"I know that finger"

A true story, from just a few weeks ago. David was an ice hockey player in his boyhood days. He is accompanying a friend to the emergency room after the latter has dramatically injured his hand. The hand surgeon comes in to take care of the friend, but pauses to shake hands with David. Never making eye contact, the surgeon does not let go of David's hand, but instead brings it up towards his face and says, "I know that finger. I fixed it in 1976 after it was sliced by an ice skate."

"You remember my finger?" says an astonished David.

"I never forget a finger," replies the surgeon.

Links

After reading about several blogs that have been discontinued, I recently checked out all the blogs to which I have been linking and have deleted those that no longer exist or have been inactive for a very long time. (By the way, here is a really interesting story about one.)

If I inadvertently knocked yours off or if you would like me to add a new one, please send it along and I am happy to consider it.

Many thanks to the dozens of you who link to mine. It is great to be part of this worldwide community.

What a difference 100 years makes

A friend sent me an article listing the major causes of death in the United States in 1907. I did a little research to verify. Here's what I found for 1907. They were:

Pneumonia and influenza
Tuberculosis
Heart disease
Diarrhea
Stroke
Kidney disease
Accidents
Cancer
Premature Birth
Senility

Today (or within the last few years), the leaders are:

Heart disease
Cancer
Stroke
Chronic lower respiratory diseases (emphysema, chronic bronchitis)
Accidents
Diabetes
Pneumonia and influenza
Alzheimer's disease
Kidney disease
Septicemia (systemic infection)

The shift shows, in part, progress in the use of antibiotics. In part, it shows the effect of changes in longevity. Between 1900 and 2004, life expectancy for males went from 48.3 year to 75.2 years; for females from 46.3 years to 80.4 years.

Uncomfortable growth

An editorial in today's Globe raises questions of several types with regard to a plan by Massachusetts General Hospital to expand its emergency department, surgical facilities, and beds. Charlie Baker, CEO of Harvard Pilgrim Health Care, also raises a number of issues on his blog.

I had trouble knowing what lessons to draw from this commentary. I understand the authors' concerns about the cost of new hospital facilities, but rest assured, no one in the hospital business builds expensive new space unless there is a reasonable assurance of the demand being there to use it.

Here are the trends we see. Even if population growth in Massachusetts is minimal or flat for the coming decade, demand for the services of tertiary hospitals is likely to grow. Why? As the baby boomers age beyond 50, they have an increasing demand for hospital services. In addition, their parents are living longer than ever, and they, too, are heavy users of hospitals. Not only are both groups displaying greater utilization of hospitals, but their ailments are of greater acuity, resulting in an increased demand for tertiary care. (And by the way, if the people in the younger generation do not change their ways with regard to weight control, they will be in the hospitals also for care of diabetes-related health problems like vascular and heart disease.)

While I have not asked the folks at Partners Healthcare about this, I am guessing it is this demographic wave that leads MGH and Brigham and Women's Hospital to plan expansion of tertiary care facilities. The same is true for BIDMC.

I know people get uncomfortable with an additional aspect of the issue: There is also a business imperative for this kind of construction. The insurance reimbursement system rewards increases in volume, especially high-end procedures and surgery. It does not reward preventative care, nor cognitive specialties in which doctors examine you and then make judgements about paths of care. It does not, in particular, provide sufficient income to primary care doctors to spend the extra time with patients that might avoid hospitalization.

So if you are running an academic medical center and you would like to be financially healthy to sustain and enhance your tri-partite mission of clinical care, research, and teaching, your business plan is simple: Grow, and expand your tertiary lines of care in particular. If you stand still, the inflationary costs affecting your hospital will soon outstrip your revenues.

Gee, in this regard, hospitals are not all that different from other businesses. After all, who would complain if any corporation decided to expand capacity in its more profitable lines of business in anticipation of increased customer demand?

But hospitals are different in that they do not sell directly to the public and are not judged every day on the quality of their service. The intermediaries in this field -- insurance companies, the federal and state government, and employers -- mask the costs of health care that you or I actually use. And, there is virtually no way for a consumer to compare the actual quality of care delivered by hospitals: Almost all the publicly available data is out of date, based on administrative rather than clinical information, and embedded in hopelessly confusing websites. So there is really no market-based set of checks and balances on hospitals of the sort faced by other types of corporations.

I fear all this is leading to an unsustainable situation and that the academic medical centers are the ones that will feel the public's wrath once that is apparent. Why? Because we are the high-cost part of the health care system. There are legitimate reasons for that, which we could discuss at another time. But those reasons will not hold sway when the bill to employers, subscribers, and taxpayers gets just too high to pay.

To me, the remedy is clear. AMCs have to become the places that set the standard for quality improvement and cost efficiencies. They need to demonstrate that their value to society goes beyond the clinical care, research, and teaching they offer. On the quality side, they need to establish the science of care as an academic discipline that informs health care providers everywhere. On the cost side, they need to engage and adapt principles of organizational efficiency from other industries to make a structural change in their production model. Meanwhile, insurers and government payers have to support both components of the solution by rewarding hospitals that improve quality and reduce costs.

Memorial Day Op-Ed

Robert Gibbons, interim president of the Mass Hospital Association, offered an op-ed on the topic of elections and union organizing in the Memorial Day edition of the Boston Globe. If you know Gibbons, you know he is no anti-union shill. And, his employer represents both hospitals with unions and those without. But Gibbons is talking about process. Excerpts:

I can remember as a child learning that one of the most important and fundamental pillars of our democracy is the right to cast a secret vote in an election.

We wouldn't think about holding an election for any office, from school committee to president of the United States, without the protection of a secret ballot.

Then why are unions in Massachusetts and throughout the country hellbent on circumventing the democratic election process, and supplanting the 1935 National Labor Relations Act, to impose what's known as a "card check"?

It's illegal for anyone to coerce an employee to sign a union card. However, it can be extremely intimidating for an employee, faced with someone waiting for them to sign an authorization form, to say no to such a request. There is no protection of the ballot box. Everyone -- particularly the union representatives -- knows who voted for the union and who voted against it.

Unions argue that secret ballot elections give management the ability to coerce people into voting against the union. No one would condone such tactics by any employer.

But there is something fundamentally anti democratic about a card check election. Even a majority of union members recognize that. In a 2004 Zogby International poll, done for the Mackinac Center for Public Policy, 53 percent of union members say they would prefer to keep the secret ballot election.

I have mentioned this topic below, and there was lots of interesting give-and-take in the comments. Check them out and draw your own conclusions.

On girls soccer

Dean Conway, a life-long soccer fanatic and my mentor in soccer coaching, once said that if he could only watch one more soccer game in his life, it would be an under-12 girls game. Having just officiated as a referee for several such games, I again find myself agreeing. There is something really special about that age, but truthfully, I'd watch almost any age group!

Here's a letter I wrote in July 2002 to a friend, Grant Balkema, after he sent me his team's yearbook summarizing one of those miraculous and a wonderful seasons he had as a coach with his high-school aged girls soccer team. He was also a fellow referee, and we had spent many, many hours on the fields together as coaches, referees, and spectators. He died suddenly and inexplicably in November 2004.

I often say that the girls who play soccer with us are the luckiest kids in the world. They get to go out and play a beautiful game with their friends in a safe environment with terrific coaches and parents who support them. But you recognized an additional bit of magic this past season, and it was reflected in one of the sentences in the yearbook. When the girls are on the field of play, they unconsciously adapt to one another’s strengths and weaknesses during the game, creating a seamless web of teamwork. As a coach, you see this happen, and all you can do is smile. You know you had something to do with it, but you also know that something has happened among the girls themselves. It is a beautiful and very special thing. They will remember it all their lives, but they will not know what they are remembering. They will think their fond memories of this season had something to do with their friendships or other social relationships or how much their coaches taught them or how exceptional the team record was. But it is not that. It is an elemental statement about the human condition: We are born to work and play together in teams, but we have to give enough of ourselves to let the filaments connect. Many people do not get to experience that sense of ensemble. You have, and your girls have, and it is very, very special. They are, indeed, the luckiest kids in the world, and we are likewise blessed in being able to share this time with them.

Happy holiday

It looks like it will be a classic Memorial Day weekend here in Eastern Massachusetts. Sunny and warm, with thunderstorms mixed in.

I'm taking time off from this blog to do some of my favorite things, coaching my girls under-14 soccer team, refereeing boys and girls soccer games at a nearby tournament, and in between games, playing the same sport with a group of friends, and in between all that bike riding in preparation for the Pan Mass Challenge in August.

Have a terrific weekend, and let's all take a moment at our cookouts to remember why we call it Memorial Day. People have died to protect our right to have the kind of friendly and passionate debates you see on this blog and elsewhere in the public arena. A quiet moment to think of them fondly is well worth the time.

On nursing homes

Atul Gawande is a surgeon at Brigham and Women's Hospital and a thoughtful and compelling writer. In today's New York Times, he discusses life in nursing homes and the deterioration of spirit that occurs among many residents in this setting. Referring to a person he met, who picked her own high quality nursing home, he says:

The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning — results not fundamentally different from prisoners, actually.

Along these lines, a friend's mother left behind a letter with this advice to her family after spending several of her last years in a nursing home (yes, also a high quality one).

Try to find an alternative to nursing homes. People are segregated by age and they have very little in common. I have found them a terrible home. I’ve done the best I could but that’s not good enough.

In the "old days", elderly relatives would have lived with their extended families. That chapter is closed for most people in the US. In lieu of that, Gawande refers to "a small band of renegades" who have created alternatives aimed at replacing institutions for the disabled elderly with genuine homes.

These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-reimbursement levels.

They have been a great success [and they are building these in] every state in the country with funds from the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.

I don't pretend to know the solution to this problem, but bravo to Dr. Gawande for bringing the issue to a large audience.

"Baseball" in Los Angeles

Heads up, Angelinos. You are not going to like this one.

I have heard of lots of promotions to encourage people to attend sporting events. For example, certain restaurants in Minneapolis offer coupons for Minnesota Twins games when you buy a meal.

But here is the best yet, from a friend of a friend:

I know you think I've gone soft livin' in LA instead of with you on Beacon Hill, but I just wanted to tell you two recent giveaway promotions at Dodger stadium which prove that we are a fierce, fightin' machine:

May 13: (I was there and might be able to track down an extra one for you if you want) Lip Gloss Giveaway -- First 25,000 -- Sponsored by Smashbox.

Also, May 22: "Dodger fans are invited to participate in the 2nd Annual Dodger Stitch 'n Pitch where fans will sit together and knit. There will be a teaching table prior to the event and a totebag giveaway to those participating in the Stitch 'n Pitch."

I don't want this to sound really snitty or snobby, but the idea that you would have to give a Red Sox fan something extra to go to Fenway Park is inconceivable. If they did a give-away, the likelihood of it being lip gloss is very, very small. As for knitting, I would fear for the public's safety if that kind of implement were available during a Red Sox-Yankee game.

Emma F. Levy -- Aug 13, 1920 - May 23, 2005

On the anniversary of her death, I can't think of a more appropriate public remembrance for my mom than to refer you again to this post and hope that this advice will prove helpful to you, your family, or your friends.

For Students -- Helicopter Parents

Not many questions from students this week, but I'll get back to those that have arrived in the future. For today, just one thought. I heard yesterday of stories of helicopter parents who actually write thank-you notes to their child's first employer, upon hiring of their offspring.

A piece of advice to students. Don't ever, ever, ever let your parents do any such thing! And parents, don't ever, ever do such a thing. Perhaps it should not have this result, but I cannot think of anything that would more quickly make me question my judgment about hiring someone than to get a note like that.

Mandate for change?

With thanks to Dr. Brian Jarman for sending this along, here is the latest Commonwealth Fund report comparing health care in several countries. The main conclusion:

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries.

Here is the chartpack with all the slides summarizing the data.

No doubt many will argue that this is proof of the need for a national health plan like those found in the comparison countries -- Australia, Canada, New Zealand, the UK, German, France, the Netherlands, or Japan.

Personally, I think it argues for broader insurance coverage in the US, perhaps along the lines recently enacted in Massachusetts. Plus, it argues for better reimbursement in the US for primary care physicians. Plus, it clearly argues for greater emphasis by US hospitals and physicians for more systematic implementation of quality control, perhaps with more than gentle nudging by government and private payers. (See chart #50 for the percentage of primary care doctors who report any financial incentive for quality improvement: The US is lowest at 30%).

But I recognize that many disagree, and my point here is not to get into that debate. (I have done that elsewhere.) Instead, I want to raise the question of whether there is broad political support in the US for a major change. Notwithstanding similar data for years and lots of speeches on the subject, there has not been movement along these lines. Why have there not been votes for passage?

Hidden away in these charts might be indications of why the national health plan idea has been politically unpopular in the United States. Chart #60 shows the percentage of "sicker adults" who had to wait more than four weeks to see a specialist: Germany 22; US 23; NZ 40; Australia 46; Canada 57; UK 60. Chart #61 shows the percent of physicians who feel that their patients often have long waits for diagnostic tests: Australia 6; Germany 8; US 9; Netherlands 26; NZ 28; Canada 51; UK 57. And chart #62 shows the percentage of people who waited four weeks or more for needed non-emergency or elective surgery: Germany 6; US 8; Australia 19; NZ 20; Canada 33; UK 41.

So, if you think about things in purely political terms, because of proximity and/or language, the US public is most likely to hear about the experience of Canadian and British citizens with regard to these aspects of care. "Everyone" has a story about a friend of a friend from Canada who choose to fly to the US for elective surgery because he or she would have had to wait months for that treatment in Toronto. In the US, there is an expectation that when you need or want treatment, you get it quickly.

In addition, chart #97 presents a fascinating story, the percentage of people above average income in the Australia, Canada, NZ, and the UK who have chosen to buy private insurance to gain access to care not provided by their national health plan -- 63, 81, 57, and 35 percent, respectively. This factor gives yet another indication that the rationing of care provided under the national plans is not viewed positively by those of better economic means.

Finally, charts #126 and #127 give an indication of physician dissatisfaction with their country's health system and their own practices. The numbers are all over the place, with no clear mandate for change in the US among physicians -- or at least no clear distinction on this point with those in other countries.

For years, the Democrats have pushed the health care agenda, citing the equity and access reasons inherent in this report. For years, the Republicans have not, citing the issues of personal choice and government rationing. While many polls have showed public interest in major change, those same polls have often showed that there is less interest among people who vote. Have the Republicans been politically astute by not pushing this agenda, or have the Democrats locked onto an issue that will finally have traction?

Laughable?

Another email ad, in case it didn't come across your screen. Who writes these things?

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Best regards,
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By the way, check out this deal on the linked site:

Try our SPECIAL ERECTION PACK! Two best ED medications in one super pack. Lowest price and FREE shipping. Time limited offer - valid till 23rd of May only!

Better hurry. But wait, if you cut and paste this section of the ad, you find the following code hidden within. I guess the must-buy-by date keeps changing!

Try our SPECIAL ERECTION PACK! Two best ED medications in one super pack. Lowest price and FREE shipping. Time limited offer - valid till function nextday(d){months = newArray('January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December', 'January'); today=new Date();var day=today.getDate();var month=today.getMonth(); day+=d;if(day>30){day%=30;month++;} var prefix = ((day==1)(day==21))?'st': ((day==2)(day==22))?'nd': ((day==3)(day==23))?'rd': 'th'; return day + '-->'+ prefix + '' + ' of ' + months[month];}document. write(nextday(2)); 23-->rd of May only!

Central line infection report

More in our continuing series on central lines infections. As always, these are presented as cases per thousand ICU patient days. Every single case undergoes a multidisciplinary review with department leadership present, after a review by the attending of record and primary nurse, as well as the Central Line Work Group which is overseeing this effort.

The chart above shows that the overall quarterly trend is in the right direction, but as you can see below, there is troublesome variation from time to time. The up's and down's, I guess, are normal, but we all wish they stay down.

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

Jan 07 ----- 0.00

Feb 07 ----- 1.15

Mar 07 ----- 3.17

Apr 07 ----- 1.22

International dateline

I want to take a moment to again welcome international visitors to this site. I have noticed visits from the following countries during the last few months. If yours is not listed, please let me know. Also, please do not be shy about submitting comments and giving your perspectives on the strange world of health care in the US.

Albania, Algeria, Argentina, Australia, Austria, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Benin, Brazil, Bulgaria, Burkina Faso, Canada, Czech Republic, China, Colombia, Costa Rica, Cote D'ivoire, Croatia, Denmark, Dubai, England, Egypt, El Salvador, Estonia, Ethiopia, Faroe Islands, Finland, Fiji, France, Georgia, Germany, Ghana, Granada, Greece, Honduras, Hong Kong, Hungary, India, Indonesia, Iran, Ireland, Israel, Italy, Japan, Jordan, Kenya, Republic of Korea, Laos, Latvia, Lebanon, Luxembourg, Macao, Macedonia, Malaysia, Maldives, Malta, Mauritius, Mexico, Mongolia, Mozambique, Nepal, Netherlands, Netherlands Antilles, New Zealand, Nigeria, Northern Ireland, Norway, Oman, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Qatar, Romania, Russian Federation, St. Lucia, St. Vincent and The Grenadines, Saudi Arabia, Scotland, Serbia and Montenegro, Singapore, Slovenia, Somalia, South Africa, Spain, Sudan, Sweden, Switzerland, Taiwan, Tanzania, Thailand, Togo, Turkey, Uganda, Ukraine, United Arab Emirates, Vietnam, Wales, and Zimbabwe.

Blogspot glitch

Hmm, for some reason, the post below did not come with a comment link. If you want to comment on it, please do so here.

Visiting Patients

Margaret asks below: How do you decide which patient to visit? What do you talk about with a patient? Doing those visits is very wise I think.

At any given moment, we might have 600 patients in the hospital, ranging from very small babies to very old folks. So, of course, I can't visit everyone.

For a while I tried to visit people in a random way, just dropping in to rooms on different floors to check in. It turns out that this was not a good idea. It was just too jarring for most people to have a stranger walk in, even the president of the hospital, with no context for the visit.

So the simple answer to your question is that I visit people who are personal friends or colleagues; who are friends of friends or colleagues; who are on our boards of directors, trustees, and overseers -- or related to a board member. There are people in some of these categories who want privacy, though, and whom I do not visit. Sometimes, too, the nurses, doctors, or social workers tell me about someone who might appreciate a visit.

What do we talk about? Everything you can imagine. I often ask about and get reports on the quality of the experience -- doctors, nurses, transporters, housekeepers, food, cleanliness, clunky television controls. Sometimes we discuss the patient's personal medical progress and expectations. Sometimes it is about the business status of the hospital. Often, this being Boston, the main topic is the Red Sox, Dice-K, Mike Lowell, Manny, Papi, or their last win or loss.

If I am really close to the person and we both know the disease is terminal, we might talk about how it feels to be near the end of life. To be clear, this is a very rare occurrence and can only happen when we are very good friends. I sometimes have similar conversations with his or her spouse or partner. I never thought I would have the emotional wherewithal to do this, but it turns out that it is a marvelous gift to the patient or spouse (and to me, too) to have this discussion.

Topics that are absolutely off-limits with all patients: Conversations about donations to the hospital. Status reports on other patients.

The other people I visit are the babies in the neo-natal intensive care unit (NICU), when the parents are not there. The nurses have gotten used to this. I find it inspiring to watch a 1.5 pound baby breathe, sleep, and otherwise get used to life "on the outside". With these patients, there is not much talking, at least from their end, but these are some of the best conversations I have.

Take Pride

Every year, we at BIDMC hold an event to recognize people who have made significant contributions within the gay and lesbian community. Awardees may be individuals or organizations, employees or people external to BIDMC, or gay or straight. We look for candidates who advance the gay and lesbian agenda related to the workplace; volunteer time and effort on behalf of gay and lesbian initiatives; demonstrate leadership in advocating for gay and lesbian community; serve as a role model for gays and lesbians within the workplace; and/or make a positive impact on medical care to gay/lesbian/bisexual/transgender patients.

Each year, when we announce this event, I receive a note like this from one of our doctors:

From: The Committee to Restore Sensible Values and Perspective
To: Mr. Levy

We are again disappointed and frankly disgusted to see the leader of the medical center endorsing an inherently unhealthy, risky lifestyle. We remind you that this is offensive to members of the BIDMC who hold to moral principles and traditional values. But more to the point for a healthcare institution, is the fact that homosexual behavior involves well recognized higher risks of STD's, HIV and AIDS, anal cancer, hepatitis, parasitic intestinal infections, and psychiatric disorders. Life expectancy is significantly decreased as a result of HIV/AIDS, complications from the other health problems, and suicide. This alone should make it reprehensible to the medical community, regardless of your personal feelings for putting this on the politically correct list for "inclusion and respect." This action again jeopardizes the credibility of BIDMC as a healthcare institution and dishonors a large proportion of its community who continue to hold to the conviction that homosexuality is immoral, ungodly, unnatural, and of course unhealthy. As we pointed out in our letter a year ago, while the controversial effort to normalize homosexuality has clearly consumed the political arena, the health risks of homosexual behavior are well known and incontrovertible. Although the political world seems oblivious to these serious consequences of unhealthy behaviors, a healthcare institution should not be. It is all together inappropriate for BIDMC to endorse, affirm, or encourage these behaviors.

It's time to put our mission as a healthcare institution ahead of misguided zeal for political correctness and inclusiveness. After all, inclusiveness of the wrong values and behaviors only serves to dishonor and discredit BIDMC and the larger community it represents.

Last time, I started my response in this manner --

I am grateful to you for writing to me with such a clear exposition of your views. I respect greatly the range of views held by people on these issues, and I believe that one of the things that makes our country great is that we have the ability to live peacefully together and yet have a variety of viewpoints.

Then I made it very clear that this program will continue. Yes, every now and then, the CEO gets to make a decision. This one is easy.

If you would like to make a nomination for this year's award, please send an email before May 21 to egandelm@bidmc.harvard.edu or, for those inside BIDMC, go to our portal and download a nomination form.

Progress on medication reconciliation

One of the most bedeviling arenas for improvement in hospital care is called "medication reconciliation." As I have noted below, part of this standard means that we are supposed to discuss with all patients the medications they are taking before entering the hospital, and review their medications again upon discharge.

Here's part of problem. Many people do not know or do not remember what medicines that are taking, so a doctor who asks these questions while doing the patient's medical history will not get accurate information.

One way to work through this problem would be if we could get access to the records of pharmacies and get the list of medicines that have been prescribed and dispensed to patients.

The good news here in Massachusetts is that we are the #1 user of e-prescribing. Under this system, when you need a medication, the doctor sends the order electronically to your pharmacy of choice, and you pick it up there. No more scripts, no more handwriting.

The program involved lots of folks, with support from Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, and Tufts Health Plan, and is done in cooperation with Surescripts, an organization founded by the pharmacy industry in 2001.

BIDMC is one of the first hospitals in the country to use this advanced technology. We've been live with Surescripts routing on our web-based online medical record system since last year. Now, the plan is to use the capability in reverse -- to be able to query the Surescripts system and other stakeholders with pharmacy databases (e.g., Rxhub, which connects mail order pharmacies). So, when you showed up for surgery or another visit, we would be able to download a list of your current medications from the database of pharmacies. Even if you lived in Nevada and showed up at our emergency room in Boston, we would have access to this national database and make sure we were not giving you a medication that interacted badly with one you are taking.

We are hoping to go live with this by September 15 and, of course, will share our experience with all others in the region and beyond.

This approach does not solve all the issues around medication reconciliation, but it is an example of where the creative use of information technology can help enhance patient safety.

Orwell revisited: "Down with inefficient and unfair secret ballots!"

Excerpts from a report from the State House News Service, written by Michael P. Norton.

UNION FORMATION BILL ADVANCES IN HOUSE AFTER ROBUST DEBATE OVER PROCESS

STATE HOUSE, BOSTON, MAY 16, 2007. Legislation changing the way public employees can form unions stirred vigorous debate in the House Wednesday, a discussion that ended with a familiar result: Democrats outvoting Republicans to advance a bill backed by unions.

The bill approved by the House on a party-line 135 to 19 vote replaces a process under which employees considering creating a union would vote on the idea on a secret ballot with a process under which a union could be formed if more than 50 percent of affected workers sign cards indicating their wish to do so. An identical bill died last year after Gov. Mitt Romney vetoed it. Its supporters hope that Gov. Deval Patrick, a Democrat, will sign off on it.

"It comes down to employees who want to organize should be allowed to do so without impediment," bill sponsor Rep. Robert DeLeo (D-Winthrop) said during floor debate on the bill. "This creates a new system by which they can do so and that system is efficient and fair and should be adopted."