Measles alert

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Photo by Mike Blyth

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A case of measles was confirmed last week in a student at the Mountain Laurel Waldorf School in New Paltz. Dutchess County’s health department immediately advised anyone who has visited this school since Sept. 10 or has had any contact with anyone from the school to immediately make sure that they were up-to-date with their measles vaccinations. On Monday, Sept. 24, Ulster County’s health department posted the same news on its website, with the name of the school omitted. As of Monday, it is believed that no other cases have been confirmed.

In his press release, Dutchess Health Commissioner Dr. Michael Caldwell said that his department had been in close communication with medical providers, with the health department in Ulster County, and with the state health department. Ulster County Health Commissioner Dr. Carol Smith said that her department had in fact initiated the investigation, immediately dispatching two public health nurses to New Paltz to begin to focus on the possible problem. Last Wednesday morning, she said, the county health department sent a blood specimen from the child in question to the state health department lab in Albany, where a confirmation of measles was made a few hours later.

Smith said the state sent out a fax blast Wednesday afternoon notifying all medical providers in the region of the situation. All medical practices and laboratories in the area were advised there may be a number of other children and families who have been exposed and could be communicable.

The students, teachers and staff at the school were questioned as well as other people who had contact with the affected child. “There’s a protocol for handling these cases quickly and respectfully,” explained Dr. Smith.

The Dutchess health department, which said it had also issued a health alert to its medical community, said that a number of students at this school were not vaccinated and may become ill. That means other children and families might be at risk for contracting measles.

To sleep, perchance to dream

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Photo by Dion Ogust

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Shakespeare had it right. But his poetic rumination from Midsummer Night’s Dream doesn’t necessarily apply to contemporary America. That collective “we” known as the American public just isn’t getting enough sleep. Forget about dreams

“I’m an insomniac,” admits SUNY grad student Tongwen Wang. “Maybe not completely. I can sleep sometimes, but rarely, and sometimes not for days.”

Wang’s problems with sleep, which began in puberty, have been exacerbated in college. “It was a bit better in high school because my life was more scheduled, but in college I’m more on my own, with lots of things to do all the time. It’s a broken-up time frame. When I can’t sleep I’ll just lie in bed and read, or watch TV or do something on the computer. The non-sleep affects my mood…I’m always tired, have headaches, and I can’t function well at all.”

Working mother Deborah Engel-DiMauro and her son Ezra, almost seven, never get enough sleep. “Since Ezra was a baby he hasn’t slept well,” she says. “He wouldn’t go down to sleep easily, and he kept waking up every few hours — which is normal, I guess, but it’s continued to this day.”

Engel-DiMauro used to be anxious about the situation when Ezra was small, but now she feels she’s handling it better. But she admits to frustration. “We start of with a routine, but then when the light goes off he comes to our bed [her husband is SUNY professor Salva Engel-DiMauro] to get our attention, crawls into bed with us, and stays awake. Recently, after we brought him back to his bed for the night, we fell asleep and found Ezra on the floor next to our bed.”

Ezra’s side of this tale non-sleep goes something like this: “I don’t sleep well. I’m afraid to be by myself alone in my room. Sometimes things spook me out. I think how I’m maybe created to not sleep well, with so many thoughts always in my head. So many thoughts about everything combining to make spooky things. So I go into my parents’ room, sneak into their bed until mom or dad take me back to my room. I try to sleep and think of good things, but then things spook me out again.” The cycle continues.

Angela Purdy, almost 90 years old, has lots of experience in this realm. Until ten years ago she never slept through the night, waking around two or three in the morning, her head full. “Racing thoughts” is how she describes it. “Thoughts that were uncontrollable, random, and sometimes I felt I would lose my mind they were coming so fast and so strong. But then my husband [Richard] passed away ten years ago and I started to sleep better. He had been not well for a few years and I think the anxiety of that, and what would happen if he did die, caused me great stress. Before that it was worrying about the kids [she has three grown children]. It’s part of being alive, I guess.”

Polls report that one in five Americans get less than six hours sleep on average per night. That’s over 60 million folks, folks! And the hours of sleep keep decreasing as the number of sleepless citizens increases.

“It’s no secret that we live in a 24/7 society,” said Dr. Carl Hunt, director of the National Center on Sleep Disorders Research at the National Institute of Health. There are many more opportunities to do things other than sleep, he says. The Internet, 24-hour cable TV, e-mail, plus long work shifts.

“And yes, how we live is affecting how we sleep,” concludes Hunt. “Often our sleep deficit is related to too much caffeine, nicotine, alcohol. Often it’s related to work: stress from work, putting in long hours at work, working night -shifts, working on our home computers until the second we go to sleep.”

The effect on our lives is negative. Polls link sleep deficits to poor work performance, driving accidents, relationship problems and mood problems like anger and depression. A growing list of physical health issues has been documented. Heart disease, obesity and diabetes have been linked with chronic sleep loss.

Hospital collaboration

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Hudson Health Partners provided this model of the continuum of care which seeks to explain the different roles of various kinds of health care providers.

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Beset by competitive pressures on all sides, some community hospitals are considering desperate measures. Used to struggling fiercely for local market share with each other and increasingly beset by other problems, hospital systems in the Hudson Valley are adopting strategies that a few years ago would have been unthinkable. In some cases, they’re even cooperating with each other.

Three mid-Hudson hospital systems last week announced the formation of a new collaboration through which they can work together to seek efficiencies of operation and to control costs. Hudson Health Partners LLC was described by its chairman, Allan Atzrott, also CEO of the two-campus St. Luke’s Cornwall Hospital, as “a true partnership.” It consists of St. Luke’s in Newburgh and Cornwall, St. Francis Hospital in Poughkeepsie and Beacon, and the Bon Secours hospital system, consisting of Bon Secours in Port Jervis, Good Samaritan in Suffern and St. Anthony’s in Warwick. The three systems have equal shares in the new corporation, said Atzrott.

The collaboration may grow to include other hospital systems. Atzrott said conversations have already been held with five additional potential partners.

The arrangement is a strategic alliance, not a merger. Each hospital will remain independent under the control of its own governing board.

A press release describing Hudson Health Partners delineated five broad areas for the collaboration. One focus was quality initiatives and best practices. Clinical collaboration, including wellness initiatives, pre- and post-hospital care, and expansion along the continuum of care, was a second. Physician services will include such significant items for collaboration as recruitment, medical education, integration of health records, and services for practice management. Cooperation in the areas of hospital services, employee benefits, pilot projects and support services will be encouraged. Finally, group purchasing and the sharing of general services will be pursued.

Jeanine Logan, spokesperson for the Northern Metropolitan Hospital Association (Normet), the regional hospital trade group, said the move would be a good thing. “Any collaboration that will help patient care, help improve physician recruitment, and do other such things could be helpful,” she said.

Fewer inpatient stays

Average in-hospital stays, said Atzrott, used to be nine days. Now it’s four — and dropping. Eighty-five percent of service used to be inpatient and 15 percent outpatient. Now the ratio is 60 percent to 40 percent, he continued, and shifting more to outpatient every year. Some 60 percent of ambulatory surgeries are now performed outside hospitals. “Forty percent of something is better than 100 percent of nothing,” noted Atzrott.

The direction of change is the same as that cited by HealthAlliance officials at the recent community forums in Ulster County. HealthAlliance CEO David Lundquist has said that he doesn’t expect the diminution of volume experienced by hospitals during the present recession ever fully to be reversed. New patterns of relationships, for instance one in which the hospital provides the space and other providers the services, are likely. In some cases, one hospital will provide specialized services for the communities of other hospitals.

“Integrating consolidations with other institutions is important,” Lundquist said at a recent forum at Benedictine Hospital. “We are fully integrated with other providers. We cannot be a standalone in this world.”

The state and regional health insurance exchanges created in New York State this year under federal legislation are intended to promote and measure patient-centered care. It is hoped they will provide a continuum-of-care scenario through which the different players will sort out their roles in a more cost-aware, efficient health care environment.

Change agents

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Fifteen people sat at a large conference table in a windowless room of a large office building in Fishkill later last Wednesday afternoon. The conferees, mainly doctors, health administrators and researchers, constituted the board of directors and staff of Thinc, the Taconic Health Information Network and Community. The Thinc board meets monthly to share information and research about the fast-paced changes in the healthcare industry, one-sixth of the gross national product.

“Welcome to Thinc,” says the organization’s website. “Thinc is the neutral, non-profit organization that convenes the community and articulates a collaborative vision for improving the quality, safety and efficiency of health care in the Hudson Valley. Thinc starts with the foundation of health information technology, then builds on that base for quality improvement that benefits the entire community.”

It was a geographically diverse group. Two of the participants, HealthAlliance Chief Financial Officer David Scarpino and Saugerties primary-care physician Dr. Eugene Heslin, are Ulster County residents. At least two more, St. Francis Hospital chief executive Bob Savage and information technologist and physician leader Dr. John Blair III, are from Dutchess.

A committee of the respected Institute of Medicine, a national doctors’ group, recently delivered the latest broadside emphasizing the urgent need for reform. “The costs of the system’s current inefficiency underscore the urgent need for a systemwide transformation,” it said. “The committee calculated that about 30 percent of health spending in 2009 — roughly $750 billion — was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best-performing state.”

Like any group used to handling specialized information, the people sitting in the chairs around the table in Fishkill tossed around jargon with which they all seem familiar, employing acronyms and other shorthand terminology in abundance.

Some of the arcane terminology they employed was medical, but most was bureaucratic: standards, programs, funding sources, government linkages. For a reporter attempting to absorb what they were saying, the experience might be likened to listening to a group of people who are constantly lapsing into a foreign language in order to express themselves.

The people around this table were cognizant that they were the de-facto coordinators in the Hudson Valley region of what is arguably the most ambitious effort at major social and economic change in American history. When it comes to leading the efforts for regional organizational development of health care, they’ve been doing the job that needs doing.

Health records are key

Five years ago, Thinc, working with MedAllies as its implementation agent, began a project to implement meaningful use of electronic health records (EHRs) at a thousand doctors’ offices in the Hudson Valley. Funded and incentivized by a $5 million state grant, the initiative has achieved its goal. The EHR adoption rate in the Hudson Valley is estimated to be 80 percent now, with Thinc’s initiative being directly responsible for about a third of those implementations.

Recently, 75 primary-care practices in the region were chosen for the next four-year effort at implementing the next phase of transformation. These practices will start delivering enhanced healthcare services this fall.

This federal program is part of a broader effort to find a new national model for the purchase and delivery of comprehensive primary care that will improve health and reduce costs throughout the country. Building on the foundation of what is called the patient-centered medical home concept, this initiative encourages multi-payer collaboration, aligning payment reform with practice transformation. Participating payers will reimburse participating practices for providing comprehensive primary care. The federal Center for Medicaid and Medicare Innovation will pay each participating practice $20 per month per fee-per-service beneficiary the first two years of the program, $15 per month the third and fourth years.

The selected primary practices will engage in systematic data-sharing and collaborative learning experiences. They will also have an opportunity to share savings achieved (at the market level). Such a collaborative effort, also involving a group of payers, has the potential to transform primary-care practices.

Tools for transformation

At the same time, the rules for meaningful use of information technology have this past month been raised to require increased technical interoperability among record systems and greater patient engagement. Medical practices and hospitals will need to be able to exchange records with each other. The government will be using its considerable market clout to push vendors toward standardization and unification of existing regional health records exchanges. Building on regional health information organizations such as Thinc, a statewide network of secure medical records is not quite around the corner. But it’s on the horizon, the Thinc participants said, and getting closer all the time.

You’d suppose that the community would want to know more about what we are doing, one board member at the table in Fishkill ventured. Other heads at the table nodded in agreement. So far, that supposition hasn’t often been translated into reality. Public involvement in this phase of health reform has been a rare commodity.

The Hudson Valley is now ready for the next phase in the long process of transformation of health information technology. A recent blogger, David Whitlinger of the New York eHealth Collaborative (NYeC), described the change succinctly as “moving from countless tons of paper files, containing life-saving data, which is trapped in file rooms across the state, toward a secure, Internet-enabled health information network that responsibly allows information to be shared across the care continuum to improve care.”

Time for a bike ride

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The Williams and Gruner families have known each other a long time, according to Anita Williams Peck. Al Gruner, father of the Al Gruner who’s now a retired dentist and chairman of the board of Ulster Savings Bank, met his future wife, Helen Foley, at Williams Lake in Rosendale. Growing up, the Gruner kids were regulars at the Williams Lake facility run by Walter Williams, Anita’s father. Anita and Rosemary Gruner, the younger Al’s wife, became friends.

Diagnosed with breast cancer 17 years ago, Anita Peck received 10 weeks of radiation. Anita learned first-hand what it was like to have to drive 15 miles round-trip to the hospital every day for radiation treatment. Fortunately, there’s been no recurrence of the disease.

A few years after Peck’s ordeal, Rosemary Gruner, who didn’t smoke, got lung cancer. Anita Peck cheered her friend up, but “she didn’t make it.”

Now a long-time cancer survivor, Anita, who operated Hudson River Valley Tours, which brings motor-coach groups to the region, has herself become a strong volunteer on behalf of cancer support programs. Having personally experienced the problems that cancer can bring, she, like the Gruner family, realized that people of more limited means have a tough time dealing not only with the disease but also with everyday problems like gas, groceries and transportation. “I realized I have to step up, and pass it on to others,” Peck explained. “They need the radiation to survive.”

To commemorate Rosemary’s life and to raise money to help out local cancer patients, Gruner’s family put out a little cookbook entitled “Rosie’s Recipes.” In 2003 they started the Rosemary D. Gruner Memorial Cancer Fund. Peck was happy to contribute and participate. The family also came up with the signature idea with which the fund has come to be associated: a September bike ride starting in Kingston. It was a big success. From 2005 through last year, the Bike Ride for Cancer raised $561,935 — all distributed to local people with a diagnosis of cancer.