Summer Conference Schedule
The summer is shaping up to be a busy one. Next month, I'll be presenting at the AAMI meeting in Boston on the topic of Point of Care Automation – with clinical engineering icon, Yadin David. There are a number of very interesting sessions scheduled on connectivity, systems integration and patient safety. This is always a great event, and I'm really looking forward to all the new research, best practices and products.
A week later I'll be back in Boston for the HCMDSS/MD PnP conference (that's High Confidence Medical Devices, Software and Systems/Medical Device Plug and Play). This event has pulled in a number of luminary figures keen on interoperability and error-resistant systems in health care – including Dr Robert Kolodner. Past meetings have been dominated by academics, providers (especially the big university teaching hospitals) and government – it will be interesting gage the level of vendor involvement. The current commercial availability of interoperability features is certainly not a result of insufficient science or technology, so a lack of vendor interest could be indicative of their relative interest in interoperability. Conference co-chair, Julian Goldman has promised me there will be some interesting announcements at the conference.
Then in July I'll be co-chairing a track at the fourth annual Healthcare Unbound conference, for the first time in San Francisco. Last year was my first involvement with this event, and I was impressed. This is probably the most focused annual event on remote patient monitoring and chronic disease management in existence – with a great mix of providers, vendors, academics, government and a few VCs sniffing around.
Fortunately there's nothing planned for August – too hot. And September I'll be taking off a couple weeks to go to the desert in Nevada. And all of this is in addition to client work – it's shaping up as a very busy summer.
Pictured right is the Ant radio for wireless sensors and personal area network applications, shot at last years Healthcare Unbound conference.
Feds to Stop Paying for Medical Errors
Overall patient safety in hospitals is not improving. The latest HealthGrades report on patient safety in U.S. hospitals showed the PSI (AHRQ’s patient safety index) rate increased 8% between 2003 and 2005 (more here). The lack of significant progress with patient safety has caused some to ask why payors reimburse hospitals for the additional care necessary after a patient suffers a preventable adverse event. It seems payors are starting to ask themselves this very question – according to this Indianapolis Star story:
Late next year Medicare plans to stop paying hospitals for costs incurred from some of the most common and preventable medical errors suffered by patients.[...]
The federal Centers for Medicare and Medicaid Services, which operates Medicare, is taking public comment on the proposal through June. The changes are scheduled to take effect in October 2008.
Medical mistakes are deadly and expensive. Infections acquired in hospitals account for about 90,000 deaths and $4.5 billion in extra spending each year, according to the U.S. Centers for Disease Control and Prevention.
Presently there are no financial penalties for hospitals when preventable misadventures occur. The hospital simply recodes the diagnosis and receives reimbursement for the additional length of stay and treatment required to treat the adverse event. It is true that hospitals have an incentive to avoid preventable adverse events; reduced length of stay can translate into higher utilization, increasing revenue. Unfortunately, most hospital administrators are more focused on cost reduction than revenue growth, and (if recent reports on patient safety “improvements” are to be believed) the stick – reduced reimbursement – will probably offer an incentive than the carrot.
The idea of not paying for mistakes probably started back in 2002 when the National Quality Forum sought to standardize adverse event reporting with their report, Serious Reportable Events in Healthcare (Word document). This report included their list of 27 things that should never happen. CMS is starting with a subset of the list. Here are the 13 “never should happen” adverse events that CMS is considering for no reimbursement:
- Catheter-associated urinary tract infections
- Bed sores
- Objects left in after surgery
- Air embolism, or bubbles, in bloodstream from injection
- Patients given incompatible blood type
- Bloodstream staph infection
- Ventilator-associated pneumonia
- Vascular-catheter-associated infection
- Clostridium difficile-associated disease (gastrointestinal infections)
- Drug-resistant staph infection
- Surgical site infections
- Wrong surgery
- Falls
Starting to withold payment for adverse events will impact the health care industry as much as DRGs and capitation did years ago. Many “old school” hospital administration management techniques will fall from favor because doing things like increasing nurse to patient ratios have been repeatedly shown to result in more adverse events. This change will also eliminate the need to regulate nurse to patient ratios, like they have in California and a few other states – hospitals that operate at unsafe ratios this will go out of business (as they should).
Every hospital wants to make improvements that are easy and cost next to nothing. One of the frustrations of being a consultant is doing the needs assessment, the cost justification, and the implementation plan only to hear that, “that’s really too much trouble – we don’t want to do it.” Of course it’s even worse if you’re employed by the hospital (or vendor) as part of a LEAN team or innovation workgroup.
I’ll be watching for the fall out from this new trend – if you come across something, be sure to let me know! Pictured right is an example of an engineering feasibility project with great patient safety potential – interoperability between a Baxter infusion pump and Philips patient monitor. This was shot at the 2005 AACN/NTI meeting – interoperability of this type has yet to make it to the market in a commercially released product.
UPDATE: Here’s the CMS notice titled, “Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates” that was published in the Federal Register on May 3, 2007. Do an Edit-Find (or Cntrl-F) and use the phrase “hospital-acquired conditions” to find the part that pertains to the 13 adverse events that CMS will not reimburse starting in 2008.
UPDATE: Welcome WEDI listserv! Should providers be reimbursed for preventable adverse events? How soon will commercial payers follow suit? Will this change provider behavior and improve safety? Hit the comments link and share your opinion.
[Hat tip: FierceHealthIT]
UPDATE: Read a subsequent post on this topic here.
Medical Device Connectivity and PACS
Mike Gray continues to evangelize DICOM Archives (his latest here and here-registration required) – which I think has interesting parallels with medical devices at the point of care.
Imaging modalities are obviously the medical devices, similar to patient monitors, point of care diagnostics, pumps, vents, etc. at the point of care. The Picture Archiving and Communications System is equivalent to the servers that many of these medical devices communicate, storing data for surveillance, alarm notification and retrospective analysis. The medical device data stored on some device servers are of little value beyond the immediate future (like full disclosure waveform data), while other data has greater long term value (like the CQI data collected by “smart” pumps).
As the servers connected to medical devices proliferate, hospitals will increasingly face the prospect of migrating data from one vendor's server to another. I would imagine some vendors will refuse to offer any migration assistance – what's in it for them? In the radiology world, many migrations are handled by third parties. Here Mike describes the latest evolution in the PACS world:
enhancement is the ability to modify the DICOM header created by PACS A
to make it compatible with PACS B, and vice versa. The library of
translations used to accomplish this multi-vendor exchange is
ironically the result of real-world data migration experience. (Isn't
it nice to see that there is another return on the painful investment
in data migration?)
Mike uses the term “tag morphing” to describe this translation between proprietary data formats contained in otherwise DICOM compliant records. Imagine tag morphing between smart pump servers for migration. Even more radical, imagine a tag morphing server that simply talks to multiple vendor's medical devices just like a PACS.
same study data. The Enhanced DICOM Archive is capable of translating
that study data to make it compatible with the requesting PACS. Most of
the Enhanced DICOM Archives that I have looked at are also capable of
using the new study Order to trigger a relevant prior pre-fetch and
auto-route the priors to a PACS that is incapable of automatic Q/R from
a foreign archive. The Enhanced DICOM Archive is also capable of
setting a study status tag, so the target PACS will understand that
this is a prior and not a new study. You wouldn't want that mistake.
So the working combination of a PACS from one vendor and an Archive
from another is real. But why would anyone want to do this? Well that
translation capability would come in handy if the Health System found
itself owning several PACS from different vendors. It would also come
in handy when it came time to replace a PACS, because data migration
would not be necessary. And that makes the enhancement worth the
investment and then some.
Hmmm.
Qualcomm Announces Healthcare MVNO
Vince Kuraitis is burning up the blogosphere with more great posts on his blog. The latest to catch my eye was the announcement that Qualcomm made during the ATA (American Telemedicine Association) meeting this month in Nashville, that they are creating a health care MVNO to be called LifeComm. An MVNO is a Mobile Virtual Network Operator who leases capacity from existing wireless carriers' network, packages it and sells it to consumers under its own brand. A successful example is the Virgin Mobile and their prepaid cell phone service.
Qualcomm is reasonably well positioned for this through their QConnect service offering (numerous posts here) and their recent acquisition of nPhase. A big cost for an MVNO is the back office – the software for managing subscribers, billing, and provisioning devices to the network. Qualcomm's telco industry experience, plus the software that makes up QConnect and nPhase have much of this covered. The second big effort for an MVNO is marketing to build awareness and pull prospective customers into your stores or to your web site.
Vince's post provides a great summary of the deal and lots of links to additional info, so I won't go into the details here (be sure to check out the comments at the end of the post, too). Besides, ruminating on the announcement is more fun anyway. LifeComm will need a big war chest for marketing. In the near total absense of third party reimbursement, they will need to market to physicians (who “prescribe” monitoring like CardioNet for patients) and/or patients and their families (who could pay for monitoring or applications out of their own pocket like MyFoodPhone). In either case, we're talking hundreds of millions of dollars for marketing.
Working against LifeComm is the fact that carriers have failed miserably with wireless data applications. Carriers have always thought of wireless data as a high profit way to boost sagging ARPUs. Much like they started billing for minutes of talk time, carriers initially packaged data by the kilobyte. It was only recently that carriers have packaged data in unlimited bundles. Ironically, the wireless data service that has kept carriers in the green has been ringtones and SMS text messaging, and not the fancy “location based services” and other glitzy applications they became enamoured with.
Much of the LifeComm business model remains hidden. Will all of LifeComm's applications be LifeComm branded, or will LifeComm provide a platform for third party applications? Will LifeComm provide or enfource interoperability (or at least coexistence) between various health care related data applications? Will specialized phones be required to use the service, and at how much of a premium price? Will LifeComm's rate plans be more attractive than the marginally successful wireless data plans from the regular carriers?
The success of LifeComm will be decided by the answers to questions like those above. The other big question is how big is the market today? If LifeComm launches in mid 2008, will there be a multi billion dollar market they can tap into immediately – and if not, how long can they bleed before they have to close the doors?
Pictured right is a CardioNet monitor shot at last summer's Healthcare Unbound conference in Boston.
