Seeing things clearly in the Netherlands

In the post below, I summarize a conference held today at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." In addition to the conference, today was a significant day in that a new website was launched by the hospital to present quality and safety data to the public and to the hospital's staff.

As explained by Dr. Marjo Jager, patient quality specialist, Jeroen Bosch has a strong commitment to transparency as a key element of process improvement in the hospital. The leadership of the hospital views transparency as the most powerful way to reduce preventable injuries, but also as essential to successful and ethical responses to patients and to safeguard employees.

Marjo noted that preconditions for successful implementation of transparency are a culture of learning rather than blaming and judging; ownership by those who deliver care; significant participation by physicians in designing new care regimes and setting an example; and strong support from the board.

Above you see an action shot of the moment of truth, as staffers Miriam Casarotto and Bart Deijkers prepare to push the "activate" button on the new website.

Beyond the website, the hospital is also posting clinical data on patient care floors for all to see. They are experimenting with locations and topics, and this is all bound to change with experience, but the commitment to openness is evident, even when the numbers indicate a need for improvement.

Here, for example, is the current scoresheet with regard to pain management on one of the floors. The hospital clearly indicates a result less favorable than they would like, accompanied visually with a cartoon face that is not smiling.


In contrast, note this one with regard to avoiding decubitis ulcers (bedsores), which indicates performance at the hoped-for standard of care.

Congratulations to the administrative and clinical leadership of the hospital, and for the support provided by its board, for these significant steps in improving the quality and safety of patient care.

Borrowing safety ideas in the Netherlands

I just attended and presented at a conference at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." It was held on the occasion of the opening of an entirely new hospital, following a merger with two other hospitals in the city (Bosch Medicentrum and the Carolus Hospitals). Hospital administrators and clinicians from throughout the country attended.

Our MC for the day was Jozein Bensing, professor of health psychology at the University of Utrecht. Relative to today's topic, she is most known for a paper she published a few years ago documenting that 1700 people per year unnecessarily die in Dutch health care facilities. This report gave substantial impetus to improvements in patient safety in the country's hospitals.

Jozein chairs the quality and safety committee of Jeroen Bosch's supervisory board (the equivalent of the board of trustees of a US hospital.) She said that the hospital has a goal of being the safest hospital in the Netherlands and plans to do so by "practicing what you preach" and learning as much as possible from others, in the health care field and beyond.

So it was appropriate that the chair of the symposium committee, Marck Haerkens (CEO of Wings of Care), and his colleagues decided to bring in the lessons of quality and safety from other fields. They see parallels with airline safety, and so we heard from Pieter van Vollenhoven Chair of the national Safety Board; Jos Nijhuis, CEO of Amsterdam's Schiphol Airport, and Tames Oud, head of training for Transavia Airlines.

Tames suggested that, while aviation and medicine are two different worlds, there some striking similarities, such as highly motivated professionals and critical processes. In both worlds safety and quality depend on effective cooperation between different disciplines. Like Captain Sullenberger back in the US, Tames asserted that the medical community could benefit from Crew Resource Management (CRM). Its objective is to reduce incidents (and worse) due to lack of situational awareness and team cooperation. He noted that CRM training makes people aware of the relevance of the human factor in team performance, and aids in creating a blame-free environment for people to work in.

In addition, Scott Higginbotham, mission manager at NASA's Kennedy Space Center, presented on "Safety and Mission Assurance." (He is seen here on the right with Willy Spaan, the hospital's CEO.) Scott's primary responsibility is to lead the multi-disciplinary team of engineers and technicians that assemble and test the experiments and satellites that fly aboard the Space Shuttle and the International Space Station. A summary: Manned spaceflight is an incredibly complex and inherently risky human endeavor. As the result of the lessons learned through years of triumph and tragedy, NASA has embraced a comprehensive and integrated approach to the challenge of ensuring safety and mission success. His presentation provided an overview of some of the techniques employed in this effort.

Regular readers of this blog will know my topic: I presented the experience of my former hospital with regard to its goal to eliminate preventable harm for its patients. I explored the hospital’s success in improving quality and safety for patients, endorsing public transparency of clinical outcomes, and engaging in process improvement driven by front-line staff.

As I have noted before, there are often misconceptions as people talk about “transparency” in the health care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency’s major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Many thanks to the symposium's major organizers, Marian de Bont and Dr. Kees Smulders, secretary and manager, respectively, of Jeroen Bosch's quality section (seen here) for their invitation and for planning a day of interesting and insightful talks.

In the post above, I include recent activities of Dr. Smulders and his staff with regard to new approaches to transparency in their hospital.

The new Jeroen Bosch Hospital

I am in the Netherlands to present at a conference tomorrow at Jeroen Bosch Hospital in 's-Hertogenbosch (Den Bosch), entitled "Quality and Transparency in Care and Training." It is being held on the occasion of the opening of an entirely new hospital, following a merger with two other hospitals in the city (Bosch Medicentrum and the Carolus Hospitals).

Today, I had a chance to view the new hospital, some 110,000 square meters. (That's roughly 1.2 million square feet.) It is not often that a hospital gets to reinvent itself this way. M0st of us are happy with renovations or incremental expansions.

Here are some nice features of what I saw, in addition to the airy design of the public spaces, as above.

The outpatient clinics are all equipped with this kind of kiosk. You waive your preprinted, encoded entrance ticket in front of the scanner, and it tells you if you are in the right place for your appointment. If you are, a display screen tells you when the time for your appointment has arrived and directs you to the appropriate room. If you are in the wrong place, it gives you directions to the right place.

I am hard-pressed to know why more hospitals and clinics don't do this. We certainly have gotten used to it in other settings, from airline terminals to the registry of motor vehicles. Sure there is an upfront cost, but the savings in personnel costs would seem to offset that. In addition, it seems to me to empower patients to take charge of their logistics. (There is always a live person present in the event someone needs individualized attention.)

At the other end of the spectrum, check out this almost unheard of phenomenon: A pathologist working in an office with windows! I thought it was a Joint Commission requirement that pathologists be locked in dungeons. (Joke.)

This does, however, raise important concerns about productivity and accuracy. After all, if pathologists actually get to see outside scenes and real people, how will they stay focused? (Another joke.) (Oy, I can already imagine the comments I am going to get.)

But, more seriously, the place has an enviable microbiology laboratory, with an automated camera gizmo that transfers the pattern of microbes from thousands of petri dishes into digital format for analysis on the computer. This results in an incredible increase in the capacity of the lab to produce and review bacterial culture results.

And then, the pièce de résistance for my pathologist friends: A sample preparation table (below) that can be manipulated to rise and fall to correspond to the best working height for the laboratory person. A simple control button (see left) moves it up or down, showing the height in centimeters above the floor, so you can remember what setting works best for you ergonomically. The contractor who built the furnishings invented this approach on his own. Seems like a good product design for some entrepreneur.

A game-changer in Pittsburgh

Here's one way to build an ACO. Have the insurance company buy the hospital.

That's the news from Pittsburgh, where "Health insurer Highmark Inc. reached a provisional agreement to acquire struggling hospital operator West Penn Allegheny Health System for as much as $475 million," according to this story in the Wall Street Journal online. Here's more:

The bold move by Highmark, which has $14.6 billion in annual revenue and 3.1 million members in western Pennsylvania, will be closely watched around the country. As spending on health care spirals, insurers and health-care providers are looking for ways to cut costs—forging a range of more-integrated relationships in an effort to become more efficient. Some health plans are buying clinics, and hospitals are exploring payment models that increasingly resemble insurance. Still, insurers have shrunk from purchasing hospitals, which typically involve large investments and operating challenges.

As a friend of mine says, this is a game-changer. Think about it this way. The most successful systems in the country today have common ownership of an insurance company and a health system, especially where they can combine to dominate a geographic area. This works because they have a common bottom line and can organize their business to take advantage of competencies in the respective parts.

As the Pittsburgh Post-Gazette reports:

The long term goal, said Highmark CEO and President Kenneth Melani, is the creation of a new model of health care, one that is outcomes based, with an integrated delivery and financing system.

I'm thinking that the folks at UPMC have just woken up to their worst nightmare.

Imagine if something like this happened in Boston, leaving the dominant provider as an outsider if a major insurance company did the same kind of deal with another network of hospitals and physician practices.

Dried shark

I passed through Iceland this week en route to a conference in Amsterdam and had a chance to taste a traditionally prepared food, dried shark. Unlike varieties in other parts of the world, the Greenland sharks caught in this vicinity have poisonous flesh. Therefore, the meat needs to be cured.

First it is left to sit, i.e, rot, in plastic containers or buried in the ground for three months. Then it is hung out to dry for another three months. Over time, the neurotoxins and urea in the flesh break down.

The flavor? Well, imagine a smelly cheese that is nonetheless delicious. There is a noticeable odor of ammonia, but the meat has a nice texture and flavor.

It is best eaten with a strong alcoholic beverage, like Brennivín, the local schnapps.

See a very different scene below.

Gray and white at Grábrók

Continuing our Iceland travelogue, the Grábrók Crater in Borgarfjörður was formed in a fissure eruption less than 3000 years ago. It is 173 meters across. The eruption spread a huge number of lava boulders in the surrounding area. (That's not the crater above. It is the path leading up to it. The wind was too strong to get past this point and climb up to the ridge overlooking the crater!)

Visually, I found the most distinctive feature of the area to be the growth of lichen on the lava. It creates a surrealistic snow-like covering. Color leaves your field of view, and you mainly see gray and white.

Please "like" Sepsis Alliance CLASSY entry

Some of you may remember my post about the Sepsis Alliance, which is focused on the early diagnosis and treatment of sepsis. Now, Dr. Jim O´Brien, from Ohio State University Medical Center, writes:

For those of you who use Facebook --

Sepsis Alliance has been nominated for a Classy Award. From Classy´s website: "The CLASSY awards recognize the top philanthropic achievements by charities, businesses, fundraisers and volunteers from across the country. The winners receive national exposure and more than $150,000 in cash & prizes for their cause."

Sepsis Alliance could use your help. All you have to do is "like" SA's entry. You can find it and like it here.

Please feel free to pass this along to others.

Sincerely,

Jim

Save $347,370: The answer is here

For the latest silly use of tax money, let's consider this summary from the New York Times about the US using mystery shoppers "to pose as patients, call doctors’ offices and request appointments to see how difficult it is for people to get care when they need it."

What's the rationale for this?

The administration says the survey will address a “critical public policy problem”: the increasing shortage of primary care doctors, including specialists in internal medicine and family practice. It will also try to discover whether doctors are accepting patients with private insurance while turning away those in government health programs that pay lower reimbursement rates.

Oh, please. For years, the government has been systematically underpaying primary care doctors relative to others, as part of a deeply flawed process of rate-setting. Let's start with that as a "critical public policy problem."

IPO = Inadequate Profit Opportunity?

The capital markets may have displayed an unusual degree of perspicacity last week in how they valued Vanguard Health's initial public offering. Vanguard owns and operates 26 hospitals in five states, among other businesses. The IPO yielded a stock price well below that anticipated. According to this story:

That $18-a-share offering price was lower than the $21 to $23 price range targeted by Vanguard, a drop that one analyst attributed to investors having a less optimistic view of publicly traded hospital chains vs. when the company disclosed its targeted price range earlier this month.

Back in February, I explained how private equity firms prepare their assets for the day of an IPO:

Part of the business strategy is to create an organization with a larger revenue stream for when it comes time for the initial public offering in a few years. This simply creates a greater sales multiple when the IPO occurs. As we have seen in other sectors in the economy, this phenomenon is remarkably independent of the actual sustainability of the business as an operating entity in the long run. Capital markets flock to size during an IPO.

This is the same strategy being employed by Vanguard Health Systems in buying the financially troubled Detroit Medical Center. Each deal is likely to be highly leveraged, and as long as the cash flow from Jackson/DMC is positive for a few years, the strategy has the potential to yield an excellent return to the investors in the private equity fund.

Might it be that the stock market has come to understand that, in health care, a large revenue base is not determinative of future levels of profitability? (Maybe investors listened to this webinar.) You just have to watch the debates in Washington, DC, to understand that Medicare rates are unlikely to rise at the overall rate of inflation, much less the rate of medical cost inflation. Likewise, if you consider the actions of state governments, you have to know that future Medicaid rates will not come closer to covering the cost of providing clinical care than they do today. Finally, there is substantial pressure on private insurers to hold rates down, too.

So, even if you believe that more people will have health insurance than in the past, this does not mean that the fees paid to hospitals will be fully compensatory. Unlike private equity firms, which can maintain cash flow to their investors by employing a high degree of leverage and not funding depreciation, a public company rises or falls based on the total margins produced by the hospitals. Those margins will be under substantial pressure for years to come, especially as hospitals face the need to fund deferred maintenance. Further, as for-profit entities, those hospitals will have to pay local property, sales, and income taxes. They also lose their ability to use the federal tax code to help generate substantial philanthropy and to garner lower interest rates on bond issues.

Can it be that the Vanguard IPO gives an early signal that the kind of investment "bubble" we have seen in other sectors is less likely in the health care sector? If so, that is probably to the good.

New York vote overcomes timeworn prejudices

Born and raised in New York but living in Boston, I had to be careful about mentioning my origins, but things improved once I reversed my sports loyalties. Now, at last, I can talk about my home state with some pride in that it has taken a major step with regard to social justice by approving gay marriage.

As the Washington Post notes, this vote essentially doubles the number of Americans who can gain access to same-sex marriage licenses.

As Derrick Jackson wrote in the Boston Globe several years ago, quoting people from South Africa, a country that truly understands discrimination: "This country cannot afford to be a prison of timeworn prejudices which have no basis in modern society."

2012-13 Harkness Fellowship

This is a great opportunity for health care professionals in the countries mentioned:

2012-13 Harkness Fellowships Open to Applicants

The 2012–13 Harkness Fellowships are open to applicants from Australia, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.
The deadline for receipt of applications is September 12, 2011.

The Commonwealth Fund's Harkness Fellowships in Health Care Policy and Practice provide a unique opportunity for mid-career professionals—academic researchers, government policymakers, clinicians, managers, and journalists—to spend up to 12 months in the United States conducting a policy-oriented research study, working with leading U.S. health policy experts and gaining in-depth knowledge of not only the U.S. health care system, but also the health care systems in the fellows' home countries. Fellows also participate in a Commonwealth Fund-organized series of policy and leadership seminars.

Applicants must demonstrate a strong interest in health policy issues and propose a study that falls within the scope of The Commonwealth Fund's mission to support a high-performing health care system, which includes improving health insurance coverage and access as well as the quality and efficiency of health care services. A peer-reviewed journal article or policy report for health ministers and other high-level policy audiences is the anticipated product of the fellowship. Each fellowship provides up to $107,000 (U.S.) in support, with a supplemental allowance provided to fellows accompanied by families.

For details and the application form, please visit http://www.commonwealthfund.org/Fellowships/Harkness-Fellowships.aspx. For further questions, please contact Robin Osborn, vice president and director of the International Program in Health Policy and Innovation (ro [at] cmwf [dot] org).

Twice-told tale

Back in 2008, Charlie Baker, then CEO of Harvard Pilgrim Health Care, and I, then head of a hospital, claimed that the market power displayed by the dominant provider system in the state and supported by the state's largest insurer resulted in a large disparity in health care payments. We argued that this disparity contributed to unnecessarily high health care costs in the state. We both did this publicly, willing to put our assertions to the test. The quotes in response to this in a Boston Globe story were notable, but they did little to undercut our premises.

About a year later, the Attorney General of the Commonwealth published an investigation of this situation, which had the effect of validating our assertions.

Then, the largest insurer in the state said that the solution to the problem was to move towards a capitated, or global, payment regime. This would control the cost trend.

Again, knowledgeable observers, like the Inspector General, raised concerns. What if the global payment regime also created disparities and locked in higher rates? He noted, "[M]oving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically."

I pointed out that, while a global payment plan might have certain theoretical advantages, without a transparent exposition of its effects, how could we know if it had been successful?

Well, the latest chapter has just been written. The Attorney General has issued a follow-up report saying, “Our examination found that paying providers on a global basis has not resulted in lower total medical expenses.” Further, "Wide price disparities unrelated to the quality of care still persist from one Massachusetts hospital to another, largely dependent on the providers’ clout in the marketplace."

The whole country is watching the Massachusetts experiment of providing universal health care coverage and is wondering how we will deal with the cost issues inherent in providing that coverage. The Attorney General has now offered, twice, a cogent and thoughtful review of the situation. The Inspector General has done likewise. How will the other parts of the government respond? When will the business community get engaged? What about the patient advocacy organizations?

Multiple health and social needs on WIHI

New Models for Patients with Multiple Health and Social Needs
June 23, 2011, 2:00 PM – 3:00 PM Eastern Time

Catherine Craig, LMSW, MPA, Director of Health Integration – National Programs, Common Ground

Maria Raven, MD, MPH, MSc, Assistant Professor of Emergency Medicine, NYU School of Medicine

Geraint Lewis, MA, MSc, FRCP, FFPH, Public Health Physician and Senior Fellow, The Nuffield Trust, UK

There isn’t a health care provider anywhere in the US who hasn’t witnessed the disconnect between a patient with multiple health and social needs and the systems available to help that individual. The gap between what’s needed and what’s available (and what’s paid for) is often staggering. Stories abound of doctors and nurses and social workers painstakingly trying to patch together services that might function as an alternative to the hospital’s emergency department, get a prescription filled, get someone a hot meal… and on it goes. There are communities in the US and other countries that have worked for years to do things better but, wherever you go, patients with multiple illnesses combined with a lot of instability in their lives present challenges far beyond the capability and current design of most health care systems.

Nothing like a challenge! WIHI has been tracking some timely work and research that goes by such exotic names as “predictive modeling” and “virtual wards” – or is as basic as care coordination and supportive housing – and key experts leading the way in these areas will be guests on the June 23 WIHI. Catherine Craig, Maria Raven, and Geraint Lewis are all at the sharp end of identifying new ways to work with patients to address underlying needs and manage chronic health problems that lessen dependence on expensive health care services. The good news is that wherever new models are being tried, they’re making a real, tangible difference.

To get ready for the June 23 WIHI, we invite you to read a brand new IHI white paper on innovations in care coordination, co-authored by Catherine Craig. You might also want to read (or reread) Atul Gawande’s article, “The Hot Spotters," from the January 2011 New Yorker. Some of you may recall that Dr. Gawande was on the hunt for solutions. That’s what we’ll be discussing on this next WIHI. Please join us!

To enroll, please click here.

Mt. Washington beauties

A summer solstice gift for my Northern Hemisphere readers, taken at Bretton Woods, NH (in the shadow of Mount Washington). Wildflowers above and below. Please submit comments with their names if you know them.


A clump of butterflies, below. Likewise, please identify them if you know them.

AHLA TWEETup on June 28

Copying a post from Bob Coffield's Health Care Law Blog:

Plans are set for a "TWEETup" during the American Health Lawyers Association 2011 Annual Meeting next week in Boston. All registered health lawyers are welcome along with other Boston area Twitter friends, Boston's Health 2.0 community, health care social media aficionados, and anyone else interested in the intersection of social media and the law.

Come join us at the #AHLABoston TWEETup on Tuesday, June 28 starting around 5:30pm at the BrasserieJO bar located across from the Prudential Center at The Colonnade Hotel, 120 Huntington Avenue. The BrasserieJO is located down Huntington Avenue near the Boston Marriott Copley Place, the location of the annual meeting.

Check out the TwtVite set up by David Harlow at HealthBlawg and RSVP that you will be attending. Help us spread the word.

The TWEETup follows an afternoon of health care social media and the law sessions held as a part of the AHLA Annual Meeting. For full details of the sessions and registration information check out the AHLA Annual Meeting schedule here (PDF version).The sessions run from 2pm - 5:30pm and will include:

A Legal Ethics Safety Line for Health Lawyers Online: How to Practice Safe Social Networking
Alan S. Goldberg (@GoldbergLawyer), Annie Hsu

E-Discovery Litigation
Gary L. Kaplan (@Gary_L_Kaplan), Joshua P. Kubicki (@JKubicki)

Cutting the PowerPoint Clutter: Using Zen-Like Visuals for more Compelling and Memorable Presentations
Susan Peterson

Should Health Lawyers Use Social Media?
David Harlow (@HealthBlawg)

HIPAA Privacy Issues in Social Media
Jodi Goldstein Daniel (@JodiDaniel), Daniel S. Goldman (@danielg280)

How to Use Social Media
Robert L. Coffield (@BobCoffield), David Harlow (@HealthBlawg), Gary L. Kaplan (@Gary_L_Kaplan)

Triaging Social Media in the Healthcare Workplace: Assessment, Analysis and Action
Mark W. Peters

A special thanks to @HealthBlawg for helping find the location for the TWEETup. Thanks to all the AHLA health lawyer and others spreading the word about the tweetup. Be sure to follow @HealthLawyers and use the AHLA Annual Meeting hashtag: #AHLABoston.

Will books someday be works in progress?

I had occasion recently to run into Roger Berkowitz, the CEO of Legal Seafoods. I made a point to compliment him on the uniformly high quality of his many restaurants, both the food and the staff. His reply was, "It's always a work in progress." In so saying, he acknowledged the nature of organizations. Even those institutions and firms with a progressive management philosophy and a long history of excellence know that continuous improvement is, as the name suggests, a work in progress.

Then, coincidentally, I was talking with Mark Graban, who is co-authoring his second book, with Joe Swartz. It's working title is Kaizen for Healthcare: Engaging Front-Line Staff in Sustainable Improvements.

As we discussed his writing and revising, I said something about it being a "work in progress," and he correctly noted, "There is no continuous improvement with books." By which he meant, of course, that once a book is published, it is a snapshot in time of the author's skill and ability in presenting a message. While you may be able to put out a second edition at some time in the future, that pesky first edition -- with all its flaws -- is still out there on people's bookshelves and in libraries.

But I wonder whether, with the advent of electronic books, that will change. Certainly, it is much easier with ebooks than paper books to put out a second and subsequent editions, so that later purchasers get a different version from the earlier buyers. But will it go further than that?

Right now, when you purchase an ebook, the version you download stays the same for all time. Can we envision a time in which the version you downloaded gets updated whenever the author chooses to make a change? Think of it as an Adobe software update!

What do you think? Are we headed that way?

Even columnists need editors

In an otherwise thoughtful column today, a local writer shows the need for fact-checking.

In recent months, catastrophic weather events have dominated headlines as rarely before — earthquakes and tsunami in Asia; volcanic cloud in Europe; massive ice melts at the poles; tornadoes, floods, and fires in America. “Records are not just broken,” an atmospheric scientist said last week, “they are smashed.” Without getting into questions of causality, and without anthropomorphizing nature, we can still take these events as nature’s cri de coeur — as the degraded environment’s grabbing of human lapels to say, “Pay attention!”

I am pretty sure that earthquakes, tsunamis, and volcanoes are not "weather events." And, I do not believe any one has suggested that human influence has yet reached the point of intrusion into geological events of this magnitude.

Things are current at the Courant

One of the gems of the journalism world is The Boston Courant. This is a weekly newspaper focusing on several Boston neighborhoods -- the Back Bay, Beacon Hill, Downtown, Fenway, and the South End. Publisher David Jacobs maintains a mixture of big and small news, seriousness and humor, in producing a paper that is remarkably engaging.

There is no website, so I can't refer you to stories in that way. One of my favorite sections is Jennifer Maiola's "Police Report." Drawing on reported crimes, she creates pathos and drama for the casual observer:

Heart Burned

On Friday, June 10 at 9:45pm, District 4 detectives were monitoring the Pine Street Inn area for prostitution when they spotted a woman standing on East Berkeley Street. An undercover officer drove by, and she flagged him down. The woman, adorned with a heart tattoo on her chest, got in and told him to drive to a nearby parking lot. She offered to get his heart racing for $40.

Clearly, she wasn't looking for a man after her heart, but this one didn't even want her body: The officer issued her a summons to Boston Municipal Court for sexual conduct for a fee.

But, the paper also acts to maintain standards of service in the community, getting the attention of slow moving governmental bureaucracies:

Residents Worry About Bad Sign
By Ashlee Fairey

Street signs throughout the neighborhood are faded, corroded and covered in graffiti or simply missing, concerned residents say.

"They've been in that condition for a long period of time, particularly on Boylston Street near the Victory Gardens, and where The Fenway meets Boylston Street by Mother's Rest," said resident Matthew Brooks.

...Due to a missing one-way sign this past February, traffic began traveling down Kilmarnock Street in the wrong direction.

With the major media focused on earth-shaking events, it is heartening to know that a newspaper dedicated to the neighborhoods still has a place.

Rads are good for you. Take twice as many.

Dear Mrs. Smith, I am writing to inform you that we exposed your body to an unnecessary level of radiation during your visit to our hospital. Oh, by the way, that was two years ago. We don't intend to do anything about this for you. Also, we have known about this problem for a long time, and we don't expect to change our procedures for future patients. Just wanted you to know. Yours in delivering the best health care in the world, Chief of Radiology and CEO. (Jointly signed.)

That's the essence of this article by Walt Bogdanich and Jo Craven McGinty in the New York Times. Here are excerpts:

Long after questions were first raised about the overuse of powerful CT scans, hundreds of hospitals across the country needlessly exposed patients to radiation by scanning their chests twice on the same day, according to federal records and interviews with researchers.

Double scans expose patients to extra radiation while heaping millions of dollars in extra costs on an already overburdened Medicare program. A single CT scan of the chest is equal to about 350 standard chest X-rays, so two scans are twice that amount.

The pattern was evident in numbers for 2008, and the practice persisted in 2009. Here is a map that you can use to check out your own hospital. Just insert your zip code.

This is transparency at work, right? No. This is transparency that is failing.

The big problem is that the numbers are not current. If numbers are not produced in real time, it permits practitioners to say, "Those are old numbers. We are doing much better now." That is just a psychological fact of life.

Here's a quote from another article two weeks ago:

[The government] information reported needs to be a lot more up to date, said Carolyn Clancy, director of the Agency for Healthcare Research and Quality. "We're not so good at timely transparency," she said. "We must get to a place where we get data in something like real time."

Why is it that CMS, the Medicare agency, can't produce numbers in real time and post them for the world to see on a map like that published today? All Medicare billing is done electronically. All CT scans have a billing code. I know a freshman at MIT who could write the algorithm to extract these figures. You don't have to wait till a calendar year is over to start compiling numbers.

Isn't it a matter of public health and medical ethics to publish this kind of data as soon as it is collected? By the way, this is not just a question for Medicare. Why don't private insurers also publish such figures? What doesn't each state Medicaid office?

In Massachusetts, the Division of Health Care Finance and Policy now collects an all payer claims data base. Why doesn't it publish these numbers or allow researchers access to the data so they could do so? Why don't the local media demand access to it to publish their own stories?

Testing the law of closure

Many people are aware of the Kanizsa Triangle. Here's how it works, as explained by about.com.psychology:

The Kanizsa Triangle illusion was first described in 1955 by an Italian psychologist named Gaetano Kanizsa. In the illusion, a white equilateral triangle can be seen in the image even though there is not actually a triangle there. The effect is caused by illusory or subject contours.

Gestalt psychologists use this illusion to describe the law of closure, one of the gestalt laws of perceptual organization. According to this principle, objects that are grouped together tend to be seen as being part of a whole. We tend to ignore gaps and perceive the contour lines in order to make the image appear as a cohesive whole.

Reference:

Kanizsa, G. (1955). Margini quasi-percettivi in campi con stimolazione omogenea. Rivista di Psicologia 49(1): 7–30.

Let's see what happens when we remove the "PAC-MAN" figures. I don't know about you, but for me the law of closure does not work to connect the three angles into a triangle.


But now, let's do the opposite, removing the angles and just keeping the PAC-MAN figures. Look!

Open Street Map in Boston

A project called OpenStreetMap is making a free street-level map of the entire world. Put your community on The Map!

Here's the local scene, for those who might be interested. Check out things in your own community.

Volunteers from Boston have already begun mapping the roads and rivers, but now they need your help to add details of street names and local amenities such as restaurants, hospitals and cinemas.

June 18th, 2011

Introduction to OSM at 12pm:
Bocoup Loft
355 Congress Street
Boston, MA (map)

Mapping the Seaport at 1pm - 4pm:
In and around the Four Points channel and the Boston Seaport.

OSM Mapping Tools at 4pm:
Bocoup Loft
355 Congress Street
Boston, MA (map)

RSVP here.
More info here.

So why not just use Google Maps (or the like)?

There are many places on the Internet where you can look at maps without charge, but that's all they usually allow you to do - you cannot re-use the map, modify it, publish it on your own web site or print it in a leaflet. To do any of that, you would have to obtain a license, which usually costs money. And if you spot a mistake in your area, the process to get it corrected is lengthy.

OpenStreetMap is different in that the map data is available to everyone, for whatever purpose they want (it's "open" or "free-as-in-freedom"). Anyone can put in the locations and names of roads, footpaths, railway stations, or whatever else is important to them. And people can immediately respond to changes on the ground, so the data is the most up-to-date information available.

Maps created from the data are available to browse on the Internet (just like other online maps), but they can also be downloaded and used for any purpose. And if you don't like the way the provided maps look, you can download the data and create your map, your way.

So what do I need to participate in OpenStreetMap?

Tools such as GPS receivers and digital cameras are useful for advanced mapping, but simply having access to the Internet will allow you to contribute by checking/editing the maps and to add that all-important local information. The only real requirement is that the information is 'first hand' from observation or local knowledge and that it is not copied from restricted sources (such as printed maps or online services).

Boston is currently being mapped! Visit here to find out more and see how you can help.

Why so long?

Mapping Parties take some time because you get a chance to go out into the world and collect real data about a new neighborhood. It's an opportunity to get a little flavor of the entire mapping process, which starts with data collection.

You also get the opportunity to work with the mapping tools after data collection, under the delicate tutelage of experienced OpenStreetMappers.

It's not necessary to come to all parts of the Mapping Party -- you can show up for the part that most interests you!

Drug adherence still falters

I had the pleasure of sharing a podium this week with Dr. Daniel Teres, Senior Director, Field Medical Physician, at AstraZeneca Pharmaceuticals, to discuss the topic of adherence to medication. We used the August 4, 2005, NEJM article by Osterberg and Blaschke as our starting point, but then went on from there to explore the topic more fully.

Regular readers with a good memory will recall that I covered this topic three years ago, quoting George Paz, CEO of Express Scrips. Well, Daniel had similar numbers to report, citing a study showing that after one year, only half of all patients with chronic conditions are taking medications as recommended by their doctors. While the NEJM article gives some of the reasons, he also explained some additional ones.

Denial of disease heads the list among patients with some conditions. Clinical depression is another. The stigma of the disease is another (e.g., among those taking psychiatric drugs.) Complexity of the prescription regime is another: "One per day is the best," he noted.

Daniel asked the audience to guess for which disease there is virtually 100% drug adherence. Quick, you guess, before reading further!

The answer is below.*

We also discussed how technology might be used to enhance adherence. I mentioned advanced design pillboxes, human or computer-aided calls to patients, and texting on cell phones. You would think that electronic prescribing of drugs would enable physicians to see if their patients had picked up their orders, but the full capability of e-prescribing is not generally in use. Most pharmacies do not fill in that portion of the electronic record, and there is no way for an individual clinician to request a fill status for a specific patient or drug order.

The setting for this discussion was a Life Sciences Insight Summit for IT professionals. The audience was engaged and offered many cogent observations.

--
*Answer. Tuberculosis. Why? The drug is administered in person on schedule by a public health nurse, who stays with the patient long enough to ensure that the pill is taken, that it is swallowed, and that it is not vomited up.

Will we ever get to this point?

An April 5 article in the Financial Times presented the story of a number of German industrial groups that have found success by selling manufacturing skills to external clients. Entitled "Profits of Inside Knowledge," the story focuses on Lean process improvement expertise. Here are some excerpts:

[A]fter the Porsche management brought in Japanese lean production techniques, overhauling the German company’s inefficient production system and network of suppliers, they discovered that there was demand from suppliers for their expertise.

The secret to the consultancies’ success lies in a rather unusual approach. Unlike most consultancies, Fischer Prozessberatung and the German sports car maker do not proffer legions of immaculate suits fresh from business school but rather experts from their shop floors.

“Some of our consultants go to the assembly plants of engineering companies and, after three days, start moving around machinery with a crane to improve production efficiency. Which consultancy would do something similar?” asks Eberhard Weiblen, Porsche Consulting’s chief executive.

As we consider the possible value of Lean in the hospital world, is it too much to imagine the same thing occurring in health care? Imagine a hospital getting so good at reducing waste that it would be asked by its medical device suppliers or other vendors to assist in making those companies more efficient.

Well, maybe we are getting a little ahead of ourselves. First, let's get good at this in the clinical setting. As Jim Womack says,

Earth to publishers: Free is not unprofitable

Let's follow up on yesterday's post about the person who wanted to read an article in The Joint Commission Journal on Quality and Patient Safety. She had seen the abstract here on PubMed and wanted to learn more.

This seems like a really worthwhile journal. Here's the description:

Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health care providers and quality and safety professionals with the information they need to promote the quality and safety of health care.

But let's say you want to read just one article. You find you cannot, without subscribing for a year at a cost of $319:


What's your option? Well, our friend crowdsourced on Facebook and found someone willing to share a copy.

@SusanCarr responded to my blog post with two tweets on Twitter, saying, first: Mixed feelings: proud that PSQH offers free subs & open access www.psqh.com. (See below.)


And then adding, And I know all too well that publishers must figure out some way 2 get readers 2 pay 4 content. Tough business these days!

Well, no, the issue is not that hard really. There are lots of options open to publishers who wish to consider them. A respected journal can have a sustainable paid subscription business model while allowing general access on reasonable terms to articles of public import or of specific interest to targeted audiences. Implementation of these options actually enhance the prestige and reach of those publishers.

For example, the New England Journal of Medicine allows full public access to its Perpectives articles and other selected articles of broad public interest.

The New York Times, which has moved to a paid subscription model for its electronic version, understands the need for some people to gain access outside of the payment plan:

For those who don't want to subscribe, the Times will offer 20 free articles per month - including blogs, slide shows, video, and other multimedia features. As you reach your limit, pop-ups will appear on the site. The paper will also provide unlimited access to the home page, section fronts, blog fronts, and classifieds. Those who comes to the Times via links from search, blogs and social media like Facebook and Twitter will be able to read the articles, even if they have reached their monthly reading limit.

In contrast, there are some organizations that persist in having a myopic view of how to maintain profitability and in so doing disenfranchise patients and consumers from a vibrant role in helping to design a more effective health care delivery system. The American Medical Association and The Joint Commission seem to be in this category. I guess I shouldn't be surprised about the latter, which collects best practices while charging accreditation fees to the hospitals that provide these stories, keeping this information in a locked-up library. How pathetic, too, that this occurs under the auspices of a delegation of authority by CMS.

How fast can you say "social media"?

Here are two social media events that prove something or other.

First, a person on Facebook made the following request of a group of patient advocates:

I'm wondering if I can crowdsource a request here. For those of you who have journal article access, is anyone willing to retrieve a copy of this article from the Joint Commission Journal of Quality and Patient Safety? The medical library I have access to doesn't subscribe to this journal. If you can obtain a PDF copy, please email it to me at [email] - Thanks!! More than happy to return the favor some time!

Within minutes, she posted:

That was quick! I love Facebook for this kind of thing!

In a private note to me, she said:

Journals clinging to the subscription model are easily disrupted by connected e-patients. I have often provided journal articles to countless patients and advocates and obtained them when my own library doesn't have a journal for some reason. Don't tell! :)

Meanwhile, up in Edmonton, Alberta, the Dean of the University of Alberta's Medical School found himself in trouble for possible plagiarism:

Students publicly complained on the weekend about Dr. Philip Baker’s after-dinner speech to the graduates Friday night. They said the speech bore a strong resemblance to one given in 2010 by Dr. Atul Gawande at Stanford University in California.

Some students said they searched the speech on smartphones and were able to follow along as Baker spoke to them.

The world has become instantaneous.

Economists running amuck

Economists are so embedded in their training with the concept of ceteris paribus -- "all other things held equal" -- that their policy prescriptions often go awry. Here are two recent examples:

First, in the March 10, 2011 issue of the New England Journal of Medicine, David Cutler and Leemore Dafney argue against transparency of pricing in the health care sector.

The rationale for price transparency is compelling. Without it, how can consumers choose the most efficient providers of care? But though textbook economics argues for access to meaningful information, it does not argue for access to all information. In particular, the wrong kind of transparency could actually harm patients, rather than help them.

Applying the sunshine rule in the provider–payer context, however, could have the opposite of the intended effect: it could actually raise prices charged to patients.

[T]he sunshine policy would create a perverse incentive for the hospital to raise prices (on average), and as a result its rivals could do the same. This adverse effect of price transparency would arise only in cases in which the buyer or supplier in question had some leverage (market power), but such leverage is fairly common in health care settings, including many local hospital markets.

What's the flaw here? In markets like Eastern Massachusetts, there is a dominant provider which uses its market power to garner above average prices from the insurance companies in its service area. That provider, in turn, can use those revenues to offer higher salaries than its competitors, drawing doctors into its orbit. It also has more resources to expand its ambulatory care facilities. Both steps serve to further expand its market power.

Then, that expanded referral base sends still more patients to the flagship tertiary hospitals. Those hospitals and the doctors therein are paid more than other hospitals in that area.

In short, the higher rates obtained in secret negotiations serve over time to increase the overall cost of care in such a region. In the absence of state rate-setting authority, a powerful way to put a break on this practice is to publish the rates paid by each insurer to each hospital and physician group. With no documented difference in the quality of care among providers, the publicity therein created creates sufficient moral authority for insurers to show some backbone in subsequent negotiations. It also creates the rationale for limited network insurance products, in which subscribers pay different premiums and co-pays for the option of using lower cost providers.

Would you like proof? Until the Attorney General published the relative payments received in the Massachusetts market, the market-power driven system ruled in this state. It was only after her office demonstrated the inflationary effect of such a system that moves to equalize rates began in earnest and tiered products took hold.

Contrary to the point raised by Cutler and Dafney, the point of price transparency is not mainly to offer individual consumers information about provider choice. After all, the vast majority of people go to hospitals and specialists recommended by their primary care doctor. Price transparency creates general awareness among providers, insurers, and large business purchasers of the dynamics of the marketplace. This providers an umbrella for effective change.

Second, in the New York Times, Paul Krugman today gets it wrong when he asserts that "Medicare Saves Money".

The idea of Medicare as a money-saving program may seem hard to grasp. After all, hasn’t Medicare spending risen dramatically over time? Yes, it has: adjusting for overall inflation, Medicare spending per beneficiary rose more than 400 percent from 1969 to 2009.

But inflation-adjusted premiums on private health insurance rose more than 700 percent over the same period. So while it’s true that Medicare has done an inadequate job of controlling costs, the private sector has done much worse.

And then there’s the international evidence. The United States has the most privatized health care system in the advanced world; it also has, by far, the most expensive care, without gaining any clear advantage in quality for all that spending. Health is one area in which the public sector consistently does a better job than the private sector at controlling costs.

Here's where Mr. Krugman is wrong. The Medicare rates paid to doctors and hospitals are set by government fiat. They are based on Congressional appropriations, political decisions resulting from the give and take of the legislative process. Ditto for Medicaid rates set by the states. They have little or no relationship to the cost of providing service to patients. When there is a shortfall in Medicare and Medicaid revenues, the difference is made up by the rates paid by private insurers.

He is also wrong in comparing the US to other countries and asserting that the difference in costs is based on the difference between private and public systems. That difference is based on a variety of factors, of which public versus private is but one. For example, many national systems rightfully put a greater emphasis on primary care than the US. This is clearly cost-effective. But, it is the Medicare-approved pricing system that overpays specialists relative to primary care doctors and other cognitive specialists -- not only for Medicare, but for private insurers, too.

Many other countries, too, provide free medical education to prospective doctors, reducing the salary needs of those professionals. Some countries, like Italy, allow virtually anyone to go to medical school, creating a surfeit of doctors, whose wages are then bid down.

Finally, of course, the national budgets for health care in public systems are -- like Medicare -- the result of governmental fiat that have had little or no relationship to the demand for health care services or the underlying cost of such services. As I have noted,

[T]his appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.

When the government doesn't want to pay for these services, what happens? A parallel, private system of doctors and insurance companies emerges.

But even there, nationalized system in other countries are starting to see US-like cost pressures as demographic and political trends push them to offer greater levels of specialized tertiary care and facilities. The systems are starting to converge:

I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

So, Mr. Krugman, ceteris paribus doesn't apply here. Nothing else is held equal when it comes to comparing health care systems.

(By the way, I agree with his conclusion that raising the Medicare eligibility age from 65 to 67 does not make sense, but that's for other reasons.)

Setting the record straight

Speaking of headlines, my favorite of all time was back in 1977. In July of that year, a blackout robbed New York City of its electricity. LaGuardia and Kennedy airports were closed down for about eight hours, automobile tunnels were closed because of lack of ventilation, and 4,000 people had to be evacuated from the subway system. Looting and arson erupted across the city. An official at Con Edison, the local utility, attributed the blackout to an "act of God."

Within just a few weeks, the Federal Power Commission conducted an investigation and released its report, finding a number of inadequacies in the utility's planning, operations, and response.

The headline in the NY Post or Daily News was:

God cleared. Con Ed found at fault.

Headlines matter

Reading a recent headline, I was reminded of these two news clips that I saved from my days as Chairman of the MA Department of Public Utilities in 1983. The case was about whether a local utility company had acted prudently with regard to purchases of natural gas in a previous year. Our conclusion was that the company had inappropriately cancelled a supply contract, leaving it vulnerable to supply interruption and therefore extra gas replacement costs when the cold weather arrived. We therefore disallowed a portion of those extra costs while permitting it to collect the remainder.

The decision was issued in late morning on December 30, and the afternoon edition (yes, they had one then!) of the Boston Globe portrayed it this way:


The next morning, though, the news had apparently changed.


This nicely demonstrates the power of the headline writer, whether for a newspaper or an on-line story. If you read the two stories, too, you will see a subtle shift in emphasis in the lede between the two versions. Both, by the way, are correct. The issue is whether you view the DPU's decision as a "glass half empty" or a "glass half full" story. Once the people at the newspaper had more time to think about the story, they changed their minds.

How to solve a computer problem

This seems about right to me.

"But they are different." Not!

Whenever I talk about the spectacular work Brent James and his colleagues have done with process improvement at Intermountain Health, someone says, "But they are different." These comments are often based on prejudice. It reminds me of the folks in the US automobile industry who initially said of Toyota's use of Lean principles, "It will never work in America. Those Japanese are different. They are so much more compliant than Americans." Then, those competitors discovered that Toyota factories in the US, with American workers, also effectively used Lean. And ate their lunch.

What do they say about IH? They talk about the homogeneity of the population in Utah, meaning that there is a predominantly Mormon population. They subtly suggest that Mormons are somehow more complaint with regard to health care treatment, have fewer health problems, or that the doctors are more likely to follow orders, or something equally foolish. Here's the more accurate description:

The IH network of twenty-three hospitals and 160 clinics provides more than half of all health care delivered in the region. Intermountain’s hospitals range from critical-access facilities in rural areas to large, urban teaching hospitals. Although Intermountain has an employed physician group and a health insurance plan, the majority of its care is performed by independent, community-based physicians and is paid for by government and commercial payers.

We need to recognize that the work done at IH is the result of thoughtful, hard work, and the application of the scientific method to improving patient care. It is documented in this article by Brent C. James and Lucy A. Savitz in Health Affairs: "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts." (June 2011, 30:6) Here's part of the abstract:

Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming's process management theory, which says that the best way to reduce costs is to improve quality. Intermountain achieved such quality-based savings through measuring, understanding, and managing variation among clinicians in providing care. Intermountain created data systems and management structures that increased accountability, drove improvement, and produced savings.

Since I can't give you a cite to a free copy of the full text -- (Ugh, like JAMA!) -- here are some more excerpts. The whole thing is about reducing variation and conducting experiments to improve key processes. Note the involvement of physicians! This did not come about as a result of payment "reform," financial penalties for "never" events, or Joint Commission surveys.

[In the early days of the effort, we focused] on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes—the “measurement for improvement” approach.... [T]he system was eventually able to document significant declines in physician variation. Physicians led almost all of the changes themselves. Declines in variation were associated with large declines in costs, while clinical outcomes remained at their original high levels.

Here is an interesting part about how to provide constructive feedback to the doctors, in a manner that persisted in reducing variation:

[T]he clinicians’ experience showed that the guideline was almost never perfectly appropriate for a patient. The clinicians had to adapt the guideline to each patient’s particular needs. Morris’s team recorded all of the adaptations as variances and reported them back to the clinical team treating the patient. The members of the care delivery team sometimes modified the guideline in response to the variances, to reflect the realities of care more accurately. In addition, clinicians often modified their practices to follow the guideline as closely as they could.

But focus matters. You don't change the entire organization at once:

Not all processes are equal in size and effect. Some are the “golden few”—the relative handful of processes that make up the bulk of the care that a clinical organization delivers. . . . Intermountain sought to identify this relatively small subset of key processes.

We divided Intermountain’s work processes into four subgroups: clinical processes associated with specific clinical conditions (clinical programs); clinical processes that are not condition specific (clinical support services, such as pharmacy or imaging); processes related to service quality (patient perceptions of quality); and administrative support processes. We identified and then prioritized the processes within each subgroup.

We found that 104 clinical processes—roughly 7 percent of the 1,400—accounted for 95 percent of all of Intermountain’s care delivery.

And, now look at how this changed the hospital-centric view of care:

Our focus on key clinical processes had a major secondary impact. These processes represent the entire care continuum that patients experience, without concern for the location of the care, such as home-based, clinic-based, or inpatient care delivery. Correctly managed, they lead naturally to patient-centered care. Instead of selling clinic visits, hospitalizations, or technologies to prospective patients, a health system organized around key clinical processes finds its business model driven toward population-level health. This means shifting the focus to modifying the factors that cause disease, with the goal of avoiding future costs for care, instead of responding to health problems only after they appear.

Whether you call it Deming or Lean, it is the same thing. The steps are straightforward and logical and completely consistent with the good intentions and scientific training of physicians: Document process waste and inefficiency using the wisdom of the front-line staff; reduce variation to standardize care as much as possible; conduct scientifically based experiments to improve the standard process; spread the story of effective solutions; repeat. Over and over.

The result is higher quality, lower cost, more patient-driven care and less anecdotal medicine. The government and the payers are not necessary participants in this process. The profession can do it on its own. If it does not, the government and the payers will force upon you an approach that is crude and ineffective and will simply make you resentful.