Archive for April, 2008

Americans Rank Healthcare Near Top of Economic Woes

April 29th, 2008 by Melanie Matthews

Healthcare costs rank among Americans' top personal economic problems, and their struggles to deal with those costs have affected both their financial well-being and their family's healthcare, a new Kaiser Family Foundation poll finds. This poll probes into the economic concerns facing Americans and the ways they have dealt with the cost of healthcare.


  • Nearly three in 10 Americans (28 percent) report that they or their families have had a serious problem paying for healthcare and health insurance as a result of recent changes in the economy, behind paying for gas (44 percent) and about tied with getting a good-paying job or raise in pay (29 percent). Smaller shares report serious problems paying their rent or mortgage (19 percent), dealing with credit card or other personal debt (18 percent), paying for food (18 percent) or losing money in the stock market (16 percent).
  • Reports of families facing serious economic problems extend up into middle-income families, with almost three in 10 (28 percent) of those earning between $30,000 and $75,000 reporting a serious problem paying for healthcare or health insurance as a result of recent changes in the economy.

Cognitive Impairment

April 25th, 2008 by Melanie Matthews

This week's Disease Management Update looks at cognitive impairment and decline in the elderly. A study from the Mayo Clinic suggests exercise can reduce the risk of cognitive impairments such as Alzheimer's disease, while the American Academy of Neurology cautions certain drugs may increase cognitive decline.

Making Web Videos on a Shoestring Budget: HIN’s Four-Part Video Series

April 25th, 2008 by Melanie Matthews

After launching our first video for the Web, Web 2.0 and Healthcare, we couldn't help but think that other organizations might also want to learn how to do this. So we've created a 4-part video series on making videos for the Web called "Vlogging 101: Videos on a Shoestring."

You can view Part 1, Getting Started, below. For the rest of the series, please visit:

Videos on a Shoestring Part 2: Creating the Script

Videos on a Shoestring Part 3: Video Production

Videos on a Shoestring Part 4: Distributing Videos on the Web

We welcome your comments! And invite you to view our other video, Diabetes and the Medical Home.

Medical Home More Than a Model These Days

April 22nd, 2008 by Melanie Matthews

A posting last week by Dr. Rob of Musings of a Distractible Mind offered an insightful interpretation of the medical home model, complete with a graphical depiction. He assesses its impact on the various "players" in the model — patients, primary care physicians, specialists, hospitals, employers and businesses. The Healthcare Intelligence Network has been covering the emergence of the medical home and its impact on primary care for several years now. Here's how we and responded to Dr. Rob's post:

First, there has been much confusion, even in the industry itself, about the term. When we surveyed healthcare execs in 2006, more than half of them had never heard of the concept, or confused it with a physical structure. Thankfully, a similar survey we conducted earlier this year revealed a growing awareness.

Secondly, the key to the medical home model is a coordinated approach to care that is reliant upon an exchange of data among all medical home team members (pharmacies, payors, community organizations, physical therapists, and the patients themselves). In most but not all cases, care will be coordinated by the primary care physician. We cannot talk about the medical home without discussing tandem efforts to redirect consumers who visit the ER with non-emergent health issues to more appropriate health settings such as primary care. The dollars that payors and hospitals spend today to dispense primary care in costly ERs can be redirected to the medical home team.

CMS last week announced $50 million in grants to 20 states that have proposed strategies to encourage Medicaid beneficiaries to avoid improper use of costly ERs, and nine of those proposals center around the creation of medical homes for these individuals.

Third, the medical home is a natural haven for the uninsured and the elderly. Several pilots in the medical home model have already been directed toward the uninsured. In North Carolina, doctors with Community Care of North Carolina served as medical homes for their Medicaid patients with diabetes. The ongoing care, information and support that physicians and case workers gave these patients made a huge difference. These patients missed fewer missed doctors’ appointments, made fewer non-urgent trips to the emergency room, and had fewer unnecessary ospitalizations. These changes saved North Carolina taxpayers more than $231 million in 2005 and 2006. North Carolina is planning related pilots for beneficiaries with other chronic illnesses.

And lastly, as we see it, the true key to the medical home's success is education. Health plans have a huge challenge in marketing the medical home to consumers, who may confuse it with the old HMO "gatekeeper" model of care. PCPs, ER staff and payors need to convey to consumers the benefits of the medical home and guidelines for determining when an ER visit is necessary. Primary care doctors need to know when patients are using the ER unnecessarily and address this during patient visits. During its pilot, Community Care equipped its physicians and patients with disease management toolkits and pamphlets on medical home vs. ER use in English and Spanish. Other health plans have found that putting these materials into consumers' hands does reduce unnecessary ER use. Many payors have placed case managers in ERs as an educational and redirection resource. Education of ER staff and patients on the medical home also figures prominently in many of the CMS grant projects.

There are so many issues related to the medical home model that we have launched a Web page called The Medical Home Monitor where we post our survey results and relevant video, podcasts, blog entries. etc on the topic, which will be updated continuously.

Protecting Your Organization from Security Breaches

April 22nd, 2008 by Melanie Matthews

A recent bevy of headline news on information security breaches underscores the importance of the need for continued auditing and monitoring of electronic medical records.

An employee of NewYork-Presbyterian Hospital/Weill Cornell Medical Center in Manhattan stole information from the records of as many as 40,000 patients, according to a New York Times article on April 12th. “The theft ­which occurred over the past several years and included patients’ names, phone numbers and Social Security numbers ­was discovered during a federal investigation, and the hospital was notified in January, the spokeswoman, Myrna Manners, said. An internal audit by the hospital confirmed the theft, she said.”

An article in Business Week last week described how a Wellpoint vendor relationship was responsible for exposing personal information that may have included Social Security numbers and pharmacy or medical data for about 128,000 WellPoint Inc. customers in several states.

In other information security breach news, a Washington Post article describes how a government laptop computer containing sensitive medical information on 2,500 patients enrolled in a National Institutes of Health study was stolen in February, potentially exposing seven years' worth of clinical trial data, including names, medical diagnoses and details of the patients' heart scans. The information was not encrypted, in violation of the government's data-security policy. Read more on this breach online at WashingtonPost.com

So how can your organization protect itself against these and other types of information security breaches?

A complimentary downloadable white paper from Absolute Software cautions not to let encryption be your only safeguard against security breaches:

"According to the 2003 Health Insurance Portability and Accountability Act (HIPAA) Security Rule, healthcare organizations must use some form of encryption to protect EPHI that is stored on open networks such as laptops2. However, encryption alone does not protect health organizations from the human factor. According to a recent survey of 1,400 enterprises, more than 60% of data breaches are the work of those operating within the firewall – insiders such as employees, contractors and others with ready access to sensitive information3. Intentionally or unintentionally, insiders such as physicians and HMO brokers with wide-ranging access to both EPHI and the necessary passwords and encryption keys represent a glaring hole in security policies that rely heavily on encryption alone."

A downloadable executive summary from Third Brigade notes that while it is impossible to remove every possible security risk to any business, it’s important to determine what level of risk you are willing to assume, and then cost-effectively implement security processes and technology that reduce the risk to an acceptable level.

"In addition to arming yourself with relevant and timely threat information, educating staff about security, and imposing security requirements with healthcare partners, there are a number of other important first steps you can take to determine how vulnerable your HCO is, and to prevent attackers from
exploiting the applications you rely on."

And finally, a downloadable executive summary from Devon IT urges healthcare IT departments to use thin client technology to protect private patient information and achieve and enhance HIPAA-compliance.

ER Redirection Grants Shot in the Arm for Primary Care

April 21st, 2008 by Melanie Matthews

Emergency Room DiversionHospitals around the country are devising new strategies to increase ER efficiency and discourage consumers from seeking care in the ER when an alternative healthcare setting will do. Scottsdale Healthcare now posts waiting times for its three ERs on its Web site, with updates every 10 minutes. Other hospitals have begun to charge a premium for non-urgent ER visits. And last week, CMS awarded $50 million in grants to 20 states that have proposed programs to reduce use of hospital ER rooms by Medicaid beneficiaries for non-emergent reasons. The grants will fund alternative healthcare settings for individuals with non-emergent medical needs, particularly in rural and underserved areas and for those programs that work closely with community hospitals.

In the news last week, studies from New York and Oregon — two states not on the CMS grantee list — indicated that ER visits from their uninsured residents are on the rise and costing their hospitals money. A report by the United Hospital Fund found that while hospital ERs in New York City often provide routine care for the uninsured, the disparities were higher than expected. Among the 10 neighborhoods where residents visited the emergency room most often, nine were among those with the highest poverty and mortality rates, the report found. In Oregon, a study by Ohio Health and Science University found that visits to ERs by the uninsured and mentally ill are up 20 percent this year, which the researchers attributed to 2003 cuts to the Oregon Health Plan, Oregon's Medicaid expansion program.

ER redirection strategies proposed by CMS grantees represent some new thinking in this space that may inspire other organizations — and much of it originates in South Dakota. One project will deliver primary care to the schools via Sioux Falls' high school-based health center and to an Indian reservation via a mobile health clinic and targeted disease management efforts there. There's also the technology-based South Dakota Telehealth Urgent Care Clinic project. And psychiatric diversion tactics are addressed by Illinois, Rhode Island and others, who will partner with behavioral health providers to permit those clients to be seen in a non-emergent behavioral healthcare or primary care setting.

Other ER redirection ideas from CMS grantees cover ground that should improve the overall condition of primary care:

  • Developing primary care medical homes (proposed by nine of 20 grantees);
  • Opening new community health centers;
  • Extending hours at existing clinics;
  • Increasing reliance on APNs, case managers and patient advocates;
  • Educating beneficiaries about appropriate ER use and new services;
  • Wiring facilities for e-health data exchange.

Below are project highlights from CMS grantees:

Colorado, San Luis Valley Region:
Operational hours for a convenient care service will be specifically designed to provide primary care alternatives during hours when there is no other choice than the ED (nights and weekends), while also overlapping mid-afternoon hours with the highest known frequency of visits in the ED, providing 61 additional hours of operation per week. The proposed model is also intended to address interventions that correlate with decreased ED usage, including providing health education, teaching patients how to use the healthcare system, and offering counseling on social/emotional issues.

New Jersey Division of Medical Assistance and Health Services:
All patients who present to the ED will be triaged and receive medical screening by an advanced practice nurse (APN). Once a patient is determined to have non-emergency primary care needs, the APN will provide express primary care services and prescriptions, either as part of the triage/medical screening or immediately following. As part of discharge services for Medicaid/uninsured patients, the APN will set up the follow-up appointment with a primary care provider in the community, such as the participating FQHC.

During ED discharge, the APN will also educate express care patients on the appropriate site of care and the importance of using a medical home for primary care services and limiting ED visits to true emergency situations. Clinical information about specific patients’ use of ED for primary care needs will be shared with FQHCs and HMOs so they may take responsibility for their patients and provide more outreach/education.

Colorado, Pike Peak Region:
Will promote the concept of the medical home and offer real time referrals to alternative non-emergency care through the use of Outreach Case Managers.

Connecticut Department of Social Services:
Launching a My Health Direct web portal to facilitate access to primary care for Medicaid recipients by removing barriers patients face to obtaining primary care appointments and enhancing linkages between emergency departments and community-based primary care providers. Will offer appointment scheduling 24/7.

Georgia Department of Community Health:
Equipping more Georgians with medical homes.

Illinois:
Partnering with behavioral health providers so clients seeking non-emergent care may be seen in a non-emergent primary care and behavioral health settings.

Indiana:
Staffing two by advanced practice nurses and a patient navigator who will help link patients with primary care providers, mental health and/or other community services. One of the advanced practice nurses at each site will have a mental health background in order to assist in screening for underlying mental health concerns that may drive individuals to seek hospital emergency room services.

Massachusetts:
In phase one, FQHCs are beginning to work with their local community hospitals to identify strategies to divert non-acute and patients without a primary care provider to the FQHC for follow-up and ongoing care. In phase two, they'll get the technical tools to support this.

Michigan Department of Community Health:
Patients will be diverted to care at the FQHC through community marketing efforts intended to help them seek care appropriately when the ER is not needed, through hospital telephone triage and through direct referral of those who do come in to the emergency room.

Michigan, Hamilton Community Health Network:
Case Management Services for Medicaid patients identified as frequent utilizers of the ER for
non-emergent care and those patients who have identified chronic care conditions. Establish a primary care home for Medicaid patients who do not have an identified primary care provider.

North Carolina Department of Health and Human Services:
Will provide incentives and support to 40 large Community Care practices, which are willing to become alternative non-emergency providers (“advanced medical homes”) in the communities they serve, offering extended and alternative hours.

North Dakota:
Will be done tracking the utilization patterns of the emergency room, confirming appropriate use and misuse of the ER, developing and launching an educational awareness outreach plan, and determining and implementing a cost-effective corrective action plan.

Oklahoma Health Care Authority:
Adding a Health Educator and two Community Health Workers (CHWs) to develop an Emergency Department Reduction Pathway and a Medical Home Pathway in conjunction with the University of Oklahoma’s Medical Center (OU), St. Anthony Hospital and Central Oklahoma Integrated Network Systems, Inc. (COINS). This is a four-week training to develop competencies in pathway development, healthcare system operations, social services, communication skills, motivational interviewing, health education and self-management of chronic diseases. CHCI will contract with OU College of Medicine to have resident physicians to provide medical services for additional 20 hours per week, thereby increasing access.

Pennsylvania Department of Public Welfare:
Will promote the medical home concept and launch a statewide campaign to educate Medicaid recipients on the appropriate use of ED services. UPMC Health Plan will establish alternate non-emergency providers to serve the target population.

Rhode Island Executive Office of Health and Human Services:
Project includes an ED psychiatric diversion project.

South Dakota Department of Social Services:
Will pilot a school-based health center in one of three public high schools in Sioux Falls. By providing convenient, alternative access to non-emergent health care, this program is intended to reduce the number of Sioux Falls high school students seeking non-emergent care in area emergency rooms.

The South Dakota Telehealth Urgent Care Clinic Pilot Project:
Will allow patients to receive local primary care, after hours, in their home clinic. Three pilot sites will be selected and will each have a nurse facilitate needed urgent care through advanced telehealth technology linked to an urgent care physician located in an urban community in the state. By providing telehealth consults, one provider is able to assist many remote sites with smaller volumes. Additional staffing is only needed for the RN to facilitate the visits.

Pine Ridge, South Dakota Chronic Care Clinic Access:
This project will increase access to non-emergency health care services for South Dakotans on the Pine Ridge Indian Reservation in Shannon and Todd Counties. Regional Health System will provide chronic disease management clinics for Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes and Warfarin management.

South Dakota’s Pine Ridge Indian Reservation:
This project will provide medical homes to children and pregnant women on the Pine Ridge Reservation through a variety of innovative mechanisms. The geography of the reservation coupled with the stark poverty of the population creates a need to bring services to outlying communities via a Mobile Health Clinic. Medical homes will also be provided to children at schools located on the reservation, and the school clinic at Red Shirt will be operationalized to maximize access to regular primary care.

Tennessee Department of Finance and Administration:
Hardeman County Community Health Center will establish partnerships with other agencies including dental, mental health, translation, and transportation to ensure financial arrangements for patients needing such services.

Nashville Medical Home Connection:
Medical Home Connection will link hospital emergency room Medicaid/TennCare members in Nashville/Davidson County with alternate non-emergency primary care providers for their non-emergency care.

Communication & the Doctor-Patient Relationship

April 18th, 2008 by Melanie Matthews

In any relationship, communication is key, and this is certainly true of relationships within the healthcare arena. This week's Disease Management Update examines how communication between patients and proviers can decrease disparities in care and another study that suggests more doctor-patient communication can actually lower a patient's risk of heart disease.

Mental Stress Reduces Blood Flow to Heart in Patients with Gene Variation

April 15th, 2008 by Melanie Matthews

University of Florida researchers have identified a gene variation in heart disease patients who appear especially vulnerable to the physical effects of mental stress — to the point where blood flow to the heart is greatly reduced. UF researchers studied 148 patients with coronary artery disease who were on average about 65 years old. Participants were asked to perform a public speaking test designed to induce stress. Images were taken of blood flow to the heart at rest and during the speech task. Blood samples also were collected and analyzed for five common gene variations.


  • Those with the gene variation are three times more likely to experience dangerous decreases in blood flow to the heart — a condition doctors call ischemia — than heart disease patients without it. Ischemia increases the chance these patients will suffer a heart attack, heart rhythm abnormalities or sudden death.
  • About a fourth of the patients experienced mental stress-induced reduced blood flow to the heart, and about two-thirds of them harbored a particular variation of the adrenergic beta-1 receptor genotype that was associated with a three-fold increased risk of this phenomenon. This receptor typically helps the body respond to stress by regulating blood pressure and heart rate, but a common variability in its gene may make certain patients more vulnerable to the effects of psychological stress.

Racial and Ethnic Health Disparities Linked to Physician Practice Resources

April 15th, 2008 by Melanie Matthews

Primary care physicians treating a disproportionate share of black and Latino patients typically earn less, see more patients, provide more charity care, treat more Medicaid patients, and receive lower private insurance payments than their counterparts who treat fewer such patients, according to a national study funded by the Commonwealth Fund and published recently as a Web exclusive in the journal Health Affairs. These same physicians also reported more problems providing high-quality care, ranging from inadequate time with their patients to difficulty obtaining specialty care. Conducted by researchers at the Center for Studying Health System Change (HSC), the study sheds new light on the pervasive racial and ethnic health disparities in the United States by looking beyond individual patient characteristics to community and physician practice resources. The study also examined how higher Medicaid payments might help physicians treating mostly minority patients provide high-quality care and reduce racial and ethnic disparities.


  • About 52 percent of primary care physicians reported having patient panels with less than 30 percent minorities, 36 percent reported 30 percent to 70 percent of their patients were minorities, and 12 percent reported that minorities constituted more than 70 percent of their patients, confirming previous research showing that relatively small numbers of physicians treat a disproportionately large share of minority patients.
  • Physicians in high-minority practices received more than a third of their practice revenue from Medicaid, compared with 13 percent for physicians in low-minority practices. Thirty-five percent of physicians in high-minority practices reported that patients’ inability to pay was a major barrier to providing high-quality care, compared with 23 percent of physicians in low-minority practices.

Elders and Technology

April 14th, 2008 by Melanie Matthews

This week's Healthcare Weekly Business Update features AARP's findings on elders' attitudes toward technology — they want to use it to help them stay in their homes longer, but are daunted by IT costs, training and support requirements. Given the current focus on collaborations in healthcare, there's an opportunity here for makers of sensors, home monitors, medication dispensers and computer games. Partnering with providers to reduce tech resistance in this population could boost patient compliance levels, provide real-time health status updates, prevent some unnecessary office and hospital visits and alert family and providers to critical events such as a fall or missed medication. The elders will also derive a sense of well-being from staying in their homes longer, which should free up more hospital and nursing home beds.

In a related story, Ovations Clinical Care Manager Judith Szilagyi-Neary shares strategies for developing partnerships that can help to fill care gaps in disease management efforts.