Combined primary care degree Brown University’s Warren Alpert Medical School is setting up a dual degree in primary care and population health. “The goal is to educate a new type of physician with a primary care background,” its proposal said.

Accelerated degrees University of California — Davis School of Medicine is creating a three year accelerated primary care program in collaboration with Kaiser Permanente called the Accelerated Competency-based Education in Primary Care program.

Technology focus New York University’s Medical School is offering an accelerated three year program with a focus on technology led curriculum to improve care coordination and quality improvement, according to a description of the program. A virtual patient panel using de-identified patient data from NYU Langone Medical Center physician network practices will help create a real world clinical setting for students.

Outcomes-based care University of Michigan’s Medical School is creating a program in which students develop leadership and change management skills alongside a study concentration. They will participate in a clinical and educational community called the “M Home,” — which will provide relationships with core faculty, and connections to clinical settings that will link improved learning with improved patient outcomes.

Patient safety Broody School of Medicine at East Carolina University has proposed a comprehensive core curriculum in patient safety for all medical students. It will include simulation, problem-based learning, clinical skills training and targeted clinical experiences. It takes an interdisciplinary approach with other health-related courses to develop interprofessional skills and prep students to successfully lead health care teams for systems-based health care transformation. There will also be an emphasis on rural and underserved populations. Faculty will be trained to provide the new curriculum.

 [Photo Credit: chanpipat]

It's one of those unhappy holiday surprises -- a visiting family member gets sick. That happened to Dr. Farzad Mostashari last Thanksgiving. 

"My dad comes downstairs and he has acute pain in his eye where he had cataract surgery. And I said, 'What's the matter, what's the story?'" recalled Mostashari, who lives in Bethesda, Md. "And he said, 'Well, I think they put the wrong lens in my eye, I'd gone back to the doctor and...'" His father didn't remember exactly what had happened at his last doctor's appointment and the office was closed anyway.

How could a local doctor in Maryland access his dad's medical record in Boston? Through Medicare Blue Button, a computer program that allows patients to download their medical history into a simple text file on their smartphones and personal computers. Then third-party applications that you download help organize this information.

Mostashari certainly knew how to handle his dad's problem. After all, he's the coordinator for health information technology at the U.S. Department of Health and Human Services, and it's his passion and profession to promote electronic health records.

And, he had signed his dad up for Blue Button, which downloads three years of a patient's medical history, as well as the Humetrix iBlueButton, a smartphone app that translates and displays the information in a simple-to-understand way. The file includes names, phone numbers and addresses of physicians as well as diagnoses, lab tests, imaging studies, and medications.

So when Mostashari took his father to a local doctor, his dad was able to hand over his iPhone and say, "Here's my history."

Mostashari predicts that soon everyone will have that kind of information at their fingertips: "Within the next 12 months if people want to, they will be able to get the same data that your doctors would send to each other to have it come to you."

The Blue Button service is available from the federal government for veterans as well as Medicare beneficiaries.

Before a patient can download medical information to a computer or a smartphone, the files must first be stored electronically. And while electronic health record advocates note that there has been a sharp increase in the number of hospitals and doctors using EHRs, they acknowledge that a complete electronic system is a long way off. According to a 2012 CDC survey, while 72 percent of office-based physicians are using some sort of electronic system in their practice, only 40 percent of practices meet the definition of a “basic” system.

Power In The Hands Of The Patients?

The federal health law is designed to encourage patients to be more involved in managing their own health. Making medical records and test results accessible to smartphones is in line with those policy goals.

The floodgates have opened for patients to use technology to manage their own care particularly those that have chronic, and expensive, diseases, said Jennifer Lundblad, CEO of Stratis Health, a nonprofit organization based in Minnesota, which aims to improve health care by translating research into practice.

Lundblad said smartphones and health-related applications can become powerful tools to help people monitor and improve their health.

"Some parts of health care are so complex that we need complex solutions," she said. "But some parts of health care can be simplified and with the prevalence of smartphones, let's use the smartphone tool that that patient already has."

But there are also risks that Lundblad and others worry about, among them the possibility that a company storing the health data could go out of business or that some patients may lose smartphones containing their medical information.

Protecting Your Data

To address privacy concerns, in February the Federal Trade Commission released recommendations to companies that build and sell mobile apps, not just those related to health care. Those recommendations followed a major report the FTC released about best practices for consumer privacy in 2012.

But even its most recent report noted that "many questions remain" about the applications. Among them: What information should be included in application developer's privacy policies? What might a model short privacy notice look like? Can a single system of icons be developed to avoid consumer confusion?

Deven McGraw, director of the Health Privacy Project at the Center for Democracy and Technology, notes that when doctors and health plans store electronic medical information, that information is covered by federal privacy and security rules. But those rules don't extend to medical information on a smartphone.

"When you take possession of it and share it, stick it in an app, share it on the web, a social networking site, it's not going to be protected beyond what's in the privacy policy for the app or what's the privacy policy for the social networking site. And you need to read that," McGraw said. "Be aware before you share."

McGraw provides some tips for consumers who want to protect themselves:

• Determine if cellphone app makers claim rights to patients' data for marketing purposes.

• Look for very clear statements about how the data is used. Language such as "from time to time we will use your data...in order to improve the services we provide for you" may warrant further investigation.

• Look for who owns the data, if the company will disclose it. Do you own your data? Or do you merely have the right to use the service, but that is the extent of your rights?

• Look for commitments on security of the data. Is the data stored on your phone or on a server?

• What are your rights to retrieve data if they cancel service? Are you permitted to have a copy of the data? What is the app provider's right to use the data after service is canceled? Ideally, McGraw said, companies should return all your data and not have the right to subsequently use it.

• You should use unusual passwords that employ varied symbols and numbers.

• If possible, you should be able to remotely delete data from the device if it is stolen.

And Medicare Blue Button has these security recommendations:

• Download your data to a secure location. You may want to download your information to a CD or flash drive. Consider purchasing an encrypted flash drive for your information. You may also encrypt or require a password to access a CD.

• If you want to send your information via email, you should encrypt the message.

• Keep paper copies in a safe and secure place that you can control.

Another problem with smartphone medical records - not related to security - is that some physicians may not know whether the records stored there are complete, said Scott Edelstein, co-chair of Squire Sanders' Healthcare & Life Sciences Industry Group in Washington, D.C.

"There may be some data that the patient doesn't want to keep on their smartphone," said Edelstein, who specializes in mobile health applications. "Maybe there's very sensitive health information. Maybe there's information that they don't want other providers to know but it could be very important information for a provider to know, for example, in the event of an emergency."

Edelstein said errors or omissions could be disastrous.

But in the case of Dr. Farzad Mostashari's father, the records on the phone had pointed to the problem: "He had dry eye; that was the diagnosis."

Then, it was an easy treatment that salvaged the Thanksgiving weekend.

This story is part of a collaboration that includes MPR News, NPR and Kaiser Health News.

The ministry said the four deaths were among previously registered cases. The new infections were in Eastern Province, in the capital Riyadh and in Red Sea port city of Jeddah.

Saudi Arabia has been the country most affected by the respiratory-system virus, with 49 confirmed cases, of whom 32 have died, according to data from the ministry.

The worldwide death toll released by the World Health Organization (WHO) on June 15 stood at 34.

The virus, which can cause coughing, fever and pneumonia, has spread from the Gulf to France, Britain and Germany. The WHO has called it the Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

It is a distant relative of the virus that triggered the outbreak of Severe Acute Respiratory Syndrome (SARS) that swept the world in late 2003 and killed 775 people.

The origin of the MERS virus is still unclear. So far, it appears to spread between people only when there is close, prolonged contact.

(Reporting by Mahmoud Habboush; Editing by Angus McDowall and Kevin Liffey)

At 5 feet 2 inches tall, at best, "Albert" doesn't have a commanding presence. However, Riverside Regional Medical Center is counting on the tubular germ-zapping robot to eradicate hospital acquired infections.

Pulsing xenon UV-C light "on the germicide spectrum," 25,000 times more intense than the sun, it obliterates all bacteria and viruses in its path, said Rachael Sparks, technical director for Xenex Healthcare Services, which started developing the disinfection system in 2009. It does so by damaging the cell walls and fusing their DNA, she explained at a demonstration at the Newport News hospital on Friday.

Antibiotic resistant infections are a growing problem for hospitals, and in January the Centers for Disease Control started mandating the reporting of Clostridium difficile, known as C. diff, which causes extreme nausea and diarrhea and accounts for 14,000 deaths annually. Its spores can linger on surfaces for more than four months. Other target infections include MRSA (methicillin-resistant S. aureus), Acinetobacter, and VRE (vancomycin-resistant enterococci). Together, they cause about 100,000 American deaths each year.

In addition to the difficulty and expense involved in treating hospital-acquired infections -- Riverside personnel pegged it at $35,000 per patient -- there are also the emotional costs for patients kept in isolation rooms, according to Sue Moeslein, infection prevention nurse manager. "Isolation has other costs associated with it. You can't put a dollar figure on it."

Riverside Regional acquired the $84,000 Xenex disinfecting system, nick-named "Albert," in mid-April. It's the first hospital in Virginia to use it, joining approximately 125 others nationwide who've adopted it since 2011, according to Sparks.

"We're already seeing a reduction in healthcare onset infections," said Moeslein, who runs weekly infection reports, divided among community and healthcare onset.

The mobile unit, which takes approximately 10 minutes to clean each room, is currently used in the medical intensive care unit and two telemetry units as a follow-up to the regular cleaning. Riverside uses it as a supplement rather than a replacement for traditional sanitizing methods using bleach. The telemetry units were chosen for their high volume of patients, many of whom go on to other areas of the hospital, said Moeslin. "The prevention is the key," she added.

Once "Albert" is plugged in and switched on, it gives the operator 15 seconds to leave the room, said Sparks. A column rises from the body and rotates, emitting the high-intensity xenon ultraviolet light, which appears as purple flashes from behind a colored glass shield. (It's the same light that flashes at the end of airplane wingtips, said Sparks.) A highly sensitive motion detector -- as evidenced during Friday's demonstration -- causes it to shut down immediately to protect any personnel in its path.

"Albert" is typically programmed to operate for 5 minutes on either side of the bed to reach all the nooks and crannies in a room, many of which may be missed during a regular cleaning. A recent study by the Cambridge Health Alliance found that the Xenex system reduced surface contamination in operating rooms by 81 percent and air contamination by 46 percent, and was particularly effective in eliminating between-case contamination.

William Velez, operations manager for the hospital's environmental services division, believes the 10 minutes it adds to the cleaning schedule is well worth it. "It's all about safety and prevention; there shouldn't be a time limit on that. I'm proud to be a part of it. It saves lives."

A pleasant side product of the cleaning is the faint smell of ozone that lingers, a fresh scent like that after a rainstorm.

Though the Xenex robot has applications to anywhere germs might be a problem -- day care settings, cruise ships, public bathrooms -- the company's priority is the elimination of hospital-acquired infections, said Sparks. ___

By his own acknowledgement, you don't want to get to the point where you have to see Dr. Joseph Quintana. Quintana, an interventional cardiologist with Cardiology Care Consultants, deals with patients who have peripheral arterial disease, or PAD.

"I see them in all stages, but most of the time I get them at the end, close to when we have to amputate," Quintana said. "What we want to do is see these patients before they get to that stage so we can help them a lot sooner with lesser complications and be more successful."

Quintana is using the Crosser Catheter system in his effort to save limbs damaged by PAD.

PAD is a disease in which plaque -- made up of fat, cholesterol, calcium, fibrous tissue and other substances

in the blood -- builds up in the arteries that carry blood to the head, organs and limbs.

Developed by FlowCardia Inc., the Crosser system is revolutionizing treatment of chronic total occlusions, or blockages that have completely closed off circulation in arteries in the heart or legs.

"What we do is we open up the arteries," Quintana said. "If the artery is totally occluded, usually with angioplasty we are able to pass a wire and balloon or another device to fix the artery."

Unfortunately, when the artery is totally blocked and a wire can't be passed through it, many times the artery cannot be fixed.

That's when Quintana and the Crosser come in handy.

The Crosser Catheter uses high-frequency vibration to

navigate a thin 1.1-millimeter guide wire beyond chronic total occlusions. Once it is up against the blockage, the tip of the wire is made to vibrate 20,000 times a second.

"Once we are able to pass the guide wire through, we can do balloon angioplasty or place stents to open the blocked arteries up so the blood flow can keep going."

El Pasoan Shirley Best came within weeks of losing both legs below her knees.

"I've always been very active, but I got to the point where my legs were always heavy and I couldn't even walk," Best said. "I was having problems even when I would vacuum a room. My heart rate would just be pounding after a half a room."

Best, 67, had the procedure done in June 2012.

"I had been living in pain for probably seven years," Best said. "I had a blood clot in my toe at that time and I thought it was an in-grown toenail, so I let it go."

When it got to the point where she had gangrene in her toes, she knew it was time to seek help.

"I've always tried to be active, and this was really dragging me down," said Best, who retired in February to take care of her husband, who is in a nursing home. "I'm able to do more. I'm able to vacuum, I can cut my own grass and I can use my own Weed Eater. It's been wonderful."

An estimated 1.7 million people in the United States are living with limb loss -- 82 percent of them due to vascular disease -- according to the Amputee Coalition's website (amputee-coalition. org).

PAD affects more than 8 million Americans.

"Most individuals begin to have problems when they walk; they start to feel pain," Quintana said. "If you could walk a mile before, now you can only walk half a mile. The body is normally fed by nutrients, and blood flow is able to ambulate. Now, all of a sudden, because of the blockage, the areas involved need to have more blood flow. If it doesn't have it, the body responds with pain."

He said not having enough blood flow could lead to gangrene, the death of body tissue due to a lack of blood flow or a bacterial infection. Gangrene most commonly affects the extremities, including toes, fingers and limbs.

"The key is to help open up the circulation whether it be in the heart or legs to prevent amputations," he said. "By preventing an amputation, we are extending the life expectancy, and quality of life, of the patient."

He said 30 to 40 percent of the people who have amputations typically die within three to five years.

"That's what we want to prevent," he said. "If you can't walk, you can't exercise, if you can't exercise, you can't help your diabetes. It also makes it difficult to lower your cholesterol or your blood pressure."

The Crosser Catheter has a success rate of 83.5 percent.

"The risk and complications are low, it's very cost-effective, and most important to me, it saves the limb and returns the patient back into the normal productive lifestyle," Quintana said.

Other treatment options for PAD include medication or conventional angioplasty.

"Sometimes the risk factors with surgery could be higher and some of these patients may have already had by-passes and don't have enough veins to do another by-pass," he said. "By doing this procedure, our success rate is very high and the outcomes are very good."

Best said it changed her life.

"Before I go to sleep, I look at my legs," she said. "I exercise my legs and think how thankful I am that I still have them. It's God's decision when I go, but when I do go, I know this has made my life more livable."

Victor R. Martinez may be reached at vmartinez@ elpasotimes.com; 546-6128. ___

Like hospital leaders everywhere, the people running Valley Medical Center in Renton, Wash., talk frequently about the need to control soaring medical costs.

"We are working to reduce the overall cost of health care and to transform health care delivery," Lisa Jensen, chairwoman of the hospital's board of trustees, said last year.

Experts believe that's a good prescription for the entire U.S. health industry, which costs the economy far more than systems in other developed countries, delivers mediocre results and is widely seen as unsustainable at its current growth rate.

But even as Valley officials talk about change, they're paying hospital CEO Richard Roodman tens of thousands of dollars in bonuses for driving the kind of profits and expansion many say are no longer affordable for patients, employers and taxpayers.

Across the nation, boards at nonprofit hospitals such as Valley are often paying bosses much more for boosting volume rather than delivering value, according to interviews with compensation consultants and an examination of CEOs' employment contracts and bonus packages. Such deals undermine measures in the 2010 health law that aim to cut unnecessary treatment and control costs, say economists and policy authorities.

"Boards of trustees in health care are oriented around top-line, revenue goals," said Dr. Donald Berwick, a longtime reform advocate who ran Medicare and Medicaid for President Barack Obama until December 2011. "They celebrate the CEO when the hospital is full instead of rewarding business models that improve patients' care."

Thirty percent of what’s spent on U.S. health care is unnecessary, studies have estimated. U.S. hospitals spend twice as much per discharged patient as those in other developed nations without delivering much better results, according to research financed by the Commonwealth Fund.

As public and private budget pressures prompt sharper questions about how the system got so bloated, here is one answer: Hospital CEOs are paid to make it that way.

Kaiser Health News obtained compensation details for CEOs at dozens of top nonprofit and government-supported hospital systems for 2011 or 2012 via public information requests and tax filings. As many bosses noted, their incentives for growth and profits are often part of a package that also promotes clinical quality, patient satisfaction or other goals.

"More than 60 percent of my performance incentives were either in academic missions or quality measures," said Dr. Sheldon Retchin, CEO of the Virginia Commonwealth University Health System in Richmond.  "To say that I'm only interested in profits misses the entire mission." Read Retchin's full response.

Retchin's goals for earning a bonus of $205,885 (plus a salary of $864,700) included boosting profits, surgeries, admissions and outpatient visits. For all the talk about reform, CEO incentives for traditional financial goals of boosting revenue and the bottom line still far outweigh those for rigorous quality and efficiency targets, experts say.

"What you're seeing is incentive plans that look pretty similar to what they looked like five years ago or ten years ago," said James Guthrie, a hospital compensation consultant for Integrated Healthcare Strategies. "They're changing, but they're changing fairly slowly."

Along with those of smaller hospitals such as Valley, KHN examined CEO pay records from 30 of the largest private and public nonprofit hospital systems. Nonprofits deliver the large majority of hospital care. KHN did not query for-profit hospitals, whose leaders have long focused on growth and the bottom line.

Examples of CEO pay linked to finance and growth include:

Incentive targets for UCLA Hospital System CEO Dr. David Feinberg included increased profits, revenues and "further hospital system growth," such as completing a $572 million rebuilding of the system’s Santa Monica campus. Feinberg earned a 2012 bonus of $262,534.

Growth accounts for "only a fraction" of Feinberg's bonus, a system spokeswoman said.

At Banner Health, a large, nonprofit system based in Arizona, CEO Peter Fine speaks of "an unwavering commitment to improve clinical quality and efficiency." But Fine's long-term incentive goals included profits and revenue growth, the organization’s most recent filings with the Internal Revenue Service show.

Banner has been shifting incentive goals away from profits, and "the gap between financial and clinical quality is dramatically closing for us," a spokesman said. Read Banner's full response.

Goals for the $84,394 bonus earned in fiscal 2012 by Dr. Steven Gabbe, CEO of Ohio State University's Wexner Medical Center, included profits, cash, and growth in admissions, according to internal documents. Read OSU's response.

Michael Tarwater, CEO of fast-growing, Charlotte-based Carolinas HealthCare System, earned a $2.8 million bonus last year that included $1.6 million tied to targets including undisclosed financial goals. His total pay of $4.8 million that year reflects the "growth in scope and scale" of the organization, according to the system. Read Carolinas' response.

In Miami, the more profit Jackson Health System records, the bigger the bonus CEO Carlos Migoya can earn. For raising net assets past a certain point last year, he was eligible to receive a portion of the increase up to about $295,000, according to his employment contract. In March, Migoya donated the bonus -- it came to $160,000 -- to charity. Read Jackson's response.

Incentive goals for Lloyd Dean, CEO of Dignity Health, a large Catholic system based in San Francisco, include unspecified "annual and long-term financial performance," according to its most recent IRS filing. Dean's bonus for 2011 was $2.1 million. Read Dignity's response.

At the University of Virginia Medical Center, CEO R. Edward Howell proposed that his 2012 incentive bonus be tied partly to profits, new clinical initiatives and "expansion of the UVA Health System," according to internal documents. His performance bonus paid in 2012 came to $199,002. Read UVA's response.

But constant expansion at the UVA Health System and elsewhere, sought by trustees and prized as a source of jobs by community leaders, drives up insurance premiums and government spending. As health care takes up larger and larger portions of the economy, it consumes resources that might be better spent on schools, roads, corporate investment or raises for American workers, economists say.

"If the creation of jobs comes when you have overpaying systems … then growth is a reflection of screwy incentives and misalignment of payments," said Barak Richman, a Duke University law professor who specializes in health and economics. "Ultimately we're all paying for it. It's coming right out of our pockets."

Richard Umbdenstock, CEO of the American Hospital Association, defended financial goals in executive bonus packages.

"They have to include profitability or you are out of business tomorrow," he said.

And while targets for revenue and admissions growth reflect a system that has traditionally rewarded volume, CEO incentive goals "are changing," he added. "They are moving toward a greater balance toward quality and safety, patient satisfaction, employee satisfaction and finances."

Growth has been the theme at Valley Medical Center almost since CEO Richard Roodman took over in 1983. Valley is a 300-bed community hospital in suburban Seattle that gets a cut of local property taxes. In a story matched at hospitals across the country, the institution has repeatedly added space, programs, amenities and technology once reserved for top teaching hospitals to become Renton's second-biggest employer, after aircraft maker Boeing.

Patient revenue doubled over the decade ending in 2012, to $406 million, as Valley added a new surgery center; a $115 million tower that included an expanded emergency department and a joint and spine center; a birthing center with whirlpool tubs and reclining chairs for dads; and a "soothing, light-filled lobby" with pyramid skylights and waterfalls.

Roodman had extra reason to celebrate the ribbon-cutting ceremonies and expansion milestones. Often, they were tied to rewards in his paycheck.

Kaiser Health News focused on Roodman's incentives not because they are unusual but rather the contrary; experts say they are typical. Washington's public record laws ensure that more detail is available on executive pay at Valley than at hospitals in other states.

Roodman declined to be interviewed, but he answered questions via email, noting that Valley delivers millions in uncompensated care each year and stating that the best treatment and care for lower-income patients can be delivered only when hospitals are financially strong.

"Improving the health of our patients through the highest quality, safest and most effective care cannot occur in a vacuum," he said. "For us, growth is necessary as long as the demand remains, and we are growing as responsibly as possible."

In 2012 Roodman's pay was $1.2 million. That included a $213,000 bonus, about a third of which was related to financial goals and expansion.

Over several years his pay repeatedly included rewards triggered by specific achievements in building the hospital's business. For example, when Valley exceeded profit goals for three consecutive years, Roodman earned a bonus each time. When patient volume increased at the hospital's primary and specialty care clinics in 2009, he got a bonus. When urgent-care center visits grew the same year, he got another bonus.

While reformers focus on changing the "pay per procedure" incentives that induce physicians to perform excessive treatment, few seem to have noticed that incentives for the bosses like Roodman who run the hospitals and supervise the doctors point in the same direction. Because hospital officials feel obligated to put expensive equipment to use, many analysts believe the mere existence of new programs increases treatment and spending whether they are needed or not.  

In 2011, Valley's board offered Roodman a reward if the hospital increased the number of angioplasties, a procedure to clear coronary arteries that many experts believe is overprescribed. The hospital missed that target but achieved another goal on the CEO bonus menu: increasing surgeries using its da Vinci robot, a system questioned for costing much more than other methods without adding any proven benefits.

"Wow," said Dr. Martin Makary, a surgeon at Johns Hopkins Medicine and author who has criticized hospitals' promotion of robotic surgery. "It's almost a story of what's wrong with American medicine. You have an expensive technology with no advantage over standard surgery and we're rewarding based on pure volume. The metrics should not be the number of procedures but how well the patients do."

Other bonus targets included expanding Valley's chemotherapy infusion center and recruiting doctors -- a common way for hospitals to boost admissions. Valley's incentives goals for 2013 do not include increasing robotic cases.

A high point in Roodman's career was Valley's 2011 alliance with UW Medicine, the health services wing of the University of Washington in nearby Seattle. The deal mimics mergers across the country blamed for giving hospitals monopoly-like power to raise prices.

The purpose of the UW marriage was "to align services so they can be provided in a more efficient manner," Roodman told local newspapers.

Not really, said Dr. Paul Joos, an ophthalmologist and member of Valley's board who has clashed with Roodman and other trustees.

"It's nothing about affordable health care. It's just about negotiating power with the insurance companies," Joos said in an interview. "All these hospitals, they talk about quality and how to make things more affordable. But in the board meetings I'm at, they're always talking about how to charge you more."

Roodman's recent incentives, like those of many CEOs, included categories for quality, patient satisfaction and charity care in addition to expansion and financial targets.

"Quality is as important as financials and really more so," said Jensen, the head of Valley's board of trustees. "We're very focused on how health care in our organization is going to transition from fee for service to focusing more on value."

Hospitals, however, tend to see satisfaction and quality scores in the same light as concierge service and luxury sheets -- another way to attract patients and boost revenue. A few years ago, Integrated Healthcare Strategies asked hospitals why they pay executives quality and safety bonuses. "Way to grow service volumes" through publicity was one of the top reasons, along with "it's the right thing to do."

Valley's quality scores as compiled by federal regulators and the Washington Hospital Association are similar to those of other hospitals in the area. It got a "B" in the latest safety ratings by the Leapfrog Group, an employer consortium, compared with grades of "C" and "B" in reports last year. It was one of the most-penalized hospitals in the state (eighth out of 48) for high readmission rates of Medicare patients.  

"Boards tend to be comfortable with kind of average performance" in quality, Berwick said. "Whereas they might demand very aggressive performance in terms of volume and expansion, they tend to fall silent when the report shows average levels of care."

At many hospitals, simply passing a basic accreditation survey is enough to earn the CEO a quality bonus.

Valley and its new UW Medicine partner are trying to improve. Roodman's 2013 quality goals -- reducing hospital-acquired infections and achieving other safety objectives -- are "state of the art" and a big advance over his previous quality targets, said Dr. David Nash, the dean of Thomas Jefferson University’s School of Population Health in Philadelphia who also advises hospitals on incentive design.

But they still account for only 15 percent of Roodman's potential 2013 bonus. Financial goals, construction and starting or expanding half a dozen programs such as neurosciences and a sports and spine clinic, on the other hand, make up a much bigger portion.  

Compensation specialists expect hospital boards to increase quality expectations and deemphasize growth and the bottom line in future CEO bonus plans, especially as insurers and Medicare reward quality and efficiency more highly. But they predict it will take years.

"I'd say we're just starting down that road," said James Otto, a health care pay consultant for the Hay Group. "Until there's more of that transition from volume to value, you'll see [incentive] plans that aren't dramatically different on a year-over-year basis. But if you and I had this conversation in say, eight years, what plans are measuring will be significantly different."

For his part, Roodman is focused on expansion.

"You can look at growth purely for the sake of growth, or you can look at who the growth is intended to serve and why," he said via email. "We plan to continue to grow and expand our clinical services because it meets the needs of our constituents."

The problem, Berwick said, is that almost every other hospital CEO thinks the same way. Executives who talk about streamlining the industry are rarely the ones to volunteer, he said.

"We want to have growing market share and let our competitors die," is their attitude, Berwick said. "When you're in a market where that's the case, guess what happens? They all continue to stand and grow -- and costs go up without value."

Kaiser Health News staff writer Sarah Barr contributed to this report.

Should hospitals award CEOs bonuses for growth and profits or for quality and efficiency? That's the wrong question, some authorities believe. They think hospital bosses shouldn't get any bonus pay.

"I don't think there's a role today for hospital CEOs to have a bonus program," said Dr. James Weinstein, CEO of Dartmouth-Hitchcock health system in New Hampshire. "Strategic growth is an enigma to me. What we're trying to do is manage people and we're trying to keep them outside of a hospital. Our success is keeping people away from health care systems and providing health."

Nonprofit hospitals have mimicked corporate America by motivating CEOs with payments tied to the bottom line and other goals. But boards and CEOs at some of the most admired and efficient health systems in the country believe any kind of incentive pay for the top boss is a mistake.

Weinstein, a spine surgeon who took over at Dartmouth-Hitchcock in 2011 after years of studying health-cost disparities at The Dartmouth Institute, isn't eligible for an incentive bonus. At the Mayo Clinic, CEO Dr. John Noseworthy "typically does not receive bonus compensation," a spokesman said.

Neither does Dr. Delos "Toby" Cosgrove, CEO of the Cleveland Clinic, which was praised by President Barack Obama along with Mayo as delivering "the highest quality care at costs well below the national norm."

Bonuses make it too easy for leaders to focus on finances instead of patients, said Joseph Scaminace, head of the board of directors' committee that sets executive pay at the Cleveland Clinic.

"Whenever the subject has ever been raised by any of our board members, it very quickly gets tabled as something that's very inappropriate," Scaminace said. "The culture of the clinic is the very core of the clinic. To tinker with that culture with incentives that are focused on return on investments wouldn't just be folly. It would be so wrong."

Weinstein, who eliminated 400 jobs in 2011 in an effort to control costs, says that he's already very well paid and that his job requires him to run the highest-quality, most efficient system he can, even without bonuses.

"I believe if you do the quality right, the finances will work themselves out," he said, suggesting financially successful hospitals could give resources back to the community instead of endlessly growing.

"Maybe we should provide [cholesterol] drugs free to everybody who lives in New Hampshire," he said. "It shouldn't be just about building more buildings and new structures."

The business of Rick Goings, CEO of Orlando-based Tupperware Brands, is selling containers for leftover tuna salad. By law, his employment contract is posted online along with all the details of his compensation incentives.

On the other side of Orlando, Donald Jernigan is CEO of Adventist Health System. His business is saving lives at more than 40 nonprofit hospitals in a dozen states. But information about the compensation and incentives that motivate Jernigan and other hospital CEOs is much harder to come by than that of bosses in less vital industries.

Health spending has grown almost twice as fast as the overall economy in recent years, shocking government budgets and eroding workers' raises at companies forced to pay more and more for health coverage. Hospitals account for the biggest piece of the rising bill.

To shed light on incentives for medical system growth, Kaiser Health News queried dozens of hospital groups, including 30 of the biggest public and private nonprofit medical organizations in the country. We asked for copies of the CEO's employment contract as well as the targets that determine his or her incentive bonus. The institutions' responses and the documents disclosing what are frequently multimillion-dollar pay packages can be found here.

State institutions such as Ohio State University's Wexner Medical Center and UCLA Hospital System are often subject to public information laws. Most of these systems furnished at least a portion of what KHN sought. The University of Michigan Hospitals and Health Centers supplied descriptions of CEO Douglas Strong's bonuses for 2010 but not for later years. Those incentives, it said, are "sensitive information" that might give an edge to competitors if disclosed.

Almost all the private, nonprofit systems declined to provide KHN with their CEO's employment contract or full details of incentive plans.  To get some information on their incentives, KHN turned to Internal Revenue Service filings. Since 2008 the agency has required nonprofits to disclose the amount of incentive bonuses for top people, descriptions of these "non-fixed payments" and indications of whether they are tied to profits or revenue.

But disclosures are limited at best. Adventist's filing gives no explanation for Jernigan's $271,000 incentive and bonus compensation for 2011. A spokesman said it was for achieving operating and performance targets, without elaboration.

At Kaiser Permanente, the California-based insurer and hospital chain, CEO George Halvorson’s pay of $7.9 million included a $5 million bonus -- the largest of any that KHN looked at. (KHN is not affiliated with Kaiser Permanente.)

Kaiser Permanente's IRS filing says that the bonus came from the achievement of goals to "support the organization's mission to provide high-quality, affordable care and improve the health of its members and the communities it serves."

Asked for details, the company said Halvorson's incentive goals included "quality measures, membership growth, operating income and expense trends and community benefit levels." But it didn't disclose targets or payouts for each category.

Nowhere are IRS filings as informative as what Catholic Health Partners, a private nonprofit system in Cincinnati, has disclosed voluntarily. All targets for CHP's "system scorecard" for bonuses -- from cash in the bank to minority employment to mortality and readmissions rates -- were published last year (see page 79) by the Commonwealth Center for Governance Studies in Kentucky.

"It never hit my consciousness screen that I wouldn't want to do this," CHP CEO Michael Connelly said of furnishing the data. Disclosing incentive formulas that many systems deem confidential, he said, is part of "our mission to be advancing the quality of health care and serving the community."

YORK, Pa -- After 10 years battling persistent cysts and tumors that formed in her breasts, Karen Muro opted for breast reduction surgery in February 2010.

Although the growths were always benign, the condition is a precursor to cancer, Muro said. Cancer was detected in Muro's pathology report immediately following the reduction surgery.

"The cancer was an embedded cancer that was not detected with all prior tests and procedures or scans," she said via email. Muro, who moved to Conewago Township in 2011, was sent to see Dr. Beth Baughman DuPree, a surgeon and medical director of The Holy Redeemer Breast Health Program outside Philadelphia. She lived in Bucks County at the time.

"I walked into the office very scared, very concerned, very afraid," Muro recalled. "That is when the true transformation of health and wellness kicked in."

DuPree, who grew up in Spring Garden Township and graduated from York Suburban High School, has earned critical acclaim for her work combining modern holistic healthcare with traditional western treatments.

Patients are encouraged to consider counseling, massage and yoga as part of their treatment regimen. DuPree also practices Reiki, a Japanese method of healing a patient by the transfer of energy through the palms.

The comprehensive treatment program put Muro in the right frame of mind to tackle cancer. The benefits to her overall health were tremendous, she said. For one thing, Muro lost 110 pounds.

"It's changed my entire life," Muro said. "It's changed my family unit. ... With all these integrated therapies, I have become very involved in meditation. It gave my husband and my daughter and I the chance to decide what is important in my treatment."

DuPree was recently named a 2013 REAL Awards recipient by the international organization, Save the Children. She joined eight other honorees nationwide. In their first year, the awards honor health care

workers who are nominated for making a difference in their communities.

Being in the best frame of mind gives her patients the best chance to overcome cancer, DuPree said.

"Every individual who comes into our facility is embraced as a whole individual," she said. "They come in with all of this stuff. The easy part is treating the cancer. You treat the cancer with chemo and radiation."

Brother's death

DuPree, 51, traces her empathy for her patients to the tragic death of her brother while in high school in 1978.

"I went through a period of questioning my faith," said DuPree, who attended St. Mark's Lutheran Church in York at the time. "I think anybody who gets hit by that kind of trauma questions things. ... It took a lot of years for me to heal that loss."

She was inspired to become a surgeon after working with Dr. Robert Davis, a retired plastic surgeon who practiced at York Hospital and still lives in York. Davis repaired her niece's cleft lip.

"He was much more of an old-fashioned doctor, but he really embraced treating the entire patient," DuPree recalled.

DuPree, who received her medical degree from Hahnemann University in 1987, has written a book entitled "The Healing Consciousness: A Doctor's Journey to Healing." It is the true story of her journey as a surgeon who awakens to the healer that resides within her.

The first edition was released in 2006 and in 2008, the second edition printing includes transcribed spiritual messages.

In addition to removing the fear of cancer and getting patients in the right frame of mind, DuPree's health strategy lastly focuses on wellness. That is, establishing healthy behaviors like exercise and a good nutrition.

"Seventy-five percent of our breast cancers are happening in women who have no family history and they're coming about because of poor nutrition, processed foods, obesity and lack of exercise," she said.

DuPree established the nonprofit The Healing Consciousness Foundation in 2007. The foundation offers patients nutritional counseling, exercise training, meditation, guided imagery, Reiki, massage, reflexology, acupuncture and other holistic therapies.

Her sister, Ann Griffiths, who also graduated York Suburban, is the executive director of the foundation.

"It's very personalized for each person," she said. "When someone is diagnosed, we actually provide them with a letter ... introducing them to the foundation. The patient gets to pick and choose which of the services they'd like to receive."

The foundation often picks up the tab for treatments not covered by a patient's insurance. Insurance companies are beginning to pay for at least some of the wellness programs, Griffiths said.

"Dr. DuPree feels that a man or a woman who has been diagnosed with breast cancer is in the fight of their life (and) they should not have to fight for the things that should be given to them," Muro said.

'The best thing'

Muro and her husband spent 20 years living in Perkasie, Bucks County. As part of her cancer recovery, they moved to York County to enjoy a more relaxed life.

A human resources specialist with the Pennsylvania Turnpike Commission, Muro calls her cancer diagnosis "by far the best thing that's ever happened to me."

"I was not a person who prior to cancer who was looking at life in a wonderful way," she said. "Had I not been diagnosed with cancer, I don't think I would recognize how wonderful life is."

That's not to say the fight was easy. Cancer-free, Muro still drives two hours one way for monthly meetings of the Bucks County Breast Friends support group started by DuPree.

"There were days I wanted to give up, days I did not want to continue the fight," said Muro, who credits DuPree. "She's a doctor who treats each patient as though they're her only patient. She's a doctor who sits in front of you and says 'You're not going to die. We're going to beat this together.'"

Although some patients do die, DuPree doesn't regret getting emotionally involved in their lives.

"I'd much rather feel that emotion and shed those tears than give up the opportunity to share those experiences with the patients," she said. "It's that connection between two individuals that we will have forever."

@jhilton32; 717-771-2024

Can health insurance companies get members to eat healthier?

Medica is trying a traditional method to influence people's buying choices -- saving money with coupons -- and giving it a techno spin.

Instead of mailing coupons on nearly 500 products for members to clip, Medica is giving members a preloaded loyalty card and adds 10 to 25 new virtual coupons each week.

No clipping, no forgetting, no fumbling. Packets and cards will be mailed to Medica's 200,000 members in Minnesota on Monday.

John Naylor, senior vice president of Medica's commercial market division, said obesity is a bulge battle that needs to be fought with "baby steps and big steps." He describes the new Healthy Savings program as a medium step.

The hope is that incentives will help members make more healthful choices at the supermarket. By saving 75 cents here and a dollar there on products as varied as Clif protein bars, Musselman's unsweetened applesauce and Gold'n Plump boneless, skinless chicken breasts, members may end up making fewer trips to the doctor's office.

Medica's program is similar to others tried by HealthPartners and Blue Cross Blue Shield of Minnesota. Coupon promotions, along with gift cards, are becoming a new health management tactic that's simple and cost effective.

HealthPartners' Linkwell program, which ended last year, mailed out coupons to nearly 80,000 members, mostly those who had filed claims related to diabetes, high blood pressure and heart disease.

Blue Cross Blue Shield of Minnesota's Market Bucks program has focused on low-income residents. It matches up to $5 in purchases made at participating farmers markets through Supplemental Nutrition Assistance Programs.

Does a coupon really have the power to change people's eating habits? Experts say any approach to better nutrition must be multifaceted and an incentive program is just one part of the plan.

The overall redemption rate for paper coupons is only 0.8 percent, but insurers have a slightly better track record. HealthPartners' redemption rate for its Linkwell coupons was between 5 and 10 percent, said Scott Aebischer, senior vice president.

Blue Cross' gift card promos have a 1 percent redemption rate, although the number is expected to increase as more farmers markets accept electronic benefit transfer cards, according to Stacy Housman, communications manager.

High expectations

Medica's program has higher expectations. "We're expecting a redemption rate of 20 to 30 percent," said Chad Kelly, chief marketing officer for Solutran, a Minneapolis-based technology company that's providing the incentive system.

That's significantly higher than the 7.8 percent redemption rate for paperless and mobile coupons, according to NCH Marketing Institute. "When it's a targeted audience that's interested in the topic, that helps increase participation," said Charlie Brown, vice president of marketing at NCH.

Part of the projected success is also the value. "The coupons represent good savings of 50 cents, 75 cents or a dollar per item," Kelly said.

In addition to the coupon redemption card, the insurer is starting an automatic e-mail program and a mobile app website to add interest. Members can use the website to track their savings and check content, including recipes, nutritional information and tips for healthier eating.

The cards can be used at Cub, Rainbow and Lunds/Byerly's stores. Rainbow will also place "healthy savings by Medica" cards near each of the hundreds of items that qualify for the discount program.

The program has no projected end date, according to Medica.

Robert Jeffery, a professor at the University of Minnesota School of Public Health, said that is important. "Most healthy eating behavior goes away when the incentive is taken away." ___

While the Supreme Court's decision to forbid patents on human genes knocked out Myriad Genetics' long-guarded patent on two genes linked to breast cancer, the Utah-based company's stock still rose soon after the news broke. That bit of investor optimism may have been due to the court's decision to allow patenting of cDNA, which they called "synthetically created" -- though it's unclear if that optimism is warranted, doctors pointed out.

The Supreme Court ruled unanimously that although "naturally occurring" DNA like the genes BRCA1 and BRCA2 could not be patented, the company could still patent the cDNA version of these two genes, classifying those as man-made products. Complementary DNA, or cDNA, copies the parts of a particular DNA strand that code for proteins (exons) while excluding the bits of non-coding DNA (introns).

Dr. Cy Stein, chair of medical oncology at City of Hope in Duarte, applauded the two separate aspects of the Supreme Court decision. Forbidding the patenting of human genes would allow more researchers to explore targeted therapies for genes linked to breast and other cancers, he said.

"It's just a fantastic thing, and it has released a serious chill that we were all feeling," Stein said.

At the same time, allowing companies to patent cDNA as a man-made product threw a bone to companies looking to protect their work.

"You have to have some protection. ... People have to be able to make a profit somehow," Stein said.

But UCLA medical geneticist Dr. Wayne Grody said that the cDNA provision didn't amount to much protection in light of technological advances since the patents were filed. Researchers no longer need to copy a strand of DNA in order to get its sequence, he said.

"The modern technology will give us the DNA sequence of anything that's in the test tube," Grody said. "We don't need to have any prior knowledge of its sequence."

Thus, the cDNA protections may not have been as much cause for celebration among Myriad's supporters as they initially seemed, he added.

"It's almost a moot point. ... It doesn't stop the rest of us from now using our own techniques to examine these genes," Grody said.

Follow me on Twitter @aminawrite. ___

I recently posted about my upcoming  Healthcare Unbound presentation on why healthcare disruption is happening too slowly and requested some thoughts from my readers. This morning I woke up to receive these terrific remarks from Jeroen Bouwens which I’m sharing with permission:

My theory as to what is holding back certain types of innovation in healthcare is the idea of distributing liability. As long as the ultimate responsibility, and therefore liability, lies with the Medical practitioner, they are extremely reluctant to accept automated systems making medical decisions.

At the same time, medical device manufacturers are extremely reluctant to accept liability, because a single system error replicated over many devices can easily result in a company-destroying avalanche of lawsuits.

The result is medical devices that, for all the fancy user interfaces, soothing colors and sexy design enclosures, are still nothing more than dumb terminals that do whatever the doctor tells them to do

Ok, maybe that is not entirely fair to modern devices, which are, in some ways, much more advanced than in the past, but it also not that far from the truth.

I mentioned to Jeroen that I agree with his assessment. I do think that a lack of clarity of what happens with liability within an ecosystem of trusted partners and how that liability is appropriately and fairly distributed is probably a great impediment to innovation in healthcare.

My specific experience in the medical device development community leads me to believe that the lack of connectivity between devices can, indeed, partly be blamed on no single vendor wanting to take on additional liability for another vendor’s errors or data.

What do you think about liability distribution? Are there are other things you think are specifically holding back innovation in healthcare? Drop me a comment here or send me a private email if you’d like to discuss it further.

Using brain scans and exercise stress tests, researchers have identified two biologically distinct subgroups of veterans suffering from so-called Gulf War illness.

Their bodies reacted differently to physical exertion, and their brains had atrophied in different regions. None of the patterns were seen in a control group of healthy subjects.

The findings, published online Friday in the journal PLOS One, are part of a growing body of work that the authors said could eventually lead to biological markers for the mysterious condition, which is still defined defined by its hodgepodge of symptoms.

"That's the hope," said Georgetown University researcher Rakib Rayhan, lead author of the study.

Still, the importance of the differences his team identified is far from clear, said Dr. Beatrice Golomb, an expert on Gulf War illness at UC San Diego who was not involved in the research.

There are many ways to parse any population of patients with a condition that is so variable and diverse, she said. After the 1991 Persian Gulf War, veterans began complaining of a wide range of problems, including pain, fatigue, headaches and cognitive impairment. The symptoms ranged from mild to debilitating.

Up to 30% of the 700,000 troops who served in the war are thought to be affected.

Though exposure to nerve agents, pesticides and smoke from burning oil wells have all been deemed possible culprits, no definitive cause has been identified.

"It was a very toxic environment we were around," said 54-year-old Angela McLamb, who developed symptoms of Gulf War illness in 1991 while she was on a U.S. base in Saudi Arabia working as an air traffic controller.

She has suffered ever since from problems ranging from severe fatigue to speech and memory difficulties, she said, and can no longer work. "We used to be in excellent shape," she said. "But our bodies have been destroyed from within."

She was one of 28 veterans with the condition participating in the study.

The Georgetown team set out to look at the structure and function of their brains.

Each subject received two brain scans while undergoing cognitive testing -- one at rest and one after an exercise session on a stationary bicycle. Physical exertion can cause extreme malaise in veterans suffering from the condition, and the researchers wanted to see how it affected their brains.

The hourlong scans, known as functional MRIs, allow scientists to see the structure of the brain and which parts are being activated. The veterans also underwent various physiological tests.

To the surprise of the researchers, two groups of veterans emerged in the analysis.

In 18 of the veterans, levels of pain were elevated after exercise. Their scans showed a loss of brain matter in the regions associated with pain regulation.

In the other 10 veterans, exercise triggered a condition in which moving from lying down to standing causes the heart to race. They had atrophy in the brain stem, which controls heart rate and blood pressure.

The two groups also had distinct patterns of brain activity during cognitive testing.

McLamb said the discovery of biological markers for Gulf War illness would help eliminate a popular but increasingly discredited belief that the condition is psychological and stems from stress.

"I never thought I would be happy to say I have brain damage," she said. "But I am. Because I deal with this on a daily basis."

Twitter: @alanzarembo ___

Consequently, providers face another tough decision to make, such as, selecting either a single or multi-specialty specific EMR. This decision is based on what the provider wants or expects from the EMR, the type of practice, and the number of different specialties  at the practice.

A single-specialty specific EMR will not be developed according to the specifications of different specialties. It will have the major or most common patient care options for a single specialty and will not incline towards multiple specialties. This can be viewed both as good and bad. It is good in the sense that for a provider who does not specialize in a specific field of healthcare, or for a hospital which employs general diagnosticians; it will be easier to get acclimatized to the single specialty EMR. It is bad for the provider(s) who practice in a specific specialty such as dermatology, oncology, orthopedic or cardiology, based at single practice.

Multi-specific specialty EMRs are geared towards and developed for practices which employ more than one specialty. If a hospital employs a dermatologist, an oncologist and a cardiologist, then the use of a multi-specific EMR would be highly beneficial for the practice since the software will be customized to usage by different specialties.

Like any other technology, there is no ideal sized solution that will cater to all types and sizes of healthcare practices.

Taking this as a consideration, Health IT vendors have developed solutions that come in different versions, catering to different types and sizes of practices. So, practices need to consider their requirements and needs before opting for an EMR.

But what is really going on in their practices? In two studies generated from a survey by AmericanEHRPartners of 1,400 with responses from about 696 physicians and 150 allied health professionals has uncovered some interesting information. AmericanEHRPartners was formed in 2010 by formed by Cientis Technologies and the American College of Physicians to help physicians compare and implement electronic health records.

In a clinical work setting, doctors who have electronic health records said they use their smartphones in clinical settings every day to:

1. Send and receive emails (65 percent);
2. Use apps (51 percent);
3. Instant messaging (50 percent);
4. Researching information about medications (35 percent);
5. Communicating with other physicians (32 percent).

But switch “smartphones” to “tablets” and you get this response:

1. Send and receive e-mails (52.4 percent);
2. Accessing electronic health records (50.6 percent);
3. Accessing diagnostic information (41.7 percent);
4. Research information about medication (33.3 percent);
5. Staying up to date with medical journals and papers (29.8 percent).

The findings in part confirm what we already knew, particularly abut physicians’ interest in sending and receiving emails. And it’s maybe not so surprising that physicians would prefer to access EHRs on a wider screen than what a smartphone can offer. But those companies focused on messaging between physicians and other healthcare professionals get some more validation with the finding that half of physicians use their smartphne every day for instant messaging.

Among the other findings were

• A little more than 60 percent access electronic medical records through their device’s browser rather than thru the vendor’s app.
•  One-third of EHR users and one-quarter of non-EHR users use a tablet device in their medical practice.

• More than 70 percent of tablet users who access EHR through them have a password.
• About 32 percent have a device tracker app installed on their tablet and the ability to remotely wipe all data on their tablet if lost or stolen (31 percent).
• EHR users spend 25 hours on their tablet each week, with a greater amount of time spent
  on business (59%) than for personal reasons (41 percent).

Every survey has its Achilles heel and this one is do different. In a question that could have been assembled by the Colbert report writers or just the tablet manufacturing lobby in general, survey respondents were asked if they were “satisfied” or “very satisfied” with using their tablet in their medical practice. Maybe it’s just a pet peeve and I don’t appreciate the value of those questions but it misses a good opportunity to get some specifics.

NEW YORK (Reuters Health) - Living in an area with few general surgeons may make people with appendicitis more likely to turn into ruptured appendix cases by the time they get to surgery, according to new research.

"The study shows that access to surgical care, especially general surgical care, is important and low access can have real impacts that affect peoples' health," coauthor Thomas Ricketts of the University of North Carolina at Chapel Hill told Reuters Health by email.

The Affordable Care Act includes a provision for incentive payments to increase the supply of doctors in areas with shortages, but those bonuses only apply in places with too few primary care doctors.

General surgeon and primary care shortage areas don't always line up, Ricketts said, and even when they do, general surgeons can't move to areas that don't already have primary care physicians to serve the community and refer patients back to them.

Almost 30,000 patients with appendicitis - a quarter of whom suffered a burst appendix - were discharged from hospitals in North Carolina between 2007 and 2009, according to data from hospitals and surgery centers in the state analyzed by the researchers.

There are 95,000 burst appendices per year in the U.S. according to the Agency for Healthcare Research and Quality. A 2008 study found that an appendectomy can cost between $10,000 and $18,000 more when the appendix has burst.

With surgery before a rupture, typically about 20 hours or less after abdominal pain begins, patients usually recover quickly. If the appendix has burst (roughly 40 hours after symptoms begin), that could mean repeat operations and longer recovery time, according to the Merck Manual.

To see whether a surgeon shortage was linked to more burst appendices in an area, the researchers compared the number of cases of appendicitis, and specifically burst appendices, with the number of general surgeons in "surgical service areas" of the state that roughly align with zip codes.

Having less than 3 general surgeons per 100,000 people increased the likelihood of having a ruptured appendix by five percent, compared to areas with at least 5 surgeons, Ricketts and his colleague report in the Annals of Surgery.

However, areas with the most severe shortage had a 25 percent rate of rupture, compared to 24 percent in areas with no shortage. According to Dr. Edward Livingston, who has written about using ruptured appendices as a measure of care but was not involved in the new study, that is much too small a difference to draw any conclusions.

Logic dictates that ruptures would be more common in rural areas, since patients have to travel farther to get to care, but that's the opposite of what the study found if the results are reliable, said Livingston, the deputy editor for clinical content at the Journal of the American Medical Association in Chicago.

There were fewer surgeons relative to the population in urban areas, but the study didn't account for the residents, physician's assistants and nurse practitioners who add to the surgical work force in large urban medical centers, Livingston said.

The results of the same study with more patients from more diverse regions might not show any difference between groups at all, Livingston told Reuters Health in an email.

It would make more sense to measure the delay between when symptoms begin and when the patient reaches surgery in several different areas, and see if areas with longer delays correspond to areas with fewer surgeons, in order to infer that fewer surgeons lead to delays which lead to ruptures, Livingston said.

"They would have to measure the delay to prove their point," Livingston said.

"This highlights a problem in studies like this one, where conclusions are made based on assumptions about what happens without really knowing what is happening at a patient level," he said.

SOURCE: http://bit.ly/ZL7CcO Annals of Surgery May 31, 2013

Waist-to-height ratio may be a more accurate measure of cardiovascular health risk than the current standard, the body mass index, a local expert says.

He's confident that the waist-to-height ratio may soon eclipse the BMI as a measure of risk for lifestyle diseases such as cardiovascular disease, heart attack, stroke and diabetes.

Not so fast, says another expert: While the height-weight ratio has value, it needs to mature a bit to be more precise.

The ratio says waistlines should be no more than half of height, said Dr. Mario Morales, medical director of the SSM Weight-Loss Institute at DePaul Health Center. For example, a 6-foot (72 inches) person should maintain a waistline of 36 inches, he said. Growing past that can lead to health risks, he said.

Recent studies show risks that developed from the 50 percent point grow with the waistlines, he said, to the point that people whose waistlines reach 80 percent of their height shortened their life spans by 17 years.

The latest research that excited Morales, a bariatric surgeon, was delivered in May at the 19th Congress on Obesity in Lyon, France. Researchers there told European media flatly: "Keeping the waist circumference to less than half of height can help increase life expectancy for every person in the world."

The European researchers suggested using the waist-to-height ratio as a screening tool to predict health risks. The study analyzed the health of more than 300,000 people and found the ratio was better able to predict high blood pressure, diabetes, heart attacks and strokes than BMI.

The new measure is "much more sensitive to (health risks) than BMI," because weight-to-height ratio takes into account "where the patients hold their weight -- apple shape, pear shape," Morales said. "Fat that's behind the abdominal wall is not just cells; it's called metabolic reactive fat. It creates (chemicals) that cause inflammation. Inflammation results in scar formation and can cause malfunction of the organs."

So organs are exposed to "... adverse hormones and inflammation chemicals that cause diabetes, heart disease, kidney disease -- those types of things," Morales said.

SOME WEIGHT LESS DANGEROUS

Carrying weight in other parts of the body is not so dangerous, he said. "If you carry weight in your hips or up around your chest, it's not so significant," he said. But, "Weight in the central region is metabolically reactive and causes metabolic syndrome."

And the BMI doesn't address that, he said.

Instead, the BMI measures the ratio of height to weight and nothing else. The resulting numbers categorize people as normal weight, overweight, obese and morbidly obese.

Another weight-loss expert wasn't so excited. He called the measure promising, but "young."

"Waist to height ratio may be a better predictor of cardiometabolic risk -- cardiovascular disease and diabetes -- than a body mass index assessment," said Dr. Samuel Klein, director of the Center for Human Nutrition at Washington University. But, "the relationship between waist to height ratio and disease risk is a continuum. The problem is that we do not know what are the optimal 'cut points' (categorized measures) on this continuum that will best identify people at increased risk. However the BMI is more precise.''

Cut points have been established for BMI (normal, 18.5 to 25; overweight, 25 to 30; moderately obese, 30 to 35; severely obese, 35 to 40; and very severely obese, 40 and over) but not for waist-to-height ratio, he said.

Granted, the BMI can be an inaccurate predictor of risk for people who have excess muscle mass, such as athletes, Klein said, as well as be inaccurate for people who have lower BMIs but excess body fat and decreased muscle mass.

But that just means the measures should be used as one of many tools for physicians to diagnose a person's health risks, he said.

LONG HISTORY OF BMI

The BMI was developed about 1850 in Belgium by researchers seeking a way to categorize degrees of weight in people. In the 1990s it became a popular tool for doctors and insurance companies to gauge health risks. However, the BMI has shortcomings.

It was found to be useless to the point of humorous for athletes whose weight is due to muscle mass rather than body fat. The most commonly used example is that Arnold Schwartzenegger's BMI was 30.8 during his peak years, which would categorize him as obese.

In addition, for African-Americans and young people the BMI is at best iffy because of ethnic and age differences in muscle mass and other factors.

Waistline circumference has long been a measure of metabolic syndrome.

In addition, Morales said. The weight-to-height ratio is consistent for all groups regardless of fitness, ethnicity, gender or age, he said.

"We've had nothing in the studies that show variances for ethnic groups," Morales said. Also, "There's no difference in the measure from children to adults of any age."

Still, Klein said, the measure needs more work.

"Waist circumference isn't anything new; we've known that it is a better predictor than BMI for identifying people at risk for cardiometabolic diseases for many years," he said.

"The problem is that we need to establish what specific waist circumference values should be used to identify people who are at increased risk and demonstrate that these values are better than the current BMI values before waist-to-height ratio is ready for prime time," he said.

While the standard of measure is in flux, the remedy is the same for getting rid of any excess fat, Morales said. Eat less, exercise more. Get help doing it if it's not possible to do it alone. ___

The financial penalties that Medicare imposes on hospitals with high rates of patient readmissions are too harsh for hospitals serving the poor and should be changed, according to a congressional advisory agency.

Since last fall, Medicare has been reducing its payments to 2,213 hospitals under a provision in the health care law that aims to improve quality at the nation's hospitals. The penalties kick in when patients with heart failure, heart attack or pneumonia are readmitted at higher than expected rates within 30 days.

While the Medicare policy seems to be having an effect - facilities are scurrying to keep better tabs on their high-risk patients after discharge - some hospital officials and other experts say the penalties are unfair because hospitals that treat the poorest patients are getting hit harder than others.

"The idea is right, but the implementation has been greatly flawed by penalizing hospitals that take care of the most vulnerable patients," said Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges.

Low-income patients, doctors and researchers say, are more likely to have trouble following hospital instructions for taking care of themselves after discharge. They don't always have easy access to doctors to monitor their recuperations and sometimes can't afford needed medications.

The maximum penalties, now set at 1 percent of Medicare payments, are scheduled to double to 2 percent starting in October and 3 percent in the fall of 2014.

In the District of Columbia, Howard University Hospital, which treats the largest share of low-income patients, is being penalized the most of any area hospital; since last October, its Medicare payments have been reduced by 0.95 percent. Sibley Memorial Hospital, which treats the smallest share of poor patients, was the only District hospital to avoid a penalty, data show.

In Virginia, Mary Washington Hospital in Fredericksburg and Culpeper Regional Hospital were penalized 1 percent. Maryland hospitals are exempted from the federal program because the state has a unique reimbursement system.

Medicare has disagreed that the readmissions penalty program needs revisions. But the report to Congress from the Medicare Payment Advisory Commission, or MedPAC, agreed with critics that there are "shortcomings" that "can work at cross purposes to the policy's intent." The criticisms carry extra weight because MedPAC helped devise the readmission penalties, calling for them back in 2008.

MedPAC found that hospitals where fewer than 3 percent of Medicare patients were low income received an average penalty of 0.21 percent. Hospitals where more than 18 percent of Medicare patients were low income had an average penalty more than twice that, 0.45 percent.

"Income is still an important … variable in explaining variation in readmissions," the commission said. It recommended that in future years, when determining penalties, Medicare compare a hospital's readmission rates to those of hospitals with comparable numbers of poor patients. Penalties can be a drain on safety net hospitals, many of which operate on slim profits or at a loss.

The Centers for Medicare & Medicaid Services did not comment on the MedPAC recommendations. In the past, officials have noted that after years of holding steady, the national hospital readmission rate last year dipped below 18 percent.

But MedPAC warned that if the penalty formula remains unchanged many hospitals will continue to get penalized in future years even if they reduce readmissions because they will be judged on how they compare to the entire industry. MedPAC proposed that Medicare set target readmission rates for hospitals each year and exempt from penalties those that succeed.

"These are all steps in the right direction," said Dr. Ashish Jha, a Harvard School of Public Health researcher who first documented the unevenness of the penalties. “MedPAC is thinking smartly about this and they're looking at the evidence coming and making changes to the metrics."

Changing the program, however, might not be easy. Medicare officials have said that many details were spelled out in the 2010 law, making them difficult to change in light of deep partisan divisions in Congress.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

NEW YORK (Reuters Health) - For people with existing heart problems, exposure to high levels of air pollution can trigger the irregular heartbeats that may lead to a stroke or heart attack, according to a new study.

Past research has linked air pollution to ventricular fibrillation, electrical confusion in the lower chambers of the heart which can cause sudden death.

The new study also finds an association with atrial fibrillation (AF), erratic quivering in the heart's upper chambers and the most common type of irregular heartbeat.

"As in all epidemiological studies we do not prove causation, but rather an association," said lead author Dr. Mark Link, a cardiologist at Tufts Medical Center in Boston.

His study included people with so-called implantable cardioverter defibrillators (ICDs), which record when the heart's electrical activity is abnormal and deliver shocks to try to right the rhythm.

Link and his colleagues analyzed data from the ICDs of 176 heart patients and compared it to air quality data collected in the region.

Over about two years, 49 of those people had a total of 328 AF episodes.

The researchers found that the level of air pollution, including soot-like particles, on a given day was directly tied to heart rhythm problems.

With every 6 microgram per cubic meter increase in fine particulate pollution, for example, people were 26 percent more likely to have an AF episode in the next two hours, the study team reported in the Journal of the American College of Cardiology.

That extra risk is greater than the 1 percent increased risk of death from heart attack and the 18 percent increased risk of stroke seen with each 10 microgram per cubic meter rise in pollution in other studies, Link noted.

The daily average particulate pollution level in Massachusetts, where the study took place, was 8.4 micrograms per cubic meter, well below the upper limit of 35 set by the Environmental Protection Agency (EPA).

More than two million Americans have AF, according to the Centers for Disease Control and Prevention. Although it can cause rapid heartbeat, lightheadedness and fatigue, AF doesn't always come with symptoms.

"This study does show that there is an increased association, especially within two hours of air pollutant levels being high, with a person having an irregular heart rhythm," said Dr. Comilla Sasson, who studies community-wide risk for cardiac arrest at the University of Colorado in Denver.

But it does not look at how often those irregular rhythms lead to more deadly problems such as heart attack or sudden death, she added.

"Although this is interesting, it still leaves a lot more questions than providing answers," Sasson told Reuters Health in an email.

She questioned whether or not the EPA should reevaluate its air quality standards and if doctors should be talking to patients about increased risks on pollution-heavy days.

"There is much more research that will need to be done, especially in other cities, to see if these results hold true," she said.

Although the study focused on people at unusually high risk already, an increase in the chance of AF could have implications for anyone, Link said.

"Unfortunately, all of us are at risk for AF, especially as we age. It is by far the most common arrhythmia in the U.S. and for that matter, the entire world," he said.

Boston has relatively clean air, which makes the results all the more troubling, Link told Reuters Health.

"Imagine what the effect of air pollution is in cities without the clean air of Boston," he said.

SOURCE: http://bit.ly/14yT1AH Journal of the American College of Cardiology, June 13, 2013.

"Bloomberg" reports that Paris prosecutors have opened an investigation into drug packaging mistakes at a Teva Pharmaceutical Industries Ltd. (NYSE: TEVA; TASE: TEVA) plant in Sens, in north-central France, which may have killed six people. The preliminary inquiry was opened today. Teva has suspended shipments from the plant.

The case involves the switching of packages of its heart failure medication Furosemide with the sleeping pill Zopiclone. France's National Agency for the Safety of Medicines and Health Products (MSNA) ordered a recall of the packaging, after the mislabeling was linked to possible patient deaths, and the hospitalization of others.

Yesterday, "Radio Europe 1" reported that MNSA suspects that product tampering may be behind the switching of the packaging, after no breakdown was found in the Furosemide production line, and that it was not possible to switch the packaging without human intervention.

Teva says that it is continuing its internal investigation into the matter and has started opening, under a court bailiff's supervision, blister packs of furosemide, adding that, so far, the inspection has found no Zopiclone sleeping tablets inside the furosemide blisters.

Teva is cooperating in the investigation, which is apparently focused on finding an employee or other person who switched the packaging on the production line.

Teva said in repsonse, "Teva has welcomed a report from the ANSM, the French regulatory body, following an inspection at the company's packaging site in Sens, France, after which the agency said that its preliminary findings did not identify any faults in the organization, practices or the equipment at the site."

"Teva France this week recalled all batches of furosemide Teva 40 mg tablets, a medicine used in the treatment of heart disease, following one pharmacist report indicating that a blister pack from one of these batches included a tablet that was not furosemide 40mg but zopiclone 7.5mg, a medicine used for the treatment of insomnia."

"Teva continues to conduct its internal investigation and to open and inspect blisters of furosemide Teva 40mg (diuretic). At this time, none of the blisters of furosemide 40mg we have opened contained a zoplicone tablet."

"Teva France has apologized for any inconvenience to its patients, and the company will work to complete its review as soon as possible. Other markets and other Teva France products are not affected by the recall."

"Some media reports have linked at least one patient death in France to this issue. Teva has expressed its sorrow to hear of the death of any patient, but the company has not at this time received any evidence that this was connected to the recalled product; and is cooperating fully with the authorities in their investigations." ___

(Reuters) - The U.S. Food and Drug Administration on Thursday urged medical device makers and medical facilities to upgrade security protections to protect against potential cyber threats that could compromise the devices or patient privacy.

It released that advisory in coordination with a separate alert from the Department of Homeland Security, which disclosed vulnerability in a wide variety of medical equipment that can make those devices vulnerable to remote attacks from hackers.

"Over the past year, we've become increasingly aware of cyber security vulnerabilities in incidents that have been reported to us," William Maisel, deputy director for science at the FDA's Center for Devices and Radiological Health, said in an interview. "Hundreds of medical devices have been affected, involving dozens of manufacturers," Maisel said, adding that many were infected by malicious software, or malware.

But he said all the infections appeared to be unintentional, largely due to malware and computer viruses that were circulating in hospital computer networks and jumped onto the devices.

An alert published on the government's Industrial Control Systems Cyber Emergency Response Team website, cited research from Billy Rios and Terry McCorkle of the cyber security firm Cylance Inc, who said they have identified more than 300 pieces of medical equipment that are vulnerable to cyber attack. They include surgical and anesthesia devices, ventilators, drug infusion pumps, patient monitors and external defibrillators.

The problem with the equipment is that it can be controlled using default passwords that can be obtained with relative ease by motivated hackers, Rios said in an interview. Those passwords give their holders complete control of the devices and in some cases can be used to gain that access remotely via the Internet, he said.

"Somebody could take over the device and make it do whatever they want it to do and it would be almost impossible for hospital staff to know that it had been tampered with," Rios said.

Rios and McCorkle are among a group of security experts who in recent years have suggested that medical devices such as insulin pumps and pacemakers could be vulnerable to hacking.

The FDA on Thursday said it is not aware of any patient injuries or deaths associated with devices and hospital computer networks that have been infected with malware and computer viruses.

In an advisory on its website, however, the FDA said manufacturers, hospitals and patients need to protect themselves better from the introduction of malware in medical equipment and unauthorized access to settings that control devices.

"Many medical devices contain configurable embedded computer systems that can be vulnerable to cybersecurity breaches," the agency said.

The risk of breaches has grown as devices have become increasingly interconnected, via the Internet, hospital networks, other medical devices and smartphones, the FDA said.

"Specifically we recommend that manufacturers review their cybersecurity practices and policies to assure that appropriate safeguards are in place to prevent unauthorized access or modification to their medical devices or compromise of the security of the hospital network that may be connected to the device," the agency said.

Among its recommendations, the FDA said manufacturers need to take steps to limit unauthorized device access to trusted users only, particularly for devices that are "life sustaining" or could be directly connected to hospital networks.

User IDs, passwords and other security controls need to be strengthened, including potential use of biometrics, the agency said. Moreover, manufacturers need to assure that devices recover and continue to work once security has been compromised.

"Cybersecurity incidents are increasingly likely," the FDA said, "and manufacturers should consider incident response plans that address the possibility of degraded operation and efficient restoration and recovery."

The FDA also urged health care facilities to evaluate their network security, including restricting unauthorized access to the network and networked devices.

(Reporting by Ransdell Pierson in New York and Jim Finkle in Boston; Editing by Ros Krasny, Dan Grebler and Bernard Orr)

Strumpf is an emergency physician and the CEO of Emergency Medicine Scribe Systems, a California company that hires, trains and manages medical scribes deployed across the country. He implemented a scribe system in the 30-physician medical group he’s part of more than a decade ago, and decided a few years ago to turn it into a business for outside clients.

Despite somewhat of a slow start, California-based EMSS now sees 30 percent to 40 percent growth annually, Strumpf said. It has just closed a $2.5 million Series A investment round and is hoping to up the growth rate even higher to 50 percent in the coming years.

As the majority of providers continue to push forward with EMR implementation, scribes can take some of the administrative workload off of physicians’ shoulders, allowing them to spend more quality time with patients. And as patient satisfaction is becoming an increasingly important metric for physicians, having a scribe to chart patient encounters into the EMR, generate referral letters and help with e-prescribing seems to be quite a value proposition.

“It’s kind of a crazy concept to have a highly compensated physician wasting time doing very low-compensation data entry work,” Strumpf said. “It typically takes two to three minutes to dictate a record, while these (EHR) systems take 12 to 15 minutes per patient to input all of the required data.”

EMSS is one of several companies providing scribe services, alongside ScribeAmerica,  PhysAssist Scribes and Elite Medical Scribes, but Strumpf said it’s a hard business to break into. The idea of a scribe might be great, but a company’s real value lies in the kinds of scribes it can recruit and how it can train them, and depends on how much providers are willing to pay for them. (Check out a great read on an emergency physician’s experience with a scribe here.)

Strumpf said scribes are typically pre-medical or pre-nursing students who use the position as a stepping stone for a career in healthcare. EMSS screen them for computer literacy, spelling and other skills, and they go through 80 to 100 hours of training in HIPAA privacy, medical terminology, coding procedures and EHR technology.

Strumpf said the company currently has 1,200 scribes under management in 14 states.

Shortly after she was diagnosed with breast cancer, Scorchy Barrington came upon her first post-mastectomy photo.

The image, one in a series of unflinching portraits at The SCAR Project (thescarproject.org), was of a young woman with very fair skin sitting in front of a window. There were horizontal scars across the her reconstructed breasts and tears streaming down her cheeks.

"I welled up. It surprised me that it was so powerful," says Barrington, 53, of New York.

"It's like darn it, she's still living. You know, you've got to live; you don't have any choice. Just keep going."

So when Barrington learned two weeks ago that Facebook, a major conduit for these increasingly popular cancer survivor photos, had removed four of them and banned SCAR Project photographer David Jay for 30 days, she swung into action, launching a Change.org petition that rapidly gained more than 20,000 signatures.

And on Tuesday, she says, she got what she wanted. Facebook, which says it has long allowed the photos, posted a formal statement on its Website affirming the value of the photos and saying that the "vast majority" comply with Facebook policies.

A Facebook spokesperson declined to comment on whether the company was responding to Barrington's petition. But Barrington said that Facebook officials had set up a conference call with her and Jay, and had been very receptive to their call for a written policy statement, even adopting the "vast majority" language they suggested.

"It turned out to be a win-win," says Barrington.

"Facebook was good to work with -- it wasn't this scary monolith."

In its statement, Facebook said:

"We only review or remove photos after they have been reported to us by people who see the images in their News Feeds or otherwise discover them.

"On occasion, we may remove a photo showing mastectomy scarring either by mistake, as our teams review millions of pieces of content daily, or because a photo has violated our terms for other reasons."

In an interview with the Tribune, Jay said he's excited that Facebook issued a formal statement.

Barrington, an archivist and blogger who has stage IV breast cancer, says mastectomy photos represent a broader shift in patient attitudes.

"I think the ship is starting to turn, with the whole pink ribbon business," she says, referring to the popular symbol of breast cancer awareness.

"There are more people out there saying, look, what I have, it's life-changing. It's life and death in some cases. It's not a pink ribbon, it's not a pink mixer, it's not a pink Coke can. This is really life and death."

[Image from flickr user wiccked]

In a unanimous vote, the nine justices reached a compromise by saying synthetically produced genetic material can be patented but that genes extracted from the human body, known as isolated DNA, do not merit the same legal protections.