Community Health Needs on WIHI

March 21, 2013: Community Health Needs Assessments —
New Rules and New Opportunities

(2:00 – 3:00 PM Eastern Time)

Featuring:
Sara Rosenbaum, JD, Harold and Jane Hirsh Professor, George Washington University, School of Public Health
Kevin Barnett, DrPH, MCP, Senior Investigator, Public Health Institute
Jean Nudelman, MPH, Director, Northern California Community Benefit Programs, Kaiser Permanente Northern California Regions

When a US hospital’s not-for-profit status is in the news, it’s usually not a good thing. It typically means someone (often a politician) is questioning whether the hospital’s federal tax exemption is deserved because of business practices, high executive pay, too little charity care, or a perceived lack of commitment to the local community. Sometimes the allegations and heightened scrutiny have been fair, sometimes not. Either way, America’s hospitals have a brand new challenge on their hands: to take newly revised IRS rules governing a hospital’s not-for-profit designation and turn them into meaningful plans to improve, in partnership with other organizations, a community’s overall health.

WIHI invites you to a timely discussion of Community Health Needs Assessments: New Rules and New Opportunities on Thursday, March 21. Three leading experts will help us understand the transformation of the decades-long “community benefit” law (largely focused on hospital support for indigent patients) into something more far reaching known as Community Health Needs Assessment, or CHNA. Section 9007 of the Affordable Care Act outlined the components of CHNA, chief among them a requirement for hospitals to conduct an evaluation every three years of the health status of the neighborhoods that surround their campuses, and then to use that information to develop strategies to reduce the community’s health risks. The new IRS rules also require greater transparency in the process and obligate hospitals to work in concert with community leaders and local public health experts.

The trio of Sara Rosenbaum, Kevin Barnett, and Jean Nudelman gathering for the March 21 WIHI exemplifies the ways in which policy and public health expertise, access to community health data, and the experience of health care providers can combine in powerful new ways to meet the demands of CHNA — and, more importantly, to meet the demands of better health and better health care at reduced costs (yes, the good old Triple Aim).

WIHI Host Madge Kaplan invites you to tune in for the March 21 show. And, if you have some questions you’d like to get into the queue for our guests ahead of time, we invite you to email those to us at info@ihi.org. Please put "Question for March 21 WIHI" in the subject line. Thanks!  

Please join us on the March 21 WIHI! Click here to enroll.

MA warns about robotic surgery

What does it mean when a state agency's Director of Quality and Patient Safety issues an advisory on robot-assisted surgery?  I think this is more bad news if you are the company that manufactures the robot.  Here's what Tracy Gay from the MA Bureau of Registration in Medicine said today in an advisory to all of the state's hospital CEOs, CMOs, and patient care coordinators:

The Quality and Patient Safety Division (QPSD) has issued a new advisory: “Advisory on Robot-Assisted Surgery.”  A link to the advisory is below.

Over the last two years, the QPSD has received an increasing number of Safety and Quality Review (SQR) reports of patient complications associated with robot-assisted surgery. This advisory is issued to draw providers’ attention to some of the potential issues involving robot-assisted surgery, to share some of the lessons learned by the reporting health care facilities, and to support health care facilities in the review and development of their systems for safe robotic-surgical practice.

http://www.mass.gov/eohhs/docs/borim/physicians/pca-notifications/robot-assisted-surgery.pdf

An excerpt, which precedes a number of case studies:

Robot-assisted surgery has increased dramatically since its introduction in the mid-2000s. A majority of radical prostatectomies and increasing percentages of other urologic, gynecologic and colorectal surgeries are now performed using robots. While there are numerous single institution, procedure-specific studies describing robotic-surgical outcomes, large-scale, high quality, prospective studies of the risks and benefits of robotic surgery as compared to laparoscopic and open procedures have not been carried out.

Robot-assisted surgeries have a number of technical advantages, such as an improved field of view and articulated instruments, but like any surgical procedure, they carry risks of complications and poor outcomes. Clinical studies and reviews of training guidelines discuss variable learning curves for surgeons, the need for significant mentoring, and greater risks associated with pursuing lengthier and more complex cases.

So simple!

Words of wisdom from MedStar's @Dmayer33 David Mayer as he addressed the Annual Recent Advances in Obstetrical Care conference in Baltimore, MD:

As you begin your educational meeting today, I want to leave you with one “take-home” suggestion – truly engage and partner with your patients. Many of us who work in quality and safety have learned so much from our patients and family members through the years. For me, one example of this valuable partnership is what I have learned through Carole Hemmelgarn, an amazing woman and patient advocate who taught me the following important communication skill.

When you enter a patient’s room, instead of standing at the foot or side of the bed (as I had done for so many years) pull up a chair, sit down and have a true conversation with them. Research has shown that patients perceive caregivers who did this to have spent twice as much time in the room with them, versus a comparison group of physicians, who actually spent the same amount of time with the patient, but stood at the foot of the bed while talking to them.

Barking up the wrong tree at United Medical Center

A few months ago, I mentioned that United Medical Center in Washington, DC. might be suffering from unintended consequences of Obamacare, a change in funding to safety net hospitals that removes some of their ability to carry out important functions.  I suggested, "Maybe UMC--an important component of the District of Columbia health system--can help send that message to Congress over the coming months.  On this matter, the Board and the medical staff should be united, along with other safety net hospitals throughout the country."

Instead, I see this report in the Washington Post:

In the fractious universe of D.C. politics, there is one thing upon which virtually every elected city official agrees: There must be a full-service hospital east of the Anacostia River. But nearly three years after the city seized control of United Medical Center, the fate of the 354-bed facility on Southern Avenue SE remains uncertain.

The ongoing saga of the hospital, formerly known as Greater Southeast Community Hospital, underscores the disconnect between city officials’ commitments to keeping the facility open and their general reticence to either commit to subsidizing its operations or significantly change how it operates.

The hospital has four days’ cash on hand. Significant bills to several creditors, including Pepco and medical suppliers, remain unpaid. “A huge part of management’s time is figuring out which vendors to pay each week,” he said. “It’s a real juggling act.”

The prospect that city taxpayers will have to pony up yearly to keep the hospital afloat has been the subject of repeated warnings from District Chief Financial Officer Natwar M. Gandhi, who has said that having a public hospital on the city’s books puts its bond ratings at risk. The warnings have struck a chord with several D.C. Council members, who raised concerns during a vote last month on a hospital consulting contract.

It is clear to me that this is not a problem that is solvable within the city's budget, and it really should not be.  In most states, safety net hospitals rely on broader jurisdictions with greater financial resources, i.e., states and the federal government.  Here, the "state" is the District of Columbia, which is a creature of the federal government.  It is severly limited in what it can do to raise funds, and it also is limited in professional capability to manage a medical property like this.  Congress, though, has impunity as long as it believes that the problems of UMC will be subject to debate and squabbling within the District's government.  The DC government and local consituencies will only solve UMC's problems when the federal government makes the proper commitment to providing the poor people in this part of the District with "a full-service hospital east of the Anacostia River."

"We see bandu as a living, learning buddy for your daily life"

An Approach to Product Design and Development in Patient-centric Health Care

MIT SDM Systems Thinking Webinar Series

Anand Yadav
Co-founder and product lead, Neumitra; SDM alumnus

Date: March 25, 2013
Time: Noon - 1 p.m. EDT
Free and open to all

Register

About the Presentation

In patient-centric health care, a product is expected to focus on the patient's interaction with it while it also delivers clinical value to the doctor. In order to fulfill its goals, the product must balance the appeal of a consumer product with the quality of a medical device. The challenge: a consumer product undergoes many iterations to deliver better user experience and aesthetics at an affordable cost while a medical device complies with strict regulatory requirements, undergoes fewer iterations, and costs more. This presentation describes a balanced approach developed during the design of bandu - a wearable biosensor and app for the mind.

About the Speaker

Anand Yadav is a product lead at Neumitra, which he co-founded in 2010. He previously worked at The Eli and Edythe L. Broad Institute of Harvard and MIT, where he led an engineering group that developed solutions for genome sequencing process improvement . Yadav was also member of a team that developed a large-scale automated system for the Human Genome Project at the Whitehead Institute. He holds an MS in Mechanical Engineering from Tufts University and a BE in Mechanical Engineering from Punjab Engineering College, India and an MS in engineering and management, earned as an SDM fellow at MIT.

Where things stand . . . and what comes next.

A recent article by Bob Wachter, Peter Pronovost and Paul Shekelle in the Annals of Internal Medicine gives a helpful update about the state of efforts to improve patient safety.  These are people who know of what they speak, as researchers, practitioners, teachers, and observers.  (I count them among my best teachers, by the way.)

Read the whole thing, but note this conclusion:

A decade ago, our early enthusiasm for patient safety was accompanied by a hope, and some magical thinking, that finding solutions to medical errors would be relatively straightforward. It was believed that by simply adopting some techniques drawn from aviation and other “safe industries,” building strong information technology systems, and improving safety culture, patients would immediately be safer in hospitals and clinics everywhere. We now appreciate the naivety of this point of view. Making patients safe requires ongoing efforts to improve practices, training, information technology, and culture. It requires that senior leaders supply resources and leadership while simultaneously promoting engagement and innovation by frontline clinicians. It will depend on a strong policy environment that creates appropriate incentives for safety while avoiding an overly rigid, prescriptive atmosphere that could sap providers' enthusiasm and creativity.

Well put, I think.  I'd like to go a step further, though, with an addendum that reflects my experience as CEO of a hospital.  An effective patient safety program requires that a hospital become a learning organization.  As the folks at Cincinnati Children's Hospital put it years ago, "We want to be the best at getting better."  A learning organization is one in which all members of the staff, not just frontline clinicians, participate in process improvement.  In our hospital, we often found that it was the housekeepers, food service workers, security guards, supply folks, and transporters who noticed and called out important problems in the delivery of care.  Bob and Peter and Paul didn't mention these non-clinicians in their summary.  I don't think they would disagree with me, though, and I respectfully offer this addendum with the hope that all of us remember to explicitly include them as we think about what should come next.

A mother's request

Marilyn Kass recently posted this note about her 13-year-old daughter in a column entitled "Open letter to my daughter's teachers."  As "Momo," Marilyn has inspired many of us over the past several years.  If you get a chance, read through previous posts on her blog.

I wanted to inform you of recent developments at home that have the potential to impact Frannie at school. Though solid, centered and never more enthusiastic about learning, challenging health issues at home may impact Frannie in school and elsewhere . The breast cancer that progressed to my bones a few years ago has metastasized to my brain. Believe it or not, I am optimistic, even good humored. However, the world, and school is filled with misinformation, touchy subjects and a couple of jerks.

A class about mitosis dove deep into the obstacles associated with curing cancer, vs dying of cancer, vs battling a variety of treatments; from chemotherapy to radiation. Frannie came home with a slew of great questions, and while some kids hear “cancer” and think pink ribbon covered bicycle races, or imminent death, Frannie knows that cancer is what we live with.

Going forward, I ask that you be aware of the complex world she navigates. She is interested, inquisitive and the best thing you can do for her now is to engage her, listen to her and keep filling her brain with the learning she loves. Thanks to her I know about tectonic plates, ancient poems, nutrition and the power of point of view and that’s just from this week.

You probably detected that Frannie is a very private person, so while she knows I am sharing this information about our family with each of you, she would not be comfortable with your sharing it with the entire class.  Unless, you specifically discussed it with her in advance and agreed on the terms and details.

You can always call me to discuss any questions or concerns you may have. No surprise, there is no one, and nothing I am more interested in discussing than my daughter and her well being.

With gratitude and respect,
xoxomomo

Danny Sands states the problem

My friend and colleague Danny Sands (seen here with e-Patient Dave) posted this remark on Facebook:

The good news: I provided superb and compassionate care to the patients, many of whom were quite complex, who I saw today.

The bad news: I ran behind and one of my scheduled patients left without being seen. 

Primary care is tough. I can either do a great job or run on time, but can't do both. Maybe I could do it if I didn't take care of sick patients, but those are the patients who really need care.

Ok, so how to deal with this? One theory--the current one traveling around the country--is that hospitals and doctors should be paid by a capitated or global payment.  This theory is based on the idea that such a payment mechanism will result in better coordinated care, with the primary care doctor empowered to act as the patient's traffic cop vis-a-vis the interaction with other participants in the continuum of care.  If and when the accountable care organization beats the capitated budget, the surplus will be recycled back to the PCPs and others who made it possible.  But I have explained before why this incentive mechanism is not likely to work.  Certainly, it does not provide a precise enough signal to PCPs that it would cause them to add the kind of time Danny seeks to take care of patients.

There is a much simpler solution:  Pay the PCPs more.  Make it possible for them to have smaller panels of patients so they can spend the time they need to.  Recognize that the value of their cognitive skills is equivalent to, if not exceeding, the skills of proceduralists who now get paid so much more.  My theory--which has at least as much empirical support as the capitated ACO theory--is that society will save the extra dollars spent on PCPs in reduced hospitalizations and procedures.

Viral taxi service to test local political leadership

Scott Kirsner @Scott Kirsner reports on the expansion of SideCar to the Boston, Chicago, and Brooklyn markets. He quotes a company press release:

SideCar works like a matchmaker for the perfect ride, using smartphones to connect people who need to be picked up with everyday drivers nearby. It’s a fast, affordable and safe way to get around town, meet new people and help keep more cars off the road. With SideCar, payment is voluntary and made directly through the mobile app. All drivers are pre-vetted for safety and are free to give rides whenever they want. SideCar’s safety system includes driver background checks, driver and rider rating systems, GPS tracking features and the ability to share details of your trip in real-time. 

Watch the local cab companies howl and use regulation to slow this down!  As Scott says, "Let the lawsuits begin." Will the Mayor of Boston support the incumbents or the expansion of "the innovation economy?"  I'm putting my money on protectionism, as has been his tendency in the past when there have been disruptive approaches to commerce.  It will be interesting to watch and see if there is a difference between him and Mayors Bloomburg and Emanuel on this one.

Going batty over organ risk assessment

Here's a case that will have the risk management folks debating for a while.  A man in Maryland recently died from rabies.  It turns out that the cause may have been rabies from the donor of his new kidney.  Lots of screening is done before kidneys are transplanted, but not for this disease.  Should there be, or is it just too rare?  Here are some excerpt from the Washington Post story:

A Maryland man who two weeks ago became the state’s first fatal case of rabies in nearly 40 years contracted the infection from a kidney transplant, according to two people familiar with the case.

The Centers for Disease Control and Prevention compared rabies virus obtained from the recipient and determined that it was genetically identical to the virus recovered from the organ’s donor, said the two people involved in the case.  

In general, fewer than five cases of rabies are diagnosed each year in the United States. Most often the virus is acquired by contact with a bat. Bites from infected raccoons and dogs, or contact with their saliva, account for most of the rest.   

Transmission of rabies through organ or tissue transplant is extremely rare. Four people in Texas died in 2004 from rabies contracted from a single donor’s tissue. There have been at least eight cases around the world contracted through cornea transplants.

Potential organ donors are screened for a standard battery of infectious diseases before their organs are offered. Rabies is not one of them, however.

“You balance the probability of infectious complications with the cost of not undergoing the transplant,” said Dorry Segev, a transplant surgeon and epidemiologist at Johns Hopkins University who had no involvement in the case. “The risk of death on dialysis is anywhere between 5 to 15 percent per year, and sometimes higher.”

Segev said that transplanting an organ from someone who died of an infection whose cause was not known would be “incredibly rare” but that it occasionally happens.

I wonder if it would be practical to conduct rabies tests on organ donors.  Look at what the CDC says:

Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single test is sufficient. Tests are performed on samples of saliva, serum, spinal fluid, and skin biopsies of hair follicles at the nape of the neck. Saliva can be tested by virus isolation or reverse transcription followed by polymerase chain reaction (RT-PCR). Serum and spinal fluid are tested for antibodies to rabies virus. Skin biopsy specimens are examined for rabies antigen in the cutaneous nerves at the base of hair follicles.

Fool me once, shame on you; fool me twice, shame on me

The people at Intuitive Surgical, the folks who made a fortune by marketing robotic prostate surgery to men across America, can't be having much fun right now.  They have been hoping to expand their business in obstetrics and gynecology.  But look at these comments by James T. Breeden, president of ACOG:

Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and a faster return to full recovery compared with the traditional total abdominal hysterectomy (TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization and a far shorter recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. 

At a price of more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2,000 per surgery for the cost of single-use instruments, robotic surgery is the most expensive approach. A recent Journal of the American Medical Association study found that the percentage of hysterectomies performed robotically has jumped from less than 0.5% to nearly 10% over the past three years. A study of over 264,000 hysterectomy patients in 441 hospitals also found that robotics added an average of $2,000 per procedure without any demonstrable benefit.  

[A]n estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.

Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.

The stock market seems to be noticing:

On empathy

e-Patient Dave posts a copy of a new video from Cleveland Clinic. See it there, or here. It is lovely, as is the quote from Thoreau:

“Could a greater miracle take place than for us to look through each other’s eyes for an instant?”

Scoping out colonoscopies

Cheryl Clark @CherClarHealth at HealthLeaders Media posts this thought on Facebook:

I know, the drugs are really really nice. But if you're over 69, beware the colonoscopy without indication. USPSTF says don't get 'em unless you've got a symptom. Maybe there should be a hard stop policy? Colonoscopies can cause harm (perforations, bleeding, false positives, etc.) They also waste resources. In a hospital, they can cost $3,000. in an outpatient setting, $600 or so depending on the region.

Check out this article by Cheryl.  An excerpt:

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these "potentially or probably inappropriate" procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

"We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines," says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

She follows up with this guide from Choosing Wisely.  Excerpts:

Colonoscopy is the most accurate test for cancer of the colon and rectum, proven to detect the disease early and save lives. But even a very good test can be done too often. Here’s when you need it, and when you might not.

Colonoscopy is a safe procedure. But occasionally it can cause heavy bleeding, tears in the colon, inflammation or infection of pouches in the colon known as diverticulitis, severe abdominal pain, and problems in people with heart or blood vessel disease. Some complications can lead to blood transfusions, surgery, hospitalization, or rarely, death. The test also has inconveniences. You have to restrict your diet and take laxatives beforehand. And because the exam requires sedation, someone has to drive you home and you may miss a day of work. So you don’t want to have the test more often than necessary.

Colon cancer screening should begin at age 50 for most people. If a colonoscopy doesn’t find adenomas or cancer and you don’t have risk factors, the next test should be in ten years. If one or two small, low-risk adenomas are removed, the exam should be repeated in five to ten years. Ask your doctor when and how often to have a colonoscopy if you have inflammatory bowel disease; a history of multiple, large, or high-risk adenomas; or a parent, sibling, or child who had colorectal cancer or adenomas. Routine checks usually aren’t needed after age 75.

Master Chef on the Jubilee Project

@jubileeproject reports on this video with @MC3Christine:

Based on a true story, this film is about pursuing your dreams no matter the odds.

In 2003, Christine Ha was diagnosed with a disease that caused her blindness. She didn't think that she could move on, and felt devastated and alone. But through her love for cooking and the people around her, she started to see her purpose in life. By picking herself up, Christine became the first blind contestant on the hit reality TV show, MasterChef.

What is your dream? Let us know by tweeting us and we will choose 5 winners who will receive Christine's cookbook, autographed and shipped to you, when it comes out in May. To be eligible, include the following in your tweet: @MC3Christine @jubileeproject #mcfilm http://bit.ly/mcfilm

Here's the video:

 

UK and US hospital governance, post-Francis edition

Dave West @Davidwwest at the Health Services Journal @HSJNews posts a pictogram showing the result of a survey among chairs of the hospital trust organizations in the National Health Service in the UK.  It was taken after issuance of the Francis Report, a review of the awful things that happened at Staffordshire Hospital.

I am breathless as I scan these results.  Why?  Because I know that if US hospital boards were surveyed on these same questions, the answers would be similar.  See my post below about mergers.  Our boards are so intent on so-called strategic moves that they fail to demand accountability and practice transparency with regard to clinical outcomes and other operational issues.

This is a moral failure of leadership.  Paul Wiles, former CEO of Novant, once said, with regard to quality and safety issues:

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.

He said it with regard to CEO leaders, but it applies equally to hospital board members.

Donut heads invade Rhode island!

Thanks to Nancy Thomas for posting this page from the Providence Journal on Facebook.  She explains the back story:

I've been engrossed with a client, Joy Feldman, who is a nutritional consultant and an author.  This week, 75,000 children in RI at over 215 schools and youth programs will hear simultaneous readings of her children's book, "Is Your Hair Made Of Donuts?".

This book's message is "you are what you eat" and seeks to empower our littlest ones to make healthier choices about their food.  Amazingly, if you catch them young they slurp up carrot juice (which Joy does onsite) and really get it!

Joy has done this by single handedly recruiting schools, going through no "systems" to do so - what has happened is extraordinary by any measure....much less a PR one!

75,000 kids.  215+ schools & programs.  8 Mayors wearing a 2 foot tall donut hat reading in their cities/towns.  The Governor reading (though not until the 20th).  The head of the Board of Education reading.  The Director of the RI Department of Health reading.  4 TV news anchors from 2 different stations reading.  The head of Capitol TV (state house) reading.  We have two Fitness/Personal trainers reading.  We even have 2 RI Beauty Queens! 

9 Corporate Sponsors buying books for schools and libraries, healthy snacks, and providing readers. From Blue Cross to United Health to Whole Foods to Sodexo!

And - on Tuesday at the rise of the house and senate Joy will be presented by a legislator wearing her hat while he reads a proclamation and the cities/towns which participated are read off.

I just thought you would appreciate hearing about this as this one woman is on a quest to improve children's nutrition.  Shows what you can do when you step out of the box of the systems.

Her websites are:  www.joyfeldman.com and www.isyourhairmadeofdonuts.com.

Mind the Gap -- This time, the real one!

More pertinent, perhaps, and definitely more heartwarming, than my post below.  Reprinted from The Time Out London Blog:

It might be freezing outside but our hearts are warm thanks to the story of the ‘Mind the Gap’ announcer’s widow.

Oswald Lawrence, the man behind the tannoy, recorded the iconic announcement over 40 years ago, however in recent years, Lawrence’s seminal recording has been replaced by updated versions in all stations but one (the Northern Line platforms at Embankment station). Since his death 12 years ago, his widow Dr Margaret McCollum took comfort in hearing his voice on that platform until late last year when his final announcement was replaced. Understandably upset, she wrote a letter to TfL explaining her distress. To her (and our) delight, not only are they reinstating his announcement, they sent Dr McCollum a recorded CD of her husband’s voice so she can listen to him whenever she wants. Awwwwwwww.

This phrase is one of the most imitated by tourists and, well, everyone. Can the original please be reinstated at all stations? We promise we will really mind the gap if Oswald Lawrence tells us to. Jude Brosnan

Merger fever today. Fever tomorrow.

Here we go again.  The cyclic fads of health care are leading hospital boards and CEOs back into the merger game.  Stand-alone institutions are being acquired or are acquiring.  Single hospitals are becoming systems.  This is all driven by a belief that the payment system will change in a manner that will reward the ability of providers to manage the continuum of care, with a form of payment in which the risks of meeting some form of capitated annual budget will fall away from insurers and more to providers.

It is time for prudent people to ask whether mergers are the best way to set up health care systems that manage care under a capitated budget.  You've heard the arguments for this, of course.  Let me be the devil's advocate and offer some contrary views.  I'm going to put them in extreme form to make the points. If you like, you can tone them down a bit, but the underlying issues still arise.

1)  The people who run hospitals do not have the competence to run health care systems.  There is little in the training of people who have become CEOs of single hospitals to run groups of hospitals and associated physician practices.  By the time they (or their boards) figure out what they don't know, they have wasted millions and reduced the overall effectiveness of the component organizations within the system.

2)  There is no such thing as a merger. Every merger is a take-over of one institution by another.  "Cost savings" from this chimera are chimeras.*  A merger inevitably makes evident cultural differences and produces jealousies and alienation.  The business benefits that are supposed to emerge are often lost in the crush of overly aggressive and overly passive aggressive participants. McKinsey reports: "Anyone who has researched merger success rates knows that roughly 70 percent of mergers fail."  And they weren't just talking about hospitals!

3)  A merger offers little that cannot be accomplished by a strategic alliance between the parties.  In an alliance, you can still have the benefits of coordinated care and payment risk sharing.  You avoid, though, the cultural problems noted in number 2, above.  Indeed, you might be more successful achieving your common goals because each of your own constituencies feels a loyal commitment to success.

--
*  I've been wanting to use that word twice in a single sentence for years!  A chimera is an organism, organ, or part consisting of two or more tissues of different genetic composition, produced as a result of organ transplant, grafting, or genetic engineering.  It  is also a fanciful mental illusion or fabrication.

But who falls into the gap?

Here's a story that writes itself.  I include the abstract from BMJ Quality and Safety:

The patient satisfaction chasm: the gap between hospital management and frontline clinicians

Abstract 

Background Achieving high levels of patient satisfaction requires hospital management to be proactive in patient-centred care improvement initiatives and to engage frontline clinicians in this process. 

Method We developed a survey to assess the attitudes of clinicians towards hospital management activities with respect to improving patient satisfaction and surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. 

Results We collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries on three continents. Overall, 90.4% of clinicians believed that improving patient satisfaction during hospitalisation was achievable, but only 9.2% of clinicians thought their department had a structured plan to do so, with significant differences between the countries (p<0.0001). Among responders, only 38% remembered targeted actions to improve patient satisfaction and just 34% stated having received feedback from hospital management regarding patient satisfaction status in their department during the past year. In multivariate analyses, clinicians who received feedback from hospital management and remembered targeted actions to improve patient satisfaction were more likely to state that their department had a structured plan to improve patient satisfaction. 

Conclusions This portrait of clinicians’ attitudes highlights a chasm between hospital management and frontline clinicians with respect to improving patient satisfaction. It appears that while hospital management asserts that patient-centred care is important and invests in patient satisfaction and patient experience surveys, our findings suggest that the majority do not have a structured plan for promoting improvement of patient satisfaction and engaging clinicians in the process.

Well Mercy me! It's a podcast.

When I was CEO, a hobby of mine was trying out new forms of social media to communicate across the hospital's population.  My friends at Children's Mercy Hospital, who are engaged in an extensive and intensive transformation of their institution, understand that effective communication is a necessity.  They also get the idea that different folks get their information in different ways.  Some like email, some like blogs, and so on.  Your job as a leadership team is to employ a wide variety of modes so that folks can use the ones they like best.

So, I was interested to see the Kansas City hospital team start up a new podcast.  It will be posted weekly and is short and focused.  An excellent tool.

It was inaugurated by this email message:

As part of the new Children's Mercy Employee Discovery Series, Dr. Jason Newland is hosting a weekly 10-minute podcast for employees. His guests will include medical staff members and administrative leaders on important issues impacting the hospital. 

The first podcast, featuring Jason and Karen Cox, RN, PhD, is available by clicking here.

(http://www.childrensmercy.org/employeediscovery/)

Karen joins Jason to talk about how our staff responded to the recent snow storms. What worked? What could we do better next time? (Time: 10 minutes)

You can listen to the podcast directly from your computer or download it to your phone, tablet or iPad.

Got a question or a topic you’d like to hear about? Just email Jason.

Find a way to help Found in Translation

Last fall, I wrote about Found in Translation, an organization with a terrific dual purpose: "To help homeless and low-income multilingual women to achieve economic security through the use of their language skills; and to reduce ethnic, racial, and linguistic disparities in health care by unleashing bilingual talent into the workforce".  Now, CEO and founder Maria Vertkin sends an update of their activities and asks for some help:

I am happy to say that 12 of the 19 women who graduated from our pilot program in April 2012 have since found employment (6 of them as medical interpreters or in a similar position), compared with only 2 employed at the start of the program.  While this is great, we are hard at work to get closer to 100% of our grads getting employed within one year of graduation.  Cambridge Health Alliance has agreed to take in our graduated into their medical interpreting internship program, with the possibility of hiring them thereafter.  We've also recently entered into a partnership with a free clinic run by Tufts medical students, where 3 of our graduates are now employed part-time as medical interpreters. This clinic serves some of Boston's most vulnerable patients who have never able had professional interpreting before.  And, of course, we are thrilled to be building a direct pipeline from our program to jobs. Our second class will graduate this month, and two have already received job offers pending graduation.

When people hear about our successes, they are usually surprised to hear that we are, in a way, homeless.  We've accomplished all this working out of borrowed rooms and Paneras.  But the need for our program is overwhelming.  We received almost 200 applications for 30 spaces in our second training, and have gotten over a dozen requests to bring our program to other communities both locally and as far away as Kenya.  We are poised for growth, and our next step will be getting an office/classroom space of our own.  We've launched a campaign on IndieGoGo to accomplish this.  Here's the link.

Found in Translation is a cause that -- pun intended -- speaks to those in the multilingual professions. But we are a young start-up with a small audience, and that is why I want to ask for your help in reaching potential supporters.  To reach our goal, we need as many people as possible to visit our campaign page, watch our video, donate (in any amount -- there are perks at every level!), comment, and share the link on their social media.

Jha-ring conclusion: Use evidence!

@ashishkjha Ashish Jha is easy to distinguish from many health care policy people in that he is "an advocate for the notion that an ounce of data is worth a thousand pounds of opinion."  Unlike yours truly, he also has access to tons of data, so when he speaks, it is worth listening.

In a recent post on The Health Care Blog, Jha draws the following conclusion:

The debate around the readmissions measure has come to the forefront because of the CMS Hospital Readmission Reduction Program, which penalizes hospitals for “greater than expected” readmission rates. It has raised the question — does a hospital’s 30-day readmission rate measure the “quality of care” it provides? Over the last three years, the evidence has come in, and to my read, it is unequivocal. By most standards, the readmissions metric fails as a quality measure.

[I]f one measure of quality is external validity – being at least somewhat correlated with the gold standard (mortality rates) — how does the readmission measure do? In a paper published recently in JAMA, we see that readmission rates don’t do so well at all. Readmission rates are un-correlated with mortality rates. In fact, for one of the three conditions, the readmission rate seems to go the wrong way: the best hospitals for heart failure (i.e. those with the lowest mortality rates) have readmission rates that are actually higher. Not perfect. Readmissions seem to have little external validity as a quality measure. Readmissions are, however, correlated with two things: how sick your patients are, and how poor your patients are. We now have good data that the Hospital Readmission Reduction Program disproportionately penalizes big academic teaching hospitals (that care for the sickest patients) and safety-net hospitals (that care for the poorest).

But does the program help at all?  Here's where Ashish goes anecdotal on us (but at least he admits it!):

So, given its poor test characteristics, can we justify using the current hospital readmissions measure to grade hospitals on quality? I don’t think we can. However, here’s where my own ideas have evolved. ... [T]he 30-day readmission measure may be a good way to promote accountability in healthcare.

In conversations with colleagues and friends, the readmissions penalty program seems to have gotten some hospitals to think outside of their four walls. Hospital leadership has started to rethink the role of the hospital. Hospitals are building relationships with community-based organizations. Some are creating follow-up clinics while others are calling all the patients who are discharged to make sure they are doing OK at home.

And the personalized summary:

The readmissions program seems to be, for some hospitals, having a positive effect. Will it pay off? Will we see a real, sustained change in the way they provide care to patients after they are discharged? I hope so. But remember – some of the best hospitals in America have the highest readmission rates, almost surely because they care for sicker, poorer patients. In the current business model, they are doing things right – taking good care of the patient while the patient is in the hospital. It’s fine to ask these hospitals to change their business model and to become accountable for what happens to their patients after they are discharged. But, let’s not call them bad hospitals or suggest that they are providing poor quality care. There is no evidence that they are.

How refreshing to hear from an honest analyst, someone who distinguishes between conclusions based on evidence, hypotheses based on anecdotes, and hopes based on societal ethical standards!  The only thing missing from this article, in my view, is the "so what?" question.  What should we actually do?

I think the answer comes from transparency.  Just post, for the world to see, the readmission rates of all hospitals by clinical specialty and let admininstrators and doctors compare their performance to others.  Even without financial penalties, the inherent competitiveness of people in this field will cause them to evaluate their work and try to do better, consistent with underlying standards of quality.  Is CMS wants to provide a financial incentive, give a small bonus to hospitals that voluntarily post such results for each attending physician in real time, not months later.  Then, you'll see changes in practice patterns!

But this approach is not likely to be considered, much less adopted.  Federal and state policy is designed by other people.  Look at this comment by another health care policy person:

Stuart Altman, a professor of national health policy at Brandeis University [and chair of the Massachusetts Health Policy Commission Board], said he gets questions from hospital chief executives and chief financial officers asking "why are we getting penalized when we take care of the patient?"

"I tell them, 'you are big, rich and powerful, and you have the ability to resolve the problem and you will be part of the solution whether you like it or not.' "

"There are appropriate readmissions, such as related to different ailments or an unforeseen health event unrelated to the first admission," Altman said. "Hospitals are not penalized in those situations.

"However, there also are non-appropriate readmissions that can be benchmarked and compared with peers and the community."

Dirty hands and clean hands on WIHI

March 7, 2013: No Excuses, No Slack!
The Latest from the Front Lines on Hand Hygiene

(2:00 – 3:00 PM Eastern Time)

Featuring:
Gene H. Burke, MD, Vice President and Executive Medical Director for Clinical Effectiveness, Sentara Healthcare
Michael Howell, MD, Director of Healthcare Delivery Science, Director of Critical Care Quality, Beth Israel Deaconess Medical Center
Lisa L. Maragakis, MD, MPH, FSHEA, Director of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital
Scott A. Miller, MD, FACP, Vice President, Medical Affairs, Sentara Leigh Hospital
Tom Talbot, MD, MPH, Chief Hospital Epidemiologist, Vanderbilt University Medical Center

One of the cornerstones of infection prevention in any health care setting, including when someone is being cared for at home, is good hand hygiene. Much of the attention in recent years has focused on hospitals and their rates of hand hygiene compliance among staff. And rightly so. Among the biggest contributors to hospital-acquired infections are, inadvertently, health professionals themselves... and others who come in contact with patients.

The good news, as you’ll be reminded on the March 7 WIHI, entitled No Excuses, No Slack! The Latest from the Front Lines on Hand Hygiene, is that awareness of the necessity of strict hand hygiene compliance has never been greater… not just in the US, but in acute care settings globally. And this awareness has been coupled with practices that are being adhered to more reliably than ever before. But not everywhere, all the time; organizations that can tout rates as high as 95% are still the exception, not the rule, and good performers continue to face challenges closing the gap.

For the March 7 WIHI, host Madge Kaplan has rounded up infection prevention leaders and clinicians from four organizations whose recent innovations with hand hygiene at their facilities represent what could be the best bet yet that 100% compliance is achievable. Sentara, Johns Hopkins, Vanderbilt, and Beth Israel Deaconess Medical Center all have fresh approaches that rely on new kinds of auditing tools to discern what really works; better surveillance, monitoring, and measuring; reengineering; constant education; and a laser-like focus on behavior and culture change. 

What’s working in your organization? How are you getting your hand hygiene compliance rates to move upward? Compare and contrast your methods with those of our guests.

Please join us on the March 7 WIHI! Click here to enroll.

Tchaikovsky arrives at Haddasah

"Forty students from the Jerusalem Academy of Music and Dance took a classical approach to the flashmob as they flashwaltzed Tchaikovsky's Waltz of the Flowers at the new Sarah Wetsman Davidson Hospital Tower in Jerusalem. Doctors, patients and passers-by joined in the fun.

"The surprise concert was part of Good Deeds Day, an annual event that originated in Israel in 2007 and now takes place in over 50 countries worldwide. On this day volunteers reach out to the less fortunate and the vulnerable.

"The Academy students enjoyed the day so much that they have decided to schedule regular concerts at the hospital. Hadassah Medical Organization treats over one million patients annually, without regard to race, religion or national origin."

If you can't see the video, click here.

 

The prisoner's dilemma in ACOs

Now comes the Society for General Internal Medicine, jumping on the global payment bandwagon. John Commins at HealthLeaders Media reports that the SGIM has concluded, "Fee-for-service medicine is a financially unsustainable payment model that should be phased out by the end of the decade."

What is this really about? SGIM has finally concluded that the existing rate structure, which favors proceduralists over cognitive specialists, will never be changed under the fee-for-service rubric.  But, if we adopt capititation, will the reallocation will somehow mysteriously occur?  Not likely. 

There remains remarkably little discussion about how capitated, or global, budgets should be allocated among the various types of doctors and facilities engaged in providing care.  As Bruce Landon noted last year, this is a key issue:

The fundamental questions become how ACOs will choose to divide their global budgets and how their physicians and other service providers will be reimbursed. Thus, this system for determining who has earned what portion of payments — keeping score — is likely to be crucially important to the success of these new models of care.

Under ACOs and many commercial global payment products, providers will continue to receive traditional fee-for-service payments, and hospitals will receive their usual contracted payments, through either the diagnosis-related-group (DRG) system or per diem payments. All spending for each patient that is attributed to the ACO will then be tracked and compared with the calculated budget retrospectively at the end of the performance year in order to calculate savings or losses. Thus, standard fee-for-service payments remain the de facto method for keeping score.

Let's go further, though, and posit a potential adverse impact of global payments that has not been discussed to date.  It derives from a phenomenon known as the prisoner's dilemma,which "shows why two individuals might not cooperate, even if it appears that it is in their best interests to do so."

Let's say that you are a surgeon in an ACO being paid per procedure.  You have been advised that, if there is a surplus for the ACO at the end of the year, you will get a small percentage of that.  You do a calculation of the likelihood of a surplus occurring and of your likely share.  You conclude that doing one or two more surgeries per month will give you more income that your likely share of the surplus.  You also figure out that the same will be true for your colleagues.  How do you act?  If you are economically rational, you do the extra procedures.  Ironically, if all the proceduralists do the same, the ACO might run a deficit rather than a surplus and might cause a clawback of all physicians' payments--including those internal medicine doctors represented by SGIM who so strongly advocated for global payments.

This quality stuff isn't easy

Jim Conway, from whom I have learned more than just about anybody, has done it again in a blog post entitled "Leadership and Pre-occupation with Failure" on the site run by the Paediatric International Patient Safety and Quality Community.

A short version might be, "Just when you think you are making progress, you don't understand how you are undercutting your own efforts.  Keep trying and learning.  This quality stuff isn't easy."

Read it and let Jim know what you think. Excerpts:

The CMO of a rural community healthcare system was pleased after kicking off a patient safety meeting with more than 100 front-line clinical, administrative and support staff.  The organization had shown a dramatic decline in serious adverse events and now the numbers for most months were very small.  The chart showing the downward trend was striking.  He was therefore stunned with the first comment from staff: “If that’s what you think then it is clear you don’t have any idea of what goes on in my unit every day.”
 
This story is real.  It occurred in an excellent organization, and I was there as it unfolded.  The organization’s leaders knew that if you try to do everything, you will accomplish nothing, so they set strategic quality and safety targets and the organization was on an active journey forward.  However, they became too focused on these few events, forgetting that their targets were a small piece of the universe of harm and failure, maybe just 5% of it.  No mention was made at the meeting of the larger context of failure.  No mention was made as to how this data linked to all the incident reports that get filed every day.  For the front-line staff, what leadership was saying bore no resemblance to the failure they, patients and family members deal with every day.

On one occasion during my own career, a physician leader was presenting some strong work from a team on a new clinical information system.  At the end of the presentation I congratulated the team and asked “What new categories of error are we implementing with this system?”  With a very frustrated and abrupt tone the leader replied, “Aren’t you ever satisfied?”  I thought and then said “No, I can’t be.” 

Every time you change a system, what is your approach to critical risk assessment, to failure detection?

As a young leader I loved being a firefighter, coming in on a great big problem, and leading the team that fixed it. Then a colleague suggested that maybe those problems shouldn’t have risen to that stage if I and we had been doing a better job in the first place.  If a strong system had been built, and we were listening to the signals suggesting problems, we could have fixed them earlier.  Many clinical colleagues say they’ve seen a similar scenario, often at morbidity and mortality conferences.  The focus is on the save and not on the fact that the harm shouldn’t have happened in the first place.

Organizations and their leaders must develop this pre-occupation with failure and then do something with the data.  

Dr. Seuss has taught us “the more that your learn, the more places you will go.” John Kelsch of Xerox noted “To do things differently, we must see things differently.  When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before.”  Each of us has seen and been part of exceptional care and caring.  A pre-occupation with failure will help us move closer to that being the experience of EVERY patient, family member, and staff member, EVERY time.     

I'm only thinking of him

In the musical Man of La Mancha, the hero's niece Antonia piously, but insincerely, sings the song "I'm only thinking of him."

I'm only thinking of him,
I'm only thinking of him,
Whatever I may do or say;
I'm only thinking of him!
In my body; it's well known,
There is not one selfish bone...
I'm only thinking end worrying about him!

A reprise is being sung in Albuquerque, New Mexico.  For years, the University of New Mexico Hospital has served as the safety net hospital for the region's poor and uninsured, supported in part by $90 million per year from a dedicated tax levy.  Now comes the Lovelace Health System, owned by Tennessee's Ardent Health Services, offering to share beds with UNMH as an alternative to UNMH building a new $146 million hospital.

I am moved by the generosity of this for-profit chain.  I'm sure they are only thinking of the needs of the public and the burden facing UNMH.

Oh wait, a story in Albuquerque Business First eventually mentions something of interest:

[Lovelace CEO Ron] Stern’s letter also said the Lovelace Medical Center in the Downtown area has an occupancy rate of 61 percent and could easily take overflow patients from UNMH.

Oh, 61 percent.

By the way, was Lovelace proposing to take all kinds of patients, or only ones with insurance?

Let's turn back to the song.  (Click here if you can't see the video).

Residency work hours revisited

What do residency program directors and residents think about the restricted work hours that were put into effect in 2011?  They don't like them.  Should we care what they think?

The New England Journal of Medicine reports on a survey of residency program directors.  Main conclusions:

Program directors reported that many aspects of training and patient care have been unchanged by the 2011 regulations, including resident supervision (62.0%), patient safety (57.0%), balance of service and education (60.9%), scores on in-service exams (73.6%), and fatigue (54.4%). Perceived quality of life for residents was the sole area identified by a plurality of respondents (49.5%) as having improved. Meanwhile, a negative effect was reported for resident education (64.8%), preparedness for senior roles (73.2%), and “ownership” of patients (78.6%); respondents also noted diminished continuity of care (82.0%) and increased frequency of handoffs (88.0%). Most program directors reported an increase in their own workload (73.8%), as well as increased utilization of physician extenders, such as nurse practitioners and physician assistants (61.4%). Finally, less than half the program directors (42.7%) reported that their residents are “always” compliant with duty-hour regulations.

In a previous survey of residents themselves, notes Kaiser Health News,

The residents themselves also [had] negative views of the changes.  A similar survey of 6,201 residents published in NEJM in June found that while 62 percent felt that quality of life had improved for interns, half reported that quality of life had gotten worse for senior residents, who were picking up the slack. Meanwhile, 41 percent reported that the quality of their education had gotten worse, and 48 percent disapproved of the rule changes.

What are we to make of this?  One observer on the National Patient Safety Foundation listserv said:

I was dismayed by this when I saw it. Then I remembered that this was an opinion survey. It is interesting, though, that residents and interns have so little regard for (and insight into) their own human limitations due to fatigue. They have already been socialized into the wonderful world of medicine, where everyone thinks she or he is superman, able to leap tall shifts in a single bound. Of course, nurses feel that way too. Most would rather work fewer longer shifts rather than more shorter shifts, even when confronted with evidence that the latter is safer.

Before we reach conclusions, it might be good to look at the science.  I recall a talk years ago by Charles Czeisler, the chief of the division of sleep medicine at Brigham and Women's Hospital.  He certainly made the point that an extended periods without sleep are dangerous (for patients, the residents themselves, and traffic accident victims as residents drove home).  But here's the thing:  I may remember this wrong, but I thought part of conclusion was that the pattern of sleep-and-awake mattered a lot--in terms of attentiveness--not so much the total number of hours of sleep that one got during a week.  If so, the prohibitions set forth by the ACGME may be mis-designed.

But, there is one thing for sure, as noted by the observer above:  Residents will never believe that any set of rules is good for them or their patients.  They are tricked by their own cognitive errors and imbued with a deep cultural prejudice into believing that they can "handle" anything that comes before them. In that regard, the medical education system has failed them.

A tale of two Blues

An MIT professor colleague, an expert in computers, writes:

The last couple of months have been very heavy duty bad medical stuff for me.  Horrendous. So, I've been able to see the dysfunctional medical insurance system in action.   Do you understand how Blue Cross/Blue Shield actually works?  Out of, oh, maybe 80 transactions over 2 months -- they managed to get one, as in the number 1, correct.  The rest are mistakes, mis-billings, computer errors, everything one can imagine.  And the only reason I can ever figure it out is because I am dogged and know something.  I can't even begin to imagine the bone-head database that lurks behind all of it, along with inept programming, but whatever it is, the people running the place (sorry if I tread on toes) -- up to and including all the executives, are simply, sorry to say, totally bonkers.  And they are just middlemen. They aren't providing services, just managing to extract rents. Badly.

P.S. BTW, my running statistics on them, is that out of 540 transactions with them over the past 1.8 years, they have gotten two, as in the number 2, correct.   Not a good batting average. Why are they so inept?

Let's see if we can correlate this description with this recent earnings report in the Boston Globe:

The state’s largest health insurer boosted its earnings in 2012, while three other Massachusetts health plans reported net income declines from the previous year as they absorbed a new state assessment to fund initiatives under a cost containment law.

Blue Cross Blue Shield of Massachusetts recorded net income of $163.9 million for the 12 months ending Dec. 31, a gain of 20.4 percent from the $136.1 million it earned in 2011. The better showing was powered by a sharp increase in fourth-quarter earnings and higher operating income in 2012, offsetting a modest drop in investment income for the year and a $65 million accounting charge taken to cover the cost of the new state assessment.

After a $149 million net loss in 2009, financial results at Boston-based Blue Cross have climbed steadily over the past three years as the insurer has focused on strengthening its business and introducing products aimed at slowing the growth in premiums.

“We’ve made a concerted effort to grab hold of our company and get costs in line with revenues,” Blue Cross chief financial officer Allen Maltz said.

Help break open The Wall of Silence

When @PatientAdvocacy, @hhask, @MLMillenson, @dmayer33, and @medstarsafety get together, its like Joshua and the battle of Jericho:  The walls will start tumbling down.

In this case, though, they need a little financial help.  Check out this request on Kickstarter to help document the most comprehensive safety, quality, and transparency cultural shift in a US hospital system:

As the new Vice President of Quality and Safety for MedStar Health, Dr. David Mayer is leading a group of hospitals in the Baltimore/Washington area to change the way healthcare responds to patient harm.

Few have attempted to change the safety culture of an entire hospital system on this scale. This is an historic moment in healthcare to track in real-time the implementation of a new safety framework – and to do it in the backyard of our nation’s capital – with the hopes that the advances made at MedStar will lead to positive change across the nation.

Will you join us in documenting this important effort? 

If you cannot see the video, click here.

Was that a Nikon or a Canon?

If we put aside issues of criminality, the most interesting part of the story of the soldier who divulged secret files to Wikileaks is how unsophisticated and commonplace his actual actions were.  As noted by the New York Times:

Private Manning said he put the files on a digital storage card for his camera and took it home with him on a leave in early 2010.

Private Manning eventually decided to release the information by uploading it to WikiLeaks. To do it, he said, he used a broadband connection at a Barnes & Noble store because his aunt’s house in a Maryland suburb, where he was staying, had lost its Internet connection in a snowstorm.

New York Times Photo