Each year, medication errors are responsible for 7,000 patient deaths and cost the healthcare system $2 billion. Even more shocking, perhaps, is the knowledge that nearly 50% of potential medication errors are caught before making it to the patient. Of those potential errors, 87% are intercepted by nurses.
Linda Flynn, RN, PhD, associate professor at the University of Maryland School of Nursing, recently led a study concerning medication errors and how the practice environment and the level of nurse staffing affect medication error rates. Flynn, also the project director and principal investigator of this Interdisciplinary Nursing Quality Research Initiative (INQRI)-funded study, presented on the topic during an INQRI Webcast on October 7. INQRI, a project of the Robert Woods Johnson Foundation, was created to examine nurses' impact on patient safety.
"Nurses are the safety net that keeps patients safe from experiencing a medication error," said Flynn. "Our question was, what are the factors that impact this nursing safety net—what are the factors that help nurses in doing their job to intercept medication errors before they reach the patient, and what are the factors that serve as barriers to this safety net?"
Flynn's study focused on identifying the costs and implications of medication errors. Her team from the New Jersey Collaborating Center for Nursing at Rutgers University's College of Nursing did so by examining both work environments and nurse staffing situations. Broken down into three separate parts, the study received participants from 14 hospitals in New Jersey.
Ultimately, the study revealed that medication errors are expensive, averaging more than $6,000 extra spent on patients who experience a medication error (not necessarily an adverse drug event). Additionally, nurses employ four distinct medication safety processes to help themselves find medication errors before they reach the patient. These processes were enhanced when the nurses felt that their work environment was supportive, giving them time to effectively use these processes.
What processes do nurses use to catch medication errors?
The first part of the study examined what it is that nurses do specifically during their everyday jobs to prevent medication errors from reaching the patient. Flynn and her team interviewed 50 staff nurses from 10 hospitals, transcribed the interviews, and analyzed the lines of text for patterns and commonalities. They found that nurses take seven routine steps in the name of medication safety:
Conduct independent review of the medication administration record (MAR) in comparison with the medication order
Perform a focused assessment of the patient prior to administering medication
Question rationale
Prioritize face time with physicians
Encourage patients and families to be the last line of defense for a medication error
Advocate with pharmacy to ensure timeliness of medication delivery.
Clarify orders/handwriting with physicians
Of these processes, Flynn and her team found that numbers 1, 3, 5, and 7 were significantly associated with fewer medication errors. Additionally, there was overwhelming evidence that these practices were enhanced when the nurses worked in a supportive staffing environment.
A new report from Mathematica found that combined inflation-adjusted Medicaid and Medicare expenditures for Buy-In participants more than doubled from $887 million to $1.9 billion between 2002 and 2005, as did program enrollment.
When compared with other working-age disabled Medicaid enrollees, the report, Analysis of Medical Expenditures and Service Use of Medicaid Buy-In Participants, 2002–2005, found that Buy-In participants in 2005 incurred lower annual Medicaid expenditures. The study added the difference suggests that Buy-In participants, who are working, may require fewer services or a less-expensive mix of services than other disabled Medicaid enrollees.
More than 200,000 people with disabilities enrolled in the Medicaid Buy-In program between 1997 and 2007. When workers with disabilities "buy into" Medicaid by paying monthly premiums or copayments, states can offer them Medicaid coverage when their income and assets would otherwise make them ineligible. Most Buy-In participants also receive Medicare coverage if they are eligible for Social Security Disability Insurance payments.
"Medicaid and Medicare expenditures will rise as enrollment in the Buy-In program continues to grow," says Gilbert Gimm, the report's lead author and a health researcher at Mathematica, a nonpartisan research firm based in Princeton, N.J. "However, much of this spending would not represent a new burden on state Medicaid budgets because most new Buy-In participants transfer from another Medicaid eligibility category.
"Since Buy-In participants overall are less expensive to Medicaid than other adult enrollees with disabilities, states without a Buy-In program might want to consider starting a new one. States with a Buy-In program might consider focusing outreach efforts toward younger workers with disabilities," he adds.
Although total Medicaid expenditures rose as enrollment increased between 2002 and 2005, the average monthly Medicaid cost remained relatively stable over this period, fluctuating between $1,287 and $1,161 depending on the year. However, the average monthly Medicare cost for Buy-In enrollees rose from $493 in 2002 to $597 in 2005, the study found.
Mathematica gleaned the study results from Buy-In participant files provided by the states, Medicaid eligibility and claims files, Medicare claims records, and administrative data from the Social Security Administration.
The report also found that:
Prescription drugs accounted for the largest share of total Medicaid spending (36% or $436 per month); more participants (91%) used this service than any other. Community long-term care services represented the second-largest share of spending (22%, or $270 per month) and were used by 15% of participants.
Inpatient hospital expenditures accounted for the largest share of Medicare spending (44% or $264 per month) among Buy-In participants who are dually enrolled in Medicare and Medicaid.
Not surprisingly, Medicare expenditures increased with the age of the participant. For example, typical monthly Medicare costs for those ages 65 and older were $785, compared with costs of $378 for those 30 and younger. Medicaid expenditures showed a different pattern: Adults ages 31 to 50 had the highest level of Medicaid expenditures.
I've gotten huge response from my column last week about the difficulty of large-scale culture change at hospitals and health systems, epitomized by the sudden resignation of Wayne Sensor as CEO of Omaha's Alegent Health after two physician confidence votes went against him. Much of that response has been in support of Sensor, some has been in support of the docs, and almost all has been off the record or otherwise anonymous. And let me tell you, I've heard all kinds of stuff. More on that later.
"There are probably not a lot of CEOs who would be comfortable talking about this," Wayne Sensor told me earlier this week. "But my greatest desire is to help others who wish to lead transformation."
Well, I can guarantee he's right about one thing: there aren't a lot of CEOs who would talk publicly about the physician revolt he oversaw or the circumstances surrounding his resignation. In fact, I don't know if I would be talking to me were I in his shoes. But Wayne Sensor has always been different, ever since I was working the finance beat back in 2005 and talked to him for the first time. And I appreciate his openness.
At the time I first talked with him, Sensor's hospital system was at the cutting edge of making patient cost in healthcare more transparent through Alegent's MyCost online tool, still alive and well on Alegent's Web site, despite the shift in public debate away from patient involvement and responsibility and toward government involvement and "public options."
At the time, the trend of hiring physicians directly to work for the hospital was well-established at some of the best known, highest quality institutions in the nation, but that was a select group. Since, employing physicians become much more of a trend, and it's produced some heated disagreements between hospital executive leadership and independent physicians who practice at and refer patients to such hospitals.
But what you want to hear about is the circumstances surrounding Sensor's dismissal, so let's get that out of the way. Here's what I know from my conversation with Sensor, as well as news reports:
A large portion of the independent physicians who refer to Alegent hospitals decided he hadn't been honest with them about a plan to gradually transform the system to an employed physician model. He tells me that he thought he had embarked on this plan thoughtfully, honestly, and with the support of both the board and key physicians who wielded power in the organization, although those physicians weren't employees. Turns out, more of them disagreed with his perception than agreed.
What's fact is that over the 5 ½ years Sensor led the organization, the employed physician contingent has grown steadily, and now numbers about 200 of the 1,200 physicians on the system's staff. Clearly, the relationship between Sensor and independent physicians soured badly evidenced by a large contingent of doctors who had stopped referring to Alegent facilities or who threatened to do so. Subsequently, the board requested his resignation and he complied. He didn't want to resign.
I've heard lots of other salacious stuff that is reported to have been a contributing factor in the resignation from well-placed sources who refused to go on the record either with me or with Cheryl Clark, one of my colleagues at HealthLeaders Media who did some early reporting on the story. So I take that information for what it's worth: not much.
When we talked, Sensor didn't want to go into the details of his departure, but he did say this:
"Our physicians didn't necessarily feel a need for the change (to an employed model) in that reimbursement hasn't largely changed, and that provides great understanding of where they're coming from. That said, they largely supported that vision, but they have to understand what that means when the rubber hits the road. If you're affecting physicians' practice of medicine and in some cases, incomes, that creates tremendous tension and anxiety."
Sensor conceded that he's learned a lot in the past couple of weeks about what went so wrong and how it might have been avoided. My sense is that this type of transformation, as I indicated last week, is inherently pioneering and dangerous to the CEO's career track, so embarking on that level of change is rare. But long-term, if fee-for-service medical payments are undone in favor of so-called "bundled payments," employing physicians seems not only the right thing to do for patient care but necessary financially and operationally. That's a big "if," though.
Perhaps Sensor's biggest misstep was that there was no immediate pragmatic need for the transformation in many physicians' eyes. That doesn't mean it isn't smart, strategically. Still, Sensor wanted me to share with other hospital executives the five main lessons he's learned on this difficult journey, all direct quotes from our conversation:
Be ever mindful of the speed of change: "The filters I would encourage others to apply are two: The organization's ability to assimilate change--uniquely the CEO's responsibility--and leadership's ability to manage the change itself. On how many fronts can you manage the change at one time?"
Create urgency and receptiveness to change, even without a driving platform: "The full impact of healthcare reform will be felt in 2012 and beyond. Reimbursement has historically been the arbiter of change in healthcare, and reimbursement hasn't changed yet. So how do we create an incentive for change when the reality is that (physician) incomes are pretty strong and practices are busy? Many physicians suggested that they don't believe healthcare reform will change anything. That suggests there's not a receptiveness to change."
Create real expectations and understanding of the implications of the change: "There's no doubt that to this day there's widespread support for the vision and strategy of Alegent Health. Yet to be pragmatic, when you start to consolidate clinical services such as cardiovascular and it impacts cardiology practices, we shouldn't be surprised if that creates tremendous tension and anxiety for physician partners. It's great to agree on philosophies, but it's important to really make sure people understand what it really means when the rubber hits the road."
Implications of a growing employed physician practice: "This must be aimed specifically at the independent affiliated physicians in your market. Part of what makes the Alegent story fascinating is that the standard-bearers in the models many want to emulate are almost exclusively closed medical staffs. Alegent has 1,200 physicians of which only 200 are employed and yet experienced tremendous growth in the employed sector in the past five years. The environment is driving physicians to seek employment, and that creates tremendous pressure on the existing affiliated physicians. But what does that mean to the ones who aren't employed? You have to demonstrate that they still have an important role as well."
Is the structure of the organization conducive to transformational change? "This can be applied to the whole organization or parts or the organization. Alegent's five metro hospitals have five independent medical staffs, each with their own structures, each organized around a hospital, while the organization is moving to create systems of care across the enterprise. Well, that's conflictual. So you must really take a hard look and make sure the structures are conducive to the change you want to achieve."
I'll finish with one more quote from Sensor, as I asked him what he would do differently if he could rewind the clock on his tenure: "This experience illustrates how difficult transformational change is in healthcare. This was a good petri dish for change and a lot of it occurred. Generally, I have no regrets. I had an opportunity to lead a progressive organization and to do some wonderful things that affect patients. I hope they carry that momentum forward and distinguish themselves. The five lessons I just shared with you are retrospective, and that's easy. In real time, those are some things I would've done more rigorously, more intentionally, and that is what I would focus on if I had a redo."
At that point, I asked Sensor if he was familiar with a little book by Joseph Heller called Catch-22, which is the genesis for that term describing a no-win situation. He laughed, but didn't take the bait.
Stay tuned to HealthLeaders Media Online and our print magazine. I'm saving a little of what I learned in my interview with Sensor for later.
Much has happened in the discussion of healthcare reform since three House committees voted to approve their versions of the initial bill (HR 3200) before adjourning for summer recess.
In the intervening three months, discussions played out in a variety of venues—from town hall meetings to Capitol Hill hearing rooms—that have created a bill with many changes. Here's a look at 12 of the new features in the Affordable Health Care for America Act (HR 3962) that was released on Thursday:
Public insurance option. While HR 3200 did have a public insurance option, the way it proposed to pay for services was different. With the lower-cost earlier version, hospitals and physicians would have been paid using Medicare rates, plus 5%—a formula that most hospitals and physicians opposed. The new public option proposal requires the Health and Human Services (HHS) secretary to negotiate rates with healthcare providers--as private insurers currently do. The House bill does not have a state opt-out measure that is likely to be proposed in the Senate bill when it comes to the floor of that chamber.
"Millionaire" healthcare surcharge. In the earlier version approved by the House Ways and Ways Committee, those individuals making $280,000 or families making more than $350,000 would have been required to pay a surcharge. In the new bill, this has been raised to encompass only the wealthiest 0.3% of the population: individuals making above $500,000 and families above $1 million would pay the surcharge.
Doughnut hole timeline. The revised bill moves up the effective date to begin reducing the Medicare drug payment doughnut hole from Jan. 1, 2011, to Jan. 1, 2010. The hole initially will be reduced by $500, with a 50% discount instituted for brand name drugs paid for in the hole. Elimination of the doughnut hole will be achieved by 2019, instead of 2024 under the earlier bill.
Value-based Medicare payment formula. A new provision was included that changes the way Medicare pays hospitals and physicians—by moving from a formula that pays for the volume of tests and procedures performed to a value based formula that emphasizes quality care and cost effectiveness. The Institute of Medicine (IOM), through two studies, will make recommendations on how to fix the current Medicare reimbursement system, including addressing current geographic variations.
Insurance cooperatives. Under the revised House bill, grants and loans would be made available for the establishment and initial operation of not for profit, member-run health insurance cooperatives. They could provide coverage through the health insurance exchanges.
Intermediate assistance for uninsured. To fill the gap before the health insurance exchange is ready, an insurance program with financial assistance will be made available for those who have been uninsured for several months or denied a policy because of pre existing conditions.
Negotiation of Medicare drug prices. With the revised bill, the HHS secretary will be required to negotiate drug prices on behalf of Medicare beneficiaries.
Employer mandate exemption. The revised bill calls for exempting firms with payrolls up to $500,000 (instead of $250,000) from the mandate and indicates only a graduated penalty for not offering coverage for firms with payrolls between $500,000 and $750,000 (instead of firms with payrolls between $250,000 and $400,000.) This change exempts more small businesses (now up to 86%) from the employer mandate.
Insurer antitrust exemption. The revised bill incorporates language that would overturn the 60-year-old McCarran-Ferguson Act that gives health and medical companies an antitrust exemption and had permitted them to share data.
Age extension. Coverage under the revised bill would permit young people up to age 27 to remain on their parents' health insurance if requested.
Long-term care insurance. The revised bill creates a long-term care insurance program that would be financed by voluntary payroll deductions to provide benefits to adults who become functionally disabled. This measure would provide cash benefits to assist individuals with community based services.
Medicaid expansion. Individuals and families with incomes now at or below 150% percent of the federal poverty level will be eligible for an expanded Medicaid program. This expansion will initially be fully federally financed, then transitioned to include a 9% contribution from states starting in 2015. To improve provider participation, reimbursement rates for primary care services will be increased to Medicare rates with new federal funding.
If you're wondering what a medical staff professional (MSP) does, Sally Pelletier, CPMSM, CPCS, president of Best Practices Consulting Group in Intervale, NH, sums it up pretty well. "I've likened the role of the MSP to that of an air traffic controller—a key individual who makes things happen behind the scenes according to established guidelines and protocols to ensure that the highest safety standards are met."
Not only are MSPs responsible for credentialing and privileging medical staff members, they also manage and take minutes at meetings, stay up-to-date on accreditation standards and state and federal regulations, maintain medical staff rosters and financial accounts, and play the roles of teacher, counselor, and mediator. They are also keepers of the medical staff bylaws, rules, regulations, and policies.
Although in some hospitals, executives may only know MSPs in passing, MSPs are also the wheel inside the clock that makes it tick. Next week, November 1-7 is National Medical Staff Services Awareness Week to honor MSPs.
Awareness week first became nationally recognized in 1992 when President George Bush signed a congressional joint resolution at the urging of The National Association Medical Staff Services (NAMSS).
Medical staff services professionals are sometimes viewed by the C-suite as an expense on the income statement, says William K. Cors, MD, MMM, FACP, CMSL, vice president of medical staff services at The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.
However, when MSPs do their job well, they can save the organization countless dollars and hours. These cost and time savings come from effective credentialing, privileging, and physician performance measurement processes that ensure problem physicians never reach the stage of due process or fair hearing. Fair hearings can cost the organization hundreds of thousands of dollars and countless physician and staff hours, Cors explains.
"The MSPs lead quietly, defuse conflicts early, and ensure best practices are followed so that the medical staff can be the best that it can be. Without them, this area would be chaos," says Cors.
Stewart Hamilton, MD, CMO of Yuma (AZ) Regional Medical Center, says MSPs' work is sometimes portrayed as nitpicking and overly detailed, "but they are the first, and often the best, safety net of any hospital or group and indirectly of the patients and families we all serve."
By recognizing and supporting MSPs, leaders can help to advance their careers. "The recognition I have received from physician leaders, hospital administrators, and my peers has been extremely rewarding and has made me know how appreciated I have been for the work that I accomplished along the career journey," says Carole LaPine, MSA, CPMSM, CPCS, manager for physician services at Trinity Health in Novi, MI, regarding her promotion from procedure analyst to director of the credentialing department.
Kathleen Tafel, a medical staff services consultant and former manager of medical staff services at Ellis Hospital in Schenectady NY, recalls how her career as an MSP got off to a running start with the help of physician leaders and hospital executives.
"I came to the world of credentialing through the good fortune of an interview with two individuals: the director of medical affairs and the chief medical officer. They assessed a myriad of talents and matched them to the skill-set they were looking for. I will always be grateful to them for their ability to match my talents to the position," she says.
Tafel says she was fortunate to work for an organization with a strong public relations department that highlighted the important function that the credentialing office plays in patient safety during National Medical Staff Services Awareness Week. The PR department spotlighted the medical staff services department and individual credentialing specialists during that week, as well.
"The credentialing crew would also have our own little celebration. It didn't need to be outrageous—just a break in time for us to connect as individuals over lunch, coffee, cookies, and a small gift," Tafel says.
"All too often, [MSPs] do not get the recognition or thanks that they deserve," says Hamilton.
So, how are you going to show thanks to your MSPs next week? Here are some tips on celebrating Medical Staff Services Awareness Week.
Liz Jones is an associate editor with HCPro, Inc. She writes Medical Staff Briefing and Hospitalist Leadership Advisor and co-writes Credentialing and Peer Review Legal Insider.
On April 6, Michael Harrigan, 58, was driving 70 mph on Interstate 94 from Milwaukee to a business meeting in Madison, WI. He never did make it to his meeting, because he suffered a stroke halfway there. The series of events that occurred following his stroke are nothing short of miraculous.
Harrigan was able to pull over his car and call 9-1-1 despite having palpable stroke symptoms. His face was beginning to slump, he lost control of his left hand, and he was having difficulty speaking.
What Harrigan didn't know at the time was that UW Health Partners Watertown Regional Medical Center, the hospital he was transported to by ambulance, had just implemented a telestroke program connecting them to the University of Washington Hospital and Clinics in Madison on a 24/7 basis.
A stroke specialist in Madison was able to evaluate Harrigan using remote brain imaging technology and videoconferencing tools. As a result, he was given tissue plasminogen activator (tPA), a clot-busting drug which needs to be administered within the first three hours of an ischemic stroke in order for it to be effective.
"I am clearly very, very blessed and lucky that I happened to be able to take advantage of the telestroke program," says Harrigan. "I'm certain that without it I would have had more permanent damage and probably even more serious complications, including life-threatening ones in my opinion. It really could have been very serious."
Instead, Harrigan was transferred to the University of Washington clinic in Madison, where he spent the next week in their ICU before he was transferred to cardiology. He was eventually diagnosed with an atrial fibrillation.
In May, the American Heart Association (AHA) and American Stroke Association (ASA) published groundbreaking statements recommending the use of telemedicine technology on stroke patients. The AHA and ASA cite that the US has a mere 4 neurologists per 100,000 people who need to care for over 780,000 acute strokes per year, many of which occur in parts of the US that do not have access to acute stroke services.
The statement encourages the use of telemedicine technology to bridge the gap by providing medical specialists with the data necessary to assist remotely-located bedside clinicians in stroke-related decision making for patients.
Here are three institutions in the country that have implemented telestroke centers and the benefits and challenges they face.
Reducing the burden of stroke in Wisconsin
Justin Sattin, MD, leads the stroke program at the University of Washington School of Medicine and Public Health, which performed Harrigan's telestroke consultation. He describes the telestroke technology in Watertown as a "glorified IV pole" that can be moved anywhere in the hospital where the tools are needed.
It is equipped with a computer and flat screen monitor, which displays the physician's image. At the top of the pole is a high quality camera. To provide a consultation, the on call physician needs a computer with Internet access, a Web cam, and client software.
"The problem is that there's a lot of stroke out there," he says. "But, there really aren't many neurologists and, certainly, not that many stroke specialists."
As a result, Sattin says that healthcare professionals lean on stroke specialists, requesting consultations for any patient who has an acute change in their neurological function. For Sattin, this means he makes many trips to the emergency room for patients who end up getting diagnosed with everything from infections to seizures.
With the telestroke technology, stroke specialists are able to remotely treat patients who may have otherwise not been able to access care, making better use of their time. Sattin believes that telestroke technology could also become a "game changer" from a public health perspective by reducing some of the barriers of giving tPA to patients.
At first, Sattin said that the hospital in Watertown objected to the telestroke services because they didn't see many stroke patients, and saw even fewer patients who were candidates for tPA. However, now that the telestroke program is in place, Sattin says the hospital calls his facility more frequently than they predicted they would.
"More of their stroke patients have become tPA candidates," which, he says, is the whole point of the program.
In fact, Sattin says they treated six out of the first 12 telestroke patients using tPA. According to Medicare data, he says only a mere 2.5% of patients receive the drug.
When patients experience a stroke in Wisconsin, they are typically transported to the nearest hospital that has a designed stroke center. Sattin believes that offering telestroke services will allow more hospitals to be designated as stroke centers in the future.
"If you can hold yourself out as a stroke center, you can get more patients coming to you instead of the hospitals around you that aren't stroke centers," he says. "We need to get some of the rural hospitals on board, because if you have a fairly sizeable rural population, you should be either developing the structure to become a stroke center yourself or you should do it by virtue of one of these telemedicine arrangements."
In the future, Sattin predicts that, as the telestroke network grows, the remote consultations may pull physicians away from caring for their own patients on site. "You can only get interrupted so many times before it really starts compromising operations," he says. "At some point, the telestroke call schedule might need to be separate from the regular on call schedule."
60:6
In Los Angeles, CA, the ratio of hospitals to stroke specialists just don't add up, says Latisha Ali, MD, director of the University of California Los Angeles Telestroke Network Partner Program. While there are 60 hospitals in the Los Angeles area, there are only about six stroke neurologists.
UCLA officially launched its telestroke program in January and has a current network in the five-to-ten hospitals range. (Ali was unable to comment on exact numbers.) They are currently in negotiations with hospitals and trying to grow their network. For now, UCLA hopes to generate enough money to pay for the technology and keep the program sustainable.
"Our goal is to provide our hospitals with 24/7/365 clinical stroke expertise which has really been lacking in the community here," she says. "One of the advantages of our program is that you get a stroke expert at the bedside whereas if you were at the community hospital you might get someone who has treated stroke patients in the past, but for whom stroke is not an area of expertise."
According to Ali, less than 50% of patients who are admitted with a stroke actually see a non-stroke specialist in neurology. For neurologists in general, she says there are only four available to treat every 100,000 people in the United States and most of them are not trained in stroke or vascular neurology.
She attributes the shortage in the profession to the inability of physicians to quickly heal patients like in other specialties. However, she finds the specialty exciting, saying that it is rewarding to watch a patient improve under her care.
Ali says she wants to share her expertise with all of UCLA's partner hospitals. During consultations, emergency room physicians, medical students, and residents are often present. She uses the opportunity to walk them through a stroke examination and through the process of localizing a patient's symptoms.
Ali can view everything that is being done to the patient at the remote hospital, which does not have to page her every step of the way because she is right there watching events take place with them. The UCLA system uses high definition video conferencing. Ali says the images are "beautiful" and allow her to view such detail as a patient's pupillary response.
"We can actually move the camera around and zoom around the room and talk to everyone as though we were actually there."
Ali says that the family members present for the consultations have been appreciative of the services they are able to provide using the technology. They understand that if the technology weren't available, then their loved one might not have gotten much by way of treatment options.
Telestroke roots run deep in the Vineyard
Massachusetts General Hospital is no newcomer to the field of telestroke medicine. According to Shawn Farrell, the director of the Partners Telestroke Program, MGH began offering consultations 13 years ago as part of a pilot program with Martha's Vineyard Hospital. The island had stroke patients who were not able to access care because of their proximity to the mainland. Today, MGH has 27 hospitals in Massachusetts, Maine, and New Hampshire in its program.
Farrell says Massachusetts is unique in that it has a stroke center designation program at the state level with the Department of Public Health. As part of that program, if a hospital is not a designated stroke center by the department, then an ambulance will bypass that facility and go to the next closest hospital that is. While other states may have stroke center certification programs, they may not have emergency medical services rerouting, so there isn't motivation to fulfill that requirement.
"Hospitals feel that stroke center designation is very important, so they do whatever they can to meet that," he says. "Telemedicine is an acceptable form of meeting that requirement.
A unique aspect of the MGH system, which was developed in house, is that it has workflow support, clinical decision making tools, algorithms, calculators, reminders, and alerts built into it. If there are contraindications to administer tPA, the system will display alerts and warnings prompting the user to take action.
According to Farrell, 2 to 4% of patients receive the medication. The MGH telestroke program rates are 20 to 30%. One of their partner hospitals averaged four tPA administrations in four years. After joining the network, the hospital had 10 tPA administrations in the first year.
"They feel much more comfortable about administering the drug to the right patients with the right support of the neurologist with the video screen," he says.
Farrell says stroke specialists are able to do so much more when they are able to visually interact with a patient, the emergency room physician, and the patient's family. "The two-way interactive communication that occurs over a videoconferencing device really helps to make a much higher quality interaction," he says.
Reimbursement overhaul needed
Reimbursement is a clear barrier for hospitals interested in providing these life-saving services. Currently, Medicare only pays for telestroke services in geographic locations that meet narrow criteria. Overall, payers are reluctant to reimburse for telemedicine services in general. As a result, only one of the hospitals in the Partners network meets that profile, so they do not bill any insurance companies for services.
Farrell hopes that, as the American Reinvestment and Recovery Act funding begins to flow, there will be an opportunity for healthcare technology to tap into the available funds to keep telestroke programs up and running.
Sattin does not believe that changing Medicare rules or private insurer rules to allow you to bill for the services is the answer. He says telestroke programs require that physicians be tethered to an Internet connection when they are on call in order to provide consultations—no small task.
"That's a big barrier," he says. "And, being able to bill $100 or $200 for an individual consult isn't going to compensate somebody for being on duty. The billing per click doesn't really capture the costs involved in signing on to this."
Instead, Sattin advocates for hub hospitals to negotiate contractual agreements with spoke hospitals, such as Watertown. Some of the financial benefits Watertown Hospital gains include a fairly sizeable reimbursement for administering tPA, which Medicare recently increased.
Licensing also becomes an issue if providers need to become licensed in neighboring states in order to provide telemedicine services—a time-consuming and expensive process.
Ali is in favor of uniform, national telemedicine licensure by state medical boards for telestroke providers. She says the American Telemedicine Association is working on this and other issues. The AHA/ASA statements will also go a long way in helping to promote change.
Making the most of unhappy ending
Not all strokes end like Harrigan's, who is now in the process of rehabilitation and making changes to his lifestyle. Sattin says that he once saw an elderly, sick patient who had experienced a stroke. He says it was a confusing case in terms of reporting neurological findings.
"That's somebody who I probably would have asked to be transported to our facility," he says. "I was able to conclude remotely that there was nothing that anyone was able to do for this person and what she really needed was palliative care. It's a heavy topic and you prefer to do that in person, but, on the other hand, we saved the family an unnecessary transfer to the big city with the whole big family having to drive over. Why should mom die in a big city hospital when she can die in her own community with her family there and the doctors who know her?"
Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.
There were 1.8 million to 5.7 million cases of swine flu in the country during the epidemic's first spring wave, according to a new estimate from the Centers for Disease Control and Prevention released Thursday. From 9,000 to 21,000 people were hospitalized as a result, and up to 800 died from April to July, when it largely faded out, according to the estimates, which were conducted by the CDC and the Harvard School of Public Health and published online in the journal Emerging Infectious Diseases. The agency has been working for months on a model that took into account the fact that most flu cases were not tested by doctors and that some people were hospitalized for conditions exacerbated by the flu without the flu ever having been diagnosed.
As the healthcare overhaul heads to the Senate floor, Senator Tom Coburn, a family practice physician, is preparing for what he considers a career pinnacle of havoc. Enacting the proposal, he said, would be catastrophic, and so if precedent holds, he will try to hinder it with every annoying tool in his arsenal: filing amendments, undertaking filibusters, and objecting strenuously. To Coburn, charges of obstructionism are a mark of honor he will wear as proudly as ever in the coming weeks.
The Senate on Thursday confirmed Dr. Regina Benjamin to be the U.S. surgeon general, elevating a well-known Alabama family physician to be the nation's top doctor. Benjamin, 53, was approved by voice vote. Benjamin was the first black woman to head a state medical society, received the Nelson Mandela Award for Health and Human Rights, and just last fall received a MacArthur Foundation "genius grant." But she made headlines in the wake of Hurricane Katrina, with her determination to rebuild her rural health clinic, Bayou La Batre, AL, which serves 4,400 patients who would be hard-pressed to find care elsewhere.
President Barack Obama says small businesses that participate in a proposed government healthcare plan could save a quarter on their premiums by 2016. Obama on Thursday told small business leaders that few people have a bigger stake in health reform than they do. He said the House version of a healthcare bill would help millions of small businesses cut growing healthcare costs and was written with small businesses owners in mind.
