Parish nurse classes sponsored by our educational partners. - Parish Nurse Perspectives

Eastern Time Zone

Jacksonville, FL

University of North Florida

Pam Marsden, 904-308-7558

Orlando, FL

Florida Hospital, Center of Health Ministry

March 16-23, 2007 OR Sept. 21-28, 2007

Candace Huber, 407-303-7153

Venice, FL

Lee Memorial Health System

May 20-25, 2007

Rita Horvath, 239-336-6721

Evansville, IN

Univ. of Southern Indiana School of Nursing

On-line starting March 12 or Sept. 24, 2007

Victoria Pigott, 812-465-1148

Indianapolis, IN

Clarian Health Partners

Pat Thorlton, 317-962-3412

Morgantown, IN

National Episcopal Health Ministries at

The Waycross Center

Diane Beyer, 317-253-1277, ext. 34

Valparaiso, IN

Valparaiso University

Janelle Fleck, 219-464-5289

Monroe, LA (Call for dates for on-line class)

University of Louisiana at Monroe School of

Nursing, March 2-3, April 13-14 & May 18-29

Linda E. Sabin, 318-342-1517

Fall River, MA

Saint Anne's Hospital

Sept-May 2007-2008 (2x month), Call

Kathleen Emerson, 508-674-5600, ext. 2064

Clinton Township, MI

St. Joseph's Healthcare FCN Network

March 2-3 and 23-24, 2007

Mary Ann Stockwell, 586-263-2117

Grand Rapids, MI

Calvin College, Dept. of Nursing

Bethany Gordon, 616-957-6012

Kalamazoo, MI

Bogress Health

June 22-23, July 20-21 and Aug. 10-11

Paula White, 269-343-1396

Saginaw, MI

Saginaw Valley State University

May 11, 18, and June 1, 2007

Vickie Jaskiewicz, 989-964-2732

Boiling Springs, NC

Gardner-Webb University

Shirley Toney, 704-406-4366 (4360)

Concord, NC

IPNRC, Northeast Medical Center

April 17-21, 2007

Pam Hurley, 704-783-4009

Buffalo, NY

July 14, 21, 28, Aug. 11, 18, 24-25, 2007

OR Sept. 8, 15, 22, Oct. 13, 20, 26-27, 2007

Catholic Charities.

Rosemary Walter, 716-856-4494, Ext. 3003

East Aurora, NY

Trocaire College and Parish Nurse Institute

of West New York

Ann Marie MacIssac, 716-566-1163

Latham, NY

Seton Health--St. Mary's Hospital

Fran Zoske, 518-268-6062

Charlotte, NC

Queens University of Charlotte

Joan McGill, 704-337-2295

Cleveland, OH

Fairview Hospital

Gayle Donahue, 216-476-7324

Toledo, OH

Congregational Nurse Project of NW Ohio

Mary Jane Fulcher, 419-262-1462

Aston, PA

IPNRC, Neuman College, June 4-9, 2007

Allison Jones, 610-358-4580

Pittsburgh, PA

Waynesburg College Dept. of Nursing

June 24-30, 2007

Joyce Schumm, 412-232-5815

Charleston, SC

Medical University of South Carolina, College of Nursing, Parish Nurse Program

Ann Hollerbach, 843-792-4624

Harrisonburg, VA

Eastern Mennonite University

May 7-June 15 (on-line)

Tammy Kiser, 540-746-6336

Lowesville, VA

Women's Missionary Union of Virginia

Rachel Cobb, 804-915-5000

Roanoke, VA

Jefferson College of Health Sciences

Linda Rickabaugh

540-985-8297

Winchester, VA

Shenandoah University

Martha Erbach

540-665-5505

Arthurdale, WV

Hospice Care Corp/West Virginia University

On-line classes, May 7-August 17, 2007

Robin Shepherd, 304-864-0884

Charleston, WV

Wheeling Jesuit University

May 17-20, 2007 and August 2-5, 2007

Alma Cunningham, 888-434-6237 x 369

Central Time Zone

Huntsville, AL

Huntsville Association for Pastoral Care

Melinda Lawson, 256-824-2462

Carbondale, IL

IPNRC at Southern Illinois Healthcare

March 1-3, 23-24, 2007

Yvonne Whitfield, 618-457-5200, ext. 67830

Oakbrook, IL

Lewis University College of Nursing

May 7-11, 2007 (9 am-5 pm)

Janice Smith, 630-752-0776

Quincy, IL

Blessing-Rieman College of Nursing

Carol Ann Moseley, (217) 223-8400

Rock Island, IL

Trinity Medical Center

Mary Slutz, 309-779-5122

Springfield, IL

St. John's Hospital

Brenda Heaton, 217-544-6464 ext. 47798

Urbana, IL

Community Parish Nurse Program, UIC College of Nursing

Faith Roberts

217-326-2683

Waterloo, IA

Allen College, On-line course

Anna Weepie, 319-226-2037

Wichita, KS

Newman University, Kansas PN Ministry

Feb. 23-24, Mar. 9-10, 23-25, 2007 OR

August 12-18, 2007

JoVeta Wescott

316-686-0111

Louisville, KY

Bellarmine University

March 3, April 14, 2007, remainder on-line

Margaret Miller, 502-452-8413

Paducah, KY

Lourdes & Western Baptist Hospitals

Mar. 12, 19, 26, 31, Apr. 2, 9, 16, 21, 2007

Carol Bradford, 270-217-1407

Duluth, MN

Concordia College, Parish Nurse Center

Jean Bokinskie, 218-299-3893

Minneapolis, MN

Concordia College, Parish Nurse Center

March 12-16, 2007

Jean Bokinskie, 218-299-3893

Minneapolis, MN

United Theological Seminary, Dates TBA

Vicki Gustafson, 612-872-7400

Kansas City, MO

St. Luke's Hospital and UMKC

Nancy Wagner, 816-935-3504

St. Louis, MO

International Parish Nurse Resource Center

March 26-30, 2007

Alvyne Rethemeyer, 314-918-2557

St. Louis, MO

St. Louis University School of Nursing

On-line course, Fall & Spring Semesters

Sally Lehnert, 314-977-8919

Springfield, MO

St. John's Hospital, March 2007 (eves/Sats)

Mary Hansen, 417-820-2770

Omaha, NE

Alegent Health

February 23-24, March 23-24, April 21, 2007

Ronette Sailors, 402-898-8350

Omaha, NE

Nebraska Methodist College

On-line course, call for next class

Susan Ward, 402-354-7063

Fargo, ND

Concordia College, Parish Nurse Center

April 23-27, 2007

Jean Bokinskie, 218-299-3893

Guthrie, OK

Oklahoma Parish Nurse Network, Catholic Charities

Andrea West, 405-364-8228

Sioux Falls, SD

Augustana College

June 18-22, 2007

Mary Auterman, 605-274-4929

Newport, TN

Tennessee Wesleyan College

Gail Lambert, 865-777-5104

Beaumont, TX

Memorial Hermann Baptist Hospital

Feb. 16-17, Feb. 23-25, 2007

Rebekah Seymour, 409-212-5648

Dallas, TX

Baylor University School of Nursing

Linda Garner, 214-820-4185

Flower Mound, TX

Dallas/Ft. Worth Faith & Health Collaborative

Debbie Seider, 214-947-2476

San Antonio, TX

University of the Incarnate Word

Jean Deliganis, 210-224-7122

Madison, WI

Edgewood College, Dates TBA

Karen Stremihis, 608-663-2270

Milwaukee, WI

Marquette Univ. & Covenant Healthcare

February 9, 10, 13, 20, 27 and

March 6, 13, 20, 27, 31, and

August 3-9, 2007

Patrice Olin, 414-550-8519

Mountain Time Zone--US

Scottsdale, AZ

Beatitudes Center DOAR Nurse & Health

Ministries Network

February 25-27 and March 25-27, 2007

Barbara Sage, 602-274-5022

Helena, MT

Carroll College, The Parish Nurse Center

Cynthia Gustafson, 406-447-4367

Pacific, Aleutian Time Zones

Anchorage, AK

Northwest Parish Nurse Ministries at

Providence Alaska Medical Center

Linda Shepard, 907-261-5053

Oakland, CA

Samuel Merritt College

July 13-16, 2007

Joan A. Bard, 510-869-8620

Kailua, HI

Puget Sound Parish Nurse and Health

Ministries, March 5-9, 2007

Sue Pignataro, 808-263-0136

Bend, OR

Northwest Parish Nurse Ministries

Central Oregon Community College

Lyn Bogie, 541-383-6861

Hillsboro, OR

Northwest PN Ministries, Portland

Community College, & Tuality Healthcare

Maria Michalczyk, 503-731-6627

Medford, OR

Puget Sound Parish Nurse and Health Ministries, May 14-20, 2007

Kathy Mahannah, 541-472-8235

Bellingham, WA

Puget Sound PN and Health Ministries

St. Joseph Hospital

Donna Gustin, 360-715-6408

Olympia, WA

Northwest Parish Nurse Ministries at Pacific

Lutheran University

Terry Bennett, 253-535-7683

Seattle, WA

Puget Sound Parish Nurse & Health

Ministries (at Seattle University)

Aileen MacLaren Loranger

206-363-1197

Canada

Toronto, Ontario (and other sites)

InterChurch Health Ministries

Location: Emmanuel College

Valerie Jenkins, 888-433-9422

Coordinator's Preparation

Fort Myers, FL

Lee Memorial Health System Parish Nurse

Program

Rita Horvath, 239-336-6721

St. Louis, MO

International Parish Nurse Resource Center

March 13-16, 2007

Alvyne Rethemeyer, 314-918-2557

Winchester, VA

Shenandoah University

Martha Erbach, 540-665-5505

Parish Nurse classes sponsored by our educational partners.(Directory) - Parish Nurse Perspectives

United States, By State

Anchorage, AK Northwest Parish Nurse Ministries at Providence Alaska Medical Center Linda Shepard, 907-261-5053

Mobile, AL Spring Hill College of Nursing August 20-November 9, 2007 Carol Harrison, 251-380-4492

Scottsdale, AZ Beatitudes Center DOAR Nurse & Health Ministries Network Barbara Sage, 602-274-5022

Oakland, CA Samuel Merritt College July 13-16, 2007 Joan A. Bard, 510-869-8620

Jacksonville, FL University of North Florida Pam Marsden, 904-308-7558

Orlando, FL Florida Hospital, Center of Health Ministry Sept. 21-28, 2007 Candace Huber, 407-303-7153

Venice, FL Lee Memorial Health System May 20-25, 2007 Rita Horvath, 239-336-6721

Atlanta, GA Gwinnett Medical Center and GA Baptist College of Nursing of Mercer University June 10-15, 2007 Linda Hughes, 678-442-2423

Waterloo, IA Allen College, On-line course Anna Weepie, 319-226-2037

Oak Brook, IL Lewis University College of Nursing Nov. 5, 12, 19, 26, Dec. 3, 2007 OR May 5-9, 2008 Kathie Blanchfield, 708-448-9429

Rock Island, IL Trinity Medical Center Mary Slutz, 309-779-5122

Evansville, IN Univ. of Southern Indiana School of Nursing On-line starting September 24, 2007 Victoria Pigott, 812-465-1148

Valparaiso, IN Valparaiso University Janelle Fleck, 219-464-5289

Wichita, KS Newman University, Kansas PN Ministry August 12-18, 2007 JoVeta Wescott 316-686-0111

Louisville, KY Bellarmine University March 3, April 14, 2007, remainder on-line Margaret Miller, 502-452-8413

Paducah, KY Lourdes & Western Baptist Hospitals Carol Bradford, 270-217-9949

Monroe, LA (Call for dates for on-line class) University of Louisiana at Monroe School of Nursing, Linda E. Sabin, 318-342-1517

New Orleans, LA, McFarland Institute Congregational Wellness Program June 22, 23, July 6, 7, 20 and 21, 2007 Rebecca Harris-Smith, 504-593-2320

Falls River, MA Saint Anne's Hospital Sept-May 2007-2008 (2x month) Kathleen Emerson, 508-674-5600, ext. 2064

Biddeford, ME St. Joseph's Hospital November 12-18, 2007 Pamela Deres, 603-225-4888

Grand Rapids, MI Calvin College, Dept. of Nursing Sept. 14-15, Oct. 19-20, Nov. 16-17, 2007 Bethany Gordon, 616-957-6012

Kalamazoo, MI Borgess Health June 22-23, July 20-21 and Aug. 10-11 Paula White, 269-343-1396

Saginaw, MI Saginaw Valley State University May 11, 18, and June 1, 2007 Vickie Jaskiewicz, 989-964-2732

Alexandria, MN with Concordia College October 29-November 2, 2007 Jean Bokinskie, 218-299-3893

Duluth, MN Concordia College, Parish Nurse Center Jean Bokinskie, 218-299-3893

Minneapolis, MN United Theological Seminary Vicki Gustafson, 612-872-7400

Kansas City, MO St. Luke's Hospital Nancy Wagner, 816-935-3504

St. Louis, MO International Parish Nurse Resource Center November 5-9, 2007 Alvyne Rethemeyer, 314-918-2557

St. Louis, MO St. Louis University School of Nursing On-line course, Fall & Spring Semesters Sally Lehnert, 314-977-8919

Sikeston, MO with IPNRC October 9-13, 2007 Krystal Jacobs, 573-635-1187

Springfield, MO St. John's Hospital Mary Hansen, 417-820-2770

Helena, MT Carroll College, The Parish Nurse Center Cynthia Gustafson, 406-447-4367 Omaha, NE

Alegent Health Oct. 5-6, Nov. 2-3, Dec. 1, 2007 Ronette Sailors, 402-898-8350

Omaha, NE Nebraska Methodist College On-line course starting January 14, 2008 Pam Mills, 402-354-7100

Buffalo, NY at Catholic Charities July 14, 21, 28, August 11, 18, 24-25, 2007 Sept. 8, 15, 22, Oct. 13, 20, 26-27, 2007 Rosemary Walter, 716-856-4494, Ext. 3003

East Aurora, NY Trocaire College and Parish Nurse Institute of West New York Ann Marie MacIssac, 716-566-1163

Troy, NY Seton Health--St. Mary's Hospital Fran Zoske, 518-268-6062

Boiling Springs, NC Gardner-Webb University Shirley Toney, 704-406-4366 (4360)

Charlotte, NC Queens University of Charlotte Joan McGill, 704-337-2295

Fargo, ND Concordia College, Parish Nurse Center Jean Bokinskie, 218-299-3893

Cleveland, OH Fairview Hospital Gayle Donahue, 216-476-7324

Toledo, OH Congregational Nurse Project of NW Ohio Mary Jane Fulcher, 419-262-1462

Guthrie, OK Oklahoma Parish Nurse Network, Catholic Charities Andrea West, 405-364-8228

Albany, OR Northwest Parish Nurse Ministries September 20-22, October 2, 2007 Rachel Hagfeldt, 541-812-4701

Hillsboro, OR Northwest Parish Nurse Ministries Tuality Healthcare October 18-19, and November 1-3, 2007 Debbie Waring, 503-413-2341

Medford, OR Asante Health System, May 14-20, 2007 Kathy Mahannah, 541-472-7235

Aston, PA IPNRC, Neuman College, June 4-9, 2007 Allison Jones, 610-358-4580

Pittsburgh, PA Waynesburg College Dept. of Nursing June 24-30, 2007 Joyce Schumm, 412-232-5815

Charleston, SC Medical University of South Carolina, College of Nursing, Parish Nurse Program Ann Hollerbach, 843-792-4624

Sioux Falls, SD Augustana College June 18-22, 2007 Mary Auterman, 605-274-4929

Newport, TN Tennessee Wesleyan College Gail Lambert, 865-777-5104

Beaumont, TX Memorial Hermann Baptist Hospital Feb. 1-2, 8-10, 2008 Rebekah Seymour, 409-212-5648

Dallas/Forth Worth, TX Dallas/Ft. Worth Faith & Health Collaborative June 17-22, 2007 Debbie Sieder, 214-947-2476

Flower Mound, TX Dallas/Ft. Worth Faith & Health Collaborative Debbie Seider, 214-947-2476

San Antonio, TX University of the Incarnate Word Jean Deliganis, 210-224-7122

Harrisonburg, VA Eastern Mennonite University May 7-June 15 (on-line) Tammy Kiser, 540-432-4186

Lowesville, VA Women's Missionary Union of Virginia Rachel Cobb, 804-915-5000

Roanoke, VA Jefferson College of Health Sciences Linda Rickabaugh 540-985-8297

Winchester, VA Shenandoah University Martha Erbach 540-665-5505

Bellingham, WA Puget Sound PN and Health Ministries St. Joseph Hospital Donna Gustin, 360-715-6408

Kirkland, WA Puget Sound Health Ministries July 8-15, 2007 Carol Story, 425-339-8034

Olympia, WA Northwest Parish Nurse Ministries at Pacific Lutheran University Terry Bennett, 253-535-7683

Seattle, WA Puget Sound Parish Nurse & Health Ministries (at Seattle University) Aileen MacLaren Loranger 206-363-1197

Arthurdale, WV Hospice Care Corp/West Virginia University On-line classes, May 7-August 17, 2007 Supplemental, May 21-August 10, 2007 Robin Shepherd, 304-864-0884

Charleston, WV Wheeling Jesuit University May 17-20, 2007 and August 2-5, 2007 Alma Cunningham, 888-434-6237 x 369

Madison, WI Edgewood College, Dates TBA Karen Stremihis, 608-663-2270

Milwaukee, WI Marquette Univ. & Covenant Healthcare August 3-9, 2007 Patrice Olin, 414-550-8519

Casper, WY (First United Methdoist Church) Carroll College, Parish Nurse Center May 14-17, 2007 Cynthia Gustafson, 406-447-5494

Canada

Toronto, Ontario (and other sites) InterChurch Health Ministries Location: Emmanuel College Karen Marks, 416-225-7231

Coordinator's Preparation

Fort Myers, FL Lee Memorial Health System Parish Nurse Program Rita Horvath, 239-336-6721

St. Louis, MO International Parish Nurse Resource Center Alvyne Rethemeyer, 314-918-2557

Portland, OR Northwest Parish Nurse Ministries at the University of Portland July 22-24, 2007 Debbie Waring, 503-413-2341

Winchester, VA Shenandoah University October 17-20, 2007 Martha Erbach, 540-665-5505

SMASH. (abolish the veterans hospitals) - The Washington Monthly

Don't fix those deadly veterans hospitals. Abolish them.

What was a nice former beauty queen doing in a place like this? A room where shell-shocked, quadriplegic patients languished unfed for three days, swimming in feces and tied to their beds? Where uncertified doctors accidentally killed some vets with faulty CPR treatment and subjected others to blood-tainted needles and bacterially infected gloves? She was making a segment of 'PrimeTime.' And after Diane Sawyer and her pen-sized camera got through with America's veterans hospitals, only one logical conclusion could be drawn: Old soldiers may never die, but the VA keeps trying.

Add to those memorable TV images the revelations of Ron Kovic and the film Article 99, and you've got the average American's mental picture of the average American veterans hospital: half infirmary, half inferno. And this popular image isn't off base; it's just incomplete. The root problem with Veterans Administration hospitals doesn't lend itself to video treatment: It's how much American citizens are paying for this substandard care. Thanks to unnecessary testing, overly long stays, mind-boggling logistics, and way too many empty beds, caring for the average VA hospital patient now costs nearly twice what it would at the average community hospital. And who's paying for that waste? You are, to the tune of hundreds of millions of dollars.

If figures like that don't move you, consider James Williams' story: When the 25-year-old Nebraskan needed a kidney stone removed last year, he might have driven to Omaha's Methodist Hospital, a top-flight private institution where he could have gotten a simple lithotripsy as an outpatient for about $5,000. But Williams, a veteran of the Air Force, qualified for free treatment by the VA. So instead he was directed to fly 500 miles via commercial jet (at taxpayer expense) from Omaha to Milwaukee, the nearest vets' facility capable of performing lithotripsy. Unfortunately, Williams first had to wait three months for a slot to open in Milwaukee, so the folks at the Omaha veterans hospital decided to insert a silicon catheter into his kidney (at risk of infection) until the Milwaukee hospital was ready to admit him. After the lithotripsy, Williams had to check back into the Omaha VA to have the catheter removed. Done? Not quite. Williams has since learned he has another stone. He'll likely be forced to retrace the same medical odyssey this summer.

Hedged vets

The Sununuesque habit of airbusing vets across the country for routine procedures may seem trivial compared to the billions spent on health care annually, but replay that type of wasteful spending a dozen different ways at dozens of VA hospitals around the nation, and the bill adds up. Today, the VA spends nearly $14 billion a year to care for a mere 3 million eligible vets.

Why are we paying Connoisseur Class prices for a third-rate medical system? Thanks goes to a Congress unwilling to say no to the 5-million strong veterans' lobby, which is quick to invoke Normandy, Inchon, or Khe Sahn whenever the question of over-spending arises. Of course, as a result of Ronald Reagan's means-testing enactment, many heroes of these battles don't actually get to use the VA system-its patients include only veterans poor enough to qualify (those with an annual income of less than $18,000) or those injured while serving. And many who do use it might jump at the chance to get free care elsewhere. Nevertheless, to the veterans' lobby and the congressmen who serve it, overhauling the system seems a betrayal of a sacred contract made in the wake of World War I: In return for serving their country, veterans should have their own hospital system to meet their needs.

Certainly, all Americans should be accorded affordable, quality health care, and until we create a universal system that works, we should make especially sure our former soldiers' health needs are met. But by clinging to a bureaucratic arrangement that's about as up-to-date as leech therapy, the VA isn't just wasting money, it's hurting the very constituency it's supposed to help. If we really want to help America's needy vets, we need an entirely new approach to providing good, free health care-an approach that would replace the VA hospital system with our underused, more efficient community hospitals.

The VA will tell you that it provides an important service to veterans, but what it won't volunteer is how few veterans use its hospital system. In fiscal year 1990, nearly one third of VA hospital beds were empty. As veterans' groups are quick to point out, the number of old and sick vets is likely to increase during the next few years, as more and more World War II veterans reach their seventies. Even so, the overall veteran population has been declining rapidly since 1980.

This shrinkage and the slew of empty beds don't leave much opportunity for economies of scale-even if the VA were interested in economy. But thanks to the peculiarities of the federal budget process, the 60,000 administrators employed by the VA have little incentive to be worried about savings. In fact, too much financial worry would put those same bureaucrats out of a job.

The OMB appropriates the VA health care budget on an annual basis, not allowing financing for the future-a setup that gives the VA a powerful incentive to spend all of its appropriated funds before the fiscal year runs out. The great fear of any bureaucrat is that by saving the federal government's money this year, he'll get a correspondingly smaller outlay in the next budget cycle. So a smart administrator-one who doesn't want to lose jobs or future funds-attempts to run through all the money he's got. The result? Once a VA gets hold of a patient, the impetus is to keep him as long and as expensively as possible, even when there's no medical rationale for doing so.

Here's how it works. Let's say you're a 25-year-old vet with a bone spur in your big toe. VA protocol requires that a gamut of tests be administered to all patients scheduled for surgery, allowing no adjustment of its policy for each type of patient. So you go through the same chest x-ray, EKG, physical, and blood and urine exams as the 70-year-old cigarette smoker in for a bypass. After waiting about two months for the tests to be processed, you'll have to check into the hospital for your relatively simple operation not once (as would be the case in a community hospital) but two or three times-each time for more unneeded exams or 'precautionary' procedures. And each time, nurses and staff are paid to put you through this diagnostic rigmarole.

Thanks to budget-extenders like these, the average expense per admission at VA hospitals in 1990 tallied $7,164, compared to the $4,947 average at community hospitals. And while, according to a Washington Monthly analysis, Medicare pays community hospitals approximately $3,000 for a gall-bladder removal and allows five and a half days to complete it, the average VA hospital cost for the same procedure is nearly $6,000 at an eight-day stay. Prostate removal? Community hospitals are forced to operate for the less than $3,000 that Medicare will give them and keep patients for an average of just under five days. The VA takes nearly seven days at a cost of $4,600.

Of course, the VA might tell you that its figures are inflated because the vets who turn to it are generally older and sicker than the average hospital patient. And some are. But even if they aren't, the hospitals won't send them home in a hurry. A 1985 General Accounting Office (GAO) study reported that with better management VA hospitals could have cut inpatient days by 43 percent. 'The VA is the only hospital system in the country where the average length of stay is measured in seasons, not days,' says a private health care consultant.

What allows this type of waste to proliferate is simple: the absence of a disciplined regulatory system for VA care. While the Medicare bureaucracy has its problems Oust ask any of the thousands of doctors who have enough Medicare paperwork to repaper their waiting rooms), the VA could learn a lesson from Medicare rules that prevent superfluous spending on items like extra overnight stays or useless exams. While a recently established VA hospital reimbursement system will pay each hospital a fixed amount depending on the type of care given to a patient, the procedures and costs are audited by no outside entity. 'The VA won't accept any requirements for accountability,' laments a former Senate veterans affairs committee staffer.

Of course, the real irony is the low quality of much of that overpriced care. To their credit, VA hospitals have been leaders in treating spinal cord injuries, initiating innovative programs to address alcohol and drug abuse, and caring for the elderly. Moreover, the system boasts a number of excellent hospitals, most of them affiliated with top medical schools, such as the Brockton-West Roxbury VA Medical Center, which has ties to Harvard's program, and the UCLA-linked West Los Angeles VA Medical Center. But, as has been documented by several recent studies, the care at the average VA hospital tends to be well below average.

So well below, in fact, that just this past November, a congressional investigator discovered incompetence and neglect at each of the six veterans hospitals she examined-failings she determined in several cases to have been the primary cause of a patient's death. In her testimony before a House subcommittee, she spoke of finding 'nurses who] allowed patients with life-threatening illness to languish for hours, even days, without monitoring.' The worst case involved a Cheyenne, Wyoming, patient whose bladder cancer, a normally curable illness, metastasized while he waited 45 days for the hospital to settle a contract dispute with its urologist. When someone finally noticed that the patient had lost 30 pounds and the cancer had spread, they shipped him to the Denver VA hospital, where he soon died.

Semper fiasco

In many ways, the care and cost problems of the VA system only mirror those that beset American health care as a whole, from lack of fiscal and medical accountability to poorly trained staff. But the VA system, with its limited number of hospitals and its manageable clientele, could be reformed into a model of first-rate health care provision. Unfortunately, nearly every major effort to change the way the veterans do their medical business has been dead on arrival, thanks to the troika that guards veterans' interests: the VA, the veterans' lobby, and Congress.

The VA's motivation to thwart reform isn't tough to plumb. A full 90 percent of the VA's staff is involved in running its medical system, thus any talk of radical change in the health-care process directly threatens the VA's main source of power, not to mention a huge chunk of its budget. And while bureaucratic self-protection is nothing new to government, the VA's intransigence is backed by one of the most formidable phalanxes in American politics: the American Legion, the Veterans of Foreign Wars, the Disabled American Veterans, and other smaller groups that comprise the veterans' lobby.

The lobby's leaders boast of being able to deliver more than a million letters to Congress on any given issue, and they don't take lightly any serious attempts to change their health care system. Consider what happened in February, when the VA agreed to join with the Department of Health and Human Services in a pilot program allowing non-vets to use VA hospitals in rural Virginia and Alabama, where hospitals are few in number. The veterans' lobby threw a fit, arguing that such a move would shut veterans out of their own hospitals, even after a VA spokesman had told them that opening the vacancy-heavy facilities to non-vets would have 'no impact' on veterans in the two states and would perhaps enhance service there.

After the Senate voted 91 to 3 to block the program, VA secretary Edward Derwinski terminated the plan, fearing the vet lobby. 'I decided, hell, I have a chance of getting rolled over or getting off the road,' he told The Washington Post, adding that the Senate felt the same pressure in this, an election year. 'Privately, everyone was saying, A great idea, but I can't vote for it.' '

Why not? Because when lobby leaders invoke the American flag, it's hard to say no. Just listen to what one vet lobbyist, Mario Raimondi of the New York State Veterans of Foreign Wars, had to say about the common-sense plan: 'This proposal is a tragic error and a shameful display of unconcern for the American veterans and their continued need for medical assistance.'

But it's not just the lobby that Congress has to worry about, says a Senate staffer who handles veterans affairs. 'The average citizen sees the hospital system and the cemeteries as the only two tangible reminders of our commitment to take care of those who have been in the military.'

VACANCIES

Of course, after so much media documentation, even diehard congressional loyalists admit that some VAs aren't taking proper care of those military men. While some call for butterfly stitches and cash infusions, what the VA really needs is major surgery-a health care voucher system that essentially eliminates the VA hospital system, turning the most viable of its hospital facilities over to community hospitals. That would help solve two American health care crises at once: the excess of hospital beds nationwide (American community hospitals are only two thirds full) and the extremely expensive upkeep of our special facilities for vets.

Without the need to staff and maintain its own facilities, the VA could shift hundreds of millions of dollars to direct medical expenses. This approach would preserve the best of the current system-free health care for veterans in need-and eliminate the worst: the bureaucracy that has stymied the VA's ability to provide adequate care at reasonable costs.

While some of the VA hospitals would be closed under such a plan (do Boston and Chicago really need four VA units when their community hospitals are one-quarter to one-third empty?), others would be converted to community hospitals, which could serve non-veterans as well as vets, just like the pilot program in the South that was deep-sixed this winter. If the voucher system alone is too expensive for our nation to bear, the government could provide a buy-in option for nonentitled vets and thus ensure care to a much greater number of veterans.

Mind you, it's not just economists who think a plan like this might work. 'There's no real medical or financial reason why the VA ought to have its own system of hospitals,' says Dr. Steve Koukol, former surgery resident at West Virginia's Morgantown Veterans Hospital. 'It would be better for veterans and more economically effective if we threw the system out and used vouchers.' But when the subject of vouchers comes up, VA loyalists tend to note their hospitals' skill in dealing with vet-specifics. In addition to experience tending to maladies commonly afflicting veterans (battle wounds, depression, alcoholism and drug addiction, and illnesses common to older men), VA hospitals are continually lauded by medical administrators for maintaining a vet-friendly environment. But can't community hospitals employ staff skilled at veterans' care? Besides, any urban trauma center today is, sadly enough, experienced at treating gunshot wounds.

Community leaders in Baltimore argued along these lines when a localized version of the voucher plan nearly took shape back in 1982. As the city planned to tear down and replace one of the three area veterans hospitals, the Maryland Hospital Association suggested that instead of erecting a new facility, veterans should be provided with vouchers to use at community hospitals-after all, the city already had more than 2,600 empty beds. For the government and taxpayers, the plan would have meant tens of millions of dollars saved by not constructing a new unit. For the veterans themselves, it would've meant more efficient care. But to the nation's veterans' organizations, it meant heresy. Fearing a backlash at the polls, not one member of Congress was willing to propose the necessary legislation to make the plan fly, even though the empty beds in Baltimore were costing an estimated $122,000 each annually to maintain. The new $118 million Baltimore VA Medical Center will open this spring.

The ultimate irony of this is that the average poor vet in Baltimore, or Omaha or Little Rock or Tacoma, probably doesn't have the same kind of allegiance to the VA hospital as he does to the notion of good health care. 'I wouldn't have any objection to going to a regular hospital,' says James Williams, the Omaha resident shipped 500 miles for his kidney stone treatment. 'If I have that choice, I'll take it.' But these vets-the ones with firsthand experience in the dilapidated VA system-aren't the ones being heard when it comes time to talk of VA reform. 'The quality of care in the VA hospitals is, on the whole, better than that in community hospitals,' boasts Dr. Earl Brown, a former Veterans Affairs health-care administrator and staunch defender of the status quo. But does he go to a VA hospital? No,' he concedes. 'The care there is not exactly the most . . . expedient.'

Evaluation of the BiliChek Being Used on Hyperbilirubinemic Newborns Undergoing Home Phototherapy - Archives of Pathology & Laboratory Medicine

* Context.-Newborns are often screened prior to discharge for hyperbilirubinemia. Transcutaneous bilirubin analyzers, such as the BiliChek, are promoted as screening tools, but it is unclear whether they also function well as monitoring devices. Newborns on home phototherapy require frequent determinations of serum bilirubin levels to monitor therapy effects. A transcutaneous bilirubin analyzer would be helpful to limit blood draws and enhance staff efficiency. We evaluated the accuracy of the BiliChek analyzer in this setting.

Objective.-Is the BiliChek sufficiently accurate to monitor the effectiveness of home phototherapy and establish when to terminate therapy?

Design.-Paired serum bilirubin results and results from the BiliChek were obtained from newborns on home phototherapy during daily home health care visits.

Results.-The BiliChek demonstrates a negative bias (mean bias, -1.71 mg/dL; 95% confidence interval, -1.89 to -1.52 mg/dL) compared with serum bilirubin values. This bias worsens as the serum bilirubin level rises. If a value of 14 mg/dL or less obtained using the BiliChek had been used as the cutoff for termination of phototherapy, 45% of newborns would have had therapy terminated prematurely. If, knowing the negative bias of the BiliChek, the cutoff for termination of therapy was set at less than or equal to 11 mg/dL, then 29% of newborns would have had therapy terminated prematurely.

Conclusions.-The values obtained using the BiliChek, compared to serum bilirubin values, have a negative bias that worsens at the higher bilirubin levels expected in newborns at home on phototherapy. The BiliChek does not provide sufficient accuracy to be utilized to monitor newborns on home phototherapy or to ascertain when to discontinue such therapy.

(Arch Pathol Lab Med. 2008;132:684-689)

Hyperbilirubinemia, with the potential risk of kernicterus, has recently gained attention as new cases of this preventable disorder were reported in the early 2000s.1 Guidelines for the management of hyperbilirubinemic newborns have been established by the American Academy of Pediatrics.2,3 In our community, many of these newborns are discharged to receive home phototherapy and require measurement of bilirubin levels to monitor the effects of therapy and to ascertain when to terminate treatment. The serum bilirubin level at which to terminate home therapy is not provided in guidelines, but for patients readmitted to the hospital and treated for hyperbilirubinemia, the recommendation is to discontinue phototherapy once the serum bilirubin level falls below 13 to 14 mg/dL.2 Most of our clinicians use 12 to 14 mg/dL, along with a general evaluation of the newborn's status.

The BiliChek (Respironics, Marietta, Ga) is a device that measures bilirubin transcutaneously. Demonstrated to be useful to screen for hyperbilirubinemia in newborn nurseries, 4-8 it is also claimed by the company to be accurate enough to use as a monitoring device in newborns undergoing phototherapy.8 As newborns on home therapy may require several days of treatment, a method of measuring bilirubin that does not entail a venous or heel puncture and that can give instant results would be very useful. We evaluated the BiliChek in this population to ascertain whether it was sufficiently accurate to allow for monitoring of patients and determining when to terminate therapy.

MATERIALS AND METHODS

The BiliChek devices were acquired (on a trial basis) by Children's Hospital Home Health Care Services (Omaha, Neb) in March 2006. Training of home health care nurses and respiratory therapists was performed. It consisted of a 2-day session of hands-on training by the manufacturer's representative and observational training at the Methodist Hospital Newborn Nursery (Omaha, Neb) teaching site to observe technicians performing a bilirubin level test with the BiliChek on newborns on the day of their discharge. Methodist Nursery has been using the BiliChek device for more than 2 years as a screening tool. A check-off sheet was used to evaluate all trainees in the operational steps of the BiliChek device (including error codes, battery removal, criteria when not to use device), as well as the step-by-step process of using the device. This was followed by hands-on training with the device and testing on each other. After all trainees were checked off as competent in the use of the device, a 2-month trial to determine variability among staff was performed to identify any retraining needs.

Three devices were obtained (1 device was replaced due to performance failure-a broken piece of plastic).

Home health care nurses and respiratory therapists were assigned to visit hyperbilirubinemic newborns for whom phototherapy was ordered by their physicians on their first day at home, and to draw a blood sample for serum bilirubin measurement, perform a bilirubin level test using the BiliChek, set up phototherapy (either a Wallaby III system and/or PEP unit [an Ultra BiliLight device]), and weigh and evaluate the newborn. Only newborns on the Wallaby system were tested with the BiliChek. All newborns were tested on the forehead. Specimens for serum bilirubin testing were transported to Children's Hospital for processing. The clinician returned each subsequent day to evaluate the newborn, weigh the newborn, draw a blood sample for serum bilirubin testing, and obtain a BiliChek bilirubin level. Each newborn received a daily serum bilirubin test for 1 to 4 days on average. When the serum bilirubin value was approximately 12 to 14 mg/dL, and the newborn was doing well clinically, the phototherapy was terminated by the ordering physician. Upon discontinuation of home phototherapy by the physician (based upon the serum bilirubin result), the clinician would return to the patient's home to remove the phototherapy equipment.

Specimens for serum bilirubin testing were collected in microtainers that protected the specimens from light. Upon arrival in the laboratory, the specimens were spun and analyzed on a Fusion 5,1 (Vitros/Ektachem; Ortho-Clinical Diagnostics), using a 10-�L sample drop volume on the dry slide technology. Both the unconjugated (Bu) and conjugated (Bc) bilirubin were measured from the same slide. The test reaction is an end point colorimetric, dual-wavelength reaction that employs the unique spectral characteristics of Bu and Bc, with readings at both 400 and 460 nm. Results are reported in milligrams per deciliter. Per routine, quality control is run daily and monitored for deviations from the expected range. Calibrations are performed at least every 6 months or whenever deemed necessary due to implementation of a new lot number, after certain service procedures, or in the event of unacceptable quality control deviation.

The data collected listed each patient's identification number, which BiliChek device was used, which staff member performed the BiliChek test, the hours of age of the newborn, the serum bilirubin level, and the bilirubin level obtained using the Bili- Chek. Allowing for a several-month learning curve, only data obtained since June 1, 2006 were used. EP Method Validator was the program used to obtain statistical values. Bias plots and Deming regression were utilized to compare the 2 methods.9

RESULTS

Two hundred nine newborns were included in the study. Only very rarely would a newborn have a significant increase in bilirubin levels after arriving home; most were already at or near their peak bilirubin level, and most of the values demonstrated a daily decline. Rarely would a newborn have a mild increase in bilirubin after several days of therapy. The newborns were greater than 34 weeks' gestation. Underlying risk factors for hyperbilirubinemia were unknown, as was racial distribution. Most of the newborns were breast-fed, but these data were not collected and many received various amounts of fluid and formula supplementation. The average age of the newborns at the time of the first home visit was 94.6 hours (median, 90.5 hours; range, 39.9-530.4 hours).

The data were subjected to Grubbs analysis for outliers. Some differences between the bilirubin levels obtained using the BiliChek and the serum bilirubin levels appeared extreme (up to 8.9 mg/dL), but there was a continuous range of differences and therefore these apparent extreme differences could not be dismissed as outliers.

A difference plot using all data points (N = 477) demonstrated that the BiliChek has a mean bias of -1.71 mg/ dL (95% confidence interval [CI], -1.89 to -1.52 mg/dL) compared with the serum bilirubin level (Figure 1). Deming regression analysis demonstrated a slope of 1.204 (95% CI, 1.083-1.324) with the intercept -4.83 (95% CI, -6.67 to -3.00) (Figure 2). The correlation coefficient (r) was 0.662.

According to its product literature,8 Respironics performed correlation studies of the BiliChek on newborns with bilirubin levels that were relatively low compared with the newborns we evaluated. Only 3.3% of the newborns in the Respironics studies had bilirubin values greater than 14 mg/dL, and only 11.8% of these newborns had values greater that 12 mg/dL. Other studies found in the literature also evaluated data on serum bilirubin values that were predominantly 13 to 15 mg/dL or less.4-6 In an article by Bhutani et al,4 the range of bilirubin values was 0.2 to 18.2 mg/dL, but only 1.1% of the values were greater than 15 mg/dL and only 21.7% were greater than 10 mg/dL. The exception is the article by Engle et al,7 in which populations had elevated levels, with 31% of Hispanic newborns and 9% of non-Hispanic white newborns having values greater than 15 mg/dL. Our population was similar to that of Engle et al in this respect. To evaluate whether the level of bilirubin affected the accuracy of the BiliChek, we evaluated bias plots for serum bilirubin levels less than 12.9 mg/dL, from 13 to 14.9 mg/dL, and greater than 15 mg/dL. We observed that at levels less than 12.9 mg/dL (n = 66; 14% of all values), the bias was less at -0.897 mg/dL (95% CI, -1.26 to -0.534 mg/dL). At levels between 13 and 14.9 mg/dL (n = 137; 29.3% of all values), the bias was -1.41 mg/dL (95% CI, -1.74 to -1.08 mg/dL). At levels greater than 15 mg/dL (n = 268; 56.7% of all values), the bias was -1.99 mg/dL (95% CI, -2.24 to -1.74 mg/dL). Thus, we observed a significant worsening of negative bias as serum bilirubin levels rose (Figure 3).

One of our goals was to ascertain whether the BiliChek was accurate enough to be used to monitor and terminate phototherapy. Home health care staff proposed the following algorithm and question. On day 1, both a serum and a BiliChek bilirubin value would be obtained. If the newborn was older than 96 hours of age, and if there had been at least 2 declining bilirubin levels via BiliChek, could the final decision to withdraw phototherapy be made based on a subsequent further decrease in the BiliChek bilirubin level alone, without having to repeat a serum bilirubin? This would mean fewer venipunctures or capillary draws for serum bilirubin levels. The staff also would be able to finalize care of the patient in a single visit, removing the equipment during the same visit at which they obtained the final bilirubin level using the BiliChek. This would improve efficiency by eliminating delivery of a specimen for serum bilirubin determination to the laboratory, awaiting the results, contacting the physician, and then returning to the home to remove equipment.

We therefore evaluated the third consecutive decreasing serum bilirubin values versus the BiliChek bilirubin levels (n = 79) and found that the bias of the BiliChek was -1.78 mg/dL (95% CI, -2.18 to -1.39 mg/dL). For study purposes, we chose a bilirubin level of 14 mg/dL or less as the decision point to terminate phototherapy. If we had chosen to terminate phototherapy when the bilirubin level obtained using the BiliChek was 14 mg/dL or less (n = 62), 45% of the newborns would have had phototherapy terminated before their serum bilirubin values were less than or equal to 14 mg/dL. Most would have had serum bilirubin values in the 14 to 15 mg/dL range, but some were in the 16 mg/dL range, with rarely a newborn having a serum bilirubin value as high as 17.5 mg/dL. Also, by using a BiliChek bilirubin level cutoff of 14 mg/dL, 12% of newborns (n = 17) would have continued to receive unnecessary therapy.

In an attempt to correct for the fact that the BiliChek has a negative bias, we re-evaluated the data based on a lower cutoff value, a BiliChek bilirubin level of 11 mg/dL or less (n = 24). Using this decision point, 29% of the newborns would have had therapy terminated before their serum bilirubin levels were less than 14 mg/dL, while 33% (n = 55) would have received 1 or 2 days of unnecessary therapy (Figure 4).

In an attempt to rule out user error, the first 2 months of data were evaluated. The overall bias (n = 89) was -1.39 mg/dL (CI, -1.77 to -1.01 mg/dL). The distribution of serum bilirubin levels was comparable to the overall distribution in the post training period data (21.3% less than 12.9 mg/dL, 29.2% between 13 and 14.9 mg/dL, and 49.5% greater than 15 mg/dL). This bias (-1.39 mg/dL) is somewhat better compared with that obtained when the training period data are eliminated (-1.71 mg/dL), possibly secondary to fewer data points.

We then analyzed the data beginning after the training period by user, to look for single user error that might account for the negative bias identified. There was no pattern evident when we compared the number of times a clinician used the BiliChek with the average serum bilirubin versus the BiliChek bilirubin difference. In other words, familiarity with the BiliChek did not lessen the bias (Figure 5).

Finally, we evaluated the impact of age of the newborn on the results obtained using the BiliChek. The BiliChek literature8 states that the instrument is designed to evaluate newborns from 0 to 20 days of age. Our age span was from 1.6 to 13.7 days (with a single outlier at 22.8 days with a difference of -1.9 mg/dL; not included in the data for Figure 6). The bias did not change based on the newborn's age (Figure 6).

COMMENT

The BiliChek is a device designed for screening newborns for hyperbilirubinemia. The BiliChek product literature8 indicates a bias of /- 1.5 mg/dL. There are numerous studies4-7 that evaluate the BiliChek as a screening device. During screening, most bilirubin levels are relatively low, within the range in which (based on our data) the BiliChek demonstrates improved accuracy compared to higher bilirubin levels. This permits establishment of BiliChek bilirubin cutoff values beyond which obtaining a serum level is prompted for further evaluation of the newborn.

Utilizing an analyzer for a completely different purpose than intended (screening vs monitoring) opens the door for great discrepancies in its performance.10 However, the literature for BiliChek also indicates8 that the device is accurate enough to use for monitoring newborns receiving phototherapy. The BiliChek study obtained a correlation factor (r) of 0.87 to 92; no bias plot or data are provided. Of interest, however, of the patients on phototherapy who were monitored by the BiliChek manufacturer,8 only 3.3% had bilirubin levels greater than 14 mg/dL.

Only a few other studies have evaluated the BiliChek as a monitoring device. One is the study by Engle et al,7 who evaluated newborns on phototherapy. As in our study, they had newborns with elevated bilirubins, most expected to be at least 15 mg/dL. They also uncovered a significant negative bias that limited the ability of the BiliChek to be utilized as a monitoring tool. Both Hispanic newborns (31%) and non-Hispanic white newborns (9%) in their study had serum bilirubins greater than 15 mg/dL; they report a similar bias irrespective of race. While we cannot confirm that race does not play a role in this bias because we do not have race data on our newborn population, we suspect that there is a nonlinear bias that worsens as bilirubin levels increase.

In addition, all studies identified to date were performed in newborn nurseries or outpatient pediatric clinics. 3-8 No studies evaluating the device in the home health care setting could be found. The home health care setting is a very different environment with many more opportunities for preanalytic error than in the newborn nursery. It is possible that this setting and the resultant error are contributing to the bias we are observing.

Although we initially considered user error as a potential confounder of our data, review of the data indicates no correlation between familiarity with the BiliChek and the bias obtained.

Potential problems with this study are several. First, the home health care environment itself, with other children, distractions, etc, may have contributed to our bias. Second, our comparison method was the Fusion 5,1 analyzer, and this could have been inaccurate, although based on quality control data and other monitors, we could identify no aberrations. Third, we do not know the racial distribution of our patients. Finally, we did not evaluate the precision of the BiliChek in this study.

CONCLUSIONS

It would be very useful to have a transcutaneous, point-of- care method to measure bilirubin in the newborn at home on phototherapy and to monitor treatment. However, in this setting, newborns have expectedly high bilirubin levels. Our data show that the negative bias of the BiliChek worsens as the bilirubin level increases. The BiliChek does not offer adequate accuracy to allow it to be used to monitor newborns on home phototherapy or to ascertain when to discontinue therapy.

[Reference]

References

1. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Kernicterus threatens healthy newborns. Sentinel Event Alert 2001;18(18):1-2. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/ sea=18.htm. Accessed September 30, 2007.

2. Subcommittee on Hyperbilirubinemia, American Academy of Pediatrics, Clinical Practice Guidelines. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114:297-316.

3. Stanley IP, Chung M, Kulig J, et al; and Subcommittee on Hyperbilirubinemia. Evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics. 2004;114:e130-e153.

4. Bhutani VK, Gourley GR, Adler S, Kreamer B, Dalin C, Johnson LH. Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000; 106(2):E17.

5. Dominguez T, Bukovitz M, Swartz H, Buckellew M. Implementation of the new transcutaneous bilirubinometer, BiliChek�, in the maternity ward and pediatric outpatient clinic. The Society of Armed Forces Medical Laboratory Scientists (SAFMLS) Society Scope. Summer 2005;8-11. Available at: http://www.safmls. org/Scopes/Scope%20-%202005%20Summer.pdf. Accessed September 30, 2007.

6. Rubaltelli FF, Gourley GR, Loskamp N, et al. Transcutaneous bilirubin measurement: a multicenter evaluation of a new device. Pediatrics. 2001;107:1264- 1271.

7. Engle WD, Jackson GL, Sendelbach D, Manning D, Frawley WH. Assessment of a transcutaneous device in the evaluation of neonatal hyperbilirubinemia in a primarily Hispanic population. Pediatrics. 2002;110:61-67.

8. BiliChek Noninvasive Bilirubin Analyzer, User Instruction Manual, Respironics, Inc.

9. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307-310.

10. Schumacher RC. Transcutaneous bilirubinometry and diagnostic tests: ''the right job for the tool.'' Pediatrics. 2002;110:407-408.

[Author Affiliation]

Christine A. Reyes, MD; Donald R. Stednitz, BA, RRT-NPS, AE-C; Carol Hahn, MT(ASCP); Kelly D. Mutchie, PharmD; Steven R. McCullough, MT(ASCP); Kent Kronberg, MD

Accepted for publication October 12, 2007.

From the Department of Pathology (Dr Reyes, Ms Hahn, and Mr McCullough), Children's Home Health Care (Mr Stednitz and Dr Mutchie), and Children's Physicians Eagle Run (Dr Kronberg), Children's Hospital, Omaha, Neb.

The authors have no relevant financial interest in the products or companies described in this article.

Should a physician reveal HIV status to patients, employer? - Dermatology Times

A situation arose in Canada recently that instigated discussion about personal responsibility if a physician tests positive for HIV - or, ultimately, is suffering from any contagious disease.

Earlier this year, officials of a children's hospital in Quebec learned that one of their surgeons had performed more than 2,500 surgical procedures over more than a decade after she had tested HIVpositive. Although the doctor had informed a hospital committee of her HIV status in 1991 and decisions were made on what surgical procedures she could and couldn't do, the hospital administration didn't learn of her illness until recently. The hospital contacted her patients from the past decade to alert them to the situation and offer HIV tests to the children.

Launched debate

The situation launched public debate in Canada, and the Quebec Medical Association has adopted a policy requiring doctors to inform their employer if they are HIVpositive, while protecting the physician's confidentiality. While the United States recognizes just one case of a health care worker infecting patients - a dentist in Florida - a Canadian HIV expert cites HIV transmission by two surgeons in France and Spain who engaged in what is described as exposure-prone procedures.

What happens north of the border can have implications in the United States down the road, and On Call wondered what dermatologists think about whether physicians have a responsibility to inform either their patients or their employers of their HIV status and when such a responsibility kicks in.

The dermatologists express mixed feelings about where the physician's responsibilities lie - the one thing they agree on is that the questions are not easily answered. Several of the doctors also raised the issue of other illnesses that can be more easily transmitted and, yet, can be nearly as devastating to a person's life.

Scott M. Debates, M.D., Omaha, Neb., outlines some of the difficulties that can arise if a physician were to make a positive HIV status public.

'There is a lot of fear in the marketplace. How many patients would go to a doctor if they knew he or she were HIV-positive - even knowing the reality is that the possibility of transmission is so clinically low on the totem pole?

'In general, the medical transmission of HIV is so very low that bringing it up may actually create more of a fearful mind-set than it probably deserves. It's a difficult issue.'

Dr. Debates, a member of a large multi-specialty clinic that is part of the Methodist Hospital System in Omaha, says the situation changes if there is a chance that transmission has occurred.

'I think there's a personal responsibility of a physician who is HIV-positive that if there would be circumstances where there would be a possibility of transmission, then they would not be silent. There is definitely a moral responsibility of the individual to take responsibility for the potential of transmission if that had happened.

'You would hope that would happen and that the person's moral compass is still working because there are medications that can be used early in the disease process that can really help.

'On the other hand, you would hate to cease providing great health care to people who need it because of unfounded fear they're going to contract HIV.'

Up to the physician

In Seattle, Wash., Rachel A. Carton, M.D., says the lack of legal requirements leaves the decision in the physician's hands.

'Ultimately it's up to each individual physician whether they want to disclose it or not - but each physician needs to consider their specialty and their practice type and determine how much they would be putting their patients at risk.

'I wouldn't favor a law requiring disclosure, but people would, or should, probably feel morally or ethically obligated to disclose it.

'I think it would basically end a physician's career - because, honestly, if a physician did disclose this, I wouldn't expect them to get many patients. Talking to co-workers, they knew of physicians who were HIVor hepatitis C-positive who were either given desk jobs, or were let go'

As Dr. Garton mentions hepatitis in the same breath as HIV, Gerald A. Gellin, M.D., in San Francisco, also raises the issue of other contagious conditions.

'I don't think it's important for a doctor to inform a patient of his or her illnesses.

'It has no relevance to the interaction between the patient and physician, possibly with the exception if the doctor has open tuberculosis. This to me would be more of a public health matter - if a doctor has open tuberculosis and is actively providing medical care.'

Even though physicians prefer to know if their patient is HIV positive because of its effect on medical care, Dr. Gellin says that doesn't happen all the time either.

'I've had patients who waited until I was ready to start surgery and then said, 'by the way, Doctor, I have HIV,' because they thought if they told me beforehand, I would not do the operation. So I think there is more risk to the doctor than there is to the patient.'

Other dermatologists weren't quite so certain.

In Cedar City, Utah, Lancing G. Ellsworth, M.D., agrees the issue is very difficult.

'People in high-risk professions for transmitting HIV - and I wouldn't want to be a judge of exactly who that would be; physicians can fit into that category, but not all physicians - should make it known to their patients that they are HIV-positive. I would think a surgeon would fit and possibly some other specialties.'

Dr. Ellsworth, in private practice for five years, says he has to put himself in the patient's position. He also recognizes that HIV isn't the only condition that raises this issue.

'If I were going to have surgery, I would want to know if the surgeon working on me were HIVpositive. I'm not sure I would support laws requiring disclosure, but I ought to know that as a consumer.

'It's a very hot topic. For example, there is a surgeon in our town who is hepatitis positive, and it is the same sort ofthing. And hepatitis is more transmissible than HIV I don't know if he discloses that to his patients or not, but if I were a patient, I would want to know.

'I support disclosure. I don't know that I would support law. I would hope the surgeon would want to disclose that on his or her own.'

Complicating factors

Dr. Carton agrees that other infectious diseases complicate the issue.

'Hepatitis is as big, if not a bigger issue because it's more easily contracted, but it just doesn't seem to push the buttons HIV does.

'It's not quite as controversial for people who don't know, but really it is. There are probably physicians out there with hepatitis C who need to disclose it, but, ultimately, no one is going to be forced to. Ultimately, it's up to the individual physician. They need to seriously consider the risk to the patient.

'They may not be legally obligated, but they should feel ethically obligated,' Dr. Carton says.

In some ways, Jo-David Fine, M.D., of Nashville, Tenn., almost doesn't think there should be any question.

'My assumption would be that any physician who is performing any procedures that could potentially risk infection to the patient should clearly be obligated to inform the patient prior to doing such procedures that he or she is HIV-positive.

'This is something all physicians should think through and act upon his personal views. The issue is primarily whether he or she could put a patient at risk for receiving the virus from the physician.'

Dr. Fine isn't convinced that it would be absolutely necessary to inform the patient if the physician is wearing gloves and there was no potential risk - unless with major surgical procedures - but he says, 'Even an aggressive dermatologie surgical procedure could certainly expose large open areas in the patient, and a tear in the glove could be a problem.'

Dr. Fine, in practice for 21 years and a professor at Vanderbilt University specializing in blistering diseases, says he can only speak for himself.

'Patients should be informed - that's how I practice. I would rather have 98 percent of my patients walk away from my door if they had concerns than mislead them.

'I can't imagine practicing dermatology without doing biopsies and I guess there's always a theoretical risk that there could be a puncture in my glove. I'd hate to have patients concerned about that. I think I would have to stop doing procedures if anything like that were ever to happen to me.'

Other issues

Other issues enter the picture when the discussion moves to whether physicians would owe it to their employer to disclose an HIV-positive status. The Canadian hospital did decide to track down former patients when the physician's HIV status was discovered. What is the physician's responsibility there? Where does that leave the employer?

Dr. Carton says, 'Physicians probably wouldn't last too long if they disclosed a positive HIV status to their employer, but I guess I think they should - again, just more for patient safety.

'You want people to have their privacy, and their medical condition should not be known. The chance of infecting patients probably isn't very high, but you would probably be opening yourself up and your employer to lawsuits.

'The problem is this extends even to conditions that aren't contagious. What if a person is in the beginning stages of Parkinson's? Should they operate?'

Dr. Debates says the issue of informing an employer is really wide open.

'I don't know anyone's status now, so we may have hired someone who was HIV- positive. I guess with everybody being careful and everybody taking the appropriate measures they're supposed to be taking, you hope to reduce the risk enough that it does not matter. I don't think employers are even allowed to ask that.

'I do wonder if the hospital didn't go overboard in tracking down the patients when there was no indication the disease was transmitted to anyone.'

Physician privacy

Dr. Gellin, a practitioner of 41 years and clinical professor at the University of California, San Francisco, says his patients have ranged from 2 weeks old to 107 years. He thinks that the physician's health status is his or her own business.

'Due to privacy matters, I think it is not necessary or incumbent upon the doctor to tell his employer what diseases he has that have no relevance in the provision of patient care.

'Presumably the employer is not supposed to find out about the illnesses of employees. If the employee voluntarily tells the employer, that is the employee's right to do, voluntarily. The employer is not to ask these specific questions, although I'm not sure much attention is paid to that in too many cases. Privacy takes precedence.'

Dr. Ellsworth agrees with that to some extent.

'I don't think the physician has to disclose that information to their employer, although it still may depend on whether it is a high risk occupation. And I still don't know how you would define high risk. The doctors should also take into consideration that they could be leaving their employer open to liability if they aren't informed.'

Dr. Fine points out that in many cases state medical boards and hospital boards would have policies on disclosure - and when it comes to patient safety, he would have to say that privacy was not the major issue.

'I would think it should be necessary to tell an employer only in situations where physicians could, in any way, put patients at risk for acquiring the disease. It would also depend on the rules of the institution in which the individual works - or the state guidelines of an individual state medical board. My impression from getting licenses in so many states over the years is that state licensing boards all have very rigid policies. If they don't require disclosure then I wouldn't think a physician would have to disclose the information.

'Since I try to adhere to the traditional philosophy of'first do no harm,' I personally believe that patient safety should take precedence over concerns of invasion of a physicians' own privacy. I would want to do nothing (by lack of disclosure) that might negatively impact the relationships I try to foster with my own patients.

'And I would obviously adhere strictly to any written guidelines prescribed by my state licensing board, the state health department, the Centers for Disease Control, or any other appropriate health-related agency.'

[Sidebar]

Karen Nash

What happens north of the border can have implications in the U.S. down the road.

[Sidebar]

'In general, the medical transmission of HIV is so very low that bringing it up may actually create more of a fearful mind-set than it probably deserves. It's a difficult issue.'

- Scott M. Debates, M.D., Omaha, Neb.

[Sidebar]

'The problem is this extends even to conditions that aren't contagious. What if a person is in the beginning stages of Parkinson's? Should they operate?'

Rachel A. Carton, M.D., Seattle, Wash.

[Author Affiliation]

REGIONAL NEWS: MIDWEST.(includes information on various hospitals' operations) - Modern Healthcare

KANSAS CITY, Kan.-The University of Kansas Hospital Authority has received an underlying A rating on $55.5 million of debt set to be issued the week of Sept. 20. Fitch IBCA, a New York-based credit rating agency, assigned the rating based on the hospital's strong debt service coverage, low debt burden and excellent clinical reputation. It also expressed confidence the university hospital will be able to compete more effectively in its marketplace as a result of its separation from the state of Kansas. As of Oct. 1, 1998, the hospital went off the state budget and became an independent organization with its own board of directors (Oct. 5, 1998, p. 24). Fitch expects the public authority status to allow the hospital more management flexibility, easier access to capital and better options for finding business partners. Under such conditions, the hospital's 5% operating margin should improve, according to Fitch. University of Kansas Hospital has 620 licensed beds and 411 staffed beds. The bond issue will be used to finance capital expenditures, refinance bank debt, reimburse previous capital expenses, refinance leases and establish a debt-service reserve fund.

WORTHINGTON, Ohio-Ohio State University Medical Center has approved a merger with 24-bed Harding Hospital, a behavioral health hospital in Worthington. OSU and Harding have operated jointly since January 1996, when Columbus-based OSU acquired an equity stake in Harding. OSU's equity reached 50% last year. The merger is expected to be completed by December. George Harding IV, M.D., grandson of the hospital's founder, will continue to have a seat on the OSU/Harding Hospital board.

MADISON, Wis.-Wisconsin's 24 HMOs lost more than $18.6 million during the first half of the year ended June 30, according to a new report from the state insurance commissioner. The HMOs collected $1.5 billion in total revenues during that same period. HMO performance has declined dramatically when compared with the same two quarters a year ago. During the first half of 1998, the state's HMOs earned $676,000 on total revenues of $1.3 billion, according to state figures.

CHICAGO-HMO enrollment in Illinois grew 3.8% last year, according to a new report on the Illinois healthcare market. Last year's slower growth comes after double-digit increases in HMO enrollment in 1995 and 1996, according to the report by Allan Baumgarten, a Minneapolis-based healthcare analyst who studies managed-care trends in seven states. HMO enrollment grew by 4.8% in 1997. In Illinois, about 2.4 million residents-just less than 20% of the state's population-are enrolled in an HMO.

OMAHA, Neb.-Two-hospital Nebraska Health System and two-hospital Nebraska Methodist Health System, both of Omaha, will merge their mental health services into a single facility. The agreement, which was signed Sept. 8, provides for shared ownership of an inpatient facility, 121-bed Richard Young Center, formerly called Methodist Richard Young. Comprehensive psychiatric services will be housed in three Nebraska Methodist-owned buildings to be renovated with $4 million provided equally by both systems. Sandra Carson is president and chief executive officer of Richard Young. University of Nebraska Medical Center will use Richard Young as a teaching facility. Governance will be through an eight-member board, with three members each from Nebraska Health and Nebraska Methodist, and two nonvoting members from UNMC.

Fees push managed accounts off 401(k) default lists; Plan sponsors are concerned about their fiduciary responsibility.(News) - Investment News

Byline: Jenna Gottlieb

Managed accounts aren't popular default options in 401(k) plans, because fees are too high for plan executives to justify, leaving them concerned about fulfilling their fiduciary responsibility, experts say.

The Pension Protection Act of 2006 encouraged plan sponsors to enroll employees automatically in 401(k) plans.

In October, the Department of Labor said managed accounts - along with target date and balanced funds - are qualified default investment alternatives.

Some industry experts are concerned that plan executives may be subject to litigation to explain additional fees that managed accounts charge.

'Managed-account providers should be worried, and plan sponsors should be concerned,'' said Richard Glass, president of Investment Horizons Inc., a Pittsburgh defined contribution communications company.

'The majority of target date fund providers keep fees in the [0.5% to 0.7%] range, but with managed accounts, how can they justify all the additional fees?'' he said.

Managed-account fees can run as high as 1% of assets.

Litigation concerns

How a fiduciary is defined has been turned on its head since the first round of 401(k) fee lawsuits was filed in September 2006, said Mr. Glass.

Some executives think that adding managed accounts as a default option could leave them open to litigation over excessive fees.

Historically, plan executives have fulfilled their fiduciary duties by selecting the providers that have offered the best service at competitive fees, Mr. Glass said.

But that has changed, he said, because of the heightened litigation environment.

Many plan sponsors are turned off by higher managed-account fees, preferring the lower fees for target date funds, said Lori Lucas, Chicago-based DC practice leader for Callan Associates Inc. of San Francisco.

'Plan executives, in this fee environment, want to be careful. I'm not saying managed accounts don't fit for some plans, but many don't like them as a default,'' she said.

Several Callan clients have added managed accounts as a stand-alone option in their 401(k) plans, but not many have used them as default options, Ms. Lucas said.

'We see a lot of them come to us and ask about managed accounts as just one option, not the default. We're seeing more of that,'' Ms. Lucas said.

Many 401(k) plan executives are apprehensive about managed-account fees, said Mike Francis, president of Francis Investment Counsel in Pewaukee, Wis.

'I think many plan [executives] see target date funds as the less expensive option, and picking the right default does have something to do with what kind of plan you have,'' he said.

'It's a lot different if you are talking about a law firm,'' where employees tend to make more money, than a manufacturer, where employees tend to make less, Mr. Francis said.

Managed accounts are a valid investment option, but offering them as a default could be problematic, Mr. Glass said.

'If an employee earns $30,000 a year and he's defaulted into a managed-account structure and stays there, how can the sponsor justify that?'' he asked.

Managed accounts make more sense for highly compensated employees with larger balances.

The Nebraska Methodist Health System in Omaha opted for target date options as the default for automatically enrolled 401(k) participants in its $200 million 401(k) plan. Plan executives considered using managed accounts as the default option but decided that they didn't make sense for the bulk of members of their work force.

Ryan Husing, director of employee benefits, said target date funds are a safer, more obvious default option than managed accounts. 'We feel that participants get the best value with target date [funds]. It was an easy decision for us,'' Mr. Husing said.

Some plan executives think that managed accounts make sense as an option but not as a default.

William F. Quinn, chairman of American Beacon Advisors of Fort Worth, Texas, which oversees American Airlines' $12.1 billion 401(k) plan, said the plan in January added managed accounts provided by Financial Engines Inc. of Palo Alto, Calif.

American is using them as an option but not as the default because managed accounts make sense for employees with higher balances, which can offset fees.

One plan that uses managed accounts as its default option is the $255 million 401(k) plan of Standard Register Co. in Dayton, Ohio. The company uses Financial Engines too.

Richard Mayer, director of benefits, said managed accounts are a great way for less financially savvy investors to manage their retirement assets. He declined to comment further.

Managed-account providers, for the most part, aren't concerned.

Financial Engines and Chicago-based ProManage Inc., two of the largest managed-account providers, have very different fee structures.

`very competitive'

Christopher Jones, executive vice president of investment management and chief investment officer at Financial Engines, said that the firm's average managed-account fee is about 0.6%.

'To say that managed accounts are more expensive than target date funds is not quite fair,'' he said.

'Depending on how they are set, [fees] can range from [0.35% to 0.6%],'' Mr. Jones said. 'I can't speak about other [managed-account] providers, but we are very competitive with target date funds.''

Financial Engines has 10 default-plan clients where employees could opt out if they choose.

'Fees are a very significant issue with 401(k) plans in general. We recognize that sponsors are fee-sensitive,'' Mr. Jones said.

'We take advantage of institutionally priced investments. With life cycle funds, the fees are bundled,'' Mr. Jones said.

'In the managed-account world, you see all the underlying fees.''

Tony Sabos, president of ProManage, said the firm's fees of up to 0.6% are very competitive with target date funds. And the safe harbor provided in the QDIA regulations ease the concerns of plan sponsors.

CAPTION(S):

Hearts and Minds - Healthcare Informatics

When it comes to automating workflow and image management for cardiology, CIOs are finding radiology was a piece of cake.

Cindy Eggert, vice president of information systems and CIO at Good Samaritan Hospital in Los Angeles, knew it would be a challenge to bring state-of-the-art cardiology PACS to the 408bed academic medical center. However, as the volume of cardiologie studies continued to climb, Eggert knew it was a challenge she had to tackle.

For one thing, says Eggert, who has been CIO for over 10 years at the hospital, it had become clear that both cardiologists and radiologists at Good Samaritan needed IT upgrading at the same time. The hospital's radiology department was still film-based in radiology in early 2007, a fact that Eggert acknowledges was both unusual for an urban, academic hospital, and also spoke to the overall focus on cardiology - for several years cardiologists had been working with a standalone electronic imaging system.

Radiology PACS went live in August 2007, while cardiology, echocardiography, and cardiac ultrasound were up with PACS in February of this year. Additionally, in May, the cardiac catheterization lab also went live with the hospital's new system.

For both cardiology and radiology, Good Samaritan is using Alpharetta, Ga.-based McKesson Corporation. Going with a single vendor is the realistic way to achieve a level of interoperability at this point in vendor development, Eggert says.

The results have been highly successful already, Eggert says, with cardiologists, as well as radiologists, expressing strong faction with the ability to share images, data, and communications across specialties. What's more, the developments fit into a strategic approach that calls for creating an enterprise-wide image management system. Eggert and her colleagues are also about to launch a physician portal to facilitate access to images and data, and inter-clinician communication.

Nationwide, diff�rent approaches

Industry experts say that planning and implementing cardiology PACS is turning out to be more of a challenge than anyone had anticipated.

'I think the biggest issue is that cardiology is much more complex than radiology,' says Joseph Marion, principal at Healthcare Integration Strategies, a Waukesha, Wis.-based consulting firm, and an HCI blogger (www. healthcare-informatics.com/joe_marion). 'That's the primary issue: there are just a lot more data elements to integrate. As a result, they're playing catch-up to radiology in terms of the standardization necessary to integrate all the elements.'

The reality, he adds, is that hospital organizations are turning to single vendors for cardiology image management, as interoperability remains a problem due to insufficient communications standards.

'Cardiology PACS' evolution has paralleled the evolution of radiology PACS, but has always been behind,' notes Joe Biegel, vice president, product management, for the Medical Imaging Group at McKesson. One very basic reason for the lag in cardiology is the diverse medical technologies, outputs, and clinical workflows involved in the sphere, which encompasses echocardiography, electrocardiography, cardiac catheterization, and angiography/hemodynamic monitoring.

With different medical technologies creating different kinds of outputs, the technological environment in cardiology is far more complex than radiology, Biegel stresses. Therefore, he says, it's not surprising that patient care organizations have difficulty automating workflow processes, image viewing, and imageand data-sharing.

At the moment, 'the workflow in hospitals has been shifting from very analog to partially digital, and towards digital,' Biegel continues. But is it the ongoing surge in cardiology volume that is driving the development of cardiology imaging systems?

Indeed, says Robert Tkachyk, a Cleveland-based staff consultant at CSC Corporation (Falls Church, Va.), it is cardiologists themselves who are aggressively pushing CIOs to implement image management systems, as they try to keep up with an increasing volume of activity. Inevitably, individual cardiologists run into bandwidth problems, particularly if they are trying to access images online. 'The images in cardiology can be so large that transmitting them reliably over a network can be a very, very significant challenge,' he says.

So far, he says, the most advanced hospital organizations 'have probably partnered with a vendor and come up with a combination cardiology PACS and a cardiology information system that they may even have worked with the vendor to develop.' Not surprisingly, he notes, the cardiology information systems, analogous to the radiology information systems (RIS), lag behind the needs of today's cardiologists.

Progress in Omaha and Cleveland

At the six-hospital Nebraska Methodist Health System in Omaha, Senior Vice President and CIO Roger Hertz notes, 'We've had a strategy of integration since the onset of our journey into the EMR back into the mid-1990s.' For Hertz and his colleague Shawn Wiese, Nebraska Methodist's applications development manager, moving forward on cardiology PACS has been a natural fit with their overall strategy. Methodist Health went live in midJanuary with PowerChart ECG, from the Kansas City, Mo.-based Cerner Corporation, in two hospitals, 'pushed by the sunsetting of the legacy system we had had,' Wiese notes. Previously, the hospital system had had a standalone ECG product that 'required techs to print everything out - it was really only semi-automated, very inefficient,' he recalls.

Hertz and Wiese feel the same way that Eggert and her colleagues do at Good Samaritan. For them, it was only natural that they should move forward with cardiology PACS development, given the importance of cardiovascular services to the Nebraska Methodist's bottom line. 'Cardiology seems to be the natural follow-on to radiology,' Wiese reflects. 'And that department is similar to radiology in that you've got a number of different medical devices, and the vendors have positioned themselves to support DICOM compliance. So it makes sense to follow on in that area; and in terms of reimbursement, it makes sense.'

At the Cleveland Clinic Health System in northern Ohio, implementing cardiology PACS while staying focused on overall integration and interoperability has been vital, says Robert Cecil, Ph.D., network director, cardiology and radiology. In fact, says Cecil, 'We negotiated for almost two years to get the right terms and conditions from our vendor,' the Malvern, Pa.-based Siemens Medical Solutions (Cleveland Clinic has been collaborating on radiology PACS development with Siemens for some time). Cecil and his colleagues have implemented cardiology PACS - they went live at the system's main facility this spring, while piloting the technology at a subsidiary hospital last summer.

Cecil notes that, in addition to the technological differences, there is a strong political dimension to cardiology PACS implementation that CIOs dare not ignore. 'Radiology has always been perceived as a service organization,' he notes. 'Radiologists service other physicians. And if you were to go into a thirdparty hospital and take over radiology, there might be some grumblings, but you wouldn't be perceived as taking over the whole hospital. That's not true of cardiology. So politically, cardio-PACS is much dicier than going enterprise-wide with radiology. There are very few single private-practice radiologists, but there are a lot of privatepractice cardiologists, and they don't want to share information.'

Indeed, when asked what the key success factors have been in the implementation at Good Samaritan, CIO Eggert says that three stand out clearly. 'First, you must have physician champions in each subspecialty,' she says firmly. 'It wouldn't have mattered if I'd had the CEO, CMO, or CNO on my side. But we had excellent physician champions in every area.' Second, she says, implementing cardiology PACS relies on having strong cardiology technologists in every sub-area, who really understand 'what each machine is supposed to do, and what images are supposed to look like as you move towards storage.' Finally, she says, 'You need really strong project management,' given the extent to which such areas as the cardiac cath lab are constantly handling emergency patients.

In the end, says, Eggert, a combination of volume increases and storage needs, and clinician demands, will compel cardiology PACS to move forward nationwide. 'There will be a push to bring it into a more consolidated environment rather than standalones. It will be slow-going,' she adds, 'but it will get there. I wouldn't have said 10 years ago that I'd be seeing what I am now,' she concludes.

CONTINUE THE CONVERSATION

Contract Award: Nebraska Methodist Hospital Wins Federal Contract for Medical Services - US Fed News Service, Including US State News

WASHINGTON, Feb. 1 -- VA Nebraska Western Iowa Health Care System (Omaha Division) (Department of Veterans Affairs), Department of Veterans Affairs Nebraska Western Iowa Health Care System, has awarded a $59,200.00 federal contract on Jan. 26 for medical services.

Contractor Awardee: Nebraska Methodist Hospital, 717 N 190th Plz, Ste. 2500, Elkhorn, NE 680223987 For any query with respect to this article or any other content requirement, please contact Editor at htsyndication@hindustantimes.com

REGIONAL NEWS: MIDWEST. - Modern Healthcare

SUPERIOR, Wis.-A new Duluth clinic will replace two existing clinics on the campus of 42-bed St. Mary's Hospital of Superior. The $13.2 million facility will be called Duluth Clinic-Superior. The clinic and hospital are part of the Duluth, Minn.-based St. Mary's/Duluth Clinic Health System. The new clinic also will house a pharmacy and optical shop.

Disability law may cover gene flaws.(protection for those predisposed to ailments)(Brief Article) - Science News

A recent Supreme Court ruling has fostered a fledgling legal strategy that could protect people from discrimination based on their genes. The ruling suggests that the power of the Americans with Disabilities Act (ADA) might extend to people who are genetically predisposed to disease--before they fall ill.

As researchers identify genes associated with diseases such as breast cancer, colon cancer, or Huntington's disease, the danger arises that employers or insurance companies could discriminate against people who carry genetic defects. No federal law specifically protects people from genetic discrimination. 'It's about all of us, folks,' said Francis S. Collins, director of the National Human Genome Research Institute in Bethesda, Md. 'We're all at risk for something.'

Lawyers, scientists, genetic counselors, advocates for the disabled, and congressional staffers met Feb. 19 in Washington, D.C., to brainstorm about legal protections for people who carry identified genetic risk factors. The conference, sponsored by Collins' institute and the National Action Plan on Breast Cancer of the Public Health Service, focused on last year's Supreme Court case Bragdon v. Abbott.

In that ruling, an HIV-positive plaintiff was found to be protected under the ADA even though she had not developed any symptoms of AIDS. The woman sued her dentist after he refused to fill her cavity. The ADA defines as disabled, and therefore protected under the act, any person who is limited in a 'major life activity.' The plaintiff argued that she met this criterion because, after learning that she carried the AIDS virus, she decided not to have children. The court agreed, in a 5-4 decision.

Bragdon v. Abbott demonstrated that the ADA can extend to people who may, sometime in the future, develop a disease. Because it rested on the plaintiff's decision not to have children, however, a strict interpretation of that ruling would not protect people whose reproductive choices are unaffected by their genetic risk factors, said Paul Miller, commissioner of the Equal Employment Opportunity Commission in Washington, D.C. 'The broader question is whether the ADA protects against discrimination on the basis of diagnosed but asymptomatic genetic conditions--those that have the potential to limit major life activities,' said Miller. The ADA should apply in such cases, he said.

Whether it will is an open question. The commission would vigorously support a test case, Miller said, and might use a legal strategy that does not rely on major life activities. The ADA also protects people who are 'regarded as' disabled, he pointed out. Arguably, someone denied a promotion because of a genetic risk factor would be regarded as disabled by the employer and therefore covered under the ADA.

Ideally, identifying genetic risks for disease should help tailor health care to individuals, said genetic counselor Jill Stopfer of the University of Pennsylvania Cancer Center in Philadelphia. For example, women with mutations in the genes BRCA1 or BRCA2 have a heightened risk of developing breast and/or ovarian cancer. Such women may choose to have frequent mammograms, take anticancer drugs such as tamoxifen, or undergo prophylactic removal of cancer-prone tissue, says Stopfer.

Fear of discrimination, however, deters some women from being tested, said attorney Kathy Zeitz of the Nebraska Methodist Health System in Omaha. Her daughter, who has a family history of breast cancer, refuses to undergo genetic screening for fear that she may someday be denied health insurance.

Tiny Hospital Has Big I.T. Agenda; How one rural hospital is using technology to survive and thrive.(Feature) - Health Data Management

Byline: Howard J. Anderson, Executive Editor

RED OAK, Iowa-While the nation's giant integrated delivery systems and academic medical centers grab the headlines, staff members at hundreds of small, rural hospitals are quietly making tangible progress in making the most of information technology.

Nestled in the rolling hills of southwestern Iowa, Montgomery County Memorial Hospital is among those making I.T. inroads. After implementing numerous clinical applications, the hospital is bringing electronic health records to the physician practices it owns.

Why is the 25-bed critical access hospital investing so heavily in I.T.? A big reason, says CEO Allen Pohren, is to build loyalty among physicians, especially 18 specialists from the Omaha area who visit the hospital in Red Oak about once a week. 'Patients don't just come running into the hospital and jump into bed,' Pohren says. 'You've got to have physicians to admit them.'

Pohren, who has been with the hospital nearly 37 years, remembers the day when he acquired the facility's first computer to help with payroll and receivables. Today, the hospital has a nine-person I.T. staff led by CIO Ron Kloewer.

Here's just one example of how far the rural hospital has come in its use of I.T.: One area neurologist who splits his time between Pakistan and Iowa can access data on patients while he's out of the country, thanks to the hospital's portal. 'I never thought I'd see the day that would happen,' Pohren confesses.

The small-town hospital CEO views I.T. as an essential tool for improving patient safety as well as staff efficiency. 'If we did not have I.T., we would be doing so much stuff manually that we'd have a lot more employees around here,' he says.

Help from Uncle Sam?

Pohren is optimistic that the hospital and the physician practices it owns will qualify for electronic health records financial incentives under the federal stimulus program.

The hospital, now ranked 3.2 on HIMSS Analytic's seven-point scale for clinical automation, likely will have to advance to a ranking of 4.0 to qualify for maximum incentives, predicts Kloewer, the CIO. HIMSS Analytics is the research arm of the Chicago-based Healthcare Information and Management Systems Society.

To achieve that ranking, the hospital, which already enables nurses to document care online, will add physician documentation as well as computerized physician order entry. Also on the horizon is an electronic medication reconciliation system, including bar coding.

For more than a decade, Montgomery County Memorial Hospital has been phasing in various components of clinical and financial systems from Keane Inc., Boston. Soon it will upgrade its clinical system to Keane's latest Optimum release.

Clinicians can sign on via an intranet to access nursing notes, test results and more. 'I do 90% of my documentation online,' says Teresa Jennings, R.N., a nurse manager. 'I don't have to go through all the old paper records trying to find information.'

Hundreds of documents, including physicians' transcribed notes, are scanned into the electronic record. But nurses have yet to automate their care plans, which they still update daily on paper, Jennings laments. The clinical system's care plan functions proved too cumbersome to use, the nurse manager says. 'To put in the things that we wanted was very difficult. You had to go from screen to screen to screen to pull things together. There were too many steps. Our paper care plan is very easy.'

Once the hospital upgrades to the next-generation clinical system, however, nurse care plans will be automated, Kloewer notes.

A key factor in helping older nurses get used to computers, Jennings says, was the training that three nurses who work in the I.T. department provided. 'Those nurses have all worked on the floors before, so all the older nurses knew them,' she says. 'Our younger nurses caught on very, very quickly, and they also helped out with Athe training.'

Nurses usually retrieve medications for patients using one of four automated medication cabinets from Pyxis, now a unit of CareFusion Corp., San Diego. The cabinets are useful because the hospital only staffs its small pharmacy for the daytime shift, Kloewer explains.

Low Turnover

Unlike some smaller hospitals, Montgomery County Memorial has yet to experience a nursing shortage, Jennings says. The nurse manager says the newer building, equipped with the latest in diagnostic equipment, has helped keep turnover among its staff of 90 nurses low.

The hospital has a CT scanner, digital mammography, and digital X-ray equipment, eliminating the need for a film processing and storage room. Area residents also gain access to MRIs when a mobile unit comes to the hospital three days each week.

In recent years, the hospital has acquired local physician practices with four doctors. Their offices are adjacent to the hospital, along with a five-physician practice affiliated with Methodist Health System in Omaha.

Two years ago, the practice owned by Methodist rolled out Practice Partner electronic health record and practice management software from McKesson Inc., San Francisco. Now, the practice is outsourcing the hosting and maintenance of the applications to the hospital's I.T. team.

Next up, the hospital will help its owned practices implement Practice Partner, eventually enabling all the doctors on campus to share their clinical data. They already can access all hospital data from any location via a virtual private network.

The Methodist practice learned some important lessons in moving to an EHR, including the need for a physician champion. In fact, the practice had two physicians, Warren Hayes, M.D., and William Artherholt, D.O., leading the way.

'Dr. Hayes is the technical champion who understands it all,' Artherholt says. 'He was the point person to bring us to the next step and the next step. I was the visionary champion who kept us going and pushed us in this direction.'

Hayes acknowledges that the first few weeks using EHR software proved difficult until physicians learned how to navigate through point-and-click templates, occasionally typing in additional notes. Today, only one of the five doctors still relies on dictation and transcription.

'An EHR is a necessary evil,' Hayes says. 'I wouldn't go back to paper. My desk is messy enough. Documentation has improved immensely as has our access to information.'

Over the long haul, Hayes is hopeful that all the doctors who practice on the hospital's campus will conduct some meaningful outcomes research fueled by data in the outpatient and inpatient records systems. For example, the physicians could research local asthma cases to determine if there are patterns that could pinpoint causes, such as chemical sprays used by farmers.

Physicians at the Methodist practice primarily use tablet computers from Hewlett-Packard Co., Palo Alto, Calif. Some nurses use laptops mounted on computer carts. Frustrated by the high costs of carts, Hayes took it upon himself to construct two low-budget models from household PCV pipes. On one recent day, a nurse was using one of the homemade carts while a high-tech cart nearby stood idle.

At the hospital, physicians and nurses primarily use thin client devices from Wyse Technology, San Jose, Calif., located mainly at nurses' stations. Some also use laptops mounted on carts and linked to a wireless network. The HP laptops serve as the equivalent of a thin client, with all applications residing exclusively on servers, Kloewer explains.

'Thin clients allowed us a lower total cost of ownership,' the CIO says. 'Chasing around to manage desktops is labor-intensive.'

The hospital originally paired the thin clients with application delivery technology from Citrix Systems Inc., Fort Lauderdale, Fla. But it eventually shifted from Citrix to Microsoft Terminal Server software, which Kloewer determined would be less costly yet efficient.

When it installs new servers, such as to support the new outpatient EHR, the hospital is primarily using blade servers from HP paired with virtualization software from Microsoft rather than more costly conventional servers.

The hospital is about half-way through construction of a $15.6 million addition for an expanded emergency department and outpatient facilities.

The addition also will house a new data center, which will consolidate equipment now located in four sites around the campus that will be converted to wiring closets. The hospital will rely on two backup data centers provided by a local telephone company once the new data center is complete. For now, it simply backs up data to tapes stored offsite.

To hold down the cost of a new phone system, the hospital bought used equipment from a former Maytag plant in Iowa that shut down.

For Montgomery County Memorial Hospital, the quest to improve efficiency through automation will continue for decades to come. Kloewer, for example, that eventually specialists in Omaha could remotely manipulate surgical robots at the hospital in Red Oak.

'Once you get into I.T., it's never-ending,' says Pohren, the CEO.

From the I.T. Mission Statement:

'Health care delivery is continually improved by using information systems that are increasingly integrated, accessible, complete and secure. Patient safety, information security, financial viability and improved productivity are further gains with the effective and wise use of these technologies for which the entire staff at MCMH plays a vital role.'

Montgomery County Memorial Hospital

Red Oak, Iowa

* 25-bed critical access facility with nine observation beds

* Independent government entity with publicly elected board and property tax support

* Owns the practices of four physicians

* Employs 300; largest employer in town of 6,000

* 60% of patients on Medicare

* $24 million in estimated net patient revenue for fiscal 2009; $825,000 in estimated net income

* $1.3 million I.T. budget for fiscal 2010

* Rated 3.2 on an automation scale of 1 to 7 by HIMSS Analytics