Extended COBRA subsidy could be extended again

The COBRA subsidy for laid off workers has been extended and expanded. On Dec. 19, 2009, President Obama signed the Department of Defense Appropriations Act for Fiscal Year 2010, which includes an extension of the government-funded COBRA premium subsidy provided in the American Recovery and Reinvestment Act of 2009 (ARRA).

The original subsidy program under ARRA provided a nine-month 65% premium subsidy for COBRA coverage to eligible individuals who were involuntarily terminated from their job and who also lost coverage as a result of the termination on or after Sept. 1, 2008 through Dec. 31, 2009.

The new legislation preserves the amount of the subsidy at 65%, but it alters the original subsidy in several ways, including: extending the period during which an eligible individual may qualify to receive the subsidy; extending the length of time eligible individuals may receive the subsidy; and providing new notice requirements.

The legislation extends the period of eligibility by replacing the original Dec. 31, 2009, cutoff date with a Feb. 28, 2010, cutoff. The subsidy is, therefore, now available to eligible individuals who are involuntarily terminated on or before Feb. 28, 2010. The new legislation also provides that the involuntary termination must occur on or before the cutoff, which differs from the previous version of the subsidy that required both the termination and the loss of coverage to occur on or before the cutoff date.

For example, an eligible individual who is terminated as of Feb. 1, 2010, and has coverage through the end of February is eligible for the subsidy under the new legislation even though the loss of coverage would occur after Feb. 28, 2010.

The new legislation also increases the maximum period to receive the subsidy from nine to fifteen months. Because that increase is also retroactive, employees involuntarily terminated between Sept. 1, 2008 and Dec. 31, 2009, who exhausted their entitlement will now have an additional six-month period. Eligible individuals whose maximum subsidized period already expired will be permitted to reinstate their coverage by paying the retroactive subsidized premiums.

Further, depending on the particular circumstances, an eligible individual may also be entitled under the new legislation to receive a refund (or credit) for any overpaid premiums that were made after exhausting the nine-month premium subsidy.

MUST GIVE NOTICE

There are also a number of new notice requirements provided in the recent legislation. For example, the recent legislation requires plan administrators to provide notice regarding these changes to individuals who were eligible for the subsidy on or after Oct. 31, 2009, or who experience a qualifying event (consisting of termination of employment) relating to COBRA coverage on or after this date. The notice must be given no later than Feb. 17, 2010; however, for individuals eligible for the subsidy on or after Dec. 19, 2009, the notice must comply with the COBRA general notification requirements.

One final point: The COBRA subsidy may be extended again. An extension to June 30, 2010, has been proposed in legislation known as the Jobs for Main Street Act, which is currently before Congress.

This column is written for informational purposes only and should not be construed as legal advice.

Barry Senterfitt is a managing shareholder at Greenberg Traurig, LLP, Austin, Texas.

Janet Farrer is an associate at Greenberg Traurig LLP, Austin, Texas.

Barry Senterfitt
Janet Farrer

Indiana Health System Sues OrthoIndy Over New Surgery Center

St. Francis Hospital and Health Centers has filed suit against three OrthoIndy-affiliated physicians over their involvement in planning Indiana Orthopaedic Hospital South in Greenwood, Ind., according to a report by the Indianapolis Star.

St. Francis currently owns and operates Indiana Orthopaedic Surgery Center jointly with OI South, an OrthoIndy affiliate.

St. Francis claims that the three physicians named in the suit breached their fiduciary duties to IOSC by taking part in the planning of Indiana Orthopaedic Hospital South, which would be a competitor to the IOSC facility.

Read the Indianapolis Star’s report on the St. Francis suit.

Indiana Health System Sues Three OrthoIndy-Affiliated Physicians

St. Francis Hospital and Health Centers has filed suit against three OrthoIndy-affiliated physicians over their involvement in planning Indiana Orthopaedic Hospital South in Greenwood, Ind., according to a report by theIndianapolis Star.

St. Francis currently owns and operates Indiana Orthopaedic Surgery Center jointly with OI South, an OrthoIndy affiliate.

St. Francis claims that the three physicians named in the suit breached their fiduciary duties to IOSC by taking part in the planning of Indiana Orthopaedic Hospital South, which would be a competitor to the IOSC facility.

Read the Indianapolis Star’s report on the St. Francis suit.

The height of health IT

Even health insurance giant WellPoint—with more than 35 million members and arguably enough reach to change the system with sheer volume alone—is taking few chances on the future of healthcare delivery. Like most plans, it’s testing new programs with cautious optimism, while aiming for large-scale implementation.

Charles Kennedy, MD, WellPoint’s vice president for health information technology, has a vital role in the plan’s innovation because few initiatives these days can be accomplished without the backbone of health IT.

Specifically, WellPoint’s emerging Individual Health Record—a simultaneously patient-facing and physician-facing electronic record—is “almost an air traffic control system to manage disease,” according to Dr. Kennedy. It’s probably one of the most promising efforts to control costs among members with chronic conditions. Pulling claims and clinical data through complex algorithms to arrive at a functional health summary differentiates the Individual Health Record from the typical EMR system.

“If you’re a hospital or institution, you have a variety of clinical data sources that have information on the patients that you see,” he says. “If you haven’t deployed an interface engine or some way of pulling those various clinical data sources together, you’re late to the party, and you need to do that ASAP.”

With more than 20 years of experience comprised of clinical practice and health IT implementation, Dr. Kennedy began his career in internal medicine. When he was a resident at Highland General Hospital in Oakland, Calif., he noticed how the patients’ needs far outstripped the hospital’s resources, and that experience solidified his vision of where medical care and information should meet.

“We tried to treat each patient regardless of who they were or their ability to pay,” he says. “It had the unfortunate side effect that we never thought about cost. We only thought about what was right for a patient. But that created a system where people are actually being hurt because they can’t afford care. I began to realize that the very laudable and applaudable approach of not caring about cost—only the patient—is right, but that doesn’t mean you can become cost unconscious. Cost unconsciousness has its own set of bad outcomes. That’s what’s led me into thinking we need to be more efficient. We need health IT.”

Earlier this year, Dr. Kennedy was named by the Government Accountability Office as a member of the new Health Information Policy Committee, which was established by the American Recovery and Reinvestment Act. Serving a three-year term, he and other committee members are creating policy framework for the development and adoption of a nationwide health IT infrastructure, including standards for the exchange of patient information. The committee will also make recommendations for handing out the $38 billion in health IT funding earmarked in the reinvestment act.

WHAT ARE SOME OF THE HEALTH INFORMATION POLICY COMMITTEE’S GOALS?

A:We’re trying to make sure the Obama health reform strategy becomes real. What people don’t realize is the number of things the industry and the government agree on. For instance, the government invested $1.1 billion in comparative effectiveness research.

The stimulus bill has $38 billion in it for health IT, and we’re trying to help the government develop policies to spend that money wisely. Our function is to say, ‘How do we take this incredible resource that Congress and the President have given us, and how do we turn it into an investment that creates healthcare value for the whole country?’ It’s a massive undertaking.

Our first objective was to ensure that the money from the stimulus package paid out over five years created value. We asked ourselves where we wanted to be five years from now, and then we worked backwards from there.

Deploying computers is not the goal. Having physicians and patients use computers to create better care at a lower cost is the goal. To do that, we have to set the bar high for the care system. Not only must you use the computer, you must use it in a meaningful way for better care. These are the ‘meaningful use’ criteria that we’ve published.

If we distribute a substantial number of computers, and physicians don’t use them, we won’t be successful. We didn’t want to focus on technical measures. We created the meaningful use criteria, and every single one is clinical.

We want physicians to achieve a clinical result, and we want information technology and the money in the stimulus package to be a contributor to that improved clinical result. For instance, one of the criteria is to avoid 1 million heart attacks and strokes by 2015. Another is to make cardiac disease no longer the leading cause of death in the United States. Those are stretch goals. That is not something simple and trivial.

It would have been much easier to say, ‘Our goal is to make sure 90% of physicians have computers.’ But we consciously didn’t do that because we recognize that health IT is a tool and that other changes need to happen.

HOW WILL THE INDUSTRY ACTUALLY ACHIEVE MEANINGFUL USE AND OTHER MILESTONES?

A:The law is actually quite specific in defining what a qualified system is, and we have a subcommittee that’s identifying the actual entity—such as the Certification Commission for Healthcare Information Technology (CCHIT)—that will assess systems as to whether they qualify or not. The bigger challenge is data integration.

Everyone recognizes that healthcare is horribly fragmented, that there are silos of care. We know that there’s massive inefficiencies, and there are significant quality concerns because information is not shared as people move across silos.

The challenge with data integration is that we really haven’t figured out how to do it correctly. If you’re an integrated delivery system and you buy one EMR, that’s fine, and that works. But 70% of physicians practice in a community setting, solo and small group practice. You have this tremendous problem that all of these systems are different. They call things by different names, and they even capture different sets of data.

WELLPOINT HAS CREATED THE INDIVIDUAL HEALTH RECORD SYSTEM THAT USES ALGORITHMS. HOW WILL THAT MAKE A DIFFERENCE?

A:Algorithms, also known as decision support, are going to be the key to getting value out of these systems. Let’s say the federal government funds a comparative-effectiveness study that identifies a new drug is great for certain people. In today’s world, we know it can take up to 17 years for that to be commonly found in a physician’s paper record. With this approach, you can create an algorithm as soon as physicians or specialty societies have decided on certain best practices. Now you’ve created an infrastructure to get that message to every doctor, but only when there’s an appropriate situation for that rule to be applied. That will take that 17 years down to 17 days. That’s a huge advance.

Let’s say we have noticed that there’s a lot of inappropriate use of PET scans. In today’s world, a doctor would have to call us for preauthorization every single time he orders a PET scan. In the future, the algorithms will be running, and they will only alert the doctor if there’s an issue with a PET scan. Today, they call 100% of the time, and we generally approve the scan more than 90% of the time. Algorithms will take hassles, administrative costs and bureaucratic burdens out of the system.

The right kind of health IT allows us to use new knowledge from our outcomes research subsidiary [HealthCore] and any gaps in a member’s care identified by our informatics company [Resolution Health] in much more effective ways. The right kind of health IT allows these advances to be applied real time at the point of care while the doctor is treating the patient or helping the patient at home.

IS WELLPOINT’S INDIVIDUAL HEALTH RECORD WORKING? HOW IS IT ANY BETTER THAN OTHER EMRS OR PHRS?

A:We’ve run a pilot in Dayton, Ohio. The idea was not just to create interoperability—don’t just allow System A to talk to System B. When you connect systems together, what you create is just a data dumpster. It’s like putting a jigsaw puzzle on a physician’s desk.

That information has to be organized to just the summarized information that the doctor needs…You don’t take all of the information out of these various systems, you only take the information necessary for the ongoing management of the patient.

Many EMR implementations have failed to show value. About 30% of the time, physicians will actually turn them off because they are incredibly time-intensive and will reduce a physician’s productivity. That will hit them in the pocketbook. We’ve looked for solutions that wouldn’t be so intensive from a physician’s data-entry perspective and would do more sorting of information and presentation of information.

Physicians are not data generators. They’re data consumers. Their orders create significant amounts of data, but the physicians themselves usually just scribble a relatively brief note. The problem with many EMRs is they will require physicians to become data-entry clerks.

In Dayton, Ohio, we have a very significant market share. We’re Anthem Blue Cross Blue Shield of Ohio, and we also have a strong partnership with Kettering Hospital Network.

Kettering had already installed an application integration solution, so even though they had 120 different clinical sources, many of those clinical sources could be accessed through infrastructure they had already built. That made it easy for us to collect all of the clinical data out of their systems. We built feeds to the application from Anthem’s claims systems. We were able to get this application up and running in a little over three months, which is incredibly rapid. We made it available to the patient in the form of a PHR and to the doctor in the form of a CCHIT-certified EMR with e-prescribing.

When we looked at who was using the tool, we found that patients who had a higher illness burden actually made preferential use of the tool. For many of the tools we’ve deployed, the ‘worried well’ have been the type of people who used it, not the people with the chronic disease that we really need to reach.

We noticed the people who used the tool and had the higher illness burden, their cost increase year over year was actually less than the people who didn’t use the tool, even though those people who didn’t use the tool were healthier.

We built algorithms in the system that exactly correlated with various HEDIS measures and every time the doctor or the patient logged on, they could see their exact compliance. By giving the patients and the doctor the same information in a simple red light, yellow light, green light format with algorithms enabled us to see quality improvement scores of anywhere from 10% to almost 40%.

WHAT’S THE BUSINESS CASE FOR A HEALTH PLAN TO CREATE A SYSTEM LIKE THAT?

A: Our strategy is maximizing healthcare value, and healthcare information technology is really a tool to get you there. But it has to be the right kind of health information technology. It has to influence doctor’s decisions, and you have to present sufficient clinical data—not mountains of data but the key things the doctor needs to know so that you can influence his decision to do something that’s consistent with the evidence base, or to prescribe a drug that will cost the patient less but has the same likelihood of creating a good patient outcome.

If you look at why healthcare spending is out of control, it’s chronic disease, not health plan profits and not health plan administrative costs. We are seeing an explosion of chronic disease in this country, and chronic disease is managed largely by the patient at home. They’re managing their diabetes 99% of the time at their home, not in the physician’s office. If you don’t make your health IT solutions patient-centric and if they don’t address chronic disease, I don’t think that you’re going to get the kind of value that you want.

HOW ARE THE PHYSICIANS EMBRACING THE INDIVIDUAL HEALTH RECORD?

A:We have 300 physicians using the system now. We’re planning for a broader rollout to the greater Dayton area in 2010 to virtually all primary care physicians.

What we’re focusing on is chronic disease management, and there’s not huge debate about many of the things that need to be done to take care of these patients. That’s not the problem. The problem is actually getting it done. The physicians in general have been positive and are beginning to see how their lives could be easier.

We also added all of our pay-for-performance rules. We pay physicians more if they practice medicine consistent with the evidence base, and we took the existing measures and turned them into algorithms in the system. As long as the physician follows all the alerts, he can be sure that he’s going to maximize his pay for performance incentive. That’s convenient for the doctors because what they usually have to do is identify the patients who haven’t had certain interventions and then reach out and call them.

We’re just starting to incorporate our utilization management rules. If we can begin to move those algorithms to the point of care, then physicians might not have to call except for when there’s a real reason to discuss something, which might be 5% of the time.

DETERMINING THE EFFECTIVENESS OF TREATMENTS IN ORDER TO BUILD THE ALGORITHMS IS AN EXPENSIVE PROCESS. HOW CAN IT BE DONE?

A:This is the beauty of health information technology…if you bring it together in a repository that’s reflective of the patient’s clinical condition and how they’re being managed, you can begin to do database-driven studies rather than very expensive prospective clinical trials where you’re enrolling patients and following them over time. You can begin to do database driven studies that are a fraction of the cost. No, they’re not the gold standard, which will always be a randomized perspective-controlled clinical trial, but there’s a lot of information we’re going to be able to glean out of database-driven studies that are more observational and more retrospective.

BE A VISIONARY. WHAT DO YOU SEE AS THE POTENTIAL FOR HEALTH IT?

A: I hope that every time a patient needs information when they’re home or need to take care of their chronic disease or want to stay well, that they have that information at their fingertips, it’s actionable, and they don’t even have to think about it. If we can make it that easy—and there is a path to get there—we could actually fix the healthcare system.

Charles Kennedy, MD, has held strategic health IT positions with a variety of organizations. He also served as the medical director of a California health center in addition to other clinical service. He earned an MBA from Stanford University, an MD from the University of California at Los Angeles, and a bachelor’s degree in genetics from the University of California at Berkeley.
” Physicians are not data generators. They’re data consumers.”

Review health risk assessment use under new GINA rules

Group health plans should be aware of interim final regulations recently released that implement Title I of the Genetic Information Nondiscrimination Act (GINA). Of particular interest are prohibitions and limitations applied to wellness programs and restrictions related to group plan underwriting, including restrictions on health risk assessments.

Under Title I, group health plans are prohibited from: 1) collecting genetic information prior to or in connection with enrollment or at any time for underwriting purposes; 2) adjusting premiums or contributions on the basis of genetic information; or 3) requesting or requiring genetic testing.

The definition for “genetic information” is quite broad. As defined, the term includes information about an individual’s genetic tests, the genetic tests of family members, or the manifestation of a disease or disorder in family members, which would include family medical history.

An individual cannot be required to complete a health risk assessment that asks for family medical history as a condition for receiving an incentive. Regulations step in to clarify that the act’s prohibition on collecting genetic information prior to enrollment applies even when there is no incentive provided to complete health risk assessments as well as in the case where incentives are not based on the outcome of the assessment.

The regulations also clarify the act by providing further analysis for the term “underwriting purposes.” The act’s prohibition on collecting genetic information for underwriting purposes extends to prohibit collecting the information for the purpose of: 1) changing deductibles or cost sharing; 2) providing discounts, rebates and payments in kind; or 3) providing other premium differential mechanisms in return for activities such as completing a health risk assessment or participating in a wellness program.

Group health plans may request a minimum amount of genetic information to make determinations regarding payment. Thus, when an individual seeks a benefit under a group health plan and coverage will be based on whether the benefit is medically appropriate, the determination of medical appropriateness is not within the meaning of “underwriting purposes.” In such a case, the plan may collect the relevant genetic information and condition the benefit on that information; however, a plan may request only the minimum information necessary.

Examples provided in the regulations are also helpful:

• A group plan provides a premium reduction for completing a health risk assessment, which includes questions about family medical history, after enrollment. Since completing the assessment results in a premium reduction, the request is for underwriting purposes and violates GINA.
• A group health plan requests that enrollees complete a health risk assessment before enrollment. The assessment includes questions on family medical history and there is no penalty or reward. Since the health risk assessment requests genetic information prior to enrollment, the request violates GINA.

As the examples demonstrate, group plans should review use of health risk assessments, removing financial incentives or penalties when genetic information is requested. Also, refrain from collecting genetic information for underwriting purposes.

This column is written for informational purposes only and should not be construed as legal advice.

Barry Senterfitt is a managing shareholder at Greenberg Traurig, LLP, Austin, Texas.

Janet Farrer is an associate at Greenberg Traurig LLP, Austin, Texas.

Green initiatives growing among healthcare facilities

From Recycling and waste management programs to nontoxic paint and permeable pavement, hospitals across the country are implementing green initiatives to produce healthier environments for patients and staff, which they say saves not only energy, but money.

Among several provider facilities going green is Stony Brook University Hospital, in Stony Book, N.Y., which recently signed an agreement with the U.S. Environmental Protection Agency (EPA). The agreement outlines energy and water conservation, waste management and the use of environmentally friendly products, and the hospital is currently auditing areas to reduce energy consumption.

“A hospital is unique in that it’s a structure that operates 24/7,” says Andrew Bellina, EPA program coordinator, “So, there are opportunities for powering down in many areas of the hospital that do not impact the people that are working or the care of the patients.”

He says the EPA is helping Stony Brook through the audit as part of its Energy Star program, which strives to reduce energy by 10%.

In addition, the hospital is taking on a number of initiatives designed to reuse materials and reduce material waste. For example, staff has eliminated the blue, disposable wrapping used for sanitary operating tools, says Bellina. Tools now arrive in reusable containers.

However, he notes, the hospital has to evaluate recycling from a practical standpoint while also maintaining strict accreditation standards. Even so, recycling at the hospital increased by about 420 tons in 2007 and 2008, and it is expected to be higher this year.

“It significantly affects your carbon footprint when you recycle waste instead of just throwing it out, because you don’t go through the actual mining, the treatment, the procurement, the manufacturing and the transportation,” he says. “You’re cutting all that out.”

Water conservation is another important aspect of the agreement struck with the EPA. Bellina notes water supply costs recently increased 20% in New York City. He predicts water shortages in as many as 36 states in the next three to five years.

The hospital is looking to conserve water in two ways. First, captured storm water can be reused for non-contact functions, such as watering lawns and landscaping. Second, he says, it will be important to reduce demand for water. The hospital is monitoring water use with equipment that limits water flow and reduces total use.

Going green will definitely show a return on investment in the long run, and in most cases, produce immediate savings, Bellina says.

“Five years ago it [going green] would have cost you money, and the payback would be seven, 10 or 12 years, but now there are immediate cost savings. For example, recycling is an immediate cost saver,” he says, “And you reap the economic benefits through the lifetime of the structure after that.”

Determining effects on the quality of care is not as easy, he says, but he postulates that once the hospital’s energy audits are complete and the air handling is upgraded to a more efficient mix of outdoor and indoor air, the quality of air will improve within the hospital. Better air means better health, especially for those who need respiratory care.

EAST CAROLINA HEART INSTITUTE

The East Carolina Heart Institute, which is attached to the Pitt County Memorial Hospital in North Carolina, has implemented both green and general health ideas into its structure, including ergonomic equipment, natural light and an energy efficient utility plant.

The structure has only been open for a year, but was built with energy efficiency in mind, according to Brian Floyd, executive director of the Heart Institute. It also contains recycled materials in the carpet as well as in bathroom, kitchen and ceiling tile.

Natural lighting is one feature that overlaps in the green movement and healthy hospital movement. An effort was made to light the Institute with large windows in patient rooms, physician work areas, waiting rooms, lobbies and cafes.

“Many studies show that people recover faster when they have access to sunlight, and we want to make people as comfortable as possible and acclimate them to the day and night cycles so they can heal faster,” Floyd says.

It also requires less energy to light the facility during the day. With the help of sensors, artificial lighting turns on only when someone is in the room and dims when natural light levels are adequate.

The utility plant powering the Institute operates on energy efficient air conditioning chillers, high-efficiency electric motors and variable-speed pumping and air flow systems, according to Floyd.

The monthly electricity expenses at the Heart Institute have averaged 30 cents per square foot, or $142,000 per month, since opening in January 2009, according to James Ryals, Media Specialist for the Heart Institute and Pitt County Memorial Hospital. To compare, over the same period, monthly electricity expenses in the main hospital have averaged 45 cents per square foot, or $533,000 per month. The main hospital was built in 1977, and is twice as big as the Heart Institute, says Ryals.

“The per-square-foot figures are a better basis for comparison than the monthly totals,” he says. “It’s safe to say that, with the efficiency measures we’ve taken, our power expenses at the Heart Institute are roughly 33% lower than the main hospital.”

Certain intangible cost savings, such as worker productivity, are harder to define, says Floyd, but he has noticed that retention of staff is higher and length of patient stays are shorter.

KAISER PERMANENTE MODESTO

Kaiser Permanente’s Modesto Medical Center in California is a pilot model for green healthcare facilities aimed at improving public health, according to John Kouletsis, national director of strategy, planning and design for Kaiser. The center is equipped with everything from solar panels on the roof, rubber flooring instead of vinyl inside the hospital and permeable pavement in the parking lot.

“We’re always looking at public health,” says Kouletsis, “so, to me it’s probably the least obvious things that I think are the most dramatic and the most impressive.”

Those not-so-obvious endeavors include eliminating toxicants from paint and upholstery and eliminating polyvinyl chloride (PVC) from flooring and carpet. There is a case for patient care: When a vinyl floor is cleaned, aerosolized particles release into the air and become asthma triggers.

“It’s ironic, because [these steps are] not very sexy, they’re not very eye-catching, but they actually have a much bigger impact on keeping people healthy,” he says.

At Modesto, calculating all the sustainable strategies show a cost savings of roughly $400,000 over what would have been spent on a typical project without those sustainable elements, Kouletsis says.

“A long-term savings in terms of public health is incalculable,” he says.

Kaiser looks at sustainability through a different lens than other providers, says Kouletsis.

“Our lens has to do with patient safety and workplace safety, and what we’ve discovered is that if you look through these two lenses first, you almost always get to a sustainable product,” he says.

Q&A with Seattle Children’s Hospital Director of Environmental Services

Tell me about the green features and programs you have implemented at Seattle Children’s.

In 2006, Children’s became an active member of Hospitals for a Healthier Environment (H2E) which included participation in online seminars to learn more about green initiatives. During this time, I noticed the work of a partner at H2E and had done some groundbreaking work on medical waste minimization as Beth Israel Medical Center’s Medical Waste Manager. Seattle Children’s initial goals in 2006 included reducing waste and making Children’s mercury free.

Children’s has additionally followed Continuous Performance Improvement (CPI) methodologies for nearly a decade. As one of the goals from CPI projects was to eliminate waste, it fit right in line with the 2006 goals.

Waste in reference to CPI is used somewhat metaphorically for wasted parts of a process and can be a physical waste or essentially anything that doesn’t add value to the customer. CPI work is really all about defining a metric and continually measuring and monitoring those defined metrics to see if you are making progress.

I quickly realized there are many costs associated with reducing waste. For example, there’s a difference between solid waste and recycling or the common misunderstanding that recycling is free when it is not. Additionally, people assume hospitals produce a lot of medical waste and that the preferred method for dealing with this waste is incineration, but this is not true either.

From 2006 to 2007, we started to look at our waste overall and were able to start profiling our waste and recycling streams. We began using a scorecard to see a baseline of our waste and from this scorecard, we found that of all the materials we processed solid waste was about 65%, recycling about 24%, regulated medical waste about 10% and hazardous materials 1%. For perspective, the numbers in terms of percentages were fairly consistent with hospitals of Children’s size.

Throughout 2006 we started to work on basic recycling schemes which included developing and promoting signage, and monitoring recycling flows. During this time we were also approved to replace the hospital’s old cardboard balers with recycle auger compactors, which could compact materials on a 6-to-1 ratio. The compactor was a game changing moment for Children’s because it meant that we could go from a labor intensive process of breaking down cardboard, to a machine that pulverized and compacted paper and cardboard materials.

What other opportunities were there to reduce waste?

One of the most interesting issues in sustainability projects is once things start to happen you can’t stop the momentum. Our Operating Room (OR) group has done very impressive CPI work and the initial program in this division consisted of a very low tech CPI approach. OR staff positioned containers in the determined right locations to capture solid waste and recycle waste. The results of this on-going work has been impressive and the OR team was able to divert solid waste and recycling materials from the medical waste stream. In 2008, the OR diverted 38,000 pounds of solid waste and recycling from the medical waste stream and since the beginning of 2009 the OR team has diverted approximately 66,000 pounds of medical waste or approximately $63,000 in cost savings.

In 2008, Seattle Children’s continued our ambitious “Go Green” initiative along with a collaborative multidisciplinary sustainability committee to promote green programs and practices. We expanded our recycling programs to include all mixed recycle materials to make it easy to recycle. In 2008, we achieved a 32% overall recycling rate as compared to 24% in 2007.

On Earth Day 2008, Children’s finalized an agreement with a vendor to recycle our sharps containers which would eliminate 9,000 pounds of plastics from the landfill in 2008 (and estimated 18,000 pounds diverted for 2009).

Additionally, we implemented a single stream recycling program allowing us to recycle mixed materials into single blue recycle containers which allows us to divert a few more tons of materials each month from the solid waste.

In September 2008, we implemented a new pharmaceutical drug waste program. and we are the first hospital in the state of Washington to implement this comprehensive program that meets both compliance and the environmental intent to ensure that we will not pollute our waterways in an effort to protect our environment and human health.

Our 2008 waste management plan: recycled 450 tons of mixed recyclable materials (90 more tons of recycled materials compared to 2007) cardboard, paper, glass, and plastics, compost, recovered metals, including recycling 3 tons of batteries, 4,930 fluorescent lights, 2,599 printer toner cartridges, 17 tons of computers and electronic equipment, 3 tons of hazardous chemicals, and 50 gallons of kitchen grease was recovered to produce bio-diesel. In 2008, we shredded and recycled so much confidential paper we saved 4,780 trees from the paper mills. Through better sorting and segregating medical waste our OR diverted 38,000 pounds of solid waste and recycling from the medical waste stream. Overall by using better ways of identifying, single stream recycling, OR segregation of waste and recycle from medical waste, consuming less and using non-hazardous alternatives, or recovery options, Children’s reduced 3.5 more tons of hazardous waste in 2008 compared to 2007.

Do these green features improve quality of care and/or create healthier patients?

Healthcare facilities are always occupied with staff and patients, requiring cleaning, disinfecting, and maintenance procedures to be performed in proximity to patients and staff at all times. Hospitals use a host of different kinds of chemicals in the cleaning process. Chemicals typically found in these products can cause: headaches, asthma, burns, permanent eye damage, major organ damage, cancer and sensitization.

Our cleaning policy is designed to provide healthy environments, reduce environmental impacts, along with many other benefits. In general this policy aims to reduce chemical use, reduce toxic chemical levels, reduce building contaminants, minimize noise/vibration, environmentally preferred purchasing, minimize damage to building surfaces/prolong the life of building materials.

All contractors must provide their cleaning schedules and list of products in advance of working with Children’s. They must also show procedures or methods for high-level and medium-level disinfection as well as evidence of employee training and log books including the times Children’s areas are cleaned.

Are the green features cost saving or do they add more cost to the hospital in the short and long term?

One of the projects we are struggling with now is our pharmaceutical waste program. Currently, we are doing an excellent job in following the intent of the state policy entitled, “WA State Department Interim Pharmaceutical Waste Disposal.” We are also making sure our waterways are not polluted and are reducing costs in a very appropriate and responsible way.

Overall, Washington state’s policy is tough but also a model policy as each state adopts its own. Seattle Children’s has additionally been active in working with the State and our licensed vendors to get guidance on how to best implement the policy and providing inputs on how we can do a better job in processing this waste. I also know that direct clinical staff, including nurses and pharmacists, view this program with great importance and are doing well in following somewhat complex disposal rules. Since we work in a 24/7 dynamic environment, by the end of 2009 I am confident Children’s will have success on the cost issues and will continue to be win for the environment and also a win for reducing our costs.

I believe healthcare organizations have an obligation to help promote the health of communities, environment and exercise overall proven and prudent business practices and organizational stewardship. Seattle Children’s has taken this leadership role as we network with our colleagues at other regional hospitals (and at hospitals across the country). I’m encouraged we are using the CPI principles to promote best practices, to even leverage with suppliers and other businesses and to understand our operations, green and sustainability projects.

This is the strategy that has little to do with promotion and more to do with building upon relationships with our patients, families, staff, vendors, suppliers and colleagues. A strategy across the organization about committing to our ultimate goal that patients and families come first and that Seattle Children’s envisions “hope, care, cure” not as a slogan but as a real goal.

Gene therapy may be able to restore color perception in monkeys

Gene therapy has been used to eliminate red-green color blindness in monkeys, with no ill effects, according to a study published recently in Nature. Jay Neitz, Ph.D., and colleagues at the University of Washington inserted a missing gene into the eyes of red-green color-blind monkeys through an injection. The gene piggybacked on a virus that had been defanged so it no longer caused illness. The researchers then tested the monkeys by measuring their responses to colors. About 20 weeks after the treatment, the monkeys were no longer color blind and could distinguish between red and green, the researchers said in a news item.

Therapy Fixes Color Blindness in Monkeys

Monkeys once color-blind can now see the world in full color thanks to gene therapy. The results demonstrate the potential for such methods to eventually cure human vision disorders, from color blindness to possibly other conditions leading to full blindness.

The primate patients, named Dalton and Sam, are two adult, male squirrel monkeys that were red-green color-blind since birth – a condition that similarly affects human males more than females. Five months after researchers injected human genes into the monkeys’ eyes, the duo could see red as if they had always had this ability.

Since human genes were used and the monkeys’ eyes and brains are similar to ours, at least in terms of color vision, the researchers hope the same procedure could work in humans.

“People who are color-blind feel that they are missing out,” said study researcher Jay Neitz, a professor of ophthalmology at the University of Washington, Seattle. “If we could find a way to do this with complete safety in human eyes, as we did with monkeys, I think there would be a lot of people who would want it.”

The findings are detailed in the Sept. 17 issue of the journal Nature.

Color-coded

The researchers chose squirrel monkeys partly because all males of the species show some form of red-green color blindness, which is the most common form of color blindness in humans and certain monkeys. About 8 percent of Caucasian men in the United States are color-blind.

The blindness primarily afflicts males because the genes encoding red and green receptors are located on the X-chromosome, of which men only have one. Women have two X-chromosomes, and a normal gene can often balance out a defective one.

Like humans, monkeys’ eyes contain cone and rod cells. Each cone contains different photo pigments that can detect specific wavelengths of light. The monkeys, Dalton and Sam, had cones that were unable to detect red light.

Monkey, see…

To try to correct their vision, Neitz and his colleagues put a needle into the monkeys’ eyes, just behind the retina, and injected a virus whose disease-causing genes had been replaced with human genes for red photo pigments. Viruses dump their genes into host cells, where the viral DNA can replicate. In this case, the virus was used to insert photo pigment genes.

Throughout the study, the monkeys were tested daily. They had to distinguish patches of colored dots that vary in size and brightness from surrounding grey dots on a screen. When the animals touch the colored target with their hands or nose, a positive tone sounds and the monkey garners a juice reward. When wrong, a negative tone sounds and a two- to three-second pause, considered a penalty, ensues before the next test.

Before the genetic injection, “Occasionally he’ll guess right and if he guesses right, right away he’ll try that same spot, like ‘Oh, maybe this is the spot,’” Neitz said, referring to the male monkeys.

About five months after the injection, the two monkeys showed no hesitation in the colored-dot tests, getting them all correct. The monkeys could pick out colored patches even when just a hint of red was added to the target patch of dots.

And now, some two years later, the monkeys show no signs of their color senses waning and no adverse effects.

What’s going on?

The study suggests more than meets the eye, however. Merely giving the monkeys red-sensing photo pigment receptors would not necessarily give them the ability to perceive red, the researchers knew. Some new ability must have been triggered in the monkeys’ brains, since it’s the noggin that ultimately analyzes the information from the eyes, Neitz said.

“People thought in order to add some new information to the brain you’d have to add some kind of new neural circuits. And once you get to be an adult all of your neural circuits are in place,” Neitz told Live Science. So scientists had thought that adding new sensory information to the brain would be possible only early in life.

Rather than brewing up new neurons or rewiring itself, the monkeys’ brains probably harnessed the abilities of existing circuitry, according to Neitz.

“Amazingly the animals behave almost exactly as if they had this capacity all along from birth,” Neitz said.

Next up: humans

Before such gene therapy could help humans, Neitz said that he and others would need to perfect it, and ensure its complete safety. For instance, the genetic insertion could have some secondary effects in humans not yet seen in the monkey subjects.

“That’s something we have to think about before this ever happens in a human – how to make it perfectly safe,” Neitz said. “Given that, we put a human gene in the monkeys and their eyes and brain are like ours, at least that part of their brain. I have to assume that if we did this exact same thing in a human being today, the human would respond exactly as the monkeys did.”

He added, “I get calls from people every day who say they wish they weren’t color-blind, but nobody wants to risk their vision in order to get color vision.”

In addition to color blindness, most of the major blinding diseases involve the retina and the inability of certain cells to sense light, Neitz said. “This could be a first step to curing a huge number of problems that cause people to be blind,” Neitz said.

He hopes that within 10 years his monkey research will at least be moving in the direction of human clinical trials.

Video – Monkey Gets Color Vision

How the Human Eye Works

Why Red is Such a Potent Color

Original Story: Therapy Fixes Color Blindness in Monkeys

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Connecticut Man Sentenced in ASC Investment Scam

Bradley Kabbash, from Greenwich, Conn., was sentenced to three years in prison for his role in an investment scam involving “bogus” investments in hospitals and ASCs, according to a report by the Hartford Courant.

Mr. Kabbash pled guilty in January for his role in the scheme involving his company, HCH Cypress. In addition to his sentence, he will pay more than $800,000 in restitution.

Read the Hartford Courant’s report on the Connecticut ASC investment fraud.

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