Tuesday, February 06, 2007
Congratulations to our competitors
Congratulations to North Shore Medical Center, Newton-Wellesley Hospital, and South Shore Hospital for being included in the Fifth Annual Health Grades Hospital Quality and Clinical Excellence Study. This study identifies hospitals that have below-average mortality rates and complications across a wide range of procedures and diagnoses. Medicare administrative data covering 40 million discharges from 2003 through 2005 were used to make these calculations. Of 4,971 hospitals nationwide, only 266 received this designation.
Monday, February 05, 2007
Thank you, Allegra Goodman
I just finished a great novel by Allegra Goodman called Intuition [Dial Press, 2006], which my wife recommended to me. I didn't know the topic when I picked it up, but it turns out to be about medical research. I don't want to give away the story, but I do want to give you a few excerpts. She has a deep understanding of the psychology of research and researchers, and her language is beautiful.
Here is one of the most lyrical descriptions I have seen of the nature of scientific research:
Science was all about failure, and bench work consisted primarily of setbacks. Conducting biological research was like climbing up a downward-moving escalator that then multiplied and divided and unzipped itself into a thousand new mutating walkways. The challenge was not to move upward or forward, but often only to stay upright. How satisfying, then, and how amusing when objects stayed in the same place, and forms and colors suddenly behaved predictably. These were the unexpected rewards of scientific life, the odd consistencies.
And the following marvelous insight about a researcher who falsifies data and who is unable to admit it to a colleague:
He didn't see. His guard was up again. Once more he maintained he had done nothing wrong. She wanted a confession, but he had nothing to confess. After all, he could not confess to [her] what he would not confess to himself. What he told himself about his work was not exactly what he had done. What he had done, not exactly what it should have been. Still, [his] own perceptions of his actions were coherent, internally consistent. He clung to his defense for safety.
Perhaps his work ... had been more about ideas than concrete facts; perhaps his findings had been intuitive rather than entirely empirical. He had not followed every rule.... He had not chosen to discuss every piece of data, but had run ahead with the smaller set of startling results he'd found. Still, aspects of his data were so compelling that in his mind they outweighed everything else. He had sifted out what was significant, and the rest had floated off like chaff.
And, finally, the dilemma of running a lab:
The postdocs answered to [the principal investigator], but she depended on them for the truth of their answers. She could not monitor them every minute of the day.
I have had the privilege of meeting many science researchers here and throughout the Boston area. Their dedication is inspiring, and their patience and fortitude is exemplary. This book presents a great story about the self-imposed and external pressures on scientists and their good and bad all-to-human response to those pressures. I recommend it highly.
Here is one of the most lyrical descriptions I have seen of the nature of scientific research:
Science was all about failure, and bench work consisted primarily of setbacks. Conducting biological research was like climbing up a downward-moving escalator that then multiplied and divided and unzipped itself into a thousand new mutating walkways. The challenge was not to move upward or forward, but often only to stay upright. How satisfying, then, and how amusing when objects stayed in the same place, and forms and colors suddenly behaved predictably. These were the unexpected rewards of scientific life, the odd consistencies.
And the following marvelous insight about a researcher who falsifies data and who is unable to admit it to a colleague:
He didn't see. His guard was up again. Once more he maintained he had done nothing wrong. She wanted a confession, but he had nothing to confess. After all, he could not confess to [her] what he would not confess to himself. What he told himself about his work was not exactly what he had done. What he had done, not exactly what it should have been. Still, [his] own perceptions of his actions were coherent, internally consistent. He clung to his defense for safety.
Perhaps his work ... had been more about ideas than concrete facts; perhaps his findings had been intuitive rather than entirely empirical. He had not followed every rule.... He had not chosen to discuss every piece of data, but had run ahead with the smaller set of startling results he'd found. Still, aspects of his data were so compelling that in his mind they outweighed everything else. He had sifted out what was significant, and the rest had floated off like chaff.
And, finally, the dilemma of running a lab:
The postdocs answered to [the principal investigator], but she depended on them for the truth of their answers. She could not monitor them every minute of the day.
I have had the privilege of meeting many science researchers here and throughout the Boston area. Their dedication is inspiring, and their patience and fortitude is exemplary. This book presents a great story about the self-imposed and external pressures on scientists and their good and bad all-to-human response to those pressures. I recommend it highly.
Sunday, February 04, 2007
In Pursuit of Patient Privacy
Some of you already know this. Apologies to you. Others may not.
Have you ever noticed that a hospital will not offer comments to newspapers and other media when there is a story on a patient complaint, a lawsuit, or other such matter? This is not part of a p.r. strategy to stonewall the reporter. It is because we are not permitted, under state and federal law, to comment on patient-specific matters.
The federal law that governs this, known as HIPAA, has very strict privacy provisions and very large penalties for those who violate them. In Massachusetts, there are even more stringent state statutes that supersede some of the federal rules.
Hospitals hold training sessions for new employees, interns, residents, and doctors on this stuff. Many of us also have electronic audit procedures in place to make sure that people who look at patient records are (1) authorized to do so and (2) are doing so for legitimate reasons. Here at BIDMC, only authorized people have access to our patient medical records system. And for these people, when they log into our view a record, there is an electronic "trail" that records when and why they did it. These audit results are regularly reviewed by our compliance people.
By the way, when a celebrity is in the house, we will often assign a fake patient name to the person. We will not confirm to the media that the person is a patient. Also, no enterprising fan or gossip columnist can slip through and call the hospital operator and ask to be connected to that person's room. We did have an amusing case in which we had done all of that to protect the privacy of a celebrity - who then called the media to make sure reporters would get a picture of him as s/he left the hospital!
(Of course, if a reporter wants to publicize his or her own hospital experience, that is a different matter. This can often result in an impressive program that helps educate thousands of people.)
But our rules go further than that. If you are a TV or newspaper photographer -- or even just a patient or visitor -- and want to take images on our property, you need to get prior permission and you need to be accompanied by one of our staff people when you are videotaping or photographing. Why? Because we do not want you to inadvertently capture the image of any patient and be able to display publicly the fact that that person was a patient.
One of the more sensitive questions occurs when one of our employees is a patient in our own hospital. Clearly, co-workers want to know enough offer support and encouragement and to visit their colleague. Here, too, we must be acutely sensitive of the desire to protect his or her privacy. Our folks always err on the side of confidentiality. But if the person happens to say, "You can tell people I am here and would like visitors", you can bet that there is a stream of well-wishers to that room!
To get back to the media, it can be frustrating to a hospital when a lawyer suing the hospital on behalf of a patient goes to a reporter to get a human interest story to engage public support that person's claim. We just cannot comment even if the claim is totally frivolous. We can't even comment if we think the claim is legitimate and that we have learned from the specific medical error. So, the TV or newspaper story can end up appearing one-sided -- and the hospital can look like it is stonewalling.
The better reporters and more responsible media outlets understand this and often will choose not to run stories of this nature. They know that they can be manipulated by a clever attorney in a heart-rending case with great human interest -- and they refuse to be used that way. Other media outlets will run the story anyway, even knowing that one side is legally handcuffed in its ability to respond.
I don't want this to change, notwithstanding the occasional discomfort to hospitals. In a society that is moving more and more to open access about all of our detailed life history, finances, habits, and other characteristics, let's hope that our medical history and experiences are kept behind an opaque veil.
Have you ever noticed that a hospital will not offer comments to newspapers and other media when there is a story on a patient complaint, a lawsuit, or other such matter? This is not part of a p.r. strategy to stonewall the reporter. It is because we are not permitted, under state and federal law, to comment on patient-specific matters.
The federal law that governs this, known as HIPAA, has very strict privacy provisions and very large penalties for those who violate them. In Massachusetts, there are even more stringent state statutes that supersede some of the federal rules.
Hospitals hold training sessions for new employees, interns, residents, and doctors on this stuff. Many of us also have electronic audit procedures in place to make sure that people who look at patient records are (1) authorized to do so and (2) are doing so for legitimate reasons. Here at BIDMC, only authorized people have access to our patient medical records system. And for these people, when they log into our view a record, there is an electronic "trail" that records when and why they did it. These audit results are regularly reviewed by our compliance people.
By the way, when a celebrity is in the house, we will often assign a fake patient name to the person. We will not confirm to the media that the person is a patient. Also, no enterprising fan or gossip columnist can slip through and call the hospital operator and ask to be connected to that person's room. We did have an amusing case in which we had done all of that to protect the privacy of a celebrity - who then called the media to make sure reporters would get a picture of him as s/he left the hospital!
(Of course, if a reporter wants to publicize his or her own hospital experience, that is a different matter. This can often result in an impressive program that helps educate thousands of people.)
But our rules go further than that. If you are a TV or newspaper photographer -- or even just a patient or visitor -- and want to take images on our property, you need to get prior permission and you need to be accompanied by one of our staff people when you are videotaping or photographing. Why? Because we do not want you to inadvertently capture the image of any patient and be able to display publicly the fact that that person was a patient.
One of the more sensitive questions occurs when one of our employees is a patient in our own hospital. Clearly, co-workers want to know enough offer support and encouragement and to visit their colleague. Here, too, we must be acutely sensitive of the desire to protect his or her privacy. Our folks always err on the side of confidentiality. But if the person happens to say, "You can tell people I am here and would like visitors", you can bet that there is a stream of well-wishers to that room!
To get back to the media, it can be frustrating to a hospital when a lawyer suing the hospital on behalf of a patient goes to a reporter to get a human interest story to engage public support that person's claim. We just cannot comment even if the claim is totally frivolous. We can't even comment if we think the claim is legitimate and that we have learned from the specific medical error. So, the TV or newspaper story can end up appearing one-sided -- and the hospital can look like it is stonewalling.
The better reporters and more responsible media outlets understand this and often will choose not to run stories of this nature. They know that they can be manipulated by a clever attorney in a heart-rending case with great human interest -- and they refuse to be used that way. Other media outlets will run the story anyway, even knowing that one side is legally handcuffed in its ability to respond.
I don't want this to change, notwithstanding the occasional discomfort to hospitals. In a society that is moving more and more to open access about all of our detailed life history, finances, habits, and other characteristics, let's hope that our medical history and experiences are kept behind an opaque veil.
Friday, February 02, 2007
Excelling in Hospital Information Systems (not only for geeks!)
OK, I am here to brag again. Use your browser to forward to the next blog if you don't want to see this.
There is a lot of talk about how hospitals are in the age of the abacus when it comes to information systems. BIDMC is not. Our CIO, Dr. John Halamka, and his team have built a set of administrative and clinical applications in our place that lead the country. Here is part of his semi-annual report, the part dealing with just the clinical matters. Tell me if your place comes anywhere close to this!
As I have done in previous years, the following is a mid-year progress report about our FY07 major IS initiatives.
Clinically, we are focused on quality improvement, patient-centered care and pay for performance projects.
We have built and gone live with a Perioperative Management System for Operating Room scheduling and workflow enhancement in all BIDMC surgical locations. In December, we added Specimen Tracking to the OR to ensure all tissue removed from patients is delivered to pathology, analyzed, and reported back to the appropriate clinician. In the Spring, we will add OR charging by exception and later this year, we will implement perioperative provider order entry (POE) in the OR holding area and begin work on adding large LCD dashboard displays to our ORs.
We have implemented our ambulatory medical record, webOMR, to all HMFP and BIDPO practices eligible for a hospital-based electronic health record. webOMR now includes e-Prescribing and we are one of the first hospitals in the country to automate prescription routing. In the next few weeks, ePrescribing will include formulary checking to ensure that clinicians choose medications that are covered by the patient's insurance. We have also implemented an automated results notification system that alerts ordering physicians to new laboratory, pathology and radiology results. We have chartered a Users Group to prioritize future webOMR enhancements.
We have launched a new intranet portal at which offers single sign on and remote access to most applications, news feeds and customizable links for research, clinical, education, human resources and departmental content. We are working with Corporate Communications to replace the BIDMC external website and add many advanced web features.
We have developed a strategy for providing a hosted electronic health record for non-owned clinicians at non-BIDMC sites of service. This system includes the ability to view all BIDMC clinical data and order tests from within a commercially developed electronic medical record/practice management system, eClinicalWorks.
We designed and implemented an innovative Oncology Management System, which automates all aspects of chemotherapy ordering and treatment. We have also developed a medication reconciliation system which enhances patient safety and complies with JCAHO best practices.
To help improve inpatient vaccination rates, we developed a new system of prompts and reminders for influenza vaccine, and we will enhance the existing system for pneumovax. Also, to improve safety, we developed and deployed an adverse events tracking system in collaboration with Healthcare Quality. As part of our ongoing work to automate inpatient documentation, we will begin work this year on a suite of automated clinical documentation tools.
We are completing our MetaVision Critical Care System pilot this year and if the pilot is successful, we will replace our existing critical care application. This new system provides multidisciplinary clinical charting and tools for measuring quality. Examples of such measurement include Central line infection, ventilator associated pneumonia, and real time alerts based on clinical protocols.
We have obtained funding for expansion of the automated labor and delivery application, OBTV, to the Emergency Department and will be installing the upgrade this Spring. This will further enhance patient safety by providing remote real-time fetal tracing surveillance and alerting of ED patients by Labor & Delivery experts.
We have completed the first phase of our Positive Patient ID wrist band project and currently 80% of all patients have bar codes to ensure positive identification when receiving medication or giving blood samples. We will pilot a process to bar code employee badges and plan the bar coding of medications this year. These initiatives lay the foundation for the creation of an electronic medical administration record in the near future, replacing the current paper process and implementing bar coding technology in support of patient safety initiatives already underway.
We are implementing a new lab system which includes chemistry, hematology, pathology, blood bank and microbiology lab support. This new system will be one of the first systems to utilize the bar coded wristbands generated by the Positive Patient ID initiative. It will track specimens from the time they are ordered to the time results are made available for viewing and will streamline lab operations. Results generated from inpatient glucometer measurements will also be available on-line.
We are implementing and supporting several department specific quality registries as prioritized by the new Registry Committee.
We are in the final stages of selecting a new radiology information system (RIS). We’re also working collaboratively with all departments at BIDMC to develop an enterprise-wide image management (PACS) strategy. Areas of focus include identification of technical commonalities among various systems that could create economy of scale benefits for the medical center, comprehensive back-up and disaster recovery planning for all PACS data and a consolidated approach to ensure all images are available to all clinicians.
Within Radiation Oncology, initiatives underway include interfacing electronic charting software to the medical center’s billing system to ensure accuracy, implementing WebOMR within the department to reduce paper charting errors, and aligning all our IS efforts to ensure we provide optimal support for the entire cancer care process.
We have implemented the 3M System for Case Management, DRG Nurse Reviewers, Audit/Denial Management and will soon implement abstracting for coding. The system enables case managers to use Interqual criteria to make decisions about medical necessity and continued stay on inpatients and observation visits. The DRG Nurse Reviewers using 3M have the ability to e-mail physician queries directly from the system regarding documentation improvement for coding.
The Lab Scanning Pilot went live in November 2006 for scanning Lab Requisitions viewable via a web application on the intranet portal. The next step is to implement Dermatology clinical documentation and Heme/Onc external lab reports scanning for viewing in webOMR. Our eScription voice recognition team is implementing new portable handheld devices and template processing in Orthopedics.
Medical Library services collaborated with Health Information Management to standardize medical abbreviations at BIDMC. We are currently investigating how to integrate "Do Not Use" and "Approved" abbreviations into webOMR.
Enough! Now, you see why I love this guy.
There is a lot of talk about how hospitals are in the age of the abacus when it comes to information systems. BIDMC is not. Our CIO, Dr. John Halamka, and his team have built a set of administrative and clinical applications in our place that lead the country. Here is part of his semi-annual report, the part dealing with just the clinical matters. Tell me if your place comes anywhere close to this!
As I have done in previous years, the following is a mid-year progress report about our FY07 major IS initiatives.
Clinically, we are focused on quality improvement, patient-centered care and pay for performance projects.
We have built and gone live with a Perioperative Management System for Operating Room scheduling and workflow enhancement in all BIDMC surgical locations. In December, we added Specimen Tracking to the OR to ensure all tissue removed from patients is delivered to pathology, analyzed, and reported back to the appropriate clinician. In the Spring, we will add OR charging by exception and later this year, we will implement perioperative provider order entry (POE) in the OR holding area and begin work on adding large LCD dashboard displays to our ORs.
We have implemented our ambulatory medical record, webOMR, to all HMFP and BIDPO practices eligible for a hospital-based electronic health record. webOMR now includes e-Prescribing and we are one of the first hospitals in the country to automate prescription routing. In the next few weeks, ePrescribing will include formulary checking to ensure that clinicians choose medications that are covered by the patient's insurance. We have also implemented an automated results notification system that alerts ordering physicians to new laboratory, pathology and radiology results. We have chartered a Users Group to prioritize future webOMR enhancements.
We have launched a new intranet portal at which offers single sign on and remote access to most applications, news feeds and customizable links for research, clinical, education, human resources and departmental content. We are working with Corporate Communications to replace the BIDMC external website and add many advanced web features.
We have developed a strategy for providing a hosted electronic health record for non-owned clinicians at non-BIDMC sites of service. This system includes the ability to view all BIDMC clinical data and order tests from within a commercially developed electronic medical record/practice management system, eClinicalWorks.
We designed and implemented an innovative Oncology Management System, which automates all aspects of chemotherapy ordering and treatment. We have also developed a medication reconciliation system which enhances patient safety and complies with JCAHO best practices.
To help improve inpatient vaccination rates, we developed a new system of prompts and reminders for influenza vaccine, and we will enhance the existing system for pneumovax. Also, to improve safety, we developed and deployed an adverse events tracking system in collaboration with Healthcare Quality. As part of our ongoing work to automate inpatient documentation, we will begin work this year on a suite of automated clinical documentation tools.
We are completing our MetaVision Critical Care System pilot this year and if the pilot is successful, we will replace our existing critical care application. This new system provides multidisciplinary clinical charting and tools for measuring quality. Examples of such measurement include Central line infection, ventilator associated pneumonia, and real time alerts based on clinical protocols.
We have obtained funding for expansion of the automated labor and delivery application, OBTV, to the Emergency Department and will be installing the upgrade this Spring. This will further enhance patient safety by providing remote real-time fetal tracing surveillance and alerting of ED patients by Labor & Delivery experts.
We have completed the first phase of our Positive Patient ID wrist band project and currently 80% of all patients have bar codes to ensure positive identification when receiving medication or giving blood samples. We will pilot a process to bar code employee badges and plan the bar coding of medications this year. These initiatives lay the foundation for the creation of an electronic medical administration record in the near future, replacing the current paper process and implementing bar coding technology in support of patient safety initiatives already underway.
We are implementing a new lab system which includes chemistry, hematology, pathology, blood bank and microbiology lab support. This new system will be one of the first systems to utilize the bar coded wristbands generated by the Positive Patient ID initiative. It will track specimens from the time they are ordered to the time results are made available for viewing and will streamline lab operations. Results generated from inpatient glucometer measurements will also be available on-line.
We are implementing and supporting several department specific quality registries as prioritized by the new Registry Committee.
We are in the final stages of selecting a new radiology information system (RIS). We’re also working collaboratively with all departments at BIDMC to develop an enterprise-wide image management (PACS) strategy. Areas of focus include identification of technical commonalities among various systems that could create economy of scale benefits for the medical center, comprehensive back-up and disaster recovery planning for all PACS data and a consolidated approach to ensure all images are available to all clinicians.
Within Radiation Oncology, initiatives underway include interfacing electronic charting software to the medical center’s billing system to ensure accuracy, implementing WebOMR within the department to reduce paper charting errors, and aligning all our IS efforts to ensure we provide optimal support for the entire cancer care process.
We have implemented the 3M System for Case Management, DRG Nurse Reviewers, Audit/Denial Management and will soon implement abstracting for coding. The system enables case managers to use Interqual criteria to make decisions about medical necessity and continued stay on inpatients and observation visits. The DRG Nurse Reviewers using 3M have the ability to e-mail physician queries directly from the system regarding documentation improvement for coding.
The Lab Scanning Pilot went live in November 2006 for scanning Lab Requisitions viewable via a web application on the intranet portal. The next step is to implement Dermatology clinical documentation and Heme/Onc external lab reports scanning for viewing in webOMR. Our eScription voice recognition team is implementing new portable handheld devices and template processing in Orthopedics.
Medical Library services collaborated with Health Information Management to standardize medical abbreviations at BIDMC. We are currently investigating how to integrate "Do Not Use" and "Approved" abbreviations into webOMR.
Enough! Now, you see why I love this guy.
Civic Duties
Warning: This is one of those butt-kissing, self-serving postings that some of you hate. It is so full of saccharine that you may gag. If you choose to read it and then want to complain, it is your own problem! That being said, it is an important aspect of running a hospital, so it deserves at least one entry on this blog.
Hospital CEOs are expected to do a good job running their hospitals. They are also expected to be leaders in their community. How well do we carry out those ancillary roles?
Several months ago, Ian Bowles, then heading MassINC and now a cabinet secretary in the new Deval Patrick administration, wrote an editorial pointing out that leaders of the non-profit sector in Boston, and the health care sector in particular, had a civic duty to become more engaged in public policy issues and other community activities. Ian echoed a theme that had been expressed earlier by Curtis Johnston and Neil Pierce, writing for the Boston Foundation.
They noted that the non-profits are now the largest corporations in Boston and, therefore they had to take on more of this mantle, which previously had resided with banks, insurance companies, and large manufacturers (many of which have since merged with national companies and moved their corporate headquarters elsewhere.)
I think Ian, Curtis, and Neil are right, but I think they neglected to mention that many hospital folks were already doing what they were suggesting. Here are some representative examples -- this is the butt-kissing part!
Hospital CEOs are expected to do a good job running their hospitals. They are also expected to be leaders in their community. How well do we carry out those ancillary roles?
Several months ago, Ian Bowles, then heading MassINC and now a cabinet secretary in the new Deval Patrick administration, wrote an editorial pointing out that leaders of the non-profit sector in Boston, and the health care sector in particular, had a civic duty to become more engaged in public policy issues and other community activities. Ian echoed a theme that had been expressed earlier by Curtis Johnston and Neil Pierce, writing for the Boston Foundation.
They noted that the non-profits are now the largest corporations in Boston and, therefore they had to take on more of this mantle, which previously had resided with banks, insurance companies, and large manufacturers (many of which have since merged with national companies and moved their corporate headquarters elsewhere.)
I think Ian, Curtis, and Neil are right, but I think they neglected to mention that many hospital folks were already doing what they were suggesting. Here are some representative examples -- this is the butt-kissing part!
- Jim Mongan, President and CEO of Partners Healthcare System, served as chairman of the Greater Boston Chamber of Commerce; has served on the board of the Kaiser Family Foundation; and was arguably one of the most important participants in the development of the recent health care reform legislation in MA.
- Gary Gottlieb, President of Brigham and Women's Hospital, co-chaired Mayor Menino's Task Force to Eliminate Ethnic and Racial Health Disparities, as well as working on a variety of other assignments for the City.
- Mike Jellinek, President of Newton-Wellesley Hospital, chaired a citizen's commission for the Mayor of Newton on the future of that city's high school.
- Ellen Zane, President and CEO, of Tufts-New England Medical Center, has been a director of Fiduciary Trust Company and a director of the John F. Kennedy Library Foundation.
- Elaine Ullian, President and CEO of Boston Medical Center has served as chair of Conference of Boston Teaching Hospitals and on the boards of Greater Boston Chamber of Commerce and Citizens Bank of Massachusetts.
That being said, these articles actually caused me to rethink my level of civic involvement and expand it. Fortunately, our hospital was also through its financial turn-around, so I had more time to engage in such things. So here is a list of my extracurricular activities, most of them new in the last two or three years: This is the self-serving part!
- Board member of the MIT Corporation, the Institute's governing body.
- Board member of the Celebrity Series, the largest local performing arts organization.
- Board member of A Better City, a business group advocating for enhanced city transportation, parks, and other quality-of-life development.
- Board member of ISO-New England, the regional electricity transmission organization.
- Chair of a citizens' commission reviewing the city budget for the Mayor and Aldermen of Newton.
For all of us, these activities are personally rewarding and informative. I know that I take no risk in saying on behalf of my colleagues that, to the extent we can contribute to the overall advancement of our city and region, we are grateful for the opportunity to be of service.
Thursday, February 01, 2007
Here are the transplant numbers for New England
Yesterday's posting raised some questions among some of my friends. In particular, they wanted to see the numbers. Here they are: Total abdominal (liver, kidney, pancreas) transplants for each of the hospitals in New England for 2004 and 2005. The number for 2006 only represents deceased donor organ transplants -- the live donor figures are not in yet.
Hospital -- 2004 -- 2005 -- 2006
BIDMC -- 124 -- 138 -- 86
MGH ---- 102 -- 153 -- 81
NEMC ---- 81 --- 65 -- 56
Lahey ---- 70 --- 75 --- 54
UMass --- 63 --- 71 --- 43
Children's - 20 -- 26 --- 26
Yale NH -- 63 -- 64 --- 62
Brigham --- 67 -- 65 --- 51
BMC ------ 29 -- 29 --- 27
RI Hosp --- 73 -- 76 --- 40
Maine MC - 66 -- 53 --- 52
DHMC ---- 36 --- 40 --- 43
Total -----794 -- 855 --621
There are multiple issues here, as I have discussed repeatedly (and probably ad nauseum to some of you!) One I have not mentioned is that smaller programs sometimes reject organs that are more problematic but usable because they don't have the technical expertise to handle the harder transplants -- and/or because they don't want to take the chance of harming their overall mortality statistics. This means patients listed in their locality have to wait longer for organs. So, is a small, local program always a good for the community? We often find ourselves in the position of being able to successfully use organs that have been rejected by less technically adept and/or more risk-averse transplant centers.
(By the way, although I include figures from Children's Hospital here, I recognize that pediatric transplants are a very special case and in no way would suggest that their program is too small.)
Hospital -- 2004 -- 2005 -- 2006
BIDMC -- 124 -- 138 -- 86
MGH ---- 102 -- 153 -- 81
NEMC ---- 81 --- 65 -- 56
Lahey ---- 70 --- 75 --- 54
UMass --- 63 --- 71 --- 43
Children's - 20 -- 26 --- 26
Yale NH -- 63 -- 64 --- 62
Brigham --- 67 -- 65 --- 51
BMC ------ 29 -- 29 --- 27
RI Hosp --- 73 -- 76 --- 40
Maine MC - 66 -- 53 --- 52
DHMC ---- 36 --- 40 --- 43
Total -----794 -- 855 --621
There are multiple issues here, as I have discussed repeatedly (and probably ad nauseum to some of you!) One I have not mentioned is that smaller programs sometimes reject organs that are more problematic but usable because they don't have the technical expertise to handle the harder transplants -- and/or because they don't want to take the chance of harming their overall mortality statistics. This means patients listed in their locality have to wait longer for organs. So, is a small, local program always a good for the community? We often find ourselves in the position of being able to successfully use organs that have been rejected by less technically adept and/or more risk-averse transplant centers.
(By the way, although I include figures from Children's Hospital here, I recognize that pediatric transplants are a very special case and in no way would suggest that their program is too small.)
Wednesday, January 31, 2007
Transplantation Darts and Laurels
The Columbia Journalism Review has a section called "Darts and Laurels", in which the editors offer short commentary on recent events in journalism, either negative or positive. With full credit and due respect to the CJR, I want to borrow their nomenclature and apply it to two recent items in the field of liver transplantation here in New England.
I understand fully that offering this kind of commentary about other hospitals is dangerous business, violating unspoken protocols in the health care field. But if we can't be open and forthright on matters relating to cost and quality, how can we expect the public to trust us? In the interest of full disclosure, I freely admit that my comments also can be viewed as an attempt to enhance BIDMC's competitive position in the region. But that does not necessarily mean that they do not have validity. You be the judge. The power of a blog like this is that anyone can offer comments in rebuttal -- or even set up their own blog.
First, a "laurel" to Dartmouth-Hitchcock Medical Center in Hanover, NH, for reportedly cancelling their plans to establish a liver transplantation program. As discussed on this blog on October 13, 2006, and as supported by commentors at that time, it is difficult to rationalize the establishment of this highly technical and expensive program for the very few patients who would be treated. We recently received word that these plans had been scuttled. If so, congratulations.
Next, a small "dart" to UMass Memorial Medial Center and Lahey Clinic for something that could otherwise be a big "laurel". In December, the two institutions announced a joint program in liver transplantation. This is a fine idea and shows the power of collaboration between two great places. But here's where we award a "dart":
UMass Memorial and Lahey Clinic will continue to function as independent transplant centers, caring for their own patients from intake to surgery, through continuing care. Surgeons and medical staff will have access to and privileges at each center and will perform operations, consult with patients, and provide post-operative care at both sites.
For the volume of liver transplants to be done in Worcester, and the relative number of faculty based at the two places, it probably makes more sense to move those patients to Lahey for surgery. Otherwise, Lahey doctors will have to travel an hour to go 50 miles to Worcester to perform surgeries and otherwise be on-call for patients there. This seems to be one of those examples where a slightly less convenient approach for those few patients would help maintain a greater critical mass for a program in one setting.
I hope to be proven wrong on this point, but I cannot imagine how asking Lahey doctors to commute to Worcester for a relatively small liver transplantation program will be a good use of their time or will optimize patient care and control costs overall.
I understand fully that offering this kind of commentary about other hospitals is dangerous business, violating unspoken protocols in the health care field. But if we can't be open and forthright on matters relating to cost and quality, how can we expect the public to trust us? In the interest of full disclosure, I freely admit that my comments also can be viewed as an attempt to enhance BIDMC's competitive position in the region. But that does not necessarily mean that they do not have validity. You be the judge. The power of a blog like this is that anyone can offer comments in rebuttal -- or even set up their own blog.
First, a "laurel" to Dartmouth-Hitchcock Medical Center in Hanover, NH, for reportedly cancelling their plans to establish a liver transplantation program. As discussed on this blog on October 13, 2006, and as supported by commentors at that time, it is difficult to rationalize the establishment of this highly technical and expensive program for the very few patients who would be treated. We recently received word that these plans had been scuttled. If so, congratulations.
Next, a small "dart" to UMass Memorial Medial Center and Lahey Clinic for something that could otherwise be a big "laurel". In December, the two institutions announced a joint program in liver transplantation. This is a fine idea and shows the power of collaboration between two great places. But here's where we award a "dart":
UMass Memorial and Lahey Clinic will continue to function as independent transplant centers, caring for their own patients from intake to surgery, through continuing care. Surgeons and medical staff will have access to and privileges at each center and will perform operations, consult with patients, and provide post-operative care at both sites.
For the volume of liver transplants to be done in Worcester, and the relative number of faculty based at the two places, it probably makes more sense to move those patients to Lahey for surgery. Otherwise, Lahey doctors will have to travel an hour to go 50 miles to Worcester to perform surgeries and otherwise be on-call for patients there. This seems to be one of those examples where a slightly less convenient approach for those few patients would help maintain a greater critical mass for a program in one setting.
I hope to be proven wrong on this point, but I cannot imagine how asking Lahey doctors to commute to Worcester for a relatively small liver transplantation program will be a good use of their time or will optimize patient care and control costs overall.
Tuesday, January 30, 2007
Helpful stuff on Prostate Disease
Marc B. Garnick, a physician in our Hematology/Oncology Division, is the brains and energy behind a new quarterly publication from Harvard Health Publications entitled Perspectives on Prostate Disease. Here is an excerpt from his introductory message in the first edition:
"Few men think about their prostate gland until they develop some kind of problem. Then it may be all they can think about.
"If you have recently been diagnosed with prostate disease, you know how difficult it can be to find the in-depth and reliable information that will help you make informed choices....
"Perspectives on Prostate Disease was created to address these issues. Our mission in launching this quarterly newsletter is to provide multiple perspectives about how best to treat the most common prostate diseases -- prostate cancer, benign prostatic hyperplasia, and postatitis -- as well as related conditions such as erectile dysfunction and low testosterone levels.
"To ensure that we provide readers with the most accurate and objective information possible, the editorial comment is devoid of any commercial bias. Perspectives is supported in part by a grant from a charitable nonprofit family foundation.... Our editorial board consists of eminent and respected Harvard and European physicians, all of whom have expertise in the disorders covered by Perspectives."
I have read through the first edition, and it is really, really good. Topics include:
"Few men think about their prostate gland until they develop some kind of problem. Then it may be all they can think about.
"If you have recently been diagnosed with prostate disease, you know how difficult it can be to find the in-depth and reliable information that will help you make informed choices....
"Perspectives on Prostate Disease was created to address these issues. Our mission in launching this quarterly newsletter is to provide multiple perspectives about how best to treat the most common prostate diseases -- prostate cancer, benign prostatic hyperplasia, and postatitis -- as well as related conditions such as erectile dysfunction and low testosterone levels.
"To ensure that we provide readers with the most accurate and objective information possible, the editorial comment is devoid of any commercial bias. Perspectives is supported in part by a grant from a charitable nonprofit family foundation.... Our editorial board consists of eminent and respected Harvard and European physicians, all of whom have expertise in the disorders covered by Perspectives."
I have read through the first edition, and it is really, really good. Topics include:
- Treat or wait?
- When to consider active surveillance
- A patient's story: Why one man opted for lifestyle changes instead of treatment
- A patient's story: Why one man chose robotic-assisted laparoscopic postatectomy
- Your benign prostatic hyperplasia medication: When to consider a change
- Harvard experts discuss benign prostatic hyperplasia drug treatments
- Search PubMed in five easy steps.
The next issue will include:
- Complementary therapies for prostate disease: What works, what doesn't
- What's new in treating erectile dysfunction
- How to handle a relapse: Your options if a PSA tests reveals your cancer has returned.
If you are interested in subscribing, please write to :
Perspectives on Prostate Disease
PO Box 9308
Big Sandy TX 75755-9308
or telephone: 877-649-9457
or visit http://www.harvardprostatehelp.com/.
Monday, January 29, 2007
Two new links
I have added a couple of new links in the menu to the right.
The one on the bottom is for the Boston Globe's new blog called White Coat Notes. Veteran reporter Elizabeth Cooney is handling this assignment, although she also gets help from other members of the Globe staff. You might want to sign up for a feed from this blog, as it will be updated quite often.
The one just above White Coat Notes is from a person named Ileana and is called Beating Social Anxiety. She is writing it to help her deal with this disorder. Please give it a visit and offer her encouragement.
Don't these two sites present an interesting microcosm of the blogosphere? From the large media company to a single individual, both reaching out to the world.
The one on the bottom is for the Boston Globe's new blog called White Coat Notes. Veteran reporter Elizabeth Cooney is handling this assignment, although she also gets help from other members of the Globe staff. You might want to sign up for a feed from this blog, as it will be updated quite often.
The one just above White Coat Notes is from a person named Ileana and is called Beating Social Anxiety. She is writing it to help her deal with this disorder. Please give it a visit and offer her encouragement.
Don't these two sites present an interesting microcosm of the blogosphere? From the large media company to a single individual, both reaching out to the world.
(BTW, the lemur has nothing to do with this. I'm just responding to lyss' request in the posting below under "More pictures from Madagascar".)
Sunday, January 28, 2007
Do I get paid too much?
Every year, the Boston Globe publishes a story listing the total compensation received by the CEOs of the major Boston hospitals. The story is derived from the Forms 990 that are filed by every non-profit, and the numbers are interesting enough that the story always gets good placement in the newspaper.
CEOs do not set their own salaries. Each hospital has a public board of trustees who determine the compensation for their chief executives and who also hold that CEO accountable for running the organization. The levels of compensation are subject to review by the Internal Revenue Service to ensure that they are within reason for that organization and compared to other organizations, and also to ensure that the board itself, rather than the CEO, has made the compensation decision.
Notwithstanding this level of legal guidance, the issue often arises as to whether hospital CEO salaries are out of line. Americans are often ambivalent about high salaries for corporate executives: They often complain about them, but, at the same, time, everybody hopes that he or she can someday earn them! Putting aside that personal sociological observation, let me ask you the question directly: Do you think I earn too much?
Here are the facts. As noted by the Globe, my total compensation was about $1 million in fiscal 2005. Of this, $650,000 was the base salary. Also, I was eligible for a 30% incentive compensation payment if the hospital achieved specified results for clinical quality, patient satisfaction, and financial performance. I received the full amount that year, $195,000. The rest of the million comprised payments made by BIDMC for life insurance and retirement. (Don't worry, there are no other perks, like cars or country club memberships!)
Now, some background on BIDMC: The hospital is a billion-dollar-a-year enterprise, about $800 million in clinical revenues and $200 million in research programs. Our annual capital budget is roughly in the range of $80 million. Last year, we raised $30 million in philanthropic donations from people in the community. We have facilities that cover about 3 million square feet. We see 50,000 emergency room visitors per year, 40,000 inpatients, and 500,000 outpatients. We have about 8,000 employees and about 800 doctors on staff. We are affiliated with six community health centers (one of which we own); several community hospitals and physician practices; and we own and run two off-site clinics in Chelsea and Lexington and one small community hospital in Needham.
So, if you were on my board, how would you set an appropriate salary? You might look at the competition, and as the Globe notes, the salaries for most of the Boston-area hospital CEOs center around the same level. Would you look at salaries of people in for-profit companies, and, if so, how do you measure comparable size and complexity? Would you look at salaries of other types of non-profits, like universities and museums?
Does it matter that the average tenure of a hospital CEO is under six years? If that is roughly the tenure of a major league baseball player, should CEO salaries be in the same ballpark? Sorry, I couldn't resist!
And, of course, how do you measure performance, so that the salary does not get out of whack with expected results. (By the way, for a broader survey of non-profit salaries, check out this site from Charity Navigator.)
This is serious business that affects both the perception of hospitals in the public eye and also the ability of hospitals to attract the talent they need to run a complicated organization that is vital to the community. What do you think: Do I get paid too much? Here is your chance to send a message to me, my board, or the community at large. I promise, all comments will be included (unless you use bad language!)
CEOs do not set their own salaries. Each hospital has a public board of trustees who determine the compensation for their chief executives and who also hold that CEO accountable for running the organization. The levels of compensation are subject to review by the Internal Revenue Service to ensure that they are within reason for that organization and compared to other organizations, and also to ensure that the board itself, rather than the CEO, has made the compensation decision.
Notwithstanding this level of legal guidance, the issue often arises as to whether hospital CEO salaries are out of line. Americans are often ambivalent about high salaries for corporate executives: They often complain about them, but, at the same, time, everybody hopes that he or she can someday earn them! Putting aside that personal sociological observation, let me ask you the question directly: Do you think I earn too much?
Here are the facts. As noted by the Globe, my total compensation was about $1 million in fiscal 2005. Of this, $650,000 was the base salary. Also, I was eligible for a 30% incentive compensation payment if the hospital achieved specified results for clinical quality, patient satisfaction, and financial performance. I received the full amount that year, $195,000. The rest of the million comprised payments made by BIDMC for life insurance and retirement. (Don't worry, there are no other perks, like cars or country club memberships!)
Now, some background on BIDMC: The hospital is a billion-dollar-a-year enterprise, about $800 million in clinical revenues and $200 million in research programs. Our annual capital budget is roughly in the range of $80 million. Last year, we raised $30 million in philanthropic donations from people in the community. We have facilities that cover about 3 million square feet. We see 50,000 emergency room visitors per year, 40,000 inpatients, and 500,000 outpatients. We have about 8,000 employees and about 800 doctors on staff. We are affiliated with six community health centers (one of which we own); several community hospitals and physician practices; and we own and run two off-site clinics in Chelsea and Lexington and one small community hospital in Needham.
So, if you were on my board, how would you set an appropriate salary? You might look at the competition, and as the Globe notes, the salaries for most of the Boston-area hospital CEOs center around the same level. Would you look at salaries of people in for-profit companies, and, if so, how do you measure comparable size and complexity? Would you look at salaries of other types of non-profits, like universities and museums?
Does it matter that the average tenure of a hospital CEO is under six years? If that is roughly the tenure of a major league baseball player, should CEO salaries be in the same ballpark? Sorry, I couldn't resist!
And, of course, how do you measure performance, so that the salary does not get out of whack with expected results. (By the way, for a broader survey of non-profit salaries, check out this site from Charity Navigator.)
This is serious business that affects both the perception of hospitals in the public eye and also the ability of hospitals to attract the talent they need to run a complicated organization that is vital to the community. What do you think: Do I get paid too much? Here is your chance to send a message to me, my board, or the community at large. I promise, all comments will be included (unless you use bad language!)
Thursday, January 25, 2007
Reducing Ventilator-Associated Pneumonia
Some patients go to the hospital because they have pneumonia. Other people go to the hospital for other reasons (e.g, stroke), are put on ventilators, and get pneumonia. We call this ventilator-associated pneumonia, or VAP. It is a big problem:
- It is common, with 10 to 20% of patients ventilated for two or more days;
- It is lethal, roughly doubling the risk of death;
- It is expensive, adding $20,000 to $40,000 in extra costs per case.
The good news is that it is often preventable, and we could be pretty good at preventing it if we took the right steps all the time. Our good friends at the Institute for Healthcare Improvement suggest the following "bundle" of steps to help avoid VAP:
- Elevation of the head of the bed;
- Daily "sedation vacation", i.e., some removal of sedation medication;
- Daily assessment of readiness to extubate, i.e, don't keep the breathing tube in longer than necessary;
- Stress ulcer disease prophylaxis, to reduce the risk of upper GI bleeding;
- Deep venous thrombosis prophylaxis, to prevent formation of embolisms.
So, if you want to reduce VAP, you institute this bundle of of steps. But, like your toughest sixth grade teacher would say, "There is no partial credit!" Unless you carry out all five steps, you do not get a perfect score.
We started working hard on this problem last year at BIDMC. Why? Because we looked at our rate of this disease, and we were not pleased. Here are our compliance scores on the IHI bundle, after lots of analysis, training, and follow-up:
FY06 Q3: 79%
FY06 Q4: 81%
FY07 Q1: 88%
FY07 Q2: 92% (only includes January, through today)
This looks pretty good, right? It appears that we are making constant improvement. Not so. Unfortunately, the quarterly figures mask monthly variations:
April 06: 83%
May 06: 74%
June 06: 82%
July 06: 80%
August 06: 76%
September 06: 86%
October 06: 92%
November 06: 85%
December 06: 87%
January 07: 92%
Still, the trend is good, but the difficulty of carrying out the full bundle for all patients is real. For example, we have virtually 100% compliance with stress ulcer disease prophylaxis; but we do not always carry out a daily assessment of the readiness to extubate. On that metric, we have ranged from 88% to 98%. Sometimes, even when you know what you would like to do, the patient's condition or other exigencies make it impossible. Sometimes, even when you know what you should do, it doesn't get done -- for a variety of reasons: training, follow-up, schedules, competing demands of other patients.
Sometimes, there are unexpected reasons. At one point, we could not elevate some beds properly because other patient-related equipment was in the way! (We fixed that. And, yes, we bought contractors' protractors, the same ones used in construction to measure the angle of a pipe bend. How else will you know if the bed angle is correct?)
IHI has published stories of places with great success in this arena. Congratulations to those hospitals. We hope to be in one of those stories some day.
Tuesday, January 23, 2007
Why can't we do that?
A recent note from our chief operating officer to several of our clinical chiefs:
I came across the NEJM from 12/28/06 and the article and editorial on catheter-associated blood stream infections done in Michigan (my medical school alma mater!)
In that study of 108 ICU’s in Michigan, the institution of a set of evidence-based interventions reduced the median rates of infection per 1000 catheter days from 2.7 to 0 and the mean rates from 7.7 to 1.4. These impressive gains were held through 18 months of follow-up. If more than half of these ICU’s can virtually eliminate these infections, it seems that we should be able to do so as well. We had 2 months in the last year when we achieved this goal, but the last two months showed a sizable bump. Are we doing everything possible to eliminate these on a sustainable basis? What will we do differently going forward to hold the ‘zero rate’ for every month?
For the record, here are the numbers for BIDMC, updated from my posting of December 17, below.
Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
We are serious about this and, like Michigan, we will share any lessons learned with others in the medical community. Recall that we engaged in an intensive training and improvement program in this arena, and the result we want is tantalizingly within reach. Nonetheless, as noted by our COO, we are not yet "best in class," which is our goal.
Here is what we are doing for now: Every single infection is now viewed as a sentinel event, for which we conduct a root cause analysis and from which we learn how to do better. Stay tuned to see how we progress over the coming months.
I came across the NEJM from 12/28/06 and the article and editorial on catheter-associated blood stream infections done in Michigan (my medical school alma mater!)
In that study of 108 ICU’s in Michigan, the institution of a set of evidence-based interventions reduced the median rates of infection per 1000 catheter days from 2.7 to 0 and the mean rates from 7.7 to 1.4. These impressive gains were held through 18 months of follow-up. If more than half of these ICU’s can virtually eliminate these infections, it seems that we should be able to do so as well. We had 2 months in the last year when we achieved this goal, but the last two months showed a sizable bump. Are we doing everything possible to eliminate these on a sustainable basis? What will we do differently going forward to hold the ‘zero rate’ for every month?
For the record, here are the numbers for BIDMC, updated from my posting of December 17, below.
Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00
Nov 06 ----- 2.38
Dec 06 ----- 1.87
We are serious about this and, like Michigan, we will share any lessons learned with others in the medical community. Recall that we engaged in an intensive training and improvement program in this arena, and the result we want is tantalizingly within reach. Nonetheless, as noted by our COO, we are not yet "best in class," which is our goal.
Here is what we are doing for now: Every single infection is now viewed as a sentinel event, for which we conduct a root cause analysis and from which we learn how to do better. Stay tuned to see how we progress over the coming months.
Saturday, January 20, 2007
What Works -- Part 5 -- Team Training
We have all heard stories of cockpit behavior in an airplane that causes a crash. The navigator or first mate says to the pilot, "Watch out for that mountain." The pilot ignores the advice, and the aircraft ends up in flames. This kind of thing can happen in a hierarchical environment.
The same kind of thing can happen in an operating room, where the surgeon is the "pilot" and the nurses and anaesthesiologists are the support crew. Doctors, like pilots, are trained to be in charge and to make split-second decisions.
A few years ago, a series of errors and bad communication in our obstetrics department resulted in the loss of a baby and almost resulted in the death of the mother. For a department that had always prided itself on providing extraordinary care, the event was a shock and caused an intense self-evaluation.
Using the experience of the military -- indeed from those cockpit situations --the Department proceeded on a full-fledged series of courses in team training.
This was not a simple seminar or two. It was a process that took many months. After all, it had to break down barriers and behaviors that had taken years to develop. Nurses had to feel comfortable offering suggestions to doctors, and doctors had to learn how to hear the nurses' comments.
Here's an article that describes the whole thing. I urge you to take the time to read it. Our OB staff would tell you that it has changed their view of practicing medicine. They would also tell you that it has created unusual bonds of collaboration and friendship in their department, even for a group that had always had a strong group ethic. Most important, the program has actually had a measurable difference in clinical results. Our folks now participate in programs across the country to spread the word.
I wish I could tell you that we have taken this experience and have infused it throughout our own hospital. We have not, at least to the extent I would like. Not that we are not trying, but it turns out that the culture of each department and each division is a bit different, even within the same hospital. So it takes longer than you might expect. What might work in OB needs to be modified to work in surgery or orthopaedics. Even within surgery, what might work for the pancreatic surgery group -- see the November 27 discussion below on Whipple procedures (What Works -- Part 2) -- might not be quite right for the transplantation group. Like other medical centers, we are still feeling our way through this issue of the diffusion of practice improvements.
The same kind of thing can happen in an operating room, where the surgeon is the "pilot" and the nurses and anaesthesiologists are the support crew. Doctors, like pilots, are trained to be in charge and to make split-second decisions.
A few years ago, a series of errors and bad communication in our obstetrics department resulted in the loss of a baby and almost resulted in the death of the mother. For a department that had always prided itself on providing extraordinary care, the event was a shock and caused an intense self-evaluation.
Using the experience of the military -- indeed from those cockpit situations --the Department proceeded on a full-fledged series of courses in team training.
This was not a simple seminar or two. It was a process that took many months. After all, it had to break down barriers and behaviors that had taken years to develop. Nurses had to feel comfortable offering suggestions to doctors, and doctors had to learn how to hear the nurses' comments.
Here's an article that describes the whole thing. I urge you to take the time to read it. Our OB staff would tell you that it has changed their view of practicing medicine. They would also tell you that it has created unusual bonds of collaboration and friendship in their department, even for a group that had always had a strong group ethic. Most important, the program has actually had a measurable difference in clinical results. Our folks now participate in programs across the country to spread the word.
I wish I could tell you that we have taken this experience and have infused it throughout our own hospital. We have not, at least to the extent I would like. Not that we are not trying, but it turns out that the culture of each department and each division is a bit different, even within the same hospital. So it takes longer than you might expect. What might work in OB needs to be modified to work in surgery or orthopaedics. Even within surgery, what might work for the pancreatic surgery group -- see the November 27 discussion below on Whipple procedures (What Works -- Part 2) -- might not be quite right for the transplantation group. Like other medical centers, we are still feeling our way through this issue of the diffusion of practice improvements.
Thursday, January 18, 2007
Wednesday, January 17, 2007
The Inside Story on Market Power in MA Health Care
I received this query, submitted last night as a comment on my initial posting. I thought I would reprint it up here, as it is worth some commentary on the questions raised:
Paul,
Just saw you on Emily Rooney show. Congratulations on the Blackberry! Why don't all hospitals offer the same discounts to all insurers to create a level playing field for competition? Are you worried that BC/BS is leveraging its power to become the only real player in MA healthcare?
The answer goes to the heart of the market power question in the Massachusetts health care environment. There are currently two dominant players in Eastern Massachusetts. On the provider side, Partners Healthcare System has built a very strong base of tertiary hospitals, community hospitals, and physician groups. PHS' ability to demand the highest rates from the insurance companies has been documented over the years. Here is a excerpt from the battle between PHS and Tufts Health Plan in the year 2000, where PHS threatened to withdraw from the Tufts network in the face of a rate offer PHS found inadequate. Tufts soon gave in because it could not afford to have insurance plans that did not include the PHS network. I don't think anyone can disagree that a sign of market power is the ability to engage in this kind of brinkmanship and win.
I am waiting for an enterprising reporter to document the extent of PHS' power by preparing a simple chart that compares the percentage market share of PHS versus other hospitals against the percentage of revenues collected by PHS versus other hospitals from the three major Massachusetts insurers. It is no secret that PHS gets higher rates for its doctors and its hospital procedures. Certainly the insurance companies know this, and perhaps there is enough public information available to document it.
Please note that I am not suggesting that this fact means there is an illegal level of market power or price discrimination. As far as I know, no such conclusion has been reached by a state or federal attorney general. I am just suggesting that size matters in the health care marketplace. PHS was created in part to enable its participants to be strong financial performers. The managers of the system have executed their business strategy well. Also, as noted below in my posting on the Harvard Medical System, the PHS hospitals are national leaders in clinical care, research, and teaching -- so I am not in any way suggesting that they have used funds unwisely. It is just that PHS' public modesty about its market influence does not reflect its true success as a business enterprise.
So, to answer the query received above, the other hospitals are fighting for whatever rate increases they can get from the insurers in the face of PHS' dominance in the marketplace. There is no way they would volunteer to offer preferred rates to an insurer while they are fighting for their lives to get rates comparable to those received by Partners.
On the insurer side, Blue Cross/Blue Shield has an even more dominant position, with more subscribers than all of the rest of the market put together. I can't speak for Harvard Pilgrim Health Care and Tufts, but I am guessing they feel the strength of this competitor every day when they seek to sign up companies as subscribers. BC/BS has the balance sheet to focus on market segments it cares about and to design rate plans that are attractive to those potential customers.
BC/BS is also part of a national network of the Blues, which gives them the ability to sign on national accounts: And if you haven't noticed, corporations with multi-state locations are a growing segment of the Massachusetts economy. HPHC has created an alliance with UnitedHealth Group to offer a similar national product line. This is a wise decision, although integrating a local company like HPHC with a huge national firm is sure to be a lot of work. Meanwhile, Tufts appears to be going on its own, an uphill battle for sure, although there is a chance that local loyalties will be an effective marketing approach.
To its credit, BC/BS has used its strong market position to push important aspects of the health care agenda. The company's focus on transforming the health care system to eliminate overuse, underuse, misuse, and waste is exemplary. Its stated goal -- to pay according to the quality of patient outcomes and efficiency in the delivery of medical services -- is the right thing for society and, by the way, is the only effective way to counterbalance the market power of a dominant provider system. When each hospital is paid for the results it achieves in patient care, rather than its market share, everybody wins. Ultimately, it is the only way to control the growth in health care costs because it stimulates the right kind of competition -- competition measured by results and efficiency -- among all providers. BC/BS' dominance in the marketplace gives it a unique ability to lead the way and achieve this result.
Paul,
Just saw you on Emily Rooney show. Congratulations on the Blackberry! Why don't all hospitals offer the same discounts to all insurers to create a level playing field for competition? Are you worried that BC/BS is leveraging its power to become the only real player in MA healthcare?
The answer goes to the heart of the market power question in the Massachusetts health care environment. There are currently two dominant players in Eastern Massachusetts. On the provider side, Partners Healthcare System has built a very strong base of tertiary hospitals, community hospitals, and physician groups. PHS' ability to demand the highest rates from the insurance companies has been documented over the years. Here is a excerpt from the battle between PHS and Tufts Health Plan in the year 2000, where PHS threatened to withdraw from the Tufts network in the face of a rate offer PHS found inadequate. Tufts soon gave in because it could not afford to have insurance plans that did not include the PHS network. I don't think anyone can disagree that a sign of market power is the ability to engage in this kind of brinkmanship and win.
I am waiting for an enterprising reporter to document the extent of PHS' power by preparing a simple chart that compares the percentage market share of PHS versus other hospitals against the percentage of revenues collected by PHS versus other hospitals from the three major Massachusetts insurers. It is no secret that PHS gets higher rates for its doctors and its hospital procedures. Certainly the insurance companies know this, and perhaps there is enough public information available to document it.
Please note that I am not suggesting that this fact means there is an illegal level of market power or price discrimination. As far as I know, no such conclusion has been reached by a state or federal attorney general. I am just suggesting that size matters in the health care marketplace. PHS was created in part to enable its participants to be strong financial performers. The managers of the system have executed their business strategy well. Also, as noted below in my posting on the Harvard Medical System, the PHS hospitals are national leaders in clinical care, research, and teaching -- so I am not in any way suggesting that they have used funds unwisely. It is just that PHS' public modesty about its market influence does not reflect its true success as a business enterprise.
So, to answer the query received above, the other hospitals are fighting for whatever rate increases they can get from the insurers in the face of PHS' dominance in the marketplace. There is no way they would volunteer to offer preferred rates to an insurer while they are fighting for their lives to get rates comparable to those received by Partners.
On the insurer side, Blue Cross/Blue Shield has an even more dominant position, with more subscribers than all of the rest of the market put together. I can't speak for Harvard Pilgrim Health Care and Tufts, but I am guessing they feel the strength of this competitor every day when they seek to sign up companies as subscribers. BC/BS has the balance sheet to focus on market segments it cares about and to design rate plans that are attractive to those potential customers.
BC/BS is also part of a national network of the Blues, which gives them the ability to sign on national accounts: And if you haven't noticed, corporations with multi-state locations are a growing segment of the Massachusetts economy. HPHC has created an alliance with UnitedHealth Group to offer a similar national product line. This is a wise decision, although integrating a local company like HPHC with a huge national firm is sure to be a lot of work. Meanwhile, Tufts appears to be going on its own, an uphill battle for sure, although there is a chance that local loyalties will be an effective marketing approach.
To its credit, BC/BS has used its strong market position to push important aspects of the health care agenda. The company's focus on transforming the health care system to eliminate overuse, underuse, misuse, and waste is exemplary. Its stated goal -- to pay according to the quality of patient outcomes and efficiency in the delivery of medical services -- is the right thing for society and, by the way, is the only effective way to counterbalance the market power of a dominant provider system. When each hospital is paid for the results it achieves in patient care, rather than its market share, everybody wins. Ultimately, it is the only way to control the growth in health care costs because it stimulates the right kind of competition -- competition measured by results and efficiency -- among all providers. BC/BS' dominance in the marketplace gives it a unique ability to lead the way and achieve this result.
Monday, January 15, 2007
The best laid plans
You know, sometimes you just can't win. You try something for the best of all reasons, and it just blows up in your face. Or, in this case, it rips up right in your hands. A sign of good management is when you realize a mistake and correct it quickly. (Yes, our folks are available to advise the Bush administration!)
Here's the story.
A hospital is like a small city. Thousands of people live and work in close proximity and engage in a full range of activities and, yes, bodily functions. BIDMC's facilities people are terrific, always looking for ways to enhance our basic services to improve safety, reduce costs, and have less impact on the environment. Here was their first message a few weeks ago:
On Monday, we will launch a program to replace our paper towel dispensers with new battery-powered, "hands free" dispensers. These new dispensers reduce the chance of cross contamination and thus facilitate improved infection control. We also expect them to save money (since the amount of towel dispensed is set at a pre-measured length and minimize instances when users pull more paper towels than needed.)
Good stuff, right? Wrong. The complaints started piling in. It appears that the new paper towels were too flimsy and would disintegrate in people's hands. You might think that the CEO would not hear about this issue, but I actually received as many email complaints about this item as I have about anything in the last five years. Maybe it is because I have been strongly encouraging people to wash their hands. (See "Clean Hands" posting below, on November 1.) Maybe because holding a damp, torn piece of paper is a really unpleasant experience for people.
Here is today's message from our facilities team:
As you may recall, last month we e-mailed you about the plan to convert the campus paper towel dispensers to a hands-free model, designed to improve infection control and potentially reduce waste of paper towels. Along with the change in dispenser (and thus vendor) was a change in the paper towel itself (to one made from recycled materials in our effort to be more environmentally responsible and that was offered with the new dispensers at a cost savings). These new paper towels were put in the new dispensers but also started to be used throughout the campus.
Clearly, this change in paper towel was not a positive one as it was not strong enough to meet our needs. We tried another one which also did not meet our needs, although did slightly better in the hands-free dispenser. Our apologies for the problems and frustrations this has caused.
We have come to an arrangement to revert back to the strength and quality of our previous paper towel choice while maintaining the option to use hands-free dispensers. We will be converting ALL areas back to the stronger paper towel this week.
I say, good for our facilities people to be creative with new approaches, and good for others to let us know when something doesn't work. I will only start to worry about our place when (1) people stop trying to make improvements and (2) when people stop complaining. Fortunately, neither is in the cards!
Here's the story.
A hospital is like a small city. Thousands of people live and work in close proximity and engage in a full range of activities and, yes, bodily functions. BIDMC's facilities people are terrific, always looking for ways to enhance our basic services to improve safety, reduce costs, and have less impact on the environment. Here was their first message a few weeks ago:
On Monday, we will launch a program to replace our paper towel dispensers with new battery-powered, "hands free" dispensers. These new dispensers reduce the chance of cross contamination and thus facilitate improved infection control. We also expect them to save money (since the amount of towel dispensed is set at a pre-measured length and minimize instances when users pull more paper towels than needed.)
Good stuff, right? Wrong. The complaints started piling in. It appears that the new paper towels were too flimsy and would disintegrate in people's hands. You might think that the CEO would not hear about this issue, but I actually received as many email complaints about this item as I have about anything in the last five years. Maybe it is because I have been strongly encouraging people to wash their hands. (See "Clean Hands" posting below, on November 1.) Maybe because holding a damp, torn piece of paper is a really unpleasant experience for people.
Here is today's message from our facilities team:
As you may recall, last month we e-mailed you about the plan to convert the campus paper towel dispensers to a hands-free model, designed to improve infection control and potentially reduce waste of paper towels. Along with the change in dispenser (and thus vendor) was a change in the paper towel itself (to one made from recycled materials in our effort to be more environmentally responsible and that was offered with the new dispensers at a cost savings). These new paper towels were put in the new dispensers but also started to be used throughout the campus.
Clearly, this change in paper towel was not a positive one as it was not strong enough to meet our needs. We tried another one which also did not meet our needs, although did slightly better in the hands-free dispenser. Our apologies for the problems and frustrations this has caused.
We have come to an arrangement to revert back to the strength and quality of our previous paper towel choice while maintaining the option to use hands-free dispensers. We will be converting ALL areas back to the stronger paper towel this week.
I say, good for our facilities people to be creative with new approaches, and good for others to let us know when something doesn't work. I will only start to worry about our place when (1) people stop trying to make improvements and (2) when people stop complaining. Fortunately, neither is in the cards!
Sunday, January 14, 2007
The Harvard Medical System
After a recent news story in which yours truly was seen to a bit critical of one of his hospitals, a trustee from Partners Healthcare System asked one of our trustees, "Are we competing or cooperating?" Our person gave the right answer, "Both."
There, in a nutshell, is the story of Harvard Medical School and its affiliated teaching hospitals. This is worth some explanation.
HMS is a research institution and a school for undergraduate medical students. Unlike many other medical schools, HMS does not own and operate a hospital. Instead it has affiliation agreements with a number of hospitals in Boston (BIDMC, MGH, Brigham and Women's, Children's Hospital, Dana Farber Cancer Institute, Joslin Diabetes Center, Mass Eye and Ear Infirmary, among others). Those affiliation agreements (amounting to a one-page letter between MGH and Harvard to longer documents for later arrivals to the system) state that the hospitals will train HMS students, will cooperate with HMS in other medical and civic responsibilities, and will follow the rules of Harvard University with regard to faculty and other academic matters.
The doctors and researchers in the Harvard hospitals are faculty members of HMS. Their promotion process is subject to the governing rules and processes of HMS. They are subject to stringent HMS conflict of interest rules. They have certain HMS civic responsibilities, notably to teach undergraduate medical students. Like faculty at the University, they are expected to be among the best in their field and to have a national and international impact on clinical care, research, and/or teaching. Indeed, when a search is undertaken for a new department chief at one of the hospitals (e.g., Chief of Medicine at BIDMC), the search committee is appointed by the Dean of HMS and comprises high-level faculty members from a number of the hospitals.
But, with few exceptions, the faculty are not paid by Harvard. Their salaries are paid by the hospitals or by the physician organizations in the hospitals -- based on clinical, research, teaching, or administrative activity.
This somewhat informal arrangement has worked well for decades, has created tremendous loyalty within the system, and has contributed to the strength of both HMS and the hospitals.
But, recall that the hospitals are independent non-profit entities, each with its own public charter, and each governed by a community-based board of trustees with a fiduciary responsibility to their institution and to the public. Part of that fiduciary responsibility is to stay financially healthy -- which in the marketplace of health care mean to compete successfully.
The result is a curious mix of cooperation and competition among the Harvard hospitals. As loyal members of the HMS system, we cooperate fully in recruiting, evaluating, and promoting faculty members; in educating medical students; in designing multi-institutional research programs; in sharing basic science and clinical research results; and in carrying out joint programs to improve patient quality and safety. But in the arena of clinical care, there is intense competition for market share, to be the most attractive place for patients for cardio-vascular services, organ transplantation, cancer treatment, or other important types of tertiary care.
This means that we vie to be the first choice for patient referrals by primary care doctors and specialty physicians in the community. After all, most patient visits to hospitals are the result of those referrals, not individual decisions by consumers. Thus, each hospital tries to create a referral network -- either by ownership, insurance contracting, or personal relationship -- that will enhance the flow of patients to that institution. Each hospital, too, engages in marketing to strengthen those same referral patterns. (By the way, this is not limited to the Harvard hospitals. New England Medical Center, St. Elizabeth's, and Boston Medical Center join in the region-wide competition.)
Since all of the Harvard hospitals provide excellent care, newspaper reports and other public commentary tends to focus on these battles for referrals. Look for that to continue.
But, also look for whole-hearted cooperation to continue among the HMS "cousins" -- in areas that are ultimately more important than the forays over market share.
There, in a nutshell, is the story of Harvard Medical School and its affiliated teaching hospitals. This is worth some explanation.
HMS is a research institution and a school for undergraduate medical students. Unlike many other medical schools, HMS does not own and operate a hospital. Instead it has affiliation agreements with a number of hospitals in Boston (BIDMC, MGH, Brigham and Women's, Children's Hospital, Dana Farber Cancer Institute, Joslin Diabetes Center, Mass Eye and Ear Infirmary, among others). Those affiliation agreements (amounting to a one-page letter between MGH and Harvard to longer documents for later arrivals to the system) state that the hospitals will train HMS students, will cooperate with HMS in other medical and civic responsibilities, and will follow the rules of Harvard University with regard to faculty and other academic matters.
The doctors and researchers in the Harvard hospitals are faculty members of HMS. Their promotion process is subject to the governing rules and processes of HMS. They are subject to stringent HMS conflict of interest rules. They have certain HMS civic responsibilities, notably to teach undergraduate medical students. Like faculty at the University, they are expected to be among the best in their field and to have a national and international impact on clinical care, research, and/or teaching. Indeed, when a search is undertaken for a new department chief at one of the hospitals (e.g., Chief of Medicine at BIDMC), the search committee is appointed by the Dean of HMS and comprises high-level faculty members from a number of the hospitals.
But, with few exceptions, the faculty are not paid by Harvard. Their salaries are paid by the hospitals or by the physician organizations in the hospitals -- based on clinical, research, teaching, or administrative activity.
This somewhat informal arrangement has worked well for decades, has created tremendous loyalty within the system, and has contributed to the strength of both HMS and the hospitals.
But, recall that the hospitals are independent non-profit entities, each with its own public charter, and each governed by a community-based board of trustees with a fiduciary responsibility to their institution and to the public. Part of that fiduciary responsibility is to stay financially healthy -- which in the marketplace of health care mean to compete successfully.
The result is a curious mix of cooperation and competition among the Harvard hospitals. As loyal members of the HMS system, we cooperate fully in recruiting, evaluating, and promoting faculty members; in educating medical students; in designing multi-institutional research programs; in sharing basic science and clinical research results; and in carrying out joint programs to improve patient quality and safety. But in the arena of clinical care, there is intense competition for market share, to be the most attractive place for patients for cardio-vascular services, organ transplantation, cancer treatment, or other important types of tertiary care.
This means that we vie to be the first choice for patient referrals by primary care doctors and specialty physicians in the community. After all, most patient visits to hospitals are the result of those referrals, not individual decisions by consumers. Thus, each hospital tries to create a referral network -- either by ownership, insurance contracting, or personal relationship -- that will enhance the flow of patients to that institution. Each hospital, too, engages in marketing to strengthen those same referral patterns. (By the way, this is not limited to the Harvard hospitals. New England Medical Center, St. Elizabeth's, and Boston Medical Center join in the region-wide competition.)
Since all of the Harvard hospitals provide excellent care, newspaper reports and other public commentary tends to focus on these battles for referrals. Look for that to continue.
But, also look for whole-hearted cooperation to continue among the HMS "cousins" -- in areas that are ultimately more important than the forays over market share.
Friday, January 12, 2007
Infectious behavior
The Globe yesterday ran a story on hospital-acquired infections, noting that the Commonwealth of Massachusetts might require hospitals to report their statistics on this matter. This is a good thing, part of a trend slowly spreading across the country.
It is good for two reasons. First, the public has a right to know about fundamental measures of patient quality and safety in institutions in their communities. Second, as a management tool, there is nothing more effective for hospital administrators than to be able to remind their staffs that actual clinical results will be made public.
But, here is the subtle and very important point. If public reporting devolves into a culture of blame, it will undo all the good that would otherwise be done. Here, reporters and politicians need to be very careful.
The idea is to use data to bring about constructive change and improvement. While some hospital-related infections, injuries, and death are the result of a doctor's mistake, many are the result of systemic problems that take analysis, understanding, and thoughtful problem-solving to fix.
I can also assure you that, when a doctor makes a mistake, he or she already feels more remorse about it than you can imagine. There is no reason to pounce on people who have devoted their lives to helping us.
I believe that many doctors and hospitals do not want to post these data because they have little confidence in the ability and motivation of the press and elected politicians. They fear they will just be punching bags or targets for commercial or political gain.
So, yes, hospitals and doctors face a challenge in overcoming their defensiveness and reluctance to share in this arena -- but the rest of society faces an equally difficult challenge in using the information responsibly.
I have chosen to post BIDMC's data because I believe the only way for us all to learn how to do this well is to actually do it. I continue to hope that my colleagues in the Boston area hospitals will join in and that our journalists and elected officials will provide the kind of positive reinforcement that makes this truly infectious behavior.
It is good for two reasons. First, the public has a right to know about fundamental measures of patient quality and safety in institutions in their communities. Second, as a management tool, there is nothing more effective for hospital administrators than to be able to remind their staffs that actual clinical results will be made public.
But, here is the subtle and very important point. If public reporting devolves into a culture of blame, it will undo all the good that would otherwise be done. Here, reporters and politicians need to be very careful.
The idea is to use data to bring about constructive change and improvement. While some hospital-related infections, injuries, and death are the result of a doctor's mistake, many are the result of systemic problems that take analysis, understanding, and thoughtful problem-solving to fix.
I can also assure you that, when a doctor makes a mistake, he or she already feels more remorse about it than you can imagine. There is no reason to pounce on people who have devoted their lives to helping us.
I believe that many doctors and hospitals do not want to post these data because they have little confidence in the ability and motivation of the press and elected politicians. They fear they will just be punching bags or targets for commercial or political gain.
So, yes, hospitals and doctors face a challenge in overcoming their defensiveness and reluctance to share in this arena -- but the rest of society faces an equally difficult challenge in using the information responsibly.
I have chosen to post BIDMC's data because I believe the only way for us all to learn how to do this well is to actually do it. I continue to hope that my colleagues in the Boston area hospitals will join in and that our journalists and elected officials will provide the kind of positive reinforcement that makes this truly infectious behavior.
Wednesday, January 10, 2007
On-line between doctors and patients
We have a nifty program called PatientSite that allows doctors and patients to exchange information on a password protected site. Doctors can send reminder notices to patients and updates on various items. Patients can use it to make appointments, get referrals, read test results, order prescriptions, and the like. (Yes, of course, the prescription orders go directly the your favorite pharmacy in your neighborhood!)
Our theory is that a lot of communication between doctors and patients can happen on-line, asynchronously. This leaves doctors free to spend time on the telephone or in person for the things that are more urgent or require more personal attention. It also means that you, as a patient, can send in a request at whatever time suits you.
Each doctor has the ability to customize the PatientSite features provided to his or her patients -- the clinician's schedule, the patient's allergy list, lab results, medication list, microbiology reports, EKGs, pathology results, X-ray reports. Most doctors offer patients most of these features, but, for example, some doctors prefer to talk to a patient about test results rather than having them available first on line.
You wonder how much this is used? Here are some statistics for those patients who have chosen to sign up for the service.
Clinical messages from patient to provider: 25 (per 100 patients)
Number of prescription requests: 4 (per 100 patients)
Number of appointment requests: 2 (per 100 patients)
Number of referral requests: 2 (per 100 patients)
Percentage of patients seeking technical support in the use of PatientSite: 2-4%
Percentage of enrolled patients who log in each month: 35-40%
Of those who logged in:
Our theory is that a lot of communication between doctors and patients can happen on-line, asynchronously. This leaves doctors free to spend time on the telephone or in person for the things that are more urgent or require more personal attention. It also means that you, as a patient, can send in a request at whatever time suits you.
Each doctor has the ability to customize the PatientSite features provided to his or her patients -- the clinician's schedule, the patient's allergy list, lab results, medication list, microbiology reports, EKGs, pathology results, X-ray reports. Most doctors offer patients most of these features, but, for example, some doctors prefer to talk to a patient about test results rather than having them available first on line.
You wonder how much this is used? Here are some statistics for those patients who have chosen to sign up for the service.
Clinical messages from patient to provider: 25 (per 100 patients)
Number of prescription requests: 4 (per 100 patients)
Number of appointment requests: 2 (per 100 patients)
Number of referral requests: 2 (per 100 patients)
Percentage of patients seeking technical support in the use of PatientSite: 2-4%
Percentage of enrolled patients who log in each month: 35-40%
Of those who logged in:
- Percentage of patients who looked at lab results: 31%
- Percentage of patients who looked at X-ray results: 20%
- Percent of patients who reviewed medications: 24%
Try the demo! I think you will be impressed.
Tuesday, January 09, 2007
Hike4Life
I'm just back from a trip to Madagascar, where I participated in a fundraising event called "Hike4Life" for Focus Humanitarian Assistance. FOCUS is an international group of agencies established in Europe, North America and South Asia to complement the provision of emergency relief, principally in the developing world. It helps people in need reduce their dependence on humanitarian aid and facilitates their transition to sustainable, long term development. FOCUS is an affiliate of the Aga Khan Development Network. The establishment of FOCUS by the Ismaili Muslim community was a result of a history of successful initiatives to assist people struck by natural and man-made disasters in South and Central Asia, and Africa.
Eighty people joined the hike, raising hundreds of thousands of dollars for this worthwhile organization. We were from the US, Canada, the United Kingdom, and France. The pictures above show our lead guide Roland, as he taught us about local wildlife, and also some our group as we hiked through Isalo National Park in south central Madagascar. (And to answer your question, yes, this activity accounts in part for my reluctance to make blog postings during the past two weeks. Web access is not so ubiquitous in Madagascar . . .)
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