For the November issue of HealthLeaders magazine, I spoke with two large health systems about their strategy regarding PACS and what healthcare organizations should be doing to prepare for an interoperable healthcare system where this information will need to be exchanged with other providers (PACS: The Next Generation, November 2009). The University of Utah Health Science Center, which recently converted to an iSite PACS from Andover, MA-based Philips Healthcare, and Iowa Health System, which switched to a PACS from San Francisco-based McKesson Corp., shared their strategies to improve speed, stability, and access to their PACS while increasing storage and clinical functionality, as well.
I was curious about smaller, community hospitals' strategy, so I contacted John Rousseau, director of the radiology department at Alice Peck Day Memorial Hospital in Lebanon, NH. In 2007, his hospital, which serves more than 20 communities in New Hampshire and Vermont, implemented a Web-based PACS system from Boston-based AMICAS Inc. that has roughly 300 users. Here's what he had to say regarding his PACS strategy.
HealthLeaders Media: What is your history with PACS? Rousseau: Our PACS system was implemented in 2007. Prior to that, we had no PACS system in place. We had some workstation software that we used to forward images to our radiologists' homes and a couple of e-film licenses that we used to make CDs. We were looking for a vendor that would allow us to integrate one PACS system for community hospitals that had disparate RIS systems. We implemented a Web-based PACS system that we deployed using three spoke servers at the other hospitals that forward images to our main server. This workflow allows for each hospital to have their interfaces and modalities point to the spoke server, and then the study is forwarded to the hub server over a wide area network. In the event that the main server goes down, the spoke can still continue to operate locally. Our main storage is a storage area network, which we find attractive for its reliability and scalability. As we move forward, it's our hope to also migrate our disaster recovery back ups onto spinning disk. At this time, we're using a worm drive that can store 30 gigabytes per disk and, as we've grown, we realize that we've outgrown our 80 disk library very quickly.
HealthLeaders Media: As the industry moves forward with health information exchanges, what is your strategy to ensure you have the proper infrastructure in place to support the exchange of data from your PACS? Rousseau: Our strategy to support our infrastructure is to continue to invest in our personnel by ensuring that they stay proficient in the use and management of the PACS system. We also have groups in IT, radiology, and administration who meet regularly to ensure we're meeting our regulatory directives and the needs of our customers—both patients and physicians. Having all three parties—from IT, radiology, and administration—together has been crucial to our success. We also have scheduled bi-weekly meetings with our PACS vendor. During these meetings, we discuss support cases and talk about ways we use the system or ways we'd like to see the system modified to meet our needs.
HealthLeaders Media: What are the key elements organizations should focus on with regard to PACS to ensure they are positioned for success in the next five years? Rousseau: Key elements would include a group within an organization that includes radiology, IT, and administration that works together to discuss PACS—not only during implementation but during its operational phase, as well. I also would strongly suggest finding a PACS vendor that treats you like a partner not just a customer. Talk to your end users—both physicians and patients—because the easier you make it for them, the more successful you'll be. And be sure you spend time understanding your needs for your interface from the RIS to the PACS. A well interfaced system will pay dividends everyday, whereas a poorly implemented one will cost you every day. One lesson learned is this: You'll always underestimate storage and bandwidth needs. That is why it's important to have groups meeting after your implementation.
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Despite challenging economic and credit conditions, bond ratings at 20 nonprofit hospitals and health systems have been upgraded since late 2008, Moody's Investors Service said in a new report that identifies common factors that have contributed to their success.
"For some, the upgrades represent a return to a hospital's prior bond rating," Choi said.
Moody's said the 20 upgrades were driven by one or more factors, including strong management and governance practices, market success with growth in an existing or new service line, and improved financial performance.
"Those management practices include the setting of clear capital and operating goals, close tracking of performance indicators, and tight management of capital project costs," Choi said. "Another key practice is the ability to adjust strategy in the face of recession and recruitment and the retention of talented senior managers."
Choi said a nonprofit hospital can also strengthen its credit standing by demonstrated financial and strategic support from a parent or a closely aligned enterprise such as a university or municipality, and through timely completion of major capital projects that have met or exceeded financial projections.
"It is clear that the upgraded hospital systems benefit from proactive management teams and actively engaged boards of directors," Choi said. "They are better positioned to weather the current credit stresses because they know how to leverage strengths, successfully identify growth opportunities, and maintain strong expense controls."
Matt Winn, IT director at Pacific Hospital of Long Beach in California, discusses the benefits and challenges of delivering a full range of applications via a thin client solution rather than maintaining traditional desktops. [Sponsored by Emdeon]
One person's trash is another person's treasure, or so the saying goes. And health systems in this country generate a vast amount of trash—a great deal of which looks like treasure to staff at needy medical centers and clinics in underdeveloped countries.
Think about the items that are thrown away in your organization every day. Extra swabs, sterile needles and syringes, soap, and other seemingly insignificant items that are taken into patients' rooms in case they are needed, but that must be discarded when patients are discharged. These supplies have not been used, but they can't be put back into supply closets or used for others patients.
So they end up in the trash, generating tons of waste in landfills and doing nothing to help reduce unnecessary medical expenditure.
But there's a better way, says Elizabeth McLellan, an administrator at Maine Medical Center in Portland, who collects these unused supplies and distributes them to impoverished towns and villages in countries across Africa and South East Asia.
McLellan has been a nurse for more than 30 years, and first identified a need to collect unused supplies when she worked as an administrator at a hospital in Saudi Arabia. She would travel to countries such as the Philippines, Sri Lanka, and India to recruit staff, where she was confronted with the reality of medical centers and clinics that had a desperate need for supplies that were commonplace at her own organization and back home in America. So she started accumulating unused medical supplies and took them with her whenever she travelled.
After returning to Maine in the 1990s, her enthusiasm grew, and two years ago, she ramped up her efforts. She met with nurses around her hospital to discuss ways the organization could recycle unused supplies. Now nurses and housekeepers gather up the unused material in bags, which they can drop off at recycling boxes that were installed at 20 different locations in her hospital.
As word spread of her efforts, McLellan began collecting material from medical centers around the state, and her stockpile soon took over her home. In September, she was able to move the supplies to a storage facility thanks to help from AAA Northern New England. When she and a group of volunteers moved the supplies from her home, it weighed more than five tons.
In the last few months, McLellan has started a nonprofit organization, Partners for World Health, to coordinate and expand her efforts and to help other hospitals around the country undertake similar endeavors.
She says there are three reasons hospitals can get behind the call to recycle unused medical supplies. First, most hospitals pay a disposal fee to get rid of trash, which is calculated based on the weight of trash generated.
"If I take 50,000 pounds of medical supplies that were headed for the trash out of Maine Medical Center," says McLellan, "that lowers their disposal fee, which decreases their expenses."
Second, such programs benefit the environment. Most of the material that McLellan collects is composed of plastic or other non-biodegradable materials. Recycling these supplies means they don't end up in a landfill. And McLellan says healthcare professionals are usually delighted to find a way to prevent needless waste. Last, and most importantly, such programs present an opportunity to distribute supplies to people who are less fortunate than us and to make a difference for good in the world.
She shares an example about sterile syringes and sterile needles of all different sizes, which are one of the most common items she receives and that are in desperately short supply in third world countries.
"They draw up the medication in a syringe and give 1 cc of medication to you and they turn around, and with the same needle, they give the other cc to another person. Because they don't have an abundant supply of sterile needles and syringes," says McLellan. "So they are passing HIV from one person to another with dirty needles."
"Every hospital throws these away by the thousand. These need to be saved so we can provide a supply to people in the third world and stop this from happening."
All of the discarded items are a gift to the recipients, which are never big city hospitals, which tend to have reasonable supplies. Rather, they are little towns or villages, such as Turmi in Ethiopia, which she says is a torturous eight-hour drive from Addis Ababa and whose medical center lacks basic necessities.
McLellan's next trip is to Cambodia over Christmas, where she hopes her newly-minted organization will eventually be able to convert a boat to become a clinic that will travel up and down the Mekong River from Phnom Penh to Siem providing medical care to rural areas of Cambodia. Her goal is for the operation to be staffed by a revolving cadre of volunteers.
In the spirit of the season, when many of us are looking for ways to do something for those less privileged than us, McLellan's effort is a shining example. To find out more information or learn how to start a similar program, follow Partners for World Health on Facebook, or contact McLellan at 207-671-4723 or Mclellan.elizabeth@gmail.com.
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Imagine you could interact with multiple patients, diagnose and treat their illnesses, administer drugs, and even ensure that staff members are following infection control best practices 24 hours per day, seven days per week, all without getting out of your chair.
This is the basic premise of the eICU, an electronic subdivision of the ICU at Alegent Health in Omaha, NE. Mark Kestner, MD, senior vice president and chief medical officer at Alegent Health, likens it to an air traffic control tower. Nurses and physicians man an off-site location filled with two-way cameras linked to ICUs in three metropolitan hospitals and one rural hospital in the system.
Six nurses in the eICU routinely manage 15–20 patients each, in conjunction with on-site ICU staff members. A physician handles high-risk patients, and Alegent recently added a pharmacist to monitor antimicrobial activity.
The software built into the eICU not only feeds real-time data for roughly 100 patients, including vital signs, laboratory tests, cultures, and pharmacy data; it also sorts the information and sets off alerts if there are concerns with a patient. Nurses and physicians in the eICU can also alert bedside staff members if a patient needs emergency care.
"What it does is it frees up the bedside staff because they know that certain elements of information are being sorted and addressed and that they can then be more available for the immediate needs of the patients or the routine bedside needs of the patient," Kestner says.
Involving infection control
In its first two years, the eICU at Alegent has focused primarily on patient care, but Emily Hawkins, RN, BSN, director of IC at Alegent Health, says the centralized location of the eICU makes it a great opportunity to integrate infection prevention compliance, as well.
A pharmacist has already been incorporated into the eICU to monitor drug interaction, but Hawkins says there are also plans to use the eICU to build antimicrobial reviews, which will forward information to the lab and pharmacy. Going forward, an infectious disease physician will be present to intervene with antimicrobial counsel.
The eICU team is already incorporating ventilator and central line bundles into its everyday care.
"I think what this allows us to do is to standardize our compliance with ventilator bundles and with standards of care," Kestner says. "We already had a very low infection rate, but this allows us to have another set of eyes on the team asking very specific questions every day. The eICU team does have the checklists and they make sure the central line is taken out if it's not needed, the ventilator bundles are adhered to, the patient's head of the bed is up, and the patient is being extubated quickly if they don't need to be on the ventilator."
It also helps that the eICU suite is in the same office as the infection prevention program.
You're on candid camera
If this sounds a bit too Big Brother for you, you're not alone. ICU staff members were initially resistant to the idea of someone watching over their shoulder from a well-placed camera, Kestner says.
"If you think of these people doing their work and all of a sudden they have a two-way video camera in the room and they know at any point in time someone could turn the camera on and be looking over their shoulders, they found that to be very intrusive," Kestner says.
The clinical practice committee that oversees the eICU created a set of rules to alleviate the Big Brother feeling, including:
A bell rings to alert the on-site employee when the camera has been turned on
Twice per day, the on-site nurse and the eICU nurse conduct interdisciplinary care rounds with patients and their families, fostering a working relationship between the bedside and eICU staff members
These team rounds were particularly helpful to establish a working relationship between the eICU and bedside nurses and the patients.
"And so not only now do the nurses have a relationship with the eICU, but families and the patients know who is on the other end of the camera and establish a relationship with those care providers," Kestner says. "It took us sort of actively intervening and teaching people how to act as a team in order to establish that relationship and not feel like the presence of eICU is intrusive, the presence of eICU is really being a part of their team."
U.S. Department of Health and Human Services Secretary Kathleen Sebelius praised the system when she visited Alegent's Lakeside Hospital July 12 to experience this interaction first hand.
Ultimately, patients and families also feel more secure when they interact with the person on the other side of the camera and they don't feel like it's just a machine, Kestner says.
"We have patients that are transferred from some of our smaller facilities to our bigger facilities, and the eICU will talk to the family before the patient leaves the smaller facility and then talk to them when they arrive at the new facility, so it makes them feel like their care has been seamless," Kestner says. "Families like having that extra set of eyes and have a sense of comfort knowing that they are there."
Absorbing the cost
Of course, as with any elaborate technology, the eICU comes with a hefty price tag. Alegent was able to integrate its rural hospital because of a United States Department of Agriculture Rural Development grant, Kestner says.
Some argue that having that extra set of eyes will decrease infections and lengths of stay and shorten patient days throughout the unit, ultimately benefiting hospitals' financials. But Kestner says it's also worth it from a patient satisfaction and efficiency perspective.
"I think the way we are looking at it is length of stay for the whole hospitalization, shortening length of stay in the whole ICU, shortening length of stay on the ventilator," Kestner says. "We just have our baseline data, so I'm not sure we can say we have absolutely saved enough money to offset the initial expense, but it allows us going forward to remain efficient."
As to whether this is sustainable technology for the future, Kestner recognizes that the startup costs are too high for most hospitals. He suggests this kind of movement in the future would require government involvement.
"You can almost suggest that it's something similar to meaningful use," Kestner says. "Is there a meaningful justification for this type of technology, and does it improve outcomes and improve care and start to rationalize our workforce issues?"
This article was adapted from one that originally appeared in the October 2009 issue of Briefings on Infection Control, an HCPro publication.
The Certification Commission for Health Information Technology today announced the first group of four electronic health records programs certified under its two programs—CCHIT Certified 2011 Comprehensive and Preliminary ARRA 2011.
Both programs inspect EHR technology for the first time against proposed federal standards to support providers in qualifying for 2011-2012 incentives under the $787 billion American Recovery and Reinvestment Act.
"These first four health IT companies, demonstrating their compliance with the proposed federal standards, are now able to offer certified products to providers who wish to purchase and implement EHR technology and achieve meaningful use in time for the 2011-2012 incentives," said commission Executive Director Alisa Ray. "We've had about 25 applications in our 2011 programs and inspections are continuing. Look for additional announcements from these early applicants in the upcoming days and weeks."
The CCHIT Certified 2011 Comprehensive program differs from the Preliminary ARRA certification program by providing a more rigorous inspection of integrated EHR functionality, interoperability, and security in addition to full compliance with federal standards.
As part of the comprehensive inspection process, key aspects of successful use are verified at live sites, and usability is rated. The CCHIT Certified Comprehensive program is intended to serve healthcare providers looking for "maximal assurance" that a product will meet their complex needs, as well as support their achievement of meaningful use to qualify for the ARRA financial incentives, according to CCHIT.
The product certified in the CCHIT's Certified 2011 Comprehensive program is ABELMed EHR-EMR/PM, Version 11, by ABEL Medical Software Inc.
The Preliminary ARRA 2011 program is a modular, limited certification and inspects technology only against the federal standards. It offers maximal flexibility for health IT companies, developers and providers in meeting ARRA 2011-2012 certification requirements. The products certified in the Preliminary ARRA 2011 program are:
eHealth Made EASY, Version 3, by eHealth Made EASY, LLC, supporting two of 27 meaningful use objectives for eligible providers and two of 24 objectives for hospitals.
KIS Track, Version 5.1, by Kaulkin Information Systems, supporting two of 27 objectives for eligible providers.
Medios, Version 4.5, by IOS Health Systems, supporting 27 of 27 objectives for eligible providers.
The ARRA certification component of both programs is considered preliminary because the definitions of meaningful use, criteria, and standards have been proposed but not yet finalized by HHS.
Chest ultrasound is a viable alternative to chest CT in evaluating pediatric patients with pneumonia and parapneumonic effusion, according to a study published in t the American Journal of Roentgenology. Researchers concluded that chest CT didn't provide "any additional clinically useful information" that was not also seen on ultrasound. Considering that chest ultrasound has has an advantage in portability, does not require patient sedation, and has superior ability to detect fibrin strands within an effusion, the authors suggested that evaluation of children with complicated pneumonia include chest ultrasound as well as chest radiography.
An online program from Medical Mutual of Ohio helps consumers organize medical bills, understand how much they owe and for what service, know what to do if there's a billing error, and pay doctors and hospitals on time. The free program is called Quicken Health and was created by Intuit, the company that developed TurboTax. It's currently available to Medical Mutual, Cigna, and UnitedHealthcare customers.
This article from the Chicago Tribune outlines the key issues of prescription data mining. Critics argue that this data on physician's prescribing preferences enable pharmaceutical companies to tailor their marketing efforts in a manner that distorts decision-making. But data mining companies and advocates say the information can help control costs and improve quality by quickly providing doctors with information on which treatments work best.
The Department of Veterans Affairs and Kaiser Permanente are launching a pilot program to exchange electronic health record information using the Nationwide Health Information Network created by the Department of Health and Human Services. The pilot program is slated to begin mid-December 2009, and will connect Kaiser Permanente HealthConnect and the VA's electronic health record system—two of the largest EHR systems in the country, Government Health IT reports.
