When Stefanie Bruemmer, the IT director for Queens Long Island Medical Group (QLIMG) in suburban New York, decided it was time to replace the legacy Avaya PBX system with new technology, she was looking to cut costs and minimize the capital outlay for replacement hardware.

“I was looking to reduce monthly expenses,” Bruemmer explains. “Originally, we weren’t considering a VoIP solution.” However, after reviewing proposals for replacement equipment, Bruemmer realized a Level 3 Communications solution would save significant financial outlays, reduce monthly communications expenses and provide a variety of scaleable and flexible features for the 21-facility, physician-owned medical group.

“At first, I was a little concerned about the quality,” Bruemmer admits. But a pilot implementation at two of the medical group’s facilities, including the corporate headquarters in Garden City, N.Y. where she is based, convinced her that VoIP was highly reliable. Another key benefit was that Level 3’s system ran on an open architecture, so that she could add a PBX or other phone equipment from virtually any vendor in future years if she so desires.

“That’s what really sold it,” says Bruemmer, who successfully lobbied the purchase through her hospital group’s chief executive and chief financial officer. “We couldn’t find a reason not to buy Level 3.”

FULL SERVICE VOIP

QLIMG started its search for a replacement phone system in December 2003. The two pilot installations involving 120 Internet phones went live in mid-August. The entire installation is planned to be completed at all 21 of the company’s medical facilities on Oct. 29. Although still in its prototype phase, VoIP appears to be delivering clear benefits.

Unlike some other VoIP business customers, the medical group will use its system to communicate not just among internal staff, but for everyday interaction with thousands of outside customers In fact the various VoIP calling features allow the medical group to handle in-patient telephone calls more efficiently. Patient calls are seamlessly transferred among the different facilities. Previously, patients had to hang up and dial different facilities separately if a health care provider was on the move or a referral was made.

The Washington, D.C.-based Marijuana Policy Project has provided more money to back voter initiatives to legalize marijuana than local supporters in three states where the issue is on the ballot.

Voters in Alaska, Montana and Oregon will decide in November.

The Alaska State Public Offices Commission reported the D.C. group has provided 93 percent of the $550,000 budget for Alaskans For Marijuana Regulation and Control.

The local organization has spent the money for radio and television ads, direct mail, paying staffers and conducting voter registration phone drives.

The Marijuana Policy Project has spent about $476,000 in Oregon and $197,000 in Montana.

The Alaska question would allow persons over age 21 to possess marijuana and require the state to adopt regulations for the legal processing and sale of the drug. Sale to minors would be prohibited.

Montana and Oregon would legalize marijuana for persons with cancer, AIDS and other serious illnesses.

The Marijuana Policy Project estimates Oregon would immediately have more than 10,000 users if the ballot initiative passes. The measure would require the state to establish nonprofit medical marijuana dispensaries.

Maintenance Organization: A Historical Perspective

As the Air Force has evolved, many factors have come into play with respect to the organization of aircraft maintenance functions–technology (to include systems and systems reliability and maintainability), budgetary constraints, spares availability, manpower availability, and training. From a historical perspective, in response to these factors, two trends can be seen–alternating centralized decentralized operations and moving between standardized and MAJCOM-driven maintenance organizations. As a backdrop for transformation and lessons to be learned, “Maintenance Organization: A Historical Perspective” reviews the evolution of the Air Force maintenance organization.

A historical perspective

Maintenance Organization

Over the years, many factors have affected the way aircraft maintenance has been organized, including training requirements, technician skill levels, availability of personnel (manning levels), availability of spares, budgetary constraints, and technical systems reliability and maintainability. Historically, training requirements have increased as aircraft complexity has increased. As the manpower levels were decreased, generalist training was resumed–but only until aircraft complexity drove the need for greater specialization.

Maintenance Organization During the Early 1900s

World War I, Decentralized Maintenance

Prior to 1917, the flying squadron had evolved as the established tactical unit. The squadron commander was responsible for upkeep and repair of all airplanes and equipment under his command. Aviation mechanics, enlisted men of any grade, were appointed after testing. There was a basic company and section formation; officers were pilots who were also in charge of section maintenance. Aircraft were technologically unsophisticated, and enlisted personnel were experts on the entire aircraft.

With today’s rising healthcare costs, specialists are under the gun to save money wherever possible, while still providing top-notch care. Providers stagger under the weight of administrative loads generated by even small practices, while the demands of patients, affiliated health plans and referring providers grow each day.

By moving paper-, phone- and fax-based processes to the Web, healthcare organizations can help slash the high cost of administrative waste. One important element of successfully managing and streamlining the administrative flow of interacting with health plans is Web-based connectivity.

Health Plans Can Help

Not long ago, Orthopedic and Sports Medicine of Erie (OSM) was a prime example of an overburdened provider. With three physicians and 35,000 patients, the practice was overwhelmed with the paperwork required to correspond with its affiliated health plans. Finally, with no viable solution to help her staff as they struggled to stay on top of the workload, Practice Manager Charlene Kellerman began looking for a way to handle the day-to-day functions required to keep the practice running smoothly.

With 30 percent of OSM’s patients covered by Highmark Inc., Kellerman went directly to the health plan to lobby for a better way to handle administrative transactions. “We asked Highmark to find a way to use the Internet for some of our paperwork and other manual processes,” she said. “The paper chase for referrals alone was unbelievably difficult, and our staff could barely keep up with the workflow. Highmark took our request seriously, and we were one of the health plan’s first providers to begin processing transactions via the Web.” That was in the fall of 2000, and Kellerman and her staff have been enjoying the benefits of Web-based connectivity ever since.

Pain-free Connectivity

Luckily for OSM, choosing the technology was painless. The practice did not have to endure the process of evaluating its needs, debating whether to buy or to build, choosing a technology vendor or integrating the technology into new and existing processes. Highmark had already done that homework and deployed the technology, NaviMedix’s NaviNet platform, offering it to OSM and the rest of its network providers free of charge.

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)–collectively known as “test characteristics”–are important ways to express the usefulness of diagnostic tests. The 2 x 2 tables from which these terms are derived are familiar to some physicians (Table).

Sensitivity is the “true positive rate,” equivalent to a/a+c. Specificity is the “true negative rate,” equivalent to d/b+d. PPV is the proportion of people with a positive test result who actually have the disease (a/a+b); NPV is the proportion of those with a negative result who do not have the disease (d/c+d).

Sensitivity and specificity are fixed for a particular type of test. PPV and NPV for a particular type of test depend upon the prevalence of a disease in a population. For example, though current screening tests for HIV have high sensitivity and specificity, the low prevalence of HIV in the general population cannot justify universal screening since the majority of positive tests would be falsely positive (ie, low PPV).

* HOW TO REMEMBER THESE TERMS

Begin by assuming that you have 4 patients. For the first 2 you know only their disease status; for the last 2 patients you know only their test result.

You know your patient’s disease status:

1. Sensitivity: “I know my patient has the disease. What is the chance that the test will show that my patient has it?”

2. Specificity: “I know my patient doesn’t have the disease. What is the chance that the test will show that my patient doesn’t have it?”

You have just gotten a test result and do not know your patient’s disease status:

3. PPV: “I just got a positive test result back on my patient. What is the chance that my patient actually has the disease?”

4. For NPV: “I just got a negative test result back on my patient. What is the chance that my patient actually doesn’t have the disease?”

The American Medical Student Association (AMSA) is leading a national reform effort in conjunction with federal legislation to address the issues of physician burnout and medical errors. AMSA is encouraging medical students nationwide to call their representatives in Washington, D.C., to support the federal regulation of resident work hours as introduced by the Patients and Physician Safety and Protection Act of 2001 (PPSPA). The legislation was introduced in November 2001 by Rep. John Conyers, Jr., (D-Mich.) and calls for a limit on resident work hours of 80 hours per week and no more than 24 hours per shift. The proposed legislation will also provide for annual surveys of resident-physician working conditions, public disclosure of hospitals that violate the hours limits and the imposition of civil penalties for noncompliant hospitals. This legislation has been endorsed by such organizations as the Committee of Interns and Residents, the Center for Patient Advocacy, the American Medical Women’s Association, Public Citizen, and the Service Employees International Union.

There it was, in an article in black and white, on page 3129 of the June 19, 2002 issue of the Journal of the American Medical Association (JAMA), unequivocally stating: “We recommend that all adults take one multivitamin daily. This practice is justified mainly by the known and suspected benefits of supplemental folate and vitamins … in preventing cardiovascular disease, cancer, and osteoproosis….” The authors of the article even included a nifty little table with an overview on vitamins and their benefits for the attention-deprived reader.

Remember, we are talking about the American Medical Association (AMA) here–doctors from the hallowed halls of mediocrity when it comes to discussing anything to do with dietary supplements. This plainly rings of some sort of endorsement since JAMA is the AMA’s official organ. Could it be someone slipped them some sort of “Sensibility Viagra” which awakened the flaccid brain cells occupying those coveted editorial chairs?

One month later JAMA created another tempest when they revealed, lo and behold, hormone replacement therapy actually carries risks (see accompanying editorial). And this, only a week or two after AMA handwringing in front of the press decrying the cost of malpractice insurance and how it is driving numerous doctors out of business. Although certainly, amputating the wrong foot, as some doctors are wont to do, will always fall under the heading of malpractice. Of course, one or two inadvertent amputations won’t get your license yanked by the “good old boy” network of state medical boards packed with AMA cronies. Bad doctors have more lives than the proverbial cat. Perhaps if that 10 percent of doctors who continually make the major mistakes truly had their licenses revoked, the malpractice insurance rates would go down. But that would be even more of a double standard, since true malpractice exists simply by ignoring what has been in front of you for years; in other words, being so shortsighted you refuse to see the value of vitamin therapy or the danger of hormone replacement. The data is all there, it always has been, it’s just not in JAMA and the other “traditional” journals. Doctors need to actually look for the relevant treatments that will benefit their patients now, not ten years later when they read the watered-down versions. Read something that will be clinically useful…. Hmmm, I can recommend a nice little journal….

Former Surgeon General Dr. David Satcher is the third recipient of the Association of American Medical Colleges’ Herbert W. Nickers, M.D. award. Satcher was honored at the association’s 113th Annual Meeting held last month in San Francisco. Satcher delivered an address on targeting health care disparities by increasing the diversity of medical school applicants at the meeting.

The Herbert W. Nickens, M.D. Award, named for the AAMC’s former vice president of the Division of Community and Minority Programs, is presented to an individual who has made outstanding contributions to promote justice in medical education and health care.

As Surgeon General from 1998 to 2002 and assistant secretary for health, the second person in history to hold both positions simultaneously, Satcher led the federal government’s effort to eliminate racial and ethnic disparities in health care. This initiative was incorporated into one of two major goals of “Healthy People 2010,” the nation’s public health agenda for the next several years.

Satcher is currently director of the National Center for Primary Care at the Morehouse School of Medicine, where he once served as professor and chairman of community medicine and family practice, over two decades ago.

Last year, the Nickens Award was presented to former University of Michigan President Lee Bollinger for his commitment to promoting diversity in higher education. The first recipient of the Nickens Award was Dr. Donald Wilson, dean of the University of Maryland School of Medicine, and founding member of the Association of Academic Minority Physicians.

The Association of American Medical Colleges represents the 125 accredited U.S. medical schools; the 16 accredited Canadian medical schools; some 400 major teaching hospitals, including Veterans Administration medical centers; more than 105,000 faculty in 98 academic and scientific societies; and the nation’s 66,000 medical students and 97,000 residents.

* Subtle, natural course changes are seen as most effective.

* Students are trained to respond to “all events,” not just specific attacks.

* Efforts are under way to enable benchmarking by other institutions.

The bioterrorism training program at the University of Pittsburgh School of Medicine, among the first of its kind in the nation, has been described as a model by the Washington, DC-based Association of American Medical Colleges (AAMC) during its recent annual meeting.

The program integrates level-appropriate content throughout the four-year medical school curriculum, placing the appropriate content into existing courses and evaluations. Students are taught how to identify, triage, and treat patients exposed to biological, chemical, and radiological terrorism, emerging infectious diseases, and environmental pollution. They also are taught about food and water source safety, the impact of pharmaceutical treatments, terrorist hoaxes, and technologic threats to the continuity of public and health services.

Officials from the school currently are working to help foster benchmarking in other medical teaching facilities in an effort to better prepare health care professionals to deal with potential future biodisasters.

“This type of content has always been included in med school curricula,” notes John D. Mahoney, MD, assistant dean for medical education. “But when I learned about it in the `80s, it was as history–anthrax was about sheep handlers, and the military worried about chemical weapons. Military medical school had hundreds of hours of classes, while we had snippets.”

But when Mahoney developed the current curriculum, he brought to the process his background as an emergency physician and toxicologist.

“Disaster response is about getting out there and getting your hands dirty. I was used to thinking about all of the bad things that could happen–and helping our hospital plan for them. As we headed toward Y2K, as the rest of the country was increasingly worried about threats of chemical weapons, I felt we should cover them in our curriculum,” he explains.

An American Medical Association (AMA) report on the effects of alcohol on the brain dispels the myth that youth are more resilient than adults to adverse effects of drinking. Harmful Consequences of Alcohol Use on the Brains of Children, Adolescents, and College Students is a comprehensive compilation of two decades of scientific research on how alcohol alters the developing brain and causes possibly irreversible damage.

On average, youngsters try alcohol for the first time at the age of 12, and nearly 20% of 12- to 20-year-olds report being binge drinkers (having four or five drinks in a row). Citing the alcohol industry’s aggressive marketing to youth as one of this trend’s key drivers, the AMA has called on cable stations and television networks to pledge publicly to stop airing alcohol commercials to young viewers. “After NBC announced their plans [In December, 2001] to run hard-liquor ads, the AMA successfully lobbied the network to reverse this ill-advised decision,” notes J. Edward Hill, chairman of the organization. “One year later, the alcohol industry is just as aggressive in pursuing underage minds through television, and television is all too willing to comply. This is out of step with public health and public opinion.”

A nationwide poll conducted for the Robert Wood Johnson Foundation found that nearly 70% of Americans favor a ban on television liquor ads and 59% support banning beer commercials. The AMA pledge calls on networks and cable TV not to broadcast alcohol ads on programs that air before 10 p.m. or that have 15% or more underage viewers. It also calls on networks and cable TV not to broadcast alcohol commercials depicting mascots, cartoons, or other characters that are targeted to younger viewers.

“It’s time TV executives and the alcohol industry stop profiting at the hands of those most harmed by drinking,” Hill argues. “This report reminds us of how important it is to protect our children during these crucial early years of development instead of filling their growing brains with the misleading notions that drinking is normal and without consequence.”