Friday, June 29, 2012

Negotiating in Ipswich

Quality and safety improvement is as much about communication and relationships as it is about protocols and techniques of process improvement.  That was my message today at Ipswich Hospital as I conducted an afternoon seminar on strategic negotiation.  About 40 people attended, from all types of positions in the hospital, to learn principles of negotiation.  These included the concepts of BATNA (best alternative to a negotiated agreement); interest-based versus positional negotiation; trading on differences; and how to recognize the structural, contextual, and personal aspects of a negotiation environment.

One of my favorite exercises to illustrate the last point above is a game called "Win as Much as You Can."  This was developed by my friend Michael Wheeler and is technically described as a four-person, simplified, iterated prisoner's dilemma exercise. A group of four participants display index cards marked with "X" or "Y" to try to win the (virtual) prize money available in the game.  The payout depends on how many people put down an "X" and how many put down a "Y" over ten rounds of play.  The structure of the game encourages people to play "X," even though doing so causes them all to lose relative to the case in which everybody plays "Y."  This causes some good-humored strife within each group of four players, with some players (above) chortling as they win by reneging on the deals struck with the others, and others (below) expressing shock that their colleagues could ever do such a thing to them.

Recognizing stars at Ipswich

As I spend more time at Ipswich Hospital in the UK, I have had a chance to get to know people and admire their approaches to improving patient quality and safety.  Given the financial issues facing the NHS, there is also a growing recognition that such improvements often have a virtuous relationship with cost efficiency.

That being said, I have found modesty to be evident, with full recognition of where improvements are still needed.  But appropriately, that does not preclude recognizing people who have made notable contributions to the organization.  On a main corridor, there are photographs of "Shining Lights," staff members who have done particularly noteworthy things.

And then, this morning as I arrived, there was a photo session taking place to prepare images to accompany an internal newsletter story about a significant improvement in one of the surgical specialties.  The colorectal surgery group has reduced the length of stay associated with major bowel surgery from 11 days to 4.5 days.  Among those getting credit for this improvement was Vicki Reid, a colorectal nurse specialist, who is universally acknowledged by the doctors as a key player in implementing the steps necessary to accomplish this.

Thursday, June 28, 2012

Patient safety lecture in Ipswich

The next event in my visit to Ipswich, UK, was a talk on patient safety at University Campus Suffolk, offered in partnership with Ipswich Hospital.  The topic was on reduction of preventable harm in hospitals, something familiar to readers of this blog.

As I often have done in lectures and classes, I promised that selected people who asked really good questions after the talk would be featured on this blog.  Here are two of them, along with some other friendly attendees.

The other, original, Ipswich

When you are from Massachusetts, Ipswich is a town that brings to mind steamed clams.  Here in the United Kingdom, the original town of Ipswich has a number of attributes -- as a major port, as the center of a farming district (the football team is known as "The Tractor Boys"), the location of British Telecomm research and development center, and -- my destination -- Ipswich Hospital NHS Trust.  I have been invited to give some presentations and hold workshops on quality and safety, front-line driven process improvement, and transparency.

The first meeting this morning was with the Trust Board of the Hospital.  (You see here interim chief executive Nigel Beverley and board chair Ann Tate.)  We discussed the similarity of issues facing hospitals in the UK and the US, notwithstanding differences in the institutional and funding structure in place in the two countries.  Questions of how to sustain process improvement and calling out of impediments, errors, and near misses was a key topic.

I was later joined at lunch by medical director Peter Donaldson (left) and chief nursing officer Catherine Morgan (above, center) for a discussion about pre-surgical protocols and check lists and other mechanisms for reducing variation in the delivery of clinical care.  Peter related a couple of stories to me from his own clinical career, many years ago, one in which he experienced a near miss before such protocols were in place.  This one involved almost removing the wrong kidney from a patient.  Each person in the clinical chain of treatment had repeated that it was the left kidney to be removed, notwithstanding the patient's saying to her GP that she was confused because it was the right kidney that was painful.  The GP said to her, "You can trust Mr. Donaldson to do the correct thing."  When Peter arrived in the OR to remove the left kidney, there were no X-ray images posted, and he asked to see them before proceeding.  Once they were displayed, he understood the error he had almost made.  He still shows evidence of the shock of that moment as he tells the story.  Peter tells this story to other doctors in training to reinforce the need for proper adherence to the pre-surgical protocol.  Unfortunately, as we all know, there are a persistent number of wrong site surgeries throughout the world (with a pertinent example shown here), and the potential for such harm exists everywhere.

I was impressed with the staff's commitment to quality and safety initiatives and their openness in learning from their own errors and near misses.  I look forward to sharing stories and ideas with them over the coming days.

Original Edwardian entrance, with maternity suite above
Ipswich Hospital original architectural detail

Wednesday, June 27, 2012

The case for science-based training in patient safety and quality

Peter Pronovost and Myron Weisfeldt make the case in an article in the Annals of Internal Medicine for an expansion in science-based training in patient safety and quality.  That it should be necessary to have to make this case is indicative of a sorry lack of commitment in medical schools, residency programs, and funding agencies.

Nonetheless, it instructive to review their logic.  The authors first note that the public has benefited greatly from prior research investments in biomedical research.  Looking at diseases like AIDS, pediatric kidney cancer, adult kidney disease, orthopaedics, congestive heart failure, chronic myelogenous leukemia, and others, they point out that many people live longer and/or with better quality of life as a result of those funding commitments.

Then, they remind us of documented results from investments made in patient safety research and researchers.  They note that cite central line associated bloodstream infections cause nearly as many deaths as breast cancer each year in the US.  They show how this rate of disease can be reduced, citing the Michigan program, children's hospitals, and elsewhere where tens of thousands of cases were eliminated and where millions of dollars were saved.  But such efforts were possible only because people with an interest pieced together available time and funding from various sources and learned how to make this progress.  Those efforts have been exceptions:

The limited progress in reducing preventable harm during the last decade was, to a large extent, because the science underlying this field was dynamic, evolving, and had little funding.  However, the field too often sought quick fixes rather than a deeper understanding of whether an intervention worked and why, undertaking less robust evaluations, failing to partner with social scientists, and downplaying or being incognizant of the need for formal degree programs in patient safety research.  For example, sentinel events recur in spite of investigations; yet, human factors engineers are rarely involved in these investigations.

The authors note that funding that has existed for research training and research in this field has been substantially reduced:

Yet, these young researchers offer hope by enhancing health care value, reducing preventable harm, reducing health care costs, improving patient-reported outcomes, and ensuring that patients receive the best possible health care for the public's investment in them.

If as David Mayer suggests, we need to "educate the young and regulate the old," this is not the right time to cheap out on the education part of training in patient quality and safety research.

Waiting for the Supremes to sing

As we await the Supreme Court ruling on the national health legislation here in the US, it is good to reflect on what the country wants.

Tuesday, June 26, 2012

Goodbye, Orbitz. Hello, Expedia.

Apple Insider reports "Orbitz displaying higher-priced hotels to Macs versus PCs."  Whoa!  Talk about segmenting a market:

Executives for the online travel agency told The Wall Street Journal that their company is testing a system that displays different deals depending on the user's operating system. Orbitz did clarify, though, that it is not offering the same room at different prices and users can always sort options by price.

"Orbitz found Mac users on average spend $20 to $30 more a night on hotels than their PC counterparts," the publication noted Wai Gen Yee, Orbitz's chief scientist, as saying.

Compared to PC users, Mac users are "40% more likely to book a four- or five-star hotel" and generally prefer higher-priced rooms when they book the same hotel as their PC counterparts, according to the report.

Brookline Booksmith tonight

I will be giving a presentation about my book Goal Play! at the Brookline Booksmith tonight at 7pm.  If you live or work in the area, I hope you can come by.

Here are details:

Please pass the word along to others who might be interested.

Brookline Booksmith is a fantastic independent bookstore, so it is worth checking out if you've never been there.  The address is 279 Harvard Street.

Jordan's song tells the message

#TPSER8 There have been many written expressions by residents and medical students about how they were affected by the time they spent at the Telluride Patient Safety Roundtable this summer.  You can read those stories over at Transparent Health.

But, in the spirit of the folk festival that occurs in the town, at least one participant has been moved to song.  Here Dr. Jordan Chanler-Berat, a PGY 1 in Emergency Medicine at NY Methodist Hospital, sings about his experience at Telluride and what he will bring back to his own hospital from the conference.  (Thanks to Hillary Kunizaki from CIR for sending this along.)  If you cannot see the video, click here.

Monday, June 25, 2012


When you have a brand and an outreach like Facebook, you can do anything you want, but why would you want to do it a ham-handed way?  Kashmir Hill at Forbes was one of the first to pick up on the latest case, calling it "Facebook's lame attempt to force its email service on you."

Technolog on MSNBC explains what happened and what you can do about it:

You see, what happened is that the email address — or in some cases, addresses — displayed on your Facebook profile was changed from whatever it was to your Facebook email address. (Your Facebook email address consists of whatever is at the end of your Facebook URL slapped in front of For example: My Facebook URL is, so my Facebook email address is

For most people, this is pretty darn annoying as all the mail they receive at the Facebook email address winds up in their regular Facebook inbox. Based on a quick survey of friends and colleagues, it seems that this is inconvenient to a majority, as they prefer to receive their email in ... you know, their actual email inboxes.

Now that you understand the somewhat bad news better, here are two good pieces of news: Facebook didn't alter the default address on your account, meaning that the social network's whacky system only altered what is visible on your profile. And you can change your profile back to normal pretty easily.

All you have to do is open up your profile page (hit the "About" button under your personal info), scroll down to the "Contact Info" box, and hit the "Edit" button. There you can toggle who can see which email address and whether it is displayed on your Timeline or not.
If you're not a fan of receiving your email in your Facebook inbox, I suggest hiding that address and simply making the one you favor visible.

Sunday, June 24, 2012

Adding votes for Vidler's

With thanks to Catherine Arnst (Vice President, Health Content Director, National Health Media, at Edelman), I share what I have learned about Vidler's, "an old fashioned 5&10 cent store now run by my best friend Bev and her brother Don. If you ever find yourself in Buffalo, take a half hour to drive there. It's like going back in time."

Here's a video to give you a sense of this 82-year-old throwback to what American towns used to be like.  After you watch the video, please vote here for Vidler's as the best company in Buffalo business.  (Click here if you cannot see the video.)

The is the first of an occasional series on old-time America stuff.  Stay tuned for more, and please send me your ideas.

Saturday, June 23, 2012

Two summer weather scenes

The first:   A little girl and her mom have different, but oddly matching hats, to keep the sun off their faces on a warm summer morning.

The second:  Fans at a Boston Breakers soccer game in Somerville, having just endured a downpour, enjoyed things as the sun came out, but missed the full rainbow behind them as they faced to watch the game.

Friday, June 22, 2012

Right-leaning? The states as laboratories of democracy?

I laughed a bit when I heard a local radio reporter refer to the "right-leaning" Pioneer Institute in her story about suggestions the organization made to the Massachusetts legislature during the current debate between the Senate and the House on their dueling bills.  I laughed because that same station never refers to liberal advocacy groups as "left-leaning."  Only in the "people's republic of Massachusetts" could one get away with applying an exclusive modifier like that and believe it to be journalistically correct.

As I mentioned before, the Pioneer Institute offers excellent analytical work in this arena and, indeed, is one of few places to employ sufficient rigor that, even if you disagree with them, you are left respecting how they get to their views.  In light of that, look at this new piece in The Daily Caller, entitled, "What Romney should do on health care."  Careful, though.  You might find right-leaning predispositions in an article that says:

Encourage individuals to become active participants in the health care they receive.

Cover Americans with pre-existing conditions who may be denied affordable insurance when between jobs.

Convert Medicaid into a per capita block grant.

Heed the lessons from the last major entitlement fix, [Clinton's] welfare reform, which demonstrated that political settlements require respect for the states.

RJR Nabisco had nothing on these guys

This article in the New York Times about squabbling and spurned suitors engaged in New York hospital mergers reads like Barbarians at the Gate.  This is what happens when you incent aggrandizement of hospitals by promoting accountable care organizations and then offer little oversight by antitrust authorities.

Either merger would create one of the largest health care systems in the city, with immense leverage under the new federal health care law. It could put pressure on outside medical practices, insurance companies and rival medical schools looking for hospitals in which to train their students. 

Thursday, June 21, 2012

Getting a handle on relative harm

I run the risk of excoriations from the environmental community by writing this post, but come on!  The AP recently reported:

Samsonite International SA is recalling 250,000 "Tokyo Chic" suitcases worldwide to replace handles on the bags after a Hong Kong consumer group found high levels of compounds linked to cancer.

The luggage maker said Tuesday that independent tests showed the suitcases posed no health hazard and it was carrying out the recall to allay consumer concerns.

The issue is the use of polycyclic aromatic hydrocarbons in the manufacturing process.
People at Cal Tech explain what PAHs are: 

PAHs are actually common in our day-to-day experience. A variety of these molecules are formed anytime carbon-based materials are burned incompletely. They comprise the sooty exhaust from automobile and airplane engines. They coat the grills where charcoal-broiled meats are cooked. They are the primary ingredients of industrial compounds like mothballs and glue for plastic 

PAHs are carcinogenic in certain concentrations and durations of exposure.  But not here:

"A human being has to eat 100 handles and then you have the probability of one in a billion chance of getting cancer."

And there is a cost:

The company expects to spend $500,000 on the recall, which involves 250,000 suitcases sold over the past three years.  The company said it will take about a week to replace the handles on 30,000 still in stock.

There is also an environmental cost:  Transporting all those suitcases back to the factory; running molds for the new handles; attaching the new handles; and redistributing the new suitcases back to the stores.  I dare say that the pollution caused by the recall will have a greater detrimental effect on the Hong Kong population than even the most aggressive estimate of harm from the handles.

This is an example, I think, of scientific illiteracy.

Wednesday, June 20, 2012

It's been working on the railroads. Why not hospitals?

#TPSER8  I am not alone in mentioning that people in health care have a lot to learn from other high-stakes, high-risk professions, like airline pilots.  Chuck Denham, for example, has teamed up with Captain Sullenberger, Dennis Quaid, and John Nance to go so far as to suggest an NTSB for health care.  (Aside:  Let's hope that this idea is paired with the equivalent of the Commercial Aviation Safety Team if it starts to catch fire.  That would pair regulatory review of adverse events with real time process improvement related to near misses and other safety impediments.)

But I am here today to talk about railroads.  As we were doing a review of our recent class reunion, my committee co-chair Duncan Allen made casual mention of NORAC.  "What's that?" I asked.  Duncan, who works at IBI Group and is a whiz about this stuff, replied, "Northeast Operating Rules Advisory Committee, which sets the common framework for railways in the Northeast, and is heavily borrowed from in other portions of the country."  My antennae went up, and he sensed that, adding, "This is very different knowledge domain from hospitals, but perhaps you will find something interesting.  The high-level principles of the rules applying to employees of one railroad on the property of another might be a case in point."

Now remember that I just spent a week in Telluride with a group of residents talking about quality and safety, and especially reduction of variation in clinical practice.  In my hospital CEO days, I had often seen what happens to residents as their training program caused them to move from hospital to hospital.  The difference in approach to quality and safety matters was dramatic, and these young doctors often found themselves middled by changes in rules and expectations.  Now check out the railroads.  When I asked if the rules are enforced, Duncan explained:

Yes, and rather zealously at that.  Technically, each railroad enforces its own ‘home’ rulebook on its own geographic territory, through a military-like structure (see Sections ‘Dispatchers’ through ‘Foremen….’ in NORAC). Larger railroads are typically divided into geographic ‘divisions’, each with a Superintendent who has ultimate authority.   The NORAC rules are incorporated into each of the member railroads’ rulebooks (explicitly or by reference), so are binding along with a lot of local territory-specific detail contained in each railroad’s ‘employees’ timetable’ and/or special instructions (usually a separate publication).  Per the NORAC rules, an employee of NORAC road B operating on NORAC road A is subject to A’s rules, which are enforced by A’s enforcers.

I asked whether there is an overall governing agreement that is in force.  He replied,  "In the strict sense I think you mean, not so far as I know.  In addition to NORAC rules, there is a General Code of Operating Rules (attached), to which virtually all non-NORAC railroads adhere.  These are somewhat narrower in scope, and address non-block territory (block systems are typical of the Northeast), and don’t say that much about operating in ‘foreign’ territory.  If a railroad joins NORAC or subscribes to the GCOR, then it has effectively agreed to make the common rulesets part of its own rulebook."

Now, look at this, the first section of the GCOR:

I like this part:  Report by the first means of communication any accidents; personal injuries; defects in tracks, bridges, or signals; or any unusual condition that may affect the safe and efficient operation of the railroad. Where required, furnish a written report promptly after reporting the incident.

Does this sound familiar?  Think back to Dave Mayer's criterion for a high quality hospital.  No organization can succeed at continuous improvement without a mechanism for recognizing and reporting out where it is not doing well or well enough.

But back to the issue of different hospitals, er, railroads.  Duncan, noting the great detail in these rulebooks, states:

It may seem incredible that so much wordsmithing goes on, but this approach has been evolving for decades, and rail safety is continuing to improve.   It’s somewhat a matter of necessity, especially in the Northeast – for instance, the Acela Express between Boston and Washington operates over five distinct ‘railroads’:  MBTA from South Station to the RI state line; Amtrak in its own right between there and New Haven; Metro North Commuter Railroad from there to New Rochelle; Amtrak again to just outside Washington; and then the Washington Terminal Company into the station in DC.  Most situations where train crew operate on other roads requires that crew to be qualified both on the ‘territory’ (information in the employees’ timetable and special instructions) and equipment (e.g. train handling, if they are going to operate the other company’s trains).  NORAC addresses the different wayside signal displays in the northeast in some detail, because so many trains operate in differently signaled territories."

An then there is the requirement for ongoing training in matters related to safety. Here's a page from the rules:

Duncan points out one provision,  "Another fun RR tradition is the ‘safety rule of the day’ (see item A-S2).  Your superiors can quiz you, and not knowing the answer is not a Good Thing."

Think of what would happen if we applied similar standards across all hospitals and forced clinicians to engage in continuing and intense quality and safety reviews as part of their professional certification.

Tuesday, June 19, 2012

Skyping with HealthAdministrationDegrees recently reached out to Bob Wachter, Professor of Medicine at UCSF, and author of Understanding Patient Safety and the blog Wachter's World, and Shahid Shah, the Healthcare IT Guy, and me to conduct Skype interviews on topics of interest to potential students in this field.  Two out of three of the interviews are very informative, and you can also check out mine if you'd like.  Here's the site.

Skills for Health Care Reformers on WIHI

Essential Skills for Health Care Reformers and Improvers:
Holding Tension and Learning Habits of the Heart
June 20, 2012: 2:00 – 3:00 PM Eastern Time

Parker J. Palmer, Founder and Senior Partner, Center for Courage & Renewal; Author, Healing the Heart of Democracy
Jeffrey D. Selberg, MHA,
Executive Vice President and Chief Operating Officer, Institute for Healthcare Improvement
The health care improvement community has often benefited from the work and perspective of other industries. Taking a systems approach to improving quality and safety in health care owes much to the concepts and work that turned the tide on risks and defects and waste in aviation and manufacturing. 

The quality improvement movement has also benefited from the wisdom of “outsiders” – individuals asked to look in at what health care improvement is trying to achieve and to tell us what we may be missing or what they see that we don't, because we’re just too close to the problems and the day-to-day solutions. Parker Palmer is just such a person, and he’s visited with the improvement community before; in 1997 he delivered a moving keynote at IHI’s National Forum about the challenges of being a dedicated health care professional.

On the eve of the Supreme Court issuing its decision on the Affordable Care Act, and with new policies and payment schemes and community-focus reshaping the very core of what it means to be an effective health care leader, WIHI thought this would be a perfect moment to invite Parker Palmer to speak with us again. IHI Executive Vice President and COO, Jeff Selberg, who knows Dr. Palmer’s ideas and writings well, will help lead the discussion, along with WIHI host, Madge Kaplan.

When one is committed to change, there are good days and bad, and successes can easily be followed by disappointments and setbacks. The challenge becomes how to hold the entire picture in a sort of “creative tension,” to avoid retreating from the public square, and to retain one’s openness and curiosity when things don’t go as hoped or planned.  Parker Palmer is very aware of the tremendous pressures and challenges all health care leaders and professionals now face to forge a new kind of contract with payers and patients alike. It’s an exciting time, and a difficult one. Parker Palmer, Jeff Selberg, and Madge Kaplan invite you to bring both your acumen and your human spirit to the June 20 WIHI. See you then!

To enroll, please click here.

Monday, June 18, 2012

Are you making more money?

Someone once showed me an analysis that demonstrated that the sum of workers’ salaries and benefits has stayed remarkably constant in real terms over the last two decades.  This means that companies have compensated for the increasing cost of health insurance over time by holding back on wage increases.

You can understand this.  After all, if companies are not able to increase the price of goods and services they sell to the public, they need to hold factor costs relatively constant.  So if it was costing them more and more to provide health insurance to their workers, an offsetting amount would have to be removed from possible wage increases.

This dynamic is still in place, but it is showing up in a different way, by shifting costs to workers in the form of higher deductible health insurance policies.  Deductibles are different from co-pays, where you plunk down $15 or $20 for each appointment or prescription.  With deductibles, you pay the first costs incurred as you and your family make use of the health care system, the entire cost of the office visit or of the prescription, until a preset amount is reached.  After that level is reached, you still pay the co-pays.  A recent story in the Washington Post documented this trend.

Currently, this kind of high-deductible policy is often combined with health saving accounts that are funded by the employer.  These accounts let patients buy medical services and drugs with pretax dollars.   So, although your insurance plan might require you to pay more of a deductible out of your own money, you could still use the HSA to cover those out-of-pocket expenses.

But the article suggested that this remaining employer contribution, the HSA, is likely to evaporate over the coming years.  “Half of all workers at employer-sponsored health plans — including those working for the government — could be on high-deductible insurance within a decade, according to a new paper from Rand Corp.”

Is this good or bad?  Supporters of high deductible plans say that the only way to make sure consumers have some “skin in the game” when it comes to society’s rising health care costs is to assign some of those costs to the consumers.  If you know, for example, that you will pay for the first $1000 of your annual health care costs, perhaps you will shop around when you need that MRI.  Instead of going to the local hospital, you will go to a specialized imaging center.  Perhaps, too, you will be less likely to go the emergency room for something that could wait a day or two.

On the other hand, opponents say that this kind of approach is unfair to people with chronic diseases like arthritis or diabetes.  They argue that these people make fewer discretionary choices when it comes to treatment.

Some people suggest that companies are “word-smithing” the trend to make it sound like it is in the public interest, even though it is really driven by corporate finances.   The article quotes Jonathan Oberlander, a health policy professor at the University of North Carolina. “Employers like it because they’re providing less coverage. If they can relabel it as consumer-driven then it even sounds good.”

One variant on high deductible plans is to allow consumers a lower deductible if they get their medical care at a “limited network.”  This would be a group of doctors and hospitals that agree to charge the insurance company less than a group of higher paid doctors and hospitals in the community.  You, as consumer, would choose.  If you really wanted to go to Dr. Really Famous at the local academic medical center, you would be responsible for the much of the cost, but if you went instead to Dr. Relatively Unknown at a community hospital, you would only be responsible for a small co-pay.

Perhaps, too, your deductible would be waived if you agreed to participate in an annual health care assessment.  The Post article told of one such plan:  “Chrysler introduced a preferred-provider plan with family deductibles as high as $3,400 for salaried workers.... The deductible falls to $1,000 for in-network care if employees receive a physical and take other steps such as completing an online health assessment.”

Of course, none of this works at all if the rates and charges assessed by doctors and hospitals are not transparent to the public . . . and if we have no quality indicators that tell us what we are getting for our money when we choose between Dr. Famous and Dr. Unknown.  Thus far, where such information is available, it is woefully out of date, often two or three years old.  If high deductible plans are coming our way, we should be demanding of our state government that both real-time price and quality data be available for all to see.

Mandl and Kohane offer an escape from the EHR trap

I had barely published the post below about opening up electronic medical record systems to innovative applications when a friend forwarded this article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine.  It is like the Gettysburg Address from two of the world's experts, a powerhouse contained in just a few paragraphs.


It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

Loss of technological leadership reflects apathy and even opposition by EHR vendors to promoting liquidity of the data they collect. This attitude has thwarted medicine's decades-long quest for an electronic information infrastructure capable of providing a dynamic and longitudinal view of the health care of individuals and populations. EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Health IT vendors should adapt modern technologies wherever possible. Clinicians choosing products in order to participate in the Medicare and Medicaid EHR Incentive Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation. New companies will offer bundled, best-of-breed, interoperable, substitutable technologies . . . that can be optimized for use in health care improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of “meaningful use,” signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.

Help for fire victims in Colorado

A good friend from Ft. Collins writes about the current wildfires going on there.  A map is shown above.  Here's the latest formal description from yesterday:

The High Park Fire is located approximately 15 miles west of Fort Collins and has burned 56,480 acres to date and is estimated 45 percent contained. 1748 personnel are working on the fire with a 24-hour schedule with night shifts and day shifts. Steep terrain, limited access, and the presence of dense stands of beetle killed trees to the west of the fire area are of concern to fire officials. Emphasis is on structure protection throughout the fire area. Fire activity increased with the winds this afternoon.

The friend writes:

I hope you will consider making a financial contribution to help the people affected by this disaster. Below is some info on a group that will help people rebuild their homes, with an emphasis on sustainability, in the months & years to come. 100% of all funds raised will stay in Larimer County helping people. This is REALLY important as all other disaster organizations (Red Cross, United Way, FEMA)  provide only temporary assistance and little to no financial support.  If you are in a position to financially make a contribution, I highly suggest this avenue. Thank you in advance and pray for rain.

The NoCo Rebuilding Network has established an emergency fund to support community members directly affected by the High Park Fire. They are in critical need of financial support.  100% of the funds collected will be allocated to those whose homes have been significantly impacted by the fire and decide to sustainably rebuild in Larimer County.  The full extent of the devastation caused by this fire is yet unknown. 181 homes have been lost to date and families are in need of help.  We want to be certain that there are funds available locally that can be dispersed for the recovery efforts. To donate online, visit

Sunday, June 17, 2012

This is not cold fusion

By the way, speaking of electronic medical records and meaningful use, we cannot fail to mention the upstart company Practice Fusion.  Focusing mainly on independent physician practices, Practice Fusion CEO's says, "We’re effectively the Salesforce for doctors, and the Facebook for health.”  Doctors can sign up for free for an EMR that will meet the meaningful use criteria, making them eligible for the $44,000 in federal incentive payments.  The service offers labs, e-prescribing, scheduling, charting, and billing.  The revenue model is based on advertising by labs, pharmacies, and drug companies who want to be seen by these medical decisions-makers.  The company promises that the basic EMR services will always be free, but I suspect that future revenue may also come from enhanced services.

Notwithstanding a movement of doctors from private practice to hospital-based practices, there are still lots of MDs working in small offices across the country.  Many of them are older people with little or no computer capability, but they know they will need to have EMRs to be included in certain insurance products and networks.  Even Dr. Oz is used by Practice Fusion to reach out to these people.

A Tech Crunch report from last November noted:

Practice Fusion’s doctor and record uptake rate is growing exponentially. It counted 70,000 clients in April when it raised a $23 million series B, and by September when it took $6 million more in funding it had 100,000 health care providers on board. Now Practice Fusion is at 130,000, and with each new doctor comes roughly 2,000 new patients who can access their own medical records from anywhere. Doctors can begin using the product in minutes, and can pay to have all their existing paper records scanned in over a few days. Practice Fusion’s competitors can take 6 months or longer to get doctors set up.

Just a few months later, the company claims to have over 150,000 subscribers.  Worth watching, for sure.

Can we make it even more meaningful and useful?

As part of the American Recovery and Reinvestment Act (ARRA) of 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was created to fund and support a paperless national health information network through the adoption of electronic health records (EHRs).  Congress appropriated over $30 billion dollars for doctors and hospitals to receive if they install EHR systems that meet minimum standards. Doctors qualifying for the meaningful use incentives in stages over five years can earn up to $44,000 per physician. Hospitals’ incentive vary but start with a $2 million base payment.  The map above shows payments made through April 2012.

This is a huge infusion of money into the hardware and software sector that serves doctors and hospitals, amounting to about a 50% expansion of the entire national installed base of these computer systems.  The result has been a windfall for those few big firms that dominate the business, like Cerner and Epic.  They promise a lot and are getting paid a lot and are recruiting a lot of software engineers and the like.

The talk in the industry is that these firms are getting over-extended because of the size of the contracts and the need to quickly recruit, train, and assimilate staff.  I do not have a way to judge that, but I do notice that there is already a parallel growing industry of firms like Arcadia Solutions that, among other things, are brought in after the big guys come through and help the systems actually deliver the promised benefits.

One thing is for sure, though.  The major firms offering EHRs are not in a position to offer much in the way of customizable systems.  In part, they simply have too much to do just to meet the market demand for the basics.  But some of the firms have adopted a strategy that, in essence, says, "This is what we offer.  We will enhance it and/or customize it on our timetable.  Don't call us.  We'll call you."  This is not a surprise, given both the required schedule for meaningful use and the dominant market position of these suppliers.

Meanwhile, though, there are hundreds of entrepreneurs and small firms -- often, but not exclusively, based in Silicon Valley and Cambridge -- who have developed apps that could dramatically enhance the delivery of care.  The rub is that these apps need to be integrated into the EHRs to preserve the integrity of the patient records.  If you have a stand-alone system on which a clinician is relying for decision support or enhanced hand-off management, for example, the results of that transaction should often be documented in the EHR.  But the big firms are too busy or commercially unwilling to prepare interfaces to make it possible for this integration to be carried out.

In a recent article, Forbes writer David Shaywitz and co-author Tory Wolff cite the special dominance of Epic in this marketplace and offers two scenarios of what might happen in the future.  They does not propose that the big vendor give up proprietary information and make its system the equivalent of open source programs.  Their proposal instead is that the vendor should adapt its systems to permit portal entry of data, in the format it desires, from these stand-alone apps into the EHR.

The optimistic scenario would be that Epic could take inspiration from Apple’s approach to apps, using its dominant market position to provide a clear set of operating standards and expectations, and cultivate a far-flung innovation ecosystem based on its established platform.  In this scenario, Epic could keep its products relevant and stay on the leading edge by adapting quickly to evolving market needs. 

Alternatively, if Epic . . . decides to maintain an essentially closed system, and to drive all innovation internally, this could prove stultifying, limiting the development of novel ideas, and forcing the many high-profile adopters of Epic to accept stagnation or pay the staggering costs of switching.  The restrictive mindset might drive determined innovators – entrepreneurs, developers, and eventually even clients — straight into the arms of competitors.

I don't buy the authors' argument that Epic's competitors will be any more nimble or willing to open up their systems, but I do agree with them that Epic is uniquely suited to set the standard for doing so.  However, they worry that:

Epic’s “capture all the information” approach certainly feels at odds with a distributed world; moreover, if Epic manages to dominate the market using their existing approach, they will enjoy significant “locked-in” revenue, and may simply not see a lot of incremental profit in rapidly changing.

I hope this is not the case.  As a privately held company with an inspirational and thoughtful leader who truly cares about the future of health care in the country -- and enough revenue and profit to carry it through for years to come -- Epic has the potential to accelerate change more than anyone in the country.  What will it be, Judy?

Saturday, June 16, 2012

The gift that keeps taking

Stopping at City Market in Montrose, CO, the other day, I was taken aback by the extensive display of gift cards.  I had never seen that much potential shelf space devoted to these items.

There were even gift cards that you could charge up with your federal income tax refund and somehow thereby double your refund.

There is nothing like this in Boston stores.  Ever curious about things commercial, I did a quick survey of friends in various parts of the country  with the simple question, "Do your grocery stores have massive displays like this for sale of gift cards?"

A Maryland observer replied, "Not quite that big in one place but in general, yes. They must get something out of it since I understand that space in a grocery store is hotly competitive."

A California-based urban planner replied, "Yes.  Also not quite this big.  Could the size of the display be linked to Montrose's distance from a major metro area?  More online shopping, that is?"

So, dear readers, what's your take on this?  Am I the only one to live in a gift-card-deficient part of the country?  What's it like where you live?  Do you have a theory to explain the differences in different locations?

Meanwhile, you will be happy to know that there is a mobil app that helps you keep track of your gift cards and spend them, too.  It even uses the GPS in your iPhone to tell you that you are near a store for which you have a card.

Here is a goofy rogue video someone produced about how to use the GoWallet.  Don't miss the love story near the end. If you cannot see the video, click here . . . or just go do something more worthwhile!

An inside view of the medical arms race

Boy, did these guys send an invitation to the wrong guy, but the language they use gives you a sense of how the proton beam juggernaut keeps cutting a swath through the nation's health care budget.  Let's recall, too, that these investments are made possible by your federal government, whose Medicare funding agency, CMS, overpays for cancer therapy using this kind of machine.  Here's the letter:

Dear Paul Levy:

After our two consecutive successful Proton therapy events, it is my great pleasure to invite you to SPEAK at our Third National Conference on "Planning, Building and Operating Successful Proton Therapy Centers" February 20-22, 2013 in San Diego, California. This conference will focus on planning, developing, building and operating Proton Therapy facilities to bring the leading edge of cancer treatment to more patients.  A site tour will be announced shortly.

We are featuring the best Proton Therapy programs nationwide.

When & Where: February 20-22, 2013 ▪ San Diego, California
Presentation: 45min. long classroom-style session focusing on specific best practices/case studies which may include, planning, implementation, etc.
About ACI: This is ACI’s third national proton therapy event, featuring tours of the Roberts Proton Therapy Institute at the University of Pennsylvania and the Hampton University Proton Therapy Institute

Topic Focus: A two-day, case study based industry event focused on how the planning, building and operating of a successful proton therapy centers can help  to meet and exceed the demands of today's oncology patients, gain competitive advantage and improve the quality of care. The goal of this event is to bring industry leaders together, highlight the best practice achievements, as well as discuss the current issues/challenges faced by healthcare executives.

Target Audience:  Administrators from hospital and healthcare systems. Titles including CEO's, Presidents, COOs, CMOs; Administrative Directors of Oncology Services, Cancer Centers, Radiation Oncology and various Oncology Service Directors. Previous conferences have gathered as many as 100 hospital executives from renowned hospitals and health systems around the nation.

Talk Desired: Typically presenters address topics related to best practices, operational success, benchmarks or a case study to represent the growth of a program or service line. You can talk about the success of your program, or more specifically to successful strategies or implementations. We encourage presenters to speak on topics that their peers would be most interested in hearing and a more acquainted subject matter. Some of the topics of interest are:

         *   Seamlessly Integrating Proton Therapy with other oncology services
         *   Ensuring patient safety and compliance with regulations while navigating the regulatory landscape involved in developing a Proton Therapy facility.
         *   Building the business case for a Proton Therapy Center by understanding the clinical applications and future advancements
         *   Effectively measuring the ROI of your cancer service line
         *   Successfully marketing your Proton Therapy Center services to the community to increase patient recruitment, revenue, and competitive advantage.

Please feel free to call or email with any questions or if I can offer you any assistance!  Thank you for your consideration! Please feel free to call or email with any questions!

Thursday, June 14, 2012

Residents, here's a new way to measure a hospital's quality

#TPSER8 At the final session of the Telluride Patient Safety Camp today, co-organizer David Mayer (who, by the way, is the recently appointed vice president of quality and safety for MedStar Health) set forth a goal for the future.  Someday, he suggested, the first question of residents arriving at any hospital will be "Where do I report?" safety and quality issues.

Why is this important?  Simply, no organization can succeed at continuous improvement without a mechanism for recognizing where it is not doing well or well enough.  Only those hospitals that cherish the opportunity to learn not only from adverse events, but also from near misses, work-arounds, and plain old inefficiencies in the delivery of clinical care will rise to a level of high quality and will maintain that level.  Residents have a key role in this because of their many hours of clinical duty in hospitals. They, especially as incoming interns, have the fresh eyes to see things that long-term attending physicians and nurses no longer see.  An organization needs to hold itself accountable to the standard of care it has set for itself, and the residents play a central role in ensuring that this happens.

Speaking of today's hospitals, David said, "A record of sustained reports on quality and safety is an indication of deep organizational commitment to improvement."

So, I take David's hope for the future and offer it as a simple metric of hospital quality and safety today.  I suggest that medical students who are applying for residency positions during the match process should ask the same question, followed by a few others, "Where will I report quality and safety issues?"  "How and by whom will those reports be received and evaluated?"  "How and when will I hear back as to whether changes resulted from reports I submit?"  "How will the story of those improvements be spread so that other floors or units will be able to learn of them and adapt those lessons throughout the hospital?"

Photo at Bear Creek Falls by Tim McDonald

Reaching greater heights at Telluride

#TPSER8  A requirement of attendance at the Telluride Patient Safety Camp is that each resident must implement, lead and successfully complete a safety or quality improvement project at his or her institution over the next twelve months. Today, we started to hear from students as to the nature of their proposed projects.  Here are some summaries.  After each summary, I present a portion of the person's biographical statement to give you a sense of the breadth of experience at this conference and also the level of commitment represented by these residents:

Christopher Smith will design and implement an improved resident hand-off system to be integrated into the new EPIC electronic medical record system being installed in his hospital.  Chris is the current chief resident for Internal Medicine at the University of Nebraska Medical Center (UNMC) in Omaha, NE.  His burgeoning interest in patient safety stems from his experience designing a patient hand-off curriculum and his involvement with his program’s Clinical Quality Improvement Conference.  In the past year he also attended several quality and safety workshops through the Veterans’ Administration and worked through the Institute for Healthcare Improvement’s Open School courses.  Starting in the next academic year, he will join the UNMC faculty as an academic hospitalist.  His professional goals include developing a quality and patient safety curriculum at UNMC and expanding their simulation procedural training.

Sujata Sofat will introduce a curriculum for new residents focused on safety, to be delivered as part of their orientation. She notes, "My mentor, Dr. Stephen Evans, and I embarked on a project to create a curriculum for patient safety for the residents at our hospital. This in turn led to me finding a passion for quality improvement that I didn’t know I had. I joined the Center for Patient Safety and then became an active member of our House Staff Quality Council. I also volunteered to be a part of the AIAMC National Initiative Phase 3, and am working with others to combine our resident curriculum with a more comprehensive curriculum which will encompass medical students and attendings.  At Georgetown, Dr. Evans is known as 'Safety Steve,' and I’ve attained the nickname of 'Safety Su' for my heartfelt dedication to aiding him in his wholehearted efforts."

Jonathan Hatoun will conduct research on why residents are not reporting adverse events in his hospital and will then recommend changes in the reporting system to increase performance in this area.  His proposed project includes focus groups, surveys of senior residents, and contacts with program directors.  Jon grew up in the suburbs of Boston and is currently a resident in pediatrics at Boston Children's Hospital and Boston Medical Center and developed a strong interest in quality improvement and patient safety after being introduced to his residency's QI curriculum this year.  He notes, "Initially I started a project at Boston Medical Center to ensure that patient's who were admitted with asthma exacerbations were discharged with their medications in hand.  Through many iterations, we have developed a system that has increased the number of patients filling their scripts before discharge from around 10% to nearly 85% in less than a year."

Jon notes that he has gone full circle this week:  "During medical school I actually biked across the country - through Telluride - with my best friend as a fundraiser for the free, student-run clinic at Columbia." 

Jennifer Pinnick had a number of project ideas, an in-service education program about epidurals for nurses; a standard check-list for intern handoffs; and creating resident forums across hospitals in Chicago, like those held in in New York City.  Jennifer is an upcoming 3rd year anesthesia resident at the University of Illinois in Chicago.  She reports, "I got my undergraduate degree in biology from the University of Kentucky in Lexington, Kentucky (GO CATS!). I also went to medical school at UK. There, I became a huge basketball fan and learned to wear hats to horse races. I also became interested in multiple aspects of patient safety. I had the opportunity as a fourth year medical student to do away rotations at 7 different hospitals. Some were huge university centers, others were very small hometown facilities. From east coast to west coast, these different experiences only further stirred my interest in improving safety for patients. "

Swing photos by Tim McDonald

Wednesday, June 13, 2012

Effective Communication Videos from CIR

#TPSER8  As I mentioned earlier, CIR (the SEIU Committee of Interns and Residents) has been a strong supporter of the Telluride Patient Safety Camp, sponsoring attendance by residents from a number of locations.  But CIR also has a much broader agenda in promoting a better patient quality and safety environment in the hospitals in which its members work.

One aspect of that improved environment is to promote evidence-based patient communication skills for physicians.  In that light, they have produced two videos on motivational interviewing and patient-centered interviewing.

Conference attendees Justin Wood and Hilary Kunizaki distributed these two videos to all the participants, asking for feedback and suggestions for future efforts in this arena.  I am taking the liberty of spreading their request more widely by presenting those videos here for your review.  Please offer comments below.

The first video features August Fortin, MD (Yale Medical School), and Sheira Schlair, MD (Montefiore Medical Center) on the topic of patient-centered interviewing.  The second video features Jonathan Fader, PhD. on the topic of motivational interviewing.  If you cannot see the videos, click here.

Physician-Patient Communication: Drs. Fortin & Schlair present patient-centered interviewing techniques from CIR/SEIU Healthcare on Vimeo.

Dr. Jonathan Fader Demonstrates Motivational Interviewing Skills from CIR/SEIU Healthcare on Vimeo.

Tuesday, June 12, 2012

Telluride Day 2 -- Informing consent

#TPSER8  The picture above shows the nearly unanimous positive response to a question I posed near the end of day 2 at the Telluride Patient Safety Camp. Hang on for a few paragraphs to learn what I asked.

The emotional aspects of health care have come forth during this conference in several ways.  Today, it was the presentation of a video entitled, The Faces of Medical Errors...From Tears to Transparency:  The Story of Michael Skolnik.  This powerful story is described as follows by the producers:

Viewers are compelled to rethink the critical role that shared decision-making and informed consent play in patient safety and transparency. This emotionally engaging program tells the story of Michael Skolnik, an intelligent, compassionate young man who died at age 25 after a three-year ordeal following brain surgery. Michael’s parents, Patty and David Skolnik, are joined by industry visionaries who together challenge viewers to consider how fully informed consent, true shared decision-making, and open and honest communication can change outcomes, how it could have changed the outcome for Michael, can change outcomes for countless others, and in the process reduce risk for institutions and the dedicated providers who care so deeply.

For our session today, the residents were asked to reflect on the training they had received with regard to obtaining informed consent from patients and/or family members, recognizing that all procedures have inherent risks and possible benefits.  The responses were clear and virtually uniform:

"In medical school, we never got training in informed consent."

"In my training, there was none.  We would always say there was a risk of infection and bleeding because we figured that was safe."

"I remember as an intern getting consents for central lines.  I was so excited [to be doing the procedure], but I didn't really understand the risks."

"Sometimes the surgeon orders the nurse to get the informed consent and send it to the OR, where he will see the patient for the first time."

From this, we migrated into a discussion of shared decision-making, how to give the patient sufficient information to know about the potential risks and benefits of a procedure, the alternative to it, and the like.  The idea is to create a true partnership between the physician and the patient to reach a decision that is acceptable and understood by all.

But some of these items are quite technical and are delivered under stressful circumstances.  People talked about the idea of "teach-back method."  Should we have in place system that allows us to get to the point that the patient can explain back to the doctor the risks and benefits and alternatives in a cogent fashion?  Is it better to have the informed consent form in hand when talking with the patient, or does that interfere with communication?  How do we deal with the fact that administration of certain medications can have risks as great as procedures but often do not require informed consent?  How does one actually quantify risks and benefits, especially if one is a doctor in training and does not have a full knowledge of those matters?

Between the movie and the discussion, we devoted about 2.5 hours of excellent thought and commentary to this topic.  The question I then asked the residents was, "Hold your hand up if this discussion was the most extensive or intensive conversation about informed consent in your entire medical education."  Virtually every hand in the room went up.

What an indictment of the medical education system.  The most basic of interactions between a physician and a patient get virtually no attention in the undergraduate medical curriculum and in the graduate medical education training program.  And, yet, as illustrated in the case of Michael Skolnik, a conversation can change a clinical outcome.  Indeed, a conversation can save a life.

Jumping for joy in Telluride

#TPSER8  We took a break during the Telluride Patient Safety Camp for group pictures.  Seen here are two of the more exuberant groups of residents.  The ones above were sponsored by CIR, the SEIU Committee of Interns and Residents.  In addition to traditional collective bargaining issues, CIR has a major focus on creating a better patient quality and safety environment in the hospitals in which its members work.  Also, it supports education and training to improve the quality of care the members are able to provide to patients.

The ones below were sponsored by COPIC, the major medical malpractice insurance company in Colorado.  In addition to traditional insurance issues, COPIC has a strong presence in the risk management arena, with active participation in state and national initiatives aimed at improving patient safety and transferring this knowledge directly to health care professionals, facilities and hospitals in its communities.

Photos by Tim McDonald

When a bulb does not represent a good idea

#TPSER8 We are all familiar with the cartoon image of a light bulb glowing or flashing as representing a good idea that has occurred to someone.  There are other types of bulbs, including those used in medicine, which are also good ideas, except when they are left in the wrong place.

A case documented in the Journal of Robotic Surgery (2009) 3:45-47, entitled, "To forget is human: the case of the retained bulb," presents a whole new category of retained foreign objects in people who have undergone laparoscopic surgery.  In this case, a 34-year-old woman had a robot-assisted laparoscopic hysterectomy.  An asepto bulb was placed in the vagina by the surgery technician "to maintain the pneumoperitoneum during the laparoscopic closure of the vaginal cuff."

Wikipedia tells us that, "A pneumoperitoneum is deliberately created by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide."

Here's how the bulb is usually configured, as part of an irrigation syringe.  In this case, the bulb was removed from the syringe to be used by the surgery technician.  In essence, s/he used it to plug up the pressurized air pocket in the abdomen needed by the surgeon using the laparoscopic instruments.

You can almost imagine the surgeon saying -- sitting in his robotic console physically apart from the operating table -- "I am losing air pressure.  Do something to stop the leakage."

Here's the interesting aspect of the case.  Unlike sponges and other operative supplies, "No verbal or written account was made of this action."  And then the non-hand-off occurred, "Subsequently, the scrub technician left the room prior to the end of the case in order to help with the next case."

"The procedure was uneventful and the patient was discharged the same day."  Except for one thing.  The bulb was left behind.  A few days later, the woman and husband came back, the object was found and removed, and after some ensuing complications, she was fine.

I first learned of this case from my colleague David Mayer here at Telluride.  He related other similar cases that he has heard about.  We discussed how a new set of operative procedures can create its own cottage industry of opportunities for patient harm.  How?  Well, it all goes back to the fact that clinicians and their assistants are extremely task-oriented as they take care of patients.  Here, the surgeon expressed concern about an inability to proceed with a case because of gas leakage.  The surgery technician, responding in the moment, cleverly created a solution that enabled the surgery to proceed.  S/he was then distracted by the next task and forgot that the solution had left behind a foreign object -- or maybe s/he figured the "next person" would remove the bulb.  The surgeon might not even know how the leakage was stopped.  Even if s/he knew, s/he would certainly not stop to ask if the the bulb had been counted, perhaps assuming that it would be counted in the same manner as sponges.  The absence of a standardized work protocol for this type of procedure and its contingencies was the systemic cause of harm to this patient -- and patients in other hospitals.

Further, if David is correct that this error has occurred elsewhere, we can note that there is no reflection of those cases in the literature.  Doctors and hospitals are very reluctant to publish papers indicating errors that they have made or that have occurred in their hospitals.  The inability of the profession to take note of this category of error is therefore inhibited, further increasing the likelihood that it will take place again.