Jane Anderson

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

Hospitals likely will see a large influx of new patients as health care reform goes into effect, and should implement measures to streamline patient flow to accommodate those new patients without the need for additional beds, according to an expert in health care efficiency.

With efficient management, U.S. hospitals should be able to achieve at least an 80%-90% bed occupancy rate – at least 15% higher than the current average – without the need to add beds, which costs around $1 million per bed, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization in Newton, Mass.

To achieve that level of efficiency, hospitals need to manage elective admissions, Mr. Litvak said in an interview. "We analyzed well over 100 hospitals around the world, and elective admissions are more variable and less predictable than arrivals to the emergency room," he said.

Mr. Litvak and Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass., coauthored an article in Health Affairs (2011;30:76-80) laying out a blueprint for increasing hospital efficiency to meet the increased patient needs created by health care reform.

According to Mr. Litvak, the vast majority of admissions to the hospital come either from elective admissions or from the emergency department. Perhaps surprisingly, almost all of the volatility stems from elective admissions, not from emergency admissions, he said, adding, "when you have a peak in elective surgery, they take over the beds," causing a logjam in the emergency department.

If a hospital is well managed, hospital bed occupancy fluctuates about 10% or 15% between its highs and its lows, Mr. Litvak said. If a hospital is poorly managed, however, it can fluctuate as much as 80% from its highs to its lows, he said.

Extreme deviations in bed occupancy can cause medical errors, as nurses become short-staffed and overworked during times of vastly increased occupancy, Mr. Litvak said. Patient satisfaction and staff satisfaction also suffer, he said.

To better manage hospital bed occupancy, Mr. Litvak suggested several steps. First, he said, hospitals should create separate rooms for scheduled and unscheduled surgery. This enables the institution to determine how many operating groups are needed without being overstaffed.

Next, surgeons from different specialties should be asked as groups to perform similar numbers of surgeries each day, Mr. Litvak said. For example, one orthopedic surgeon could perform several surgeries in one day while a colleague might have a light surgical day; the next day, those two – or others in the same specialty – might switch off, he said. Once the surgery schedule has been "smoothed," the hospital can determine with some accuracy how many beds are needed on the floor, Mr. Litvak said.

"What happens when you smooth those peaks?" he asked. "You can afford a much higher census without hitting the ceiling" and producing overcrowding.

These techniques can provide a 5% increase or greater in surgical volume while reducing operating room staff overtime by 50%, he said.

At Cincinnati Children’s Hospital, where Mr. Litvak helped to implement this system, the hospital had an average census of 76% prior to the changes. "Compared to the U.S. average, they’re in pretty good shape," he said.

But after the "smoothing" of the surgical schedule, the hospital has an average census of 91% – "and they’re not overcrowded," Mr. Litvak said. "If you know the average length of stay and number of surgeries, you can go well above 95%."

Following the changes, surgical volume at Cincinnati Children’s Hospital Medical Center rose by 7% annually for at least 2 years, with no increase in staff, according to Mr. Litvak, who also said the hospital expects to generate $137 annually in additional revenue as a result of the higher patient throughput, and has realized savings of $100 million in avoided capital costs. Quality of care also improved, he added.

Other hospitals have seen improvements using similar systems, he said. For example, after Palmetto Richland Hospital in Columbia, S.C., started performing scheduled and emergency surgeries in different operating rooms, surgical volume increased 3% and weekday waiting times for nonelective surgeries decreased 38%. In addition, "anticipated efficiencies could add $8 million to its annual margin while improving services to patients," Mr. Litvak and Ms. Bisognano wrote in Health Affairs.

If the 5,700 hospitals in the United States achieved just 10% of the financial improvement that Cincinnati Children’s Hospital achieved, they would save $57 billion in avoided capital costs, the authors wrote. Assuming that the currently uninsured population will have hospitalization rates similar to the rates of the insured population, an increase in average hospital bed occupancy from 65% to more than 80% would be enough to provide hospital care for 40 million Americans who currently lack health insurance, they wrote.

Mr. Litvak said these strategies can help hospitals cope with the anticipated influx of newly insured patients without needing to expand. "There is no need to build those beds if you’ll only address these issues," he said, adding, "there’s absolutely no way you can cover the uninsured without doing this."

States Boost Medicaid Rolls

The Department of Health and Human Services has awarded $206 million to 15 states for enrolling more uninsured children in Medicaid. Last year, the Children's Health Insurance Program Reauthorization bonuses totaled just $75 million to 10 states. To qualify, states must have adopted specific program features known to encourage Medicaid enrollment and retention and then document increases significantly beyond what would have been expected. States qualifying this year are Alabama, Alaska, Colorado, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, New Jersey, New Mexico, Ohio, Oregon, Washington, and Wisconsin.

Less Fluoride Recommended

The Environmental Protection Agency and HHS have joined forces to lower the amount of fluoride in drinking water. Americans don't need as much from that source because they have others – from toothpaste to regular dentists' treatment – than weren't available when public water fluoridation was introduced decades ago. The two agencies announced in the Federal Register that they want to replace the currently recommended range of water fluoridation, 0.7-1.2 mg/L, to a single target of 0.7 mg/L. The action will leave enough fluoride in the water supply to prevent tooth decay but protect children's teeth from dental fluorosis. The announcement said that the HHS expects to finalize the proposed change this spring, based on the EPA's assessment of fluoridation needs.

Combination Vaccines Avoided

One in five pediatricians reported that inadequate reimbursement prevented them from using at least one of two combination vaccines studied, according to the RAND Corporation. The study looked at infant vaccines – the diphtheria and tetanus toxoids and acellular pertussis, hepatitis B virus and inactivated poliovirus (DTaP-HepB-IPV) vaccine and the DTaP, IPV, and Haemophilus influenzae type b (DTaP-IPV/Hib) vaccine. Although 78% of the 492 pediatricians surveyed said they used one or both of the combination vaccines, more than half said their practice did not receive adequate reimbursement for vaccines in general. More than one-fifth said they didn't use one of the combination vaccines either because of inadequate reimbursement for doses or for administration. Smaller practices were less likely to use the combination vaccines, as were those with fewer publicly insured patients and those in a state with a less generous vaccine-financing policy, the study said.

Grant Will Fund Residencies

The Josiah Macy Jr. Foundation has awarded $500,000 to the American Academy of Pediatrics for pediatric residency training initiatives to improve care for underserved children. The two organizations said the grant will support pediatric residency programs that teach community health and advocacy, train future leaders, enhance future pediatricians' involvement in caring for underserved populations, build community partnerships, and use technology effectively. “It is clear that skills and involvement for pediatricians in community pediatrics focused on improving the health of underserved children are desired and achievable, but more work needs to be done in order to provide effective training,” said AAP President Dr. O. Marion Burton.

Food for Kids Found Wanting

Tests showed that 49 out of 58 supposedly healthy foods commonly marketed to children failed to meet at least one “healthy” standard, according to a study from the Prevention Institute. Food manufacturers increasingly use nutritional claims on the front of food packages to tout the foods as healthier choices. However, almost all the foods contained added sugar, and more than half qualified as high sugar, according to the institute's analysis. In addition, more than half were low in fiber and contained no fruit or vegetable. About one-fourth of the prepared foods contained too much saturated fat, and one-third contained too much sodium, according to the study. Foods evaluated included staples such as Campbell's Tomato Soup, Skippy Super Chunk Peanut Butter, and Rice Krispies.

FDA Seeks Pediatric Devices

The Food and Drug Administration is inviting grant proposals from nonprofit organizations to facilitate the development, production, and distribution of pediatric medical devices. “There currently exists a great need for medical devices designed specifically with children in mind,” the agency said in its announcement. The grants, which will be issued by the agency's Office of Orphan Products Development, will go to “consortia whose business model and approach to device development will either result in, or substantially contribute to, market approval of medical devices designed specifically for use in children.” However, the program won't support single-device projects, the agency said. Although the grant program is administered by the orphan products development office, it's intended to encompass devices for all conditions, not just rare diseases, the FDA said. Grant applications are due May 2.

States Boost Medicaid Rolls

The Department of Health and Human Services has awarded $206 million to 15 states for enrolling more uninsured children in Medicaid. Last year, the Children's Health Insurance Program Reauthorization bonuses totaled just $75 million to 10 states. To qualify, states must have adopted specific program features known to encourage Medicaid enrollment and retention and then document increases significantly beyond what would have been expected. States qualifying this year are Alabama, Alaska, Colorado, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, New Jersey, New Mexico, Ohio, Oregon, Washington, and Wisconsin.

Less Fluoride Recommended

The Environmental Protection Agency and HHS have joined forces to lower the amount of fluoride in drinking water. Americans don't need as much from that source because they have others – from toothpaste to regular dentists' treatment – than weren't available when public water fluoridation was introduced decades ago. The two agencies announced in the Federal Register that they want to replace the currently recommended range of water fluoridation, 0.7-1.2 mg/L, to a single target of 0.7 mg/L. The action will leave enough fluoride in the water supply to prevent tooth decay but protect children's teeth from dental fluorosis. The announcement said that the HHS expects to finalize the proposed change this spring, based on the EPA's assessment of fluoridation needs.

Combination Vaccines Avoided

One in five pediatricians reported that inadequate reimbursement prevented them from using at least one of two combination vaccines studied, according to the RAND Corporation. The study looked at infant vaccines – the diphtheria and tetanus toxoids and acellular pertussis, hepatitis B virus and inactivated poliovirus (DTaP-HepB-IPV) vaccine and the DTaP, IPV, and Haemophilus influenzae type b (DTaP-IPV/Hib) vaccine. Although 78% of the 492 pediatricians surveyed said they used one or both of the combination vaccines, more than half said their practice did not receive adequate reimbursement for vaccines in general. More than one-fifth said they didn't use one of the combination vaccines either because of inadequate reimbursement for doses or for administration. Smaller practices were less likely to use the combination vaccines, as were those with fewer publicly insured patients and those in a state with a less generous vaccine-financing policy, the study said.

Grant Will Fund Residencies

The Josiah Macy Jr. Foundation has awarded $500,000 to the American Academy of Pediatrics for pediatric residency training initiatives to improve care for underserved children. The two organizations said the grant will support pediatric residency programs that teach community health and advocacy, train future leaders, enhance future pediatricians' involvement in caring for underserved populations, build community partnerships, and use technology effectively. “It is clear that skills and involvement for pediatricians in community pediatrics focused on improving the health of underserved children are desired and achievable, but more work needs to be done in order to provide effective training,” said AAP President Dr. O. Marion Burton.

Food for Kids Found Wanting

Tests showed that 49 out of 58 supposedly healthy foods commonly marketed to children failed to meet at least one “healthy” standard, according to a study from the Prevention Institute. Food manufacturers increasingly use nutritional claims on the front of food packages to tout the foods as healthier choices. However, almost all the foods contained added sugar, and more than half qualified as high sugar, according to the institute's analysis. In addition, more than half were low in fiber and contained no fruit or vegetable. About one-fourth of the prepared foods contained too much saturated fat, and one-third contained too much sodium, according to the study. Foods evaluated included staples such as Campbell's Tomato Soup, Skippy Super Chunk Peanut Butter, and Rice Krispies.

FDA Seeks Pediatric Devices

The Food and Drug Administration is inviting grant proposals from nonprofit organizations to facilitate the development, production, and distribution of pediatric medical devices. “There currently exists a great need for medical devices designed specifically with children in mind,” the agency said in its announcement. The grants, which will be issued by the agency's Office of Orphan Products Development, will go to “consortia whose business model and approach to device development will either result in, or substantially contribute to, market approval of medical devices designed specifically for use in children.” However, the program won't support single-device projects, the agency said. Although the grant program is administered by the orphan products development office, it's intended to encompass devices for all conditions, not just rare diseases, the FDA said. Grant applications are due May 2.

States Boost Medicaid Rolls

The Department of Health and Human Services has awarded $206 million to 15 states for enrolling more uninsured children in Medicaid. Last year, the Children's Health Insurance Program Reauthorization bonuses totaled just $75 million to 10 states. To qualify, states must have adopted specific program features known to encourage Medicaid enrollment and retention and then document increases significantly beyond what would have been expected. States qualifying this year are Alabama, Alaska, Colorado, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, New Jersey, New Mexico, Ohio, Oregon, Washington, and Wisconsin.

Less Fluoride Recommended

The Environmental Protection Agency and HHS have joined forces to lower the amount of fluoride in drinking water. Americans don't need as much from that source because they have others – from toothpaste to regular dentists' treatment – than weren't available when public water fluoridation was introduced decades ago. The two agencies announced in the Federal Register that they want to replace the currently recommended range of water fluoridation, 0.7-1.2 mg/L, to a single target of 0.7 mg/L. The action will leave enough fluoride in the water supply to prevent tooth decay but protect children's teeth from dental fluorosis. The announcement said that the HHS expects to finalize the proposed change this spring, based on the EPA's assessment of fluoridation needs.

Combination Vaccines Avoided

One in five pediatricians reported that inadequate reimbursement prevented them from using at least one of two combination vaccines studied, according to the RAND Corporation. The study looked at infant vaccines – the diphtheria and tetanus toxoids and acellular pertussis, hepatitis B virus and inactivated poliovirus (DTaP-HepB-IPV) vaccine and the DTaP, IPV, and Haemophilus influenzae type b (DTaP-IPV/Hib) vaccine. Although 78% of the 492 pediatricians surveyed said they used one or both of the combination vaccines, more than half said their practice did not receive adequate reimbursement for vaccines in general. More than one-fifth said they didn't use one of the combination vaccines either because of inadequate reimbursement for doses or for administration. Smaller practices were less likely to use the combination vaccines, as were those with fewer publicly insured patients and those in a state with a less generous vaccine-financing policy, the study said.

Grant Will Fund Residencies

The Josiah Macy Jr. Foundation has awarded $500,000 to the American Academy of Pediatrics for pediatric residency training initiatives to improve care for underserved children. The two organizations said the grant will support pediatric residency programs that teach community health and advocacy, train future leaders, enhance future pediatricians' involvement in caring for underserved populations, build community partnerships, and use technology effectively. “It is clear that skills and involvement for pediatricians in community pediatrics focused on improving the health of underserved children are desired and achievable, but more work needs to be done in order to provide effective training,” said AAP President Dr. O. Marion Burton.

Food for Kids Found Wanting

Tests showed that 49 out of 58 supposedly healthy foods commonly marketed to children failed to meet at least one “healthy” standard, according to a study from the Prevention Institute. Food manufacturers increasingly use nutritional claims on the front of food packages to tout the foods as healthier choices. However, almost all the foods contained added sugar, and more than half qualified as high sugar, according to the institute's analysis. In addition, more than half were low in fiber and contained no fruit or vegetable. About one-fourth of the prepared foods contained too much saturated fat, and one-third contained too much sodium, according to the study. Foods evaluated included staples such as Campbell's Tomato Soup, Skippy Super Chunk Peanut Butter, and Rice Krispies.

FDA Seeks Pediatric Devices

The Food and Drug Administration is inviting grant proposals from nonprofit organizations to facilitate the development, production, and distribution of pediatric medical devices. “There currently exists a great need for medical devices designed specifically with children in mind,” the agency said in its announcement. The grants, which will be issued by the agency's Office of Orphan Products Development, will go to “consortia whose business model and approach to device development will either result in, or substantially contribute to, market approval of medical devices designed specifically for use in children.” However, the program won't support single-device projects, the agency said. Although the grant program is administered by the orphan products development office, it's intended to encompass devices for all conditions, not just rare diseases, the FDA said. Grant applications are due May 2.

Sam's Club Offers Health Care

Wal-Mart warehouse retailer Sam's Club has begun offering a $99 annual health care plan that includes at-home screening tests and health coaching but does not include access to a physician. The “Prevention Plan” uses an online health assessment, which is based on results from cholesterol and blood glucose tests, to develop personalized advice for participants, according to Sam's Club. The program also provides a 24/7 hotline to nurses; health alerts and reminders; and a summary of the plan for each patient's physician. The service is intended to augment, rather than replace, care from a primary care physician, according to U.S. Preventive Medicine, the company that is providing the product for the retailer.

Health Reform Helps Primary Care

The health care reform law that Congress passed last year will begin to reverse decades of neglect of the primary care system in the United States, but only if state and federal governments follow through, according to a report from the Commonwealth Fund. The new law includes multiple provisions that will strengthen primary care, including temporary increases in Medicare and Medicaid payments to such providers, support for innovation in care delivery, increased emphasis on better health outcomes and patient experiences, and more investment in the primary care workforce, according to the report. In order for the changes to work, however, they'll need to be implemented carefully and thoroughly, and Congress will need to fund them fully, the report said.

Private Cash for Community Health

Robert and Myra Kraft have donated $20 million to Partners HealthCare in Boston to create a new community health center and provide recruitment incentives for more than 100 physicians and master's-level nurses to practice in community health settings. The gift will fund the Kraft Family National Center for Leadership and Training in Community Health, which will create a fellowship program for training new community-based physicians, the announcement of the gift said. “Very simply, we hope to inspire a new generation of clinicians to make a commitment to solve many community health problems here in Massachusetts and across the country, and greatly improve the health of those in need,” Dr. Gary Gottlieb, Partners HealthCare CEO, said in a statement. The Krafts own the New England Patriots football team and Gillette Stadium in Foxboro, Mass., where the team plays.

Diabetes, and Its Costs, Doubled

The number of U.S. adults who were treated for diabetes more than doubled in 11 years, according to the Agency for Healthcare Research and Quality. In 2007, about 19 million adults said that they had been treated for diabetes, compared with 9 million in 1996, the agency said. The increase occurred in all age groups: The number of seniors who were treated for diabetes rose from 4.3 million to 8 million; for people aged 45-64 years, the increase was from 3.6 million to 8.9 million; and treatment among 18- to 44-year-olds went from 1.2 million to 2.4 million. Total treatment costs for diabetes also more than doubled, from an inflation-adjusted $18.5 billion in 1996 to $41 billion in 2007. Prescription costs alone more than quadrupled, from $4 billion to $19 billion.

FDA to Review Tobacco Products

The Food and Drug Administration said that it needs to review tobacco products that were introduced or changed after early 2007. To continue marketing a product, the tobacco manufacturer must prove to the FDA that a product is “substantially equivalent” to products commercially available on Feb. 15, 2007, when legislation placing tobacco products under the agency's jurisdiction was introduced in Congress. President Obama signed the tobacco legislation into law in June 2009. The agency said that it may deny applications for substantial equivalence if the new product, as marketed, would raise different questions of public health – for example, if the new product were more addictive than the old. Manufacturers need to apply for equivalency status by March 22 of this year. After that date, tobacco companies will need to obtain marketing orders from the FDA before being allowed to sell a product.

Group Sues Over Pyramid

The animal-advocacy group Physicians Committee for Responsible Medicine has filed suit against the Department of Agriculture and the Department of Health and Human Services, saying they're ignoring a healthier vegetarian alternative to the national MyPyramid nutritional tool. In the U.S. District Court for the District of Columbia, the group charged that the departments violated federal law by failing to respond to a petition from the group offering “a simple, plant-based alternative to MyPyramid.” The petition notes that obesity and diabetes rates have skyrocketed since the food pyramid was introduced 2 decades ago, and asks that the two agencies' latest version replace the pyramid with the committee's Power Plate vegetarian alternative. “MyPyramid is confusing, and it recommends meat and dairy products despite overwhelming evidence that these foods are unnecessary and unhealthy,” said group nutrition education director Susan Levin in a statement.

Sam's Club Offers Health Care

Wal-Mart warehouse retailer Sam's Club has begun offering a $99 annual health care plan that includes at-home screening tests and health coaching but does not include access to a physician. The “Prevention Plan” uses an online health assessment, which is based on results from cholesterol and blood glucose tests, to develop personalized advice for participants, according to Sam's Club. The program also provides a 24/7 hotline to nurses; health alerts and reminders; and a summary of the plan for each patient's physician. The service is intended to augment, rather than replace, care from a primary care physician, according to U.S. Preventive Medicine, the company that is providing the product for the retailer.

Health Reform Helps Primary Care

The health care reform law that Congress passed last year will begin to reverse decades of neglect of the primary care system in the United States, but only if state and federal governments follow through, according to a report from the Commonwealth Fund. The new law includes multiple provisions that will strengthen primary care, including temporary increases in Medicare and Medicaid payments to such providers, support for innovation in care delivery, increased emphasis on better health outcomes and patient experiences, and more investment in the primary care workforce, according to the report. In order for the changes to work, however, they'll need to be implemented carefully and thoroughly, and Congress will need to fund them fully, the report said.

Private Cash for Community Health

Robert and Myra Kraft have donated $20 million to Partners HealthCare in Boston to create a new community health center and provide recruitment incentives for more than 100 physicians and master's-level nurses to practice in community health settings. The gift will fund the Kraft Family National Center for Leadership and Training in Community Health, which will create a fellowship program for training new community-based physicians, the announcement of the gift said. “Very simply, we hope to inspire a new generation of clinicians to make a commitment to solve many community health problems here in Massachusetts and across the country, and greatly improve the health of those in need,” Dr. Gary Gottlieb, Partners HealthCare CEO, said in a statement. The Krafts own the New England Patriots football team and Gillette Stadium in Foxboro, Mass., where the team plays.

Diabetes, and Its Costs, Doubled

The number of U.S. adults who were treated for diabetes more than doubled in 11 years, according to the Agency for Healthcare Research and Quality. In 2007, about 19 million adults said that they had been treated for diabetes, compared with 9 million in 1996, the agency said. The increase occurred in all age groups: The number of seniors who were treated for diabetes rose from 4.3 million to 8 million; for people aged 45-64 years, the increase was from 3.6 million to 8.9 million; and treatment among 18- to 44-year-olds went from 1.2 million to 2.4 million. Total treatment costs for diabetes also more than doubled, from an inflation-adjusted $18.5 billion in 1996 to $41 billion in 2007. Prescription costs alone more than quadrupled, from $4 billion to $19 billion.

FDA to Review Tobacco Products

The Food and Drug Administration said that it needs to review tobacco products that were introduced or changed after early 2007. To continue marketing a product, the tobacco manufacturer must prove to the FDA that a product is “substantially equivalent” to products commercially available on Feb. 15, 2007, when legislation placing tobacco products under the agency's jurisdiction was introduced in Congress. President Obama signed the tobacco legislation into law in June 2009. The agency said that it may deny applications for substantial equivalence if the new product, as marketed, would raise different questions of public health – for example, if the new product were more addictive than the old. Manufacturers need to apply for equivalency status by March 22 of this year. After that date, tobacco companies will need to obtain marketing orders from the FDA before being allowed to sell a product.

Group Sues Over Pyramid

The animal-advocacy group Physicians Committee for Responsible Medicine has filed suit against the Department of Agriculture and the Department of Health and Human Services, saying they're ignoring a healthier vegetarian alternative to the national MyPyramid nutritional tool. In the U.S. District Court for the District of Columbia, the group charged that the departments violated federal law by failing to respond to a petition from the group offering “a simple, plant-based alternative to MyPyramid.” The petition notes that obesity and diabetes rates have skyrocketed since the food pyramid was introduced 2 decades ago, and asks that the two agencies' latest version replace the pyramid with the committee's Power Plate vegetarian alternative. “MyPyramid is confusing, and it recommends meat and dairy products despite overwhelming evidence that these foods are unnecessary and unhealthy,” said group nutrition education director Susan Levin in a statement.

Sam's Club Offers Health Care

Wal-Mart warehouse retailer Sam's Club has begun offering a $99 annual health care plan that includes at-home screening tests and health coaching but does not include access to a physician. The “Prevention Plan” uses an online health assessment, which is based on results from cholesterol and blood glucose tests, to develop personalized advice for participants, according to Sam's Club. The program also provides a 24/7 hotline to nurses; health alerts and reminders; and a summary of the plan for each patient's physician. The service is intended to augment, rather than replace, care from a primary care physician, according to U.S. Preventive Medicine, the company that is providing the product for the retailer.

Health Reform Helps Primary Care

The health care reform law that Congress passed last year will begin to reverse decades of neglect of the primary care system in the United States, but only if state and federal governments follow through, according to a report from the Commonwealth Fund. The new law includes multiple provisions that will strengthen primary care, including temporary increases in Medicare and Medicaid payments to such providers, support for innovation in care delivery, increased emphasis on better health outcomes and patient experiences, and more investment in the primary care workforce, according to the report. In order for the changes to work, however, they'll need to be implemented carefully and thoroughly, and Congress will need to fund them fully, the report said.

Private Cash for Community Health

Robert and Myra Kraft have donated $20 million to Partners HealthCare in Boston to create a new community health center and provide recruitment incentives for more than 100 physicians and master's-level nurses to practice in community health settings. The gift will fund the Kraft Family National Center for Leadership and Training in Community Health, which will create a fellowship program for training new community-based physicians, the announcement of the gift said. “Very simply, we hope to inspire a new generation of clinicians to make a commitment to solve many community health problems here in Massachusetts and across the country, and greatly improve the health of those in need,” Dr. Gary Gottlieb, Partners HealthCare CEO, said in a statement. The Krafts own the New England Patriots football team and Gillette Stadium in Foxboro, Mass., where the team plays.

Diabetes, and Its Costs, Doubled

The number of U.S. adults who were treated for diabetes more than doubled in 11 years, according to the Agency for Healthcare Research and Quality. In 2007, about 19 million adults said that they had been treated for diabetes, compared with 9 million in 1996, the agency said. The increase occurred in all age groups: The number of seniors who were treated for diabetes rose from 4.3 million to 8 million; for people aged 45-64 years, the increase was from 3.6 million to 8.9 million; and treatment among 18- to 44-year-olds went from 1.2 million to 2.4 million. Total treatment costs for diabetes also more than doubled, from an inflation-adjusted $18.5 billion in 1996 to $41 billion in 2007. Prescription costs alone more than quadrupled, from $4 billion to $19 billion.

FDA to Review Tobacco Products

The Food and Drug Administration said that it needs to review tobacco products that were introduced or changed after early 2007. To continue marketing a product, the tobacco manufacturer must prove to the FDA that a product is “substantially equivalent” to products commercially available on Feb. 15, 2007, when legislation placing tobacco products under the agency's jurisdiction was introduced in Congress. President Obama signed the tobacco legislation into law in June 2009. The agency said that it may deny applications for substantial equivalence if the new product, as marketed, would raise different questions of public health – for example, if the new product were more addictive than the old. Manufacturers need to apply for equivalency status by March 22 of this year. After that date, tobacco companies will need to obtain marketing orders from the FDA before being allowed to sell a product.

Group Sues Over Pyramid

The animal-advocacy group Physicians Committee for Responsible Medicine has filed suit against the Department of Agriculture and the Department of Health and Human Services, saying they're ignoring a healthier vegetarian alternative to the national MyPyramid nutritional tool. In the U.S. District Court for the District of Columbia, the group charged that the departments violated federal law by failing to respond to a petition from the group offering “a simple, plant-based alternative to MyPyramid.” The petition notes that obesity and diabetes rates have skyrocketed since the food pyramid was introduced 2 decades ago, and asks that the two agencies' latest version replace the pyramid with the committee's Power Plate vegetarian alternative. “MyPyramid is confusing, and it recommends meat and dairy products despite overwhelming evidence that these foods are unnecessary and unhealthy,” said group nutrition education director Susan Levin in a statement.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

A research team based at the Cleveland Clinic has released a new risk assessment tool designed to allow fair comparison of hospital outcomes across institutions. The tool provides a reliable way for hospitals to predict length of stay and mortality for surgical patients using only administrative data, the researchers said.

The tool, called the Risk Stratification Index, is in the public domain. It was detailed in the journal Anesthesiology in November (Anesthesiology 2010;113:1026-37), and the Cleveland Clinic currently uses it to stratify risk in its internal outcomes analyses, according to Dr. Daniel Sessler, lead author of the article and chair of the department of outcomes research there.

"Hospitals are already being compared," Dr. Sessler said in an interview. "But comparisons only make sense after adjusting for baseline and the risk associated with different operations. Our Risk Stratification Index allows for an accurate and fair comparison among hospitals using only publicly available data."

Dr. Sessler said it was necessary to develop a new risk assessment tool because institutions use various systems to evaluate outcomes, and many of these systems are proprietary and nontransparent.

"Available systems are either inaccurate or require special clinical data that are not generally or publicly available," he said, adding that the Risk Stratification Index (RSI) is more accurate than other generally available nonproprietary systems, and uses only publicly available billing information.

To develop the index, Dr. Sessler and his colleagues used more than 35 million patient stay records from 2001-2006 Medicare Provider Analysis and Review files, randomly dividing them into development and validation sets. RSIs for length of stay and mortality end points were derived from aggregate risk associated with individual diagnostic and procedure codes.

Next, the researchers tested performance of the RSIs prospectively on the validation database, as well as on a single institution registry of 103,324 adult surgical patients, and compared the results with an index designed to predict 1-year mortality.

The researchers found that the risk stratification model accurately predicted 30-day and 1-year postdischarge mortality, while separate risk stratification models predicted length of stay and in-hospital mortality. The risk predictions are accurate for as few as 2,000 patients, meaning the system can be used effectively by small hospitals.

"RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data," Dr. Sessler and his colleagues concluded in their paper.

The research team wanted to make the RSI available to any hospital that wants to use it, so it put it in the public domain, Dr. Sessler explained. He anticipates that it will be adopted rapidly because it’s objective, transparent, requires only billing codes, and is free to use. Details of how to use the system and sample files are available online. 

The tool shows good promise but also has some drawbacks, noted Dr. Charles Mabry, of the University of Arkansas in Pine Bluff, in an interview. "Like many risk adjustment methods, this relies upon the administrative data set, which is submitted with hospital bills to insurers. As such, many clinical factors, such as weight, blood pressure, drugs used, socioeconomic status, etc., aren’t reported, and thus [are] unavailable to help with risk stratification."

For large numbers of patients, the administrative data set can help reveal major differences in such factors as treatment and medications, Dr. Mabry said. However, for smaller numbers of patients – for example, the number in a group that had one particular surgical procedure – it becomes weaker, he said. Other large organizations, along with the Centers for Medicare and Medicaid Services, already are using the administrative data set for their own risk adjustment algorithms, Dr. Mabry noted.

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) does measure the clinical factors omitted from the administrative data set, along with some complications that might also be missed, said Dr. Mabry. "Thus, compared with the Sessler index, it can more reliably detect differences in outcomes for smaller numbers of patients, such as comparing the outcomes of gallbladder surgery between various hospitals," he said.

However, the Physician Quality Reporting Initiative (PQRI) primarily measures process as opposed to outcomes, Dr. Mabry said. "I think PQRI is a waste of time and effort," he said. "Many feel that outcomes measurement is really what we need to be aiming for, rather than process compliance."

Dr. Chad Rubin, a surgeon in Columbia, S.C., agreed that the Risk Stratification Index is limited through its use of the administrative data set. "While it appears a useful tool, I am always reticent to give credence to something so important as hospital (and maybe doctor) outcomes when the original data may be flawed," he said in an interview.

NSQIP, meanwhile, "may be more relevant to quality. For instance, the definition of skin and soft tissue infection, while a very common diagnosis/complication, varies widely in the claims data but has a strict definition by NSQIP," Dr. Rubin said. "While NSQIP is expensive (both the enrollment and FTE required), it depends on the quality of the data as to whether it is too resource-intensive. I’m sure hospitals have spent a lot more on SCIP [Surgical Care Improvement Project (pdf)] than on NSQIP for a lot less improvement in quality."

NSQIP remains the gold standard, Dr. Rubin said. "The use of good clinical data carefully collected and carefully risk-adjusted is, in my opinion, the way to go," he said. "I’m worried that lesser claims data will not be accurate but will be acted upon as if it were."

Dr. Sessler said he agrees that the NSQIP registry is a valuable resource, but notes that it applies to a limited number of hospitals, and fewer than 1% of U.S. surgical patients. "Specially trained nurses must abstract clinical details from the records of each NSQIP patient," he said. "Because NSQIP applies to so few patients in so few hospitals, it cannot be used to compare hospital performance." In contrast, he said, the Risk Stratification Index can be used for all patients and all hospitals.

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

Photo courtesy of Patricia Heiden

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

[Proposed EHR 'Meaningful Use' Criteria Chart Path to Incentives]

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don’t begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs’ prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastman added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they’re working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It’s often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a ‘Trojan Horse.’?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

[Physicians Object to Proposed EHR Timeline]

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

Photo courtesy of Patricia Heiden

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

[Proposed EHR 'Meaningful Use' Criteria Chart Path to Incentives]

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don’t begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs’ prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastman added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they’re working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It’s often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a ‘Trojan Horse.’?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

[Physicians Object to Proposed EHR Timeline]

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

Photo courtesy of Patricia Heiden

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

[Proposed EHR 'Meaningful Use' Criteria Chart Path to Incentives]

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don’t begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs’ prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastman added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they’re working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It’s often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a ‘Trojan Horse.’?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

[Physicians Object to Proposed EHR Timeline]

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

Photo courtesy Patricia Heiden

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released in this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don't begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs' prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastern added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they're working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It's often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a 'Trojan Horse.'?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

Photo courtesy Patricia Heiden

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released in this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don't begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs' prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastern added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they're working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It's often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a 'Trojan Horse.'?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

Dermatologists have been slow to adopt electronic health record technology, in large part because few of the products available meet their needs, experts who have studied and implemented the technology report.

It is likely that incentives provided by the Centers for Medicare and Medicaid Services (CMS) to encourage widespread implementation of EHR technology will lure some additional dermatologists into the EHR marketplace, but the systems remain expensive and may not be worth the costs for some, said Dr. Joseph S. Eastern, a dermatologist in private practice in Belleville, N.J.

Photo courtesy Patricia Heiden

To be eligible for the incentive payments, which can total up to $44,000 over 5 years under Medicare or up to $63,750 over 6 years under Medicaid, physicians will need to implement EHRs and then achieve what CMS calls "meaningful use" of those records, which will mean reporting numerous quality measures to CMS beginning in 2012.

A survey released in this month suggested EHR adoption among physicians is set to soar in response to the promise of the incentive payments: some 41% of office-based physicians polled by the National Center for Health Statistics said they are planning to achieve "meaningful use" of EHR technology in time to take advantage of the payments.

Still, Dr. Eastern said, "my hunch is the actual figure will be lower when push comes to shove, and lower still for dermatologists, because the incentives don't begin to compensate for the problems inherent in making the switch from paper to electronic records."

Dr. Mark D. Kaufmann, of the dermatology department at Mount Sinai School of Medicine in New York, agreed. "Many will be enticed to adopt now, but when confronted by the actual cost of adoption, they may become more hesitant," he said in an interview.

Also, despite claims that EHRs will improve quality, it’s not clear whether that will be the case for dermatologists. Dr. Kaufmann said the systems can set up clinical decision support that can help to remind physicians to check certain labs and keep track of melanoma patients.

However, Dr. Eastern was more pessimistic about EHRs' prospects for improving quality. "I frankly don’t think they can [improve quality], other than some limited coordination of care with other specialists, and elimination of some treatment redundancy and prescription errors. The government says it wants to improve quality, but what it really wants to do is collect data on physicians; that’s the primary reason for incentivizing EHRs," he said.

The technology may help improve office efficiency, but it may also "amplify errors," Dr. Eastern said. "Attempting to automate a chaotic system of paper records will only increase the chaos. If your paper records are poorly organized, solve that problem before even considering a switch to electronic records. Well-structured paper records predict well-structured EHRs."

There’s no question that adopting EHRs will be expensive for dermatologists.

Stand-alone EHR systems can cost anywhere from $50,000 to $100,000, Dr. Kaufmann said, and may be more practical for larger dermatology practices.

Small solo practices tend to purchase Application Service Provider (ASP) or Software as a Service (SaaS) systems, which don’t involve hardware installation and require only Internet service, Dr. Kaufmann said. ASP and SaaS start around $500 a month, he said.

Few systems meet the needs for dermatologists out of the box, according to both practice management experts.

Some vendors offer templates – blank forms customized to the practice of dermatology that can be filled in easily when seeing the patient – as part of the EHR system to make it more "dermatologist friendly," Dr. Kaufmann said. However, nearly every dermatologist winds up having to design his or her own templates to meet specific needs, he said.

Dr. Eastern added that dermatologists should avoid any system designed for other specialties, regardless of any claims the vendor might make about how easily it can be adapted for dermatology. In addition, he warned that dermatologists should avoid using a hospital’s "free" EHR, since the physician often has to purchase hardware and service contracts. Many so-called free EHRs come with strings attached, he said.

Dermatologists considering implementing their own EHR systems should visit colleagues using similar systems to see how they're working, said Dr. Kaufmann. Vendors often will provide names of physicians who have implemented their systems, and EHR seminars at professional meetings also can provide some leads.

It's often not an easy process, he said. "The learning curve is steep, ongoing costs may be steep, and the incentive money may wind up being a 'Trojan Horse.'?"

Dr. Eastern recommended a hosted ASP service for a dermatologist just starting out in practice. Eventually, that dermatologist can move to an in-house system "if that becomes necessary or advantageous." But dermatologists in the midst of their careers might want to think twice about taking the plunge, he said. "For someone mid-career, I suggest holding out with paper, with the hope of retiring before EHR becomes mandatory."

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.

Cardiopulmonary resuscitation training should be a requirement for graduation from high school and should include instruction on the purpose of an automated external defibrillator and how to use one, according to an American Heart Association consensus statement released Jan. 10.

Photo credit:Flickr user John Trainor (Creative Commons)

The science advisory statement, developed in collaboration with the American Academy of Pediatrics and the American College of Emergency Physicians and published in the journal Circulation, also recommends that students have opportunities to practice and master psychomotor skills related to CPR, since trainees do not learn enough unless they get the chance to practice.

Although secondary school students most likely won’t encounter a victim of cardiac arrest at school, they may encounter one elsewhere in the community, and teaching CPR skills early can lead to more proficiency later, the AHA statement said.

"Increasing the percentage of the population trained in CPR is an integral part of an overall strategy to improve community response" to out-of-hospital cardiac arrests, the statement said. "Schools provide excellent access to a large part of the community. ... Therefore, over time, a significant percentage of the overall community will receive training."

In 2003, the International Liaison Committee on Resuscitation recommended that CPR instruction be incorporated into standard school curriculums, and the next year the AHA recommended that schools train all teachers in CPR and first aid and train all students in CPR in order to prepare for potential medical emergencies on campus.

As of the 2009-2010 school year, laws or curriculum standards in six states require CPR training as a component of mandatory health education, while 30 states encourage schools to teach CPR, according to the AHA statement. However, implementation of these laws isn’t uniform, and not all schools teach CPR, even in states that have the strongest language encouraging such training, the AHA statement said.

Therefore, requiring CPR training as a condition of high school graduation would significantly increase the level of CPR knowledge in the community over time, the statement said, adding, "the evidence shows that previous training, at any interval before there is a need to use the skills learned, will increase the likelihood that a bystander will provide appropriate care to a victim."

It’s critical to target the correct age group for training, the AHA statement said. Students younger than about 13 years old may not have the necessary physical strength to perform correct chest compressions. Therefore, "it is reasonable to limit practice of adult CPR chest compression skills to children in middle school (around 13 years old) and older," the statement said (Circulation 2011;123:[doi: 10.1161/CIR.0b013e31820b5328]).

Programs designed for schools should include the core skills of conventional CPR and hands-only CPR developed by the AHA, and should emphasize recognition of the emergency and provision of high-quality chest compressions, the statement said.

The statement does not urge mandatory automated external defibrillator (AED) skills practice, although it recommends that schools providing AED skills practice give students an opportunity to practice and master all steps of CPR and AED use, with special emphasis on minimal interruptions in performance of CPR, correct application of pads to an appropriate surrogate for the human thorax, and proper "clearing" of the patient when so instructed by the AED.

Schools have cited a lack of available class time as a barrier to implementing CPR instruction. However, it should be possible for schools to implement such training as part of health courses or as part of a "community service" requirement for high school graduation, the AHA said. In addition, schools can make use of video-based, self-directed training programs and online or other e-learning programs, the statement said.

Several members of the writing committee had relationships that the AHA deemed significant: Dr. Tom P. Aufderheide of the Medical College of Wisconsin, Milwaukee, has received research support from Zoll Medical and Advanced Circulatory Inc.; and has served as an advisor or consultant to Medtronic and JoLife Inc.; Dr. Keith Lurie of the University of Wisconsin is also founder and chief medical officer of Advanced Circulatory Systems, as well as the inventor of that company’s ResQPOD. Dr. Vincent N. Mosesso Jr. of the University of Pittsburgh has received research support from Zoll Medical.