Nearly a million doses of swine flu vaccine for infants may have been slightly less potent than required but should work anyway, federal officials said in announcing a recall of the shots. The maker of the vaccine, Sanofi-Aventis, voluntarily recalled 800,000 doses of low-dose, thimerosal-free vaccine in prefilled syringes intended for infants ages 6 months to 35 months. Since most of the vaccine was released a month ago, it presumably has already been used, but the recall is intended to alert doctors to return any supplies they have left, the New York Times reports.
The New York City Health and Hospitals Corporation today launched a new Web site for its 58,000 diabetic patients with the hope of making them more active and informed participants in their own care.
The HHC online Diabetes Wellness Center features advice from clinicians, patient success stories, healthy eating and exercise tips, access to free blood monitors, and a comprehensive list of support groups and diabetes wellness classes that are available in the health system's 11 acute-care public hospitals.
"We know millions of people seek health information on the Web and we wanted to tap this resource as an additional tool to help patients do all they can to manage diabetes at home," HHC President Alan D. Aviles said in a media release.
"We want to help patients take control of their diabetes care and become true partners with their physician and other healthcare team members. To accomplish this, patients need a lot more support and encouragement beyond what they can receive during periodic visits to their doctor because diabetes must be managed around the clock," Aviles said.
HHC, which is largest municipal healthcare organization in the nation, said the Web site is needed to help address the epidemic of obesity-fueled diabetes in New York City. The New York City Department of Health reports that the city's diabetic population has more than doubled in 10 years. About 530,000 adult New Yorkers know they have diabetes and another 265,000 New Yorkers have diabetes, but don't know it.
The HHC online Diabetes Wellness Center will be promoted at HHC hospitals and clinics, and through direct mail to more than 58,000 diabetic patients that are monitored through HHC's Diabetes Patient Registry, an electronic disease-tracking program.
Using the tracking program, HHC has increased the number of patients who have achieved healthy levels of blood sugar, blood pressure, and cholesterol. In 2008, HHC diabetic patients achieved better quality outcomes than those achieved at the state or national level in 2007.
The HHC diabetic patient population is 59% female and 41% male. Approximately 44% are Latinos, 35% black, 5% Caucasian, 4% Asian, and 13% are other ethnicities.
It started with a simple goal: to send radiology images to healthcare facilities throughout Montana in a manner that was cheaper and more efficient than using FedEx to mail CDs overnight. About 30 healthcare organizations in Montana joined the grassroots organization called the Image Movement of Montana.
The group needed a solution that would work not only for more tech savvy facilities with picture archiving and communications systems, but also for folks who don't have PACS and would need to access images on a PC, says Gayle Knudson, radiology manager at Great Falls Clinic and IMOM co-founder.
After looking at several different vendors' product demonstrations, the group chose to implement eMix, a new cloud-based technology to securely share radiology images and reports, from DR Systems. With eMix, providers can send full-res images to other hospitals, referring physicians, or even patients "using the Internet and a standard SSL connection with secure encryption," says Bill O'Leary, regional outreach and PACS administrator at Kalispell Regional Medical Center and IMOM co-founder.
I've read a lot recently how other industries are using cloud-computing technology to improve business processes. But this is one of the few healthcare examples that I've heard about. Here's a strategic look at how IMOM is using the eMix technology and why they determined cloud-computing was the solution for them.
How it works
Organizations pull up the image on their PACS that needs to be sent to a patient or another facility and send it with the eMix client that sits on their desktop. The image goes to an offsite eMix server in San Diego where it is temporarily stored until the receiving physician or radiologist accesses it. That provider, who is sent an e-mail notification, can choose to simply view the image on his or her desktop, burn it to a CD, or push it out to the facility's own PACS.
IMOM is currently beta testing the system at three diverse locations in Montana—Kalispell Regional Medical Center, a regional healthcare delivery system that uses a PACS from DR systems; Great Falls Clinic, a multi-specialty practice that uses a PACS from McKesson; and St. Luke Community Healthcare in Ronan, a critical access hospital that uses a PACS from Amicas Inc.
The challenge with some of the other proposed solutions was that they required the organizations to put in a server, a router, and VPN connections between several facilities. "They were all capital out of pocket upfront," says O'Leary. The eMix solution works because anybody can use it and there is no upfront cost. "The cost is when you download data," he says, explaining that the size of the data determines what your charge will be. Organizations can pay per image or they can set up an account to pay a set rate for say 40 gigabytes of transfer data per month.
The cost of sending 200 megabytes of data one time is less than $2 versus the $10 to $12 it costs to send an image on CD with FedEx, says O'Leary. He expects the technology will save his organization roughly 50% of its FedEx rate. Kalispell Regional, which is in a resort area, probably has one of the higher use rates of CDs than other facilities, he acknowledges.
Questions and concerns
But what about security and the capability of the technology to meet the needs of such a diverse set of providers? The concerns that many providers have about cloud computing is the security of patient information. eMix has security measures in place at its data center, such as limiting the number of people who can access data, biometric scans to confirm people's identity, and network level security between end users and the data in database and content servers.
No data is stored on Web servers and all of the data is encrypted when in motion. Providers and patients trying to access the data have to go to a secure Web browser, log into the system, and then they can download the exam. eMix can track and audit everything that happens to the exam until it is downloaded, from there it depends on each individual provider's security protocols and guidelines.
The other question many providers have is how long the image stays on the server. IMOM is still in the process of determining the length of time an image will stay active on the eMix server before it is purged, but one thing is certain—this is not intended to be a repository, says Knudson. "We are not in the PACS business," she says. "We can't go to rural Montana to a 10-bed hospital and say it will cost this much to play the game."
Meeting the needs of such a diverse group can be a challenge, but so far eMix has resolved any issues that have arisen, says Knudson. For instance, at first the group thought providers would need Internet Explorer IX 8, but the system can be used on Internet Explorer 6 or 7.
"That is important when talking about rural America," says Knudson. Currently, IMOM, which plans to fully implement the system in the first quarter of 2010, is trying to figure out how to send images to more than one computer within a facility.
This model seems like a no brainer for rural regions like Montana. Even though some providers may have to deal with a slow DSL connection, the technology is still faster than FedEx, says O'Leary. It also provides a full-res image, which is what radiologists and physicians want. Kalispell Regional has already been using a Web-based product to share images with physicians, but those are compressed images.
"They can view the images, but can't send them to their PACS or compare to full res images," he says.
O'Leary says this type of exchange offers benefits to metro areas, as well as, rural. "Everyone has problems sending data," he says. "There is no downside to it. You don't have any overhead costs or costs for setting up the applications. You don't have software and hardware; it is using standard Internet connections. And you can save money and get images to other facilities immediately."
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The American College of Radiology today challenged the validity of two studies published this week in the Archives of Internal Medicine that link the overuse of CT scans with thousands of new cancer diagnoses and deaths.
At the same time, ACR acknowledged that widespread CT scan use has resulted in increased radiation exposure for Americans, and called for greater oversight and vigilance to prevent needless overuse.
"No published studies show that radiation from imaging exams causes cancer," ACR said in media release. "The conclusions of the authors of the Archives' studies rely largely on data which equates radiation exposure and effects experienced by atomic bomb survivors in Japan to present day patients who receive computed tomography scans."
One of the AIM studies used claims data from Medicare, and commercial insurance databases, and estimated that there were 72 million CT scans performed in 2007, which resulted in 29,000 excess cancer diagnoses, and as many as 15,000 additional cancer deaths for that year.
"Presumably, as the number of CT scans increase from the 2007 rate, the number of excess cancers also will increase. In light of these data, physicians (and their patients) cannot be complacent about the hazards of radiation or we risk creating a public health time bomb," AIM wrote in an editorial supporting the studies.
However, ACR challenged the studies' assumptions. "The articles—after excluding patients with cancer or within five years of the end of life—assumed that those undergoing CT scanning have the same life expectancy as the general population. This is not accurate, so the estimates are undoubtedly high," ACR said. "Moreover, 25% of people in the United States die of cancer with a lifetime incidence of 40%, about 1.5 million new cancers per year. The 29,000 figure, if even close to accurate, is overall a very small risk versus the immediate, proven life-saving benefits of CT."
Rather than posing a medical menace, ACR said CT scans have been linked to greater life expectancy, declines in cancer mortality rates, and are generally less expensive than the invasive procedures that they replace.
ACR said it supports and recommends that imaging exams be performed only if there is a clear medical benefit that outweighs any associated risk. ACR added it supports the "as low as reasonably achievable" concept which urges providers to use the minimum level of radiation needed in imaging exams to achieve the necessary results.
Nurses often try to find ways to do more for the profession that they love. In many facilities, nurses make note of how they can help and lend a hand to those in need.
One nurse who is lending a hand to others is psychiatric nurse, Trisha Pearce. Pearce witnessed firsthand what the war can do to returning soldiers and their families when her brothers returned from Vietnam and the Gulf War.
Pearce, with more than three decades worth of experience in mental health and chemical dependency, did not want to see returning soldiers suffer without help, so she founded the Soldiers Project Northwest in 2007.
The project reaches out to veterans of the wars in Iraq and Afghanistan, along with active-duty personnel and military families. The project provides free, confidential, therapeutic counseling, and aims to educate communities on the psychological effects of the war. Volunteers also benefit from the project, and are able to receive training to better aid these soldiers and their families.
There are currently 57 volunteers involved with the project that is now an affiliate of the Los Angeles-based national Soldiers Project. Pearce volunteers more than 20 hours a week to ensure military families can receive the support they need. Named the Outstanding Female Non-Veteran of the Year by the Washington state Department of Veterans Affairs, Pearce rode in the Auburn Veterans Day parade alongside groups of veterans.
Another nurse who has been practicing for more than three decades is also leaving her mark and helping those hospitals in third-world countries.
After her first medical mission trip to the Amazon in South America, Mary McMahon, a nurse from Georgia, returned home and founded the nonprofit organization, Nurses for the Nations. The organization is gearing up for an 11-day trip to Liberia in January, where nurses will test for malaria, provide mosquito nets, and teach sanitation and proper use of the nets in six remote villages.
The philosophy of Nurses for Nations is to focus on one small region of the world at a time, which McMahon believes can inspire long-term change. McMahon plans to turn the organization's focus on another medically desperate part of the world during the next three to five years.
In December 2008, Trinity Medical Associates, a Knoxville, TN–based family physician practice, bucked a growing trend in American healthcare, and politely declined a merger offer extended by colleagues and friends at the much larger Summit Medical Group.
"Our primary decision came down to the fact that we really just valued our independent culture that we had established," says Randy Pardue, MD, a family physician and one of five physician-owners at Trinity. "We did not conclude that joining [Summit] would destroy our culture by any means. It was one of those things that, having thought and prayed about it, we just thought getting into the bigger group could compromise what we had established. We really enjoy the culture that has been established here."
It was not a decision that the physicians at Trinity took lightly or made quickly. Summit is highly regarded and one of the largest physician groups in East Tennessee. Declining the merger offer meant that Trinity could not access the lucrative in-house ancillary services that Summit provides, such as lab, imaging, and other diagnostic services. Staying small and independent also means having less bargaining clout with hospitals, insurance companies, and other payers.
The physicians at Trinity knew they were leaving money on the table. "We would have definitely seen an increase in income, but we just decided that wasn't the most important thing," he says. "It's not that we would serve our patients less in the larger group. But we like the particular ways we are able to serve our patients in our own private group."
Marc D. Halley, MBA, president and CEO of Westerville, OH–based The Halley Consulting Group, LLC, says a number of factors—many of which are beyond physicians' control—are threatening the financial viability of small, independent practices. "My personal opinion is that we are going to see an increase in the consolidation," he says. "The healthcare industry is maturing, and as industries mature, they consolidate. That is Business 101. So, it will continue to consolidate in urban, suburban, and rural settings."
That doesn't mean it's a lost cause, Halley says. But if your group intends to stay small and independent, you must realize that you will be swimming against a strong current.
"Can some groups remain in private practice, independent of others? Absolutely. But they have to be in the right setting, with the right age mix," Halley says. "They have to be smart about how they do business, how they negotiate. And they have to be important enough to other players in the community to be left alone."
Evaluate internal factors
To make an informed decision about whether your practice can go it alone, Halley recommends a frank review of internal and external factors affecting your practice. Internally, you should consider factors like owner demographics.
"If I have a small group practice and the doctors are all 58 and they are saying 'We are tired of this. We've done our thing. We've been entrepreneurs.' Then it might make sense for them to say 'We want to get out. We are having a hard time recruiting. We don't have the capital we need to recruit new doctors. We are afraid that if we don't join somebody we will be unable to negotiate with payers.' "
Another internal factor is practice performance, particularly as it relates to finances. "Am I able to fund my retirement plans and provide benefits? If I am able to do that still, I may be able to stay independent," Halley says.
Strategic capability also should be factored in. "That simply means that I am able to make decisions and remain independent because I have a specialty that is needed. I've got access to capital. My debt ratio is low enough so that I have access to all kinds of capital if I need it. So I have the resources to recruit and add equipment or diagnostics. Or, I can't. I'm up to my eyeballs. I'm barely making payroll. I can't remain independent," Halley says.
Assessing the quality of leadership within your practice also is critical. "Are there physicians in my group that love business in addition to the clinical side of medicine?" Halley says. "You tell us you don't want to worry about business administration, you want to practice medicine. Our message to you is the day you leave your medical training program you are in business. Either you will be smart about being in business or somebody else will make those decisions for you, and that will affect how you practice clinically."
Consider factors outside your control
Then there are the external factors, many of which are beyond your control. "What is going on in your market externally? Do you have the internal capacity to respond to that and remain independent?" Halley says. "If you don't you have to consider who would be the best partner. You'd rather be making a partner selection than being forced into slavery, as it were, by a bigger player that is just gobbling up everybody."
It's not simply a question of buckling down and working harder to survive. "We don't know what is going on with healthcare reform, but there is one thing we can be assured of: Reimbursement will go down," Halley says.
To prepare for that, Halley says, small primary care practices can no longer be reliant solely on cognitive services. "We are saying to our family physicians, ‘Be smart, start looking for products and services you can offer. Don't think you can make it just on cognitive services and go from seeing 25 patients a day to 45 patients a day.' In a health practice, as a rule of thumb, we are looking for at least 20% of net patient revenues from ancillaries."
To stay independent, physician groups also must adopt stringent highest- and best-use staffing practices, where the physicians' valuable time is spent doing only what the physicians can do, with other work delegated to clinical assistances facilitating patient interaction. "One of the most important responsibilities of a clinical assistant is to help the doctor be productive, to keep that doctor moving all day long," he says. "That enhances the physician's productivity. But you have to staff for that. In some cases, you may have to increase staff to increase productivity."
In March 2008, a task force was formed to review and revise the American Nurses Association's (ANA) Professional Development Scope and Standards of Practice. This document establishes the range of practice and the principles by which nursing staff development professionals conduct our professional lives.
It is no easy task to revise such an important document. Why undertake such a critical venture? To begin with, says task force member Dora Bradley, PhD, RN-BC, vice president of nursing professional development at Baylor Health Care System in Dallas, "it has been 10 years since the last version was created. There have been so many changes in healthcare as well as our profession, so we must look at the Scope and Standards in terms of how our roles have evolved." Bradley notes that, for example, technology was not even addressed in the most recent Scope and Standards.
"The new version of the Scope and Standards must also consider the fact that the continuing education target audience is now worldwide," she says. "We must think in terms of a globalization concept and how education needs can be assessed across the world. Simulation and virtual reality must also be incorporated as these teaching modalities grow in scope and importance. I remember someone saying that 98% of the change in the world has occurred in the last 100 years, and 90% of that change has occurred in the last 10."
The task force started by conducting an intensive literature review of training and continuing education in and out of the healthcare arena. The ANA mandated that the group create something "that would represent not only current practice, but a future trajectory to guide practice for the next five years," says Bradley. "We must create a 30,000-ft. view because our specialty has so many different arms where we practice, our roles, and practice setting, etc."
The task force identified specific future trends to be addressed. These include (Bradley et al., 2009):
Increased use of technology
Global target audience
Teaching/learning modalities
Evidence-based practice
Increased accountability
Increased interdisciplinary involvement
Fiscal management
Need for complex implementation expertise
Professional development metrics
Decreasing time to achieve competency
Generational differences, including the emerging adult (Tanner, Arnett, and Leis, 2009)
Escalating competing priorities
Knowledge management and succession planning
Increased need for clinical affiliations and academic partnerships
Move toward learning as an investment in human capital
Cost avoidance versus expenditure
Focus on transition into practice
Bradley says the "influence of the work environment became very apparent, which was not addressed in previous editions. Learning and practice environments have tremendous influence on how much of this role [as identified in the Scope and Standards] can be operationalized by the individual specialist. For example, a one-person staff development department can't do orientation, continuing education, research, etc., not when there is only one person doing everything. We must be respectful of the practitioner's practice environment."
There was a significant struggle as the task force altered the practice model. The former model was a triangle with three intersecting circles (continuing education, staff development, and academic education), which appeared to reflect the professional development aspects of the nurse.
The proposed new model is a systems model focusing on the practice of nursing professional development (NPD). The system includes inputs (environment, learner, NPD specialist), system throughputs (evidence-based practice, practice-based evidence, orientation, competency program, inservice education, continuing education, career development, research-systematic inquiry, scholarship, academic partnerships, pole of NPD specialist), and system outputs (outcomes, change, learning, professional role competence and growth). Note that academic education is now addressed via partnerships. Nurses in academia have their own set of competencies and a certification model separate from the Professional Development Scope and Standards. The proposed model is also more fluid, documenting inputs, throughputs, and outputs (Bradley et al., 2009).
The suggested changes were posted on various professional association Web sites, including the ANA and the National Nursing Staff Development Organization (NNSDO), for public comment. Education requirements generated the most buzz: The task force proposed that educational preparation for NPD specialists be a master's degree in nursing. This is controversial because many NPD specialists have a master's degree in education. Due to public comment, the proposal has been changed to a master's degree in nursing or appropriate related discipline such as education.
However, if the master's degree is in such a related discipline, the NPD specialist must hold a baccalaureate in nursing. Additionally, the task force recommends that executive leaders for NPD be RNs prepared at the doctoral level in nursing or education. At a minimum, department administrators are strongly encouraged to have a master's degree in nursing or related field.
When will the revisions be published? At presstime, the task force was working to approve the final revisions and submit them to the ANA. The ANA must guide the proposed document through its approval process, and hopefully, the new version of the Scope and Standards will be ready to print in the first quarter of 2010.
Bradley points out that the task force received about 30 pages of public comment pertaining to the proposed document. She notes that this is comparable to feedback received from other specialties, which have more practitioners, when their Scope and Standards undergo revision. Professional development specialists are obviously deeply committed to their specialty and the way they practice.
Those of us involved in this specialty would be wise to incorporate the future trends identified by the task force into our practice settings. The effect and the rapidity of change greatly influence how we incorporate these trends. The new Professional Development Scope and Standards should be used to enhance our professional growth and development as well as our practice initiatives.
References
Bradley, D., et al. (2009). "The Past, Present, and Future: The Evolution of the ANA Nursing Professional Development Scope and Standards." General session at the 2009 NNSDO convention, Philadelphia.
Tanner, J.L., Arnett, J.J., and Leis, J.A. (2009). "Emerging Adulthood: Learning and Development During the First Stage of Adulthood." In M. C. Smith & N. Defrates-Densch (Eds.), Handbook of Research on Adult Learning and Development, 34–67. New York: Routledge.
This article was adapted from one that originally appeared in the December issue of The Staff Educator, an HCPro publication.
The Los Angeles Timespublished an exposé this month about temporary nursing firms that fail to perform thorough background checks on nurses they hire to fill the temporary staffing needs of hospitals in California.
The article contains shocking tales of nurses with criminal records, suspended licenses in other states, or serious allegations of unprofessional conduct who nonetheless are hired by temporary agencies and sent to work at California hospitals. When unsuspecting hospitals have problems with nurses and instruct agencies to not send that individual again, nurses are often simply placed with another facility. Nurses fired by one agency can be easily hired by another.
The temporary nursing industry is a $4 billion behemoth. Agencies run the gamut from firms with strict background checks that provide hospitals with well-qualified and vetted staff to those that hire nurses without even conducting an interview.
Some hospitals interview and check the credentials of every temporary nurse brought onboard. Others rely on the agency to do that for them, particularly when nurses are needed on short notice, and the news that some staffing agencies may not be vetting nurses as hospitals expect has been received with horror.
The issue of agency nurses is particularly relevant in California, where nearly 6% of RNs are temporary and the use of agency nurses has been considered imperative for meeting the state's strict nurse-patient ratios.
I talked with a couple of executives from the newly-consolidated National Nurses United union about this issue. We discussed ways hospitals can avoid using temporary nurses, California's nurse staffing regulations, and whether NNU supports the creation of a national "bad" nurse registry.
Jean Ross and Deborah Burger, two of the three co-presidents of NNU, say temporary agencies can be a blessing for hospitals occasionally, but that the only way for hospitals to really solve the issue of being staffed with competent RNs is to focus on ensuring a stable, long-term workforce that is committed to the organization, their coworkers, and their patients.
They say the solution to solving nurse turnover and retention is to create healthy working environments, and they believe this is demonstrated by hospitals that address nurses' issues using fewer travel or temporary nurses. And they reject the argument that California's staffing ratios have increased the need to hire agency nurses.
"In California, as a result of the ratios, nurses have come back into the profession from other states," says Burger. "They have increased their hours. There was a shortage until we had the ratio law. At that point, nurses came back in to nursing. I think something like more than 50,000 nurses came back into California as a result of the ratio law."
While acknowledging there are occasional nurses who do not belong in the profession, Burger says most of the problems associated with temporary nurses result from the fact they often do not receive adequate orientation or time with preceptors at the facility to which they are assigned.
"Even if they were good nurses, it's difficult to expect they will know the politics, policy, and procedures of a certain facility. Even though the practice is similar, it's usually the politics and policies and layout that get people into trouble," says Burger.
This is why NNU is supporting a bill currently in the California legislature that would require organizations provide ample orientation to temporary nurses and ensure their competency before they are allowed to practice at the facility.
For those so called "bad" nurses, Burger does not support the creation of a nursing registry that would track nurses nationally. She believes this is a function of the state Boards of Nursing that should receive appropriate funding to be able to fulfill their responsibilities.
"I'm all for that making sure patients are protected," says Burger. "That's why a third-party clearing house like the state Board of Registered Nursing should be the authority body. They are the ones who give the temporary nurse the license in the respective state."
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The impact of inaccurate patient identification on a healthcare organization and its patients is wide-spread and significant. An inefficient master patient index results in duplicate and/or overlaid patient records. It can also result in inappropriate, delayed treatments, or other adverse events.
This, in turn, can create a life-threatening situation due to inaccurate medical records and clinical information at the point of care. An inefficient MPI also increases the workload for health information management and IT in terms of managing system integrity and creates a significant drain on financial resources.
Industry-wide estimates are that 5% to 20% of a hospital's records are duplicates. That rate increases to 40% or higher for organizations that have acquired and/or merged with other facilities or are part of an integrated delivery network. Each duplicate record carries direct costs ranging from $20 to identify and correct it to several hundred dollars in variable costs for repeated diagnostic tests when a patient's record cannot be located in a timely fashion.
Why an EMPI?
Multiple MPIs that are not linked across an enterprise can result in data being entered into multiple records for the same patient, with no ability to merge those records until post-discharge or sometimes not at all. This leads to inconsistencies and inaccuracies that impact care decisions. It can also affect the interoperability between and among a facility's information systems and those of its partners and affiliates.
These were the challenges Exempla Healthcare, which includes three hospitals and a network of clinics throughout the Denver metro area, was determined to overcome with the implementation of an enterprise master patient index.
In addition to the need to mitigate the risks created by an ineffective MPI, a primary driver of Exempla's push for EMPI was its migration to Epic. As part of that process, data would be aggregated from two MEDITECH systems and one Kaiser Permanente-hosted Epic system into a single Exempla-wide Epic system.
Exempla's objectives with its EMPI project were to:
Enable clinicians and physicians, including those from affiliated external provider entities, to accurately identify patients throughout the enterprise and provide them access to pertinent clinical information regardless of where the patient received clinical services within Exempla.
Provide the clinician/physician with a complete view of a particular patient's health status.
Adopt an advanced record search algorithm to enable patient registration and scheduling staff to more accurately identify patients and reduce the risk of incorrect patient identification and duplicate record creation.
A fourth goal was to reduce the cost Exempla was already incurring related to duplicate records. Estimates placed the duplicate volume for all three facilities at more than 17,000 records. Of those, an estimated 4.3% incurred additional clinical costs averaging $205.38 for repeated tests and treatment delays and incremental costs of $2.50 for additional registration times and $20.63 for correction. As a result, the total annual cost to the Exempla system for duplicate records was estimated at $554,000.
Industry reports have cited much higher clinical and treatment costs associated with unavailable historical medical information; in the neighborhood of 20% to 30%. This higher estimate would place Exempla's total annual cost in excess of $1.2 million.
Expectations were that the EMPI would reduce duplicate records by 70% after the first year. This would result in a return-on-investment within two years due to reduced costs in management of patient data, a reduction in the variable costs for duplicate tests, and elimination of on-going costs associated with resolving duplicate records.
Setting the Standards
Accomplishing these goals and objectives required Exempla to first determine whether an external EMPI was even necessary in light of the pending migration to Epic. They also needed to establish a clear understanding of key areas of weakness and set expectations for whatever EMPI solution was ultimately selected.
Recognizing that these critical tasks required a depth of experience and proven expertise that was not available in-house, Exempla engaged Just Associates, a consulting firm specializing in data integrity, to evaluate its strategic needs related to interoperability and an external EMPI. The firm was also charged with establishing a standard set of requirements to evaluate potential vendors.
This process started with a comprehensive data integration and patient identity data capture assessment to identify specific needs. Individuals involved in registration and scheduling were interviewed to gain a clear understanding of their work processes. Specifically, how pertinent information was collected from the patient, how that data was captured, how searches for existing patient records were conducted, and how that patient's identity was validated. Front-end search capability was evaluated in the registration and scheduling system with emphasis toward searching for records where multiple demographic data discrepancies might exist based on data being searched against what was stored in the database.
Next, back-end processes, namely the 200-plus system interfaces across which patient data was exchanged, were evaluated to ascertain how accurately the receiving system's record matching performed. Areas of potential risk were identified for each downstream system.
This led to the development of more than 250 functional requirements for prospective EMPI solutions. Among these were the ability to search on multiple data elements, identify individual records despite multiple data discrepancies, extensibility for future enhancements (including open source capability of the source code), and ease with which data could be extracted from the database for reporting. System requirements were also identified, including interoperability with the existing interface engine operating system and database platform, system scalability, response time metrics, etc.
Other specific requirements for the prospective EMPI solutions included:
Ability to support patient conversion from legacy systems into a single Epic system
The ability for Exempla to manage content across multiple data sources
Be able to integrate with Exempla's ambulatory EMR strategy
Open architecture system for extension needs
Ability to integrate bi-directional feeds with other ambulatory EMRs
Ability to easily integrate with Exempla's integration engine
Justifying Costs, Establishing ROI
These requirements ultimately drove vendor selection. However, to validate that selection and to secure approval and funding to move forward with implementation, a total-cost-of-ownership and ROI analysis was conducted.
The goal was to provide not only the cost justification, but also an explanation of goals and the consulting hours needed for EMPI implementation. It also served to identify general interoperability with and without EMPI implementation, and duplicate vulnerability for downstream systems in the absence of an EMPI.
The analysis was highly detailed and included:
Ability to support patient conversion from legacy systems into a single Epic system
The ability for Exempla to manage content across multiple data sources
Be able to integrate with Exempla's ambulatory EMR strategy
Open architecture system for extension needs
Ability to integrate bi-directional feeds with other ambulatory EMRs
Ability to easily integrate with Exempla's integration engine
An educational component was also developed to help the capital approval committee understand that EMPI is more than just a filter to identify duplicate records; it is a complete data management tool designed to improve patient safety through delivery of accurate information.
A Blueprint for Long-Term Success
Exempla's EMPI project is currently in the implementation phase, but the organization is already realizing the benefits of conducting the comprehensive assessments, evaluations, and justifications that led to the decision to move forward.
That is because the thorough analyses did more than validate Exempla's need for an EMPI. By identifying the weaknesses in the existing collection and maintenance of patient data, Exempla was able to take corrective action even before implementation is complete. This will ensure that the organization realizes immediate benefits from the elimination of duplicates within the system.
More importantly, this approach ensures that the organization–and its patients–will realize the long-term benefits that come from the permanent resolution of those data integrity issues that would otherwise continue to plague the system and limit the effectiveness of EMPI.
Barbara Manor is the senior system director of health information management for Exempla Healthcare. She can be reached at ManorB@exempla.org. Laszlo “Lots” Pook is the chief information officer for National Jewish Health and the former chief technology officer for Exempla Healthcare. He can be reached at PookL@NJHealth.org.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Five national hospital groups have sent a letter to the U.S. Department of Health and Human Services expressing their concerns about the department's expected definitions of a "hospital" and a "hospital-based physician" under the federal stimulus package.
The definitions will help determine eligibility for Medicare and Medicaid incentive payments for the "meaningful use" of electronic health records. Earlier this month, a group of 43 hospitals and health systems also sent federal officials a letter urging them to redefine certain terms to maximize the number of medical providers that will be eligible for health IT incentive payments under the federal economic stimulus package.
