Dominance visualized

For those of you who don't believe me when I talk about the problems related to market dominance in health care, I refer you to a recent post by John McDonough, one of the stalwarts of public concern for the health care system.  Focusing on Massachusetts, John links us to recent reports produced by the Blue Cross Blue Shield Foundation.  John properly expresses "kudos to Massachusetts Health Quality Partners which did the legwork on this terrific resource."  He notes:

If you want to begin to understand why Partners Healthcare is so dominant in the state's healthcare market, don't go to this page, Hospital Systems by Size, on which Partners is #2 after Steward Health Care System.  Go this this page: Physician Networks and Major Medical Groups, where the size of Partners' physician network (called Partners Community Healthcare Inc., PCHI, or "peachy") is larger than #2 (Steward) or #3 (Atrius), combined. 

I don't see it listed, but I am guessing that a chart of specialists would be even more skewed to Partners. Remember this chart produced by the system for its presentation to Wall Street?

That helps explain this point raised by John:

Or look at hospitals by Net Patient Service Revenue, and see that Partners total NPSR in 2010 ($4.2 billion) was the same as #s 2 (UMass Memorial), 3 (Steward), and 4 (Beth Israel Deaconess) combined.

John ends his article by saying:

So much more to explore in this highly useful and accessible tool as the state debate over cost and market dominance continues.

Except for one thing:  I'm not sure what John means about state debate over market dominance in Massachusetts.  Sure, the new state law has a provision that:

Establishes a new “Cost and Market Impact Review” to examine provider organizations to determine whether any provider's market concentration exceeds certain federally-established parameters. If the Commission determines, based on its review, that actions of a provider constitute unfair practices or unfair methods of competition or other violations of law, the Commission must refer the matter to the Attorney General for further action.

The problem is that that game is over.  There is no way the Massachusetts AG will have the authority to break up an existing health care system.  If s/he tried, the legal process for getting there would take forever.

No, the focus in Massachusetts remains with a misplaced belief that moving the system to one based on capitation will solve the cost problems. (Look at these comments by the chairperson of the state health policy commission.)  In addition, there is to be a consideration of the potential for consumer-driven health plans (those with a high deductible component or a health savings account) to influence customer behavior in the selection of doctors and hospitals.

While I am not sanguine about the efficacy of the latter, a condition for its success would be real-time total price and quality transparency, at the consumer level.  As Barry Carol notes in a recent comment on this blog, "Perhaps CHIA in MA can lead the way toward true price and quality transparency in healthcare so both patients and referring doctors can much more easily identify the most cost-effective high quality providers and steer their business to them."

When public values compete

An intriguing story has developed in Kentucky.  Several months ago, the UK's Kentucky Children's Hospital announced that it had suspended its pediatric cardiothoracic program, pending an internal review.

Read more here: http://www.kentucky.com/2013/05/01/2621750/uk-errs-in-suing-wuky-reporter.html#storylink=cpy

A local public radio reporter from WUKY-FM (which is owned by UK) filed a freedom-of-information request asking for:

1. The number of surgeries Dr. Mark Plunkett, chief of cardiothoracic surgery, performed in the previous three years.
2. The date of Plunkett's last surgery.
3. Payments received for surgeries performed by Plunkett in 2010 and 2011.
4. The mortality rate of pediatric cardiothoracic surgery cases in the previous three years.
5. Documentation related to any evaluations/accreditations of the program in those three years.

She did not request the names of, or any other identifying information about, the patients. UK answered questions 1 and 3 but declined on the rest, citing patient confidentiality. UK said Plunkett performed so few surgeries that it might be possible to identify individual patients.

The reporter appealed to the state's Attorney General, who ruled in her favor.  The University has now appealed that ruling in state court.  UK's general counsel said:

The open records requests impact three competing values — the right of the public to know what transpires at a public institution, the right of individual patients to privacy and the obligation of the health-care providers to engage in critical self-examination so as to improve patient quality and safety.

Read more here: http://www.kentucky.com/2013/04/25/2615368/uk-appeals-ruling-requiring-release.html#storylink=cpy

Read more here: http://www.kentucky.com/2013/05/01/2621750/uk-errs-in-suing-wuky-reporter.html#storylink=cpy

The University is taking some heat in the matter from a local newspaper:

In a really sad day for both open inquiry and freedom of information, the University of Kentucky last week sued a reporter for its public radio station.

If UK is trying to manage its image, it has made a huge blunder.

Stonewalling on this request only makes it appear that the university is more interested in keeping under wraps whatever has gone wrong in Plunkett's department rather than protecting the confidentiality of its patients — living or dead. 

When the story began back in December, questions were raised.  The radio station reported:

Kentucky Children’s Hospital treats some of the sickest and smallest patients from across central and eastern Kentucky. But for the past several weeks, pediatric heart surgeries have been referred to other hospitals. ...UK Healthcare is reviewing its program, but the reasons why are unclear.

UK Healthcare officials have not identified what prompted the review, but they say it is limited to the pediatric cardiothoracic surgery program, not any other pediatric areas or the adult heart program. “We’re looking at what can we do best and how do we best deliver the services and the care that kids need,” said Dr. Carmel Wallace, Chair of UK's Department of Pediatrics.

UK’s head of surgery, the chief medical officer, and Dr. Michael Karpf, the Executive Vice President for Health Affairs, all would not comment for this story.  Dr. Mark Plunkett, the surgeon at the center of the review, also declined to be interviewed.

One of the trustees said that he thought UK should consolidate its pediatric heart program with the University of Louisville because of high operational costs.

So are there economic reasons?  Are there reasons related to sustaining a high quality clinical environment?

Read more here: http://www.kentucky.com/2013/05/01/2621750/uk-errs-in-suing-wuky-reporter.html#storylink=cpy

UK's position is understandable if we take as a given the hospital's obligation to preserve patient confidentiality under HIPAA and also the need to protect the peer review process as applied to clinical decision-making.

But it is giving the impression of stonewalling by not explaining much about the reason for the program's suspension. That kind of image is usually not good for a public institution.

I wonder if there is a middle ground that might be negotiated here between the university and itself.

Read more here: http://www.kentucky.com/2013/05/01/2621750/uk-errs-in-suing-wuky-reporter.html#storylink=cpy

Why it is called the Affordable Care Act?

Sometimes when something is right in front of you, you don't see it.

A friend who serves on a Boston hospital board writes:

Great cover story in the New York Times today on how the new private owners of Bayonne Hospital made it for-profit and canceled their insurance contracts.  By becoming out-of-network they were able to jack up their prices and make a lot of money. Talk about gaming the system!

The writers of the story, "New Jersey Hospital has the Highest Billing Rates in the Country," missed the major point. My friend did, too, but less so.

This is not about the relative prices in the hospital's chargemaster, nor is it about gaming the system.  It is the system.

The name of the game is to have sufficient market power in a geographic area that you can demand higher than market prices from the insurance companies.

In recent years, Bayonne Medical put up digital billboards highlighting the short waits in its emergency rooms in an effort to attract more patients. Insurers complained that the hospital was seeking to take advantage of the higher rates it could charge. 

Community leaders in Bayonne, fearing the hospital could close, said the buyers were always candid about the methods they intended to use to make the hospital a profitable enterprise.  

In 2009, Horizon Blue Cross Blue Shield of New Jersey filed an injunction in New Jersey Superior Court saying Bayonne Medical’s owners had “flatly rejected” and refused to negotiate an in-network hospital contract with Horizon. When the existing agreement expired in early 2009, Horizon said Bayonne sharply increased its prices. Bayonne’s in-network charges to Horizon averaged $13,000 a day in 2008. A year later, when it was out of network, the charges soared to $29,000, the insurer said in a spring 2009 news release. 

The two eventually settled in 2011, and Horizon became an in-network insurance provider. A spokesman for Horizon declined to comment on Bayonne Medical’s charges, citing terms of the settlement agreement.

Still, many other large insurance companies, including Cigna, United Healthcare and Aetna, remain out of network at Bayonne and are paying the higher bills. 

Aetna’s internal data showed that Bayonne Medical’s emergency room charges jumped again in 2012 and are running 6 to 12 times as high as those of surrounding hospitals.

Now, Aetna is one of the largest insurance companies in America.  But in the Bayonne area, that size means squat.  Bayonne Medical Center, by an accident of geography, is viewed as an essential medical center by patients.  The hospital's owners are extracting monopoly-like profits as a result.

Unusual?  No.  In Boston, we have had a larger variant on this, as the Partners Healthcare System, dominant in the region, has extracted above-market prices from the insurers in town.  PHS proved its ability to do so well over a decade ago, when Tufts Health Plan objected to paying the high rates PHS was demanding.  Partners threatened to drop THP from its network, and the health plan folded within 72 hours.  That set the stage for rate deals that have generated (my guess) an extra $200 million per year for this large system.  Other hospitals were left to fight over the scraps.  PHS used the extra money to expand further, enhancing its market power year by year.  (The only company that could have taken PHS on, Blue Cross Blue Shield of MA, which has corresponding market power on the insurer side of the ledger, chose to be complicit.)

And it will be more common over the coming years.  The impetus coming out of the so-called Affordable Care Act (aka, Obamacare) is for hospital systems to consolidate into accountable care organizations to become dominant in their market area.  Ostensibly, this is to better manage care across the spectrum of care.  Part of the reason, too, is to have a broader pool of patients as pricing moves to more of a risk basis.

The Federal Trade Commission has determined that it does not have the authority to deal with these increases in market power.  An FTC commissioner said:

“The net result” of ACOs, says Rosch, “may therefore be higher costs and lower quality health care—precisely the opposite of its goal.”

As in Bayonne, we can expect continued upward price pressure across the country as these large systems hold a hammer over the head of insurers.  So why it is called the Affordable Care Act?

By the way, let's review this quote:  The two eventually settled in 2011, and Horizon became an in-network insurance provider. A spokesman for Horizon declined to comment on Bayonne Medical’s charges, citing terms of the settlement agreement.

With all this fuss about the chargemaster, reporters and some patient advocates are again missing the point.  Let's make public the actual rates charged by hospitals and physician groups. 

"I Remember Better When I Paint"

This event on May 29 (3:30-5:30) at the Metropolitan Museum in NY is worthwhile for any health care provider who encounters people with dementia and for family members of persons with any form of dementia.

Description:

Please join us for a screening of I Remember Better When I Paint, a film by Eric Ellena and Berna Huebner.  I Remember Better When I Paint is the first international documentary about the positive impact of art and other creative therapies on people with Alzheimer’s and how these approaches can change the way we look at the disease. Among those who are featured are noted doctors and Yasmin Aga Khan, president of Alzheimer’s Disease International and daughter of Rita Hayworth, who had Alzheimer’s.

Following the screening, filmmaker Berna Huebner will be joined by Dr. Sam Gandy, Chair of the Mount Sinai Alzheimer's Disease Research Center, and Gail Sheehy, bestselling author of Passages in Caregiving: Turning Chaos into Confidence, for a lively discussion moderated by Carolyn Halpin-Healy, Founder and Executive Director of Arts & Minds.

Waterfalls>cowbells

We go back to infrastructure for a break from health care (although the two are intimately related in many ways.)  Some of you will remember my story about the use of cowbells to forestall too-low trucks from hitting underpasses along the Boston river roads.  Now comes this story from Australia, where waterfalls do the trick!

A continuing display of weak leadership

I admire President Obama in many ways, but I think he does not understand one important element of leadership.  He has repeated the following behavior:  Something goes wrong in his administration.  He expresses anger about it, and says such behavior is inexcusable, as though it is someone else's responsibility.  Then, someone falls on his sword and resigns, or someone is blamed and is fired.

A strong leader would take personal responsibility, say what he is going to do to fix the problem, and then permit himself to be held accountable for the required changes.  The President's approach emphasizes his own leadership weakness.

The two most recent examples are the inadequate steps taken by the military to avoid sexual harassment and the improper use of the IRS to investigate organizations of a certain political persuasion.  How did he react?

On the first:

President Obama said today he has “no tolerance” for sexual assault in the military and said perpetrators are “betraying the uniform that they’re wearing,” even as a new Pentagon report indicates the problem is growing.

“For those who are in uniform who’ve experienced sexual assault, I want them to hear directly from their commander in chief that I’ve got their backs. I will support them. And we’re not going to tolerate this stuff. And there will be accountability,” Obama said at a joint White House press conference with South Korean President Park Geun-hye.

“I expect consequences,” he said. “I don’t want just more speeches or, you know, awareness programs or training, but ultimately folks look the other way. If we find out somebody’s engaging in this stuff, they’ve got to be held accountable, prosecuted, stripped of their positions, court-martialed, fired, dishonorably discharged — period. It’s not acceptable.”

The President is the commander-in-chief and has been for over four years. How about something that indicates the buck stops with him?

Anybody who knows me knows that I personal abhor this kind of behavior.  Although I instituted programs several years ago to reduce its likelihood, I have to accept responsibility for the fact that our efforts have not been strong enough or thorough enough.  I could offer excuses, but as people in the military say, "No excuse, sir."  I intend to work with the Joints Chief of Staff to do a top-down evaluation of what we have done so far, what works, and what doesn't work.  A part of my plan will certainly be to protect people who report this kind of behavior--whether victims or observers, whether subordinates or supervisors.  But beyond that, we will borrow the best of ideas that have been successfully employed by businesses and institutions to eliminate this kind of behavior.  I will publishing monthly reports indicating our progress.  The people of this country and in the military have a right to hold me accountable.

On the IRS problem, he said:

I have now had the opportunity to review the Treasury Department watchdog’s report on its investigation of IRS personnel who improperly targeted conservative groups applying for tax-exempt status. And the report’s findings are intolerable and inexcusable. The federal government must conduct itself in a way that’s worthy of the public’s trust, and that’s especially true for the IRS. The IRS must apply the law in a fair and impartial way, and its employees must act with utmost integrity. This report shows that some of its employees failed that test.

I’ve directed Secretary Lew to hold those responsible for these failures accountable, and to make sure that each of the Inspector General’s recommendations are implemented quickly, so that such conduct never happens again. But regardless of how this conduct was allowed to take place, the bottom line is, it was wrong. Public service is a solemn privilege. I expect everyone who serves in the federal government to hold themselves to the highest ethical and moral standards. So do the American people. And as President, I intend to make sure our public servants live up to those standards every day.

The president is chief executive officer of one branch of the government and has been for over four years. How about something that indicates the buck stops with him?

The IRS is part of my administration, and I take responsibility for any misdeeds and impropriety that occur in that administration.  It would not be enough for me to say that some people acted outside of their authority and in a manner inconsistent with our political and constitutional system.  If they acted in such a way, it might reflect their wish to do something that they mistakenly thought I would condone.  Or more innocently, it might just reflect misjudgement, misunderstanding, or bad training.  Whatever the reason, I have not done enough to ensure that the standards I hold dear have been maintained in my administration.

I have directed a top-to-bottom review of our training and compliance programs.  I will publish the results of that review for all to see, and I will act on that review with specific steps and milestones and provide public progress reports on our implementation of that plan.  Meanwhile, I request that any organization that has felt itself to be abused in this manner to file a statement of complaint on a new public website, and I will ensure that the resolution of that complaint is published for all to see on that website within 60 days.  I will also request any IRS employee who feels that any organization has been abused in this manner to file an anonymous statement of complaint on a new public website, and I will ensure that the resolution of that complaint is published for all to see on that website within 60 days.

Unrealistic? Showing political weakness?  Just the opposite.

On the organizational level, by taking ownership of the problem, the President would invite the cooperation of people in the government to help solve it.  In contrast, the way he now frames it is an invitation for people to hunker down.  If they see something wrong, they will fear reporting it.  The president needs to learn from some examples of leaders.  In my book Goal Play!, I relate some of those stories.

Here's one from health care:

In an article by Dr. Charles Denham, he relates the practice of nursing chief Jeannette Ives-Erickson, Senior Vice President For Patient Care and Chief Nurse at Massachusetts General Hospital. When there is a screw-up in nursing, she calls the involved nurse into her office and asks one question: “Did you do this on purpose?” When the nurse answers, “No,” then Jeannette says, “Well then it is my fault. … Errors stem from system flaws. … I am responsible for creating safe systems.”

Chuck notes, “In a few short moments with a caregiver after an accident, the leader declares ownership of the systems envelope, and the performance envelope of her caregivers, and creates a healing constructive opportunity to prevent a repeat occurrence.” 

He warns us that it is easy to “automatically fall in a name-blame-shame cycle, citing violated policies, and ignore the laws of human performance and our responsibility as leaders.”

Here's one from the oil industry:

A number of years ago, Tom Botts was involved in a tragedy aboard an oil rig in which he personally had to call off the search for men missing at sea. Deeply shaken, when he later moved on to be Executive Vice President for Shell Oil Company’s exploration and production activities in Europe, he decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean. Notwithstanding that new program—the best in the industry—two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits. It would have been easy to blame the two men who, after all, entered a prohibited area. Instead, Tom launched a thorough, top-to-bottom review of the organization. He explained: 

We decided to be as open and transparent about the incident as possible and went through a “Deep Learning” journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we ‘owned’ the system that led to the tragedy. 

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
 
And finally, another from health care:

Paul Wiles, former Pres­ident and CEO of Novant Health in Winston-Salem, NC, once told me and a group of hospital CEOs a heart-wrenching story about an infant’s death from sepsis in his hospital, which was tracked to an MRSA (antibiotic-resistant staph) infection. The infection was part of a spread of a bug in his neo-natal intensive care unit (NICU) that reached 18 infants in all and may have contributed to the deaths of two others. “This was a direct result of staff not washing their hands appropriately,” he said. Since that event, “We have been on a relentless hand hygiene campaign.” 

The crux of his entire presentation was this comment: “My objective today is to confess. ‘I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties,’” he noted, by focusing instead on the traditional set of executive duties (financial, planning, and such).
 
This president came into office having never really run an organization of size and complexity. He has played for years in the political environment, where the blame game is part of the culture and is viewed as a way to win the next election. Now, however, it is his last term. It would be a good time for him to learn how to be a leader of the executive branch.  By the way, it would also be good politics, as it would help establish him as a strong leader and not a weak one.  The dividends would flow to other aspects of his presidency.

Delete email. Not email messages. Email altogether.

On February 11, @lucienengelen (Lucien Engelen) announced to his world that he would stop reading and replying to email as of April 2.  As he later noted:

After I previously attempted to make my work more focussed in other ways it turned out to a large extent that 250 to 300 emails a day made this impossible.

An analysis of my incoming emails taught me that some 70 percent of the information sent to me also was also on our intranet. It was clear that email was increasingly used as a some kind of chat — some up to 10 other messages cc'd to easily 10 people each. For that, I think, we have other more appropriate tools, such as our UMCN, Yammer or social media.

I therefore decided to stop email. Just stop. Not just bcc or cc, but everything. Now you might think: "One can’t just stop" — and that is true. This would not be possible for everyone, but it fits with my role as bit of a rebel (with a cause ;-).

In support of this decision, he posted this marvelous video called "Business Practices that Refuse to Die: #No. 44, Email."


How'd it go?  Very well.  Lucien summarizes:

I can firmly tell you that it already saves me a lot of time: approximately 1.5 to 2 hours per day. In addition to that, my colleagues are surprised that I can find time time for a cup of coffee, pick-up the phone and respond to messages more swiftly through other channels like social media.

I'm not quite this far along, but I am sympathetic.  Beyond the inherent flaws in email as a tool for collaboration, it is also a tool for avoiding personal interaction.  It is an enabler of passive aggressive behavior.  If I hadn't left my hospital job, I was planning on an experiment:  Asking people not to use email every Monday.  I was looking forward to the idea that a person with an idea, a suggestion, a comment, or a complaint would have to get up and walk a few meters to talk to another person.  I felt that people would quickly solve their problems or share ideas and do so in a manner that would avoid the "email trees" described in the video.  By looking at one another, too, they would send subtle messages using body language, tone, and humor that are not possible in email messages.  There would be fewer misunderstandings.  People would get to know, and maybe even like, one another.

In my book Goal Play!, I tell the story of how we used to arrange informal dinners for the managers at BIDMC.

We'd get a group of 15 to 20 mid-level managers to an off-site location for conversation, group games (like “two truths and a lie” and Trivial Pursuit), dinner, and wine to get to know one another. 

For us, the game gatherings, of which there were several, were a great opportunity for people to open up and relate in new ways.

“I have been sending you emails for five years, but I never met you,” was one typical reaction. “You go hang-gliding!” said another. “You have how many children?!” would be another.

People got to know one another as individuals and members of their community, separate from their work responsibilities. They discovered that they enjoyed each other’s company. Later, back in the office, they remembered and treated one another with much less of a bureaucratic attitude. They became more helpful, considerate, and empathic towards their colleagues.

Think about it. The supposedly utilitarian and powerful connecting force of email had become perverted into a means for keeping people separate.  We have to start breaking this down.  Bravo to Lucien for going the distance by risking an alternative view of the world.

Apologies to CHIA and Commissioner Boros

I was dramatically wrong in a recent blog post when I suggested that the MA Center for Health Information and Analysis had failed to make broadly available an all-payer claims database.  I apologize to the agency and to Executive Director Áron Boros.  I print below the full text of a reply from Commissioner Boros which, for some reason, I did not receive earlier.  I'd like to offer a reasonable excuse for my error, but--having done a root cause analysis--can best attribute it to the equivalent of diagnostic anchoring.  I believed that CHIA had not acted to free the data.  I conducted a (clearly incomplete) web search for information on the topic and found nothing to suggest an alternate view, so I concluded that I was correct.  A good lesson all around.

Here's Commissioner Boros' complete comment to me, which will also be posted on the original site, along with an addendum by me in the text.

Paul,

While I appreciate your continued advocacy for transparency and, in particular, your focus on patients, I am concerned that this post does not reflect any research on your part into the current state of transparency in Massachusetts.

My agency, the Center for Health Information and Analysis (CHIA), is responsible for collecting, enhancing, and sharing the data in the all-payer claims database (APCD), among many other data sets.  You are wrong when you state that CHIA has “failed to act.” Even a cursory look at our website would confirm this.  www.mass.gov/chia/apcd. 

Since July of 2012, the all-payer claims database has been available for public release.  Applications to use this data are posted to our website (at http://www.mass.gov/chia/researcher/health-care-delivery/hcf-data-resources/apcd/accessing-the-apcd.html).  There, you can see that we have handled more than 15 applications in the last 9 months. The first one is dated July 13, 2012.  The applications come from a wide variety of researchers and other users, and address a number of interesting policy questions. 

We also recently updated the fee schedule for access to the APCD (http://www.mass.gov/chia/docs/g/chia-ab/ab-13-03-apcd-fee-schedule.pdf).  The fee schedule reflects a careful consideration of appropriate pricing for this kind of data including, among other things, a public hearing and comment process. The fee schedule also provides for full or partial fee waivers for a variety of applicants, including students and qualified researchers in certain circumstances. 

I am proud of our accomplishments in increasing data transparency, and confess to a little bit of frustration that your post appears to assume that we have not been working to fulfill this mission without a minimum of research into what has actually happened over the last year.  In addition to the public release, the APCD is currently also being used to help implement to the Affordable Care Act, is being used to support the Division of Insurance in some of its market monitoring activities, and is being used internally by CHIA for health care research and analysis. 

Looking forward, there is much more to come.  As Pat G mentions, last year’s Cost Containment bill provides for new access to the APCD. We are in the process of revising our regulations to reflect the requirements of the new bill, and anticipate releasing a proposed revision in May. Moreover, the APCD will be used over the next 3 years to accelerate other health care reform initiatives, including data sharing with providers under the Executive Office of Health and Human Services’ State Innovation Model grant. http://innovation.cms.gov/initiatives/State-Innovations-Model-Testing/index.html

I would be happy to discuss the APCD with you more.  As should be clear from my comment, there is a lot to say.  

Cordially,

Áron Boros

Executive Director

Center for Health Information and Analysis

Natural Disaster Response on WIHI

May 16, 2013: Reliable Practices for Responding to Natural Disasters:
Lessons from North Shore-LIJ and Hurricane Sandy
(2:00 PM - 3:00 PM ET)

Featuring:

Mark P. Jarrett, MD, MBA, Chief Quality Officer, North Shore-LIJ Health System
Mark J. Solazzo, MBA, Executive Vice President and Chief Operating Officer, North Shore –LIJ Health System 
Joseph Cabral, MS, Senior Vice President, Chief Human Resources Officer, North Shore-LIJ Health System

Hurricane Sandy first struck the Caribbean and then the entire East Coast of the United States at the end of October 2012. The storm smacked into New York and New Jersey especially hard, impacting millions. The story of how the largest health care system in the region, North Shore–LIJ, operated throughout to ensure patients and staff were protected and supported, under fierce circumstances, is one that communities and hospitals everywhere can learn from. This is our focus for the May 16, 2013, WIHI: Reliable Practices for Responding to Natural Disasters: Lessons from North Shore-LIJ and Hurricane Sandy, featuring three leaders from NS-LIJ who were responsible for every kind of decision imaginable before, during, and after the storm.

Some of the decisions included transferring hundreds of nursing home residents out of harm’s way, taking in patients from other hospitals, assisting at area shelters, buying up fuel for ambulances, and opening up a resource center for hospital staff whose homes and neighborhoods had been torn apart and flooded. One of the back stories to NS-LIJ’s response is the degree to which it was built upon critical lessons learned during Hurricane Irene, a year before. In 2009, there was the H1N1 outbreak. In each instance, the health system did things well, and saw where it fell short; now that Hurricane Sandy has come and gone, this same type of assessment continues.

Health care organizations and first responders must prepare for many types of crises and disasters. Reflecting on the recent Boston Marathon bombings, which killed three and seriously injured over 200 (NEJM, April 24, 2013), authors Arthur Kellermann and Kobi Pelag write, “The best way hospitals can prepare is to base their response on a strong foundation of daily health care delivery.” So, routine and reliably safe practices, guided by continuous quality improvement, is lesson one for emergency planning. WIHI host Madge Kaplan invites you to bring your experiences and your interest to this timely discussion on May 16.

Please click here to enroll.

Big Blue pushes accessibility, with help from others

Back in the late 1970s, when I was Director of the Arkansas Department of Energy, the state disabilities commission ran an awareness event in which corporate and governmental leaders were given a disability for the day and were expected to try to carry out their work and personal functions.  You might be given heavily fogged glasses to be partially sighted; or you might be confined to a wheelchair; or (in my case) you were given earmuffs that severely limited your ability to hear.  At the end of the day, we all met to discuss what we had learned.  My observation was that the disabilities tended to isolate people from "normal" social and business intercourse with other people.  The result was that talented, skilled, and intelligent people were foreclosed from full participation.  I remember saying, "What a waste to society" in terms of capabilities that were being lost.

The world has changed somewhat.  In the United States, the Americans with Disabilities Act was signed into law in 1990.  Later in that decade, the United States required federal agencies to purchase electronic and information technology that was accessible to people with disabilities.  Other countries have similar laws requiring public accommodation for people with disabilities and similar requirements for integration of accessibility standards into computers and the like.  All of that is a good thing.

 But I think an equally important thing is happening now, in that technological changes are making it possible for disabled people to have more and better accessibility at work, home, and play.  I learned this week that IBM has demonstrated a particular commitment to this field.  While there is a clear business reason for many of their activities, their initial interest was philanthropic and several programs remain so.

I was intrigued by many of the company's activities, but one aspect in particular resonated with a message you have often read on this blog and on those of other patient advocates in the health care system.  We have been asserting that health care providers, researchers, and related service providers should be patient-driven.  We aim to encourage and establish true partnerships between those who provide health care services and those who use those services.  To date, the health care system has been slow to adopt this philosophy.

Look in contrast, at a portion of the IBM accessibility workplan:

To help IBM gain a deeper understanding and foster an accessible environment, IBM forms external relationships with leading experts on accessibility. These relationships help IBM understand specific issues and collaborate with key constituents to continually drive accessibility into mainstream IT.

• Understand how people with disabilities and seniors need information presented to them.
• Work with advocates to gain better understanding of their needs in the market.
• Demonstrate the value of integrating accessibility practices into businesses and communities through collaboration with advocates and early adopter clients.

Imagine if your hospital were to have a parallel portion of its workplan:

To help our hospital gain a deeper understanding and foster a patient-driven environment, we form external relationships with leading patient advocates and experts. These relationships help us understand specific issues and collaborate with key constituents to continually drive a partnership with our patients into our mainstream care delivery system.

• Understand how people with diverse medical conditions and demographic characteristics need information presented to them.
• Work with advocates to gain better understanding of their needs in the market.
• Demonstrate the value of integrating patient-driven practices into health care related entities and communities through collaboration with advocates and early adopter partners.

MedStar, Contra Costa, and a few others are taking this seriously.  Many others are just going through the motions or not even trying. This is a topic deserving attention by hospital boards of trustees, who should hold management accountable for adopting a philosophy and building the infrastructure to make such collaboration the norm.

Regina + Dave = Something else!

I feel grateful to know @ReginaHolliday (Regina Holliday) and to watch her use her artistry and her language as one of the world's most important patient advocates.  I also enjoyed watching today on her blog as she gently took apart someone who was trying to commercialize that advocacy role.  Among other things, she advised:

A word of advice: Don’t ever ask a patient activist how you can take advantage in the realm of patients…

She went further, and her article would have been enough, but then the first comment by e-Patient Dave deBronkart piles on with a blistering response that is worth a blog post in itself.  Directed at the person who wrote to Regina, he said:

Wake up and get a clue. (I'm being blunt because your situation is critical, as in ICU critical.) You just got $50,000 of marketing consulting from Regina Holliday. (I mean that literally. If you'd engaged a PR firm for $50,000 . . .  it would be worth every cent.)

If you feel defensive, squelch it and learn, buddy. Take every single word Regina said as gold. Or, really, honestly, non-snarky: find a different industry. This ain't appliances and iPhones.

Whew, these patient folks have gotten uppity, no?  I think it is great.

"It's not our job."

Some people were criticizing me the other day when I suggested that CMS was wasting its time by publishing hospital chargemaster data while neglecting its real responsibilities.  "Why are you so hard on them?" was the typical comment.

Why?  Because the agency is neglecting important duties, tasks that could actually improve the quality and safety of patient care.

Well, just a few days later, Pro Publica makes the case so strongly that I will just quote excerpts from their report:

An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive. Federal officials have done little to detect or deter these hazardous prescribing patterns.

How does CMS respond?

"CMS's payments don't go to physicians, don't go to pharmacies. They go to plans, which is how our oversight framework has been established," Jonathan Blum, the agency's director of Medicare, said in an interview. The philosophy "really has been to defer to physicians" about whether a drug is medically necessary, he said.

Other disagree.

Asked repeatedly to cite which provision in the law limits their oversight of prescribers, CMS officials could not do so.

The Office of the Inspector General of the Department of Health and Human Services has repeatedly criticized CMS for its failure to police the program, known as Part D. In report after report, the inspector general has advised CMS officials to be more vigilant. Yet the agency has rejected several key recommendations as unnecessary or overreaching.

Other experts in prescription drug monitoring also said Medicare should use its data to identify troubling prescribing patterns and take steps to investigate or restrict unsafe practitioners. That's what state Medicaid programs for the poor routinely do.

"For Medicare to just turn a blind eye and refuse to look at data in front of them . . . it's just beyond comprehension," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

"They're putting their patients at risk."

Brava to Tejal and NPSF!

The Board of Directors of the National Patient Safety Foundation have done a very, very good thing in appointing Tejal K. Gandhi to become the Foundation’s next president.  Tejal brings a wealth of experience in the field.  After 10 year as executive director of quality and safety at Brigham and Women’s Hospital, she moved on to chief quality and safety officer the entire Partners Healthcare System.

I had a chance to see Tejal in action as we served together at the Risk Managament Foundation. She was invariably thoughtful and well prepared and diligent in pursuing sensible quality and safety improvements throughout the Harvard system. Beyond that, she exhibits a warm and modest demeanor that will hold her in good stead and generate support and involvement among medical professionals as she pushes hard to achieve the "so much work to do to ensure the safest care for all patients."

The Orange Line

I am very pleased to announce the publication of The Orange Line, A Woman's Guide to Integrating Career, Family and Life.  Here's the review I wrote for it:

I am confident that when people look back a decade from now they will view publication of The Orange Line as a watershed event.  In the book, authors Jodi Detjen, Michelle Waters, and Kelly Watson challenge women to confront assumptions they have that surround and limit their personal and professional lives.  While the authors issue this challenge with empathy and caring, they never lose sight of its underlying message: The power of change lies within.  The authors' advice is not easy, and their book has no place for self-pity or excuses for blaming "the system."  Indeed, it may create some discomfort for some women as they internalize its messages. But The Orange Line gives hope to all of us who believe that women's integration of work and family is the key to a successful society.

Here's my neighbor and friend Jodi showing off the recently arrived book on a perfect spring day in front of a beautifully flowering apple tree!

And now presenting . . . robotic lap choles!

As a non-medical person, I was so excited when I could say "laparoscopic cholecystectomy" without pausing or tripping over all the syllables.  In English, this is a surgery to remove a gall bladder using laparoscopic instruments through holes in the abdomen instead of cutting it open.  Lap choles, for short, are among the most routine and safest surgical procedures.  The folks at USC note:

Laparoscopic cholecystectomy is a very safe operation. The overall complication rate is less than 2%. The complication rate for laparoscopic gallbladder surgery is similar to the complication rate for traditional open gallbladder surgery when performed by a properly trained surgeon. Many thousands of laparoscopic cholecystectomy have been performed in the USA and this operation has an excellent safety record.

An article on Medscape notes:

Laparoscopic cholecystectomy has rapidly become the procedure of choice for routine gallbladder removal and has become the most common major abdominal procedure performed in Western countries. LC decreases postoperative pain, decreases need for postoperative analgesia, shortens hospital stay from 1 week to less than 24 hours, and returns the patient to full activity within 1 week compared to 1 month after open cholecystectomy (OC).

In 1990, 10% of cholecystectomies were being performed laparoscopically. By 1995, 10 years after the introduction of LC, close to 80% of cholecystectomies were being performed laparoscopically. 

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

So, what do you do if you are a robotic surgery device company that has saturated the marketplace for robot-assisted prostate surgery and if the president of the American College of Obstetricians and Gynecologists has said:

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.

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. 

Answer:  You try to create a demand for robot lap choles. You drool as you read the last line of the quote above:

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

This is huge compared even to the 90,000 radical prostatectomies that are undertaken each year, where you have grabbed 70,000 of the total.

Just imagine if we could get doctors and hospitals to buy our robot to do a portion of those.  

Let's even make a video and have a doctor and a patient make unsupported assertions about the relative benefits compared to the excellent safety record of traditional lap choles.  The narrator says, "Having gall bladder surgery is a lot easier."  "It's a lot better," says the patient.

A few months later, the surgeon, Dr. Babak Eghbalieh, announces: "As of February 1st, 2013, the Robotic Surgery Program at CRMC [Community Regional Medical Center in central California] will be the fourth busiest Single Site Robotic Gallbladder surgery in the west coast of US!!"

Where do these videos come from?  No production credits are provided, but if you watch the next one, you'll see (starting at 59 seconds), an lengthy insertion of visual material from the company that produces the robot.



The patient notes, "Everybody was so friendly."

Useless noise from CMS

What on earth did CMS have in mind when it released the FY2011 chargemasters for America's hospitals?  Well, according to one report:

The public release of the data is part of an effort by Medicare to increase transparency in the health system. 

“Historically, the mission of our agency has been to pay claims,” said Deputy Medicare Administrator Jonathan Blum. “We’ll continue to pay claims, but our mission has also shifted to be a trusted source in the marketplace for information. We want to provide more clarity and transparency on charge data.”

CMS explains:

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service.

This is a case where the release of bad data is worse than having no data at all.

A hospital's chargemaster is an archaic fiction, a way previously used to allocate the joint and common costs of the hospital to particular services.  It does not serve as the basis for how much a hospital is paid by Medicare.  It does not serve as the basis for how much a hospital is paid by Medicaid.  It does not serve as the basis for how much a hospital is paid by private insurers.

Further because of federal and state prohibitions against balance billing of patients (i.e., the difference between the amount paid by an insurer and the amount of the charge), it also provides no basis to consumers that means anything at all.

But it sure creates a stir to be able to say: "For joint replacements, which are the most common hospital procedure for Medicare patients, prices ranged from a low of $5,304 in Ada, Okla., to $223,373 in Monterey, Calif. The average charge across the 427,207 Medicare patients’ joint replacements was $52,063."

For the record, Medicare pays hospitals based on a formula that takes into account the difference in overall wages and prices in different parts of the country.  There are also adjustments for rural hospitals.  There are also adjustments for academic centers to pay for residency training. The chargemaster employed by a hospital is not a consideration in the establishment of these federally determined rates.

Likewise, Medicaid rates are based on a state-determined formula.

Likewise, private insurance companies often base their hospital and physician rates off the Medicare formula, or have their own approach (often not even related to the hospital's actual costs).  Very, very few have rates based on "a percentage of charges."

I don't know what CMS really hoped to accomplish in the way of transparency by publishing out-of-date, irrelevant data.  But such behavior is consistent with CMS publishing out-of-date, irrelevant clinical outcome data.

Transparency, CMS style.

CMS says that the recent release of information is "part of the Obama administration’s work to make our health care system more affordable and accountable."  Oh, wait, this is the same president who had a photo-op with a robotic surgery company that has made its fortune by marketing high cost clinical equipment that lacks clinical evidence to support its relative efficacy.  This is the same president who compared hospital readmissions to going to an auto mechanic and having to bring your car back for re-repair, who doesn't seem to understand the unintended consequences of poorly design federal payment penalty strategies.

Meanwhile, CMS fails to take action to solve the well established and recognized problems in its own rate structure that encourage the medical arms race.  Even Mr. Obama's former adviser wonders why the agency won't or can't solve that kind of problem.

When Brent James advises doctors "Don't wait for Washington," he knows of what he speaks.  Improvement in the health care system will not come from confused and politically conflicted federal officials.  The challenge is whether it will come from the health care professions, or whether we will start heading down an inexorably declining slope towards higher costs, poorer quality, and (quiet) rationing of services.

Creating an insatiable appetite for improvement

John S. Toussaint and Leonard L. Berry masterfully set forth the essence of Lean in an article entitled, "The Promise of Lean in Health Care."

Lean is not a program; it is not a set of quality improvement tools; it is not a quick fix; it is not a responsibility that can be delegated. Rather, Lean is a cultural transformation that changes how an organization works; no one stays on the sidelines in the quest to discover how to improve the daily work. It requires new habits, new skills, and often a new attitude throughout the organization from senior management to front-line service providers. Lean is a journey, not a destination. Unlike specific programs, Lean has no finish line. Creating a culture of Lean is to create an insatiable appetite for improvement; there is no turning back. As Lean consultant Joan Wellman states,“With Lean, you will keep changing your definition of what ‘good’ is."

Mayo Foundation for Medical Education and Research: Mayo Clin Proc. 2013;88(1):74-8.

Now on e-books: How a Blog Held Off the Most Powerful Union in America

I'm pleased to be able to offer my new book on all e-book platforms.  Just go to this Smashwords page, and you can find the whole gamut of options, from Apple iPad/iBooks, Nook, Sony Reader, Kobo, to most e-reading apps including Stanza, Aldiko, Adobe Digital Editions, and others. You can find the Kindle version there, too, but also over at Amazon.  If you'd like, there is a free sample for sampling!

Of course, the paper version is still available at Amazon, too.

@EricTopol says, "Show me the data!"

Many of us were excited when it was announced in February that Eric Topol would be the new editor-in-chief at Medscape.  I think big things are in store.  He recently wrote:

Medicine is . . . poised for its biggest shakeup ever as it transforms to a more precise, individualized, and democratized model. My charge at Medscape is to help capture this excitement, the changes and opportunities, along with the challenges and the need for validation. Medscape will be expanding its breadth of coverage in areas that will be rebooting, which include not only diagnostics, imaging, and medical devices but also the operational aspects of office visits, hospitals, and medical informatics.

We intend to take Medscape to the next level, one that embraces the need for change and zooms in on the ways to get there -- the ways to provide better, more efficient care for your patients.

But what really gets me excited about Eric's sense of purpose is this slightly reworked video from Jerry Maguire.

The thoroughbreds were in MD, not KY

As I headed to BWI airport early Friday morning, my seatmate turned and asked if I was staying on the flight to connect to Louisville, to watch the Kentucky Derby.  "No," I replied, "I'm going to Maryland to watch the real thoroughbreds in action."  A quizzical look was the response.

I was headed to a meeting of MedStar Health's Patient and Family Advisory Council for Quality and Safety, convened by Dr. David Mayer, Vice President, Quality and Safety.  With strong suport from the system's CEO and Board, David is leading a system-wide effort to make the Medstar hospitals the best in the nation for quality, safety, and transparency.  He decided to enable a strong voice for the patients and has recruited the ultimate dream team for the PFAC.

Here's the list:

Michael Millenson (photo at right)

Patty Skolnik (photo at right, with Michael)

Armando Nahum

Victoria Nahum

Martin Hatlie

Rosemary Gibson (top photo)

Carol Hemmelgarn (top photo, with Rosemary)

Sorrel King (below, left)

Helen Haskell (bottom photo)

Those of you who have been following this field know that this is the Who's Who of internationally acknowledged experts in patient advocacy.  Sadly, many of the group came to this field because of family tragedies, loved ones killed by preventable medical errors.  They have channeled their grief into a commitment to help others avoid what they have been through.  In so doing, they have also become experts in process improvement, root cause analysis, behavior science, and the like.   

David put the group through their paces, with an extensive and intensive agenda.  They, in turn, did the same for David and his team, asking probing and difficult questions and making programmatic suggestions to enhance the MedStar effort.  This is no rubber-stamp body!

In memoriam: Ricardo Portillo

You probably haven't heard of Mr. Portillo, of Murray, Utah.  Here are excerpts and pictures from the AP:

A Utah soccer referee who slipped into a coma after being punched by a teenage player during a game a week ago died Saturday night, police said.

Ricardo Portillo, 46, of Salt Lake City passed away at the hospital, where he was being treated following an assault, Unified police spokesman Justin Hoyal said.

Police have accused a 17-year-old player in a recreational soccer league of punching Portillo after the man called a foul on him and issued him a yellow card.

"The suspect was close to Portillo and punched him once in the face as a result of the call," Hoyal said in a press release.

The teenager was playing goalie . . . when Ricardo Portillo issued him a yellow card for pushing an opposing forward trying to score a goal.

The teenager, quite a bit heavier than Portillo, began arguing with the referee, then unleashed a punch to his face. Portillo seemed fine at first, then asked to be held because he felt dizzy. He sat down and started vomiting blood, triggering his friend to call an ambulance.

When police arrived around noon, the teenager was gone and Portillo was laying on the ground in the fetal position. . . . He was considered to be in fair condition when they took him to the Intermountain Medical Center.

But when Portillo arrived to the hospital, he slipped into a coma with swelling in his brain.

There's just too much wrong here. One life lost. Many others will be in turmoil for years to come.  Here are Mr. Portillo's daughters Johana and Ana:

Sometimes things like this happen because of bad chemistry in the moment, and that may have been the case here.  Not that it excuses the behavior.

But sometimes things happen like this because a coach has not set a proper standard of behavior for his players--particularly at this age, where testosterone levels are apt to surge.  A short story, fortunately not in this category.  I recently was an assistant referee in a game with 16-year-old boys.  There were some scuffles on the field, and one team felt particularly (but not justifiably) aggrieved by the fact that the referee did not call as many fouls as they felt were warranted.  As the boys returned to their bench after the game, several complained to their coach about the referee, and the coach said, "I can't say anything as long as he has my (coach ID) card."

In others words, "You are right to be upset.  I would have yelled at the referee, but he would have sanctioned me."  What a standard of behavior!  How about, "The referee calls it as he sees it, and our job is to just play a fair game."

Referees who officiate at youth games in all sports do so for the love of the game and for the chance to enable children to have a pleasant experience that promotes individual and team development.  When violence occurs as a result of one immature and uncontrolled child, that is tragic.  When anger occurs as a result as a result of the poor example of a misguided coach, he or she has failed in exercising proper leadership with the children who are his or her charges.

This story was not from The Onion

It was not my plan to publish another post on this topic for some time, but you'll soon see why I felt compelled to.

As I was writing my recent piece about the potential financial slide of a private-equity-owned health care system, I never, ever, ever considered that part of the workout of such a system might be to sue an insurance company in another state for a terminated buy-out deal of another hospital.

And yet here it is.  Here are excerpts from Robert Weisman's report in the Boston Globe (not The Onion):

Steward Health Care System, which terminated an agreement to buy a Woonsocket, R.I., hospital last fall, charged in a lawsuit Wednesday that Rhode Island’s largest health insurance company blocked the deal by failing to negotiate reasonable health care payments.

In a complaint filed in state Superior Court in Providence, Steward, which runs a chain of hospitals and doctors groups across Eastern Massachusetts, alleged Blue Cross & Blue Shield of Rhode Island engaged in anticompetitive practices and interfered with prospective contractual relations to thwart Boston-based Steward’s proposed acquisition of Landmark Medical Center.

Steward, owned by the New York private equity firm Cerberus Capital Management, demanded a trial by jury and asked for Blue Cross & Blue Shield to pay unspecified financial damages as well as reimburse its attorneys’ fees involved in taking the court action.

The collapse of Steward’s deal to take over Landmark marked a setback in the health care chain’s efforts to build a national for-profit hospital and physician network.

But while it has negotiated with financially troubled hospitals in Florida and Maine, in addition to Landmark, it has yet to complete an out-of-state deal.

Aging in Place on WIHI

May 2, 2013: Home for Life, Aging, and Aging in Place

2:00 - 3:00 PM ET

Featuring:
Sharon J. King, Principal, Starfield Consulting Ltd. & Special Advisor, South Georgian Bay Collaborative
Mimi Toomey, Director, Policy Analysis and Development, Administration for Community Living, US Department of Health and Human Services

With the aging of the population in many countries, where are the best ideas going to come from to help older people remain in their communities, and among the friends and families — and other seniors — they know best? How can we shift mindsets and models from ones that include endless and expensive health care interventions to a vision that factors in the role that supportive people and support services can play further upstream — to reduce isolation and loneliness, to ensure good nutrition and management of chronic health issues, to prevent avoidable hospitalizations?

On the May 2 WIHI: Home for Life, Aging, and Aging in Place, we’re going take a stab at some answers. We’re going to travel to South Georgian Bay, a community along the Severn River in Ontario, where six organizations have come together to create a web of resources called Home for Life, focused on the growing population that’s over 65. Anchored by volunteers, a 211 system to initiate and engage services, and a “back to the village” vision that also includes empowering older individuals with computers and new technologies, Home for Life isn’t just another in a long string of well- intentioned social service initiatives. WIHI guest Sharon King, one of its creators, believes Home for Life should be studied, measured, and monitored for its effectiveness. She’s hopeful they’re on to something in Canada that can be adapted elsewhere.

How does this look to Mimi Toomey from her perch at the US government’s Administration for Community Living? With over 25 years of experience developing policies to support aging populations, is this the kind of “break the mold,” more cost-effective experimentation that communities in the US need to tap into, too? Do we have similar examples popping up that we need to learn more about? Probably so. If we’re going to get out from under headlines and reports that focus exclusively on aging as unaffordable for society most of all, we need fresh ideas and compassionate innovation. That’s why WIHI host Madge Kaplan hopes you’ll join the discussion on May 2.

What, me boisterous?

@BGlennWrites (Brandon Glenn), writing at Medical Economics, names me as "perhaps Epic's most boisterous critic" because of two columns I have written about the firm's taxpayer-supported rise to dominance in the EHR field.  I don't think so, at least compared to people I have talked to in the industry, but if I did deserve that sobriquet before Brandon's article, he now deserves the honor.

The points he makes about why Epic's dominance could stifle EHR and health care IT innovation are cogent.  Here are some excerpts:

If Epic (already based on an antiquated technology – MUMPS) 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," wrote physician-scientist David Shaywitz in Forbes.

In other words, the "closed" nature of Epic's systems - coupled with its dominant market position - could mean that Epic ends up setting the defacto standards for EHR systems, effectively stifling innovations that its competitors might develop in the EHR market. That, in turn, could lead to Epic's big hospital customers - and those hospitals' patients - being frozen out from advances in EHR technology.

Health IT analyst John Moore of Chilmark Research predicts that's exactly what'll happen. Writing at The Health Care Blog, Moore said Epic is operating on a model that "will ultimately hinder healthcare organizations’ ability to rapidly innovate and respond to market changes. Epic simply will not be able to move fast enough and their customers will struggle as a result."

I don't claim to have the IT expertise of these people. I have witnessed the normal trend of a dominant player in a marketplace to squelch innovation, regardless of the sector.  Brandon's article now has me even more worried.