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Nurse Staffing, Patient Mortality, And a Lady Named Louise

Mar 23, 2011• 12

By BOB WACHTER

How many nurses does it take to care for a hospitalized patient? No, that’s not a bad version of a light bulb joke; it’s a serious question, with thousands of lives and billions of dollars resting on the answer. Several studies (such as here and here) published over the last decade have shown that having more nurses per patient is associated with fewer complications and lower mortality. It makes sense.

Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.

Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.

As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”

The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings).Continue reading…

Sermo teams with J&J

Mar 22, 2011• 2

By Matthew Holt

One of the big stories at the Health 2.0 Conference in San Diego is that Sermo is partnering with Janssen Global Services (part of J&J) to create tools for doctors to help them move their patients through the health care system. It’s the first time Sermo has explicitly both added a mobile app and moved into the transactional end of its physician community members’ businesses. Sermo’s figured out that a significant portion of their referrals never result in an actual appointment. So they’re going to be working with Jannsen to help close that loop, and we can assume that there’ll be a series of physician and consumer-aimed services to come from the partnership. Sermo says to expect the first product by end of spring. While new entrants like Doximity are aiming at the same market, Sermo’s marketing reach and J&J’s muscle makes them a formidable competitor.

And if you’re at the Health 2.0 Conference in San Diego, Dan Palestrant, Sermo’s CEO will be making an appearance to explain a tad more!

The CMIO Should Be a Doctor

Mar 22, 2011

By MAGGIE MAHAR

A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center, “because nobody knows a doctor’s business like a doctor.”

As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.

It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.

On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.

It is telling that before coming to Maimonides in 1995, Brier spent fifteen years in New York City’s municipal hospital system, and still says: “Even though I’m not working for government anymore, I still feel that I’m a public servant.”Continue reading…

Who Owns Patient Data?

Mar 22, 2011• 11

By DAVID HARLOW

Walgreens is being sued by customers who are not happy that their prescription information – even though it has been de-identified – is being sold by Walgreens to data-mining companies.

The data privacy and security concerns surrounding the transfer of de-identified data are significant. To “de-identify” what is otherwise protected health information under HIPAA, some outfits will simply strip data of 18 types of identifiers listed in federal regulations. However, the relevant regulation (45 CFR 164.514(b)(2)(ii)) also provides that this only works if “the covered entity does not have actual knowledge that the information could be used alone or in combination with other information to identify an individual who is a subject of the information.” Thus, the problem with this approach is that, these days, nobody can disclaim knowledge of the fact that information de-identified by removing this cookbook list of 18 identifiers may be re-identified by cross-matching data with other publicly-available data sources. There are a number of reported instances of this sort of thing happening. The bottom line is that our collective technical prowess has outstripped the regulatory safe harbor.

Is this the basis of the lawsuit brought against Walgreens? An objection to trafficking in health information that should remain private? No. The plaintiff group of customers is suing to share in the profits realized by Walgreens from trading in the de-identified data.Continue reading…

What’s The Worst Case Scenario In Japan Nuke Crisis?

Mar 22, 2011• 4

By MERRILL GOOZNER

This from John Beddington, the United Kingdom’s chief science advisor at its Tokyo embassy:

Let me now talk about what would be a reasonable worst case scenario. If the Japanese fail to keep the reactors cool and fail to keep the pressure in the containment vessels at an appropriate level, you can get this, you know, the dramatic word “meltdown”. But what does that actually mean? What a meltdown involves is the basic reactor core melts, and as it melts, nuclear material will fall through to the floor of the container. There it will react with concrete and other materials … that is likely… remember this is the reasonable worst case, we don’t think anything worse is going to happen. In this reasonable worst case you get an explosion. You get some radioactive material going up to about 500 metres up into the air. Now, that’s really serious, but it’s serious again for the local area. It’s not serious for elsewhere even if you get a combination of that explosion it would only have nuclear material going in to the air up to about 500 metres. If you then couple that with the worst possible weather situation i.e. prevailing weather taking radioactive material in the direction of Greater Tokyo and you had maybe rainfall which would bring the radioactive material down do we have a problem? The answer is unequivocally no. Absolutely no issue. The problems are within 30 km of the reactor. And to give you a flavour for that, when Chernobyl had a massive fire at the graphite core, material was going up not just 500 metres but to 30,000 feet. It was lasting not for the odd hour or so but lasted months, and that was putting nuclear radioactive material up into the upper atmosphere for a very long period of time. But even in the case of Chernobyl, the exclusion zone that they had was about 30 kilometres. And in that exclusion zone, outside that, there is no evidence whatsoever to indicate people had problems from the radiation. The problems with Chernobyl were people were continuing to drink the water, continuing to eat vegetables and so on and that was where the problems came from. That’s not going to be the case here. So what I would really re-emphasise is that this is very problematic for the area and the immediate vicinity and one has to have concerns for the people working there. Beyond that 20 or 30 kilometres, it’s really not an issue for health.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at GoozNews, where this post first appeared.

Death Panels Everyone Can Live With

Mar 22, 2011• 9

By DAVID E. WILLIAMS

Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person’s] ‘level of productivity in society,’ whether they are worthy of health care.”

A Health Affairs article (Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries) makes a far more level-headed and evidence-based contribution to the discussion. The authors studies the use of palliative care teams at four urban hospitals in New York State. To be clear on what these teams do:

Palliative care aims to relieve suffering and improve quality of life for patients with advanced illness and for their families. It does so through assessing and treating pain and other symptoms; communicating about care goals and providing support for complex medical decision making; providing practical, spiritual, and psychosocial support; coordinating care; and offering bereavement services.

Palliative care is provided in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies. It is optimally delivered through an interdisciplinary team consisting of appropriately trained physicians, nurses, and social workers, with support and contributions from other professionals as indicated.Continue reading…

Direct project heading in right direction

Mar 21, 2011• 1

The Direct Project is the lightweight version of moving health data around between providers. While there’s been lots of fuss about NHIN, HIEs and data interoperability, the Direct project has sensibly been dumbed down enough so that it reminds everyone of email. Sure, it’s encrypted, standardized, blah blah, but it looks enough like email that it may just work. Today ONC announced that more or less every vendor has signed on, so that emailing medical records should soon be very common.

Insurance Companies Dancing Without Touching

Mar 21, 2011• 4

By PAUL LEVY

A story in the Washington Post talks about health insurance companies seeking new lines of unregulated business as the profitability of health insurance falls and as more and more requirements are placed on that line of business as a result of the federal health reform law. Here’s an excerpt: “Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures in wide-ranging efforts to mitigate the new rules imposed by the law.”

I raised some of these issues several months ago, where I also suggested that a merger of the Number 2 and Number 3 Massachusetts health plans might be forthcoming. Well, they tried, but decided not to, as they announced a few weeks ago.

Meanwhile, Blue Cross Blue Shield of Massachusetts is clearly laying the groundwork to shed its non-profit status. And, really, why not? It is in no way a charitable organization of the sort envisioned in earlier years, and the constraints of being a nonprofit bind in a number of ways.

When the HPHC and Tufts merger fell through, the operative statement was: “We have now determined that we are stronger as individual competitors than one company.”

I predict that will turn out to be a strategic error. In the new world order, scale matters. This statement is, to me, revealing in its own way: “Our operations are very different and, in many important aspects, not fully compatible without significant changes to existing processes and applications.” In other words, they chose not to merge because it felt like it was not currently cost-effective to change. This suggests that the operations of the two plans as presently configured are not scalable. But if they don’t merge, they will be left behind by those with stronger market power. For now, that is BCBS of MA. In the future, as the business becomes less about taking on insurance risk and more about other services, it could well include some major national players as well. Now, rather than later, would be a better time to consolidate assets and use the cash on hand to make the investments that will be needed to grab market opportunities in the future.

Unjust Enrichment

Mar 21, 2011• 5

By MARGALIT GUR ARIE

A new lawsuit has been filed this month in an attempt to curtail the unconsented and currently legal traffic of de-identified medical records, this time against pharmacy giant Walgreens. The class action suit brought by Todd Murphy, a citizen of the State of California, on behalf of his children, is alleging that the company’s sale of prescription histories to data mining companies, servicing the marketing efforts of pharmaceutical companies, is an unfair, unlawful and deceptive business practice allowing Walgreen Co. to unjustly enrich itself while depriving the rightful owners of the data of their ability to benefit from the commercial value of their prescription records. There is no mention of privacy violations anywhere in the brief, and this is what makes this legal action very unique and potentially a landmark in the effort to control unauthorized sales of medical records.

The deceptive business practices are pretty straight forward to understand, since it seems that Walgreens makes all customers sign a privacy notice stating unequivocally that the company will not disclose patient information without first obtaining authorization from the patient. Furthermore California law prohibits pharmacists from disclosing prescription information to unauthorized third parties, which arguably makes the sale of data also unlawful. The bulk of the brief is describing the injury to plaintiffs caused by “detailing”, i.e. targeted in-person marketing by pharmaceutical reps to physicians, which is substantially aided by information extracted from plaintiffs prescription patterns. Detailing is portrayed as a ruthless drug company strategy to increase sales of newer and more expensive brand-name drugs, thus increasing the costs of health care, endangering patients and harming the doctor-patient relationship.

And here is where the complaint gets interesting.Continue reading…