The CEO of a Cambridge, Mass.-based hospital recently wrote a great blog post about how his own health issues have impacted his views of healthcare reform.

"The true promise of health care reform is a transformation to a system that prevents disease more than it treats it," Dennis D. Keefe, CEO of Cambridge Health Alliance, writes for WBUR, a Boston-based National Public Radio affiliate. "There's plenty of money in the system, we just aren't spending it correctly, or aiming it at the programs that produce the best results."

Noting how the proactive steps he has taken to control his diabetes has resulted in fewer medications and trips to his doctor's office, he writes that while "it may seem strange for a hospital CEO to be envisioning declining patient volumes...that's the point. If we are to really succeed with reform that lowers costs as well as improves outcomes, physicians and other clinicians will have to become health educators and hospitals and clinics will be wellness centers."

You can read the rest on WBUR's website.

If you work at a hospital, you know these institutions are pretty traditional when it comes to modes of communications. And now there's the brave new world of social media thrown into the mix. If you've already dipped your toes into the water, bravo!

If your organization is still on the fence, you'll likely meet up with a few nervous naysayers who, understandably, have concerns. Here are a few ways to alleviate their apprehension:

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We could be sued! Your legal and risk management folks very likely can tick off a lengthy list of potential liabilities that exist in the social media world. You'll hear words such as slander, libel and even a new term--"twible" (defamation made through a Twitter account) and their potential for lawsuits. Of course their concerns are valid, so how do you work through them?

At Lifespan, we worked with our legal and risk management department to discuss these potential threats and recognize they are out there. At the same time, the facts of social media must be discussed--the rapid increase in the use of this technology for communication is first and foremost and the numbers speak for themselves. More and more people--including your patients, staff, and competitors--are diving into the waters of social media and talking about you. If the chatter is good--fantastic. If it's bad, address it through these methods, and take larger steps if necessary.

There's always the chance of lawsuits--but this is true of any industry. But does the fear of malpractice lawsuits stop our physicians from practicing medicine? No. And having your legal department on board with this new vehicle of communication will help them be aware of the realities of social media.

The website LegalTechnology has a whole section dedicated to just this topic. There's also a great report out there by Russell Herder and Ethos Business Law that discusses all these issues. Should you be concerned? Yes. Should it stop you from building a brand loyalty and reaching out to people through the fastest-growing mode of communication? Definitely not.

What is someone violates our corporate standards? HR may be concerned about violations of corporate standards and your corporate compliance policy. Rightly so, but there are conversations happening in hallways, break rooms and elevators every day that you might never hear.

These same types of conversations are also taking place in the social media sphere, allowing you to monitor them and even be part of them. Get HR involved early on, help them understand that this is just another form of communication, and all the same rules apply, and then have a plan in place to communicate to staff.

Our firewalls won't allow it. If your organization is like ours, IT is a high priority and firewalls are in place--all for good reason. But that protection can create a nightmare when trying to access blocked sites like Facebook and YouTube when you begin to implement a social media presence. It's vital to get your IT folks on board beforehand so you'll have access to the sites you need.

This will invariably bring up another issue--now that you've entered the world of social media, do you have your staff come on board with you, or will social networking sites remain inaccessible from computers within the hospital? (Of course you can't forget about mobile devices that already provide access anyway!) A recent blog post by Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, addresses this issue.

All of these issues are warranted, especially when we are in the business of providing healthcare and we are held to the strictest standards in protected health information. So what do you do? Build a plan that includes the development of policies and guidelines.

Develop a policy: Even if you've already become part of the social media world, it's not too late to develop policies that will serve as a guide for your employees. It's also good to let your fans and followers know what your public policy is.

If you don't know where to start, there are plenty of sample policies out there to help you mold your own. You can even find them with one simple search in Twitter, because the "tweeps" (those who follow others on Twitter) out there are always so helpful. (Another reason to enter social media--information at your fingertips!)

Here's the bottom line: People will be talking about you and your hospital in the world of social media. If you're not involved, you'll never know what's being said, and you certainly can't respond. So it's better to see the obstacles and work your way through them to be part of this new mode of communication. The rewards definitely outweigh the risks.

Nancy Cawley Jean blogs regularly about social media for Hospital Impact. She is a senior media relations officer for Lifespan, a five-hospital system in Rhode Island. A communications and media relations specialist, she manages the national media relations for research at Rhode Island Hospital and Hasbro Children's Hospital, in Providence, and oversees social media for Lifespan.

In my last post for Hospital Impact, I spoke of the possibility of standards-based meaningful use criteria, and performance-based meaningful use, such as recording the number of smokers enrolled in cessation. Hidden beneath these regulations are a whole other set of compliance standards that are yet to be discussed: internal controls.

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When you hear the term 'internal controls,' you may think of them in terms of the financial industry's Sarbanes-Oxley (SOX) compliance. However, internal controls have also manifested within the healthcare and life sciences industries. HIPAA deals with internal controls in the concept of how privacy is protected. The FDA regulation, 21 CFR Part 11, takes into account internal controls by requiring audit trails on access to GMP data stored electronically.

Internal controls will ultimately be required for meaningful use compliance, especially the performance-based regulations. For instance, if a provider must report the number of smokers enrolled in a cessation class, how can it verify whether the number is accurate? Although there is no way to be 100 percent certain, internal controls could help improve the certainty. Audit trails and electronic signatures can verify who accessed the files. Standard Operating Procedures can confirm whether those individuals have authority to adjust the enrollment number. Then, training records can confirm if those individuals understand what those enrollment numbers represent.

The need for providers to establish a meaningful use compliance framework is not a question of "if," but rather a question of "when." Providers must begin thinking in terms of standards, performance and internal controls.

Joseph Ingemi is a blogger, Certified Information Systems Auditor, and certified Project Management Professional who writes about healthcare IT issues. He also consults on healthcare IT issues through his company, Pinarus Technologies.

FierceHealthFinance: Based on the experiences of your member hospitals, what is your global forecast for hospitals nationwide in 2010 as the national RAC program ramps up?

Rueben: Florida, like New York and California, served as the initial testing ground for the Centers for Medicare and Medicaid Services to develop the RAC program.

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For example, the demonstration RACs could look back four years, but in the national program CMS has limited the look-back period to three years past the claim paid date, as well as setting a maximum look-back date of Oct. 1, 2007. In addition, CMS has limited the amount of information that the national RACs can collect without good reason. The RACs won't be able to conduct either automated or complex medical reviews of more than 10 records without obtaining CMS approval via a new issue review process and identifying all approved issues for review on their websites. And even with this, there is now a limit on the number of records that can be requested every 45 days.

Much debate and wringing of the hands occurred nationally as the demonstration unfolded in the test states. These and other changes to the national program mean that hospitals around the country can breathe easier about RAC implementation in 2010 and beyond. That said, hospitals certainly need to take the program very seriously and prepare for national implementation.

FHF: If CMS holds to its current timetable, hospitals could begin seeing complex reviews for DRG (diagnosis-related groups) validation and coding errors by the end of the year, and for medical necessity in 2010. Based on Florida's experiences with complex reviews in the demonstration, what should hospitals expect?

Rueben: In complex reviews, the RACs are looking for claims that aren't substantiated. It is up to the hospital to ensure that physicians provide documentation that adequately substantiates coding, DRG assignment, and medical necessity of services. Hospitals in Florida have worked to develop billing systems that will help them avoid having claims pulled in the first place and documentation systems that will substantiate any claims that do get pulled by a RAC. Hospitals must understand that they have to get it right the first time if they want to avoid extra bureaucratic burdens.

FHF: What do you foresee as the biggest misunderstanding about the appeals process in the national RAC program?

Rueben: With a program like this, the contractors get very ambitious in terms of the claims that they feel should be disallowed. So I anticipate a continued aggressive approach from the RACs and a lot of claims being flagged initially. However, I also expect many of those claims to end up being paid--if the hospitals appeal. At some Florida hospitals, we have found that as many as 75 to 80 percent of the claims that were first recouped are now being paid.

Interview conducted by Caralyn Davis.

FierceHealthcare: Do you have a prediction, or even a personal preference, as to what type of insurance model is going to work?

Paul Levy: The approach we're using in Massachusetts which, I think works pretty well, basically requires people to have insurance--in other words, there's a personal mandate that you have to have insurance, and then the state has created an insurance exchange. The insurance companies in the state have to live by the rules of that exchange and provide the insurance coverage, and then subsidies exist for the lower income people. I think that's a pretty practical way to do it.

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The Netherlands has a similar kind of approach where there's a requirement to have insurance, insurers are required to take anybody who wants insurance, and they use the private companies to do that. The alternative approach is to have a public option alongside those private insurers. I don't personally favor that one, because I think the other one can work as effectively, if not more so.

FH: From your comments, I take it that directly government-funded schemes--like a Medicare for all, or even single-payer--are not something that you favor?

PL: That's right. I don't like the idea, just personally, of the government controlling the broad base of health insurance in the country. I recognize that it does so with regard to Medicare--that's a particular population group--but I think for the broad base of the population, I'd prefer to rely on the private markets to do that.

FH: What effect has the Massachusetts reform scheme had on your institution?

PL: It has had very little effect. It's re-categorized some people who used to be free-care patients, to now being on an insurance plan. Financially for the hospitals, it has had very little effect because we used to get some payment through the free-care system to pay for the free-care patients, and now we get some payment through the insurance system to pay for those same patients. So overall, I think it hasn't had a big effect on the hospitals, generally.

FH: But that might not be the case in other states where, perhaps, there's not a free-care fund of any substance?

PL: That could be, but I'm not that familiar with other states. The thing with legislation is, there are always unintended consequences. I've always thought that you shouldn't make major global changes in this field. You should work on the edges and make incremental changes. But that's my personal view about how public policy should be done.

FH: Are there any issues in your mind that are so hot right now that incremental change won't do the job?

PL: I think the answer there lies with the public, and what their concerns are. I think people who currently have insurance are mainly worried about what happens if they change their job or lose their job, or if they have a pre-existing condition and they have to change insurance companies. That's why I think changing the overall regulatory scheme around insurance companies is important. The second thing is, there should be some system in place where everybody can have insurance. To me, those are the two major things, and I would focus on those.

FH: What impact--again, if any--do you think changes like mandated insurance coverage would have in a facility? It sounds like you're saying probably none at all.

PL: In our case, we're kind of ahead of the curve in Massachusetts. A lot of those changes have already happened here, so the question is, to what extent can they happen elsewhere, and be done in a way that doesn't have unintended consequences.

FH: Have there been observable, unintended consequences in Massachusetts? For example, one of your local daily newspapers reports that the wait for a primary-care doctor in the Boston metro area has jumped.

PL: I don't know if that's true. I've read stories in both directions. I just don't know.

FH: In your opinion, do you see any areas in which a system, other than in a primary-care capacity, may have trouble absorbing ranks of newly insured. Are there any other stress points you're anticipating?

PL: I haven't seen real stress points here, no. Remember, we had a very small percentage of the population who did not have insurance. There are other states that have a bigger percentage. So it may be different.

FH: Have you seen people who are not acutely sick appearing in your EDs?

PL: That's always been the case. And it's not clear how much of that has been related to having insurance versus not having insurance. I'm not sure I can really give you a complete answer to the cause of that. I'm not sure if there’s been an increase or a decrease. I think it varies, and if there is an increase or decrease, it's also hard to quantify the reasons. Sometimes it's because people actually have insurance, but they've been going to a primary-care doctor who says 'Go to the emergency room.'

FH: One question about Massachusetts: What are the unintended consequences of perhaps the market reactions to the mandated coverage issue? While people with, say, chronic illnesses can still get insurance, but there will be traps billed into the insurance that still make it very hard to use and the insurance companies will still win, somehow in terms of denying care, just in a different way.

PL: You do need to regulate the companies to ensure you don't get unintended consequences. There's a question there as to what extent the federal government is willing to take over that regulatory function from the states. That's an issue that Congress has to deal with.

FH: Do you think systematic health reform is really needed?

PL: Well, the use of the word reform is always problematic because one person's reform is one person's reverse. I think what's really needed is a movement to provide as many people as possible with insurance so they can get access to preventative care and primary care and the like. That kind of change, in terms of insurance coverage, I think has to occur at a national level.

There are a few parts of this that would be helpful. One, which I believe is in almost every bill that's been proposed so far, is changes in the rules so that insurance companies cannot deny coverage to people because of pre-existing conditions, and other provisions like that which make it difficult to get insurance. That does take a change in national law, because right now the insurance industry is regulated in several states, and there's wide variation in those rules.

For example, insurance companies in Massachusetts are not allowed to use pre-existing conditions as an exclusion. I'm hard-pressed to find anyone who disagrees with that kind of regulatory change, and I'm hoping that that survives all of these different bills.

The next question is, how do you provide insurance to all members of a population? And here, obviously, you have to make it available, but also, a large number of people can't afford it. So some kind of subsidy is required. This gets to the nub of the problem in Washington, which is that if you provide a subsidy to one group of people, someone has to pay for that. And the forum--how that payment takes place--is a major political fight, because when you are creating a new subsidy, you're taking money away from some other group in some other way. That's a traditional political problem that Congress and the president have to face--what's the best way to finance a national mandate?

A lot of the discussion in Washington right now is about that issue. The degree to which Congress is willing to do some kind of broad-based tax is directly correlated to the degree in which they want to provide a subsidy; which is to say, the more subsidies you offer, the more money you have to raise, and the more money you have to raise, the broader the tax vehicle. If you have a very narrow tax plan, it can't raise as much money as you otherwise would want.

That, I view as the major political battle going on in Washington right now, and I think it's one that will be hard to work out.

FH: What do you think would happen if the entire souffle of health reform collapsed, and nothing changed?

PL: It's inconceivable that that would happen. Something will pass, and the world will be better for it.

Interview by Anne Zieger, senior editor, FierceHealthcare and FierceHealthFinance.

"We have some issues here," a CEO of a mid-sized community hospital told me.

"We have a pluralistic medical staff of employed, contracted, and independent doctors who are in revolt. After our residency was put on probation several years ago, we set up a hospitalist teaching service, where a third of unassigned patients went, which angered the private doctors.

"Also, we have adopted a more hands-on policy with our case managers, to meet state and federal core-measure guidelines, which physicians feel interferes with their autonomy to care for patients. And we just divested a service line that lost over $2 million in the past five years, which meant that some physicians who've been with us for more than 30 years lost their jobs.

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"Nobody is happy. The private docs split admissions, so our volumes and revenues have tanked as they voted with their feet, which has decreased the volumes that our employed specialists see. Everybody is contemplating next steps.

"I can't afford to lose the private or the employed docs. I would like to engage them in a different way...if they want to be engaged. Do you think that a physician advisory group is a solution?"

At the end of the call, I told the CEO that even though I had worked with physicians in 40 states over the past decade, I've learned that when you work with one medical staff, you've worked with one medical staff. Each group of doctors has its own culture based on beliefs, attitudes, habits, and stories that one ignores at one's own peril.

To avoid "skeet-shooting," in which people make suggestions that physicians eventually shoot down, one has to admit cluelessness and encourage the physicians to come up with their own ideas so they'll have buy-in and eventual ownership. Resolving a medical staff crisis requires a facilitator--"a guide from the side, rather than a sage on the stage," a VP of medical affairs once told me.

Working with the president of the medical staff, we devised a questionnaire that could provide insight into what was going on rather than assume that we knew the answers. Questions included:

* How would you rate your experience here?
* What is going well for you?
* How likely are you to recommend this hospital to a friend, colleague, or a family member?
* On what do you base your rating?
* What is the future of this hospital?
* What role do you see yourself playing?
* Which obstacles need to be addressed now for the hospital to thrive?
* Whom else should we interview?

Most found the discussions that resulted therapeutic, and an indication that someone valued their input and validation of why they were angry and apprehensive.

Momentum began to build. Physicians who were initially too busy to participate began asking why they weren't interviewed, so I returned about a week later until we had more than 25 physicians' comments in our database.

We then set up an evening meeting chaired by the medical staff president, with opening remarks by the CEO. About 40 physicians attended. We seated them at tables of eight and asked them to discuss the things that resonated with them, the successes that we could build upon, and their recommendations for how we could improve the practice environment and their care for the community. These small-group sessions were critical for promoting physician-physician dialogue rather than physician-administrator harangues.

Result: Affirmations, such as "This is our hospital," and "We can turn this situation around," outweighed negative comments that insufficient time was allotted for discussion of past injustices.

Although I was surprised that the physicians' recommendations were not more specific than, "We need to involve physicians in proactive strategic planning rather than informing them of decisions that were made," we now have a few areas to pursue where we can draw up focused action plans for physicians to review.

And while volume, revenues, and trust may require months or even years to return, heightened transparency can facilitate an improved working environment, provided that action to improve outcomes occurs promptly. As I have previously written, chunking large tasks into two-week increments in which each step represents an outcome measure to be checked off, can bring a sense of momentum and progress to otherwise skeptical physicians. Although a kitchen cabinet of physicians may help prevent future crises, that step will have to wait till the physicians see proof that people are listening and that physicians are making their time count.

What do you think?

* Do you see reason for optimism in the face of crisis, an opportunity that creates urgency for change?
* Does reading about crises like this one make you more proactive about acting on physicians' complaints in a timely fashion, to prevent crisis where you work?
* What successes can we build on where physicians and hospital leaders work together to improve care for their communities?

I welcome your input.

Kenneth Cohn is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations.

Every once in a while, a hospital error comes to light that's so tragic and egregious, it makes national news headlines and holds our attention: Josie King, the child who died at Johns Hopkins Hospital due to severe dehydration and a medication error; Jesica Santillan, who died after receiving organs with the wrong blood type at Duke University Hospital.

This month, we learned of the latest shocking error; massive radiation overdoses at Los Angeles-based Cedars-Sinai Medical Center.

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At the heart of such errors, no doubt, are communication breakdowns, flawed work processes and documentation errors. In fact, these deficiencies likely form the basis of many of the 40,000 errors that occur in the healthcare delivery system every day.

Many hospitals have made great strides toward reducing errors and improving patient safety--including Johns Hopkins, which is now viewed as a driving force in patient safety. But other organizations continue to fall down, including some of the largest, top-funded and best-known healthcare systems in the nation.

So this begs the question: What small--and large--steps could be taken at your own organization to reduce errors and improve safety?

Where are leaders and front-line staff falling short? Where are we excelling and what can we learn from other's success? And perhaps most importantly; what have you done today to prevent a mistake?

Wendy Johnson is a healthcare journalist and publisher of FierceHealthcare and Hospital Impact.

Anne Zieger, FierceHealthcare's senior editor who named Levy as one of nine people to watch in healthcare, recently talked with Levy about how his views on blogging have evolved over the years.

FierceHealthcare: So what do you think has been the net benefit to the hospital--or you--with having this ongoing relationship with the blog?

Paul Levy: I'd be hard-pressed to say that it's had any benefit to the hospital, per se; at least it's hard to measure that kind of thing. My only hope in the blog is that it would be interesting for people to read, and that it would promote some debate and maybe educate some people as to the issues that are going on. That's all it is. It's kind of a news magazine from my point of view.

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FH: And you write all of it? Not your PR people?

PL: No, I don't let them near it. They read it when you read it. The first time they read it is when it's been published. I don't want to overstate what it is, it's a blog. There are, I don't know, 800 million blogs in the world. If people find it interesting and useful then they'll read it, if not, then they'll ignore it. I try to make it interesting, mainly by writing about things that are interesting to me--where I've learned new stuff, or I have strong opinions about something--and I guess there are enough people out there who think it's useful that they follow along, which is very nice.

FH: Do you think blogging is a good thing for hospital CEOs to do, generally?

PL: I think you don't enter into this unless you're going to be serious about it, in terms of writing on a regular basis and writing it yourself so it's in your own voice and people know it's you.

FH: So you don't have a particular strategic approach?

PL: No! This is social media! We're talking about blogging! This is not writing the great American novel. This is sitting down every day, or several times a week, writing something that comes to mind that you think is interesting and will be interesting to other people, and then it gets the immediate market test, where people out there either read it or don't.

If part of your job as CEO is to represent what's going on in your hospital and what it stands for to the public, why would you exclude a medium like this, where you can do that without being edited or filtered by reporters or editors at the newspaper or the TV station? It's a powerful vehicle if you choose to use it that way.

FH: Have you considered other forms of social media, like, say, having your own YouTube channel?

PL: No. I borrow videos from other people, but enough is enough. I don't have time to make videos. That requires real editing and the like. Blogging is fast. I mean, how long does it take to write 300 words? I enjoy it.

FH: You've been a prominent blogger--you've stuck your neck right out there. I really admired your candor in disclosing your own pay package and asking people if they approved of it.

PL: The pay of hospital CEOs is published every year by the newspapers, so it's not like I was disclosing something that wasn't going to be public. I thought it was important for people to think about how these salaries are actually set. You know, who sets them, and why, and what criteria they use; I think the public has a right to debate that kind of thing.

FH: You have to admit, though, that that's an unusual position, nonetheless.

PL: Apparently it is, for reasons I don't understand.

Next week: Read more from this interview with Levy.

While dozens of media outlets picked up on a Kaiser Permanente-led study, published in the American Journal of Managed Care, about how a "bundle" of two low-cost medications could prevent heart attacks, nearly every report I saw missed out on one major detail of the report: The researchers would never have found a link without the help of EMRs and predictive modeling technology.

Kaiser mined its KP HealthConnect EMR--its name for the Epic Systems installation across all nine Kaiser regions--to find patients at risk for heart attack or stroke to participate in the study. Once the program started, the EMR helped Kaiser clinicians track their patients' adherence to the recommended treatment.

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One of the authors, Dr. David Eddy, is the developer of the Archimedes Model, a computer-based simulator of human health, diseases, behavior and medical interventions. The Archimedes predictive modeling technology, combining mathematics and data mining, helped the researchers forecast which drug bundles would have the greatest effect on prevention of heart disease.

Yes, it's significant to know that the bundle of a statin and a blood-pressure-lowering medication cut the risk of heart attack and stroke by 71 percent in a study group already at high risk for heart disease. But isn't it much cooler to know that the drug combination was less the product of many rounds of trial and error, and more the result of a smart application of an EMR?

Compliance will be a central issue, for HHS and for providers, once the Office of the National Coordinator (ONC) releases its meaningful use criteria for physician practices and hospitals. (It's expected to be published in the Federal Register by the end of the year.)

To receive federal funding, each entity will have to comply with the criteria. Translation: All providers will need to set up quality assurance programs to ensure compliance. That's where skilled, thorough IT auditors will come in handy. But even the most experienced IT auditor will be charting new territory in evaluating meaningful use compliance.

Based on the current work of ONC, here's where an auditor's system evaluation might take two approaches:

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Performance-based: Meaningful use has desired outcomes, such as "engage patients," with desired goals attached to them, such as "provide patients with access to timely data."

Drilling down, there are also objectives within each goal. "Provide patients with an electronic copy of health records" is an objective of the "access to data" care goal. In turn, each objective has measures. The measure for this objective is the "percent of patients with access to electronic health records." The evaluator would focus on the objectives and the measures.

Standards-based: In this approach, the system is divided into functional categories, such as "communications and diagnosis." These categories are further divided into quality types, such as "communication with patients." These types have data elements that must meet certain standards. "Communication with patients," for example, includes "smoking cessation counseling/advice." In this case, free-text is acceptable. Other standards include ICD-9 and SNOMED CT.

One can envision the system evaluation process as beginning with a standards-based evaluation with periodic performance evaluations following. One thing is certain; those who are talking about meaningful use will be discussing compliance in the near future.

Joseph Ingemi is a Certified Information Systems Auditor and certified Project Management Professional who writes about healthcare IT issues at his blog, Health IT Politics. He also consults on project management and audit services in area of healthcare IT implementation and compliance through his company, Pinarus Technologies.