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America’s New Export: Hospitals And Medical Schools

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I often cringe when I see charts displaying parallel growth lines of these two variables: the number of American fast food restaurants in a given country and local obesity rates. The bad news is that our unhealthy eating habits have been exported successfully to foreign countries. The good news is that we’re going to export hospitals and health services next.

I spoke with Emme Deland, Senior Vice President of Strategy at New York Presbyterian Hospital, about the globalization of healthcare and the exportation of American health technology and expertise. You may read my summary of our discussion, or listen to the podcast here:

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Dr. Val: Where does New York Presbyterian Hospital stand in terms of the global marketplace for medical tourism?

Deland: We’ve spent the last couple of years reviewing our strategy regarding medical tourism because we want to be a part of the global healthcare economy. There is a growing market for hospital development overseas, particularly in India, the Middle East, Eastern Europe, and China. The US offers the most advanced medical care in the world, and it’s only natural that other countries want to begin importing it. Whether it’s minimally invasive surgery, infertility techniques, or prenatal diagnostics and care – America is among the global leaders in health technology and services.

Dr. Val: What do these countries want to import exactly? Providers, infrastructure, physical plants, data systems, consultants who can advise on ways of doing things to reduce errors and improve quality?

Deland: I think there is a great need for infrastructure. Middle Eastern countries, for example, spend as little as 1.5% of their GDP on healthcare. Compare that to the United States where we spend about 16% of our GDP on healthcare. There is a tremendous amount of wealth in Middle Eastern countries that could be spent on building hospitals and developing systems of care for their citizens. Right now, when Middle Eastern nationals require advanced medical care, their government pays for them to be treated in the UK or the United States. That’s not a sustainable model. In addition, since 9/11, visa restrictions have made travel to the United states increasingly difficult – so there is great interest in developing the infrastructure to handle complex medical issues locally.

Dr. Val: When you say that there’s a need for “infrastructure” do you also mean academic centers with physician and nursing schools and so on?

Deland: Absolutely. The Weill Cornell Medical College – which is affiliated with New York Presbyterian Hospital – has a medical branch in Doha, Qatar already and the first class of physicians graduated in May 2008. Johns Hopkins manages hospitals in Abu Dhabi, UAE too.

Columbia University has many scientific affiliations globally, and New York Presbyterian will begin offering management services internationally in 2009.

Dr. Val: What are management services exactly?

Deland: They come in two forms: 1) “Green field” opportunities where we send a team of experts to help to design a hospital from scratch, and then we also help to staff it and manage it with a “c-suite” of administrators (CEO, CIO, COO) who will initiate training in hospital quality, safety, and patient-centered care. 2) We also can help improve the quality and efficiency of current facilities – providing assistance with IT, human resources, tele-radiology, teleconferencing, and physician collaboration and oversight.

We’re not trying to be a franchise, though – because we’re very cautious about our brand and how we utilize it and we’re aware of the time and travel limitations of our medical staff and management teams. If we decide to put our name on a hospital abroad, we must be absolutely confident that the quality will be equivalent to our flagship hospital in New York City. Our standards reach beyond the Joint Commission minimums.

Dr. Val: Who are the other players in this global health franchise space?

Deland: They are all the ones you’d expect: Johns Hopkins, Harvard, the Cleveland Clinic, the University of Pittsburgh, and Methodist Hospital in Houston. Duke does some educational work overseas and there are a couple of hospitals in California who are thinking about branching out into the Asian markets.

Dr. Val: Are you worried about the current economic downturn and that it might slow your efforts?

Deland: The good news is that there is still a huge global demand for healthcare services. The challenge is that if the respective governments of these countries is sponsoring the importation of U.S. healthcare systems, it could slow down the process. However, in a down economy, healthcare is still considered to be an essential commodity and private equity firms will often consider investing in healthcare if they invest in anything. Short term, the economy will slow our progress, but long term there’s still a great need for healthcare infrastructure in many developing nations.

Dr. Val: Where do you think New York Presbyterian will be in 20 years in this new global economy? What’s their “end game?”

:  Unfortunately I don’t have a crystal ball, but I can tell you that the greatest challenge is to get enough quality medical staff (nurses, doctors, administrators, and so on) to run tertiary and quaternary healthcare systems. I think it will take at least 20 years to train the necessary staff to globalize healthcare on a large scale and make sure that quality standards are met.

The opportunity for expanding clinical research efforts through global collaborations is really exciting to me. Imagine all the advances that we could make with shared data, tissue banks, and pooled resources.

I think we’ll find that India and China will develop strong healthcare infrastructures in the next 20 years. I think that development in the Middle East may be slower because of their climate (it’s over 130 degrees for several months of the year) and staffing (most of their work force is imported from other countries) challenges. However, some of these countries (particularly in the Gulf region) certainly have the financial ability to move their healthcare forward despite adversity.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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