkiewicz, MD, president, New Jersey Academy of Family Physicians. "In this current healthcare delivery system, family medicine and other primary care practices must make a significant investment in their front desk staff time managing these types of communications with multiple health plans in New Jersey.  We are hopeful that the NaviNet Web-based portal will provide a uniform means to interact with health plans and access a broad range of information for our patients from a single Web site in real time."

iPhone app to keep track of alcohol units

The NHS has launched a free iPhone app to let people keep track of how much alcohol they are drinking.

By Rebecca Smith, Medical Editor
Published: 6:45AM GMT 01 Dec 2009

Drinkers will be able to keep track of their units with a new iphone app launched by the Department of Health Photo: PAUL GROVER

The new application was launched by Gillian Merron, public health minister, as the festive party season gets under way to help people keep track of their alcohol consumption.

The device which can be downloaded onto smart phones like the iPhone, will allow users to see how many units of alcohol there are in their drink, keep a running total of their consumption and get personalised feedback on their drinking habits.

Studies have shown that people underestimate how much alcohol they have drunk on a night out and may exceed the safe limits without realizing it.

Recommended limits are two to three units a day for women - the equivalent of a medium to a large glass of wine - and three to four a day for men - a large glass to a glass and a half, or two pints - with at least two alcohol-free days a week.

Because of the increasing strength of alcoholic drinks and the trend for larger measures, one large glass of wine now counts as three units, a medium glass as two and a small glass as one-and-a-half.

Research earlier this year by Government statisticians showed more than 7 million middle-class drinkers are putting their health at risk by enjoying evenings at home with a bottle of wine.

Public Health Minister, Gillian Merron said: “It is all too easy to lose track of how much you drink. So as the festive parties start to build up, this innovative tool will help people keep tabs on their drinking – wherever they are.

“It’s one of many ways the Government is helping people to understand how much they are drinking. Sticking within the NHS recommended limits means you reduce the risk of serious conditions such as mouth cancer and strokes.”

Chris Sorek, Chief Executive of Drinkaware, said: “Efforts to help people keep track of how much they’re drinking over the festive season and throughout the year are a good idea. Trying to stick within the daily unit guidelines will help people avoid the January slump and the long term health implications associated with drinking too much alcohol.”

The app is available from iTunes and www.nhs.uk and people who do not have a smart phone can text the word UNIT to 64746 and receive information on the NHS Choices alcohol unit calculator.

The application can be found at:http://www.nhs.uk/Tools/Pages/NHSAlcoholtracker.aspx

Four Critical Steps Insurers Must Take Now

Les Masterson, for HealthLeaders Media, August 5, 2009

With a public insurance option hanging over their heads and a sputtering employer-based market, health insurers are rightfully concerned about their future. But there is another issue slated for 2013 that could prove as difficult for health insurers.

On October 1, 2013, the Department of Health and Human Services will mandate that healthcare companies comply with ICD-10 diagnosis and inpatient hospital procedure codes.

Health insurers are understandably edgy just thinking about the breadth of this change. This transformation will potentially touch nearly all operational systems and procedures, according to Deloitte Consulting LLP, which recently joined forces with America's Health Insurance Plans to serve as its ICD-10 and 5010 training partner.

Deloitte said ICD-10 implementation requires a "massive wave of system reviews, new medical coding or extensive updates to existing software, and changes to many system interfaces.

"Because of the complex structure of ICD-10 codes, implementing and testing the changes in EMRs, billing systems, reporting packages, decision and analytical systems will require more effort than simply testing data–it will involve installing new code sets, training coders, re-mapping interfaces and recreating reports/extracts used by all constituents who access diagnosis codes," said Deloitte in its ICD-10: Turning Regulatory Compliance into Strategic Advantage.

Just how large is the ICD-10 change over? It should easily surpass the Y2K system upgrades of 1999-2000. David Biel, principal of the ICD-10 service offering for Deloitte in Chicago, says this is because health plans will have to deal with business processes and staffing. In other words, ICD-10 is more than technological improvements. "These codes are embedded in all of their financial transaction systems as well as their clinical systems. In order to order a drug in a hospital, you need to have a diagnosis. All of those things are going to change. This means huge people changes and huge training issues that they will have to deal with," he adds.

But with the ICD-10 changeover also comes an opportunity. Deloitte said ICD-10 could be a "potential platform for future strategic innovation." Though most health insurers will simply comply with the ICD-10 standards, Deloitte estimated that 10 to 15% of health insurers will become "innovators." Deloitte predicts that these innovators will "approach ICD-10 compliance as a strategic initiative and, as a result, could increase patient satisfaction and quality of care, while moving their business and clinical model into new markets."

To become an innovator, however, health insurers will need significant capital and personnel investments, which many insurers might not be able to achieve. What's important is to think of the ICD-10 change not as merely a bottom line concern, says Biel. "We're out in the market talking to a lot of insurers about ICD-10, and they're a number of them asking, 'what can I get out of this' rather than just thinking of costs," he says.

One potential benefit for health plans is having more accurate and a wider breadth of health data. This could help insurers learn more about member health issues and could allow insurers to break down the data into smaller groups for more targeted interventions. This could especially help disease management and care management programs find at-risk members and link them to programs that could improve their health outcomes.

Whether a health plan wants to merely comply or become an innovator, the company needs to prepare now. The North Carolina Healthcare Information and Communications Alliance, Inc., and The Workgroup for Electronic Data Interchange recently released a timeline for ICD-10 preparation. The groups estimate that it could take four years for providers to implement ICD-10.

Biel concurs with the assessment. "Even though we're four years away technically, the magnitude of the change is large enough that if you don't start looking at the impact now, then you won't have created a budget for 2010 to start the process," he says.

So, what can health insurers do now? Biel offers these four steps:

1. Review your technology to understand the impacted areas and how they are embedded in your systems.
   

• Conduct an operational assessment to see the business processes that are touched by this change.


• Conduct a people assessment to see the people who will need training in ICD-10.


• Conduct a strategic assessment and figure out how your company wants to handle ICD-10 (i.e. comply, collaborate, or innovate) and review what would go into each option.

But don't wait to start this process. If your company has not already started the process to implement ICD-10, you are already behind your competitors. Get to work now.
"I believe all health plans before the 2010 budgeting cycle should have an idea of what the impact is, what their road map is to compliance, and how much they need to budget over the next three years—especially the next year," says Biel.

Facing End-of-Life Talks, Doctors Choose to Wait

It’s a conversation that most people dread, doctors and patients alike. The cancer is terminal, time is short, and tough decisions loom — about accepting treatment or rejecting it, and choosing where and how to die.

When is the right time — if there is one — to bring up these painful issues with someone who is terminally ill?

Guidelines for doctors say the discussion should begin when a patient has a year or less to live. That way, patients and their families can plan whether they want to do everything possible to stay alive, or to avoid respirators, resuscitation, additional chemotherapy and the web of tubes, needles, pumps and other machines that often accompany death in the hospital.

But many doctors, especially older ones and specialists, say they would postpone those conversations, according to a study published online Monday in the journal Cancer.

It’s not entirely clear whether these doctors are remiss for not speaking up — or whether the guidelines are unrealistic. Advice that sounds good on paper may be no match for the emotions on both sides when it comes to facing patients and their families and admitting that it will soon be over, that all medicine can offer is a bit of comfort while the patient waits to die.

Dr. Nancy L. Keating, the first author of the study and an associate professor of medicine and health care policy at Harvard, said not much was known about how, when or even if doctors were having these difficult talks with dying patients. But she said that her research team suspected that communication was falling short, because studies have shown that even though most people want to die at home, most wind up dying in the hospital.

The researchers surveyed 4,074 doctors who took care of cancer patients, instructing them to imagine one who had only four to six months left, but was still feeling well. Then the doctors were asked when they would discuss the prognosis, whether the patient wanted resuscitation or hospice care, and where he or she wanted to die.

The results came as a surprise: the doctors were even more reluctant to ask certain questions than the researchers had expected. Although 65 percent said they would talk about the prognosis “now,” far fewer would discuss the other issues at the same time: resuscitation, 44 percent; hospice, 26 percent; site of death, 21 percent. Instead, most of the doctors said they would rather wait until the patients felt worse or there were no more cancer treatments to offer.

They were not asked for their reasoning, but Dr. Keating offered several possibilities. One is that doctors may disagree with the guidelines, which are based on expert opinion rather than data.

“Or they may not be comfortable discussing it,” she said. “These conversations are time-consuming and difficult. Some doctors may feel patients will lose hope. It’s easier to say, ‘Let’s try another round of chemotherapy,’ instead of having a heart-to-heart discussion.” Training may also be a factor, Dr. Keating said. Medical schools spend more time on end-of-life issues than they did in the past, and the greater willingness of younger doctors to broach the subject may reflect that change.

Dr. Daniel Laheru, an associate professor at the Kimmel Cancer Center at Johns Hopkins and a specialist in pancreatic and colorectal cancers, said he was not surprised by the study.

“The natural tendency is not to provide more information about this than you have to,” he said. “It’s such an uncomfortable conversation and it takes such a long time to do it right.”

He added, “People come to us with hope, and if you kind of yank that away from them right away, it’s very unsettling.”

A terminal diagnosis plus the grim details of “do not resuscitate” orders and hospice care may be too much for a patient to hear in one day. Dr. Laheru said he tried to prepare patients on their first visit for the idea that during later visits they would discuss different possible outcomes.

“They don’t always hear that part,” he said.

Dr. John Boockvar, a neurosurgeon at NewYork-Presbyterian/Weill Cornell Medical Center who treats many patients with malignant brain tumors, said he favored postponing such discussions until the end was drawing close. During his own late father’s illness with leukemia, he said, his family was upset by an oncologist who brought up end-of-life issues early.

“As a patient and a family member, I don’t know if I would have wanted to hear a doctor say, ‘In 18 months we’ll be dealing with hospice or end-of-life discussions — do you want to have that discussion now?’ ” Dr. Boockvar said. “I don’t know what the emotional benefit is to the family. I don’t think it’s been studied.”

As a doctor treating patients who are terminally ill, he went on, he did not hesitate to discuss end-of-life issues. But he said, “As the time approaches, there’s usually ample time.”

But Dr. David R. Hilden, an internist at Hennepin County Medical Center in Minneapolis and an assistant professor of medicine at the University of Minnesota, is not so sure.

“I think many of us wait until there’s just a few weeks left and then you have no choice,” he said. “It’s going to happen in a week or two, and they’re in the hospital and they’re on their last legs. The time to talk is much earlier.”

Without planning, Dr. Hilden said, dying patients may wind up in exactly the situation they dreaded most, tethered to machines in a hospital instead of being kept comfortable at home in their own beds.

“This last week, I had a patient with prostate cancer and end-stage heart disease, who probably has less than a year,” he said. “I talked to him and his wife. ‘How do you want your remaining days to be? How much do you want us to do?’ He and his wife were very receptive. Many patients appreciate it. We had a good conversation. It’s easier when the patient is older and it’s not entirely unexpected. He’s 86.”

The patient said he did not want tubes or machines, but just wanted to be comfortable for his last few months.

“They were at peace with it,” Dr. Hilden said, adding that many patients who get aggressive treatment for advanced cancer might in retrospect have made a different choice.

“They might say: ‘After that last three or four months of radiation and chemotherapy, I’m sick, I’m nauseated, my hair fell out and it didn’t extend my life. I might not have done it if I’d known, if I had had the chance.’ ”

Dr. Keating agreed, saying she thought that often when terminally ill patients choose to continue chemotherapy, they don’t understand its limits.

“They say, ‘I want to do everything,’ and they mean ‘everything to cure me,’ ” she said. “They don’t understand it’s not curative.”

Despite the difficulties, she went on, doctors should level with their patients.

“When you know someone’s going to die of their disease, it’s only fair to the patients to help them understand that,” Dr. Keating said. “But these conversations are very challenging. Figuring out how to do it well — it’s so tricky. It’s definitely not something everybody believes in.”

HHS unveils nation's first health security strategy

WASHINGTON – Health and Human Services Secretary Kathleen Sebelius has unveiled The National Health Security Strategy, focused on protecting people's health during a large-scale emergency.

Sebelius said the "comprehensive" document, the first for the nation, sets priorities for government and non-government activities over the next four years.

"As we've learned in the response to the 2009 H1N1 pandemic, responsibility for improving our nation's ability to address existing and emerging health threats must be broadly shared by everyone – governments, communities, families and individuals," Sshe said. "The National Health Security Strategy is a call to action for each of us so that every community becomes fully prepared and ready to recover quickly after an emergency."

National health security focuses on preparing for health threats or incidents with potentially negative health consequences, such as bioterrorism and natural disasters. The strategy provides a framework for actions designed to build community resilience, strengthen and sustain health emergency response systems and fill  gaps in healthcare delivery.

"Events which threaten the health of the people of this nation could very easily compromise our national security. Whether it's a pandemic or a premeditated chemical attack, our public health system must be prepared to respond to protect the interests of the American people. In order to be prepared to both respond to an incident and to recover, we need a strong national health system with individuals and families ready to handle the health effects of a disaster," Sebelius said.

The National Health Security Strategy and an accompanying interim implementation guide outline 10 objectives to achieve health security:

1. Foster informed, empowered individuals and communities.


2. Develop and maintain the workforce needed for national health security.


3. Ensure situational awareness so responders are aware of changes in an emergency situation.


4. Foster integrated healthcare delivery systems that can respond to a disaster of any size.


5. Ensure timely and effective communications.


6. Promote an effective countermeasures enterprise, which is a process to develop, buy and distribute medical countermeasures.


7. Ensure prevention or mitigation of environmental and other emerging threats to health.


8. Incorporate post-incident health recovery into planning and response.


9. Work with cross-border and global partners to enhance national, continental and global health security.


10. Ensure that all systems that support national health security are based upon the best available science, evaluation and quality improvement methods.

The National Health Security Strategy also highlights specific actions that the nation – including individuals, communities, non-government organizations and government agencies – should take to prevent, protect against, respond to and recover from health threats.

Those actions include conducting a review to improve the system for developing and delivering countermeasures such as medications, vaccines, supplies and equipment for health emergencies; coordinating across government and with communities to identify and prioritize the capabilities, research and investments needed to achieve national health security; and evaluating the impact of these investments.

Federal, state, local, tribal and territorial government agencies, as well as medical, public health and community-based organizations, collaborated to develop the strategy and interim implementation guide. To determine additional issues and themes the strategy should address, the HHS solicited input from non-federal participants during six regional workshops. HHS officials also worked with the Institute of Medicine to engage the medical community.

The Pandemic and All Hazards Preparedness Act directed the HHS secretary to develop the National Health Security Strategy with an accompanying implementation plan by 2009 and revise the documents every four years. The HHS, however, will update the implementation plan every two years to reflect advances in public health and medicine.

Obama Urges Excise Tax on High-Cost Insurance

WASHINGTON — President Obama told House Democratic leaders at a meeting on Wednesday that they should include a tax on high-priced insurance policies favored by the Senate in the final version of far-reaching health care legislation, aides said.

The White House has long expressed a preference for the excise tax on high-cost plans, which health economists say could be an important tool in controlling long-term health care spending for the government and for individuals and families.

But House Democrats have resisted the idea, which is also strongly opposed by many organized labor groups — an important part of the party’s base — because the tax may hit a number of more generous union-sponsored health plans.

The Senate proposal would impose a 40 percent excise tax on the cost of individual insurance policies above $8,500 and on family policies above $23,000, with higher thresholds for retirees and employees in high-risk fields like police officers.

The tax would raise $149 billion over 10 years, according to the Congressional Budget Office. The Senate bill would cost $871 billion over 10 years, while the House bill would cost nearly $1.1 trillion.

The meeting among Mr. Obama, Speaker Nancy Pelosi and top committee chairmen responsible for the health care bill came as Congressional leaders have stepped up efforts to reconcile differences between the House and Senate bills.

Ms. Pelosi, emerging from the meeting, said she expected those differences to be worked out soon.

“We have had a very intense couple of days with meetings in our leadership, meetings with our staff,” she said. “After our leadership meeting this morning, our staff engaged with the Senate and the administration’s staff to review the legislation, suggest legislative language. I think we’re very close to reconciliation.”

Mr. Obama has mostly tried to avoid taking public positions on potential disputes between the chambers, to the point that some lawmakers, including some Congressional leaders, have complained that the White House has not provided enough guidance.

Instead, the president and some of his advisers have talked circuitously about what they believe to be some of the more useful policy goals.

The budget director, Peter R. Orszag, for instance, has repeatedly extolled the potential economic merits of the proposed tax on high-cost insurance plans, as well as an independent agency to recommend potential government savings in Medicare.

Both of those ideas were included in the Senate bill, but not the House measure.

Senate Democrats are generally believed to have greater leverage in the negotiations to reconcile the two bills because they cannot afford to lose a single vote and some centrists have warned that they would turn against the bill depending on how it changes.

The Senate approved its bill on a party-line vote, 60 to 39, on Dec. 24.

But the House does not have much wiggle room either. It approved its bill on Nov. 7 by a vote of 220 to 215, with just one Republican joining 219 Democrats in favor. That means Ms. Pelosi could spare just two votes without jeopardizing the bill’s chances.

Among the big differences between the two bills are the provisions to pay for the legislation. Both measures rely on huge reductions to slow the growth in government spending on Medicare.

The Senate also proposed an increase in the Medicare payroll tax for individuals earning more than $200,000 and couples earning more than $250,000. The House proposed an income surcharge on individuals earning more than $500,000 and couples earning more than $1 million.

Joining Mr. Obama and Ms. Pelosi at the meeting on Wednesday were the principal authors of the health care bill: Representative George Miller of California, the chairman of the Education and Labor Committee; Representative Charles B. Rangel of New York, the chairman of the tax-writing Ways and Means Committee; and Representative Henry A. Waxman of California, chairman of the Energy and Commerce Committee.

Representative Louise Slaughter of New York, the chairwoman of the House Rules Committee, also attended.

Mr. Rangel, who has expressed frustration at the pressure on the House to defer to the Senate, said he appreciated Mr. Obama’s time and attention.

“The president has been very patient with his time and understanding that we have to get 218 votes and we really have to be able to sell it — not just to our Democratic caucus, but to the American people,” Mr. Rangel said. “And we could not have asked the president to be more cooperative — even though he’s doing more listening than talking.”

Mr. Obama may have little choice but to emerge from listening mode in the days ahead. Senate leaders return to Washington next week, and pressure will only mount on him to help broker the final differences between the bills.