Surfing the Web can shorten quality search

Practice makes perfect, but watch for speed bumps

The quality improvement, resource utilization, and accreditation arenas are overflowing with information. You’re constantly absorbing and analyzing data, trying to cost-effectively apply new research to the bedside. Quality managers have traditionally relied on textbooks, journals, and day-to-day observation to help them carry out these responsibilities. But with new clinical developments occurring almost daily, these resources are no longer enough. Enter the Internet. It could make your job — and life — easier.

As you visit the sites described in this issue, place "bookmarks" with your browser so you can find them again quickly.

If you don’t regularly access the following sites, surf to them first. They are most important to your job:

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The site at contains a report of the commission’s history and standards, updates on its new outcomes reporting program, ORYX, and a detailed description of the accreditation process, including how to prepare for a survey. Individual performance reports can now be ordered by mail, but next year the Joint Commission will start posting these reports at its site as well. The site’s newsletter contains announcements and articles about ongoing programs.

The National Association for Healthcare Quality (NAHQ) in Glenview, IL. Founded in 1976, NAHQ currently has upward of 7,000 individual and 100 institutional members. The site at contains a description of its mission, its standards and code of ethics, and information about membership, course offerings, publications, and the annual educational conference.

The National Committee for Quality Assurance (NCQA) in Washington, DC. NCQA began to accredit managed care organizations six years ago, and has become increasingly important as the role of managed care has grown in this decade. If you have Health Plan Employer Data and Information Set (HEDIS) responsibilities, NCQA is a good site to visit regularly at You can find 17 national HEDIS averages on line there. In addition, NCQA provides summary reports on accreditation for almost 200 health plans. The site maintains a list of facilities and the types of credentials, licensure, hospital privileges, and malpractice insurance for which each is certified. National averages for the performance of health plans on aspects of care such as childhood immunization and prenatal care are available too. You can order full HEDIS information on paper or CD-ROM from the site.

The Health Care Financing Administration (HCFA) in Baltimore. In addition to general information about the organization that manages Medicare and Medicaid, the site at http://www. contains statistics on providers, cost limits, cost reports, and payment rates. The section on laws and regulations links to updates on such matters as fraud, abuse, and waste. Press releases from 1994 to the present are available, as are many consumer publications, such as the Medicare Handbook, the 1997 Guide to Health Insurance for People with Medicare, and documents on Medicare Managed Care.

Superhighway downside

On-line tools can add a whole new dimension to your career. Like all emerging technologies, however, the information superhighway has a downside — it could be dangerous to your health. Important issues for nursing managers and quality improvement staff to contend with revolve around confidentiality and legal liability.

"Confidentiality and liability are intertwined," warns Renee Martin, JD, RN, MSN, a Wayne, PA, attorney, "because it’s the disclosure of confidential information that gets you into trouble."

Putting a patient’s medical chart into electronic form makes it easy prey for any computer hacker able to gain access to your hospital’s network. Sending that chart over the Internet to another hospital makes it vulnerable to further interception. E-mail has its risks, too. What if you accidentally forward a message with sensitive material — HIV test results, for example — to a hundred people, or send it to a worldwide newsgroup?

"Transmitting electronic data over the Internet should undergo a cost-benefit analysis," says Martin. Are its rapidity and ease worth possible liability concerns?

"Electronically stored and transmitted medical information will likely remain an evolving area of law and policy," says Richard A. Lazar, a Portland, OR, attorney. Martin concurs: "Legislation surrounding the Internet varies from state to state, but what the court would look at in the case of a suit against a hospital is the clinician’s reasonableness in using this tool, especially as it pertains to sensitive patient information. If, for example, a patient’s HIV status is inadvertently revealed to multiple parties by the push of a wrong key, the person at the keyboard is exposed to liability. The question, however, is whether that person acted reasonably, and that would be a jury question."

Another problem: Suppose a couple of clinicians at your hospital answer a question about diabetic foot care for a person who posted the question in a newsgroup. Is your facility now legally liable if, by chance, one offers the wrong advice with an unfortunate outcome?

Clinicians are deemed to give prudent, well-thought-out advice whether they’re confronting patients in person or over the Internet. The underlying question that a court would look at is, "Has a nurse- or physician-patient relationship been established? Is a nurse- or physician-patient relationship ever established even though this conversation is taking place in a chat room or newsgroup, not in a doctor’s office?"

News groups limit responsibility

Probably not, says Martin. "Physician-patient relationships are based on contract law, and the court would probably find that such a contract doesn’t exist in a newsgroup encounter. Only if that relationship exists is a duty established with attendant liability. I think probably the court would determine that that relationship does not exist in that situation, so no liability would be imposed."

What if, for example, the newsgroup correspondent seeking diabetic foot care advice had congestive heart failure as well but didn’t think to offer that information?

"Common sense would prevail," says Martin. "The clinician would be expected to give the best advice possible based on the information given. So if the patient didn’t provide information that would be crucial to your advice — comorbidities — the nurse or physician still would be deemed to have acted reasonably based on the information given."

Information posted at a Web site is exposed to many more viewers than that posted at a newsgroup or sent by e-mail message. "You generally wouldn’t want to put out sensitive information on a Web site," says Martin, "unless the site is confidentiality-protected by firewalls or passwords. The degree of confidentiality of the information should correspond with the security measures in place to protect it." Martin’s advice is to have security personnel come in on a regular basis to ensure the effectiveness of a Web site’s security system.

The bottom line: Use caution and common sense, and the Internet can become one of your most useful professional tools.