ORs of Tomorrow Can Yield Pay-offs Today

The operating room (OR) of the future is closer than many facilities think. While the level of sophistication in equipment and technology depends upon a facility’s budget and ability to retrofit to accommodate exciting new developments in OR modalities, facilities should be aware of the changing dynamics of OR design and planning.

The challenges of efficient and effective surgical planning are numerous, according to Charles Martin, AIA, and Lynne Shira, RN, BSN, both principals with the Seattle architecture firm NBBJ, who were part of the Designing High-Performance ORs, a day-long symposium presented by STERIS Corporation last October. Martin and Shira explain that owners/operators of medical facilities must find a way to juggle their increasing equipment needs, technology demands and compatibility issues. They see an upward trend among healthcare facilities in the overall demand for additional space to grow their surgical service lines, including new ORs, procedure rooms and the requisite spaces needed to support these new rooms. Today’s facilities require much greater flexibility in the infrastructure and its operational capacity to accommodate more integrated systems both in and out of the OR. Not only can this flexibility create an environment to better foster staff recruitment and retention, Martin and Shira say, but it can improve the patient experience.

The size of ORs has been increasing over time, with the OR of yesterday being about 400 to 500 square feet, with a total department space of about 2,000 square feet. The OR of today and tomorrow is now an average of 600 to 800 square feet, with a total departmental space between 3,200 and 4,500 square feet. The reason for this expansion can differ greatly from facility to facility, but many institutions are creating hybrid ORs that encompass and integrate surgical and interventional services, imaging and clinical services. This kind of OR can accommodate multiple care-delivery models and new technologies, as well as support clinical and administrative uses.

Fred Bentley, practice manager for syndicated research at the Advisory Board Co., says that ORs have been invaded by numerous “space-eating” technologies, such as PACS, C-arms, endoscopic towers, robotics and inter-operative MRIs. The space around the operating table has become increasingly cramped; an OR of 300 cubic feet frequently must accommodate about 115 cubic feet of surgical and anesthesia personnel and about 150 cubic feet of equipment, leaving just about 35 cubic feet of free space. It can be a struggle for facilities to balance comfort and efficiency, Bentley adds, that an OR of less than 400 square feet is now considered to be an anachronism because of its cramped, inflexible space; the 500-square-foot OR is now a tight fit; and an OR with more than 800 square feet is probably an over-indulgence and has the potential for too much dead space. The sweet spot, Bentley says, is an OR of about 600 to 650 square feet, which has enough space to accommodate equipment, but facilitates enough unimpeded circulation throughout the room. To cope with smaller ORs that cannot be immediately retrofitted, some facilities are opting to move some bulkier pieces of equipment out of the OR, such as a mobile C-arm that can stored in a corridor alcove or an adjacent equipment closet, or using utility booms to get equipment lifted off of the floor. Other facilities are opting for more streamlined integrated interventional suites that come turn-key from manufacturers such as STERIS.

A hybrid OR is quickly becoming a favorite option for some facilities wishing to make better use of their OR space. Neurological surgeon Jeffrey Yablon, MD, of the Lake Norman Regional Medical Center in Mooresville, N.C., defines a hybrid OR as “an actual operating room located within the surgical suite that accommodates uncompromised interventional, open and minimally invasive surgery within a given specialty.” Yablon says that a number of trends are driving the hybrid OR craze, especially recent technological advancements and specialists’ desire to expand their sphere of expertise amidst competing services. Another driver is the limited space with which many facilities must contend; Yablon says a hybrid OR can be used for several services or procedures and will provide maximum utilization of space. Yablon also cites increased competition for procedural services, with cardiothoracic moving into interventional cardiology, interventional radiology moving into vascular surgery and interventional cardiology moving into interventional radiology. Another factor is tighter reimbursement; Yablon says a hybrid OR’s flexibility will allow for this space to be fully used with a continual stream of reimbursement dollars. He adds that increased readiness and flexibility results in fewer complications and better outcomes, which ultimately achieves lower costs and higher profit margins.

Hybrid ORs are a win-win situation for surgeons, Yablon says, because they allow for improved patient care because of integrated technologies, and because they provide room flexibility and improved workflow. Nursing staff members like these ORs because they improve staff productivity, workflow and ergonomics, as well as improve room utilization and reduce scheduling challenges. And administrators like them because they help to retain surgeons and nurses as well as optimize capital monies. Yablon adds that hybrid ORs are not without their challenges – including costs, simultaneous competition for the room’s unique resources among surgeons and the need for continual future upgrades – but says the advantages frequently outweigh the challenges.

One healthcare system that has moved boldly into the OR of the future by embracing cutting-edge technology is the Carondelet Health Network in Tucson, Ariz., whose hybrid ORs boast the BrainSUITE iCT, a dual-room intraoperative large-bore, multi-slice CT with sliding-gantry from BrainLAB. Neurosurgeon Eric Sipos, MD, FACS, medical director of the Carondelet Neurological Institute, says the advantages of a two-room CT scanner system include the minimized disruption of the familiar surgical workflow with a maximized CT scanning range providing the widest range of patient positioning. The surgical table position for scanning can be stored prior to draping to avoid collisions with scanner, and once positioned for surgery, the patient is not moved, especially outside of the sterile air field; the anesthesia is fixed and constant throughout the surgical and imaging procedures. With a sliding gantry moving between two ORs, there might be the opportunity for cross-contamination, but Sipos emphasizes that the preservation of the sterile environment is achieved and the patient in the adjacent OR is not compromised in any way. Carl Colombi, technical consultant with the Integrated OR Solutions (iORS) Division of BrainLAB, says the BrainSUITE fully integrated intraoperative CT surgical operating room can facilitate surgical planning and navigation, as well as achieve data management and coordinated equipment integration.

While this level of technology might be reserved for the larger health systems, ASCs shouldn’t count themselves out of the technology game nor assume they cannot replicate a hybrid OR set-up. “Over the years, we have seen more and more surgical cases migrate to the outpatient environment, primarily due to the advances in anesthetic agents and minimally invasive technologies,” Shira says. “Our previous thinking that an outpatient surgery is for ‘minor’ surgical procedures simply doesn’t hold true any longer. The equipment and technology required for minimally invasive work demands a surgical footprint and boom configurations that are not unlike the inpatient environment. ASCs that want to plan for this technology in the future need to remember this as they are planning.” Shira continues, “Recognizing that ASCs are held to a different building standard than hospitals, there should still be planning for proper air exchanges, good surgical traffic patterns with non-restricted, semi-restricted and restricted zones understood with the design. And of course, there can be no compromise on safety protocols and cleaning protocols regardless of the location of the surgical environment.”

Martin and Shira emphasize that the numerous rapid advances in imaging technology are dictating some OR planning and design elements, and note that many imaging interventions are transitioning from diagnostic to therapeutic, thus blurring the boundaries between imaging and surgery. The goal of many facilities is to integrate these departments into a single service with common support in terms of supplies, equipment and staff. If designed correctly, this concept also can eliminate the all-too-common duplication of pre- and post-operative functions, as well as eliminate the duplication of space, equipment and supply storage. Martin and Shira add that integration of staff with similar skill sets can greatly improve operational efficiencies. The integration concept also can apply to universal procedure rooms that specialists can share, as well as universal prep and recovery areas that can accommodate varying patient volumes throughout the day, as well as minimize patient transfers and reduce the number of supply-distribution points.

While we have seen how the physicality of the OR is evolving for the future, it’s important to note that healthcare professionals are following suit. Bentley points to the trend of surgeons and interventionalists becoming one and the same in the future; in the past, these two groups have performed distinct classes of procedures, while in the present, some surgeons are learning select interventional techniques. In the OR of the future, it may be no surprise to see surgeons familiar with nearly all major interventional procedures and perform them frequently; there may also be the rise of the multi-purpose proceduralist. Bentley says these proceduralists can be co-located on the same floor of a facility, or they can even be housed in the same suite, functioning in what Bentley calls a “multi-purpose sandbox” to accommodate all kinds of disciplines.

No next-generation OR can be planned and executed without buy-in from all stakeholders during the project planning and management process, including surgeons and clinical personnel, administration, the architect, the engineer, the IT department and key vendors, according to collaborators Chris Kantorak, technical consulting manager with BrainLAB, Inc., Brian Hartman, project design manager with STERIS Corporation, and Paul Niehaus, project manager with Philips Healthcare. They say that advanced OR suites require space for technology, personnel and ancillary equipment, and that design input from all user groups must be obtained to ensure an optimal environment for all. More specifically in terms of roles among stakeholders, the architect is responsible for evaluating trends such as fixed-based imaging versus mobile imaging, and OR integration; providing for the expansion to a larger OR footprint ; and understanding the changes in sterility needs when going from an imaging suite to a flexible hybrid OR suite, for example. They must also design into the OR future flexibility, such as empty conduits for information/video routing, blank structural plates and positions to accommodate new equipment in the future. To this end, the equipment manufacturer can help plan for the support of new technologies as they are added. In turn, the vendor plays a key role by helping to maximize functionality and the placement of multiple technologies, offering design expertise with proper sequencing of design needs, and planning for both existing and future technologies or evolving clinical procedures.

Medical homes in practice

Healthcare is notorious for trying out solutions that seem to work in theory, only to watch them collapse in practice. Like throwing spaghetti at the wall, players from all segments have experimented, looking for new ideas that might stick.

The most recent concept that is showing real sticking power is the patient-centered medical home.

Since 2006, more than 30 states have initiated projects to apply the medical-home concept to Medicaid and Children’s Health Insurance Programs. Reduced costs, better support for chronic care and improved population health are the impetus behind the local efforts, which comprehensively hold the potential to effect system change, piece by piece.

Although no two projects are identical, all reflect core principles of aligning reimbursement, supporting primary-care practices, measuring results and scaling the model beyond an initial pilot phase. Early results have shown promise, which is inspiring more payers and providers to adopt the model.

The general arrangement of a team of clinicians providing a home base of individualized, coordinated care and prevention emerged through the American Academy of Pediatrics in the 1960s for specific pediatric populations. It wasn’t until recent years—as the industry began to focus more on healthcare value—that the medical-home idea was identified as a potential formula for improvement of service delivery within broader primary care practice.

In 2007, four major physician groups defined a set of joint principles to describe a patient-centered medical home, which was soon followed by the creation of the Patient-Centered Primary Care Collaborative (PCPCC), which represents employers, plans, providers and other organizations that endorse the principles. The National Committee for Quality Assurance (NCQA) is currently in the process of updating standards for its medical-home recognition program, which were initially released in January 2008.

Policymakers and the healthcare industry continue to assess the local projects, anxious to determine their financial worth and their promise for large-scale implementation.

MANAGED HEALTHCARE EXECUTIVE recently brought together a roundtable of executive thought leaders to discuss the issues related to patient-centered medical homes. The panel includes:

• Paul Grundy, MD, chairman of the Patient-Centered Primary Care Collaborative and director of healthcare technology and strategic initiatives at IBM;
• Lori Heim, MD, president, American Academy of Family Physicians;
• Len Nichols, economist, New America Foundation;
• Jerry Salkowe, MD, vice president of clinical quality improvement, MVP Healthcare; and
• C. Edwin Webb, PharmD, associate executive director, American College of Clinical Pharmacy

MHE: What do you see as the long term potential of applying the medical-home model in the next five to 10 years?

Grundy: The early pilots’ results are—well, first of all, they’re early—but I think they’re quite impressive. The PCPCC presented data from 10 of those pilots to the White House a few months ago, and what we’re seeing is better integrated, coordinated care.

When you have comprehensive, accountable, accessible, integrated, coordinated care, that results in lower downstream costs. We’re seeing hospitalizations dropping by 20%. We’re seeing hospitalization readmissions dropping by 40%. We’re seeing emergency room utilization dropping by 12% when patients have access to more robust, integrated primary care—which is better upstream care. That bodes well for the future, in which we really need to look at value creation.

Salkowe: The enthusiasm is growing by leaps and bounds outside of the pilots, so physicians who have been either ignoring or sitting back and watching what the earlier doctors did aren’t sitting back and watching anymore. They’re getting very engaged and very interested in pursuing [NCQA recognition] and many of the features in medical homes now, even if they’re not an active part of an organized pilot.

Heim: I see the medical home being integral when you look forward to whether or not it’s an ACO [accountable care organization] or just more generally talking about value-based design. As hospitals and big health organizations begin to look at this, how they integrate with the small practice is going to be one of the biggest challenges.

If you look at the North Carolina Community Care project, that was community based. It showed incredible cost savings and increases in quality, but that was another way to virtually link a bunch of community based practices, which is going to be one of the models we’ll have to accept because large health organizations are not going to be in all communities. But yet, the hospitals and the communities are still going to have to figure out a way to control the costs. And the other critical component then is getting the IT linked up.

MHE: Some say medical homes will not solve the problem of fragmented care. Primary care will continued to be siloed apart from subspecialists. Do you foresee that?

Heim: If people are saying that medical homes will further fragment care, I don’t think they understand the model because it’s the opposite that’s true. The basic tenet of the medical home is the personal physician is the coordinator of the care, and there’s integration of the patient’s needs, not only when they walk into the office, but by taking advantage of knowing your population and doing population management, using IT and tools and a team approach to coordinate that care.

Without something like the ACOs and aligning incentives, we have a mismatch in terms of how much the subspecialists and the other members of the team are brought into integrating that care. I definitely would say it’s not going to go in the opposite direction.

Webb: I’m not sure we could fragment healthcare any worse than it is right now, particularly across professions and disciplines. One of the things that is exciting to the pharmacist community is the potential for the medical home model to integrate across professional care concerns—again, assuming that we can find mechanisms to realign payment incentives, also understanding it’s obviously not possible to have a pharmacist in every three- or four-person medical practice in the United States.

Community Care in North Carolina has done an excellent job of integrating pharmacists’ services as part of the team in a virtual environment across several small- and medium-size practices. The only way we can integrate health professionals into a team is with the medical home because the current payment methodology and our cottage-based industry of silos just isn’t doing the job anymore.

Grundy: From the standpoint of the patient, the patient wants to see the specialist or the person who focuses on a certain part of the body as part of their medical home team. When they need a hip replaced, they have more than a hip. They have a whole bunch of other parts that somehow interconnect, and there has to be medication management adjudication, for example. There have to be linkages and integration, and that’s not happening now at all.

There are places in the United States where it will cost $177,000 for the last six months of life and other places where it costs $17,000. When you look at the places where it costs us seven times as much, what you’ll find is seven specialists doing seven different things—none of it linked, none of it coordinated, none of it integrated, and some of it, by the way, toxic to what the other providers are doing.

I just happened to be in New Mexico at Presbyterian Hospital recently and in Dallas and Tulsa where they’re doing a fantastic job of actually integrating the specialists into the medical home, where everybody’s practicing at the top of their license. In Tulsa, the primary care docs will email the specialists and integrate and pay for an email consult, which the specialists love, and the primary care docs love, but most importantly, the patients love it because it keeps them from wasting half a day [at a medical appointment] when the primary care doc’s doing a good job.

I would agree that whoever asks that question doesn’t understand the model.

Salkowe: There is one aspect of this we need to be conscious of. There are individuals who have one major chronic illness, and 90% of their care is being provided by a specialist: a gastroenterologist, rheumatologists or an oncologist, for example. And health plans are expected to and allow such a specialist to function as a PCP, even though we know that the focus of that care is on specialty needs, and there may be gaps in preventive health needs or other unrelated health conditions. That’s an important reality.

Now, I think we all agree that in a well managed medical home, care that specialist is providing is enhanced because of the improved communication coordination with other physicians that invariably are involved, whether it’s preventive services or hypertension or something else. There is a bit of hesitancy on the part of some of the specialists because of the scenario and uncertainty of whether a PCP should be treating everything. What happens when I have a patient where I really need to be out in front in terms of making decisions?

Heim: There are certainly many patients that I have had over the years, when the oncologist is functioning as the patient-centered medical home. I have no problem with that. From the standpoint of being recognized as a patient-centered medical home, that’s different than a subspecialist who then begins to assume the majority of the care and becomes the director. The problem is that oftentimes they’re handling maybe 70% of what’s currently going on in that patient’s life. However much of the other stuff gets either ignored or sidelined.

So if a rheumatologist becomes the patient-centered medical home, then in order to make sure that they are truly functioning in the whole aspect of managing that patient, they need to fulfill some sort of recognition program. In order for this model to work, you have to realign the payment. That would not be a major barrier if the payment were going to switch from the patient’s PCP to a subspecialist as the designated patient-centered medical home and have the payment model then switch over to that of a patient-centered medical home. That’s not a problem so long as they are then willing to take on the requirement to manage or coordinate the entire care of the patient.

MHE: What is the best strategy for reimbursement in medical home models?

Salkowe: The model that most programs seem to circle around is one that preserves perhaps 60% of the compensation as traditional fee-for-service reimbursement with the other 40% divided between process measures, care management activities and outcomes. The numbers that I’m generally seeing are 30% for the care management piece and 10% for the outcomes piece, although from the early projects where the outcomes just haven’t been measured yet, it may focus solely on care management.

That seems to get us to the dollars that are needed for support, the additional resources the practices need, whether it’s trained staff or new systems, and also to include the extra remuneration that’s needed to really engage the primary care physicians and the work around this new model.

Nichols: I like the structure that Jerry just described, and it makes a whole lot of sense, especially in transition, which is what we’re going to be in probably for three to 10 years—with a fee-for-service base but with a lot of incentives packed around care management and outcomes. Those proportions may very well change over time and may be different in different parts of the country.

The most creative thing we can do in the pilots that we hope come out of healthcare reform is to work out different kinds of shared-savings models. What’s an average cost for a diabetic? You think about the number of diabetics and different comorbidities and you can work out an expected expenditure over the year, including, in my view, expected hospitalizations and utilizations of specialists.

Then instead of holding a primary care team or even a formal medical home at risk, you could have them share in the savings that they might achieve if they hit the targets to achieve savings. Then you really do align incentives. A 2.0 model might include some incentives back to the patient so they too can see a real monetary gain in participating, because after all, health is a participation sport. You want the patients very much engaged. It’s unambiguously true we have to find a way to leverage our rather short supply of primary care professionals, in particular as we think about expanding coverage and access to care in the next five years.

Heim: One of the concerns that I’ve had with shared savings is it being time-limited. If you look at the efficiencies you will gain over time, eventually those efficiencies are going to diminish. Have you thought about making sure that the shared savings don’t become the major component of the blended payment model?

For example, I was in the Air Force for 25 years and after I had a stable population and managed them, I had already found disease and managed it and achieved significant cost savings and decreasing utilization. But then we reached a steady state, relatively. Were you saying, Len, that would be something on top of a designated funding stream for the blended payments?

Nichols: Well, Lori, remember I used the word ‘transition,’ and you are talking about a steady state and a longrun. I would agree that the ideal would be we will get to a place where all patients, especially those with chronic illnesses, are managed optimally and there are no savings to be reached out of the system. I think we all know we are a very long way from there.

What I’m talking about is a mechanism that can enable us to turbo-charge the transition. Ultimately I think you’re right. You would want to go to a more blended payment at the end, but I don’t see how you get from here to there fast without a shared savings component.

It enables you to reach beyond the primary care team to enable the hospital and the specialist and the pharmacist and everybody else to participate. That has a greater potential for aligning interests quicker in a way that is much more likely to be transformative. And yes, once we’ve reached the level of efficiency you reached with your patients in the Air Force, it’ll be a different world. But we’re a long way from there.

Webb: The blended payment model approach that PCPCC has recommended has one other interprofessional political advantage, and that is it defuses some of the potential battles at the feeding trough of fee-for-service. If all members of the team are participating in a blended payment approach, that brings revenue into the medical home based on those performance parameters, then the physician-directed leadership of the practice can then pick and choose among the various members of the team who are needed to be involved in the care of a particular patient at a particular time. There’s not that kind of competition for the fee-for-service dollars among the providers blended into a payment model that rewards team performance rather than individual fee-for-service performance.

As a profession that’s been fighting for years and years to have its non-dispensing services recognized under Medicare Part B—pharmacists have been fighting that battle for 10 or 15 years—this may be a very good thing in terms of an approach that blends all of the qualities that have been mentioned already because that really is what will generate patient-centric care among all the team members.

Grundy: I think there’s another constituency that we need to include in the considerations around shared savings. There’s also the reality that our employers are not competitive in a world market, and in many ways that’s because of healthcare costs. We have large numbers of individuals who can’t afford insurance so some of the savings really needs to come back to those who are actually paying for the healthcare…which will allow them to be more competitive with other parts of the world where healthcare may be more heavily subsidized by the government.

Nichols: That’s right and trust me, they can get their share of the same things, too. I definitely would concur in the short run, the best thing we could do is incentivize clinicians to work together across the traditional silos. Then I’m pretty sure the employers and plans will figure out how to get their piece of that.

MHE: Are behavioral health professionals increasingly being included as part of the medical home?

Grundy: I was in Albuquerque at Presbyterian, and they had a very integrated behavioral health model and a very integrated pharmacy model. The combination was really magic. We were seeing medication-management education and behavior-management education that was enhancing care and amplifying and cadencing the message that the primary care provider was delivering—on ’steroids.’ I mean, it was really impressive.

I was in Dubuque, Iowa, with a primary care provider who was seeing an 84-year-old nun. The issue with her was medication management and care coordination. Once the relationship part of it was established with the primary care provider, it migrated over to a nurse care coordinator working with the pharmacist who was working with a behavioralist with a team approach to care for the next year. I saw that mapped out for the nun, and it had gone over well enough to the point that she really began to understand it and give feedback.

MHE: With all these easily accessible services, what about the potential for increased utilization?

Webb: Particularly with regard to the use of medications, the some of the evidence from the model in North Carolina does indicate that in some cases, the medication-use costs go up. But with a concomitant reduction in consumption of some of the other more expensive services, particularly emergency department business and things like that, the increased utilization of some things may well be a very good thing and what the patient may benefit from most. You have to look at utilization across the entire spectrum of service consumption rather than just in the silos.

Grundy: From the perspective of the buyer of care, we really do want to see increased utilization of appropriate medication, and we want our patients to be healthy and productive. For us, the cost of the care is just the tip of the iceberg. We also have the whole issue of productivity. So it’s really a matter of appropriate utilization addressing both under- and overutilization of services. It’s a win-win for the pharmaceutical companies because increased utilization means they sell more medication, also a win for us because we want our folks healthy and productive. The best way to do that is for them to take their medication and comply with wellness instructions and other things.

Heim: Look at some of the data that came out of the Kaiser Foundation surveying patients. Twelve percent of the patients said the doctor had to redo a test or procedure because they didn’t have the earlier test results. So those are the low hanging fruit. We can decrease unnecessary procedures just from that standpoint alone.

MHE: How do we measure the success of medical homes? How can we quantify whether they’re doing any good?

Grundy: The state of Vermont’s early studies indicate a 7% reduction in overall costs. That’s a real bending of the curve. That’s data, right? We’re seeing improved outcomes in terms of indicators of compliance with diabetic management and asthma management. I was just at a physician’s practice in Florida where he used to have on average of one patient a month hospitalized for asthma. In the past 19 months, he’s only had one asthma hospitalization, and that’s data, right? We’re beginning to see pretty robust data and would love comments from other folks on that.

Nichols: I think another aspect of measuring success has to do with the experience of care both from the patient and the physician perspective. For this to be sustainable, patients need to recognize that this is something different, and it’s something different that they really like. It may not be an easy sell for some patients who’ve just been accustomed to picking a specialist out of the yellow pages or calling a friend to see who to go to next.

From the provider’s side, there are two big issues around the experience. There’s a lot of work up front [in creating a medical-home model] so it’s important that physicians see this as being something very positive, something that they advocate to their colleagues. But perhaps even more importantly is one of the underlying driving factors, which is the critical state of primary care in this country and the need to convince more and more of the upcoming graduates from medical school to pursue primary care as a field. The more convincing stories there are about the positive experience that these models are bringing to practice, the more likely we’ll succeed from that perspective.

MHE: What cautions do you have for the industry regarding medical homes?

Heim: Coming from the TransforMED demonstration project that AAFP did, we learned you have to provide enough resources to pull this off. It has to be adequately financed, and the transformation process can be stressful. So provide strong leadership to enable that to occur. The other problem that we’ve seen is that many of the projects have too short a timeline. They’re looking for a quick return on investment in less than two years, and two years is probably the bare minimum.

Nichols: Payers have to have a realistic timeline, and I do think five years is a much better frame. It’s easy for a think-tank guy to say, but I just think that’s the reality. The clinicians will tell you the same thing because of the up-front investment.

I would also hasten to emphasize my favorite phrase from Ronald Reagan: ‘Trust but verify.’ The people who claim that these models don’t work are stuck in defending the status quo, fee-for-service, unaccountable model. They’re just afraid of change, that’s part of it, but they don’t want to move to a world in which they’re going to be held accountable and things are going to be measured.

Not every patient is going to go to some quantitative provider comparison on a Web site, but enough will as we evolve as a society. Look at the number of people using smart phones. And now we’re going to move to a world in which if you can’t show that your treatment modalities and your health plan are achieving outcomes as good as [top-rated] systems and medical homes and health plans, you’re going to be at a competitive disadvantage.

Just look at the companies that…are in many ways poised for the new world because they’ve invested in information systems and information management, and selected forward-thinking and better organized providers. The other plans are really going to have to step up and participate in that ‘trust but verify’ competition or risk very serious competitive problems.

Grundy: That is not an easy transition for the providers to make. We learned in working with MVP Healthcare and others that we need to help pay for the process of this transformation. We’re dealing with oftentimes small groups of providers that are trying to survive on either a -1% margin or a 1% margin. We need to instill a bit of hope in them. If we’re reaping the benefit of that, we as the buyers have to begin to pay for the process of this transformation.

Heim: What we hear most from people who are practicing in a patient-centered medical home is that they feel like they’re back to practicing medicine the way they were trained to. They’re back to taking care of their friends, their patients and their communities, and that is incredibly rewarding for them.

Salkowe: I think just one area that we need to be careful with is the enthusiasm around this topic and the eagerness to move forward.

There’s been a tendency to slip outside of the structured pilots and just throw money at the medical home by financially recognizing providers solely based on recognition rather than how well they’re coordinating and managing the care of their patients.

The practice transformation that’s required goes well beyond whatever any individual recognition can possibly measure. In the pilots, for the most part, there’s been a structure that’s enabled practices to learn from each other and to share and develop communitywide resources. It’s going to take some time for resources to be well enough established in a community that all physicians in the community might be able to readily become a part of this.

We just need to be careful that we don’t get ahead of that infrastructure development and make sure we’ve figured out how to do this right before it becomes a standard for everybody.

Heim: Jerry, are you talking about concern whether or not the NCQA recognition program now truly recognizes those things that are of value?

Salkowe: No. I think it does recognize those things that are of value. It’s necessary, but I don’t think it’s sufficient. Over time we’ll come up with additional measures that will help, but testing itself never really tells the whole story, particularly in something like this, which isn’t just about what an individual practice does. It’s really about what’s happening in a community and how that practice interfaces with the community. Unless you have the right infrastructure in place, a practice might pass the test and really still not be able to deliver on the promise.

Webb: One of the challenges that we face is being flexible enough to recognize that how you construct these teams virtually in small communities and small practices is going to take a lot more creativity. It’s a lot more difficult to do than in those settings where you have large physician groups or managed care organizations or hospital-based teams where that functionality has been existent for a long time.

Particularly from the pharmacy side, we’re looking to create models that integrate pharmacists into the team in a very creative and constructive way. For the small medical practices, the best way to do that remains to be defined… With IT and with virtual framework, it’s entirely possible to do this even if we can’t all be physically present in this mythical place called the medical home.

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.”

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.

NCQA tracks plateau in quality yet increased reporting of measures

As if it weren’t bad enough news that healthcare costs continue to spiral upward, the benchmark quality report for 2009 from the National Committee for Quality Assurance (NCQA) reveals that quality has stalled somewhat. In fact, the report examined the link between the cost and quality of care and found little or no connection between the two.

“The State of Health Care Quality: 2009″ report examined quality data submitted by 979 health plans across the country that collectively cover 116 million Americans, a 9% increase over 2008’s sample.

“Hundreds of health plans have made the commitment to measure and report on the quality of care provided to their members. Those plans have made remarkable progress in improving care,” said Margaret E. O’Kane, president of NCQA. “But they can’t do this alone. It’s time for all plans and providers to step up to the plate and do the right thing for their members.”

The stagnation of quality came as a disappointing surprise after a decade of improvements and was seen in all areas of healthcare—private coverage, Medicaid and Medicare.

“The status quo is unacceptable,” O’Kane said during a press conference last month. “Overall, the [quality] gains are pretty small, particularly among the most vulnerable populations,” as plans serving Medicare and Medicaid patients failed to show noticeable improvement in many key quality measures for the third consecutive year.

Among the notable areas in which quality has stalled:

Only 46.4% of people taking anti-depressant drugs are monitored by their physicians;

34.1% of children prescribed medications for attention deficit hyperactivity disorder are seeing a doctor for follow-up care;

Half of patients previously hospitalized for mental illness see a physician for a follow-up visit;

45.3% of people are receiving colon cancer screening at the appropriate age; and

Only 42.6% of patients with alcohol or drug dependency are get treatment for the condition.

Despite those disappointing results, there were several bright spots. Among them were a 12% increase in the provision of beta-blocker drugs to Medicare patients who had a heart attack within the previous six months; nearly across-the-board high-quality care for asthma patients; and substantial gains in smoking-cessation efforts in the Medicaid population.

“Sometimes, a plateau is just a place to get your bearings and figure out what your next strategy is going to be, and that’s the kind of plateau I think this is,” O’Kane says.

The need to get healthcare quality back on the path to improvement is dramatic, however. NCQA says that if all health plans were able to perform as well as the top 10% of plans did, the United States would realize fewer deaths and save at least $12 billion in medical costs and lost productivity every year. If every American were able to receive care that matched the quality of that provided by those plans in the top 10%, the number of lives saved would range between 165,000 and 272,000 annually.

Where those saved lives come from might depend on geography; the New England region had the highest-quality health plans, while the South Central region of the United States came in last.

“Every American deserves to have quality care, and a diabetic in Alabama shouldn’t get poorer care than a diabetic who lives in New Hampshire,” O’Kane says.

Deeper data points revealed in health risk assessments

The employee health risk assessment (HRA) remains a powerful tool for employers, but uncertainty over incentive guidelines and frustration over participation rates can stall even the most innovative programs. The goal of an HRA is two-fold.

HRAs provide employees with measures of their current health status and future health risks as well as actions they can take immediately to improve health. Additionally, employers can use the HRA information—aggregated and de-identified—to develop a wellness strategy.

“Most employers recognize that you can’t manage what you do not measure,” says Michael Taitel, vice president, Alere Center for Health Intelligence. “If you are trying to manage the health of your population, you can’t achieve that goal unless you have the data that shows the prevalence of health risks, chronic conditions, and absenteeism and presenteeism rates in your population.”

More data can be better when it comes to health measurement. Alere offers a Health and Productivity Assessment (HPA), which analyzes the effects of specific health problems on work performance and absence.

“For example, we ask them to indicate if they are missing work because of a health condition,” Taitel says. “In another series of questions, we ask them to rate and compare their performance to other employees. So simply looking at risks alone only gives part of the picture.”

For example, many HRAs assess the presence of depression.

“We understand that depression plays a key role in an employer’s productivity losses, as well as overall benefit costs, so we believe it is an important component to study,” Taitel says.

Another feature of an effective HRA includes a link into personal health support interventions so that employees may be steered into programs that can provide assistance. Employees who require assistance may also be identified for contact by a health coach or for participation in special wellness or prevention programs.

DRIVING PARTICIPATION IN HRAS

According to “Wellness Programs, Survey & Sample Series,” published in February 2009 by Brookfield, Wisc.-based International Foundation of Employee Benefit Plans, only about 14% of employers have indicated participation rates in HRAs above 75%, while 18% of employers indicated participation rates of 51% to 75%.

Bryce Williams, director of prevention and wellness at Blue Cross Blue Shield of Massachusetts (BCBSMA), believes that best-in-class participation begins at 80%.

“When [80%] of a population completes an HRA, the data becomes more meaningful and informative to future program strategy,” Williams says.

LURING EMPLOYEES WITH CASH

Incentives are the most popular tool to encourage participation, and there are a number of carrot-and-stick approaches, according to Carl R. Mowery, managing director of SMART Business Advisory and Consulting LLC, a business advisory services firm based in Devon, Pa.

“Some employers have even required employees, as a condition of participation in the healthcare program, to complete an annual health assessment,” Mowery says. “Others will give discounts on premiums for those who complete a health assessment, and others will provide cash or gift certificates to the employees.”

The Equal Employment Opportunity Commission (EEOC) issued an informal opinion letter stating that requiring employees to participate in an HRA may violate provisions of the Americans with Disabilities Act (ADA). However, HIPAA had earlier outlined a recommendation that noted the incentive can’t be greater than 20% of the cost of the health plan. Most employers are currently following the HIPAA guidelines.

Much discussion has taken place on how to apply incentives for completing HRAs. The company can opt to pay cash or the incentive may be tied to reduced health insurance premiums.

“The important thing to keep in mind is that incentives do not have to be costly,” says Taitel.

In CIGNA’s experience, its clients with the best overall HRA completion rates have offered a reduced premium or cash payment.

“Incentives play an instrumental role as a mechanism to engage individuals to participate in HRAs and in other programs designed to improve lifestyle behaviors,” says Emelia DeMusis, CIGNA product manager. “Levels of participation in HRAs have been found to vary significantly depending on the type of incentive that is used to motivate participation.”

While DeMusis says that optimal participation rate is obviously 100%, she believes that “even at levels below 100%, such as 20% to 40%, there can be medical savings.”

WALKING THE TALK

Participation is greater when it is supported by management and when it is linked to a more comprehensive intervention, specifically when it becomes an instrument used to help shape the corporate culture.

Incentives are a useful tool, but the best thing employers can do to encourage participation is ensure there is organizational commitment to the process, Alere’s Taitel says.

“Top leaders must become wellness champions,” he says.

In fact, in a peer-reviewed study Taitel led last year, researchers found that the strongest predictors of HRA completion are the monetary value of incentives and the employer’s level of communication and organizational commitment.

In the study, organizational commitment was a metric that included communications, the level of employee involvement through committees and internal champions, and visible executive management leadership support through advocacy, program participation and allocation of resources.

“Perhaps the most important finding was that the higher the organizational commitment, the lower the incentive cost needed to be,” Taitel says.

BSBSMA’s Williams agrees. Communicating with employees in advance of an HRA launch can ensure employees have a clear understanding of what data from their HRA will be shared with their health plan and their employer, he says.

CASE IN POINT

Visible senior management support, an engaging wellness platform and meaningful data have been demonstrated at SPS New England (SPS), a Salisbury, Mass.-based construction services company with 211 subscribers.

Under SPS’s wellness program, which is offered through BCBSMA, employees who elect to participate receive a higher contribution (up to 20%) from the company on their health insurance premiums depending on several wellness factors. SPS’s goal is 100% participation, says the company’s CEO and chairman, Wayne Capolupo.

Participation includes completing the BCBSMA online HRA, as well as being individually screened for tobacco use and three health metrics (BMI, blood pressure and cholesterol) and setting goals to maintain or improve those metrics over the coming year. BCBSMA wellness consultants work with SPS to run analytics on the HRA data and identify population health risks, which inform future interventions.

“SPS’s company contributions to health insurance premiums are based not only on employee participation but also on whether employees meet the health goals they set for themselves,” Capolupo says. “In the long run, it is our hope that by focusing employees on their own health issues and high-risk behaviors, and providing services to attenuate those risks, that employee wellness will improve and lost time and claims will be reduced. As a result, SPS’s health insurance premium will be reduced.”

DIG DEEPER

Historically, HRAs were mortality based and data didn’t go far. Today, data analytics get more mileage out of HRAs.

“Analysis of HRA data at the population level is used to support client decision making by analyzing how current health risks impact future health status, costs, productivity and disability, by identifying the most appropriate health strategies to support a population and by monitoring health status and health changes over time.” CIGNA’s DeMusis says.

By employing the University of Michigan HRA and Trend Management System, CIGNA is able to forecast costs and health status, use targeted improvement strategies and recommend the optimal outreach method to engage individuals, according to DeMusis.

But, in today’s economy, can employers afford to implement full-scale HRAs? Overwhelmingly, experts believe employers can’t afford not to implement an HRA as part of an overall wellness program.

“These programs can help employers reduce turnover, increase productivity, improve employee health and help potentially high-risk individuals from becoming future high-cost claimants,” says SMART Consulting’s Mowery.

HRAs typically cost just pennies per member per month. It’s a small investment with high potential for return.

However, there’s no real ROI for an HRA alone, according to Taitel, who asserts that the value of an HRA comes in measuring the changes in health risks over time. Large employers can link HRAs to claims data to see actual changes in costs.

However, the real key is link HRAs back to meaningful interventions. To secure true value, employers must take the information and use it to build tailored and useful health and wellness programs.

Tracey Walker is a senior editor with Advanstar Communications.

Staying Motivated & Proactive in Today’s Ophthalmic World

Elective case volumes are down in this poor economy; government healthcare plan is reducing Medicare reimbursements even further; and your house hasn’t recovered in value since the 2008-09 real estate down turn. What’s a healthcare person to do?!?  

Like our forefathers, we need to adapt and modify the way in which we do business and expend monies during poor economic times. Perhaps to counter the decrease in cases, you might look to provide added value services to your patients. An example would be to provide hearing tests and hearing aids to your patients. To elaborate on hearing services, here are some little known facts; (1)  50%+ of all senior citizens have significant hearing loss, (2) 80% of them have never been tested for such loss, and (3) hearing aids are the only effective treatment for 90% of such patients.  So think about it — for every 100 patients who come through your waiting room, 50 of these patients have a hearing problem and 40 have done nothing to address it. Baby-boomers’ hearing loss is far greater than earlier generations. Plus, this group is more apt to seek treatment. Hearing services could prove to be a natural fit in ophthalmology.

Another step forward would be to engage the creative side of you & your staff by having brainstorming sessions with your key people. The objective for these meetings would be to come up with ideas for added services, ways to improve efficiencies, and areas for cost cutting.

Most importantly, remember to focus on your blessings, not your misfortunes. It’s a known fact that positive people are more successful (and with less health problems) than negative thinkers. If you have difficulty staying positive, I would encourage you to give yourself daily pep talks and keep telling yourself “I can’t change this bad situation, but I can certainly change my attitude toward it.”

Best Practices in On-Site Wellness Series: Guidelines for Choosing a Health Screening and Flu Shot Vendor

Today, more companies are implementing wellness programs in order to improve the health and
productivity of their employees, while at the same time reducing overall health care expenses. However, it is easy
to think of health screenings as a commodity instead of what they truly are ? health care.

ASCs Taking Market Share Away From HOPDs

Ambulatory Surgery Centers (ASC) provided services to 70% of the growth in Medicare services between 2000 and 2007, thus capturing market share from hospital outpatient departments (HOPD) to less expensive ASC setting. This was according to KNG Health Consulting, who conducted a comprehensive study of the growth factors for ASCs.

Factors that contributed to this growth was the œpayers incentives to pay for care in a the most cost-effective setting, demographic changes, and consumer and physician preferences. Patients too seem to prefer ASCs as their copayments are lower, the wait time is shorter, the ease of scheduling and the convenient locations of surgery centers. Physicians prefer ASCs due to shorter turnaround times, able to do more with increased productivity, better control of staff decisions, and more involved with equipment selection decisions. If an owner, physician also benefits from income generated from ownership.

Interesting enough, ASCs saw the average price of procedures fall by 11% between 2000 and 2007. Therefore, Medicare paid much less for procedures performed during this period as growth in Medicare cases increase, yet average price decreased.

Standardizing Electronic Documentation Using a Perioperative Nursing Language

Our places of work and homes are abuzz with new terms: toxic assets, monetary policy and stimulus packages. While the current state of the economy is to many a relatively new development: cost containment, productivity and revenue struggles are not new to healthcare. Consider the dizzying predicament for healthcare professionals when economic issues are mixed with industry issues such as safety, quality, evidence-based care and pricing transparency. Adding regulations offering incentives for the “meaningful use” of electronic health records (EHR) and the clinical care environment transitions into a tense, high-pressure conflict between actual care, documentation and data collections.

In the midst of this conflict and pressure is the professional nurse. No doubt, nurses affect clinical care and patient outcomes. A report studying the effects of nurse-to-patient ratio validated a strong correlation with reducing patient morbidity and mortality.¹

However, healthcare organizations, especially perioperative areas, have difficulty with data collection, integrity and retrieval that provides the basis for operational and clinical decisions. Poor or inconsistent data restrains the allocation of appropriate resources or tools to develop a scientific foundation for an evidenced-based nursing practice model.

Increasingly, healthcare and the perioperative environment are going digital. With this transformation, there is a need to provide rigorous standards that promote safe patient-centered care. A market survey of over 200 perioperative units in healthcare facilities and ambulatory surgery centers (ASCs) revealed many wanted, or had some version of, the Perioperative Nursing Data Set (PNDS) in their documentation, but did not know how to incorporate it into their plan of care. Additionally, the respondents were unsure if their documentation met standards or regulatory requirements due to the complex regulatory environment and the difficulty of maintaining the frequent updates.²

Clearly, healthcare organizations need to identify the critical factors to be employed when developing an information infrastructure and the tools to quantify efficient, cost-effective quality care. By applying a standardized perioperative language, the clinical environment has a mechanism to aggregate consistent data representing patient-centered care. The American Medical Informatics Association (AMIA) also offers additional guidance for selection and implementation of an information system to promote a national infrastructure for healthcare:

• Establish a local, regional and national health information exchange (HIE) to ensure that health information is available whenever and wherever needed
• Create standards, policies and practices that foster security, confidentiality, transparency and public trust
• Identify health terminologies and classifications allowing health data to be uniform and consistent across information systems
• Link information related to individuals in order to ensure the validity and integrity of health data for care and research
• Develop decision making and other knowledge management tools in order to permit delivery of individualized, evidence-based care
• Develop appropriate and secure linkages between EHRs and the public health surveillance systems.³

The PNDS is foundational to this effort as it meets an essential point of the information infrastructure criteria by providing clear, consistent and precise terminology, and definitions for clinical problems (nursing diagnoses), nursing interventions and patient outcomes, and reflect perioperative nursing practices.⁴ The PNDS is not a standard of care, but a structured vocabulary allowing the aggregation of clinical information across the perioperative continuum of care. In a standardized perioperative framework, the PNDS is associated with practice standards, accreditation criteria and regulatory requirements to facilitate efficient and safe patient care, while staying current with changes in healthcare. Throughout the healthcare system, initiatives to promote patient safety, improve outcomes and report consistently on quality metrics are gaining considerable momentum. Congress has directed the Centers for Medicare and Medicaid Services (CMS) to put into place a reporting system for ASCs to track quality by the end of this year, with financial penalties for those failing to submit the required data.⁵

Responding to this heightened emphasis on quality reporting will not be easy. Compliance with the Joint Commission or other accreditation standards is another concern for ASCs. Automating documentation in the clinical setting can greatly improve the ability to meet these goals. Information systems not only satisfy regulatory demands, it also reduces inefficient manual processes.

Healthcare organizations do not want to re-invest in a new surgical information system but want collected data to be used more efficiently for benchmarking and quality initiatives. A standardized data framework that overlays the existing user information documentation system and standardizes perioperative documentation and nursing workflow will help guide decision making for patient-centered care. Such a framework enables hospital decision makers and nurses to:

Guide safer care by integrating:

• The Association of periOperative Registered Nurses’ (AORN) Perioperative Standards and Recommended Practices
• Regulatory and mandatory reporting requirements
• Accreditation standards
• PNDS
• Consistent, standardized communication.

Guide effective care by:

• Enabling evidenced-based clinical decisions
• Providing information to develop protocols
• Integrating current regulatory requirements, accreditation criteria and national standards
• Promoting nurse-sensitive interventions and plan of care.

Drive efficient care by:

• Returning nurses from the conference room to the operating room
• Reducing nurse documentation time
• Facilitating perioperative staff training by
• Training new orientees
• Orientating temporary staff.

The framework should complement rather than replace any information technology (IT) vendor system, focusing on standardizing the perioperative content of the EHR, nursing documentation and functionality with surgical information systems. There are four general categories of technology that should be considered when purchasing any new IT application:

• Presentation – what is seen on the screen
• Workflow – how information is proceeded and sequenced
• Reference files – tables and files of predetermined values, such as allergy types or patient positions
• Data – where patient-level information is stored

With this framework, healthcare organizations can standardize the perioperative content for workflows and reference files.

Workflows should be standardized across both the perioperative continuum (pre-admit to post operative recovery) and throughout the nursing cycle (assessment, nursing diagnosis, desired outcome, implementation, evaluation and actual outcome)

Reference files should be created by the organization implementing the system. The framework provides a comprehensive and detailed list of standardized reference files scalable to any organization.

So how does all of this represent patient-centered care?

1. It does not require more documentation; it is transparent to the user
2. It integrates national standards, recommended practices and regulatory requirements across all phases of perioperative care
3. It employs PNDS as the universal perioperative language with associated data elements reflecting nursing interventions
4. It reflects nursing workflow in the entire plan of care, assessment, implementation, evaluation and patient outcomes
5. Enables data to be used for benchmarking, both internally and externally
6. It supports national mandatory reporting measures (e.g., Surgical Care Improvement Project measures) by utilizing continued documentation of the assessment findings throughout all phases of perioperative care
7. It supports the submission of required CMS quality data.

References

1. J. Needleman, PI Buerhaus. Nurse Staffing Levels and Quality of Care in Healthcare Organizations. The New Eng J of Med May 30, 2002, No. 22, Vol 346:1715-1722
2. CSC market survey conducted on behalf of AORN from 8-1-2008 thru 9-30-2008.
3. D. Detmer. AMIA recommendations for achieving a national infrastructure for HIT and  informatics to President-Elect Obama. January 7, 2009. http://www.amia.org/files/ObamaLetter_January2009.pdf. Accessed April 3, 2009.
4. C. Peterson, ed. Perioperative Nursing Data Set Revised 2nd ed. Denver: CO: AORN, INC; 2007:9-15.
5. Centers for Medicare & Medicaid Services (CMS). 2008Deficit Reduction Act (DRA) 2005 (c). http://www.cms.hhs.gov/HospitalAcqCond/. Accessed April 3, 2009.

Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, is a perioperative nurse specialist, in Clinical Informatics for AORN. Julie Hammersley, RN, is a senior manager in the Perioperative practice at CSC. Louise Kenney, RN, is a senior manager in the Perioperative practice at CSC. Barbara Ripollone, RN, is a partner and the solution leader for the Perioperative/Supply Chain practice at CSC.

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