Tuesday, July 31, 2007

More effective email

Our CIO, John Halamka, recently authored a column for Computerworld in which he offers some ways for dealing with the large influx of emails many of us get and also suggestions for reducing the quantity we get in the first place. He notes, "With some enforced discipline, we may be able to learn how to communicate with one another more effectively and get back to our creative work." I reprint excerpts with his permission. Adding to item number 5, I would also encourage people to diminish the use of exclamation marks in the text of their emails.

I believe we need to rethink our e-mail communication habits before our workday devolves into a continuous ping-pong of e-mail messages without any time for creativity, thought or judgment. Here are 10 suggestions for returning sanity to e-mail:

1. E-mail marked with a “high importance” exclamation point must pass the “cry wolf” test. Is the sender a habitual “high importance” e-mailer? Are his e-mails actually important? If less than 50% are, the e-mail loses points.

2. Give points to high-priority people: your boss, your family members and your key customers.

3. Same for high-priority subjects: critical staff issues, health issues and major financial issues.

4. Rate according to the “To,” “cc” and “bcc” fields. If you are the only person in the To field, the e-mail gets points. If you are in the To field with a dozen other people, it’s neutral. If you are only cc’d, it loses points. A bcc should lose a lot of points to keep folks from the reprehensible practice of using blind copies as a political maneuver. Similarly, an e-mail from a co-worker who cc’s your boss should lose points. E-mail should not be used as a weapon.

5. E-mail with emotional words, capital letters or anything less than civil language should be penalized.

6. E-mail threads that go back and forth more than three times should be downgraded. So should e-mail messages longer than five BlackBerry screens.

7. E-mail responses that say only “Thanks,” “OK” or “Have a nice day” are social pleasantries but should be moved to the bottom of the queue.

8. E-mail with colorful backgrounds, embedded graphics or mixed font sizes lose points.

9. Companies that send bulk e-mail should be forced to pay before an e-mail gateway delivers their mail. How many newsletters have you “opted in” for? A micropayment fee system will keep companies honest about their opt-in and unsubscribe policies by aligning financial incentives.

10. Spam filters need to be more effective. Although they are very good at removing clearly labeled ads for Viagra or mortgages, they aren’t effective against ads for V 1@G RA or mortgage offers embedded in graphic files that are readable by humans but not computers. The more we tune our spam filters to eliminate offensive content, the greater likelihood we will miss real mail. Thus, the approach used by Earthlink, which requires first-time senders to be added to an approved buddy list, may be the defense with the highest sensitivity (block the bad stuff) and specificity (don’t block the good stuff).

OK, John! Thx!! Have a nice day! :)

Monday, July 30, 2007

Pages from the Playbook

I have received lots of questions recently from hospital colleagues and others wondering about the status of the Service Employees International Union's apparent plans to organize the Boston teaching hospitals and BIDMC in particular. So, here's the latest, as seen from the corner of Longwood and Brookline Avenues.

Several months ago, I pointed out the type of approach employed by the SEIU when seeking to organize workers in hospitals elsewhere in the country. It consists of publicly denigrating the reputation of the targeted hospital, its senior management, and its board of trustees in an attempt to put pressure on the hospital to agree to certain concessions in the union certification process, i.e., either to agree to a "card check" form of organizing to replace elections or to agree to a so-called "neutrality agreement" during the elections to enhance the probability of winning a certification vote.

A key element of this tactic is to attack the hospital for not carrying out key aspects of its public service mission, aspects inherent in its non-profit status. In this way, trustees are meant to face embarrassing questions from their colleagues in the business world and the community on issues of general concern. "I hear your hospital is not taking care of poor people." "I hear your hospital discriminates against minorities."

Here's how it works in detail. Any hospital the size of BIDMC ($1 billion in revenues, hundreds of thousands of patients, millions of square feet of space) files tons of documents with federal, state, and local regulatory agencies. The union hires several dozen bright, committed young researchers and tells them to scour every line and item in all these reports. You look for inconsistencies, ambiguities, and patterns, and then you issue a public report stating that the hospital was incorrect in the handling of a certain matter or knowingly misrepresented some issue or other. You also ask for a review of the matter by a legislative committee.

The key is to pick a topic that garners a headline and public concern, like provision of care to poor people. It is also helpful to pick an arcane accounting issue that few understand, so that a cogent and concise rebuttal by the hospital is virtually impossible in the regular media.

(Meanwhile, SEIU will point to its membership and participation in various state bodies (like the Connector Authority board) as the rationale for raising these items. It will say that its concern has nothing to do with union organizing or this particular hospital but is only reflective of its interest in matters of public import.)

The next page in the playbook is an important intermediate step. You send letters to the homes of the hospital's board of trustees asserting that they are not carrying out their fiduciary responsibilities in properly supervising the management on the matters raised. Later -- if there is no response or if you don't find the answer fully responsive -- you publicly assert that the hospital's board is not sufficiently diligent about those responsibilities.

And now let's speculate about the next play that could be used to support that proposition: An expose might be released about specific poor people who arrived at the hospital's emergency room and did not get the care to which they were entitled, or who were later hounded by a third-party collection agency. Here would be a vivid (and media savvy -- although I truly hope that people are not used in that fashion) demonstration of the institution's insensitivity to the poor and also a portrayal of the board as ineffective in insuring that the management carries out its public service obligations.

And, what if the patient stories are exaggerated or untrue? Well, since a hospital is not allowed to discuss individual patient cases under HIPAA or state law or under the hospital's quality assurance peer review process, it would be left to give a general response that will not appear persuasive in the public eye.

And so it begins. We are only a few pages into the playbook so far. My colleagues wonder: Is the SEIU taking steps in preparation for a unionization drive at BIDMC, or is it sending a message to other hospitals in the city that it will attack anybody who has the nerve to speak out against its tactics, or both?

And please remember: No matter how this discussion is characterized, this is not about the right of workers to organize, a right we all support under the laws of the nation.

Sunday, July 29, 2007

Face transplants

Liz Kowalczyk writes in the Boston Globe today about a decision by Brigham and Women's Hospital to do face transplants. These are rare cases, indeed, and the Brigham has introduced very thoughtful criteria as to which patients would be eligible.

While there will be critics who will state that this kind of procedure is expensive and unnecessary, there is a humanitarian aspect to this that is compelling. In addition, I am guessing that much will be learned about the science of organ rejection as a result.

This may come as a surprise to regular readers of this blog, but I think this kind of development is fully consistent with the role of academic medical centers. We are expected to push the boundaries of medical science for humanitarian purposes. Congratulations to our neighbors for having the fortitude to take on a procedure that was bound to raise lots of moral, ethical, and financial questions.

Friday, July 27, 2007

Building Plans

A press release we issued yesterday follows. Story by Jeff Krasner in the Boston Globe today offers more context and details. See my post on May 29 for related commentary.

Focus is on increased capacity on main campus
and proposed new ambulatory care center to support growing patient needs

BOSTON – Beth Israel Deaconess Medical Center (BIDMC) has begun its long-term plan for growth that envisions increased clinical capacity at its main Longwood Medical Area (LMA) campus and enhanced convenience and access for patients at a new ambulatory care center at a yet-to-be-determined suburban location.

This conceptual blueprint for growth, approved last month by the BIDMC Board of Directors, calls for more private rooms, more operating rooms, new technology and more rational use of space on BIDMC’s main campus in the LMA. The projects, to be carried out over the next 10 to 15 years, will create an estimated 500-700 construction jobs in Boston and ultimately add more than 550,000 square feet of space for patient care.

Over the next year, BIDMC staff will launch more detailed programming, planning and architectural efforts in cooperation with the Boston Redevelopment Authority officials and neighborhood leaders to turn its conceptual blueprint into a specific plan.

Services in the proposed 100,000-150,000 square foot suburban ambulatory care center will likely include primary care and specialist physicians, ambulatory surgery and ancillary services like radiology. BIDMC is about to issue a request for proposal to launch the planning and design process, with a target opening date in 2011. Pending site selection, approvals and permitting, construction of the off-site ambulatory center will begin within the next two years.

This long-term facilities plan reflects BIDMC’s success in recent years in turning around its finances and increasing its volume in the highly competitive Boston health care arena.

"To provide the best care for our patients and our community, we always need to be looking ahead," said Lois Silverman, chair of the BIDMC board. "We are planning for both volume growth and changing patient needs, as well as for advances in technology and clinical practices."

"Our goal is to maximize the limited space available on our campus to create a more rational and convenient medical center for our patients," said Paul Levy, BIDMC’s President and CEO. "We intend to be a model for how care is organized, both physically and clinically."

"The Shapiro Clinic Center will continue to be a vibrant, busy, multi-specialty center of ambulatory care," added Eric Buehrens, BIDMC’s Executive Vice President and Chief Operating Officer. "But we also want to do our part to reduce the traffic and parking burden in the LMA by providing convenient, accessible care for patients living and working in the suburbs."

BIDMC will partner with its physicians’ group, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, in the development of the suburban ambulatory center.

"Upgrading our facilities is critical to the mission of providing the best care and service to our patients, including convenient access to ambulatory services," said Stuart Rosenberg, MD, HMFP’s President and CEO. "To that end, HMFP has committed to support the jointly developed facilities plan."

The new blueprint analyzed volume trends, assessed existing facilities and analyzed various alternatives for adding the estimated 700,000 square feet of additional space needed for patient care.

Some key features in the plan:

Growth on the west campus will include expansion of the West Clinical Center located at One Deaconess Road and construction of a new building at the site of the current Libby and Deaconess buildings on Pilgrim Road;

BIDMC will continue to concentrate the majority of inpatient beds on the west campus, eventually including maternity services, to improve both operations and access to inpatient services for emergency department patients;

At the same time, the east campus will increasingly house most outpatient and ambulatory services, administrative offices and research labs;

Over time, the medical center will add approximately 130 beds, with an emphasis on creating more private rooms and greater intensive care capacity, reflecting the trend toward caring for sicker patients;

Capacity will be expanded in several other clinical areas, such as in operating rooms and radiology suites. New operating rooms will be larger and capable of handling the increasingly sophisticated technology, including minimally invasive surgical instruments and additional imaging equipment;

The total cost of the 10-15 year plan is expected to be $1 billion.

Projects already underway will not be affected. For example, BIDMC will lease approximately 50 percent of the space after the opening of the Center for Life Sciences, a new research building currently under construction by private developers in the LMA. Also, Beth Israel Deaconess Hospital-Needham, a community hospital affiliated with BIDMC, is currently planning to expand its emergency department, add inpatient rooms and enhance its radiology services.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.harvard.edu.

Thursday, July 26, 2007

Simpson Sox

From Boston.com, "What some of the members of the 2007 Sox might look like if they spent time in Springfield. " Check it out.

On to New Orleans

A message to our staff yesterday.

Another transition here at BIDMC. First, Herb Kressel, our chief of radiology, stepped down to become editor of the most respected radiology journal in the country. Then, Jeff Flier accepted an offer to become Dean of our local medical school. Now, Ben Sachs, our distinguished chief of obstetrics and gynecology, has announced that he has accepted an offer to become Senior Vice President of Tulane University and Dean of the Medical School.

Those of you who know Ben knows that he would not leave us for a "standard" academic appointment at another institution. Here, he is taking on a mission of great humanitarian import. As he says in a letter to his friends today:

"Two years ago, the Gulf region was devastated by hurricanes Katrina and Rita and yet people today are still struggling. What attracted me to this position was the opportunity to help rebuild the healthcare system of New Orleans and the Gulf coast. Both a redesigned medical system that provides high quality care for all and a marked growth in world class biomedical research are vital for the region's economic recovery. Tulane is absolutely committed to these goals and playing a major role in the region's recovery. I am energized by the thought that I can help make a difference using the skills and experience I have gained over the last 3 decades."

This assignment is so consistent with Ben's philosophy of life and his prior good deeds throughout the world (e.g., in Ukraine, where he was driving force for improvements in the medical system), that we cannot be surprised. Of course, here at BIDMC, Ben has also been known for running a superb department, with an outstanding record in clinical care, education, and research. He has been an innovator in everything from team training to encouraging young researchers in fields like preeclampsia.

All of us at BIDMC take some pride when one of our senior medical leaders - in this moment Dr. Sachs, and also recently Drs. Flier and Kressel - move on to be of service to a broader audience. We wish Ben well and look forward to receiving his favorite recipes for jambalaya!

Wednesday, July 25, 2007

Panamanian Wedding Cake

Following up on an earlier post about a St. Thomas charoset recipe, here is an article on salon.com written by my daughter Sarah about the family recipe(s) for Panamanian wedding cake.

A verdict is delivered

David Abel at the Boston Globe reports today on the results of a high profile malpractice case involving bariatric surgery. The jury returned a verdict in just three hours in favor of the defendants. I have previously addressed what it feels like for doctors going through these kind of cases. I don't know these two doctors, but it must be a tremendous relief to them to have this resolution.

(By the way, an odd moment in the lawsuit came in the first trial, when the two doctors being sued came to the aid of a juror who had collapsed in the courtroom. The judge declared a mistrial in that case, and the entire proceeding had to be repeated.)

The Harvard hospitals (BIDMC, MGH, Brigham and Women's, etc) jointly own a captive insurance company that covers us for malpractice cases like this. I have discussed the odd relationship among these hospitals and Harvard Medical School in a previous post. Notwithstanding our competition in the clinical arena, we jointly work very hard to learn about ways to improve patient care and safety through our experience in the risk management realm. That research, analysis, and training is an integral part of each institution's quality and safety program.

Monday, July 23, 2007

Hub on Wheels

My friend Nicole asked me to let you know about this event:

Coming up in September is one of those events that helps define Boston as the truly unique city that it is — Boston’s only citywide bike ride & festival:

Mayor Thomas M. Menino's Hub On Wheels
Citywide Bike Ride & Festival Sunday, September 23, 2007

For one day in September, bikes rule in Boston. It’s a chance for us to get together and explore the greenways and the shoreline, the neighborhoods and the communities of Boston. Riders can choose from a 25- or 45- mile loop with food and support provided along the way. Plus, many streets will be closed off to traffic—imagine being able to ride down Storrow Drive with no cars to get in your way.

A great cause. A fabulous time. Your participation in Hub on Wheels will support the Boston Digital Bridge Foundation, an organization that brings technology and its benefits to Boston Public School students and their families.

Please, sign up now. So pump up those tires and get ready to ride. The first 100 people to register will receive free Hub on Wheels T-Shirts. But the important thing is that you get out there on September 23rd and have some fun and help raise money for a good cause.

To register, go to http://www.hubonwheels.org/, or send questions to Nicole.Freedman.bra@cityofboston.gov.

It's Monday and . . .

. . . . the Joint Commission has arrived for our unscheduled survey. As I have noted in the past, if the Joint Commission didn't exist, we would want to invent it. It is really important to have an objective, outside review of an organization from time to time.

And, yes, we will publish our results once they go through the process of review at the Joint Commission headquarters.

Friday, July 20, 2007

Profoundly shaped by relationships

As we go into a beautiful summer weekend here in New England, I want to share an equally beautiful bit of prose with you. It is by David Brooks and was published as an op-ed in today's New York Times. Here are the first few paragraphs:

Douglas Hofstadter was a happily married man. After dinner parties, his wife Carol and he would wash the dishes together and relive the highlights of the conversation they’d just enjoyed. But then, when Carol was 42 and their children were 5 and 2, Carol died of a brain tumor.

A few months later, Hofstadter was looking at a picture of Carol. He describes what he felt in his recent book, “I Am A Strange Loop”:

“I looked at her face and looked so deeply that I felt I was behind her eyes and all at once I found myself saying, as tears flowed, ‘That’s me. That’s me!’

“And those simple words brought back many thoughts that I had had before, about the fusion of our souls into one higher-level entity, about the fact that at the core of both our souls lay our identical hopes and dreams for our children, about the notion that those hopes were not separate or distinct hopes but were just one hope, one clear thing that defined us both, that wielded us into a unit, the kind of unit I had but dimly imagined before being married and having children. I realized that though Carol had died, that core piece of her had not died at all, but that it had lived on very determinedly in my brain.”

The Greeks say we suffer our way to wisdom, and Hofstadter’s suffering deepened his understanding of who we are, which he had developed as a professor of cognitive science at Indiana University.

Hofstadter already understood that the mind is not a centralized thing. There are dozens of thoughts, processes and emotions swirling about and competing for attention at any one time. It’s like a quantum mechanics light show.

Carol’s death brought home that when people communicate, they send out little flares into each other’s brains. Friends and lovers create feedback loops of ideas and habits and ways of seeing the world. Even though Carol was dead, her habits and perceptions were still active in the minds of those who knew her.

Carol’s self was still present, Hofstadter sensed, even though it was fading with time. A self, he believes, is a point of view, a way of seeing the world. It emerges from the conglomeration of all the flares, loops and perceptions that have been shared and developed with others. Douglas’s and Carol’s selves overlapped, and that did not stop with her passing.

More on surgery disclosure

Following our discussions below, here is the link that presents cardiac surgery results for individual doctors in Massachusetts. It covers 2002 through 2004 and presents the 30-day mortality for isolated coronary artery bypass graft procedures, and there is a risk-adjustment aspect to calculation.

Please note that the chart does not given the numerical mortality figures for each doctor. Instead, it groups doctors into three statistically valid groups: mortality significantly higher than state average; mortality the same as state average; and mortality significantly lower than state average. It also shows how many cases have been done by each doctor during this period.

There is also a link that groups this information by hospital.

I don't know about you, but I think this is pretty well done. It has the same kind of statistical validity that doctors would expect among themselves, and yet it is available to the public. It presents information in a way that would be useful to me as a consumer. (It is a bit out of date, but I am guessing physician performance usually does not change by all that much year to year.)

Now that you have seen it, do those of you who have objected below still have objections? Specifically, do you feel this would cause doctors to avoid certain cases? Do you think consumers could not understand this information?

To those of you below who wanted information, does this give you what you want?

Thursday, July 19, 2007

Crossing network boundaries

An interesting story by Jeff Krasner in the Globe today about an expansion of the physicians network in the Partners HealthCare System. For those of you unfamiliar with the business, every academic medical center (BIDMC, too!) tries to build an extensive network of physician groups and community hospitals to generate referrals to the main tertiary center.

There are federal rules that make it impossible to require doctors in the network to refer patients to the downtown hospital. This is indirectly noted in the story:

[The] chief executive of the Partners' physician organization said the affiliation agreement doesn't require Tri- County doctors to send patients to Partners hospitals.

But here's the key. If those community doctors are tied into a proprietary patient information system, they will tend to refer to the "mother ship" that hosts that information system (as well as to other affiliated hospitals). The story goes on:

But should they choose to send patients to Partners hospitals, referrals and medical records transfers will happen more smoothly.

This is an obstacle to enabling consumer choice of providers. So the societal issue is whether we should require that patient information systems be able to talk to one another so that referring doctors do not encounter this computer-generated friction in sending patients to an out-of-network tertiary hospital. What do you think?

There are no Wednesdays in summer

I received a comment asking why I have not been making posts in my Wednesday is for Students series. The simple answer is that I have not been receiving many questions from students. Maybe they are taking a summer break. Or maybe they are reading other blogs. Or maybe there are no questions left to ask. So, the plan is to try to start that up again in the fall -- if there is enough interest.

Wednesday, July 18, 2007

Our geeks excel again

Back in February, I wrote a post unabashedly touting our hospital information systems, and giving lots of credit to our CIO, John Halamka. I found out today that we have been named to the list of the nation's Most Wired and Most Wireless Hospitals. This is found in the July issue of Hospitals & Health Networks magazine, which has named the 100 Most Wired hospitals and health systems since 1999. Here's our press release on the topic, which has the following tidbit:

BIDMC is one of three hospitals or health systems in Boston to be named Most Wired and the only to achieve both designations. It is the seventh consecutive [year] on the Most Wired list and the third year in a row as Most Wireless.

Congratulations to John and his staff for this recognition. The key to their success is that, not only do they build great information systems and applications, but they work closely with our clinicians in designing them. So those systems are actually in use every day to provide support to the delivery of clinical care.

Tuesday, July 17, 2007

Let's all help Jim

Please check out this link to view Jim's story about trying to quit smoking. Let's all send him some encouragement by posting messages on this blog.

You go, Jim!

Business opportunity?

For a change of pace from our more serious topics: The above was sent by an Indian friend, suggesting that we consider this as a new revenue opportunity. It is heartening to see that clinical results can be published so clearly!

Saturday, July 14, 2007

Above averages

As a follow-up to yesterday's post, guess which of the following stories is true and which is false:

Red Sox slugger David Ortiz has told manager Terry Francona that he will no longer bat against any pitcher who has an ERA below 3.0. Ortiz, furious that his batting average has been made public, said "It just isn't fair that they include my at-bats against the really hard pitchers. No one is going to think I am good at this game." Ortiz has said that he will sit out games until the starting pitcher is relieved and replaced by someone less difficult to hit against. "I don't care if this causes my team to lose," he was heard to say. "I have a career to think about." Francona has yet to respond publicly.

OK, you already know that's not true! Our local hero thrives in taking on the really good pitchers. So, here's the actual story from SFGate.com.

California health authorities on Thursday released a study showing for the first time how many heart bypass patients die after surgery, the names of their surgeons and the hospitals where the operations were performed....

Dr. Ismael Nuno was furious with [his worse than average] rating. "I've had a very illustrious career, and when my name comes out tomorrow I might just retire," he said in a phone interview. "Nobody in the state is going to write right next to your name that Dr. Nuno tried really hard to keep this patient alive. All it's going to say is Dr. Nuno is a terrible surgeon."

Nuno warned that some surgeons already are turning away patients with poor outcomes for fear they'll get tagged as bad doctors. "People are dying because of what the state of California is doing. Surgeons are walking away and saying, 'Tough, it's either my career or your death.' "

It looks like Dr. Lee and his colleagues have some more empirical support for the conclusions of their article.

OK, I know this is not a fair comparison, and I don't make it to disparage this doctor, who, by all accounts, is a very fine surgeon. Beyond having a little fun with the topic, I make it to frame the question:

"Why are many doctors so sensitive and/or resistant on these matters while people in other fields have come to accept public reporting of their results?"

I look forward to your answers.

Friday, July 13, 2007

At the heart of the matter

Liz Cooney, on White Coats Notes, offers a summary of a new article in the New England Journal of Medicine by Doctors Thomas Lee, David F. Torchiana, and James E. Lock. It is called "Is Zero the Ideal Death Rate?" Here are some excerpts from her report:

[Dr. Lee] is concerned that public reporting of mortality rates for individual cardiac surgeons carries unintended, perverse consequences. He fears that surgeons might hesitate to operate on high-risk patients if they are seeking a perfect performance record, he and two colleagues write in tomorrow's issue of the journal.

"If you are being ranked, you may walk away from a patient who's very sick, even though that patient may be at high risk for surgery but even higher risk with medicine" as treatment, he said in an interview. "When so few patients can swing things for you being ranked, we're worried about that effect on the decision-making process."

[The authors say that] reporting on cardiac surgery by institution makes sense, with individual reports available only to those hospitals. Massachusetts recently joined New York, New Jersey and Pennsylvania in publicly reporting death rates for individual cardiac surgeons.

Two elements make individual reports undesirable, they said. The first problem is that risk-adjustment methods intended to account for how sick a patient is do not include variables such as socioeconomic status. The second problem is the small sample size. If the average death rate after coronary artery bypass surgery is 2 percent, one or two deaths among the 200 operations a surgeon performs can make a large difference in that surgeon's ranking, the authors say. Lee said a better way to report performance would be the measures the federal government chose when it rated hospitals recently: better than expected, as expected, and worse than expected.

"I worry about having a patient with diabetes who's doing very poorly. They may have a 20 percent mortality rate with surgery but an 80 percent mortality rate without surgery," he said. "I don't want to have to beg surgeons to operate."

I am not quoting from the actual NEJM article, because Liz's summary is what members of the public are more likely to see. So I recognize that some of the subtleties in the article may not be fully presented. To my mind, it raises tons of questions.

First, is the premise correct, that doctors will stop taking high-degree-of-difficulty patients if their clinical results are made public? I am not sure how to test that statistically, but when I have raised the issue at BIDMC, the response was, "If you are a good enough surgeon to take those kind of cases, you will still take them. If you are not -- or if you are so afraid of your "numbers" -- you shouldn't be taking them anyway."

Second, if we can't make the results of individual doctors public, what basis is there for referring doctors and patients to choose among surgeons? We fall back on anecdotal or reputational methods -- the methods used today -- which have no statistically valid quantitative basis and are therefore subject to errors of a different type.

Third, a hospital-wide rate doesn't help me choose a surgeon. It helps me choose a hospital, for sure, but it doesn't tell me which surgeon in that hospital offers me the best record of success.

Fourth, if we do want to use hospital-wide rates, there is currently a system in place that moves along the path suggested by the authors. Back on April 6, I posted a column entitled Surgical Gag Order. Here's the pertinent excerpt:

The American College of Surgeons, the preeminent surgical organization in the country, has developed a superb program to measure the relative quality of surgical outcomes in hospital programs. It is called NSQIP (National Surgical Quality Improvement Program) and is described in this Congressional testimony by F. Dean Griffen, MD, FACS, Chair of the ACS Patient Safety and Professional Liability Committee.

What makes this program so rigorous and thoughtful is that it is a "prospective, peer-controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, allowing valid comparison of outcomes among the hospitals now in the program." In English, what this means is that it produces an accurate calculation of a hospital's expected versus actual surgical outcomes. So, if your hospital has an index of "1" for, say vascular surgery, it means that you are getting results that would be expected for your particular mix of patients. If your NSQIP number is greater or less than "1", it means you are doing worse or better than expected, respectively.

I am inferring from Liz's article that this is the kind of ranking recommended by the authors in the NEJM article. Here's the catch. The American College of Surgeons will not permit the results to be made public.

So here's our Catch-22: No reporting method is statistically good enough to be made public. But if a method is statistically good enough, we won't allow it to be made public.

The medical profession simply has to get better at this issue. If they don't trust the public to understand these numbers, how about just giving them to referring primary care doctors? Certainly, they can trust their colleagues in medicine to have enough judgment to use them wisely and correctly.

We hear a lot about insurance companies wanting to support higher quality care. When is an insurance company going to demand that the hospitals in its network provide these data to referring doctors in its network? How about this for an idea? If a hospital doesn't choose to provide the data, it can still stay in the network, but the patient's co-pay would be increased by a factor of ten if he or she chooses that hospital.

I have been in many industries before arriving in health care, but I am hard-pressed to remember one that is so intent on preserving the "priesthood" of the profession. The medical community is expert at many things, but particularly at raising stumbling blocks and objections to methods to inform the public and be held accountable. Meanwhile, they are quick to engage in protectionist behavior to keep others out of their field. The insurers, fearful of introducing products that require real-time clinical data from dominant providers in their network, stand by and are complicit.

And then they wonder why state legislatures pass laws about reporting and accountability.

Wednesday, July 11, 2007

White smoke over Mass. Hall

Ending weeks of speculation, Jeff Flier, a member of our faculty and BIDMC's Chief Academic Officer, has been chosen to be the new Dean of Harvard Medical School. This is a superb appointment by Harvard President Drew Faust. Jeff is an accomplished scientist, educator, clinician, and administrator -- as well as a person of the utmost caring and integrity. He will be a great dean, and we are so proud that he has been appointed to this important position. Following is the text of the announcement from Harvard University.


Jeffrey S. Flier, the George C. Reisman Professor of Medicine at Harvard Medical School (HMS), will become the new dean of Harvard's Faculty of Medicine on Sept. 1, President Drew Faust announced today (July 11).

A member of the HMS faculty since 1978, Flier has served for the past five years as chief academic officer of the Beth Israel Deaconess Medical Center (BIDMC), one of Harvard's leading affiliated hospitals, where he is also the Harvard faculty dean for academic programs. He has been closely involved in recent discussions of the future of Harvard-wide science, as a founding member of the Harvard University Science and Engineering Committee, and previously through his service on the University Planning Committee for Science and Engineering.

A prominent authority on diabetes and obesity, Flier is known for his research into the molecular mechanisms of insulin action and insulin resistance, as well as the molecular pathophysiology of obesity.

He has also been active in shaping medical education through his work in overseeing HMS teaching programs conducted at the BIDMC and his involvement with the Harvard-MIT Health Sciences and Technology program (HST).

"Jeff Flier is an outstanding academic leader, scientist, and medical educator, whose impressive experience, broad perspective, and collaborative instincts promise to guide the Harvard medical community smartly forward," said Faust. "He enjoys broad respect among his colleagues both for his leadership qualities and his academic accomplishments, and he combines exceptional intelligence with an admirable ability to bring people together around issues of academic and institutional importance. His outlook and experience will position him well to build on the remarkable strengths of our Medical School, to strengthen cooperative efforts within the broader Harvard medical community, to pursue important new opportunities for fruitful connections with other parts of the University, and to speak more broadly to medical and health issues of national and international concern.

"Harvard takes great pride in being home to one of the world's most productive and dynamic centers of academic medicine," Faust added, "and I am delighted that Jeff Flier has agreed to serve as our new dean."

"I am deeply honored, as well as thrilled, by the opportunity afforded to me by President Faust to serve as the next dean of Harvard Medical School," said Flier. "During the 29 years that I have pursued an extraordinarily rewarding academic life within the Harvard medical community, I have come to know its amazing strengths from its students to the faculty, both on the Quad and within the Harvard-affiliated hospitals and research institutions.

"This medical school is a national treasure, and while it is a humbling thought that I will now have great responsibility for maintaining and enhancing the accomplishments of HMS, this is a responsibility that I accept with great optimism and excitement.

"Joe Martin has capably set the stage for the next evolution of Harvard medicine and I thank him and my many colleagues and friends on the faculty for their support. I know that together there are few things that we cannot accomplish."

Flier succeeds Joseph B. Martin, who stepped down as dean on June 30 after a decade of distinguished service. Barbara J. McNeil, the Ridley Watts Professor of Health Care Policy and Professor of Radiology, became acting dean on July 1 and will serve through the end of August. In his current roles as chief academic officer and Harvard faculty dean for academic programs at the BIDMC, Flier oversees both a broad range of hospital-based teaching programs and a biomedical research enterprise that is currently ranked third among independent hospitals nationwide in funding from the National Institutes of Health. Earlier in his career, he was vice chair for research of the BIDMC's Department of Medicine (1998-2002), chief of the Division of Endocrinology (1990-2000), and chief of the Diabetes Unit (1978-90).

Flier joined the HMS faculty in 1978, and rose through the ranks to become a full professor in 1993 and the Reisman Professor of Medicine in 1998. Before taking up his role as Harvard faculty dean for academic programs at the BIDMC, he was a member of the curriculum committee for the Health Sciences and Technology program and for several years directed the HST endocrine pathophysiology course.

Having published more than 200 scholarly papers and reviews, he is internationally recognized for his investigations of the molecular mechanisms of insulin action, the molecular mechanisms of insulin resistance in human disease, and the molecular pathophysiology of obesity. Most recently, his research group has assumed a leading position in the use of transgenic models to explore the pathophysiology of metabolic disease, and in studies of the biological role and mechanism of action of the fat-derived hormone leptin.

"This is an extraordinarily exciting time for Harvard medicine, as transformative developments in biomedical research greatly expand our opportunities to understand disease and improve human health," said Harvard Provost Steven E. Hyman. "At such a moment, we are very fortunate to have someone with Jeff Flier's broad leadership experience in medical research and education, deep familiarity with Harvard, and strong sense of future possibilities to help Harvard Medical School rise to the challenges ahead."

For 14 years, Flier was editor of the Beth Israel Hospital Seminars in Medicine series. Through this series he edited over 70 papers that were published in the New England Journal of Medicine. He was associate editor of the Journal of Clinical Investigation from 1989 to 1992, and has served on the editorial boards of Molecular Endocrinology, the Journal of Clinical Endocrinology and Metabolism, and the American Journal of Medicine. He currently serves on the board of consulting editors of Science magazine.

Flier received the Eli Lilly Award of the American Diabetes Association for Outstanding Scientific Achievement in 1991, and was awarded an honorary doctorate in medicine by the University of Athens in 1997. He has also received the Transatlantic Medal of the British Endocrine Society (2004) and the American Diabetes Association's (ADA) Banting Medal for Scientific Achievement (2005), the ADA's highest award for scientific achievement.

A member of the Institute of Medicine of the National Academy of Sciences, Flier is an elected fellow of both the American Academy of Arts and Sciences and the American Association for the Advancement of Science. In addition, he is an elected member of the American Society for Clinical Investigation and the Association of American Physicians.

Flier holds a bachelor's degree from the City College of New York (1968) and his M.D. from the Mount Sinai School of Medicine (1972), where he graduated with the Elster Award for highest academic standing. He trained in internal medicine at the Mount Sinai Hospital (1972-74), then served as a clinical associate at the National Institutes of Health (1974-78) before joining the HMS faculty.

Flier is married to Eleftheria Maratos-Flier, M.D., and associate professor of medicine at Harvard Medical School. They have two daughters and live in Newton, MA.

Harvard Medical School (HMS) has over 10,000 faculty and 17 affiliated hospitals and research institutes. Program offerings include MD, PhD and joint MD-PhD programs. In addition to 50 hospital-based clinical departments, HMS has nine school-based basic science and social science departments. This depth and breadth in academic pursuit fosters interdisciplinary collaborations feasible at few institutions.

Uh oh, questions keep arising

The good news is that Virginia Mason identified ways to streamline and improve care; the bad news is that the medical center’s bottom line may take a significant financial hit as a result.

Apropos of a post I ran a few weeks ago raising questions about our strategy of improving efficiency and lowering costs, we find the following study summarized on the Health Affairs website. I include the summary in its entirety.

I again ask my loyal readers and business advisors out there, "What does this mean?" Should I be encouraging a movement back to capitation? What if one payer prices services that way and another prices on fee-for-service? We can't practice medicine in different ways depending on who the insurer is. Can the insurers ever get together and decide to cooperate on payment design (if not actually rates)? And, if capitation returns, should it be just for the services we provide, or do we need to include the whole continuum of care (e.g., rehab centers and nursing homes to which we discharge patients but which we do not own or control?)

Health Affairs Article Details Care Redesign At Seattle Medical Center
Virginia Mason’s Quest To Improve Patient Care And Reduce Costs Without Being Awash In Red Ink

Bethesda, MD -- The tale of one Seattle medical center’s quest to improve care and reduce costs illustrates the obstacles physicians face in practicing more efficiently under a fee-for-service payment system that overpays for some medical services and underpays for others, according to a study by researchers at the Center for Studying Health System Change (HSC) published today as a Web Exclusive in the journal Health Affairs.

The article, “Redesigning Care Delivery in Response to a High-Performance Network: The Virginia Mason Medical Center,” takes an in-depth look at Virginia Mason’s efforts to improve care and lower costs for four common conditions: uncomplicated lower back pain; gastroesophageal reflux disease (GERD); migraine headaches; and cardiac arrhythmias.

Faced with exclusion of several physician specialties from Aetna’s high-performance network, Virginia Mason Medical Center (VMMC) officials worked with the insurer and four large Seattle employers -- Costco, Starbucks, King County, and Nordstrom -- to redesign care delivery for the four conditions. Adapting aspects of the Toyota Production System to a health care setting, VMMC mapped out how to improve efficiency per episode of care for each of the conditions, according to the article.

“The good news is that Virginia Mason identified ways to streamline and improve care; the bad news is that the medical center’s bottom line may take a significant financial hit as a result,” said Hoangmai H. Pham, M.D., M.P.H., an HSC senior health researcher and lead author of the study funded by the California HealthCare Foundation (CHCF).

In an accompanying HSC Issue Brief, “Distorted Payment System Undermines Business Case for Health Quality and Efficiency Gains,” also funded by the CHCF, Paul Ginsburg, Ph.D., HSC president, points out that “most efforts to improve efficiency for a specific medical condition usually reduce the number of services per patient that can be billed, posing financial challenges for providers. These challenges are often magnified by the current fee-for-service payment structure, where some services are highly profitable and others are unprofitable.”

Although Aetna and the participating self-insured employers agreed to pay higher rates for certain unprofitable services if VMMC could achieve reductions in highly profitable services, VMMC still faces a financial challenge from applying more efficient care practices to patients covered by other insurers, which account for more than 90 percent of VMMC’s revenues.

And most other medical groups would find it very challenging to do what VMMC did. “Their experience may be the best-case scenario,” Pham said, “because they at least had a large group of salaried physicians to work with, who might not be as sensitive to the loss of revenues from profitable services as physicians in most practice settings, and who had the resources to define the problems and coordinate a plan of action.”

The Health Affairs article concludes on a cautionary note, stating, “Aetna, employers, and [Virginia Mason] used an ostensible business case to motivate [Virginia Mason] to improve efficiency, only to confront the possibility of that business case turning on its head. It is an example of a provider organization attempting to do what purchasers, including the Medicare program, all exhort -- improve care delivery while reducing costs. . . . It also stands as a cautionary example of how fee-for-service payment and uncoordinated payers present stubborn barriers to sustaining cost control.”

Tuesday, July 10, 2007

Hizzoner strikes gold

The last in my series of catching-up stories from the holiday week. April Yee's July 3 article in the Boston Globe presented the story of Camp Harbor View. Read it and feel good.

The camp is the brainchild of Boston Mayor Tom Menino, who was looking for a place for city kids to escape, play, get fresh air, and eat good food during the summer. It is an extraordinary example of the power of municipal leadership. He engaged community leaders like Jack Connors, a retired advertising executive, John Fish, CEO of Suffolk Construction, and others.* Creating an alliance with the Boys and Girls Club of Boston, the Mayor created a children's paradise on Long Island, one of the harbor islands just minutes from downtown Boston.

Here are details from the organizers: Camp Harbor View will provide a fun and safe environment for youths to challenge themselves, make new friends, and experience a world beyond their neighborhoods. The camp experience will include athletics, arts, leadership development, and environmental education. Activities will include arts and crafts, tennis, basketball, hiking, field trips, a ropes course, and aquatics. The camp will also provide each camper with three nutritious meals per day. An on-site health facility will be staffed by healthcare professionals during camp hours of operation, to attend to any medical issues that may arise.

The campers are picked up by bus each morning at 8:00 a.m. at designated areas within Boston neighborhoods. Buses return campers to those designated areas each evening, departing the camp at 6:00 p.m. following the evening meal. The fee for each camper is $5 for the four-week session ($1.25 per week). Admission is based on referrals from community and neighborhood organizations. Upon acceptance to the camp, each youngster receives a welcome kit that includes a warmup suit, a T-shirt, a hoodie, and a backpack.

Mayors get all kinds of criticism and praise, often for things beyond their control, and sometimes earned and sometimes not. Here, though, is a fine example of civic leadership for which "Hizzoner" deserves unqualified congratulations. Bravo to him and the community leaders who helped him make this program possible!

You can make donations to support the camp here.

*By the way, Jack is Chairman of the Board of Partners HealthCare System and John is a member of the BIDMC Board. The competitive rivalry between our two hospital systems fades away completely when these two work together to help the community.

Monday, July 09, 2007


Still catching up on the holiday week, I refer to a Boston Globe op-ed written by Derrick Jackson on July 7, in which he refers to "the abject addiction of the state to the lottery." He notes:

The average American spent $177 playing the lottery, more than the average spent on reading materials. Massachusetts is fifth in the nation in per-capital lottery spending at $700.

I had seen this number in previous years, but each time I do, I am blown away. That is $700 for every man, woman, and child in the Commonwealth of Massachusetts. According to the US Census, the average family size in Massachusetts is 3.14 people, so let's call that $2100 per family. (Since we don't buy tickets, some other family is covering our share in addition to their own.)

Back in 1990 or so, when I was running the local water and sewer system and needed to raise water and sewer rates to $800 per household to pay for sewage treatment plants to clean Boston Harbor and to replace decades-old water and sewer pipes, I was told that this was not affordable.

This past winter, when I chaired a citizens' commission suggesting that our home town pass an override to increase property taxes by a couple hundred dollars per year to repair and replace aging schools, fire stations, streets, and parks, some said that this was not affordable.

Most recently, I have seen some observers suggest that the now mandatory health insurance in Massachusetts of about $1200 per year is not affordable, and lots of studies have been done on this matter.

So what does affordability really mean? I know I am lucky enough not to have to personally worry about this. But lots of people do. Governors, legislators, and other policymakers have to stand in their shoes and make specific decisions about rates, taxes, and premiums, decisions that can indeed result in people making choices among food, clothing, shelter, and medicine.

But Mr. Jackson's column should prick all of our consciences. The lottery is a form of taxation that tends to be regressive, hitting the poor and working poor the most. It can encourage a type of gambling addiction because it offers hope, especially to the poorest. But the hope is illusory because no lottery survives if it pays out more than it takes in. As a friend once said to me as we walked through a fancy casino in Las Vegas, "This place was not built with our winnings."

We have decided that it is acceptable to impose this form of taxation to keep the cost of other public services "affordable." By any standard of affordability, this is a deceptive definition and, in Mr. Jackson's words, "a social crime." Bravo to him for the reminder.

Faith isn't enough

Catching up on the news over the holiday week, Jeff Krasner at the Globe reported on June 29 that a deal by Ascension Health of St. Louis to take over the "troubled" Caritas Christi Health Care system here in Massachusetts had fallen through.

I feel great empathy for the folks in our neighboring hospital system: For several years, whenever we read about about our hospital in the newspaper, it was always the "financially troubled BIDMC." This was an accurate moniker for our place, by the way, and it appears to be so in this case, too. Even though these hospitals compete with us, I take no pleasure in watching them go through these hard times.

While many hospitals have faced financial problems over the last decade, it is particularly troubling to see it happen to faith-based hospital systems. Such hospitals -- whether Jewish, Methodist, or Catholic -- begin life with noble missions. They combine the best of medical treatment with moral and ethical standards of care that are meaningful and heart-warming to their host communities. Their staffs of doctors, nurses, and other caregivers and administrators choose to work in those hospitals as a matter of personal conviction that is generous of spirit.

And yet, that is no guarantee against financial failure. When I took over BIDMC in January 2002, Attorney General Tom Reilly was pushing to sell the hospital to a for-profit company. Why? For several years, he had watched while the organization squandered millions of dollars in charitable assets, and he had no confidence that it would have the business acumen and commitment to engage in the hard-nosed decisions necessary for our survival. He and I had a personal agreement that I would have a financial plan, milestone, and reports -- and that if we did not show progress within six months, we would be put on the block.

A key part of our turn-around and ultimate survival is that I persuaded our Board to reorganize itself and exercise real authority vis-a-vis that of our holding company, Caregroup. Previously, CareGroup was trying to operate an integrated health care delivery system comprising BIDMC, New England Baptist Hospital, Mt. Auburn Hospital, and several small community hospitals. This approach failed, in part, because of animosity among the several hospitals in the "system" and also because the authority of the local boards to set their own direction and to be held accountable had been diluted by the holding company's board.

It may not be my place to say -- but that never stops me! -- but I believe that a governance problem of both a similar and slightly different form exists at Caritas Christi. Having talked with many people in that system, it is clear that both the larger system board and the individual hospital boards exercise no real authority. Rather, the Archdiocese of Boston holds the reigns of authority. CEOs have been relieved of their jobs and suitors like Ascension have been solicited without real input of the lay leaders. This is understandable for historical reasons, but future success requires a change.

The marvelous hospitals of the Caritas Christi system and the caring and thoughtful staff in those hospitals need to be governed by the communities they serve. Local board members who are held accountable for their actions will have the business sense and the dedication to make the decisions needed to ensure that the faith-based mission of their institutions is successful. Referrals among the CC hospitals will be strengthened -- not weakened -- when each hospital has the authority to decide how and if to have clinical relationships with the others.

As mentioned above, the current weakness in the CC system sometimes works to the commercial advantage of BIDMC. But, we draw no pleasure from this. There is place in Massachusetts for all of us, and the people of the state would draw great benefit were this system healthier. But faith isn't enough to solve the system's problems.


Thanks very much to Kami Hyuse for listing this blog in the "Healthcare 100" (currently #13).

And thanks, too, to David Wescott for his designation as his first Best Blog EVAH.

I really appreciate the votes of confidence from them and all of you. My first blogging anniversary is approaching, and I never would have predicted this kind of enthusiastic response. It's been a great ride. Stay tuned for more!

Sunday, July 08, 2007

Trial for asthma

A few days ago, I learned of a fascinating clinical trial that could have implications for people with asthma. The description is on this site.

Here's the deal. Beyond the inflammation that occurs with asthma, the muscular spasm that makes it difficult to breathe is a serious problem. In this trial a catheter that emits RF radiation is used to deliver bronchial thermoplasty that actually reduces the size and functioning of the smooth muscles in the airways that is the home of those spasms.

I know this sounds a bit odd, but apparently the smooth muscle in our airways is vestigial, from the time mammals were amphibious and needed to close their airways while diving under water. (Actually whales still use those muscles to expel water when they surface.) So, if you zap this muscle with RF, it is reduced in size and put out of business. In that state, it cannot create the kind of spasms from which asthmatic people suffer.

The procedure is still in trials, but I thought it was interesting enough to pass along to you. If it works as presented, it could be a huge development in the treatment of this very pervasive disease. Also, if it works as presented, this would be one of those medical developments that actually offers a reduction in the cost of health care.

Addendum on July 16: It has come to my attention that BIDMC has had commercial relationships with the company engaged in these trials. I was not aware of this before today, and I apologize for not mentioning it in my original post. I will consult with the BIDMC contracts office from now on before discussing new therapies and devices on this blog.

Wednesday, July 04, 2007

Happy 4th of July

Please read Monique's column in the Globe today for a full treatment of this subject.