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24 beds to go at Morriston Hospital, Wales – a casemix exercise

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I have not blogged about casemix yet, and with this post I intend to kick-start my attempt to share my comments, opinions, views on how health management everywhere have changed the way of doing things in hospitals by applying casemix ideas as an information tool involving the use of scientific methods to build the classifications of patient care episodes by classifying patients into classes or groups which are both clinically coherent and resource homogenous.

I learned about a news article from the South Wales Evening Post about how health management in Wales intends to change the case mix in their hospitals, because they claimed that the existing service is splintered between various sites and therefore inefficient.

To better understand the situation there, I ran an Internet check of healthcare services in Wales, so I could better comprehend what the article was reporting, and to focus on how casemix ideas were applied to bring about the changes at Morriston Hospital, Princess of Wales Hospital, Neath Port Talbot Hospital, and Singleton Hospital, namely the hospitals referred to in the article.

In Wales, seven Local Health Boards (LHBs) are responsible for planning and securing delivery of primary, community, secondary care services, and also the specialist  services for their areas. Abertawe Bro Morgannwg (ABM) University Health Board is one of the largest Health Boards in Wales. It is responsible for three localities – Swansea, Neath Port Talbot and Bridgend areas (see map below of all Hospitals in these ABM localities).

Map credit : Abertawe Bro Morgannwg (ABM) University Health Board

It covers both primary (GPs, pharmacies, dentists and optometrists etc) and secondary (hospitals) care.

Photo credit : http://www.thisissouthwales.co.uk/

Morriston Hospital (left) covers the same geographical area as the City and County of Swansea and has around 750 beds. Morriston Hospital is the site of the major Accident and Emergency Department for Swansea and, with its accessibility to the South West Wales population, is recognised as the Major Trauma Centre for South West Wales.


Photo credit : http://www.wales.nhs.uk/

Princess of Wales Hospital (right) is a district general hospital located on the outskirts of Bridgend town in South Wales. This hospital provides a comprehensive range of acute surgery and medicine for patients of all ages, including inpatient, outpatient and day services, including Accident and Emergency Services.


Photo credit : http://www.thisissouthwales.co.uk/

Neath Port Talbot Hospital (left) has 270 beds and provides a range of inpatient, outpatient and day case services for the people of Neath and Port Talbot.


Photo credit : http://www.thisissouthwales.co.uk/

Lastly, Singleton Hospital (right) is a modern District General Hospital with 550 beds situated on Swansea Bay, adjacent to the campus of Swansea University.


Health authorities in the ABM localities plan to lose hospital beds as a result of a shake-up of health services due to take place during September or October 2012, although the planning for them had already started. As a result, Morriston will lose 23 beds and Singleton, 1 bed.

Health authorities think advances in patient care mean they no longer need as many beds as were necessary in the past.

The change of the case mix in the hospitals served by ABM will change as follows :

  1. Morriston Hospital will to continue to deal with emergency cases, along with Princess of Wales in the Bridgend  area
  2. Morriston Hospital will take care of all complicated elective (pre-planned) orthopaedic operations from across the ABM area
  3. At the moment trauma and orthopaedics are also carried out at Neath Port Talbot Hospital;
  4. Trauma and orthopaedics will no longer be carried out at Neath Port Talbot Hospital but will become a centre of excellence for short-stay orthopaedic surgery

Patients who have had complicated surgery in the two acute hospitals (Morriston and Princess of Wales hospitals) will, as soon as they are well enough, be moved for rehabilitation in Singleton, Neath Port Talbot and Princess of Wales hospitals, depending on where they live; this will free up beds at Morriston for trauma and complex surgery, and it will also mean patients will recover closer to their homes and families.

The drive to rehabilitate results in quick turnover, and hopes to enhance the recovery process after surgery which in turn will lead to better outcomes and reduced readmission rates. For example, if patients have to travel to Morriston or Bridgend for major joint replacement the time they will be there will be much shorter. This according to Phillip and Julie 2011, patients with greatest needs are treated preferentially (vertical access equity as according to Phillip and Julie 2011).

ABM said the aim was to establish a level of care across the board area so that, no matter where people were from, patient health needs are treated alike (horizontal access equity as according to Phillip and Julie 2011).

Health chiefs in the ABM Area have insisted as long as the patient flow was right, the changes in trauma and orthopaedics do not represent any reduction of the service by withdrawing the service and by losing some beds. They also insisted cost-cutting was not the objective of this patient care exercise, but to actually lead to improvement in patient outcomes and pathways for specific patients, particularly the frail and elderly, who have fractured neck of femurs. ABM says that, in the past, elderly patients with serious fractures tended to spend a long time in hospital and their condition deteriorated, sometimes fatally.

ABM has also flagged up the need to strengthen links with social services, particularly to ensure elderly patients who need support at home are not stuck in hospital longer than necessary.

This case mix exercise in Wales seemed like a good idea given the reduction in beds. ABM remained confident there would be a sufficient number of beds to run the service and they could manage as they had built-in some capacity to expand if they do have a busy time.

ABM believes the change in casemix among its hospitals is sensible from all angles – finance, and patient care and also resolving ABM’s significant issues with junior doctor cover. I think the change in casemix has allowed for meaningful comparison of activity between hospitals managed by ABM in Wales.

Internet sources:
Abertawe Bro Morgannwg (ABM) University Health Board , viewed 30 July 2012, <http://www.wales.nhs.uk/sitesplus/863/home>

Phillip B & Julie B 2011, Casemix for Beginners, viewed 15 July 2012, <http://casemixconference2011.com.au/LiteratureRetrieve.aspx?ID=103882>

Abridged by R. Vijayan from an original article in the South Wales Evening Post, July 19, 2012

Medical Records Optimization

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Last friday, I was googling for casemix for a future post when I stumble upon the announcement by The International Centre for Casemix and Clinical Coding (ITCC), UKM Medical Centre, Universiti Kebangsaan Malaysia (UKM), Malaysia which was planning to organise the 6th International Casemix Conference 2012 (6ICMC2012) from the 6th -7th June 2012  in Kuala Lumpur , Malaysia.

Reading through this announcement, I noticed for the first time the words “Medical Record Optimization”.  The organiser was calling for invitations from local and international participants to attend and present their findings and papers in several areas, including on Medical Record Optimization.

I abandoned my search for casemix (after surfing briefly some casemix websites) and decided to find out what Medical Record Optimization was all about and blog about it soon after as in this post before you. More googling and reviewing my search led me to locate MedNeutral which stood out prominently in the search list.

MedNeutral which has its roots in the insurance industry is a Brahma Holdings company which provides transformational solutions to the insurance industry in the United States of America, is headquartered in La Jolla, CA, USA.

MedNeutral’s proprietary Medical Records Optimization™ (MRO) solution is a next-generation service comprising of a set of digital medical record solutions that performs a triage on the medical records for claims processors, legal counsel, financial personnel, medical professionals, and government agencies.

As you will be aware in the Malaysian hospital setting, medical records contain extremely important information for claims processing, and also for data analytics. As Health Information Management (HIM) / Medical Records (MR) practitioners still dealing with paper-based medical records in most of Malaysia’s public and private hospitals (as in most parts of the developing world and under-developed world regions), something as basic as illegible handwriting is still the biggest problem in paper-based medical records. Other challenges in paper-based medical records include the absence of medical context, missing or incomplete documentation, difficulty in accessing the necessary medical information and use of jargon and/or symbols.

MRO converts these unstructured data – as found in paper or imaged medical documents, housed in document management or claims transaction systems into highly structured information through file assembly.

Key features of MRO are:

  • medical records are sorted and arranged in chronological order (with sorts also available by other fields). Raw medical data in different formats, and hand-written are further transformed into a set of electronically scanned, chronologically based, consistently indexed, and formatted records packages.
  • medical abstracts for key record types, which summarize the medical facts contained within the files
  • search and indexing tools embedded in the MRO solution allow to quickly call up facts and medical context around specific treatments or body parts; tracking algorithms enable automated identification of changes in diagnosis, medication, provider or facility
  • MRO also features collaboration tools to facilitate rapid sharing of abstracts, facts and analysis which leads to improved organizational productivity and faster and efficient decision making

MedNeutral’s MRO solution (clicking on the image below for a larger view opens the larger view in a new tab of your current window) adds value in the following ways:

Soruce : MedNeutral, medneutral.com/solution-value/

Many top institutions like LexisNexis Communities  have applied MedNeutral’s MRO solution platform to streamline the medical review process and make more accurate and informed decisions for example during the Gulf Oil spill, as an example of a scalable solution capable of processing voluminous medical records, identify factors which impact value, establishes legitimacy of claims and expedites the resolution of claims from the rash of personal injury claims during this man-made disaster.

An on-going, systematic study by Accenture (a global management consulting, technology services and outsourcing company) of insurance claims performance dating back to the 1990s, showed that insurers have difficulty accessing the information in medical records due to unstructured data and believes that investment in information technology in this area, with a shift to a structured data approach, is necessary.

It was clear from the articles I sourced that the hurdles for optimizing medical records for a meaningful use are both technological and organisational. An area for investment is in developing and promoting industry standards for medical records. But what is really important is taking a comprehensive look at the way medical information is acquired and handled, a probable progression to electronic medical records.

As hindsight, I could not find any mention of MRO from the scientific programme for the 6th International Casemix Conference 2012.

I can only assume that the topic Medical Records Optimization was planned to be included for this casemix conference as the processes of digitization, indexing, abstraction, collaboration and analysis are similarly applied to optimize medical records contents for casemix.

After knowing what MRO was all about, I decided to refresh my rusty memory about Casemix as I vaguely remembered casemix is about the difficult challenge of reducing costs while maintaining or improving quality of care and access. I also remember that Casemix was about methodologies, which categorise patients into statistically and clinically homogeneous groups based on the collection of clinical and administrative data  and the interpretation of hospital patient data related to the types of cases treated, in order to assist hospitals define their products, measure their productivity and assess quality.

Casemix data also allows support for a unique collaboration between clinicians, statisticians, accountants, managers, funders and policy makers as it provides a common language that is freely shared with a strong focus on Peer Group review.

From further reading about Casemix lead me to believe that Casemix used similar techniques by MRO in claims processing, to optimize medical records. Casemix classified patients into a manageable number of groups (patients in the same group should cost roughly the same to treat) but poor quality information meant poor quality casemix information, and thus the quality of Casemix information rests with clinician documentation, clinical coders and accuracy of information systems, that is much needed and desperate call for a structured data approach in medical records.

I shall conclude that the reference to medical records optimization for the 6th International Casemix Conference 2012 had nothing to do with MedNeutral’s trademarked Medical Records Optimization™ (MRO) product solution that was largely used by companies for claims processing, but wanted would-be speakers to speak and present on how medical records could be optimised for Casemix purposes.

References :
Casemix for Beginners, The National Casemix & Activity Based Funding Conference, 3 to 7 October, 2011 – Radisson Resort Gold Coast, Queensland, Australia, casemixconference2011.com.au/

Casemix, Canadian Institute for Health Information (CIHI), cihi.ca/

“Mastering Medical Information”, May 2009, Accenture, accenture.com/

MedNeutral, medneutral.com/solution-value/

“MedNeutral’s Medical Records Optimization for Gulf Oil Spill”, August 19, 2010, LexisNexis Communities, lexisnexis.com/

“Optimizing medical claims: A data-centric approach”, March 5, 2010, Accenture, accenture.com/us-en/blogs/accenture-blog-on-insurance/default.aspx

The Irish Casemix Programme, casemix.ie

ICD-10 ‘drives him crazy’

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This is what Kaiser Permanente’s CEO  George Halvorson thinks and feels about ICD-10.

“I hate ICD-10. It drives me crazy, it adds so little value, and I can’t find any therapeutic upside”

“The upcoming deployment of ICD-10 is anathema to my organization”

“The use of ICD-10 is a response to running out of current diagnosis-related group (DRG) codes rather the a logical expansion based on clinical data”

“They’re putting the current codes into certain buckets to expand them, and they’ve run out of room”

“It is more suited to work with a paper-based medical record system”

“I am looking toward the ICD-11 iteration, in the hopes it might be better integrated with electronic health records”

“Kaiser’s rollout of an EHR system is saving about $3 billion in annual costs by making it more efficient to treat chronic conditions and combat sepsis, which kills tens of thousands of hospital patients a year”

However, communications officer Ravi Poorsina at Kaiser said Kaiser will still deploy ICD-10 since according to him,  “I think we’re required to”.

Abridged from Kaiser CEO on why ICD-10 ‘drives him crazy’ by Ron Shinkman, June 26 2012, FierceHealthFinance

Note: The above remarks by Halvorson were made during a question and answer session after delivering a keynote speech at the Healthcare Financial Management Association’s Annual National Institute on Monday, June 25 2012, at the Mandalay Bay Resort and Convention Center in Las Vegas, USA.

One Entrepreneur’s Rise, the Future For EHRs/EMRs and of Medicine

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Forbes magazine is one of my favourite reads. Last evening before bedtime, I was catching up on the May 21 issue – (opposite left), my copy now almost 9 days old was lying idle altough I had skimmed through its pages already, when I noticed on page 28 from the Leaderboard pages, a short commentary on computing entrepreneur Neal Patterson, founder and Chief Executive of Cerner, “the world’s largest stand-alone maker of health IT systems – and company number 1,621 on FORBES’ Global 2000 list”.

I remember reading a past issue about this man (the May 7 issue to be exact, as I found out from this page 28 commentary).

I also remembered Patterson’s startup beginnings when I was researching for my other blog I am working on, Internet Start-ups.

This May 7 issue (opposite right) ran a cover story – “Obamacare Billionaires: What One Entrepreneur’s Rise Says about the Future of Medicine”, on this billionaire health information technology personality.  I retrieved back this past issue and read this cover story again, as I thought it would make an interesting re-read, make a post to blog out and share, since I am been passionate lately on enhancing this blog, from stories ranging from anything traditional paper records to EHRs/EMRs.

Last  night I quickly assembled this post, touched up the post this morning, and its before your eyes now. I don’t wish to write a long post and drown you with all that is in this cover story(you can research it as well if you wish to know more), but what I wish to do with this post is to share with you some reflections from this man who for 33 years “has preached better health through information”, and the future on EHRs particularly in the U.S. along with President Obama’s plan to mandate an EHR for every US citizen by 2014( p. 445 of H.R. 1, Economic Stimulus Bill).

Pals, below I quote his vision and thoughts I picked from my Forbes read which I think are worthy of mention, from the minds of a start-up entrepreneur “growing up on a wheat farm on the Kansas-­Oklahoma border”:

  • Patterson “insists that health care’s moment of digital transformation has arrived. “It is finally happening,” he says. “Without a doubt in my mind, it is happening this decade.”1
  • Both Patterson and Bernard Birnbaum, vice dean and chief of operations at NYU Lang one Medical Centre in New York City maintain that they are “off to the races”2
  • Both Patterson and Bernard Birnbaum are adamant that “health costs are ramping up too fast”,  “you need well-implemented electronic health records ………you need to manage the data”, and “the trajectory of health care in America and elsewhere is set”2
  • Patterson cites “To Err Is Human” report “as the moment when health IT entered the mainstream”3
  • “Patterson says he isn’t worried at all” what Bates4 thinks the day when“Microsoft and Google could finally move into the health care industry, exploding the niche that has protected Cerner and its rivals for so long”, and that “he’s ready for revolution”.
  • Pattersons claims, “There is going to be fundamental change that’s going to happen,” he says, “but the elements of that change are all here today. And it’s going to be better for almost every participant.”

1 What is really “happening this decade”, is Cerner’s financial gains past 5 years. Patterson is visionary, made many innovations in computing and data storage and this has made him a very rich man. President Barack Obama’s healthcare reform has given him a healthy boost as well.

2 There is little likelihood business will be hurt for Cerner and that of its rivals. Cerner’s fortunes and Patterson’s as well, is predicted to continue to grow no matter what happens in the election and regardless of what happens when the Supreme Court rules on the Obamacare plan.

3 When I was managing hospital quality management, the 1999 “To Err Is Human “ report from the prestigious Institute of Medicine, was a favourite report to quote and reference on patient safety. This report “detailed how between 44,000 and 98,000 people die every year in hospitals from preventable mistakes, like getting the wrong medicine or the wrong dose of the right one.” “The ­report specifically prescribed better computer systems as a way to prevent these deadly mistakes”.

4 David Westfall Bates, a Harvard professor was the lead author of the Institute of Medicine report.

I think with the hype surrounding the Obamacare plan blowing through the US amidst all the confusion and concerns over privacy and freedom to choose, health IT and EHRs/EMRs will still get a tremendous boost in the US, and this I believe will have a spiralling effect all over the world(the trajectory effect)2, when other nations emulate the US’s strides towards switching to EHRs/EMRs.

What I tried to do here in this post is to bring you excerpts of a visionary’s push for a greater IT enabled industry in the US which would have direct impact for medical records and health information management there and the world, and what’s trending now in health IT.

< Happy weekend as I shall continue posting only next week! >

The Innovator’s Prescription by Clay Christensen, an early review of this book

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Why am I raving (not too much I hope) about the book, The Innovator’s Prescription by Clay Christensen and team?

Well two-fold, first I am a firm believer in innovation and entrepreneurial practices, so I researched deep when I did my subject matter for my MBA studies, That’s when I discovered the book by none other than by Harvard Business School’s Clayton M. Christensen best-selling book, The Innovator’s Dilemma  I researched well into this book then. Second, I knew about his new book, The Innovator’s Prescription, when I was getting used to the corporate world at Pantai Holdings, and its direct connections with Parkway Health, Singapore,that one day in the course of duty I read the MoH Singapore website which carried a press coverage of the Health Minister there and his references to this book.

I then quickly owned a copy, had read through many of its 426 pages, you need to be informed when you are talking to corporate bosses you know, and since then I shelved it for some time now, and now that I am busy with this blog and with time on my side lately, I am thumbing through it again.

So, what is so revolutionary in these 426 pages? what is so special about this book you may ask? “do I need to read the book too?”, you may ask yourself.

One thing is for sure, “the authors present many insightful ways to analyze and understand the dysfunction of the U.S. health care system,”, that is according to the influential Health Care Blog.

By reading this book, you can expect to know the following :

  • the two major “enablers of disruptive opportunities” in health care :
    • technologies that will enable less skilled individuals to do tasks that previously required specialized expertise (like medical assistants taking on a bigger role), and
    • business models allowing care to move from centralized locations (hospitals and doctors offices) to distributed environments (home, work and community)
  • explaining the critical role of standardized personal electronic health records
  • introducing a new terminology that differentiates between intuitive medicine, empirical medicine, and precision medicine
  • describing the three key elements for innovation: the technological enabler, business model innovation, and something called a “value network”
  • explaining in detail the need for systemic integration in health care
  • describing the type of medical practice required to diagnose and treat a range of chronic diseases

I am convinced that this book does a great job explaining what EXACTLY is wrong with the US healthcare system – in a pretty readable fashion, that is if you’re used to slogging through descriptive non-fiction. It also apparently offers very valuable insights about how to fix their system.

Nonetheless, I’m excited to start slogging through The Innovator’s Prescription once again, and tell you more after I am finished.

Meanwhile, you can browse a copy of the introductory chapter of the book here. It’s a great overview.

By Clayton Christensen, Jerome H. Grossman, M.D. Hwang
ISBN : 0071592083 / 9780071592086
Publisher : McGraw-Hill