Last thoughts on Telluride residents' program

#TPSER9 Over the last few days, I've provided some stories from this year's Patient Safety Summer Camp in Telluride.  I hope you've enjoyed them and found them of value (and made you envious of the students and faculty who were lucky enough to attend!)

Now, if you have time, take a look over at the Transparent Health website.  You will find observations there from the students and faculty members.  To whet your appetite, here's one from Stephanie:

I just can’t believe I am surrounded by such an amazing and inspiring group of people. I cannot even begin to reflect on all the incredible moments of which I have been a part so far this week (and it’s only Wednesday!) but this is definitely going down as one of them. From the team building and communication we learned from the Teeter Totter game yesterday to the powerful and emotionally stirring video on the tragic story of Michael Skolnik to the unbelievable scenery and serenity of the Bear Creek Trail hike this morning, this is an experience that can never be recreated but that I will hold in my heart and my mind forever. It is so easy to become jaded in medicine, especially as a resident, and this is exactly what I needed at this point in my life to reinforce why I went into medicine in the first place: for the patient.  I’m making a personal commitment to myself and to everyone here at TSRC that I am taking this home and will implement more patient safety measures and quality improvement at my home program at MedStar Georgetown University Hospital. I am going to start with resident education because I feel like this is the greatest need at present. We can each make a difference as long as we keep our eye on the common goal which is the health and safety of the patient, and thanks to this amazing week, I truly believe this and am ready to do my part.

As David Mayer likes to say, health care will change only if we educate the young.  The Telluride "campers," who are now alumni, are part of a growing cadre of young doctors (over 300 strong), who have fanned out to make incremental changes to improve the quality and safety of patient care and build an empathic health care system. Transformation does not come as a large one-time change in clinical practice: It comes from the sustained efforts of well-intentioned people in communities of care throughout the country.

Answering to Stewie's family

#TPSER9 I reported yesterday on the distressful case of Stewie, seen to the left, who met his untimely fate when a group of Telluride residents failed to properly execute a team-based procedure.  Was this adverse event preventable or not?  Poor planning and communication and finger-pointing may have contributed to the failure, but the inexorable law of gravity certainly played a key role.

This afternoon, there was an unexpected interruption, as Stewie's parents broke into the meeting, and the teams were confronted by the angry relatives.

Their comments evoked memories of happier days, when Stewie and his family were closely tied in so many ways.  (See below for a picture from the family album.)

But today they demanded answers.  "Was Stewie made aware of the risks of this procedure?" "Is there a detailed record of that disclosure?" "Was this the first time the doctors carried out this procedure?"  "Is anyone going to be fired?"

The residents responded.  They expressed true regret and sympathy, saying also:

It is still too early to understand exactly what happened.  As soon, as we know, you will know.  We will be totally transparent with you on that point.  Yes, he was informed of the risks.  It was a fairly new procedure, and I explained that to him.  Here are our cards: Please call us at any time, day or night, if you have questions or concerns. 

To my readers:  How'd they do?

Stewie faces the promise (or threat) of teamwork at Telluride

#TPSER9 The curriculum at the Telluride Patient Safety Camp is rigorous and multi-faceted, with the goal of enhancing residents' abilities to improve the quality and safety of care given in their home institutions and also their ability to make changes in their work environment. Team-building and teamwork are necessity components, and the residents today had a chance to engage in an exercise that stretched their competency in this arena.

Team 1 has 2 out of 6.  Will they make it?

A long plank is balanced on a cinder block, and a team of seven to eight residents has ten minutes to figure out how to get six people standing on the plank without losing balance. 

Team 2 on their way: 3 out of 6!

The rules require each person to get on the plank at its midpoint, one person at a time.  Once six people are on the plank, they must remain there for ten seconds, and then dismount in the reverse order.

Happy Stewie!

Underneath each end of the plank is a raw egg, which is crushed if the plank goes out of balance.  Patient harm is immediate and irrevocable.  The team's turn ends.

Poor Stewie!

Some teams designate coaches to be on hand (or hands and knees) to watch the plank carefully and warn of any imbalance.

The time pressure facing the teams causes real stress.

Lessons learned:  Have someone act as team leader, but being responsive to reports from other observers; learn from other groups' mistakes and from their best practices; be clear in communication; avoid rushing, even under the pressure of time.

Telluride Patient Safety Summer Camp

#TPSER9  I am very pleased to be attending and presenting at the ninth annual Patient Safety Summer Camp in Telluride, CO, organized by David Mayer and Tim McDonald (seen above).  Twenty-eight residents from around the country are here for the week under the following theme: “The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency."

The learning objectives are that, by the end of the Patient Safety Summer Camp, residents will be able to:

1) Give an in-depth presentation that provides at least three reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement and reducing risk in health care;

2) Utilize tools and strategies to lead change specific to reducing patient harm, and:

3) Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.

This is jam-packed several days with lectures, videos, exercises, individual projects, team-building and the like.  If today's first day is any indication, this is a strong-willed and thoughtful cadre of residents who will make a difference in their hospitals and their profession.  It is an honor to spend time with them.

Dave posted this slide today as part of his introductory remarks.  It sets forth a key concept for the residents, that of mindfulness.  Take a look and see how Dave outlines its key attributes.  This is an excellent statement of purpose, one that can form the foundation for all clinicians to do better for their patients, their colleagues and for themselves.

Caution: Use 2 hands to dispose of trash

New readers may not be aware of my fixation on signage.  It turns out that signs are useful indicators of underlying problems in the work environment.  Signs that are designed well and placed well can facilitate the production of a product or the delivery of a service.  On the other hand, signs that are poorly designed or placed can cause confusion.  They are also telltale signals of underlying process flow problems.  This is true in health care and almost every other field.

My regular readers have come to see my occasional reports on signs.  Some are in Boston, but the most interesting ones often turn up in airplanes, like this clever depiction of a changing table.

This week's report comes from Southwest Airlines (one of my favorite carriers), where I noticed the following sign in the lavatory.

 

Here's another shot to give you a sense of the placement:

For those of you who want to spend a lot of time on the issue of the quotes around open and in, go to the "blog" of "unnecessary" quotation marks.  But that is not my issue today.

For today, we have to ask the question of why Southwest Airlines felt it necessary to offer instructions in the use of the disposal bin, along with the big red CAUTION sign.  Were people's hands getting stuck in the bin because they weren't letting go of the paper they were disposing?  Homer Simpson fans will immediately recall the episode in which Homes got his hands stuck in two vending machines at the same time. When the paramedics tried to get him out, they asked, "Homer, are you still holding onto the can?"

When it comes to hand hygiene, by the way, the instructions are counterproductive.  If I wash both hands and then use one to hold open the lid to the disposal bin, I have just gotten that one dirty again. 

Wouldn't it be interesting to hear from folks at Southwest how it came to pass that they spent thousands of hours and dollars designing, printing, and placing this sign?  What was the chain of command that led to this?  I don't know but I am guessing that the risk management section of the legal department had something to do with it.  I have not seen it on any other airline.  Either Southwest is breaking new ground in avoiding in-air catastrophes, or there is something worrisome about the people who choose this airline.

Patient Advocates: Demand payment!

Dale Ann Micalizzi, @JustinHOPE, Founder/Director/Health Educator at Justin's HOPE, posted the following note on Facebook:

Something needs to be said regarding pro bono work in healthcare: Please consider offering patient/family members a stipend or donation to their foundation when government or hospital organizations are asking for their assistance on multiple projects. I have 10 meetings next week and only one offered a donation for our scholarships. We will do this for free but most of us have a mission that we're working toward that depends on support. Most of us did not receive any compensation from the harm caused and have started improvement projects from scratch. Thank you. 

I responded:
 
You, and others, are being too generous. You and other notable patient advocates are now viewed as "trophies" when you are invited to help in this manner. It is perfectly reasonable to start to ration your time--at least in part--by insisting that hospitals, associations, and other institutions make contributions to your patient safety/education organizations. Trust me, those hospitals and other places always have money to pay for consultants--and you offer greater value than lots of those consultants!

Poor integration between hospital EHRs and NICUs

Responding to my story about lack of funding for electronic health records for pediatric nursing homes, Brian Carter, a superb neonatologist at Children's Mercy Hospital in Kansas City, notes:

The limits of meaningful use for HITECH also exclude all of my patients – newborns and young children (age 2 or less). These children, especially those managed in neonatal intensive care units, comprise a significant portion of the pediatric population dependent upon medical technology – even upon their discharge home – and are affected by complex and sometimes chronic diseases of childhood (pulmonary, cardiac, gastrointestinal and neurologic). Neonatal ICUs have long utilized EHRs, but often this occurred in large hospitals that either didn’t develop or adapt EHRs system-wide, or had a different system for other units of care. Today, many hospitals are hampered by EHR adoption, and many NICUs by having to integrate a smoothly operating NICU-oriented EHR system into the new broader hospital EHR, or totally refit or rebuild the NICU system and lose years of meaningful and accessible data.

Brian quotes a colleague: "Children are often little considered in broad societal or systemic healthcare changes, because they are little people, with little problems, and have little power (there is no lobby for children akin to the AARP), so they receive ‘little’ budgets."

Brian cites a recent paper by Kelly Stuart at the Virginia Health System on the matter. Entitled "You can't get there from here: Misplaced incentives can undermine the goals of health care reform in the NICU setting," it is summarized in this abstract: 

The article discusses the exclusion of babies from the benefits of meaningful use standards. This will undermine the goal of decreasing health disparities in the Affordable Care Act (ACA). Transition of the healthcare system to electronic medical records (EMRs) and the unsuitability of meaningful use standards for the neonatal intensive care unit (NICU) are the reasons hospitals are left without a means of addressing patient needs in Health Information Technology (HIT) when it comes to babies.

Here's an excerpt:

It is difficult to determine why babies were not considered when meaningful use standards were created.  Perhaps the reason resides in the fact that the exemplar HIT model for meaningful use is that used by the Veterans Administration and the VA does not see babies.  Perhaps it is because neonatal care requires different thought processes and benchmarking that time constraints ruled out. In any case, this is a justice issue for a vulnerable group.

Stuart argues, in fact, that babies under 2 years old should be considered a special category with increased incentives rather than no incentives. 

I wish you could read the article for yourself, as it is quite persuasive, but unfortunately it requires a fee or a subscription.

On that point, here's some free political advice to the neonatologists. You have important things to say to the body politic. Put pressure on your journals to make public policy articles like this free and widely available so that your advocates can use them to support your positions. The New England Journal of Medicine does so with no loss of revenue and with a concomitant increase in political influence.

Drowning does not look like drowning (reprise)

Back in 2010, I published a story entitled "Drowning does not look like drowning," based on a note sent to me by Jim Weadick, CEO of Newton Medical Center, in Covington, Ga.  The key phrase:  This article is on what it looks like when someone is drowning. It's not like in the movies.  

It's a good time for a reminder now that summer is here.  Mario Vittone has republished the article in Slate.  Excerpt:

The Instinctive Drowning Response . . . is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind.

So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.

No meaningful use help for nursing homes

One of the things I learned from Holly Jarek at Seven Hills Pediatric Center is that pediatric nursing homes are not eligible for federal funding support for electronic health records (i.e, for "meaningful use.")  The problem this raises is that the patient information systems between this kind of nursing homes (and adult ones, too) are therefore not integrated with the hospitals and physicians that serve these patients.  The patients with the severe complex conditions found at Seven Hills are quite likely to need emergency or other treatment at Children's Hospital or other facilities.  Holly pointed out that the lack of a common EHR interfered with management of patient care.

Using the crowdsourcing capability of Twitter, I asked my followers how this exclusion came to pass.  Ashish @ashishkjha Jha quickly answered:  "MU $ not available to nursing homes etc. A financial call when HITECH put together. Not enough $ to go around."

When I responded that this was a shame, he expanded on the thought:  "We wrote a paper about ineligible providers and potential implication for fragmentation. It's a challenge."

Indeed.  Here's a link to the paper. Here's the abstract, with emphasis added:

The US government has dedicated substantial resources to help certain providers, such as short-term acute care hospitals and physicians, adopt and meaningfully use electronic health record (EHR) systems. We used national data to determine adoption rates of EHR systems among all types of inpatient providers that were ineligible for these same federal meaningful-use incentives: long-term acute care hospitals, rehabilitation hospitals, and psychiatric hospitals. Adoption rates for these institutions were dismally low: less than half of the rate among short-term acute care hospitals. Specifically, 12 percent of short-term acute care hospitals have at least a basic EHR system, compared with 6 percent of long-term acute care hospitals, 4 percent of rehabilitation hospitals, and 2 percent of psychiatric hospitals. To advance the creation of a nationwide health information technology infrastructure, federal and state policy makers should consider additional measures, such as adopting health information technology standards and EHR system certification criteria appropriate for these ineligible hospitals; including such hospitals in state health information exchange programs; and establishing low-interest loan programs for the acquisition and use of certified EHR systems by ineligible providers.

Goal Play! is now on Audible.com

My book Goal Play! Leadership Lessons from the Soccer Field is now available as an audiobook on Audible.com.  It will be available on iTunes and Amazon.com within the next few days.  Please check it out and listen to a free sample.

Of course, the actual book is still available on Amazon (in print and Kindle versions) and at Smashwords in almost in any e-book format you might desire:  Apple iPad/iBooks, Nook, Sony Reader, Kobo, and most e-reading apps including Stanza, Aldiko, Adobe Digital Editions.

How a market works

The landscape company I use bills me on a fee-for-service basis.  I get billed for every time they cut the grass. Sometimes, I think they cut it too often.

I guess I could offer to pay them a monthly retainer (global payment) instead, but then they would have an incentive to not cut the grass often enough.  Also, during the dry summer months when the grass doesn't grow, I would be paying them for nothing.

Or I could not have them on contract at all and call them when I need them, but they might not be available.  Then, I would have to spend time shopping around to see who is available at that time.

Or I could buy a lawnmower and cut the grass myself, but then I would have to use time I'd rather spend refereeing soccer games or doing something else.  Plus, I like the idea that I am helping to provide jobs in my community.

Or I could dig up the lawn and plant ground cover instead.

Time running out on a good deal at Tufts

Lisa @lisagualtieri Gualtieri at Tufts University School of Medicine reminds us that the early registration discount for Digital Strategies for Health Communication ends tomorrow.  Here are the details. 

Digital Strategies for Health Communication covers how to develop a digital strategy to drive a health organization’s online presence, specifically the selection, management, and evaluation of web, social media, and mobile technologies. This skills-based course featuring case studies and guest lecturers from organizations such as Massachusetts Medical Society, Consumer Reports, and ABC Health News. The course runs from July 14-19, 2013 on the Tufts University School of Medicine Boston campus. Enroll for early registration discount before June 5, 2013.

Blue Button CoDesign Challenge

Pat @Docweighsin Salber informs us of a crowdsourcing approach to designing medical information systems.  The folks at Health Tech Hatch, who are working with Rebecca Mitchell Coelius and Adam Wong at the Division of Science and Innovation in the Office of the National Coordinator for Health IT, ask:

Blue Button is a symbol for easy, online access to your own health information, including clinical and financial data. What tools and applications do you need to make sense of the data and take care of yourself and your family? Tell us and vote on other ideas through June 11th! Over the summer developers across the country will build the most popular submissions and then in August you will choose the winner.

This is a lovely and innovative idea.  Anyone can participate. As of the moment I am writing this, the most popular idea is:

Please help my wife...

Manage our children's immunizations! As any mother knows managing immunizations for children can be a huge hassle. Not only is it a hassle, but there there are well documented dangers of not getting the proper immunizations at the right time and being over immunized (not to mention the costs on the latter). We have 3 children under 6 and a fourth one on the way. I have literally taken phone calls from my wife crying, frustrated that she had to take all three kids to the doctor's office and wait an hour to get a nurse print the immunization records so that we can take a trip or enroll them in school. All states have an immunization registry that is funded by the CDC. We also have a HealthVault account for all of our kids. Can someone please build a HealthVault app to leverage BlueButton+ to aggregate and allow us to manage our kids immunizations? An added plus would be the ability to easily share (print, email, fax?) the records to the school or other necessary recipient!

Another side of health care

Many months ago, Holly Jarek wrote to me:  "I was wondering if sometime in the future, we might schedule a visit for you to come out and see Seven Hills Pediatric Center. Would love the opportunity to share another side of health care with you."

Well, "sometime" finally happened, and I had a chance to visit this pediatric nursing home in Groton, MA.  This is one of several such facilities across the country, serving an estimated 6000 or so residents who are cognitively under the age of 12 months and are non-ambulatory.  Many require oxygen, feeding tubes, tracheostomies, and other complex medical equipment.  The vast majority are on permanent formula diets.  The 80+ children at Seven Hills receive all necessary medical, nursing, therapy and leisure services.  They also attend a private, special education school, go on field trips and participate in community activities.  Because there is no other place for them to go upon reaching adulthood (age 22), they stay on.  One resident is in his 30s.

Funding for the medical services is provided by Medicaid.  Funding for the school programs is provided under the state's special education laws by the school districts from which the children come.  A small amount of additional funding comes from the state DSS.

An adjacent dental clinic provides dental services for the residents but also other developmentally disabled people in the community.

Eyal Cohen and others have noted, "Increasing prevalence of children with complex and chronic diseases has occurred in the last half century and will likely continue to occur." Why? Well, the good news is that medical advances in neonatal intensive care and trauma care have saved lives of children who previously would have died.  The bad news is that some of those who have been saved end up with the kinds of impairments that lead them to places like Seven Hills.  These patients require care that is much more expensive than others.  Cohen and others note (in a review of Canadian patients), "Although a small proportion of the population, CMC (children with medical complexity) account for a substantial proportion of health care costs."  A recent unpublished presentation about North Carolina noted the same thing, with 5% of children under 18 incurring 54% of the cost for children’s care in Medicaid.

The current political environment for this kind of care is not good.  Let's start with the votes:  48 million Medicare voters versus 0 children voters!  But beyond this, the current focus on Medicaid is on budget cuts.  Where expansion is being considered, it is adult-centric.  Safety net hospitals are seeing phased reductions under the health reform law.

So the prognosis for organizations like Seven Hills that take care of severe cases, as well as others that take care of other children with medical complexity, is an increased demand for their services combined with a disproportionate reduction in state and federal support.  This group thus joins other disenfranchised sectors of the health care community while the government pours money into those sectors with the political power to get what they want when they want it.

One of these three is not like the others

I borrow this old expression from Sesame Street to present a contrast that is indicative of the health care environment in the US, made all the more poignant by the fact that this is occurring in our nation's capital.

This is United Medical Center, a safety net hospital serving one the poorest parts of the District of Columbia.  The Washington Post reports that the District paid $12 million to Huron Healthcare to operate the hospital and make recommendations for its future.

Under its contract, Huron assumed management of United Medical Center in late March. It is undertaking a “strategic review” of the hospital’s operations and is expected to develop a proposal to help turn around the hospital in the coming weeks for the approval of the hospital’s board in July.

(By the way, I provided recommendations pro bono a few months ago.  Remind me to raise my rates!)

That UMC is failing financially is a multifaceted problem, but it basically a result of the structure of compensation provided to safety net hospitals.  The body politic in DC--including the US Congress and the current Administration--has failed to deal with the issue.  The result is a degradation in the quality and availability of service to people in this neighborhood.  As I have said:

The DC government and local constituencies 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."

Meanwhile, look what's happening a few miles away, as a result of the kind of federal commitment that can send tens of millions of dollars to wasteful clinical endeavors.  This is MedStar Georgetown University Hospital:

This is Sibley Memorial Hospital, affiliated with Johns Hopkins Medicine:

This is a map of their relative locations, about 3 miles apart:

The two hospitals have both just received permission from the District of Columbia to install proton beam radiation therapy machines, at a total cost of $153 million.  The Post notes:

The decision has been closely followed by health experts because critics say it reflects a nationwide medical arms race, as hospitals scramble for dominance by investing millions of dollars in technology that has not been proven to be better than cheaper alternatives for some cancers.

Jenny Gold at NPR reported:

"Neither [Hopkins nor MedStar] should be building," says Dr. Ezekiel Emanuel, a former health care adviser to the Obama administration who is now at the University of Pennsylvania. "We don't have evidence that there's a need for them in terms of medical care. They're simply done to generate profits."

Meanwhile, another facility, the Maryland Proton Treatment Center, is already being built 40 miles away in downtown Baltimore.

The organization that is making this possible is CMS, which has set rates for use of proton beams for "normal" cancer therapy that far exceed their value compared to traditional forms of radiotherapy.

Dr. Emanuel was a key advisor to President Obama on health care issues. He and others in the administration have had years to fix this problem, but they have not.  When I recently asked a high ranking CMS official why they didn't act to change this payment scheme, s/he answered, "I think you know the reason why."  The reason why, obviously, was that political pressure from those who stand to benefit from the medical arms race have enough influence on the federal agencies to protect the status quo.

When we compare the outright waste of tens of millions of dollars on duplicate machines of unproven clinical effectiveness with the human suffering that results from the degradation of places like United Medical Center, we see political corruption of the highest order.  I am not suggesting personal corruption, nor I am suggesting that either political party is solely responsible.  I am suggesting corruption of political processes to protect the strong, big, and well connected at the expense of the poor and less powerful.

Goal Play! goes electronic--in every format

My book Goal Play!, which has been available for some time only on Amazon (in print and Kindle versions), is now available at Smashwords in almost in any e-book format you might desire:  Apple iPad/iBooks, Nook, Sony Reader, Kobo, and most e-reading apps including Stanza, Aldiko, Adobe Digital Editions.  Here's your chance to add it to your digital library.

(My other book, How a Blog held off the Most Powerful Union in America, is also available on Amazon in print and Kindle versions and on Smashwords in all of these e-book formats.)

David Hartzband on Patient-Centered Coordination of Care

Trust Frameworks and Asymptotic Identity Proofing:

A Systems Approach

MIT SDM Systems Thinking Webinar Series

David Hartzband, D.Sc., Lecturer, MIT Engineering Systems Division.

Date: June 3, 2013

Time: Noon – 1pm EDT

Free and open to all

Register

About the Presentation

This webinar is based on Dr. Hartzband's work as PI for a grant entitled “An Identity Ecosystem for Patient-Centered Coordination of Care.”  He will describe how two health information exchanges link with a unique policy-enabled authentication, authorization, and identity proofing system that can gather and utilize identity attributes from disparate sources and use them to provide a very high level of assurance for cyber identities. This systems-based approach can be useful to consider in many other industries.

Dr. Hartzband will discuss several use cases from the grant pilot, as well as the following topics:
• The need for trusted identities in healthcare (and elsewhere)

• The role of identity in online privacy and security

• The design of the NSTIC healthcare project and pilot

• The architecture and function of identity syndication

• A probability model for identity syndication

• What’s next in the development of trusted identities

We invite you to join us!

Sorry, your study is not PC . . . yet.

@JordanRau at @KHNews (Kaiser Health News) has correctly framed the public policy issue raised by a new report:

The idea that uneven Medicare health care spending around the country is due to wasteful practices and overtreatment—a concept that influenced the federal health law -- takes another hit in a study published Tuesday. The paper concludes that health differences around the country explain between 75 percent and 85 percent of the cost variations

“People really are sicker in some parts of the country,” said Dr. Patrick Romano, one of the authors.

That’s a sour assessment for those hoping to wring large savings out of the health care system by making it more efficient. Some, such as President Barack Obama’s former budget director, Peter Orszag, assert that geographic variations in spending could mean that nearly a third of Medicare spending may be unnecessary.

I hold no brief for this study, or for the previous ones by the folks at Dartmouth.  What I view as interesting is the manner in which public policy in the health care arena is or is not whipsawed by the latest study.  What would happen now if a major part of the framework for ACOs, risk-based contracting, and increased concentration of the health care industry is viewed as up for grabs?

Here's what I predict.  That re-evaluation will not happen, at least right away.  The new report will be viewed as politically incorrect, disagreeably contradicting the current views of many parties who now have a vested interest in the new direction of the national health care system.  It's methodology will be critiqued by those benefiting from the new status quo--just as the Dartmouth report was critiqued for many years with those benefiting from the old status quo.  Then, the conclusions will take hold, and policy will shift again.

It takes a while for a pendulum to reach its high point and for momentum to shift, but gravity is not just a good idea:  It's the law.

Subversive brand readjustment at Abercrombie

The e-pages have been full of stories about the statements made by the CEO of Abercrombie, e.g., “Candidly, we go after the cool kids. We go after the attractive all-American kid with a great attitude and a lot of friends. A lot of people don’t belong [in our clothes], and they can’t belong” and “I don’t want our core customers to see people who aren’t as hot as them wearing our clothing.”

He also said that the communication between "hot people" is his primary marketing tactic: “It’s almost everything. That’s why we hire good-looking people in our stores. Because good-looking people attract other good-looking people, and we want to market to cool, good-looking people. We don’t market to anyone other than that,” he said.

Here's a first-person validation of this from a young friend of mine:

The first time I went in to buy a pair of shorts and the woman at the counter asked if I lived around here. Right after I said yes, she asked if I needed a summer job and said I would be "great." I remember her actually making me feel really good! I decided to take it and went back to the store for an "interview" where they asked about my personal style, but I remember feeling very uncomfortable. She took a photo of me to send to the national office, they recruit all of their models from their stores. They told me my title would be "store model" where I would just greet people who came in. I went back another time to buy clothing for the position (over 90 dollars, they didn't have my discount in the system yet) and everyone there told me not to take the job. They kept everyone who was not white in the back room of the store as well. They seemed extremely unhappy. I called and said I wasn't going to take the position and went to a different Abercrombie to return the clothing. As soon as I walked in, an employee followed me around the store to the register and asked me if I lived around here, and then immediately offered me a summer job

It's hard to know what to do to counter this approach and the CEO's view of the world.  After all, if you're not "hot" or "cool," a boycott won't do much good!  One person has creatively taken on a subversive crusade to create a "brand readjustment."  Check out this article. Excerpt:

Greg Karber posted a YouTube video entitled “Abercrombie & Fitch Gets a Brand Readjustment #FitchTheHomeless,” which asks the public to go to their local thrift shops and purchase all of the Abercrombie & Fitch they can possibly grab and distribute the clothes to the homeless.

“Together, we can make Abercrombie & Fitch the world’s number one brand of homeless apparel,” Karber says in the video.

Screening inpatients for MRSA—case closed.

It isn't often that you see a headline like this in the medical world.  But such are the conclusions reached by Michael B. Edmond, M.D., M.P.H., and Richard P. Wenzel, M.D.in an editorial in the New England Journal of Medicine.  The editorial commented on the results of an extensive study by Susan S. Huang et al published by NEJM, entitled, "Targeted versus Universal Decolonization to Prevent ICU Infection."

This is a big deal. For a number of years, people have been arguing over the issue of whether screening patients for methicillin-resistant Staphylococcus aureus, or MRSA, with subsequent isolation, would be better than a generalized (non-pathogen specific) infection control approach.  As explained by Edmond and Wenzel, that study concluded:

Active detection and isolation without decolonization was not effective in reducing rates of MRSA-positive clinical cultures, MRSA bloodstream infections, or bloodstream infections from any pathogen. In contrast, targeted and universal decolonization resulted in significant reductions in MRSA-positive clinical cultures and bloodstream infections from any pathogen but not MRSA bloodstream infections; however, the effect of universal decolonization was greater than the effect of targeted decolonization.

The study design was as follows:

We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital.

The results:

Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation.

(Note: Universal decolonization was accomplished with intranasal mupirocin for 5 days and chlorhexidine bathing for the entire ICU stay.) 

The editorial concludes (with my emphasis):

The implications of this study are highly important. The lack of effectiveness of active detection and isolation should prompt hospitals to discontinue the practice for control of endemic MRSA. A benefit will be a reduced proportion of patients requiring contact precautions, which is a patient-unfriendly practice that interferes with care. In addition, the folly of pursuing legislative mandates when evidence is lacking has been shown, and laws mandating MRSA screening should be repealed.

Lastly, this study has implications beyond MRSA. New resistance mechanisms continue to emerge in nosocomial pathogens. The recent dissemination of carbapenem-resistant Enterobacteriaceae has stimulated calls to implement active detection and isolation for these organisms. We hope that the results of this study will redirect that discussion and reinforce the utility of horizontal interventions to control not only the pathogens of today but those of tomorrow as well.

When good teams go wrong

Please take a look over at Athenahealth's Leadership Forum:  A new post about common lessons about dysfunctional teams and leaders from sewage treatment (really!), the IRS (also!), and hospitals (of course!).

Options? Subprime wasn't enough for you?

Do you have the same reaction as I when you read this New York Times article?  Excerpts:

Some of the brokerage firms that helped pique Americans' interest in stocks are now luring them into something much riskier: stock options. 

As the stock market soars to new heights, E*Trade, Ameritrade and Charles Schwab are advertising the potential rewards of options, which give buyers the right to buy or sell stocks at predetermined prices in the future. Options, like their cousins, futures, have traditionally been the domain of Wall Street traders. But the brokerage firms say futures and options can be profitable for ordinary investors, too — a claim that, while true, does not square with many investors’ actual experience.

Options?  Come on.  Most individual investors don't even know how to pick individual stocks, much less try to determine potential future valuations that would justify options.  The chance of financial disaster is high.  The article continues:

Analysis done for The New York Times by SigFig, a company that tracks 200,000 retail investors, showed that people who traded options last year received only about one-fifth the returns of people who did not trade options: 1.1 percent compared to 5.1 percent. 

All this is driven by greed, of course.

[E]xpansion of this business . . . has clearly been an area of growth. An analysis of scattered data from company filings and presentations indicates that derivatives trading, which includes options, has risen at all the major firms since the financial crisis of 2008, which left many Americans with big losses in their investment portfolios. 

At Ameritrade, which has been the most aggressive, derivatives trades accounted for about 40 percent of all customer trades last year — more than double what it was just five years ago. A vast majority of those trades were in options. 

The growth has been a big help for the online brokers at a time when stock trading has fallen. The commission on the average options trade is more than twice that on the average stock trade.

When a friend saw the Times article, she wrote me, "Aha! You have just explained why my assigned Ameritrade 'advisor' keeps bugging me and specifically suggested options a while ago. I know enough to know that's not for me."

But others are not so wary.  How can this be happening in an era of greater consumer protection in financial markets?  Well, that protection has not been forthcoming.  CNBC explains:

Dodd-Frank authorized the SEC to impose a fiduciary standard on brokers. But the agency, swamped with other rule-making related to the act, has so far done little. 

Under such a standard, hundreds of thousands of brokers would be legally obligated to act in their clients' best interests when recommending investment products. The most important change for consumers is that they would have greater legal standing to sue in cases where they had evidence they had been wronged.

At the moment, brokers (including people working for big Wall Street firms), small locally owned brokerages and insurers are obliged only to recommend "suitable" products. 

The new SEC chairperson wants to fix this, but look who is lining up against her:

Various interest groups are hardening their stands. The most powerful player is the Securities Industry and Financial Markets Association (SIFMA), which represents broker-dealers, including the big financial firms, such as Bank of America, Merrill Lynch and Charles Schwab. The stakes in an industry upheaval are big: According to Boston-based Aite Group, about 450,000 people give consumers financial advice; 45,000 to 50,000 of them work as registered investment advisors (RIAs) , and the rest operate under the aegis of broker-dealers. 

Until and unless the government acts, caveat emptor--and the seller, too, when it comes to options.

Closing the barn door after . . .

The State House News reports that the Massachusetts Health Policy Commission "has chosen the proposed merger of the large Partners Healthcare System and with the smaller South Shore Hospital for its first review . . . to examine the merger’s effects on costs and the health care market."

The HPC does not have veto authority over the merger.  It can delay it slightly, as the transaction cannot proceed until 30 days after its report is issued. "If it chooses, the commission may refer findings to the state attorney general for action on behalf of health care consumers."

What do the parties to the merger say?

In a commission filing, Partners Vice President Brent Henry wrote that the affiliation with South Shore “will enhance clinical care and is intended to yield economic and operational efficiencies” that are “expected to result in the delivery of high quality, cost effective health care to all patients served by the parties in Southeastern Massachusetts, expand access to needed health care services, and should contribute, over time, to moderating the rate of growth in health care expenditures for the benefit of patients and employers.”  In a separate filing, Richard Aubut, president of South Shore Hospital, used the exact same language to describe the anticipated impact of the merger.

To understand this fully, we need to understand that South Shore has been a vassal of Partners for years, with extremely close clinical relationships and referral patterns. The Patriot Ledger reported: 

Sarah Darcy, spokeswoman for South Shore Hospital, said the two hospitals have worked together since 2004 on providing a wide range of medical and surgical care. Among them are the Dana-Farber/Brigham and Women’s Cancer Center, the Breast Care Center, and a Harvard Medical School-affiliated surgical residency program at South Shore Hospital.

(See here for more detail with regard to cancer care, and here for the very close residency program for obstetrics and gynecology.)  Do you think it is a coincidence that it is only with the passage of the so-called "cost containment legislation" last summer that a formal merger is proceeding?  That legislation provides the framework for "state action" that will insulate Partners from future anti-trust action in this transaction.

Why?  Because the parties will be able to demonstrate "economic and operational efficiencies."  Consider the expansion of the Partners' EHR system, purchasing, cost of capital, and the like to this community hospital. At a small marginal cost, SSH will accrue major marginal benefits.  Expect Partners also to argue that consolidation will result in better care management for SSH's patients.

Who is going to make a counter case before the HPC and the AG?  No other hospital system will attempt to intervene, for fear that whatever metrics it would propose for the HPC or AG to slow down the PHS-SSH merger would also be used to slow down growth of their ACOs.

No, the market power card is no longer available to be played in Massachusetts.  Well done, Partners.

The only hope for consumers in the state is real-time transparency of the actual prices paid for care in the various health care systems, accompanied by real-time quality data.  Then, people would see that they are paying extra for little or nothing by insisting on insurance products with PHS doctors and hospitals.  Then, insurance products with lower-cost limited networks with equal or higher quality might have a chance to grow.

What price is correct for transparency?

As noted previously, the Massachusetts legislature has entrusted the handling of the all-payer claims database (APCD) to a new independent state agency, CHIA (Center for Health Information and Analysis) which has issued proposed regulations concerning the availability of the data.  Among the issues CHIA had to decide was what fee, if any, to charge for access to the data and the terms under which someone can request a waiver. Those regulations are here.  Here is an excerpt:

The proposed fees reflect the cost of systems analysis, program development, computer production, vendors’ fees, consulting services and other costs related to the production of any requested data. The proposed fees are based upon four factors: (1) the type applicant requesting the data; (2) the type and number of data files requested; (3)the data elements requested; and (4) the number of years of data requested.  The Center may reduce or waive the applicable fees for qualified applicants. 

The Massachusetts Hospital Association recently filed complaints about some aspects of those regulations:

When CHIA released its initial proposed APCD fee schedule in November 2012, a mid-size organization, such as a community hospital, would have had to pay as much as $39,375 for just one year of restricted data, which would be insufficient to study trends and analyze the impact of any interventions over time. Such a hospital would have to pay multiple times for the data it needs. Under CHIA’s new fee schedule, released this month, a provider organization requesting restricted data from all categories would have to pay $40,500. And while the proposed new fees were reduced for obtaining public, de-identified data, it would still cost a provider organization up to $15,000 for a single year/single use.

“MHA appreciates that CHIA significantly reduced the fees for researchers,” MHA’s Sr. Dir. of Managed Care Karen Granoff wrote in testimony in response to CHIA’s fee schedule. “Like researchers, providers have a legitimate need to access the data for all of the purposes outlined in Chapter 224, yet unless CHIA adjusts the fees and makes them more reasonable, it is unlikely that many providers will be able to take advantage of this resource.”

Granoff noted that APCD costs in neighboring New England states are significantly lower and she noted that hospitals already pay an assessment to fund CHIA’s budget.

“The proposed fees will discourage use of the data by providers at the same time that the state is trying to promote the use of transparency around care delivery and to encourage care coordination and a transition to population-based care delivery,” Granoff wrote. “It would be an unintended consequence if the Commonwealth’s multi-year, ambitious effort to control healthcare costs were to fail due to barriers to data access set up by the agency itself.”

I asked CHIA Commissioner Áron Boros if he would like to use this forum to respond to the MHA comments, and he kindly did so: 

As we consider adjustment to the fee schedule in light of the comments we received, we are conscious of CHIA's competing responsibilities: to defray the operational costs of the APCD while also maximizing its value by facilitating access to many diverse users. 

Over my term at CHIA, I am committed to continuously expanding the use of our data resources. Novel uses of public assets like the APCD hold the promise of accelerating improvements in cost and quality in Massachusetts. Fees are necessary part of the investment needed to support this future, but I welcome all thoughts on how to ensure such fees are appropriate.

Having served in fee-based agencies, I am acutely aware of the trade-offs facing CHA.  If it incurs direct costs in serving requests for data and does not have a state appropriation to pay those direct costs, the fees it charges must be compensatory for the work needed to satisfy the requests.  To the extent it waives fees, it would be required to add those amounts to the fees paid by others.  If there is a broad public interest--as here--in making data broadly available to those with insufficient resources to pay the direct costs, it turns to the Legislature and Governor to make those funds available.

In this instance, though, perhaps the rules could be read to mean that the MHA--a voluntary, not-for-profit organization with a strong emphasis on education programs--could make a single request on behalf of a group of hospitals who would share the data, reducing the cost for any one institution.

The best deal in America

@HopkinsMedicine quality and safety leaders Peter Pronovost and Cheryl Dennison Himmelfarb are offering a MOOC—a massive online open course--starting June 3.  See here for sign-up details.  It is free.

Peter explains more in this post:

Through the five-week course, participants will explore fundamental topics in the science of safety, patient safety culture, teamwork and communication, patient-centered care, and strategies for assessing and improving care. The course workload is two to five hours per week, which includes up to two hours of video instruction, as well as readings and assignments.

Clinicians, hospital administrators, students, patients—indeed anyone with an interest in this topic—should consider enrolling. Students receive a statement of accomplishment upon passing the course.

A+ for Canton-Potsdam Hospital

@TerryFairbanks, director of the National Center for Human Factors in Healthcare, sends this story from the Daily Courier-Observer with a note, "Great story of how one patient can transform a hospital." Indeed, also a great story about the transformational power of teamwork that extends throughout the front lines!  And the leadership that made this all possible.  Excerpts:

Canton-Potsdam Hospital, a not-for-profit facility with its main campus located in Potsdam, New York, was recognized with an “A” Hospital Safety Score by The Leapfrog Group, an independent national nonprofit run by employers and other large purchasers of health benefits. The A score was awarded in the latest update to the Hospital Safety Score, the A, B, C, D or F scores assigned to U.S. hospitals based on preventable medical errors, injuries accidents, and infections. The Hospital Safety Score [is] the first and only hospital safety rating to be peer-reviewed in the Journal of Patient Safety (April 2013),

“This is an honor that is shared across our organization,” said David B. Acker, FACHE, President and CEO of Canton-Potsdam Hospital. “It actually derives from the courage of a patient and her husband, who spoke to me back in 2009 about an infection acquired at our hospital that drastically curtailed their involvement in the community and enjoyment of life. The husband subsequently spoke to our entire staff through a series of meetings. The couple’s story was life-altering for them and for us and they share in this honor,” he said.

“Their experience set us on the path to a total redesign of our processes, extensive training in and reinforcement of best practices, investments in new equipment, commitment to gathering and using data to drive decisions, and a total, unwavering dedication to patient safety, always, in every situation,” said Mr. Acker, who credited everyone from physicians to housekeeping staff for working as a team to approach safety and quality proactively.

Emita's gift to her children

In honor of the yarzheit (anniversity) of my mother's death, I am reprinting a post from March 14, 2007.  The message remains important for all families, and I think she would have liked me to remind you.

In the story below, there is an important sentence: We discussed possible actions with Dr. X and decided to halt all invasive treatments, a course that my family has long agreed to.

I know from personal experience what this simple bit of family planning can mean for the terminally ill patient and for his or her relatives. My Mom's living will had this directive, among others:

That no extraordinary measures be used to prolong my life if in the sole judgment of my daughter and my physician such measures will not restore me to a level of life that is commensurate with the mental and, to a lesser degree, physical standards by which I have been fortunate enough to live. Without limitation, such extraordinary measures include cardiac and/or pulmonary resuscitation, mechanical respiration, tube (intravenous and/or nesogastric) feeding and antibiotics.

She wrote and signed this in the early 1990's, when she was in her early 70's and therefore likely well before it would be likely to be applied. The application of her directive occurred two years ago after an accident left her with a severe head injury and internal bleeding in her brain. When it became clear that, in her words, "the application of life-sustaining procedures would serve only to artificially prolong the moment of my death", my sisters and I were empowered to have a short and decisive conversation to remove the respirator and other measures that were keeping her alive. With no regrets on our part, she died just a few hours later.

Afterwards, the ICU nurse kindly reaffirmed our decision, saying to me: "You, of all people, know that we can keep people alive forever. You did the right thing. She would have spent the rest of her life on her back in a nursing home, unable to talk or move. Surely, she would not have wanted that."

A living will with this kind of advance directive is one of the greatest gifts a parent can give to his or her children. If you don't have one, or your parents don't, please have one prepared and discuss it with your relative while you are both still able to do so.

Some kind of service

Best (worst) hotel service story I have heard: My friend Ray is taking a nap in his room in the afternoon and has put up the "do not disturb" sign." The maid had not yet made up the room. Someone from the front desk calls on the room telephone, wakes him up, and asks, "Why do you have the 'do not disturb sign' up?"

More pain, please?

Have we gone overboard in hospitals in our desire to minimize pain?  Several years ago, there was a lot of effort to require hospitals to inquire of patients where on the 0-10 pain scale they fell.  This was a good idea for many reasons.

But has it led to overuse of opiates like morphine, particularly those self-administered using patient-controlled analgesia (PCA) pumps?

There have many articles on this topic expressing concern about depression of respiration to the point that the patient dies.  The Happy Hospitalist explains:

Why is PCA morphine dangerous?  Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea.  This is the cause of death in a heroin overdose.  This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news.  Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms.  This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside. 

The Joint Commission published a sentinel event alert on the matter in August 2012.  The JC addresses the question of monitoring by suggesting that hospitals should:

Create and implement policies and procedures for the ongoing clinical monitoring of patients receiving opioid therapy by performing serial assessments of the quality and adequacy of respiration and the depth of sedation. The organization will need to determine how often the assessments should take place and define the period of time that is appropriate to adequately observe trends.  Monitoring should be individualized according to the patient’s response.

We have to recognize, though, that while ICU patients might have continuous monitoring of respiration, the vast majority of patients on PCA pumps are those on the regular medical/surgical floors of the hospital.  They include "normal" (i.e., otherwise healthy) people recovering from orthopaedic surgery and other procedures.  But that normality does not exempt them from the kind of respiratory depression cited in the literature.

What is the systemic solution to ensure that the possibility of such a result is minimized? The patients with PCA pumps might have continuous oxygen saturation monitoring, but most certainly do not have continuous respiratory monitoring.  The "frequent documentation of respiratory rate" can fall victim to the many other responsibilities and distractions that nurses face.  (It was Anita Tucker at Harvard, I believe, who documented that nurses only spend 20% of their time at the bedside.  As this article reports, "She learned that nurses' time ticks by in minutes or fractions of minutes; their average task took just two minutes.")  Given the demands on nurses and the poor design of work flows with which most of them live, there is a some probability that a percentage of nurses will not accurately assess patients' respiratory rates.

While there are technical fixes to the problem of continuous respiratory monitoring that might prove useful*, I wonder how much of this problem is related to the antecedent decision to reduce pain to a very low level.  Is there a standard of care that is presumed to be appropriate by hospitals?  Is the goal to drive the pain level down to a 1 or 2, or is the goal to reach a level of 3 or 4?  Is there a thought given to the relative risks of different doses for a patient on a PAC morphine pump when the two goals are compared? For sure, reaching a pain level of 0 is noteworthy, but not if it is achieved by killing the patient.

---

Disclosure:  I am on the advisory board of a company that makes and sells instruments of this sort.

Stupid and cruel, both

One of the signs of political sickness in America is the degree to which some Republican governors, apparently out of sheer spite for President Obama, have decided to be both stupid and cruel to citizens in their own states.  I refer to those governors who have chosen not to permit their Medicaid-eligible residents to participate in the federally funded health care insurance subsidies under Obamacare (aka, Affordable Care Act.)

The deal is this:

The Act fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country.  Beginning in 2014 coverage for the newly eligible adults will be fully funded by the federal government for three years.  It will phase down to 90% by 2020. People newly eligible for Medicaid will receive a benchmark benefit or benchmark­ equivalent package that includes the minimum essential benefits provided in the Affordable Insurance Exchanges. The law includes a number of program and funding improvements to help ensure that people can receive long-term care services and supports in their home or the community.

I think there are about a dozen governors who have turned their back on their citizens.  Here's one example from Pennsylvania:

Pennsylvania Gov. Tom Corbett (R) announced Tuesday that his state will turn down the Medicaid expansion, becoming the first governor of a blue state to officially say no to the coverage provision of the Affordable Care Act that the Supreme Court made optional.

“At this time, without serious reforms, it would be financially unsustainable for Pennsylvania taxpayers, and I cannot recommend a dramatic Medicaid expansion,” Corbett wrote in a letter to U.S. Health and Human Services Secretary Kathleen Sebelius.

The decision will please conservative advocates who are urging leaders to stonewall Obamacare implementation. But it’s a blow to the many thousands of uninsured Pennsylvanians who would have received coverage through the program, which extends Medicaid eligibility to Americans up to 133 percent of the poverty line for participating states.

Something is seriously wrong with these people.  They are intentionally creating an uninsured underclass in their states.  I hope that the successors to these governors will see the light.