The ever-increasing role of technology in healthcare will bring security and privacy challenges into the forefront for physician practices in 2009. Consider the following expert predictions.
Disaster recovery planning. Disaster recovery planning has always been a challenge, but it will pick up steam in 2009 because of the continued automation of healthcare records in the industry, says William M. Miaoulis, CISA, CISM, manager of HIPAA Security Services at Phoenix Health Systems in Montgomery, AL. To know whether your current disaster plan is up to par, Miaoulis says providers must first ask themselves these important questions:
If your computer systems went down, would you have access to medication history and lab results?
What would be the effect to your current patients?
Would the way you deliver care be affected?
Minimum necessary standard. The minimum necessary standard, a key protection of the HIPAA privacy rule, requires covered entities to make reasonable efforts to limit protected health information (PHI) to the minimum necessary.
The challenge is defining what is "reasonably necessary" and determining how you will manage these uses, disclosures, and requests.
The minimum standard doesn't apply when information is:
Requested by a provider for treatment
Authorized by the patient
Needed by the Department of Health and Human Services or the Office for Civil Rights for a complaint investigation or compliance review
Required by law
Required for HIPAA compliance
Security audits. The Office of Inspector General (OIG) released a report October 27, 2008, regarding how well CMS is enforcing the security rule.
Although the OIG's report did not specifically state whether the OIG has scheduled another performance review, it is highly likely it will revisit CMS' progress and activity in carrying out its HIPAA enforcement responsibilities, which should signal a red flag for organizations, says John Parmigiani, MS, BES, president of John C. Parmigiani & Associates, LLC, in Ellicott City, MD, and chair of the team that created the HIPAA security rule.
Organizations need to be aware that CMS and the OIG are continuing to audit for HIPAA security compliance. Health information technology initiatives, increased consumer awareness of data losses, and a new administration are additional drivers for increased compliance with healthcare privacy and security safeguards enforcement. Organizations may need to increase the money and internal resources they set aside for security compliance, says Parmigiani.
Medical identity theft. Healthcare organizations should also be aware of the Federal Trade Commission's Identity Theft Red Flags rule under the Fair and Accurate Credit Transactions Act of 2003 (FACTA), says Miaoulis, adding that the regulation requires many healthcare organizations to implement programs to prevent and detect identity theft by May 1.
To mitigate the risk of identity theft, Miaoulis says organizations should take the following steps:
1. Research the FACTA Identity Theft Red Flags rule.
2. Implement the HIPAA minimum necessary standards to include demographic information. "Specifically, organizations should inventory which systems maintain the Social Security numbers and patients' birth dates," Miaoulis says.
3. Determine who has access to information and whether access is appropriate. For roles that require the use of patients' Social Security numbers, determine whether limiting access to the last four or five digits of the number would be sufficient. Organizations could also consider limiting the use of patients' birth dates, Miaoulis says, noting that it may not compromise patient care to see someone was born in May 1970 versus May 15, 1970.
Editor's note: This article was adapted from one that originally appeared in the January issue ofBriefings on HIPAA, a publication from HCPro, Inc.
As expected, there was a lot of talk about the economic recession at the American Medical Group Association's annual conference in Las Vegas last week. I could barely walk between sessions without hearing someone ask, "Did you see how much the stock market dropped today?" And I heard from plenty of physicians and practice managers about budget strains and areas they have been forced to cut.
But attendees didn't travel to Caesar's Palace (a surreal place to be given the current economic climate) to talk about cutting budgets. They were there to learn where and how to invest the limited resources that remain in this challenging environment. Leaders are being forced to trim operating expenditures, but they must be careful not to cut the legs out from under the organization while doing so.
For me, the most important takeaway from the more than three days I spent at the conference was a phrase delivered by Tanya Chermak from Harvard Vanguard Medical Associates before the conference officially began.
"Leadership training and development can't be cut, even in hard economic times," she said during a presentation that was part of a day-long, pre-conference physician leadership workshop.
Some areas require more, not less, investment in a recession, and for many attendees and presenters in Las Vegas, physician leadership was one of those areas.
It isn't just enough to search for physicians with leadership potential or support existing leaders. Organizations are spending money to actively train physicians for leadership roles ranging from clinical department heads to vice presidents and CEOs.
They're teaching physicians to be better leaders the same way you teach almost any subject: In a classroom.
Harvard Vanguard was just one of several organizations experimenting with regular leadership classes designed to train physicians business and leadership skills. Chermak started Harvard Vanguard's leadership academy with 19 physicians in February of last year, and it has grown in popularity—the latest class has nearly 40 participants.
Physicians are nominated by department heads to add an element of prestige to the academy, and a mix of in-house experts and external consultants teach classes ranging from basic economics ("running a lemonade stand") to dealing with disruptive doctors and managing more complicated budgets.
Nancy J. Gagliano, MD, vice president for practice improvement for Massachusetts General Physicians Organization, has developed a similar program that provides a monthly, four-hour class for selected physicians over a two-year cycle. So far, the results have been overwhelmingly positive, she says. Each month, budding leaders come to class with stories about how a previous class has already helped them manage a problem within their department. After a class on how to talk to disruptive physicians, one participant was able to diffuse a situation with an older doctor in his department who had been clashing with nursing staff, for instance.
Johnathan Schwartz, MD, MBA, director of managed care for Henry Ford Medical Group talked about a "managed care college" that teaches physicians basic business concepts, including acronyms and the fundamental language used in budgets and other business transactions.
I could go on. There were a wide range of approaches to leadership development at the AMGA workshop, but the common thread was recognition that the transition from physician to physician leader isn't one that often happens without guidance.
As organizations undergo major changes, driven both by the markets and by federal healthcare reform, leadership in all forms is an increasingly valuable asset—which perhaps explains why the Commission on Accreditation of Healthcare Management Education is seeing substantial increases in applicants.
Medical groups and hospitals that continue to invest in developing physician leaders at all levels will see the rewards as delivering healthcare becomes even more complex.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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When the topic is the ongoing shortages of necessary personnel at hospitals, clinics, and physicians offices, the professionals that come immediately to mind are physicians and nurses. However, athletic trainers and other healthcare professionals are qualified to fill the role of physician extender.
Many clinics are now hiring physician extenders in their practices in order to save time and improve patient satisfaction, increase revenue, enhance physician productivity and efficiency, and educate patients about treatment plans.
Far from the athletic fields, athletic trainers and other physician extenders help improve productivity, patient outcomes, and satisfaction at clinics and hospitals nationwide. That's why they are so often employed in physician offices and specialty practices, including by specialists in orthopedics, osteopathy, family practice, pediatrics, and sports medicine.
In 2006, nearly 34% of athletic trainers worked in hospitals, clinics, and physician offices, according to National Athletic Trainers' Association. The Bureau of Labor Statistics expects athletic trainers' employment to grow 24% between 2006 and 2016—much faster than the average for other occupations.
Because athletic trainers tend to be less rushed than surgeons and other physicians, they have more time to spend with patients, providing them with post-injury or post-surgical rehab programs.
Athletic trainers' vital role in hospitals, clinics, and physician offices
In their growing role as physician extenders athletic trainers help physicians increase their productivity and efficiency. "Athletic trainers are a committed, essential component to physicians delivering the highest standard of team medical care to the patients of the Andrews Institute," says James Andrews, MD. "They know how to relate to the patient so his or her recovery is as quick as safely allowable, whether that person is a professional or youth athlete or just an average mom or dad."
According to NATA, a 1998 time-to-task study showed that athletic trainers working as physician extenders increased clinic production by 12 patients per day. The athletic trainer serves a vital role in the clinical setting by reducing re-injury rates through patient instruction, reducing recovery time from non-surgical injuries, and rehabilitating musculoskeletal injures.
"My patients experience excellent outcomes as a result of therapy provided by athletic trainers," said Thomas D. Kohl, MD, director of sports medicine at the Comprehensive Athletic Treatment Center in Pennsylvania. "My patients love working with them. Athletic trainers are a value-added service to my practice. I could not do without them."
Professional training leads to better healthcare coordination
Athletic trainers earn a bachelor's education and national certification that enables them to work closely with physicians and other medical professionals to develop better-coordinated, efficient, and responsive healthcare in a team environment. And their training equips them with the expertise needed to perform immediate and emergency injury management, injury assessment, and rehabilitation.
"I believe that athletic trainers provide a critical service as physician extenders in the doctor's office, and I work with them daily in that role," said John Xerogeanes, MD, at Emory Sports Medicine Center in Atlanta.
Athletic trainers' professional preparation is based on the development of specified educational competencies and clinical proficiencies. Through a combination of formal classroom and clinical instruction complemented by clinical experience, athletic trainers are prepared to provide healthcare within each of the following content areas:
Risk management and injury prevention
Pathology of injuries and illnesses
Orthopaedic clinical examination and diagnosis
Medical conditions and disabilities
Acute care of injury and illnesses
Therapeutic modalities
Conditioning, rehabilitative exercise and referral
Pharmacology
Psychosocial intervention and referral
Nutritional aspects of injury and illnesses
Healthcare administration
Until recently the relationship between physicians and athletic trainers has been on the sports playing field, where for years they have partnered in delivering healthcare to athletes. However, the increased need for providers during this shortage, means increased number of athletic trainers moving into the physician clinical setting, too.
Case Study: Emory Sports Medicine Center
In an effort to evaluate the benefit of employing certified athletic trainers, Emory Sports Medicine Center implemented a study to determine the financial and clinical effectiveness of using them as the primary clinical assistant in the orthopedic office.
"Athletic trainers help enhance a physician's communication with patients by serving as another source of expert information that patients can absorb," says Xerogeanes. "Athletic trainers are a key part of our sports medicine service delivery model."
By comparing the number of patient encounters and bill charges of two primary care physician practices—both before and during the introduction of a certified athletic trainer—it was shown that certified athletic trainers had a positive effect on patient throughput and revenue. Results showed that certified athletic trainers can increase a physician's productivity up to 23% and increase revenue by up to 42%.
"The use of certified athletic trainers has allowed us to better leverage our non-operative physicians, thus increasing productivity and professional billings," says Mark Miller, senior clinical administrator at Emory. "Over a six-month study period, we have seen improvements in provider productivity, as measured by encounters, on the order of 22%."
Athletic Trainers: Education, National Certification
Athletic trainers must have a minimum of a bachelor's degree (and seven in 10 have a master's degree or higher), and in most states, they must maintain certification through the Board of Certification, an organization independent of NATA. Certified athletic trainers differ from "personal trainers" who focus solely on fitness and conditioning and whose training does not require a college degree.
Before being certified, those hoping to become athletic trainers must complete an academic major or graduate-equivalent program that is accredited by the Commission on Accreditation of Athletic Training Education (CAATE).
Athletic training programs use a medical-based education model in both classroom and clinical settings that teaches students to provide comprehensive preventive services and care in six domains of clinical practice: prevention, clinical evaluation and diagnosis, immediate care, organization and administration, professional responsibility, and treatment, rehabilitation, and reconditioning.
Program graduates then take the Board of Certification (BOC) exam in order to be credentialed as a certified athletic trainer. The ATC credential is recognized and required by all but one state that regulate or license the practice of athletic trainers. They are licensed or recognized in 46 states.
Marjorie J. Albohm, MS, ATC, is president of the National Athletic Trainers' Association. To learn more about athletic trainers, contact the National Athletic Trainers' Association at 800-879-6282, or visit the NATA Career Center directly at www.NATA.org/careercenter.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Each day, patients trust physicians to make decisions about how to best treat illnesses. Physicians trust hospitals to provide them with the most effective medicines and medical equipment. Hospitals trust manufacturers to produce the most reliable, innovative healthcare products. Together, the healthcare industry shares a responsibility to honor this trust by abiding by the highest ethical standards.
Successful ethical standards help ensure that relationships among these healthcare actors are appropriate and transparent. Relationships between manufacturers and providers yield mutual benefits that positively affect patient outcomes. But when financial relationships that could influence decision making are established and not disclosed, a line has been crossed that can shatter patient confidence and damage credibility in an industry that depends on maintaining trust.
Understanding this reality, a groundswell of disclosure initiatives have started to emerge.
Universities such as the University of Pennsylvania and large hospital systems like the Cleveland Clinic recently started voluntarily disclosing all manufacturer payments to physicians. The top five makers of hip and knee implants have agreed to disclose all payments to physicians, and Eli Lilly, GlaxoSmithKline and Merck say they will follow suit next year. The Pharmaceutical Research and Manufacturers of America and the Advanced Medical Technology Association, two of the largest associations representing drug and device manufacturers, respectively, strengthened their codes of conduct related to gifts and other payments, and will make public the list of members who abide by the new guidelines. And, most recently, Senators Charles Grassley (R-IA) and Herb Kohl (D-WI) have re-introduced the Physician Payment Sunshine Act that would require manufacturers to disclose payments of value to physicians.
These and other disclosure efforts, when effectively executed, create transparency and can drive a more empowered culture of ethics. But today's efforts are not as comprehensive as they could be.
Trust requires that virtually every healthcare industry organization create a systematic process to ensure that all dimensions of this critical issue are thoroughly addressed.
Healthcare companies need to be regularly measured against their industries' ethics codes. Codes of conduct and the measures created to ensure compliance must be publicly disclosed. Participating companies should be benchmarked against one another to identify gaps and best practices. An external oversight body of experts in the field should provide input into the ethics and compliance process. Information about ongoing compliance should be publicly reported on a regular basis. And clear and understandable rules should be developed to punish those who fail to comply.
The Premier healthcare alliance, a healthcare group purchasing organization (GPO), has a high-level commitment to transparency, best practices in accountability and business ethics. Demonstrating that commitment, Premier led an effort to form an effective voluntary ethics oversight organization called the Healthcare Group Purchasing Industry Initiative (HGPII). HGPII provides a model for other healthcare organizations in creating a comprehensive, self-regulating program.
Developed with guidance from Kirk Hanson, a longtime consultant to industry ethics efforts and professor of business ethics, HGPII exhibits key elements of an effective voluntary effort. HGPII requires participants to follow six core ethical principles. Adherence to the principles must be documented in an annual accountability questionnaire, which is reviewed by a third-party ethics expert and updated or expanded each year to ensure it is reflective of emerging issues and ethical best practices. All responses to the questionnaire are posted publicly on the Web.
HGPII members must also participate in an annual Best Practices Forum to share business conduct practices with other GPOs and representatives from government or other organizations. HGPII plans to expand the current model to be governed by a third-party external advisory board, and to embrace third-party auditing. Failure to follow the HGPII recommendations carries the penalty of expulsion, which would raise questions about that GPO's commitment to ethics and affect its ability to attract customers.
Through HGPII, we have learned that industry ethics that are reinforced by external oversight, measurement, and reporting are effective. With HGPII's transparent system, the public can evaluate financial and business interactions to ensure they are in the best interest of hospitals and patients. In this way, GPOs are earning greater levels of trust.
Many healthcare organizations have implemented ethics programs and strategies, but the current climate demands industry-wide efforts, such as those undertaken by HGPII. Anything less will fail to convince a skeptical public that we are worthy of their trust. We need to commit to extra efforts to reassure consumers that we are serious about enforcing ethical behavior, and that we are doing everything possible to avoid impropriety.
With concerns about integrity at a critical point, and with a national healthcare debate on the horizon, we must ensure trust in the current system. We must heal ourselves first.
This is becoming one of those "get over it" moments for healthcare professionals. You can resist the notion all you want; the fact is patients more and more see themselves as consumers, and that's not necessarily a bad thing.
Sure, you might look back fondly on those paternalistic Marcus Welby days, when a patient not only knew his doctor's name, but took the physician's word as gospel. But the good Dr. Welby was canceled a long time ago, and today far too many people have limited access to care, or their employers are shifting more of the cost onto them.
With large employers, like GM, wrangling to get out of the bad business of paying for healthcare, it probably should not have surprised me that our new HealthLeaders Media Industry Survey reports that top healthcare executives say consumer-directed healthcare offers the best hope for the industry. (See below.)
Survey responses of 1,119 senior healthcare executives: In your opinion, which model offers the best hope for healthcare?
33.6% - Consumer-directed healthcare
25.11% - Government-mandated universal health insurance
21.89% - Government-funded universal healthcare
9.92% - Employer-sponsored healthcare
9.47% - Other
Many private global providers have recognized this shift and have developed a value equation based on service excellence, quality, and cost. Here in the States, there are patient-centered care movements that combine the best of quality care and consumer engagement, but too few hospitals and medical groups have the vision or wherewithal to design these kinds of experiences.
Whether to call them patients or consumers might sound like a debate over semantics. Far from it. I read recently a humorous essay on the Aggravated Doc Surg blog on this topic. The self-described general surgeon and blog author takes the idea of healthcare consumerism to the rhetorical extreme by wondering what healthcare infomercials might look like. (As a related note, at a recent conference a healthcare marketer seriously floated the idea to me of infomercials to promote medical tourism.)
This physician blogger—and there seem to be more of them every day—sums up his argument this way: "It is my privilege and duty to care for people who come to see me—as patients. There is a respect involved with that term which is absent from the term consumer, and which is important in maintaining the dignity of the individual as he or she interacts with physicians, hospitals, and other places where medical care is delivered. When we lose that perspective—when physicians are seen only as 'providers,' or interchangeable widgets, and when patients are seen only as 'consumers'—we will have totally lost any semblance of dignity as a profession, and by extension, as a people."
That might be a powerful emotional appeal, but then everyday experiences with the healthcare system are pushing people to see themselves not as patients but as consumers. I'll give you a couple of anecdotes from personal experience, but I bet you have plenty of your own.
As a healthy Gen-Xer (I turned 37 earlier in February), I can say honestly that even though my employer provides good health insurance, I've always had to be a mindful healthcare consumer for myself and my young family. When I visit a primary care physician, the impression I get is that my visit is costing the doctor money. He runs through his assessment as quickly as possible and makes a point to remind me that I don't need to schedule another visit for at least two years. The last time I saw him was about three years ago, and I'm really in no rush to go back anytime soon.
And I will never forget the tone of my son's pediatrician when we told him we were concerned about our toddler's development. We said that our boy, then only 3, seemed resistant to his peers, hypersensitive to sound, and was fixated on numbers and maps. This experienced senior physician dismissed our observations as he checked a few boxes off my son's chart. "Yes, I bet he knows all his shapes and colors by now, too," he said. It was more than a year later when our son's preschool teacher suggested that we have him tested for Asperger's syndrome.
Don't forget that we are among the fortunate ones who have health insurance, and I hardly consider these hard-luck stories. The fact is that I'm just like most people. When it comes to my health, I have to do my own homework and make my own decisions. When it comes to my kids, I end up getting the best help and useful information from teachers and non-physician providers. The tired notion that as a patient I have some special connection with a physician who partners in my health is an alien concept. I don't blame physicians for this; it's just the way the system has evolved. As a result, I have no choice but to be a conscientious healthcare consumer.
Consider this: In a down economy, U.S. employers are saying they cannot keep up with the cost of healthcare, and paying an average of $8,482 per worker for health coverage puts them at a competitive disadvantage globally. For the first time, American workers in 2008 on average paid more than $1,000 for employer-sponsored insurance coverage, according to benefits consulting firm Mercer, which is up 17% from $859 in 2007. What's more, the high-deductible, consumer-directed insurance trend is only expected to escalate in the coming years. Employers want workers to pick up more of the healthcare tab so that they will make smarter and more cost-effective health choices.
Healthcare consumers are a big part of the future of healthcare, and providers will need to interact with them in new and innovative ways.
Rick Johnson is senior online editor of HealthLeaders Media. He may be reached at rjohnson@healthleadersmedia.com. View Rick Johnson's profileNote: You can sign up to receiveQualityLeaders, a free weekly e-newsletter that provides strategic information on the business of healthcare management from around the globe.
Atlanta-based Grady Memorial Hospital has announced 150 job cuts, in response to severe economic pressures and an increase in indigent patients, officials said. Among those who left was the head of the hospital's cancer center. The job cuts included about 140 layoffs, and about 10 positions that were not filled. The laid off included staff in the departments that focus on purchasing, nurse scheduling, and legal services, and also include one ultrasound technician.