February 2009 - Products & Serives

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February 2009

Products & Services

New Technology

Smoke-free policy leads to dramatic, sustained drop in heart attack

Heart attack hospitalizations in the city of Pueblo, Colorado fell sharply after the implementation of a municipal law making workplaces and public places smoke-free, and this decrease was sustained over a three-year period, according to the Morbidity and Mortality Weekly Report.

The study found there were 399 hospital admissions for heart attacks in Pueblo in the 18 months before the city’s smoke-free ordinance took effect on July 1, 2003, compared to 237 heart attack hospitalizations in the similar period from 18 months to three years after this date – a decline of 41 percent.

Nine published studies have reported that laws making indoor workplaces and public places smoke-free were associated with sizable, rapid reductions in hospital admissions for heart attacks. However, most of these studies looked at only a year or less of data after the implementation of smoke-free laws. This latest study, which covers three years after the Pueblo smoke-free law’s effective date, suggests that the initial reduction in heart attack hospitalizations observed after a smoke-free law takes effect is sustained over an extended period. Smoke-free laws likely reduce heart attack hospitalizations both by reducing secondhand smoke exposure among nonsmokers and by reducing smoking, with the first factor making the larger contribution.

Researchers also looked at two nearby areas that had not implemented smoke-free ordinances and found no significant decline in heart attack hospitalizations during the same time periods. The full report is available at www.cdc.gov/mmwr.

A new cigarette hazard: ‘third-hand smoke’

Parents who smoke often open a window or turn on a fan to clear the air for their children, but experts now have identified a related threat to children’s health that isn’t as easy to get rid of: third-hand smoke. That’s the term being used to describe the invisible yet toxic brew of gases and particles clinging to smokers’ hair and clothing, not to mention cushions and carpeting, that lingers long after second-hand smoke has cleared from a room. The residue includes heavy metals, carcinogens and even radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor.

Doctors from MassGeneral Hospital for Children in Boston coined the term "third-hand smoke" to describe these chemicals in a new study that focused on the risks they pose to infants and children. The study was published in the January issue of the journal Pediatrics.

Among the substances in third-hand smoke are hydrogen cyanide, used in chemical weapons; butane, which is used in lighter fluid; toluene, found in paint thinners; arsenic; lead; carbon monoxide; and even polonium-210, the highly radioactive carcinogen that was used to murder former Russian spy Alexander V. Litvinenko in 2006. Eleven of the compounds are highly carcinogenic.

Checks for balance

Vendor credentialing efforts strive to thwart red ink, red tape, risk exposure

by Rick Dana Barlow

Certifying vendor credentials means big business for just about everybody in healthcare. But that means something different to either providers or suppliers with patients somewhere in the middle.

Depending on your point of view, vendor credentialing carries some positive and negative baggage. As a market niche, it has grown in popularity in recent years. Witness the Strategic Marketplace Initiative’s established guidelines for vendor access, as well as the passel of vendors vying for attendee eyeballs at last year’s Association of Healthcare Resource and Materials Management conference in San Antonio.

On the plus side, vendor credentialing virtually guarantees that the assigned sales representatives venturing through hospital corridors and in surgical suites are legitimate – something that’s inherently necessary in a privacy- and security-driven culture, as well as a regulation-heavy industry.

Troy Kyle

“Not only is it inherently necessary, but when you look at it from a risk manager’s perspective it is at the heart of privacy and security,” said Troy Kyle, president and CEO, Vendor Credentialing Service LLC, Spring, TX. “Some vendors often come to me and say, ‘Look at all of the visitors running around. Are they going to have to be credentialed before they can come to a hospital too?’ That raises a good question, but you have to start somewhere and you must control what you can control. If you look at that same logic, if you are not credentialing everyone in the hospital, why must doctors and nurses go through similar processes?”

On the negative side, vendor credentialing may lead to costly delays to sales rep access, which affects customer service, according to vendors, arguably impeding clinician exposure to new technology or even to devices clinicians need to practice healthcare. Why? Every individual must be cleared, and to vendors even an automated or online process can slow productivity by a group used to unfettered access.

On the flip side, Kyle argued that unfettered access actually slows the productivity of the hospital staff. “This directly affects the quality of service that patients receive,” he indicated. “On any given day a nurse manager may see 5 to 15 different representatives from pharmaceutical companies or medical device companies. If she gives each one 5 to 10 minutes of her time, you are looking at 30 minutes to an hour and half of time taken away from patients.”

But ethics and fiscal transparency now trump access, productivity and sales.

Earning a split vote: Hospitals’ controversial practice of charging vendors a fee per rep for clearance. Hospitals argue that the time and effort needed to develop tracking and training mechanisms cost money; vendors counter that it’s nothing more than shameless revenue grab on hospitals’ part.

Kyle acknowledged that vendors have a valid point. “It can be a revenue stream for any hospital that wanted to develop [its] own system,” he noted. Now, if every hospital were to develop their own system and charge the vendors, it would lead to higher cost for all supplies. Vendors will increase their cost to offset the cost that the facility places on them. Vendors will not just recover the cost of credentialing, but the added increase will be much higher as it will be buried in price increases. What they can’t do is get back the time it cost them to register at every hospital they visit.”

Outsourcing this to a vendor that specializes in background checks, due diligence measures and related services may offer at least part of the solution. Both hospitals and vendors could log into a database, typically Web-based, to check clearances by facility and company.

In an industry – and a world – beset by ethical lapses and sales chicanery and sure to be fueled by a shrinking economy, it’s safe to say that vendor credentialing – like employee checking – is a necessary administrative evil to ensure good. Kyle offered this case in point: “We recently had a representative go through our credentialing program only to find out that they had contracted [tuberculosis]. It was caught very early, and now they are on a treatment program.”

But how do you convince healthcare industry providers and suppliers to participate? Soft incentives or big stick?

Kyle objected to the inference that vendor credentialing, necessary for risk assessment and aversion, should be a voluntary decision, particularly when federal reimbursement is affected. “This is not a system we are hyping on fears and false statements to somehow make people believe it is necessary,” he said. “I think that people who believe we are making something out of nothing may need to do a little research before they make the assumption that we are somehow misleading the industry.” He referred to the Department of Health and Human Services’ Office of Inspector General’s fraud alert, which can be accessed by visiting the OIG’s Web site here at http://oig.hhs.gov/fraud/alerts/
effect_of_exclusion.asp or click on HPN Online for the content.

Resistance movement

Objections to vendor credentialing by the vendors can be loud and numerous but the excuses they use tend to center on privacy and cost, typically in that order.

“Providing personal information that has hitherto been unrequested can feel intrusive,” said John Wills, founder and president, Status Blue LLC, Marietta, GA. “We encourage vendors to take a step back and consider the information that the hospital is requesting. The hospitals wants to know whether reps are safe, competent and otherwise an asset to them in their facility or are they an undocumented potential liability? Immunizations, letter of competence, proof of a background check, and the like are all very reasonable requests for any hospital to ask of their business partners.

“True invasion of privacy is intrusion in one’s personal life without just cause,” Wills continued. “The world we live in today provides just cause for hospitals to ensure the safety of their patients and employees by knowing that vendors on their property adhere to their specific standards for providing service.”

Kyle agreed. “All vendors have their right to privacy and they should demand that any company that is holding their information let them know what steps they have gone through to insure their privacy,” he said. “We do not ask for Social Security numbers, and the only information we allow hospitals to see is the representatives’ business contact information. There is no need for any person at any facility to have access to a representative’s home phone, address, etc.”

While cost may raise another red flag, depending on what the vendor credentialing company and the hospital require and how they bill for services, its sting can be blunted when placed in the proper perspective, sources said.

Bill Hayes

“Some [integrated delivery networks] have been concerned about the cost of the program to the vendors,” said Bill Hayes, COO, Vendormate Inc., Atlanta. “In reality, this cost already exists but has been borne by the IDNs in the soft cost of lost staff time and inefficient manual tracking systems. Vendormate suggests that this needs to be viewed as a vendor cost of business or marketing expense.

“Buyers have the right to require vendors to provide the information and support needed to make sound decision,” Hayes continued. “If the IDN questions the expense to the vendor, simply walking through the physician mail box area and looking at the invitations to education sessions at the town’s best restaurants usually counters any cost concern.”

Wills offered a similar argument. “We encourage vendors to do the math, and the numbers tell the truth,” he said. “We also encourage them to scrutinize what they spend on parking at the hospital on an annual basis or what they may spend on entertaining physicians.”

But Wills, along with his competitors, admit that the cost of some vendor credentialing services “may outweigh the benefit of it,” he said. Wills cited several examples, including a company that charges “a few hundred dollars per hospital” to the hospital system that charges $100 per representative to cover its costs. Kyle referenced companies that grant “preferred vendor status” or offer performance ratings as additional services that detract from the fundamentals.

“We are asked to do one thing; that is to verify the representative’s credentials and alert the hospital if they have not complied,” Kyle said. “By grading vendors or giving them some kind of preferred status you are promoting unfair business practices and are hindering doctors and nurses from seeing and learning about new products and techniques that a non-preferred vendor may have.”

Timing can be a roadblock for those physicians “that leverage [healthcare industry representatives] in direct patient care,” according to Hayes, but more likely it’s a red herring due to unnecessary documentation delays, be it procrastination or bluff-calling.

“Before the HCIR assists, he or she must complete the registration and provide the documentation, and that takes more than five minutes,” he said. “If the HCIR has failed to do that, then the physician can be caught short at the time of a procedure. We emphasize that the requirements for the HCIR are designed for patient safety. In a well-communicated vendor credentialing program, the HCIR has had ample time to complete the registration. The physicians, as the champion of the patient, typically realize that the breakdown was with the individual rep, not the vendor company and not the program.”

Even so, any credentialing procedure is unlikely to please everybody.

“There is the minority of vendors who just want to point a finger at the credentialing company and complain about the process,” Wills said. “When a third party is involved there is a tendency to throw the third party under the bus. We hear all kinds of ridiculous excuses from the resistant vendors. There are tens of thousands of compliant, responsible and cooperative vendor representatives who are adjusting and flourishing in the regulatory environment the industry finds itself in today. In the end, these small numbers of unhappy reps who look for someone to blame for their lack of compliance need only to work with the system rather than against it to experience the true benefits of an online credentialing service.”

Ginny Borncamp

From the hospital side, Ginny Borncamp, director of purchasing, Allina Hospitals and Clinics, Minneapolis, has fielded a bevy of complaints, ranging from privacy and integrity issues to technology issues, such as the proverbial “can’t log on” and “the computer ate my homework” variety. On the cost side, vendors complain that because every healthcare system in the region uses a different registry they have to pay more than one registry fee, she indicated. Others raise legal issues, as in some of the documents required have to be reviewed by the vendor’s legal department before registration, she added.

“Our response is that we have picked a provider that does service multiple hospitals and that was cost competitive in order to maintain their costs effectively,” Borncamp said. “The process is simple to complete if done ahead of time. We try to be flexible if we know you are working on it. We’ll support any issues you may have with the provider if you let us know. By registering and not just stopping in it helps your entry be so much faster. It can also help you maintain a history of your visits.”

Further, Borncamp insisted that Allina has “no financial incentive” in the process. “Our health system does not charge suppliers to access any of our sites,” she said. “The fee is to the registry, and we encourage the suppliers to negotiate discounted rates for their representative registrations.”

Peter Sheehan

Peter Sheehan, manager, business development, deView electronics, Lewisville, TX, and founder of REPtrax, takes a more positive spin, not viewing negative vendor feedback as excuses, “but rather understandable resistance fueled by misconceptions. Once we address the misconceptions we find that our vendors become strong advocates of REPtrax,” he said. They don’t collect any unnecessary data nor do they sell any information, he added.

Moving target

In an environment pursuing standardization of data and procedures, one common complaint leveled against the vendor credentialing market segment is the inherent variability of processes required to fulfill compliance obligations.

First, there is no monolithic, industry-wide searchable database where you enter in your information once for anyone with the appropriate clearance can access. In fact, each of the companies in the vendor credentialing space maintains its own database that only its vendor and hospital customers can access with certain relevant security restrictions.

“All VCS facilities use the same database of information,” Kyle said. “They only have access to their representatives, companies and log systems. This means that a vendor company or representative has to be attached that facility. This is done by the representative selecting the hospital as one of theirs or stepping foot on the premises and checking in. A hospital in Florida cannot pull up the representatives in Seattle for fun.”

But logging into a secure standardized industry-wide database raises eyebrows.

“If there was a central registry, and we could still meet our vendor management objectives, we would certainly be interested in evaluating,” Borncamp indicated. “But each hospital does have different policies so to update all potential differences would probably be difficult.”

Observed Wills: “The idea of there being one searchable database would require there being one third-party vendor credentialing partner for the entire industry. Currently there are three or four national leading credentialing companies and a few smaller/regional credentialing companies. The consolidation of any or all of these companies is a little hard to conceptualize happening, especially when considering the infancy of this market niche,” he added. Further, Wills said healthcare facilities can benefit from the competition during their evaluations.

Second, while there might be a broadly defined and specified number of informational categories in the databases, the information within each category varies by facility. For example, facilities may seek financial health, insurance status, legal status and contract status of a particular vendor, but also on the individual level contact information, access and influence privileges, security issues, training, immunizations and ethics as stipulated by such organizations as The Joint Commission, CDC, AORN and ACS as well as HIPAA, according to Hayes.

“Some of this information reflects the IDN’s relationship with the rep and some if it reflects the relationship with the vendor company,” Hayes noted. “This information cannot effectively be managed at a standardized, national level. Because the service is about managing the supply chain as much as it is about the documentation of the individual rep, the function needs to be managed by each IDN. The goal is to centrally communicate and manage the policies and documents that the IDN believes it needs to operate and provide optimum care. Since we do not have nationalized healthcare, each IDN has the freedom to create specific practices that reflect its operations.”

And it’s not like this process has to be completed by and for every hospital and healthcare facility, every vendor and every rep within that vendor, Wills indicated. “In today’s current regulatory requirements there are no specific regulatory or legislative mandates that require vendor credentialing,” he said. However, the industry is anticipating [The Joint Commission] standards in 2009.

“Does it make sense to credential the Diet Coke delivery driver? Should the hospital’s electrical contractor be restricted from accessing the hospital? These are very good questions and ones that should be answered by each hospital when they consider the scope and audience of their vendor policy,” Wills continued. “The intended audiences for most facilities are the vendors who have a significant potential exposure to the patient population or who are able to access patient care areas.”

Financial, legal incentives

While vendor credentialing may appear to be an opportunistic venture to those unclear of the concept and context, non-participation and non-compliance can lead to serious financial and legal repercussions, ranging from federal reimbursement withholding to false claims violations and costly litigation.

“When you look at the litigation risk that facilities are faced with on a daily basis, you start getting at the root of this risk management issue,” Kyle said. “When will a good lawyer sue the facility because there was a vendor in the room who did not have their immunization records up to date, especially if the patient acquires a nosocomial infection while in that facility? Facilities are being asked to track when a representative is in the room during a procedure and document it in the patient’s records. Anytime you document information, someone will figure out how to use it to their advantage.

“What happens when a vendor contracts Hep B or Hep C, and his lawyer discovers that the vendor company and the hospital facility did not insure that he had documented blood-borne pathogens training as defined by OSHA?” he continued. “Did you know that the typical vendor representative can visit an average of 4 hospitals per day? There are reasons that credentialing companies do what we do, and the real question that should be asked is, ‘Why did it take so long?’”

Vendor credentialing represents sound business practices, Hayes noted, something any business needs to do regardless of a regulatory environment. A facility’s supply chain partners should meet its standards, he added. With the OIG calling for company checks against its excluded provider list for Medicare and Medicaid reimbursement, and the Deficit Reduction Act requiring contractors to be trained about false claims, a regulatory environment may be eminent, according to Hayes. “There is an expectation that the financial exposure will only increase with exclusion of reimbursement for ‘avoidable’ incidents,” he added. “These concerns typically drive the first foray into credentialing. But customers quickly realize that disjointed, manual processes are inefficient and create unnecessary costs that IDNs cannot afford.”

Concurred Sheehan: “It is indisputable that not knowing what reps are in your hospital and whether or not they are credentialed poses a significant risk.”

Wills insisted that this issue should focus on protecting patients and the supply chain from undocumented and identified vendors, regardless of financial incentive or that vendor violations can lead to very significant financial risks or losses. He cited several legal cases as prime examples: In one a vendor rep allegedly participated in a hip replacement surgical procedure and the OR supervisor falsified records to conceal the participation, resulting in a malpractice settlement and criminal indictment of the OR supervisor. In another, a patient died during a routine ambulatory surgical procedure to remove uterine fibroids when a new device being used by the clinicians on her caused excessive infusion and absorption of saline with vendor rep present. The last involved hospital employees teaming up with vendor reps who were found guilty of stealing and reselling products.

“Healthcare facilities cannot afford to be without policy and procedures in place that minimize these potential risks,” Wills said. “Credentialing vendors is much like the ‘time out’ process that many facilities and operating rooms now take in accordance with The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. During this ‘time out’ the staff, anesthesia, and physician all confirm patient name, procedure, operating physician, etc. The healthcare facility is simply telling their vendors ‘time out – let’s make sure this business relationship happens on our terms, consistent with our patient safety goals, and our vendor compliance initiatives.’”