One giant laboratory

Imagine research not bound by walls, campus boundaries, or state lines. A giant laboratory where investigators, regardless of geography, can enter each other's lab or clinic to share an idea, problem, unpublished manuscript, or clinical trial protocol.

Thanks to the largest, federally funded, three-year award for prostate cancer research in history, investigators at 13 universities in eight states will soon work together as if they were all located in one place. Using web-based technology, they will share data to find new ways to treat advanced prostate cancer.

With a $10 million grant from the Department of Defense Prostate Research Program, the Winship Cancer Institute (WCI) will develop the consortium over the next three years. Jonathan Simons, WCI director, and Leland Chung, director of molecular urology, are the primary investigators.

Participants will use web-based videoconferencing and online, real-time videostreaming data-sharing technologies, developed under a 2001 competitive planning grant award in which WCI researchers created a Virtual Corridor of Adjacent Programs (V-CAPs) to connect consortium team members. "To our knowledge, this infrastructure for real-time interaction across space is a first in prostate cancer research," Simons says.

Investigators are from Emory's WCI, Wayne State in Detroit, Johns Hopkins Oncology Center in Baltimore, Harvard Medical School in Boston, University of Texas Southwestern Medical Center in Dallas, Fred Hutchinson Cancer Research Center in Seattle, University of California at Davis, Memorial Sloan-Kettering Cancer Center in New York, UCLA Jonsson Cancer Center in Los Angeles, University of Washington School of Medicine in Seattle, University of Virginia, and Harvard/Brigham and Women's Hospital in Boston. Investigators include PhD-level basic scientists in tumor biology, bone physiology, molecular genetics, pharmacology, and biostatistics as well as urologists, pathologists, radiation oncologists, and medical oncologists.

NO MORE chicken scratch

Based on reports that about half of all medication errors begin with prescribing, Emory Hospitals launched its Medication Error Prevention Initiative (MEPI) in 2000 and standardized prescription writing to increase patient safety.

In the first year of the project, the total number of reported prescribing medication errors declined by 13%. And the percentage of prescribing errors detected prior to patient administration rose to 95.2% by November 2002, says William Bornstein, chief quality and medical officer at Emory Hospitals and medical director of Emory Healthcare Information Systems.

Now the MEPI team is working on "problem prone" abbreviations, says Tish Kuban, Emory Hospitals' pharmacy assistant director for sterile products and performance improvement. Although there is a list of approved abbreviations to use when writing a prescription, the list constantly changes and is hard to manage.

To cut down on potential errors, the MEPI team not only identified a group of abbreviations as high risk, but went one step further by getting professional service committees at the hospitals to agree not to use them. The MEPI team continues to work on identifying risky activities that could lead to potential errors and plans to implement additional patient safety projects in the future.

The Georgia Hospital Association recently recognized Emory Hospitals and Wesley Woods for the initiative and awarded Emory the 2002 Partnership for Health and Accountability Award for Quality and Patient Safety for Hospital Health Systems.

Hard evidence

Emory medical school faculty, residents, staff, and students are trying out and evaluating clinical guidelines that offer best practices in medical care for more than 100 medical conditions. They're using evidence-based medicine via a pilot project called EBM Solutions (formerly WebEBM).

The guidelines, many authored by Emory physicians, are on a private, password-protected website. Each topic includes a parallel guideline written specifically for patients to help them understand the recommendations and the underlying evidence.

Organizations licensing EBM Solutions' guidelines make them available to physicians and other health care providers, who can, in turn, make consumer-friendly versions of the guidelines available to their patients. Patients can also report on their understanding of and compliance with the guideline. There are also links to the evidence underlying the guideline so the user can find further information.

In 1999 Emory Healthcare joined four other academic health centers (Duke, Oregon, Vanderbilt, Washington University, and later Mt. Sinai NYU Health) to create the evidence-based guidelines. Many have been authored by Emory clinicians, working under the direction of Emory medical advisors: formerly William Bornstein, chief quality and medical officer at Emory Hospitals, and medical director of Emory Healthcare Information Systems, and currently Kimberly Rask, associate professor of medicine and health policy and management. Emory physicians continue to author new guidelines, update existing guidelines, and review guidelines written at other institutions.

Depending on feedback and use during the pilot phase, the license for the EBM content may be expanded to other Woodruff Health Sciences Center and Emory Healthcare users.

Authorized Emory users can obtain a password to the site by going to www.emory.edu/WHSCL/EBM.

For more information, contact Rask at krask@emory.edu or 404-727-1483 or Jon Saxton, special assistant for health policy and communications, at jsaxton@emory.edu or 404-778-4798. Or see the EBM Solutions website at www.ebmsolutions.com.

Physician, evaluate thyself?

That doesn't quite have the same ring to it as the old saying, "physician, heal thyself." Maybe there's a reason. When hospitals review patient outcomes, they usually use data collected by doctors who at best are too busy to devote their full attention to the matter and at worst are not disinterested observers.

That's part of the idea behind the National Surgical Quality Improvement Program (NSQIP). Developed to evaluate outcomes at VA medical centers nationwide, NSQIP was recently put to the test at Emory University Hospital (EUH), one of just three private medical facilities in the nation so chosen.

Unlike other mandatory report cards now being generated on hospitals and surgeons, NSQIP data is risk-adjusted for death and complications rates, says Aaron Fink, chief of surgical services at the Atlanta VAMC. "In most other outcomes studies, numbers or percentages don't reflect severity of illness or any complication of surgery. So quality institutions that treat the sickest patients might appear below par. Or surgeons who hesitate to take on complex, high-risk cases give the false impression that they are rendering good care."

NSQIP evaluations are based on detailed, impartial data. Surgical nurses not involved in patient care look at 40 preoperative and intraoperative clinical factors‹from laboratory tests indicative of malnutrition or chronic illness to anesthesia risks to whether the case is a high-risk emergency. Researchers sort outcomes into 21 well-defined categories, such as wounds or respiratory problems.

"For example, we define exactly what is superficial and what is deep wound infection," says Fink. "Nurses don't have to make a judgment call about how to report a slight stain on a bandage." Patient outcomes are tracked for 30 days after a procedure.

NSQIP can predict the number of expected deaths or complications for patients with defined risks. Hospitals that score below the published accepted values reflect high quality of care; scores above signal concern and merit a call for change.

In the decade since the VA first implemented NSQIP, 30-day post-op deaths at the VA have dropped 27%. While part of the credit for the decline can be attributed to advancements in medical care, Fink believes that NSQIP's detailed analysis is also a factor. And he's confident that Emory and 15 other hospitals trying NSQIP can show a similar improvement over time. EUH did well in preliminary data, and the alpha trial proved that NSQIP analysis could be transferred to a more typical hospital setting.

To learn more, see www.NSQIP.org.

What price security?

New laws intended to boost homeland security may have major implications on Emory research -- in ways that go beyond restricting possession and transfer of "select agents" and toxins that could pose serious threats to public health and safety. They may affect how the university builds future labs and provides security as well as how researchers share information. The laws may also have a profound effect on Emory's growing contingent of postdoctoral students from other countries and on researchers from the Middle East.

The laws - specifically the Patriot Act, the Public Health Security and Bioterrorism Preparedness and Response Act, and the Agricultural Bioterrorism Act, as well as regulations proposed by the Centers for Disease Control and Prevention and the US Department of Agriculture (USDA) - went into effect in February. The Patriot Act criminalizes possession of select agents except for medical or clinical purposes or for "bona fide research" but does not define the latter.

Emory has identified 16 researchers studying three highly infectious diseases who will be affected by the act.

"To meet the requirements of the act, the culture at Emory will probably change on the health sciences campus," says Kris West, director of research compliance. Wherever certain biological or chemical agents (60 select agents) are used and studied, labs will have to be locked at all times with only approved users provided keys or card keys. It's possible that buildings themselves will be locked even during the day and that staff, faculty, and students will have to have card key access. Guards will be stationed outside designated labs and will be charged with searching all packages going in and out of those labs.

Anyone working in those labs, including some administrators, will be subject to security risk assessments by the US Department of Justice and must be approved by the Department of Health and Human Services or USDA every five years.

The new security and human guard requirements will be costly. In fact, the Association of American Universities says the cost of compliance in just one 1,000-square-foot lab at one university was estimated at $400,000.

Among the considerations are whether it is cost-efficient to maintain separate labs and separate security systems for the various select agents on campus or whether all such work should be combined in one controlled location.

"Does this mean we'll have to provide locks on cubicles in the future?" asks West. "We don't know yet whether we'll have to designate a building or a floor for those agents and researchers who are affected by the act."

Facing such troubling questions, a university-wide task force is studying the campus-wide implications for research and education. It is charged with determining how Emory will proceed to meet the requirements of the act and continue its building program, which in the past has emphasized collaboration in open labs.

While these new laws currently affect only a small number of researchers at Emory, as the university's vaccine work and other research continue to gear up, more people and their working environments probably will be affected.

The task force, headed by the Environmental Health and Safety Office and the Office of Research Compliance, is expected to come up with options and recommendations by this summer. For more information about the Patriot Act, see www.cdc.gov/od/sap.

EHCA realigns

EHCA, the joint venture between Emory Healthcare and HCA-The Healthcare Company, continues to evolve and shift its focus (See "Emory and Columbia/HCA open new doors," Spring, 1999 at www.emory.edu/WHSC/MOMENTUM).

Last year, Emory Cartersville Medical Center and Emory Northlake Regional Medical Center left the EHCA fold, returning to HCA. Emory Dunwoody Medical Center and Emory Eastside Medical Center, the two other hospitals currently operated by EHCA, remain in the joint venture.

The goal of the realignment, say EHCA chair Michael Johns, and HCA's Tom Gilbert, is to better direct resources and concentrate efforts on specific programs and services for the communities served by HCA, Emory, and EHCA. Both HCA and Emory Healthcare remain committed to the EHCA joint venture and say the changes will benefit the communities they serve.

The recent relocation of Emory's Family Practice Residency Program to the Emory Dunwoody campus exemplifies this mutual commitment. Capital improvements will include renovations and expansions of Emory Eastside.

EHCA plans to develop Emory Johns Creek Hospital, which will replace Emory Dunwoody Medical Center and the now-closed West Paces Medical Center. Restructuring will not result in the closure of any other hospital or the loss of any jobs. The management team of each facility will also remain in place.

The joint venture EHCA was originally formed in 1999 for several reasons, including the desire to work with managed care companies in contract negotiation and to compete with other networks that were being formed in the metropolitan area. Since then, there have been significant changes in the health care industry as well as in the competitive hospital landscape in Atlanta -- managed care contracting has become less exclusive and the strength of networks such as Promina has lessened considerably.

"During this time, EHCA has made some difficult decisions such as the closure of two facilities and the pending sale of Emory Peachtree Regional Hospital, events which have contributed to the need to make additional structural changes to the joint venture," says Gilbert. "Those considerations have led us to conclude that our primary focus is the north metro area which includes, among others, Dunwoody, Johns Creek, and the Snellville communities."

MILESTONES

• A 42-year-old pharmacist no longer needs to give herself five insulin injections a day for her type 1 diabetes, thanks to Emory and Georgia's first islet transplant.
• Work began on a new Orthopaedics and Spine Center at Executive Park off of North Druid Hills Road. All orthopaedic outpatient services from The Emory Clinic and the Emory Sports Medicine and Spine Center will move to the 95,000-square-foot, five-story building in early 2004.
• The Agnes Raoul Glenn Building opened in January at Emory Crawford Long Hospital. The two-story building is devoted to radiation and medical oncology and staff training.
• After more than 30 years in trailers, the Emory Children's Center will get a new home next year. The School of Medicine is now designing a new $40 million pediatric building to be located on Ridgewood Drive, behind Children's Healthcare of Atlanta at Egleston and across from the Emory pediatric clinics.
• The state's first Cancer Center of Excellence opened at Grady Hospital early this year. As one of four regional centers planned by the Georgia Cancer Coalition, it will focus on the most common types of cancer in Georgia - breast, cervical, prostate, lung, and colorectal - and will seek to lower disproportionate cancer mortality rates among African Americans, the poor, and the uninsured.
• The Emory Autism Resource Center opened recently on the Emory Clairmont campus in a new 16,000-square-foot, $3.4 million facility. The center provides comprehensive services for children, adults, and their families.
• Yerkes National Primate Research Center broke ground in April for its new 92,000-square-foot, $27 million neuroscience building. The new facility is funded by a partnership of federal, state, and university resources, including two NIH grants for $2 million each and Georgia Research Alliance funds.