Why wait four years?

I was struck during President Obama's health care speech before Congress several months ago that the reforms he advocates would not go into effect for four years, until 2014. This timetable, too, is written into both the House and Senate versions.

Why the delay?

It is hard for me to imagine, even given the federal rulemaking process, that it should take four years to establish an insurance exchange from which people can buy coverage. This is the exchange that would eliminate the nasty practices of insurance companies: Denying coverage because of pre-existing conditions; limiting annual or lifetime payments; and rescission of policies. It is hard for me to imagine, too, why it should take four years to fully deliver targeted subsidies to lower income people so they can afford insurance.

As noted by Princeton Professor Paul Starr in yesterday's New York Times: "By comparison, when Medicare was enacted in 1965, it went into effect the next year."

This leaves me with a bad feeling. It looks like the Obama team does not want implementation of the health care bill to take place during their first term. Why? Perhaps they know that the cost of the plan is higher than they are saying. Or maybe they know that the options available to consumers will be less attractive than currently portrayed.

Maybe they are worried that if all this happens on their watch, re-election in 2012 will be in jeopardy.

I have yet to find a knowledgeable observer who does not agree that the cost of universal coverage will be high and that consumer choice will become more limited to the degree that federal policy tries to control costs.

I personally think the cost of universal access is worth it and an important public policy imperative; but the administration puts itself into a box when it downplays the consequences of the legislation. It is forced to postpone the effective date until after the 2012 election, so it will not suffer political backlash from a public that has been misled.

Let's hope that Congress sees this otherwise and implements these important measures more quickly. (Wouldn't it be ironic if the Republicans offered a floor amendment accelerating the effective date? How could the majority party oppose that?)

Leftovers on the run

Dan Nadworny sends out the weekly email update to our Emergency Department staff. Above is an excerpt from his latest edition. The photo was taken at the entrance to our ED.

On guard. Whew!

One in an occasional series about email solicitations from total strangers for products and services that just make you wonder. In many cases, as here, they feel comfortable with the familiarity of using a first name even though we have never been introduced, they use the wrong name of our organization, and they have bad grammar or punctuation. In this instance, too, the surveillance product offered here is provided for no charge by Google and other web servers.

I wonder whether their monitoring skills will pick up this post about themselves.

Hi Paul, would you have time in the next week to discuss better ways to monitor what's being said about CareGroup, on the Internet and learn how to use social media in your marketing strategy?

PRWatchdog provides healthcare facilities with alerts on high-level negative and positive mentions of your brand online (blogs, news, social media, and community sites), we ferret out the ones that could damage you and send you real-time notification with suggested action items. We help you maintain a top reputation score with minimal demand on your already busy day. In addition, we can help you capitalize on websites like Facebook and show you how to use them to better communicate your message to your patients.

Let me know a time that you're available, thanks Paul.

Regards,
[name deleted]
President, PR WatchDog
600 Northpark Building, #1700
Atlanta, GA 3O328
[email and telephone deleted]
www.PRWatchDog.net

Thanks to Gourmet Caterers

As the Thanksgiving holiday weekend draws to a close, I want to give a "shout-out" to Robert Wiggins, President, and his staff at Gourmet Caterers in Roslindale, MA. Each year Mr. Wiggins donates dozens of gift certificates for Thanksgiving and Christmas "turkey dinners for 10 with all the trimmings" to charities who then auction them off to support their causes. (I purchased mine at The Boston Harbor Association annual gala, which supports environmental education programs.)

When I went to pick up my food on Wednesday morning, I was told that I was one of 58 holders of such gift certificates that day. You go around the back to the white tent to pick up your food. There I met Glenn, an employee of 14 years, who helped load the dinner into my car.

This is no small meal: 22 pound turkey, stuffing, gravy, mashed potatoes, fresh green beans, candied yams, butternut squash, cranberry orange relish, cheese and crackers, Parker House rolls, and choice of two pies (apple, pumpkin, or pecan). When they say this is dinner for 10, they must be thinking of 10 hungry lumberjacks!

Thanks to the folks at Gourmet Caterers for their generosity to so many organizations in the Boston area.

Engage with Grace Blog Rally

The Engage with Grace blog rally has spread far and wide, for the second year. Here is a list of participants that I have seen so far. I'll keep adding. If I missed you, please submit a comment with the name and url, and I will update this posting.

In case you wonder why we do this, see this post on my blog below:

Last year I had a discussion with my loved one because of the blog rally and unfortunately it actually came into play in Sept. when she was diagnosed with end stage pancreatic cancer. Something that we did not anticipate but really must be brought to light, especially with elderly couples; often the primary advocate is so distraught at the probability of losing their 47+ year partner, emotions cloud key judgement. We experienced battles with my uncle over increasing pain meds., etc. and hospice walked such a fine line because he, as her health proxy could have asked them to leave at any time (as we were told). So in addition to having a discussion regarding these end of life questions -- elderly couples really need to think about whether their spouse will truly be able to carry out their wishes when the time comes.

Matthew Holt's The Health Care Blog
ElizaBlog
NetAge Endless Knots
Boston Globe White Coat Notes
NPR Health Blog
Kim Painter on USA Today
Pallimed
Health Care Law Blog
33 Charts
The Tsunami Mommy
NickDawson.net
EMed concepts
e-patients.net
Diva Marketing Blog
Health Populi
David Fisher, MD, MPH
A Traveler from the World of Work
Roni Zieger on the Huffington Post
Melissa Cooks Gourmet
The Medical Quack
David Harlow's HealthBlawg
Kevin, MD
Massachusetts Liberal
Michael Miller's Health Policy and Communication Blog
Beating Social Anxiety
Pam Ressler's Blog
Ted Eytan, MD
Suture for A Living
Project Health Design
Bouncing Baby Boomers
Muck Rack
Justin's Hope
Osteopathic Injustice
NHPCO
Trusted MD
Grief, Loss, and Transitions
Reflections in a Head Mirror
Fresh Widow
Public Healthcare Promotion
Just So you Know
Precious Bodily Fluids
Operation Marathon
Networks, Complexity, and Relatedness
Dr. Shock, MD
The Orthopedic Posterus
Compliance Building
Laika's MedLibLog

(from here down -- added after initial posting)
The New Life of e-Patient Dave
Cathy Arnst at Business Week
Justen
PharmaGossip
Musings of a Distractible Mind
Palliative Care Grand Rounds
MITSS -- Medically Induced Trauma Support Services
Health IT and Healthcare Reform
Jazz Ramblings
Grief Healing
Anatomy on the Beach
Medicalcenterinfo.com
McDoc
Ignite09
E-Learning
Brass and Ivory
Colorectal Cancer Coalition
Suzi's Musings
Chronic Healing
Perfect Memorials
Hefidi
Esse Diem

(In case you are wondering, that's 70, so far . . .)

MITSS (again, their other blog)
Emerging Medical Concepts
Street Prophets
Grief, Loss, and Bereavement Edublog
BIDMC
Adam Bosworth's Welblog
Healthcare Ruminatio
Epidemiology Cafe
Marty Bonick

An Evening of Thanks

This is a short break from Engage with Grace to consider the other end of the spectrum of life. Each year on the night before Thanksgiving, our Neonatal Intensive Care Unit (NICU) holds a small party called "An Evening of Thanks". It is a chance for parents and their now-larger babies to return and visit with the nurses and doctors with whom they spent time while those premature or seriously ill babies developed or got well enough to go home.

Here are some visitors who came tonight. Many came with siblings. In the bottom picture, you see nurse Melissa Adams holding one of her alumnae.

Engage with Grace -- Reprise

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.

Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. If you want to reproduce this post on your blog (or anywhere) you can download a ready-made html version here

The NICU goes Lean

Our Lean process improvement efforts proceed. The most dramatic evidence comes in the form of 5S process improvement events, but please recall that this is all part of a "tortoise-like" engagement throughout the whole hospital.

But check out the BEFORE and AFTER of the NICU supply room. This improvement took 6 weeks of prework and 2 days of physical transformation. $15,600 overstock was removed from the carts. More importantly, as this improvement is sustained, it will make life easier for all of the nurses and doctors working on this floor taking care of really little babies.

Click here to see Pink Gloves

I usually avoid posts with a commercial tilt, but this is a worthy exception. A note from a friend:

Emily Somers created, directed and choreographed this video in Portland last week for her Medline glove division as a fundraiser for breast cancer awareness. This was all her idea to help promote their new pink gloves. I don't know how she got so many employees, doctors and patients to participate, but it started to really catch on and they all had a lot of fun doing it.

When the video gets 1 million hits, Medline will be making a huge contribution to the hospital, as well as offering free mammograms for the community. Please check it out. It's an easy and great way to donate to a wonderful cause, and who hasn't been touched by breast cancer?

Sidney Borum auction reminder

As you start thinking about holiday shopping after Thanksgiving, please give some thought to shopping at my online auction to benefit the Sidney Borum, Jr. Health Center.

There are already a lot of good items. Look here for a preview.

Several cash gift cards: You could use those as presents or to buy presents. Travel, books, golf equipment, and more. Inspirational speakers, too, for your business meetings or civic events.

More to come. Check back.

This auction runs from Dec. 1 at 6am to Dec. 7 at 8pm. Please tell your friends, and feel free to donate items if you would like, too.

In memoriam: Arnold Rosoff

Arnold Rosoff, known to the world as an exceptional advertising executive, died this week at age 93. Arnold was a trustee and volunteer in our hospital.

Here's the most fitting tribute I have heard, from one of our nurses, Jane Wandel:

I wanted to share my memory of Arnold as an ED volunteer. He volunteered as an orderly and worked alongside the paid orderlies in the department - indistinguishable from them in terms of his role. In fact, it was many months before most of us on the staff realized that he was a hospital trustee. He was kind and quiet, gentle and humble. He ran specimens and pushed stretchers; he readily helped with the most menial and, at times, unpleasant jobs in the unit. He treated everyone - from housekeeper to attending physician - with enormous respect and kindness. We adored him.

US Healthcare Reform Photoshop Contest

Dr. Wes announces the first (and perhaps only) US Healthcare Reform Photoshop Contest. Photographs in support or against the current efforts will be equally considered. The winner receives an iPod Touch. Get more details here.

How our staff gets high

Mount Everest is the background. This was taken two weeks ago from Kala Patar in Nepal. The people are Margie Serrano, RN (nurse manager of Farr 6 and CVICU), Alan Lisbon MD (Executive Vice Chair, Anesthesia), and Judi Deveau RN, NP (cardiac surgery).

Evidence in Medicine

A new blog by David Rind. Very timely.

We are eating ourselves to death

I'm taking a risk of offending here, but I don't mean it that way at all. It could be written about much of this country.

This particular post is prompted by an AP story by Mike Strobbe, pointing out that rates of obesity in the United States are highest in the Southeast and Appalachia.

On my recent incoming flight to Kentucky, an MD from the area who was sitting next to me pointed out that I would notice a large number of people with high body-mass indices. I expressed surprise, and said, "You mean noticeably different?" He said, "Yes."

I mentioned this story upon arrival to a number of my hosts at UK, and they confirmed it. They attributed it to the diet in their part of the world, combined with an increasingly sedentary population. Still I wondered, "How different can it really be?"

Then I noticed the breakfast buffet at my talk (seen here). And then a friend sent me a picture of the breakfast she was served after delivering her baby, with eight pieces of bacon.

There is much talk of the cost of health care in America. That talk tends to focus on the costs of doctors and hospitals, but a growing determinant of that cost is the diet and exercise pattern of our culture. I have previously posted slides from the CDC showing this trend over time. Sure, Kentucky and some other states are in the lead, but the whole country is following suit.

If I had taken pictures of the meals available to waiting travelers at Boston's Logan Airport, you would see similar patterns. A single sandwich with 1500 calories. A 32-ounce drink from the soda fountain with hundreds more.

We are eating ourselves to death.

There is no billing code for compassion

Our Dr. Amy Ship won the Campassionate Caregiver Award from the Kenneth B. Schwartz Center last night. The center conducts programs to educate, train and support caregivers in the art of compassionate health care. It received over 100 nominations for this award, which is designed to recognize people who have exemplified the practice of compassionate care to patients. Here is a background story from NECN television.

Amy's acceptance speech kept the audience in rapt attention. Here are some excerpts. I am hoping to be able to lead you to a video soon. One peak moment was when she emphasized the importance of primary care and bemoaned the current environment that often results in short, unsatisfactory visits. Noting that "there is no billing code for compassion," she called for a restoration of the proper role for primary care doctors.

Optimism? Other options?

This New York Times story by Michael Grynbaum tells of a new transit pass in New York City that has the word "optimism" printed on the reverse. Why?

“God knows people want to feel good, they want to feel up, they want to feel positive,” said Christopher P. Boylan, who oversaw the project at the Metropolitan Transportation Authority. “If I can make a couple of customers smile a day, that’s nice.”

Shouldn't we be more flexible here in Boston? New York is so old. In this high tech town, where social media reigns and where everyone has a status bar on Facebook, shouldn't we have Charlie Cards that give us a choice on any given day?

Optimism, sure.

Next year, absoxlutely.

Still waiting (for my train/bus/trolley), clearly.

Wrong choice (for Monday morning quarterbacks), Patriotically.

Some choice, for Election Day.

Dim sum, for riding on Sunday.

Esplanade, for the Fourth of July.

Your ideas?

Donate Life New England

BIDMC was just presented with this award for its role in promoting organ donations. The sponsor, Donate Life New England, coordinates organ donation programs throughout the region. It has a new website, as well as presence on social media like Facebook and Twitter, to get the word out about how important it is -- and easy it is -- to be an organ donor.

Many people think they have to wait for renewal of their driver's license to become an organ donor, but you can do it at any time. (I actually thought so, and then forgot to do it during my recent renewal!) You can do it on the website. It only takes a minute, and it will be legally binding. And, yes, you can revoke it at any time and also put various conditions in your record.

After going through the adventure below, I was moved to fill out the form. You never know.

Thanks for the rush!

It has been a beautiful fall here in New England, and I have been taking some early morning bike rides. It is dark when I head out, so I have the full panoply of reflective gear and a clear and strong headlight. It is good to be seen by drivers in their cars.

In the picture, I am the "X" just making a right hand turn at a corner in which there is a rotary around which approaching cars from the opposite direction are supposed to go when making a left turn (top black line).

Except, this time, the guy driving a minivan at about 30 mph decides he is at Le Mans and choose to make the left turn by bypassing the rotary altogether and driving in the left lane and cutting the corner (lower line).

He finally wakes up and sees me and swerves and misses me by a foot. Never stopping. But accelerating off as he departs the scene.

I can't tell you how much I appreciated the adrenaline rush. I had been just a little chilly as I set out that day, and this event quickly warmed up my whole body.

A long day

Even with enforced restrictions on duty hours, it can be a long day for residents. Next time, I hope this fellow can find a bed instead of a chair at the end of a corridor. He probably woke up feeling pretty stiff.

Tweeting while you talk?

So, I have been doing a fair number of speeches lately, and you always wonder what people in the audience are thinking. Might they be publishing tweets with their opinions while you talk? Here is a humorous view from Marc Perry at The Chronicle for Higher Education.

Caught between mammograms

Here is a great commentary by WBUR's Rachel Zimmerman about the uncertainties raised by recent articles about mammograms.

Dean Flier offers his views

Harvard Medical School Dean Jeffrey Flier offers a thoughtful and honest perspective on the health care bills circulating in Congress in this Wall Street Journal op-ed. Jeff is not just an academic observer. He is an accomplished physician-researcher-educator with lots of experience in the trenches.

He must know that his column will raise the ire of those on one side or the other of the health care debate, and then what he says will likewise be used in the political debate. I am confident that he raises these issues because he senses a need for someone to speak directly and help our political leaders on both sides of the aisle do the right thing.

He starts with a plain-spoken summary: "As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade."

And then he leads to an important point: "Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true." Hmm, that sounds familiar and is strongly supported by everything I have heard. He continues, "So the overall effort will fail to qualify as reform."

But, for me, the major insight is this: "Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern."

And finally: "So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead."

Stories about Harvey Goldman, MD

I reported in April on the death of Dr. Harvey Goldman, one of our beloved and esteemed colleagues (who loved baseball and is here seen with a Red Sox World Series trophy). Today, we honored this eminent pathologist with a memorial celebration and dedication of the Pathology Department Conference Room in his name. Speakers at the event included people from BIDMC, but also Fred Silva, Executive Vice President of the United States and Canadian Academy of Pathology, and Henry Appelman, Harvey's long-standing friend and colleague from the University of Michigan Medical School.

There were humorous and poignant remarks, too, from Robert Najarian, a gastrointestinal pathology fellow at BIDMC. He remarked that there were so many stories he had heard from residents and fellows that he felt badly he could not tell them all. I suggested we might give people a chance to tell those stories right here on this blog.

So, if you have studied or worked with Harvey at any point in your training or career and wish to offer stories or comments here for your friends, colleagues, and the world, please submit them.

The former Speaker speaks

Here are some folks from around the country at the Press Ganey National Client Conference today in Maryland. The "clients" is this case are hospital and physician groups who employ Press Ganey to conduct surveys of their patients. Over 1700 people attended. I was invited to talk at one of the sessions about the issue of using transparency to help create a culture of quality and safety.

The keynote speaker was Newt Gingrinch, former Speaker of the US House of Representatives (fuzzy picture above). Mr. Gingrich and I agree on some things and not on others. For example, his behavior with regard to the issue of so-called "death panels" was, in my mind, despicable. And, even in this speech, he had tendency to introduce partisan divisiveness when not really necessary.

That being said, he made some good points. He implored those in attendance to engage in continuous process improvement in their hospitals and not await government action to improve the quality and safety and cost-effectiveness of patient care. Essential to those improvement programs, he noted, is accurate data about clinical results, with concomitant transparency of those outcomes.

You can review other aspects of his work and ideas at the Center for Health Transformation.

City Sourced, a great app idea

I met a fellow today named David Kralik who is part of a new venture that has developed a wonderful iphone, Blackberry, etc. application called City Sourced. The idea is that, if you see something wrong in your town (a pothole, a broken street sign, or some other unsafe condition), you can immediately send a GPS-ed message with a picture of the problem to the municipality to inform them of the problem.

Just think, if I had had it this morning (and if I still had a Blackberry), I could have reported the problem I saw on the local transit system.

Art on the MBTA

A short while back, I wrote about new uninformative signs and annoying audio messages on the local transit system. Having run a large public agency, I really understand and sympathize with the logistics involved in introducing a new system. But it seems to me that these folks are missing something: If your system is not ready for prime time, don't bring attention to it.

The previous loud message warning us not to be fare evaders has now been joined by a message urging us to follow the safety rules and regulations of the transit system -- as though we might know what those are. It was amusing to be told to be careful riding the escalators, since the stations at which this broadcast was delivered are at ground level.

This morning, too, we had a new feature. Check out the artwork portrayed on the sign. If you click to enlarge the photo, you can see a random pattern of energized LEDs. Thanks to the MBTA for offering this visual treat!

Market failure --> New entrants?

This story by Rob Weisman in today's Boston Globe is about large insurance rate increases being faced by small businesses in Massachusetts. But, it is really about the lack of effective competition in the Massachusetts health care market, both on the provider side and the insurer side.

Although there are many contributors to rising health care costs in the state, one major one is the fact that the largest provider system is paid rates that far exceed the rest of the industry. This is the result of its market power and leverage over the insurance companies during rate negotiations. Yes, part of the problem is a fee-for-service payment regime that encourages overuse; but that is compounded when the dominant system's FFS rates are very high relative to the market. Why? Because it enables that system to recruit community physicians into its network at higher salaries, away from other systems. Those local doctors, in turn, refer their patients to the higher priced hospitals in that same network. This is a vicious cycle of higher rates, leading to network growth, leading to still more bargaining power, leading to higher rates.

Why do the insurers put up with this? Because there is a public perception, unsupported by clinical outcomes data, that the dominant provider must be part of any insurance plan's network. The plans, therefore, are afraid to leave those hospitals out of their insurance products. They also seem reluctant to create a market for insurance products that would charge customers a higher co-pay or add other features that would encourage the patients to go to lower-priced facilities.

The result: Utilization in the network served by the dominant provider grows at a rate exceeding the regional average. And because that utilization is reimbursed at a higher differential rate, the insurance company sees a huge cash outflow, and feels it necessary to raise rates -- especially to the market segment that has the fewest choices.

The second problem is a similar lack of competition in the insurance market itself. In any other industry, a competitor would enter the market and create a niche product -- a plan for small businesses and individuals, based on a limited high-quality, low-cost provider network.

National insurance companies have had a very small market presence in our state. Those who have thought about expanding their share of the Massachusetts market are probably concerned about the relative costs of doing so or about the ability of the insurers in this state to simply underprice their products. Well, we now see evidence that even the dominant insurer might feel it cannot afford to respond competitively to a new market entrant. That insurer, along with the others, is so persuaded of the market power of the dominant provider that it has been reluctant to take on that provider by leaving it out of its product mix or by including it at the premium price necessary to cover its costs.

A new entrant might feel differently and focus its efforts on a vulnerable market segment, one that would find a high-quality, low-cost network attractive. When you are fighting for your financial life as a small business or individual purchaser of insurance, you are more willing to make different kinds of choices. And, as a small business, you can more easily explain to your employees why you have done so.

To me, this seems like an opportunity for competition.

At the Saturday Club

Rob Velella (the one on the left) wanted to commemorate the 200th birthday of Oliver Wendell Holmes, and so he wrote a one-act play called "At the Saturday Club." The Club, which still exists today, was founded in 1855 and was an informal gathering of the great writers and thinkers of that age. They met at Boston's Parker House for "extravagant meals and even more extravagant conversations."

This play begins in 1892, with Holmes being the last survivor of his generation of writers. In his mind, he travels back to 1860, where he revisits his old friends Henry Wadsworth Longfellow, James Russell Lowell, and Ralph Waldo Emerson. The dialog in the play is taken from the original words of these historical figures.

The play was performed this afternoon at the Massachusetts Historical Society.

Another great soccer season

Another successful soccer season closed out today. Well, not quite. The last game was postponed because of bad weather, but the end-of-season party went as planned. We'll see next week whether we can extend the 7-1-1 record to 8-1-1. In the meantime, the girls and parents fought off the rainy weather blues with the above cake and lots of other goodies.

It was also a chance for me marvel again at how many of the girls' parents are doctors (both MDs and Ph.D.s.) They seem to be endemic to this city. They include the following specialties: psychiatry, internal medicine, infectious disease, endocrinology, neurology, nutrition and aging, and risk management to name a few. We are clearly ready for any medical emergencies that might occur on the field!

Right on Target from The Onion

This is more true than you can imagine. It has happened to me many, many times during TV interviews.

How not to save energy

The second US energy crisis occurred in 1979, after the Shah of Iran was deposed, and oil production in Iran plummeted from 6 million barrels per day to under 2MBD (black line in the chart to the right). Saudi Arabia and other OPEC countries increased production to try to offset this, but the results were uneven. While the overall reduction in supply was only 4 percent, panic resulted, leading to hoarding behavior and shortages.

President Carter responded to this with a package of energy legislation and his now-famous "malaise" speech, in which he discussed an American crisis of confidence and urged people to use less energy.

The most correct thing the President said in terms of energy policy was that "We often think of conservation only in terms of sacrifice. In fact it is the most painless and immediate way of rebuilding our nation's strength." But this lesson was soon lost as the government acted to equate conservation with deprivation.

An example is in the certificate above. The Emergency Building Temperature Restrictions were implemented the day after Carter's speech and set maximum temperature levels for public buildings in the heating season and minimum temperature levels in the cooling season, as well as maximum temperatures for hot water. Specifically, space heating was restricted to a maximum of 65 degrees Farenheit, hot water temperature to a maximum of 105 degrees F, and cooling temperature to a minimum of 78 degrees F.

The damage done to American's understanding of energy conservation was that a policy that could have been equated with efficiency, competitiveness, and improved comfort was instead seared into the public consciousness as sacrifice and discomfort. (It is no accident that the regulations were rescinded by President Reagan shortly after taking office.)

I had seen a similar portrayal during the first energy crisis in 1974, when the OPEC nations imposed an embargo on petroleum sales to the United States and other Israeli allies. Rogers Morton, Secretary of the Commerce at the time said, "Americans don't want to conserve energy. They want to win." At a private meeting at Harvard during that period, as an intense 25-year-old Deputy Director of the MA Energy Policy Office, I rather directly and perhaps a little rudely told Energy Czar Frank Zarb that he was dead wrong when he said that America had reached the limits of possible energy conservation.

Sure enough, investments in plant, equipment, and appliance over the years have changed the underlying structural relationship between energy use and GDP in the US and other countries, and they have done so while preserving and even enhancing the efficiency and comfort of American life.

But reminders persist. The certificate above is today posted in a building at MIT, no longer relevant or in force, but a shadow of a failed policy direction.

There is still tremendous potential for energy efficiency in America and the world, but only if we approach the problem in a way quite different from that adopted in 1979.

Atrius-BIDMC Relationship

We announced yesterday an important partnership between the state's largest multispecialty group practice, Atrius Health, and BIDMC. This is a promising new relationship between a physician practice group and an academic medical center.

Here's the press release. Please note, in particular, the comments by Don Berwick, which help explain the context and significance of this.

While exciting to me, I also know that this will also require a lot of work to pull off, and I expect we will learn much from each other. I would also be happy to hear comments from my readers as to your experiences in similar ventures, and your advice to us to help make this a success.

ATRIUS HEALTH, BETH ISRAEL DEACONESS MEDICAL CENTER WORKING TO CREATE NEW HEALTH CARE MODEL

Atrius Health and Beth Israel Deaconess Medical Center are expanding their relationship to establish a new model of health care delivery between a large ambulatory multi-specialty practice and a leading academic medical center, according to Gene Lindsey, MD, president and CEO of Atrius Health.

The boards of directors from Atrius and BIDMC both voted Wednesday evening to build the expanded relationship. The first step will be that Harvard Vanguard internists from the Kenmore, Copley Square, and Post Office Square offices will send their patients who need emergency care or hospitalization to BIDMC. Over time, Atrius Health will also look to collaborate with BIDMC in ensuring hospital care for patients with more complex needs, including cardiovascular and oncology patients as well as other surgical specialties. The organizations will utilize electronic medical records to help coordinate patient care. Atrius Health will continue all of its existing hospital relationships to serve patients in communities it serves.

Guided by an overarching goal of patient-centered care, Atrius Health and BIDMC also envision a robust agenda of quality improvement and cost efficiency strategies. Both parties have a vision of working together far into the future. Additional details about joint clinical, quality, and cost reduction programs will be introduced over time.

This new expanded relationship comes amid the current statewide and national debate on cost control and health care reform, and the move toward global payments in Massachusetts. The collaboration will be built around a strong emphasis on primary care and a continuum of care from the ambulatory setting to the hospital and beyond.

“The goal is to demonstrate that by working together, the two organizations can provide the highest quality, best service, and lowest cost health care in the Commonwealth.” Lindsey said. “We have the utmost respect for the progress BIDMC has made towards eliminating preventable harm and doing so with transparency,” he added.

The collaboration is also part of a larger Atrius hospital strategy to work together to improve quality and reduce costs with hospitals that share their vision and want to work on lowering cost and improving quality. Atrius Health and BIDMC have a long history together and both were involved in the Blue Cross Blue Shield of Massachusetts LEAD program for process and quality improvement.

“We intend to establish the model for health care delivery in the Commonwealth,” said BIDMC President and CEO Paul Levy. “That model offers a full spectrum of health care services that are patient-centered, compassionate, integrated, and evidence-based. Fundamental to our model will be an emphasis on primary care, alignment of the organizations, and transparency. Atrius Health has demonstrated leadership in all these areas, which is why we are so excited to be working and learning together.”

“Almost for certain, the American health care system is on the threshold of a leap into a new era of integrated, coordinated care. Patients as individuals and society as a whole badly needs that leap to achieve better quality at lower total cost. That re-forming of care will require new, highly cooperative relationships between foresighted hospitals and progressive medical groups,” according to Don Berwick, MD, MPP, President and CEO, Institute for Healthcare Improvement. “I cannot think of two organizations better equipped to welcome that reinvention, and to succeed at it, than BIDMC and Atrius Health. Each has a strong and distinguished track record of innovation, and their combined efforts will blaze a trail for many others,” he added.

The goals of the new relationship follow many of goals and principles outlined by the Massachusetts Health Care Quality and Cost Council, the Massachusetts Payment Reform Commission, the Mayor’s Task Force on Improving Access to Primary Care in Boston, and the Institute for Healthcare Improvement (IHI), including: Putting primary care at the center of patient’s care; Making sure that physicians work together as a team with nurses, technicians, and other allied health professionals; Enhancing and further integrating electronic medical records; Advancing health equity and ensuring a diverse, culturally competent, interdisciplinary workforce; Preventing and reducing medical errors and being transparent about results; Improving the efficiency of health care delivery by continuous process improvement as exemplified by the Lean methodology; Empowering patient involvement in the design of the health care delivery system through advisory councils, secret shoppers, patient satisfaction surveys, and other mechanisms.

Harvard Vanguard and its predecessors have a long history with BIDMC. Harvard Community Health Plan originally formed as a combination of a Brigham & Women’s practice and a Beth Israel practice, and benefited from the relationships with both of these outstanding institutions. Today, Atrius Health has existing relationships with BIDMC for obstetrics and oncology.

How to make health care remarkable

An excellent interview with e-Patient Dave here on Phil Baumann's blog.

The harp soothes the soul again

A few months ago, we established an "online community of gratitude" called Grateful Nation to give patients and family members an outlet for feelings of gratitude they might have about a doctor, nurse, housekeeper, transporter, or other member of our medical staff. Items can also be sent in by mail.

Here's one that arrived this week. I have written about the harp before. This is another affirmation of the power of music in a clinical setting. The 7th floor is our oncology clinic.

Following Ruth

I love this video of our archivist Ruth Freiman giving a tour of the BIDMC archives, containing items from the BIDMC's antecedents, the New England Deaconess Hospital and the Beth Israel Hospital.

Caller-Outer of the Month Award #9

Our Board of Directors awarded this month's caller-outer award to Tinea Simpson, Practice Representative in our GI department.

GI staffers on Tinea's floors are practicing a “Leaner” way to conduct their day to day business thanks to her call-out, and the resulting reorganization that came from her work with Resource Nurses Mary Ellen Johnson and Christine Hunt.

As you may know, there is a patient packet for every procedure that happens in a hospital. For the past several years BIDMC volunteers have assembled these packets covering the entire demand of our GI unit – over 100 procedures a day.

As medical practices are revised and forms become obsolete or go unused, the end result can be a tremendous waste of paper and money. These three women evaluated the situation, decided what forms were necessary and what were not, and with the help of Volunteer Services, took action to correct the packets and reduce the use of hundreds of forms.

They created a path of action to include creating new sample packets for volunteers to follow and purging forms that were no longer warranted. Congratulations to Tinea for demonstrating the concept that each person should feel encouraged and empowered to recognize and go about seeking solutions to inefficiency and waste that he or she sees in the workplace.

Translation Service

A friend sent me this training page that appears to be from the SEIU. The link to the website from which it was obtained is disabled. Maybe someone from the union can point us to the document's new location. Maybe not. It was entitled, "For internal use only -- Not for distribution."

Veterans Day Thanks

An idea we have adopted for Veterans Day. Have you considered a similar thing for your hospital?

To: BIDMC Community

From: Paul Levy, President and CEO

Eric Buehrens, Chief Operating Officer and Executive Vice President

Subject: Veterans’ Day Thanks

BIDMC pays tribute to those who serve our country through military service.

It is our privilege to say, “Thank You,” to the many employees who are among the 24 million living American veterans – as well as the numerous staff and family members who are on active duty now. We appreciate their service and honor them for their sacrifices.

Tomorrow, Veterans Day (Wednesday Nov. 11, 2009) employee veterans and United States Armed Forces active duty personnel will receive a free meal (breakfast, lunch or dinner) in the east or west campus cafeterias. Just present your BIDMC ID badge and let the cashier know you are a veteran or active duty personnel member.

Also, if you would like to have a prayer offered for any veteran or active duty member of the military, please send the name and details you wish to include to either the Pastoral Care mailbox (select Pastoral Care from the dropdown menu in the “To” field of the e-mail) or directly to Rev. Julia Dunbar, Director, Pastoral Care and Education, at [email excluded here].

Next month: Helping The Borum

Thanks to those of you who visited my auction site to support the Bowdoin Street Health Center, whether you chose to bid or not. Next month's auction, starting December 1, will benefit the Sidney Borum Jr. Health Center.

I have already received some great auction items, including many that are just right for holiday gifts -- whether you live here in Boston or anywhere in the world. Visit the auction before you go to the mall!

Located at 130 Boylston St, across from the Boston Common, the Sidney Borum Jr. Health Center opened in 1994 to serve the health care needs of homeless youth and young adults, many of whom engage in unsafe sex with adults in exchange for money, food or a place to sleep.

The Borum provides primary medical care as well as mental health and substance abuse counseling, HIV counseling, testing and risk reduction reinforcement, as well as other clinical and social services. Its primary focus is on young people who have been unable to gain acceptance in more traditional health care settings for a variety of reasons, including homelessness and involvement in street life and the sex industry.

Through the online auction on this blog, The Borum seeks support for its linen service and grooming/hygiene products that help patients live with the dignity they deserve.

Please donate items at any time and stay tuned here for the latest auction details.

Bourbon, neat

OK, I have to admit that not all of the time in Lexington, Kentucky (see below) was spent on health care issues, unless we consider bourbon a therapeutic substance. I had a little time to visit the Bourbon Trail with some friends, and we toured the Four Roses distillery. Here is a picture of our tour guide offering samples and a video of the fermenting mash.

With the Wildcats

I just attended a session run by the University of Kentucky's Program for Quality, Safety & Patient Rights in the Center for Enterprise Quality and Safety. The director of the program is Dr. Joe Conigliaro, who related stories of meeting Bostonians during his matriculation at Harvard Medical School. "How's your brother/cousin?" he would be asked, even though he was not related to Tony.

But that's not the main point of this post. UK, in cooperation with the Lexington Veterans Administration, has a keen interest in patient safety. My role in the morning plenary session was to lay out legal, ethical, and practical implications of disclosing adverse events. Participants then attended concurrent sessions, one on transparency and disclosure evaluation through incident reporting, and the other on historical perspectives on transparency and disclosure.

My last event of the day was a panel discussion on these topics with: Dr. Steven Kraman, Vice Chairman of Internal Medicine at UK College of Medicine and Margaret Pisacano, Director of Risk Management (seen above). Unfortunately, I had to leave before hearing from State Representative Tom Burch, who I am sure gave an insightful perspective from the public policy point of view.

It is so satisfying to be with advocates and practitioners of patient quality and safety and to learn from one another's experiences. Wait, did I tell you they have a blog, too! It is hosted by Ann Smith, chief administrative officer at UK Albert B. Chandler Hospital, and jointly written with some of her colleagues. Please check it out and submit comments.

Tempus fugit

Just 15 more hours left to bid on great items and services at my auction to benefit Bowdoin Street Health Center.

Hybrid Vigor, or Heterosis to you

I am extremely fond of many of our staff, but Dr. Rafael Campo is near the top of my list. He is an excellent physician . . . and poet . . . but also head our Office of Multicultural Affairs. He has written a credo for this office, and I wanted to share part of it with you. I cannot think of a better way to explain the importance of diversity and inclusiveness in a hospital setting. I also love the way he stretches the use of a term from another field, "hybrid vigor," as a metaphor for what we hope to accomplish. See what you think.

The Office of Multicultural Affairs . . . is an embodiment of BIDMC’s belief that the best possible medical community is one in which the maximum diversity and inclusiveness is found. We believe that the best research and medical care occurs in a context where differences are highly valued; that "hybrid vigor" is not just relevant but fundamental to the structure and optimal functioning of human groups. We do not advocate a sublimation of our differences, however. Our inherent tendency to cluster into our group identities is also essential to the preservation and nurturing of each of our unique cultures. Multiculturalism is the search for an appreciation of the richness gained by the co-existence and mutual respect of our differences, as well as an acknowledgment and embrace of our similarities. We feel that these values are essential to the development of outstanding physicians and the delivery of extraordinary patient care.

Monique exclusively for you

The last time Monique Doyle Spencer gave a talk at a corporate retreat, the CEO reported that it was the single most motivational event in all of his years with the company. She has donated her time for a session for your company or civic organization to my online auction to benefit Bowdoin Street Health Center.

Here's some background:

Spencer believes in humor as a powerful force in restoring the human spirit under any conditions. She is a three-time cancer survivor who has used laughter to reach wide audiences, to teach people how to survive and even thrive under challenges. Whether the audience has been women in prison, business groups, firefighters, cancer patients or grieving spouses, Spencer’s unique approach has inspired countless people to find their personal courage and restore joy in their lives.

Spencer is a contributing columnist to the Boston Globe. Her Globe columns also appear on NYTimes.com and in the International Herald Tribune. She is author of The Courage Muscle: A Chicken’s Guide to Living With Breast Cancer; and How Can I Help? Everyday Ways to Help Your Loved Ones Live with Cancer. Her third book, The Real Life Body Book, will be available in March, 2010.

Rational choice?

I'm trained as an economist, and I understand the theory of comparative advantage, but I still have not figured out how the world's economic system makes it possible for this bottle of water to find its way from Fiji to Boston, a distance of about 8000 miles. It is not just the water, it is the plastic bottle, which is either manufactured somewhere and imported to Fiji, or the raw ingredients of which have to be imported to Fiji and made into a bottle there. Then, the bottle and the water both have to be shipped around the world to this market.

But what I really don't understand is why anyone would buy this water. (I acquired this bottle at a hotel in Boston, where I was attending a conference. Do they really think that we make choices about hotels based on which bottled water is served?)

A 24-pack of the Fiji 500 ml bottle weighs 27 pounds and costs $38.00 on this website. That's 12 liters for $38.00, or over $3 per liter.

A comparable pack of San Pelligrino from Italy costs $26.00, or a little over $2 per liter.

Poland Spring water from Maine costs $7.49 per pack, or less than $1 per liter.

Tap water in Boston costs $6.oo per 1000 gallons, which is roughly 3780 liters, for a price of .16 cent per liter.

Another part of economics is the theory of rational choice, which basically says that people consider the costs and benefits of their actions before making purchases or taking other economic steps.

Right.

Tired?

Direct Tire offers a service package (including oil and filter change, tire rotation, and more at any of its locations (Watertown, Norwood, Peabody and Natick) in my online auction to benefit Bowdoin Street Health Center.

Sleepy, too? Maybe you have guests coming to town? Don't forget to bid on an overnight at the Courtyard by Marriott in Cambridge.

Spreading the word to CEOs on transparency

The VHA Foundation is a 501(c)(3) that aims to improve individual and community health by promoting and diffusing new, effective models of health care. It has a program called the Health Care Safety Network for hospital CEOs to help them accelerate their patient safety leadership skills in an environment where they can learn from their peers and national safety experts.

I had a pleasant visit last week from Dr. Peggy Naas, vice president and leader of Physician Strategies for VHA. She was in my office to tape a session about BIDMC's efforts to improve the safety and quality of patient care, with a particular emphasis on our view of the importance of transparency as a management tool in this journey. This video will be shared with the CEOs in the Health Care Safety Network.

I hope our experience proves useful to my colleagues and that it will make them feel more comfortable in sharing their clinical outcomes and process improvement successes and failures with others.

Sweet tooth?

Cookies, gelato and more at my auction to benefit Bowdoin Street Health Center, courtesy of Dancing Bear Baking Company and Giovanna Gelato.

Great dance

A new auction item has just come in, a dance performance by the Trey McIntyre Project at the ICA theatre on Friday, November 20. It is courtesy of World Music/CRASHarts and is available here at my auction to benefit Bowdoin Street Health Center.

Cooley-Dickinson vanquishes VAP

About a year ago, I wrote about the great progress made by Cooley-Dickinson Hospital in Northhampton, MA with regard to eliminating ventilator associated pneumonia. I now hear from Daniel J. Barrieau, RRT, CPFT, Director of Respiratory Care Service, that "we are now counting our time between incidences of Ventilator Associated Pneumonia in YEARS instead of days. This week we passed the 2 year mark and took a moment to celebrate the milestone. Here is a pic of the cake. . ."

Congratulations!

Zip-a-Dee-Doo-Dah

Find custom made jewelry made from zippers! Really. Courtesy of ZipBling's owner and designer, Louise Loewenstein. Check out my auction to benefit Bowdoin Street Health Center.

Working with a family advisory council

The concept of patient and family advisory boards to hospitals is gaining currency. The idea is to integrate the perspective of patients and families into decisions about clinical practices, space, priorities, and the like. We have had a Family Advisory Board for our Neonatal Intensive Care Unit (NICU) for some time. Here is its mission statement:

The mission of the BIDMC NICU Advisory Board is to touch the lives of each NICU family in a positive and lasting way. Our goal is to complement the NICU's outstanding clinical care and embrace the hospital's commitment to Family-Centered Care with programs and initiatives that acknowledge and support the family in a time of crisis, and to extend the relationship between the family and hospital well beyond discharge. The NICU Advisory Board will support this mission through representative feedback on existing and future programs, facility and policy enhancement, staff/family relations, development and fundraising, and other issues related to the needs of NICU families.

If you are going to create an advisory body like this, you need to share key information with them. I am showing here a few slides of a presentation delivered yesterday by Dr. DeWayne Pursley, chief of service. Among other things, the presentations contained a full exposition of progress on the metrics by which the NICU judges its success with regard to family interactions, along with a statement of initiatives in the various dimensions of care. This kind of transparency leads to a greater sense of involvement, and it also prompts discussions that often lead to good ideas.

In a post below, I wrote about some recent success in our adult ICUs. That success was dependent on involvement by a similar patient and family advisory council. Our experience with the NICU council helped us design the adult council, but it also gave the medical staff some confidence that the effort involved in creating and meeting with the council would be worth the effort. Clinicians and hospital administrators are often skeptical on this point. Let's hope that such skepticism gradually erodes as the good work of these councils becomes more widely known.

Feeling the need to wine?

A limited edition, new California wine from Je Suis is available at my auction to benefit Bowdoin Street Health Center.

Help for migraines

Here's a short and excellent discussion about migraine headaches on the FOX25 Morning News with Dr. Carolyn Bernstein, a headache expert with BIDMC's Arnold Pain Management Center. She is the author of The Migraine Brain: Your Breakthrough Guide to Fewer Headaches and Better Health.

Need inspiration?

Planning a meeting for your company or civic club? Hire one of three great inspirational and informative speakers at my auction to benefit Bowdoin Street Health Center. Look under "Unique Experiences."