Maryland Regional Medical Program * March, 1974 so volume 8 number I o promoting  cooperation  to  improve  the  quality  and  distribution
            of health care services 0 health manpower development 0 encouraging the regionalization of health facilities manpower and  other  resource.
                      Maryland Regional Organ Procurement and
                     Transplantation Program Receives Approval

            G. Melville Williams, M.D.,  Co-Program Director,  Professor of         Left, Ron E. Purser, Physician Assistant, Coordinator of  Technical
            Surgery, Chief, Division of Transplantation, The Johns Hopkins          Programs of Division of Nephrology, University of Maryland.  Right,
            University School of Medicine                                           John H. Sadler, M.D., Project  Director  for  MRMP  Organ  Procure-
                                                                                    ment and preservation Program,  Associate  Professor  of  Medicine,
                                                                                    Head Division of Nephrology,  University  of  Maryland,  School  of
                                                                                    Medicine.
            MRMP  originally  submitted   this   project    ogy Division at  the  University  of  Mary-     family member is able  to  give  a  kidney.
            proposal  on  October  31,  1972  to   begin    land  School  of  Medicine,  is  the   pro-     If this kidney is well matched,  the  like-
            May  1,  1973.  However,  it   was   delayed    gram  director.   G.   Melville   Williams,     lihood  of  success  is  better   than   80
            by    the    "phase-out"    telegram    from    M.D.,  Professor  of   Surgery   and   Head     percent.  Most  people  are  not  so   for-
            RMPS  on  February  1,   1973.   After   re-    of.  Transplantation   Surgery   at   Johns     tunate.  Their  kidney   must   come   from
            ceipt   of   the   letter   and   memorandum    Hopkins University is co-director.              someone  dying   without   renal   disease.
            of  September  7,  1973  from  Dr.   Herbert      The   program    represents    an    out-     This  source  of  kidneys   provides   over
            J.  'Pahl,  Acting  Director  of  RMPS,   it    standing  example   of   full   partnership     half  the  kidneys  transplanted  in  Amer-
            was  resubmitted  with  the  full   endorse-    between   the   Region's   two   university     ica each year, but this  is  only  a  small
            ment  of  the   Regional   Advisory   Group,    medical  centers  and   other   cooperating     fraction of the need  for  transplants.  It
            the    Maryland     Comprehensive     Health    institutions in  furtherance  of  the  goal     is an even smaller  fraction  of  the  kid-
            Planning   Agency,   the    Maryland    Com-    of   a   comprehensive   regional   program     neys  which  might  potentially   be   made
            mission   on   Renal   Disease    and    the    of  care  for  all  chronic  renal  disease     available  for  transplant,  some  estimate
            Chronic  Illness   and   Aging   Administra-    patients. It  supplies  the  major  missing     100,000   potential   donors   per    year.
            tion  of  the  Maryland   State   Department    link  in  the  Maryland  renal  program  in     Half  of  these  would  be   enough.   Last
            of   Health   and   Mental   Hygiene.    The    making  transplantation  the  top  priority     year,   there   were   less   than    2,000
            grant   became    effective    October    1,    in  management  of   chronic   renal   dis-     donors.
            1973   for   $35,960   and   was    extended    ease    whenever    possible.    MRMP    is       A  major  public  and  professional  edu-
            January   1,   1974   through    June    30,    proud of  the  way  in  which  the  several     cational program  is  carried  on  by  many
            1974 for an additional $29,038.  It  is  ex-    key  health  institutions   involved   have     agencies  to  stimulate  a  broader   will-
            pected  that  the  program  will  be   self-    worked  out  really  effective  cooperative     ingness  to  donate  organs.  Progress   is
            supporting  following  July  1,  1974   from    arrangements  to  make  the   most   effec-     slow.  A  major   problem   was   obtaining
            third   party   payments    from    Medicare    tive use of the resources available.            kidneys  at  a  time  when  the  transplant
            (Section  2291,  Title  11  of  the   Social       For'most  patients  with  chronic  renal     could  be  done,  maintaining  them  in   a
            Security   Amendments   of    1972),    John    failure,  kidney  transplant   offers   the     viable state until the recipient, the  kid-
            , .-               . I - -I -@ @ - k     I      k,@+  fr@@f-.nt   ;:nr  Qr)mp  r)f thpm   n                          @, nnno 7


          I-
          norizonf                                                                                                                                     2

                  New Projects Approved for Fiscal Year 1974

          The   Regional   Advisory   Group,    acting     decrease  in  available   physicians   serv-
          on  instructions  from   RMPS   dated   Sep-     ices.
          tember  7,  1973,  approved  a   first   re-       Several   years   ago   the   State    and
          quest  application  for  $160,740  for   the     Areawide    CHP     agencies     anticipated
          months    of    October,    November     and     the   problem   and   the   former   commis-
          December,  1973.  A   second   request   for     sioned   a   "Study   and   Plan   to   Meet
          $226,878   for   the   new   budget   period     Health  Needs  in  Ocean   City"   by   con-
          January  1,  1974  through  June  30,   1974     sultants  from   the   Operations   Research
          was also approved,                               Division  of  the  Johns   Hopkins   Univer-
            In  addition  to   maintaining   the   re-     sity   School   of   Hygiene   and    Public
          duced  program   staff   and   providing   a     Health.
          modest  fund   for   "mini-contracts,"   the       One  of   the   recommendations   was   to
          first request  initiated  the  Maryland  Re-     form a Greater  Ocean   City   Health   Care
          gional   Organ   Procurement   and   Preser-     Corporation    which    was     accomplished
          vation  Program  and   the   contract   with     in  part  by  previous  MRMP  support.   The    Pediatric nurse practitioner,  Mrs.    Marcia
          the   Greater   Ocean   City   Health   Care     objective of the  Corporation  is  to  bring    Katz,  demonstrates  her  skills  in  gaining
          Corporation  to  start   implementing   rec-     together all  those  elements  in  the  com-    confidence of the child and his mother.
          ommendations   of   the   CHP   Ocean   City     munity responsible for  the  health  of  the,   of nurse  clinical  practitioners,  pediatric
          Health  Care  Study  for  solving   problems     area  and  to  serve  as  the  focal   point    nurse    practitioners,        nurse-midwives
          of accessibility to  health  services.  Both     for   planning,    development,    implemen-    and  physician  assistants.   The   RAG   as-
          of  these  projects,   which   are   briefly     tation  and  evaluation   of   present   and    signed a no. 1 priority to this project.
          desc ribed   below,   had    been    included    future  health  care  services  within   its      The   program   located   at   the   School
          previously   in   MRMP's   Anniversary   Re-     area  of  responsibility.   At   present   a    of  Nursing,  University  of  Maryland,   has
          view   and    Application    submitted    on     principal activity  is  the  creation  of  a    already  prepared  1  6   registered   nurses
          November  1,  1972,  but  were  stalled   by     new   Medical   and    Diagnostic    Center,    from  rural  and   urban   areas   of   Mary-
          the   RMPS   "phase   out"    telegram    of     w IC   wou      e  related  in  t  e   uture
          February 1, 1973.                                to  an  existing  community   hospital   for    land  to  practice  in  this  expanded  role.
                                                           secondary   care   and   specialized   diag-    All  16  graduates  are  employed   in   com-
           The   second   request   continued    these     nosis  and  to  a  university   center   for    munity    based    programs    or     private
          two   programs   and   added   five    addi-     tertiary   care   and   continuing   profes-    physicians'   offices   and   have    assumed
          tional  projects.   MRMP   has   also   been     sional education programs,                      full  responsibility  for  a  case  load   to
          assigned   $1   78,620   (from    FY    1973                                                     provide  primary   care   for   infants   and
          fund),  but  "expenditure  of  these   funds     Maryland Regional                               children  in   their   respective   agencies.
          cannot   be   made   until   instructed   by     Procurement  and  Preservation                  Activities  include  initial  new  born   as-
          RMPS."   In   the    most    recent    award                                                     sessments  at  local  hospitals  (in  two  of
          notice    dated    December    27,     1973,     Program-$29,038                                 the  rural  counties);  routine   well   baby
          which   approved   the    application    for     (January 1, 1974-June 30, 1 974)                health  supervision;  diagnosis  and   treat-
          January  1,  1974  through  June  30,  1974,     This  program,  which  is   a   key   compo-
          this instruction was continued.                  .nent  of   Maryland's   comprehensive   pro-   ment  of  minor  childhood  illnesses;   col-
                                                           gram for the  care  of  chronic  renal  dis-    laboration  with   pediatricians;   providing
           Since    the    extended    budget     year     ease, is sponsored jointly by the       Uni-    continuity  of  care   between   the   Health
          ended   on   December   31,   1973,   carry-                                                     Department  and  the  private   sector;   and
          over  of  $52,61  7   in   estimated   unex-     varsity  of  Maryland  and   Johns   Hopkins    providing   health   guidance    and    coun-
          pended  funds  has   also   been   approved.     Medical  Schools.  This  is   described   on    seling to parents.
                                                           page one.                                         The  objective  of   the   present   exten-
          Greater Ocean City Health                        Pediatric Nurse                                 sion'  is  to  prepare  another  group  of  8
          Care Corporation-$17,742                         Practitioner Program-                           registered  nurses  to  function  in  a  pri-
          (January 1, 1974-June 30, 1974)                  $9,075                                          mary   capacity    in    ambulatory    health
          This  is  an  example  of  health   planning                                                     care  for  children   through   collaboration
                                                           (January 1, 1974-June 30, 1974)
          to  promote   geographic   equity   of   ac-     This project is  the  only  one  which  rep-    with  physicians  and   other   health   pro-
          cess to health  services  in  a  rural  (but     resents  an   extension   of   an   existing    fessionals.  Some  aspects  of  the   curric-
          changing)   area   of   Maryland's   Eastern     MRMP   program.   It    deals    effectively    ulum will be  revised  as  a  result  of  the
          Shore   where   the   summer    (four-month)     with   the   maidistribution-access    prob-    evaluation  of   the   performance   of   the
          population    soars    from    approximately     lem  which  the   Administration   has   re-    16  graduates  now   practicing,   i.e.   in-
          3,500  in  non-vacation  months  to   nearly     peatedly   emphasized   in   recent   policy    creased   emphasis   upon    defining,    in-
          200,000   at   peak   periods.   This   phe-     statements,   namely   the   high   priority    terpreting   and    implementing         role
          nomenon   has   been   accompanied   by    a     which  will  be  placed  on  increased   use    change  for  the  nurse  practitioner.  After


             horizor)f                                                                                                                                       3

             termination   of   MRMP   support   in    July     ment  to  provide  reports   to   serve   the    Of course,  the  "end  result"  will  need  to
             it is expected  that  the  program  will  con-     following purposes:                              be   adjusted   for   age   and    type    and
             tinue   from   other   sources   of    support     9  report  patient  care  outcome   as   com-    severity of the disease,
             available  to  the  School  of   Nursing   and     pared   to    pre-established    norms    and       In  conjunction  with  the  Medical   Staff
             the  activity  will  be  coordinated  with   a     standards  of  care  for  use  in  a  medical    of   the   participating   community    health
             similar   program   at   the   Johns   Hopkins     staff's medical audit function.                  centers,  the     Management          Advisory
             School   of   Health   Services   to   achieve     *   management   and   evaluation   of    the    Services,   Inc.   will   develop   the    key
             maximum    benefit    from    teaching     re-     utilization/claims    review,    preadmission    parameters   for   which   norms   and    cri-
             sources   and   to   avoid   duplication    of     certification,   and    discharge    planning    teria will  need  to  be  established  in  the
             effort.                                            functions.                                       future  for  ambulatory   services   in   com-
                                                                *  report  all  hospital  data  for   service    munity   health    centers,    health    main-
             Demonstration of a Model                           area  analysis;  utilization  analysis;   pa-    tenance   organizations    and    other    or-
             Hospital Quality Assurance                         tient profile analysis.                          ganized   health    care    delivery    models
             Information     System-$31,280                                                                      which are evolving.
             (January 1, 1974-June 30, 1974)                    Development of          Quality                     Comparative   evaluation   of    the    pa-
                                                                Assurance Norms, Criteria                        tient's  health  profile  will  be   performed
             The  primary  leadership   for   this   demon-     and Standards  for  Community                    on  the  basis   of   disease   category,   as
             stration  comes   from   the   Maryland   Hos-     Health Care-$30,000                              well as  use  rate  of  health  care  by  dis-
             pital   Association   in   cooperation    with     (January 1, 1974-June 30, 1 974)                 ease type.
             five   hospitals-3   urban   and   2    rural.                                                         In brief,  the  expected  results  are  the
             The    Maryland    Foundation    for    Health     The principal  sponsor  of  this  project  is    development    of    methods    and     proce-
             Care  is  also   participating   and   discus-     the   West   Baltimore   Health   Care   Cor-    dures   for   establishment   of   norms   and
             sions   are   underway   with   other   groups     poration  located  in  an  urban  setting  in    criteria  for  quality  assurance   of   ambu-
             with  a  view  to  ultimate   development   of     close   collaboration    with    the    South    latory  care  on  the   basis   of   "outcome"
             a   commonly   held   corporation   to    man-     County    (Anne    Arundel)    Health    Care    and "end results" as indicated by:
             age  a  statewide   health   services   infor-     Center which is  located  in  a  rural  area.    o   The   frequency   and   use   pattern   of
             mation service.                                    Technical  consultation  and   direction   is    the  patient's   ambulatory   care,   adjusted
                                                                                                          cry
               The  project     will    demonstrate     the     provided  by  Management  Advis                  for age,   type   and   degree   of   disease.
             feasibility  and   effectiveness    of    per-     Services,  Inc.,   of   Columbia,   Maryland.    For  selected  diseases   this   will   result
             forming   the   following   quality    assess-       The  activity  is  directed   towards   de-    in  the  establishment   of   numerical   per-
             ment/claims   review    activities,    consis-     velopment   of   methods    and    procedures    centile tables.
             tent  with   Joint   Commission   on   Accred-     to assess  the  quality  of  personal  health   .
             itation   of   Hospitals   (JCAH)   and   Pro-     care  delivered  in   two   ambulatory   set-    9  An  analysis   of   potential   differences
                                                                                                                 between  urban   and   rural   patient   popu-
             fessional    Services     Review     Organiza-     tings,   both   administered   by    consumer    lations   pertaining   to   their   use   fre-
             tion   (PSRO)   requirements,   through    the     citizen groups.                                  quency  and  pattern   of   ambulatory   care.
             use  of  a  centrally  managed,  single,  uni-     .  The  program   will   utilize   the   data
             form,  reporting  and  review   process   for:     base of  a   currently   operating   computer
             0  utilization  review  and  certification  of     based    encounter    system    to     derive    Supplementary Studies to
             medical   necessity   acceptable   by    third     norms,  -  criteria,  standards   and   tech-    Augment  State   Comprehensive
                                                                niques   associated    with    current    en-    Health Plan-$7,299
             party purchasers                                   deavors  to  assure  quality   of   care   in    (January 1, 1974-June 30, 1974)
             o the collection    of    uniform    discharge     various   Federally   funded   medical   care
             data abstract information                          programs.   The    encounter    system    has    This   is   a   supplementary   grant   adding
             o  interfacing  with   medical   audit   func-     a   data   base   which   includes    disease    to  the  State  Health  Plan  Study  currently
             tions                                              diagnosis,     medical     procedures     and    being   undertaken   by   the    Johns    Hop-
               Related  objectives  will   be   to   demon-     medication   for   every   patient    treated    kins   University   Multidisciplinary   Health
             strate  the  value  and  feasibility  of   de-     for  each   encounter.   Subsequently,   dis-    Planning  Group.   The   source   of   funding
             veloping   a   single,   uniform   method   of     ease   profiles    and    associated    usage    for  the  Maryland  Health   Plan   Study   is
             external  third  party   claims   surveillance     rates  of  health  care   services   can   be    the     Maryland     Comprehensive      Health
             and  utilization   review   which   could   be     determined   as   a   function    of    demo-    Planning Agency.
             applied  to  all  hospitals   in   the   State     graphic     and     socioeconomic     charac-       The   supplementary   activity   has    two
             and  to  all  patients  regardless  of  source     teristics.                                       main   objectives   of   great   interest   to
             of  payment,  utilizing  a   process   similar       For   example,   the    information    con-    MRMP:
             to  that  of  the   Maryland   Admission   Re-     tent  of  the  encounter  form   allows   for    o  To  describe  and   determine   the   vari-
             view   Program   (MARP)   of   the    Maryland     the  comparative  evaluation   of   different    ous   health   services   in    72    Maryland
             Fouri-dation for Health Care.                      medical     procedures     and     medication    hospitals   and   surrounding   hospitals   in
               Also   the   program   will   endeavor    to     and  the  outcome   as   indicated   by   the    West  Virginia,  Virginia,  District  of   Co-
             establish  a   health   services   information     frequency   and   duration   of   acute   and    lumbia,     Pennsylvania     and     Delaware.
             system  utilizing  a   single   source   docu-     intensive  care  required  by  the   patient.    Through    the    use    of     questionnaires


           horizonf                                                                                                                                         4

           and  personal   interviews,   these   specific
           services   and   procedures    available    in               Development of an H MO
           each  hospital  will   be   determined   using
           levels   of   care    methodology    approach.                      Information System
           9  To  attempt  to  determine   patient   flow
           for  Maryland  to  West   Virginia,   Virginia:    Background     -     By     December      31,     Institutions,  with  grant  support  from  the
           District   of   Columbia,   Pennsylvania   an@     1973, the  terminal  date  of  the  grant  to     Bureau    of    Health    Services    Research
           Delaware  in  order   to   determine   overait     the  Office  of  Health  Care  Programs   and     and    Evaluation    (DHEW)    and     Founda-
           regional   patient-flow   patterns   and   the     the    Health    Services    Research     and     tions,  is  being  directed  at   the   issue.
           effects  of  hospitals  located  in  the   fiv     Development  Center   of   the   Johns   Hop-     The    groundwork    laid    by    the    MRMP
           surrounding    areas    on    the     Marylano     kins   Medical   Institutions,   the    major     grant  is  making  possible  this   study   of
           health care delivery system.                       objectives  of   MRMP   Project   #36,   "De-     the  strengths  and  constraints   of   infor-
                                                              velopment  of   an   HMO   Information   Sys-     mation   systems   in   addressing    specific
           Hypertension Materials                             tem,"   had   been   met,   Briefly,    these     planning and evaluation questions.
           Development Project for                            objectives  were  directed  at   the   devel-     The     Information     System     -     Major
           Lower Socio-Economic                               opment  of  a  data  collection  and   infor-     components   of   the    information    system
                                                              mation  system   which   would   serve   man-     operating    in    the    Columbia     Medical
           Levels-$10,000                                     agement,  clinical,  and   evaluation   func-     Plan   and   the   East   Baltimore    Medical
           (January 1, 1974-June 30, 1974)                    tions  that  are   particularly   useful   to     Plan  follow  (the  system   has   also   been
           This   is   a   modest   cooperative   project     HMOs   in   their   quality   assurance   and     introduced     in     the     Broadway-Orleans
           between    the    Central    Maryland    Heart     related utilization review programs.              Housing    Project    clinic,    a     non-HMO
           Association,  the   Educational          Films      Before   considering    the    details    of     facility):
           Foundation   (a    non-profit    organization)     progress  made,  it  is  worth  noting   that     o  Routine   reports   of   face-to-face   en-
           and   the   MRMP,   Financing   is    coopera-     national  events  since  the  start  of   the     counters   between    enrollees    and    pro-
           tive  as  well,  e.g.  total  budget  $25,400,     project  have  increased   the   significance     viders   (physicians,   nurse   practitioners,
           plus  one-half  time  of  staff   coordinator:     of   the   program.   The   Health    Mainte-     health   associates,   and   other   mid-level
           Educational    Films    Foundation    $15,400,     nance  Organization  Act   of   1973   (S.14)     health personnel).
           MRMP    $10,000    and    Central     Maryland     emphasizes  evaluation  and  there  is   lit-     o   Computer    stored    information    about
           Heart   Association   one-half   time    staff     tle  question  but   that   the   development     the   encounter    including    identification
           salary.                                            of   data   information   systems   in   HMOs     of  patient  and  provider   seen,   diagnosis
             Objective  is  the   production   of   audio     will accelerate  as  a  result.  Contributing     (or    problem),     procedures     performed,
           visual  materials  suitable  for  use  in  ed-     to  this   movement   is   the   recent   ap-     disposition,  referrals,   laboratory   tests,
           ucating   and    motivating    known    hyper-     pearance   of   recommendations   that    de-     and    X-ray    procedures    ordered,    pre-
           tension  patients   in   the   lower   soci'o-     fine  the  structure  and  content  of   such     scriptions  filled,  unit  cost  assigned   to
           economic   level,   with   the    object    of     systems  and  provide  a   minimum   set   of     each   service,    and    other    descriptive
           making   the   patient   a   member   of   the     items  and  tabulations   for   adoption   by     data about the visit.
           therapeutic team,                                  HMOs.*  The  basic  elements   of   the   in-     9  Reports  of   hospitalizations   and   com-
                                                              formation   system   developed   under    the     puter   storage   of   data   on   where   pa-
                                                              MRMP   grant   and   implemented    at    the     tient  was  admitted,   dates   of   admission
                                                              Columbia   Medical   Plan   and   the    East     and    discharge,     discharge     diagnosis,
                 NARMP WINS                                   Baltimore   Medical   Plan   are   consistent     surgical    procedures    performed,    admit-
                                                              with   these    recommendations    and,    in     ting  physician;   computer   files   on   am-
                           SUIT                               fact,  the  experience   with   this   system     bulatory  and  in-patient   care   are   being
                                                              contributed  to  the   formulation   of   the     merged.
             A U.S@ District Court    in      Washington,     recommendations,                                  0  Computer   based   enrollment   file   that
           D.C.  on  February  7,  1.974  has  ruled   in       Accompanying   the   interest   in   infor-     identifies  families  and   each   member   of
           favor   of   the   National   Association   of     mation  systems  is  the   recognition   that     the  family   enrolled   in   the   HMO;   the
           RMPs  in  a  suit  calling  for   release   of     realization of their full potential  for  ad-     file  also  contains   information   on   per-
           impounded 1973 and 1974 funds.                     dressing   management   and   clinical    is-     sonal characteristics  (data  of  birth,  sex,
             Judge   Flannery   enjoined    any    inter-     sues  related  to   economics   and   quality     marital  status,  relationship   of   individ-
           ference  with  the  actual  spending  of   the     of  care  in  HMOs   requires   new   reseach     ual   to   primary   subscriber,    contractor
           money,   denied   a    stay'pending    appeal,     efforts.  A  major  activity  of  the  Health     group   through   which   family    enrolled).
           and   ordered   the    government    to    pay     Services     Research     and     Development     o   Computer   programs   to   retrieve    in-
           costs   of   the   plaintiff,   The   National     Center,    The    Johns    Hopkins    Medical     formation   for   currently    defined    man-
           Association  of  RMPS,   Inc.   A   non-profit                                                       agement,   clinical,   and   evaluative   pur-
           corporation,   NARMP   -receives    no    pro-     *Murnaghan,  J.   H.   (Editor):   Ambulatory     poses  (with  aid  of   other   grants   these
           gram  funds,   but   is   supported   entirely     Care  Data,  Report  of  the  Conference   on     programs   are   to   be    expanded    during
                                                              Ambulatory   Care   Records,    Philadelphia,
                                                                   I D I          rn   107@q                    1974 and 1975).


              horizonf                                                                                                                                        5

                Costs  for  operating   the   above   sys-     availability   of    comparative    data    in    tem.  Of  interest  here  is   how   often   a
             tem  is  being  met   by   the   HMOs   where     other   prepayment   medical    plans.    This    more    definitive    diagnosis    is    made,
             they   were   developed   under   the    MRMP     has   become   apparent    from    the    com-    whether   these   patients   are    especially
             grant.  Manuals  and  programs   are   avail-     parisons   made   between    the    experience    high  utilizers,  and   in   what   situations
             able to facilitate the  introduction  of  the     in  the  East  Baltimore  Medical   Plan   and    referrals  are  made  for   psychiatric   con-
             information   system   by   other   HMOs   in     the   Columbia   Medical    Plan    and    be-    sultation.                                   i
             the region,  in  consultation  with  the  de-     tween   the   experiences   of    these    two      To   extend   these   applications   to    a
             velopmental staff.                                HMOs  with   those   of   other   HMOs   which    wider  range  of  conditions,  a   major   in-
             Management       Applications       -       A     are   producing   similar   types   of   data.    vestment   has   been    made    to    develop
             monthly  series   of   reports   to   monitor     Although this is still highly limited,  it  is    an  automated   procedure   for   coding   the
             the  volume  and  types  of   medical   serv-     expected  that  as  a  result   of   the   HMO    diagnostic   information   being   stored   in
             ices   rendered   by   the   physician   anci     legislation    and     the     recommendations    text  format.  By   February   1974,   a   dic
             non-physician  practitioners   in   the   HMO     for    establishing    information     systems    tionary    of    terms    and    corresponding
             is in effect. This  series  routinely  covers     in   organized   health   delivery   programs,    codes   that   are   consistent    with    the
             many  of  the   items   of   information   on     many  additional  sets  of  utilization   data    ICDA   (and   a   compatible   symptom   list)
             the  encounter  form  and  reports  of   hos-     will   become   available.   The   information    will   be   programmed   for   this   purpose.
             pita@  stays  and  is  designed  to   provide     system     implemented       through       the    All  but  a  small  proportion  of  the  terms
             management with a means for de                    MRMP   grant   can   be   used   to   parallel    that   appear   on    the    encounter    form
                                                     t         almost  all   types   of   data   that   might    will be  codable.  This  will  facilitate  the
             mining (1) trends in  utilization  of  d@irf:
             ferent    specialties    and    non-physician     conceivably   be   produced   by   both   well    conduct  of   many   clinical   and   epidemi-
             manpower,  laboratory   tests,   X-ray   pro-     established   and   newly    emerging    HMOs.    ologic studies.
             cedures,   drugs   prescribed   and    hospi-     Clinical   Applications   -    A    relatively    Evaluation    Applications    -    The     im-
             tal  care;  (2)  the  influence  of   changes     costly  but   essential   item   of   informa-    plementation   of    the    HMO    Information
             in   subscriber    composition    on    these     tion  for  clinical  application  in   quality    System   has   opened   the   door   to   com-
             trends;  and  (3)  the   need   to   consider     assurance   programs    is    the    statement    plex   evaluation   studies   of    approaches
             modifications   in   manpower    allocations.     of  diagnosis  (or   medical   problem).   The    to increase  the  efficiency  and  quality  of
                Utilization  data  are  in  the  form   of     HMO   Information   System    has    routinely    care  in   HMOs.   Examples   of   the   types
             numbers   and   rates    per    person    per     included   this   item   in    the    computer    of   studies   planned   or   underway    that
             year  and  are  aggregated  on  a  "year   to     data   bank   and   significant   steps   were    are  dependent   on   the   information   sys-
             date"   basis   to   supplement   the    sum-     taken  during   1973   to   develop   profiles    tem follow  (all  of  the  projects  are  sup-
             mary  of  monthly   experience.   Two   addi-     of   medical   care   received   by   patients    ported by other grants):
             tional sets of  data  that  give  insight  to     with  specified  diagnoses.  With   the   par-    9  Utility  of  the  information  system   for
             the  functioning   of   the   HMO   are   the     ticipation  of  clinicians,   several   condi-    quality  of  care   assessment.   Central   to
             distributions  of  patients  by   number   of     tions  have  been   selected   to   test   the    the  review   of   outcome   of   care   under
             encounters    during    specified     periods     capability  of'the  system  to   provide   in-    the   Experimental   Medical    Care    Review
             of  time   and   the   relationship   between     formation  that  would  be   useful   in   un-    program    (EMCRO)     in     the     Columbia
             duration of enrollment and utilization.           derstanding   the   patterns   of   care   re-    Medical  Plan   is   the   derivation   of   a
                The  above  data  are   related   to   co-     ceived  and  variability  in  these   patterns    problem  status  index  during   each   of   a
             payment   revenues   and   capitation   costs     associated   with   patient    and    provider    repetitive  series   of   inquires,   followed
             to  provide   a   basis   for   judging   the     characteristics.                                  by  evaluation   and   modification   of   the
             effect  of  demand  for   services   on   the       Conditions   that   are    being    examined    questionnaires.   An    objective    of    the
             current  economics  of   the   HMO   and   to     from   this   standpoint   include   hyperten-    EMCRO   study    is    to    measure    change
             estimate  future  utilization   and   revenue     sion,   bronchial   asthma,   urinary    tract    in  problem  status  over  time  and  its  re-
             in  the  program.  Information  on   utiliza-     infection  and  headache.  In  the   care   of    lationship  to  accessibility  and   the   ex-
             tion  and   enrollment   that   is   computer     hypertension,   profiles    of    care    have    penditure  of  health   care   resources.   In
             stored   includes   the   identity   of   the     been generated for patients who            had    coordination    with    the    EMCRO    study,
             membership    group    which     makes     it     this    diagnosis    during    the     period.    the   relationship    between    process    of
             possible  to  generate   utilization,   reve-     September-December,      1972.       Intervals    care  determinable   from   data   stored   in
             nue, and  cost  data  for  different  groups.     between   initial    diagnosis    and    first    the  information   system   and   changes   in
             In  addition,  the  data   will   provide   a     follow-up  visit,  between  first   and   sec-    problem status will be examined.
             starting   point   in   determining   whether     ond   follow-up   visit,   etc.   have    been    o  Impact  of  drug  utilization   review   on
             some     groups     require       educational     determined,       medications       prescribed    prescribing   practices.   This   project   is
             efforts  to  improve  utilization   practices     are   being   determined,   and   cases   that    designed   to   measure    the    change    in
             (under  or  over  utilization)  with   impli-     require  further  studying  to  assess   qual-    prescribing  patterns   over   time   as   ap-
             cations  for  both  the  economics   of   the     ity of  care  are  being  identified.  In  the    propriate  criteria  for  drug  use   is   im-
             plan and quality of care.                         case  of  headache,  a  sample   of   patients    plemented  in  the   clinic   and   to   docu-
                The ability to assess  utilization  levels     presenting    this    problem     has     been    ment  cost   savings   as   non-essential   or
             and  costs   would   be   enhanced   by   the     identified  through   the   information   sys-               continued on page 7


             horizonf                                                                                                                             6
                  HMO Legislation: Maryland Health Maintenance
                                   Plan Continues Local Involvement
             The   long-awaited   Health    Maintenance    operational  corporation,   the   Maryland      The Plan will serve as  a  unifying  ele-
             Organization  Act  (of  1973)  was  signed    Health     Maintenance     Plan     (MHMP)    ment  as  well  as  a  development  vehicle
             by  President  Nixon   on   December   30,    which   engaged   in   negotiations   with    to bring  about  the  high  quality  health
             after  some  three  years  of  legislative    the  Blue   Cross   of   Maryland.   After    care delivery  intended  by  the  new  leg-
             deliberation.  According  to   the   Amer-    sixteen  months   of   negotiations,   the    islation. The Plan is in  a  unique  posi'-
             ican  Medical  Association  News  of  Jan-    two  organizations  signed  an   agreement    tion  to  take  what   has   already   been
             uary 21,  1974,  President  Nixon  is  en-    in  December,  1973  to  collaborate,  of-    done  in  operating  centers  and  use   it
             thusiastically   endorsing   the    Health    fering  the   Committee's   network   pro-    to   minimize   development   and   operat-
             Maintenance   Organization   program   ef-    gram  to  Blue  Cross  group   subscribers    ing costs in new centers.
             fort. The government is  "going  all  out"    as an alternative  choice  to  traditional      The  Maryland   Regional   Medical   Pro-
             to  implement  the  new  law  "as  rapidly    fee-for-service benefit programs.             gram    (MRMP)    approved     two     com-
             as   possible",   according   to   Charles      It is expected that  the  Plan's  agree-    panion  programs  in  the  Fall   of   1971
             Edwards,  M.D.,   Assistant   HEW   Secre-    ment with Blue Cross  will  permit  offer-    - one     involving   funding       support
             tary  for  Health.  Proposed   regulations    ing in the near future high  quality  care    ($79,816)   for   the   MHMC    information
             to carry  out  the  HMO  program  are  ex-    in  conveniently  located  health  centers    system  and  evaluation  effort,  and   the
             pected  to  be  issued  by  the   end   of    in  increasing  numbers  to   the   people    other  involving   funding   support   (ap-
             March.                                                                                      proximately  $140,000)  to  the  Office  of
                                                           of Maryland. It will  encourage  the  pro-
               The  $375 million bill  provides  for  a    gress  of  these  centers  to  operational    Health   Care   Programs   of   the   Johns
             program  of   grants,   loans   and   con-    prepaid  group   practices   through   its    Hopkins  Medical  Institutions  in  an  ef-
             tracts  to  encourage  the  expansion  and    development effort.                           fort  to   develop   an   HMO   information
             development   of   both   non-profit   and                                                  svstem  that  would  have  general   appli-
                                                             The    Maryland    Health    Maintenance
             for-profit HMOs. In addition  to  defining    Plan  is   now   anticipating   enrollment    cat)iiity to HMOs of  a  variety  of  types
             HMOs  and  the  fixed   payment   (capita-    from  the  first  subscriber  group:   The    and in a  variety  of  settings.  The  MHMC
             tion) method of  financing,  the  Act  re-                                                  and  the  Office  of   Health   Care   Pro-
                                                           State  of  Maryland  is  offering  a  dual    grams   conducted   these   two    programs
             quires  all  employers  with   twenty-five    choice  program   for   its   50,000   em-
             or  more  employees  and  covered  by  the    ployees and retirees  and  their  approxi-    in concert.
             Fair  Labor  Standards  Act  to  offer  an    mately 100,000 dependents.                      In the near  future,  the  MHMC's  activ-
             HMO  option  (dual  choice)  in  its   em-                                                  ities  in   management   information   sys-
             ployee benefit  plan.  To  qualify  as  an      Already   in   agreement   to-   deliver    tems  will  be  based  on  the  actual  re-
             HMO,   the   health-   care   organization    services 'to   State   of   Maryland   em-    quirements  of  the   operational   network
             must  have  consumers,   i.e.,   subscrib-    ployees   are   the    Columbia    Medical    and its participating  health  centers.  As
             ing  members,  comprising  at  least  one-    Plan  in  Howard  County  and  the   Group    a vehicle  for  consumer  participation  as
             third of its policy-making body.              Health    Association    of    Washington,    well  as  a  coordinator  of  provider  re-
                                                           D.C., through its  two  Maryland  centers,    resources,  the  Plan  will  work  to   de-
               Over the  last  three  years  the  Mary-    one  in  Rockville  opening   February   7    velop   standards   for   medical    groups
             land   Regional   Medical   Program    has    and  one  in   Takoma   Park,   Montgomery    practicing  in  the  network   program.   A
             participated  with  other  groups  in  the    County.  In   addition,   the   Chesapeake    Medical  Standards  Board  will   be   con-
             development  of   such   an   organization    Physicians  Professional  Association   of    vened  to  plan  for  establishing  quality
             in   Baltimore,   The   Maryland    Health    Baltimore City  Hospitals  has  contracted    assessment  programs  which   satisfy   the
             Maintenance    Committee    (MHMC).    In-    to deliver services in east  Baltimore  in    medical   community   and   contribute   to
             corporated   (non-profit)   in    February    conjunction  with  the  Eastpoint   Health    patient satisfaction.
             1971,  the  MHMC   was   funded   by   the    Center,  Inc.,  a  labor  community   cor-      One of the Plan's vital roles  in  infor-
             Health   Services   and   Mental    Health    poration organized  to  establish  a  con-    mation systems  will  be  to  use  existing
             Administration  of   the   Department   of    sumer-oriented HMO.                           forms   and   systems,    modifying    them
             Health,  Education,  and  Welfare   during
             -Fiscal Years '72 and '73 to develo             Nenotiations   are   underway   with   a    where  necessary  to  satisfy  the  quality
                                                      a    medical  group  at   Mercy   Hospital   in    assurance  and       management        data
             network   of   prepaid   group    practice
                                                           downtown  Baltimore;   and   merger   dis-    needs  of  emerging  network  health   cen-
             health centers in the State.
                                                           cussions  are  in  progress  between   the    ters. As in  other  areas,  the  Plan  will
               MRMP    awarded    some    $80,000    in    Plan  and  the   First   Maryland   Health    draw  from   the   experience,   procedures
             Fiscal Years  '72  and  '73  for  research    Care  Corporation,  funded   by   OEO   to    and  methods  already  developed   in   our
             and development  efforts  in  quality  as-    deliver  services  to  "grey  area"  popu-    operating centers  to  assure  the  quality
             surance  and   information   systems   for    lation.  The  merger  is  directed  toward    of  care  in  new  health  facilities   and
             HMOs    and    demographic    and    third    eliminating  duplication   and   achieving    minimize  development   costs   by   elimi-
             party enrollment analyses,                    maximum  utilization  of   available   re-    nating the  necessity  of  doing  what  has
               Tho (nmmittoiz erpntprf   n  nnn-nrnfit     qntirrpq And experience.                      already been done successfully.


             ho(izonf                                                                                                                                  7

              When    the    Maryland    Health    Main-    grant  to  the   combined   Johns   Hopkins/           HMO Information
             tenance Plan  begins  its  initial  market-    University  of  Maryland   transplant   pro-
             ing  and  enrollment  effort  this  Spring,    gram   has   made   this   available.   Also                   System
             with  from  two  to  five  autonomous  pre-    through  help  from  MRMP  a   shared   tis-               continued from page 5
             paid   group   practice   centers    linked    sue  typing  exists.   Now   a   cooperative
             organizationally, it will be the first time    organ  preservation  lab  in  University  of    duplicative   expensive   drugs   are    d6-
             a   prepaid   group   practice   plan   has    Maryland   Hospital   maintains   a    group    leted from  the  formulary  or  are  limited
             initiated operations as a network.             of  organ  preservation   machines   to   be    in their use.
              Single  copies  of   Public   Law   93-222    continuously   ready   when    organs    are    9   Effect   of    changes    in    manpower
             "Health   Maintenance   Organization    Act    procured.    The    equipment    will     be    mixes  on  utilization.  In  both  the   Co-
             of  1973",  which  was  signed  by   Presi-    shared  by  all  procurement  teams  in  the    lumbia  Medical   Plan   and   East   Balti-
             dent  Nixon  on  December  29,  1973,   are    region and portable  units  will  be  avail-    more   Medical   Plan,   the   number    and
             available  on  request  ot  Maryland   RMP,    able   at   Johns   Hopkins   Hospital   and    type   of   health   care    manpower    has
             Suite  201,  550   North   Broadway,   Bal-    Baltimore  City   Hospitals   as   well   as    changed with time.
             timore, Maryland 21205.                        University   of   Maryland   Hospital.   The    9  To  assess  the  relationship  of   these
                                                            console  machine  which  is  not   portable,    changes  to  services  provided,  a   retro-
                                                            but  can  carry  out  more   extended   pre-    spective  analysis   of   utilization   data
                   MRMP Regional                            servation will be  maintained  in  the  cen-    stored   from   the   encounter   form    is
                Organ Procurement                           tral laboratory.                                being carried out.
                      continued from page 1
             ney  and  the  operating  team   could   be        Regional Medical Programs Are
             together and testing the viability  of  the
             kidneys.  With  the  advent  of   machinery                            Back   in            Business
             for  extended   organ   preservation,   far
             better  answers  to   this   problem   were      The     reappearance     of      HORIZONS,      As a  result  of  this,  the  Division  of
             obtained.                                      MRMP's   publication,   signals   the    end    Regional     Medical     Program     (DRMP),
              If  the  kidney  procured  can  be   main-    of  a  long  series  of  on-again  off-again    the  new  name  for  RMPS,  is   hosting   a
             tained in a healthy  state  for  40  to  80    non-events  and  vicissitudes  set  in   mo-    National  Conference   of   Regional   Medi-
             hours  on  this  machine,  a  patient  from    tion  by   the   "phase-out"   telegram   of    cal  Programs  on  March  18-19,   1974   at
             even  remote  areas  can  be   brought   in    February  1,  1973  from  Dr.  Harold   Mar-    Arlington,   Virginia   to    discuss    the
             and made  ready  for  transplant.  All  the    gulies,  who  was  then  director   of   Re-    future  course  for   1975.   The   Chairman
             necessary  tests  to  determine  the  match    gional   Medical   Programs   Service.   De-    of   the    Maryland    Regional    Advisory
             and  the  viability  can  be  carried  out.    tailed   chronological   account   of    the    Group,  Mr.  J.  Cookman  Boyd,   Jr.,   and
             The characteristics of  the  kidney's  per-    zig-zag  events  since  then  may  be   left    the    MRMP    Coordinator,    Dr.    Edward
             fusion on this  machine  is  a  major  test    to   historians   and   to    constitutional    Davens, will attend'this meeting.
             of its viability. Small  versions  of  this    lawyers  interested   in   the   interaction     According  to   present   information,   at
             equipment are portable  so  that  the  kid-    between    executive,    legislative,    and    least   $97   million   in   impounded   RMP
             ney may  be  transported  to  the  site  of    judicial   branches   of   government   dur-    funds  for  FY  1973  and  1974  are  to  be
             best   matched   recipient.    Since    the    ing a period of national stress,                released.   MRMP   will   be   expected   to
             transplant   programs   of   Maryland    at     Insofar   as    the    Maryland    Regional    submit  two   applications:   One   on   May
             University of  Maryland  Hospital  and  the    Medical   Program    is    concerned,    the    1,  1974  and  the   second   on   July   1,
             Johns  Hopkins  Hospital   participate   in    matter  has  now   been   resolved   (tempo-    1974.  These   applications   will   include
             the  Southeastern   Regional   Organ   Pro-    rarily  at  least)  by  recent  actions.  In    funds  for   program     staff       expense
             curement  sharing  program,  it  is   often    October,   1973,   the   President    signed    from  July  1,  1974   through   June   '30,
             necessary   to   transport   kidneys   from    the  HEW  appropriation  bill   for   fiscal    1975   and   new   projects   as    approved
             Maryland  to  other  parts  of  the  region    year   1974   which   contained    $81,953,-    and  priority   ranked   by   the   Maryland
             and  from  other  centers  into   Maryland.    000   for   the   Regional   Medical    Pro-    Regi onal    Advisory    Group.    The    RAG
             With this machinery, there is  no  loss  of    grams.  At  the  same  time   he   announced    will  meet  in  mid-April  to  act  on   the
             transplantability   of   the    transported    release  of  $1.1   billion   in   impounded    May  I  application  and   again   in   June
             organ.                                         health  and  education   funds,   but   with    for the July I application.
             Although    hemodialysis     and     trans-    the stipulation that the  funds  are  to  be     A variety  of  interesting  project  appli-
             plantation   have   been    available    in    stretched  over  fiscal   years   1974   and    cations  by  various   health   groups   and
             Maryland  for  the  last  six   years   and    1975   (and   perhaps   longer).    However,    agencies   which    deal    with    improve-
             more, the ability  to  effectively  procure    on  February  7,  1974  Judge  Flannery   of    ments in  the  delivery   of   health   care
             organs  has  been  limited   by   the   ab-    the,District  Court  of   Washington   ruled    services  are  currently   in   preparation.
             sence   of   such   equipment   and   staff,   that   RMP   impounded    funds    for    FY    These   pending   applications    are    di-
             trained in'  its  operation.  The  Maryland    1973  and  FY  1974   be   released   forth-    rected  to  quality  assurance   of   health
             Regional   Medical   Program   through    a    with (see page 4).
                                                                                                                    rnntinitpri nn npyt nan,-


              ho(izon/                                                                                                                                               8

                           RMP Back in                              grams-RMP,  CHP,  and  Hill-Burton                          Appropriate Motto
                             Business                               -should be consolidated as an  im-                                for MRMP?
                                                                    portant  step   in   preparing   for   national           "and   it   ought    to    be    remem-
                           continued from page 7                    health insurance.                                      bered   that   there   is   nothing   more
              care,   improving   nursing    care    of    the        With t is in mind,            P wi  exe              difficult   to   take   in   hand,   more;
              aged    and    chronically    ill,    comprehen-      special effort  to  ensure  that  all  projects        powerless    to    conduct,    or     more
              sive   approach   to    hypertension    control,      or   proposals   brought   before    the    Re-        uncertain  in   its   success,   than   to
              implementation   of    the    recently    issued      gional    Advisory    Group    for     approval        take  the   lead   in   the   introduction
              Standards      for      Cardiopulmonary      Re-      and  setting   of   priorities   will   receive        of   a   new   order   of   things.    Be-
              suscitation    (CPR)    and     Emergen'cy    Car-    careful   review   and   comment   either    by        cause    the     innovator     has     for
              diac    Care    (ECC),    data    systems    for      the     Maryland      Comprehensive      Health        enemies   all   those   who   have    done
              manpower   planning    and    criteria    deter-      Planning   Agency   (the   "A"    Agency)    or        we//    under    the    old    conditions,
              mination   in   large    hospital    out-patient      by       the       Areawide       Comprehensive        and    luke     warm     defenders      in
              departments,   and   local   planning    by    a      Health     Planning     Agency     (the     "B"        those  who   may   do   well   under   the
              health       services/education       consortium      Agency)   as   appropriate.    The    objective        new.   This   coolness    arises    partly
              to   improve    access    to    primary    care,      is  to  fund  only  projects  that   will   fit        from   fear   of   the   opponents,    who
              continuity  of  care,   and   a   health   serv-      comfortably   and   merit    continuation    in        have   the  laws  on   their   side,   and
              ices regionalization model.                           the   anticipated   reorganization   by    Con-        partly    from    the    incredulity    of
                   One   feature   of   the   new   turn    of      gress  of  the   key   functions   of   regula-        men,   who   do   not   readily    believe
              events  is   $4.275   million   has   been   set      tion, planning and implementation.                     in  new  things  until   they   have   had
              aside   on   request   by   the   Congress   for                                                             a   long   experience   of   them.    Thus
              proposals    on    a    national     competitive                                                             it    happens    that    whenever    those
              basis   to   develop   models    for    "Compre-                                                             who   are   hostile   have   the    oppor-
              hensive      Arthritis      Care      Programs."         ho(izoni                                            tunity  to  attack   they   do   it   like
              Such   a    proposal    is    being    developed         Vol. 8, No. 1                                       partisans,   whist    the    others    de-
              in   Maryland   for   review   by   MRMP   proc-                                                             tend   luke   warmly,   in    such    wise
                                                                       Published bi-montl
              ess   and   then   submitted   to    Washington.         land Regional  M,                                   that    the    prince    is     endangered
                   A  high  level  health  official   in   HEW         with officei@in the                                 along with them."
              has   stated   that   a   bipartisan   concensus         in , 550 '@North B
                                                                         9
                                                                       more, Maryland 21@                                     from the  Prince:  Nicolo  Machiavelli,
              exists   among    both    the    Congress    and                                                                published 1513 translated by
              the   Administration   that   the   three   pro-                                                                W. K. Marriott

              The programs, projects and activities of the Maryland          Regional Medical     Program are operated on a non-discriminatory basis. This
              regulation prohibits discrimination on the basis of race, color, sex or             national origin and applies to the provision of services, use
              of   facilities, opportunity to participate, practice of employment and granting of advantages, privileges and accommodations.

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