Weather? Or not?

Remember the Boston columnist who didn't know the difference between meteorological events and geophysical events? Now, there is another, Alex Prud'homme in the New York Times:

Floods, tornadoes, earthquakes, tsunamis and other extreme weather have left a trail of destruction during the first half of 2011.

Helpful name tags at Health Foo

#healthfoo Courtesy of @motorcycle_guy, aka Keith Boone, add-on's for name tags at Health Foo.

Health Foo

#healthfoo I am attending the Health Foo Camp in Cambridge, MA this weekend. Organized by O'Reilly Publications (Sara Winge and Tim O'Reilly) and the Robert Wood Johnson Foundation (Paul Tarini), this is a self-organizing conference (see the process at work above) at which people decide if and when they want to present sessions on whatever topics they choose. You attend whatever you want. You talk with anyone you want. You avoid people you know and try to meet new ones. Tim describes the goal as "creating new synapses in the global brain."

So the first guy I met was Brian Krejarek, who loves and makes wireless sensors of all kinds. Each one of those adhesive patches in the picture is a different kind of sensor that can monitor some behavior, environmental features, or whatever and deliver the data to a program where it will be processed and analyzed. His company is called Green Goose, where the tag line is Seriously Fun Sensors. Here's an article with more description, entitled "Green Goose Tracks Whether Your Kids are Doing Their Chores."

I wasn't surprised to meet my buddy e-Patient Dave deBronkart in the crowd. Dave has been on a whirlwind world tour talking about patient empowerment. The video from his TEDxMaastrich presentation, "Let Patients Help," has been spreading far and wise, with over 150,000 views. I have also written about a great presentation by Dave and Dr. Danny Sands at last year's IHI Annual Forum, also well worth your time. You see him here with organizer Sara Winge.

It was great to meet up with David Rosenman, on leave from transforming medicine at Mayo Clinic (and beyond!) to attend the Sloan Fellows Program in Innovation and Global Leadership at MIT, and Boston-local Jill Shah, Founder of Jill's List. Jill's List styles itself as "the ultimate directory of Comprehensive Medicine for patients, practitioners and organizations. Every day credentialed practitioners of complementary and alternative, integrative and conventional medicine join to connect with new patients."

After introductions, the group created the schedule for first set of sessions to begin today and run through Sunday morning. Examples are below.

The myrmidon problem

Myrmidon means, "a loyal follower; a subordinate who executes orders unquestioningly or unscrupulously.” Check out this Back Story, entitled "The myrmidon problem," on the CommonWealth Magazine blog.

Looking at revelations of overly secretive behavior within the MA Department of Transportation, I quote from a Boston Globe story:

[O]ne transportation consultant . . . compared the atmosphere to President Nixon’s White House.

The consultant, C. David Taugher, wrote in a March internal report, “How deep does the culture go where nobody says anything, even when they know they should?’’

Then, I implicitly raise these questions:

Can't we draw lessons from process improvement in hospitals -- the power of transparency and a just culture -- and apply them in the political environment? Isn't it worth trying? Wouldn't it represent a powerful form of leadership for elected officials?

Here's my conclusion. Do you agree?

It is, indeed, an unusual organization that does not look for scapegoats when something goes wrong. The press coverage of the DOT this summer has made clear that a fear of blame underlies the senior officials in the agency. It is precisely at a time like this that those in charge – in this case, the governor and the secretary of transportation – must make it clear that their goal is for lessons to be learned, not to punish for real or perceived lapses. Holding someone accountable does not mean firing him. It means that the person has acknowledged the error and is committed to improving the organization’s capability for the future.

It will be a measure of this governor’s commitment to transparency if his administration adopts such a just culture and his cabinet head acts thoughtfully to change an environment in which the public is put at risk.

Noting this blog

Many thanks to the folks at the Blogger Team for designating this blog as yesterday's "Blog of Note." A warm welcome to all new readers.

Riaz reasons

Thanks to Samantha Riley at the NHS South East Coast for leading me to this thoughtful blog by Riaz Dharamshi, a junior doctor working in London. I am adding it to my blog roll. Excerpts:

We often get distracted by the challenge of creating change in the NHS, and forget that a lot of leadership involves enabling people to perform at their best. I was reminded about how bad we can be at supporting each other during a conversation I had with some colleagues: we were talking about doctors who struggle with the different pressures that the job entails, and one of them said that when working for consultants who don’t provide enough support, some doctors flounder, while others just deal with it and get the job done. I pointed out that not doing anything about an unsupportive consultant did not amount to "dealing with it."

Leadership involves a great deal of personal reflection. It is very difficult to change and improve an organisation if you are not prepared to change and improve yourself.

Leadership is about examining your ability to help other people reach higher, from the ordinary and the mundane, to the truly gifted; it is not just about talent spotting, it is about nurturing your colleagues every day.

Get some patients - Yes, Minister

These are two wonderful clips from the BBC's Yes, Minister television program, of several years back. Perhaps they still have some validity in certain parts of the world.

I am prompted to think so by a quote I saw recently from the CEO of a major hospital system, after major recent expansions of clinical facilities, that his system "is on track to cut cost increases in half in two years." Not costs. Cost increases.

The follow-on line in that same story: "Employers, State House leaders and consumers are anxious to see that reduction translate into lower health insurance premiums." I fear they will be waiting a long time.

If you cannot see the videos, click here.

Attack the problem, not the people

Back in May, I wrote about an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended. I wrote, "Guessing from a press report, I am betting that this story is not totally a person problem," suggesting instead that there were systemic problems at UPMC that underlay the error.

Now, the Pittsburgh Post-Gazette offers support for this view. Sean Hamill reports:

The positive hepatitis C test that was missed at UPMC, leading to the shutdown of its living donor kidney transplant program, was not noticed by its entire transplant team despite a highlighted alert in the hospital's electronic records system.

"Everyone just missed it," a source with knowledge of the case said.

The alert was missed by as many as a half dozen people on the transplant team who typically would have reviewed such a test result, according to interviews with several current or former UPMC employees. A number of those interviewed said the problem lies more with the larger system of ensuring that medical errors are caught than with the individuals involved in the incident.

Here's my unsolicited advice to people at UPMC: Attack the problem, not the people.

Seeing red on the Red Line

As foreshadowed in my recent article in Commonwealth Magazine, look for more of these kinds of events as the Boston transit system shows the strains of systemic underfunding.

I said:

The metropolitan area transit system is the current poster child for this built-in dynamic that leads us to put off infrastructure investments. The MBTA is severely underfunded with regard to maintenance and upgrades of the regional bus and subway system. On the Orange Line, 120 cars built between 1979 and 1981 need to be replaced. On the Red Line, 74 cars from 1969 are well past their useful life. More than half of the MBTA’s 82 commuter rail locomotives date to the 1970s, and nearly all are at or past the manufacturer’s recommended lifespan of 25 years.

Public officials, having depleted one-time financial fixes, lurch about for long-term funding solutions, while the system deteriorates more each year. Michael Widmer, president of the Massa­chusetts Taxpayers Foundation, describes this as an “exploding structural gap between revenues and expenses.”

Today's Boston Globe says:

The T has systemwide maintenance needs of about $4 billion, including a backlog of track, vehicle, station, and power demands that require $700 million in investment annually just to keep from getting worse, said Brian Kane, budget and policy analyst for the MBTA Advisory Board, which represents cities and towns served by the T. But the T has rarely spent a sufficient amount on maintenance, even while investing in politically popular expansion projects, Kane said.

“Three trains in two months - that’s pretty bad,’’ Kane said. “We’ve been saying that these breakdowns were going to start happening more and more frequently, because we’ve ignored the needs of the fleet.’’

Samantha creates spaces to pursue her career

I received this inquiry as a comment on a post below from a young person:

I read your blog post from a while back regarding JD-MPH and other degrees for health care. I know that you will have probably answered my main question in that post, however I was wondering if you could elaborate slightly on the role a lawyer might play in a hospital setting. My health care experience is limited and I am currently switching majors to achieve a career in the field, and have considered a JD-MPH degree; or at least up until I read your post. I am interested in Law and Medicine, so I wondered how one might combine the two.

My answer is that there is a disconnect at work right now. The demand for lawyers in the health care world will never be stronger than over the coming years. The reason is that there is a dramatic increase in compliance activities by the federal and state governments. Whether in Medicare rates and conditions, labor relations, ADA, or other arenas, the government is seeking to enforce laws governing patient care. We could theorize as to the reasons for this. Perhaps it is based on an underlying concern about patient care. Perhaps is based on the hope of extracting financial penalties from providers to help offset the rising cost of Medicare. In any event, the trend is real.

The difficulty is that hospitals, physician groups, and other providers are facing major financial pressures. Therefore, while they might have been willing in the past to offer paid internships to students wanting to pursue careers in health care law, they are less able to do so now.

The same holds for areas closely aligned to health care, such as elder law. Here, the demographic trends are strong and evident, portending an increasing demand for these services over the coming decades as the large cohort of baby boomers creates a large need for them. But, likewise, firms and social service agencies involved in those fields are not able to afford to pay law school trainees much before graduation or before you pass the bar exam.

How, then to square this circle of your personal interest and a growing societal demand for this type of lawyers with an inability of people to pay you much before you are credentialed?

The answer is that internships are available if you want to follow your interests in this area, but you need to be creative about how you will supplement your income beyond what agencies, firms, and institutions are able to pay you.

Here's one example of that kind of creativity. It is from a law student (yes, one of my former soccer players!) who was able to nab an internship with a small firm that specializes in this field. She writes:

The only issue with this internship is that they were only able to offer me $1000 for the whole summer. I know that a lot of other law students are working full time for no pay this summer, however, this was not going to work for me. Instead of moping about, I decided to be proactive and start my own side business to help support my soaring student loans. Since childhood I have always loved helping people get organized, so I thought, why not make some money doing it? I decided to call my business "Samantha's Spaces." I have created a website, advertised on craigslist, Facebook, and Angie's List, and left my business cards around at local businesses. So far I have very successful. Here is the link to my website if you would like to take a look.

So, if you want to pursue your interests in this field, you may have to join Samantha in the ranks of those in the informal economy while you pursue your training and career ambitions.

Google+: Cutting down on the irrelevant cruft?

If you have to look up the meaning of cruft, you might not be ready for this.

Several months ago, I wrote about the relative levels of utility of the social media platforms to which I have subscribed.

Where did this all start? With this blog, of course, on August 2, 2006:

The other day, I was reading a NY Times article that mentioned that only 1 CEO of a Fortune 500 company had a blog. I don't run a Fortune 500 company, but I do run Beth Israel Deaconess Medical Center, a large academic medical center in Boston. I thought it would be fun to share thoughts with people about my experience here and their experiences in the hospital world. This is my first blogging experience, so please excuse if I mess things up . . .

Later, I joined Facebook at the suggestion of Nick Jacobs, former CEO of Windber Medical Center, the first hospital CEO to write a blog. He told me about Facebook, and I said, "Why on earth would I want to do that?" He replied, "It's fun. Try it." Now, I have over 4000 intimate friends.

When people started to ask me how much time I was spending on these social media, I rationalized it this way:

Writing a blog does not take much time. After all, how long does it take to write 400 words? But, to achieve effective outreach with a blog, you need to invest the time in creating links with others and reading their posts and commenting on them. Your goal . . . is to create a sense of community with potential constituents who happen to like this medium.

Ditto for Facebook. The time you spend on Facebook is infinitely expandable, as you invite friends, create groups, create causes, and the like. But here, too, your goal is to create a sense of community with potential constituents who like and use that medium.

Then, over two years ago, I explained how I had been led to Twitter.

When you have an addictive personality (any doubts, check my blogging record here), you have to be careful what you start. I figured, though, that I could trust Scott Hensley, one of the guys who runs the Wall Street Journal Health Blog. He strongly suggested that I sign up for Twitter, noting that their blog appears there.

Oh, it was all too easy to slip into this. After all, I already had a Facebook account and was used to the idea of that kind of social media interaction. Sure enough, after just two days of updates (42), attracting followers (60), following others (35), Hensley writes: "You're on fire! Good stuff."

But it was too late that I learned. As noted in an early update to me, Bob Coffield, who writes the Health Care Law blog, "Facebook was the gateway drug that led me to the crack that is twitter."

And now Google+ has come along. With the benefit of experience, I knew I should be careful. But, no. My addictive personality craved an invitation. I clawed at the first one I found available. I have already signed up.

But, I did post this query on Twitter:

Comments on Google+, please. Inherently worth it in terms of design and functionality? Or a must-do to keep up and in touch with others?

After one partial reply, I expanded:

But is G+ just another site to spend time on to have to cover, in addition to FB, or does it offer some potential value?


A friend saw the tweet, forwarded it by email to a colleague, who sent an extended reply, which I now print it on this blog, whence it will be posted on Facebook, and whose link will appear, yes, back on Twitter and, of course, on G+ itself.

The most dispassionate advice I can give is that it's probably too soon to decide. Most of the value of any social network is about who is on it. Since it's existed for only a week and is in closed field trials, it's only got early adopters on it right now. As an early adopter, you get to appear "on the cutting edge" or "abreast of emerging trends". That's a good move for celebrities, publicists, journalists, technologists, or anyone who feels that they need to have their finger on the pulse of social media. But it's hard to imagine that there is some terrible fate in store for a retired professional if he's a few months (or even a year) late to the G+ party. If, however, a year or two from now it has a billion users, it would probably be a mistake to ignore it. :)

As for its qualitative or intrinsic differences from Facebook, I would comment that in theory the privacy architecture is very different, and has some important implications. For example, I predict that because G+ lets you speak to (and listen to) both small, close Circles and also large, broad Circles, the resulting conversations that happen on G+ may be much more relevant.

That is, on Facebook I can only be "your friend" or "not". If you've got 4100 "friends", then you broadcast (and hear) a pretty tame set of things across a wide blend of topics that are guaranteed to be, in part, uninteresting: You simply don't love every single thing that all 4100 people might post, and you simply can't post something to 4100 people that they all find interesting. Any given post is always interesting to some people, and noise to most others.

In contrast, on G+ you organize people into as many disjoint or overlapping circles that you like. You could make circles for "Friends", "Family", "Redskins Lovers", "Gardening Nerds", "Medical Discuss", and "Jerks I Ignore". (The people in the "Jerks I Ignore" circle don't ever find out that that's the name of the circle you put them in. It's handy. :) And when you post, you always post to specific Circles. So you can share medical stuff with only your "Doctor friends", and share your gardening stuff with only "Gardeners", baby pictures with only your family, etc. And you can politely and easily ignore people that are irrelevant to you.

The theory is that this feature will allow your posts to be much more relevant to the people who see them, and of course also cut down on the irrelevant cruft that is coming at you because other people are doing the same.

The nature of circles could also make these discussions more candid: for example, if I found a controversial article about religion that would be very interesting to 18 of my friends but will almost certainly offend some of the other 4082, I sure as heck will not be posting it on Facebook. But I would certainly share it with a small circle on G+. So if you're on G+, you might receive that kind of more candid post from others. If you're on Facebook you probably won't.

But again, that's just the theory based on the intrinsic design of the two products. How often these kinds of scenarios will actually happen in practice is something that the users will only show us with time. For all I know G+ could become primarily used by locksmiths and nobody else, just like MySpace is now only really for musicians, and Orkut is only for Brazilians.

Here's a less reverent view of all of this:

Premium column

As a public service to those Bostonians who were away for the holiday week, I link to and recommend the column entitled "Influence Premiums," by Yvonne Abraham, published in the Boston Globe on July 3. Her lede:

It’s as American as the Fourth of July. Legislators grapple with a huge issue that affects everyone, but a small group of politically wired people determine the outcome.

. . . Plenty of wired types are massing as Beacon Hill prepares to tackle the skyrocketing health costs that hurt all of us.

The Attorney General recently concluded: "Wide price disparities unrelated to the quality of care still persist from one Massachusetts hospital to another, largely dependent on the providers’ clout in the marketplace." Yet, what is striking is the degree to which non sequiturs are used to justify this pricing differential. Here's a quote, for example, from one CEO:

[H]e warned that the data used in the reports is incomplete because it does not capture quality differences among hospitals that warrant higher or lower payments.

Last year, he said, 1 in 6 patients at [his hospitals] were transferred from other hospitals "in the hope that we can provide unique life-saving care. Higher prices for services like cardiac surgery subsidize poorly reimbursed care like treatment for mental illness," he said.

"We should be careful not to overreact or overreach, especially based on incomplete data. We don't want to jeopardize truly precious resources."

None of that is the point of course. The exact same thing can be said for all of the tertiary hospitals in Boston. Tertiary hospitals exist, in great measure, to receive referrals from community hospitals when the patients' conditions are more complex. They also tend to be training centers for young doctors and nurses. They all subsidize underpaid services by using revenues from services that are paid a bit better. In other words, the policy question remains: Why should some tertiary hospitals get paid more than others?

Also, these remarks do not address the fact that the community hospitals owned by this CEO's holding company, and the company's network of community-based doctors, also get paid more than their counterparts. How are those resources more "truly precious" than their neighbors?

All of this is about market power, not clinical quality.

For more on this subject, see here. The issue is joined. Ms. Abraham is correct to focus, now, on the political process through which it will be addressed.

Jon Kingsdale understands this political dynamic well:

By comparison with global payment and care coordination, there are simpler interventions to right the balance of market power in the short-run: a “Public Option” for Massachusetts; hospital rate-setting, a la Maryland; the anti-trust enforcement that Martha Coakley’s predecessor ignored; and/or caps on payments to providers with out-sized market leverage. (In full disclosure, I recently helped the Mass. Association of Health Plans craft a bill along the latter lines.) But capping prices means capping resources for those who save lives. It is far more PC to talk of re-organizing care and payment reform.

Building on Jon's remarks, here are some questions for the Administration that it has yet to answer as part of the current Massachusetts discussions:

If global payments are instituted with the current differential in payments between the “have” and “have not” provider groups, that differential will be locked in for the future. How would you propose to avoid this result?

Instituting global payments shifts risks from insurance companies to providers. Insurance companies have maintained balance sheets to protect them from such actuarial risks. What should be done to ensure that the risk-related savings accruing to insurance companies from the transition to global payments are passed through to business subscribers and individual consumers?

Global payments and the required management of care implicit in global payments suggest that consumers will have a limitation on the choice of specialists and hospitals when they need to seek care beyond primary care. You seem to have been reluctant to talk about that aspect of “payment reform.” Do you think the public is ready for that change? Do you think the advocates for this form of care have an obligation to explain more about its ramifications to the public?

When will your Division of Health Care Finance and Policy make available to the public the all-payer claims data base that it has been collecting so that independent observers, researchers, patient groups, and business groups will be able to review the transactions underlying the state's health care industry? That transparency would allow others to test the global payment hypothesis in a rigorous way, even if some in the government are reluctant to do so.

Follow-up from Den Bosch

Those of us involved in improving the processes of health care understand that this is always a work in progress. You never know, though, what will prompt an improvement in an organization. Sometimes, an action in a passing moment sparks a change.

In a previous post, I expressed great admiration for the quality, safety, and transparency initiatives underway at the newly constructed Jeroen Bosch hospital in the Netherlands. The hospital, in many ways, is setting a standard for others in the country and beyond, and they have cause for great pride and satisfaction.

One reason for that progress is that the staff has an almost compulsive drive for order. But, this is a new hospital, and things are still in shake-down mode. With over 1 million square feet of space, there are bound to be things that go unnoticed for some time.

As I received a tour of the place, we passed through a corridor to the operating rooms, and I saw this scene in a corridor -- a visual cacophony of clogs left behind by the OR staff. I could see that my host, Jan Olsman, the Chief of Surgery, was aghast. Jan has been meticulous about maintaining a shipshape environment around the ORs.

He and others noted that I took a picture of the scene. I just thought it created an interesting visual pattern, but I did promise not to publish the incriminating evidence for the world to see. I sent it along to Jan, and he, in good humor replied:

Thanks a lot for the nice footwear "tableau!" I actually start liking it as a piece of art. But not in this place.

Today, I received this photograph in my email. It came unadorned, with no explanatory message, but I knew immediately what had happened. I wrote:

I assume the picture came from you. Congratulations!

Sure enough, in a follow-up note, Jan said:

Correct! The threat of that picture with all the white shoes put on your weblog was enough for one of my staff members to remove them that same day!

And he also said he would be comfortable if I told the story, with illustrations. Perhaps this is another example of the power of transparency: Even the threat of disclosure prompts self-improvement!

I think, though, that is mainly an example of good humor and intellectual modesty by Jan and his colleagues at Jeroen Bosch. Thanks to them for letting me tell the story and, again, for setting such a fine example for so many in the hospital world.

Playing hooky in the summer

It has been beautiful weather here in New England, and writing a serious and thoughtful blog post is out of the question, especially when I have a chance, instead, to be outside with my visiting daughter. So, here are some scenes from yesterday.

The first two below are from lunch, sitting at the outdoor tables at Ming Tsai's Blue Ginger restaurant in Wellesley, MA. (Shiitake-Leek Springrolls with Three Chile Dipping Sauce; Sake-Miso Marinated Alaskan Butterfish, Wasabi Oil, Soy-Lime Syrup and Vegetarian Soba Noodle Sushi.)



The flowers are from a post-lunch hike in the Mass Audubon Broadmoor Wildlife Sanctuary in Natick. (Milkweed and what? Someone please identify.)

Global Health Care on WIHI

Improving Health Care: The Global View
July 7, 2011, 2:00 – 3:00 PM Eastern Time

Guests:
Lord Nigel Crisp, Strategic Advisor on Global Health and Senior Fellow, Institute for Healthcare Improvement; Author, Turning the World Upside Down: The Search for Global Health in the 21st Century.

Pierre Barker, MD, Senior Vice President for IHI improvement initiatives in South Africa, Ghana, Malawi, and India

Pedro Delgado, MSc, Executive Director for IHI large-scale health system improvement efforts in Europe and Latin America

Health care improvers in the US have so much on their plates these days, it can seem like a luxury to focus on what’s happening in other countries. That’s unfortunate because health care improvement has become a global endeavor, and nations of all sizes and stages of development are confronting strikingly similar issues. These include how to care for aging populations, how to give individuals the tools to be shared decision makers and managers of their chronic conditions, and how to design systems that optimize communication and coordination across the continuum of care. Also, how to take advantage of the resourcefulness patients and communities themselves bring to the table. On any given day, improvers on several continents are taking part in collaboratives and applying improvement methods to increase cancer screenings, improve maternal and child health, track the days a hospital’s ICU is infection-free, and more. The riches of new ideas and innovations now come as equally from South Africa as South Carolina… as generously from Jonkoping, Sweden, as Green Bay, Wisconsin.

It’s not every day that one can get Lord Nigel Crisp, Dr. Pierre Barker, and Pedro Delgado in the same room, on the same day, at the same time – but we’ve done this for the July 7 WIHI. If you’re ready to widen your lens to take in more knowledge from around the globe, join us to hear about maturing work in Ghana and South Africa, new improvement initiatives in Latin America, and what Nigel Crisp meant when he titled his recent book, Turning the World Upside Down. There isn’t a country, anywhere, that can afford to stand still when it comes to rising health care costs, and this creates a tremendous opening for the international improvement community to demonstrate what’s possible when the focus shifts to quality, safety, and overall population health. WIHI host Madge Kaplan hopes you’ll join us for this exciting program anchored by three outstanding health care leaders who look forward to your questions and contributions on the next WIHI!

To enroll, please click here.

Down the Drain

Commonwealth Magazine has just published an article I wrote, entitled, "Down the Drain, Infrastructure Needs a Cheering Section." (Access is free. You may have to register.)

Regular readers here will know of my passion for this topic. This piece is based on interviews I did several years ago about the metropolitan area sewer system, but the article is really focused on the deterioration of the Boston transit system. Some of the folks I interviewed are no longer around, so this will be a throw-back for some Bostonians.

Here's a teaser, the lede from the article:

Infrastructure degrades slowly, indeed imperceptibly. The bus arrives a little less frequently; the subway breaks down a bit more often; the water pipe loses water through leakage; the sewer system adds a bit more pollution to the environment. For the most part, there is no political consequence from a deteriorating infrastructure.

In contrast, investment in infrastructure occurs episodically, with direct political consequences. It often requires a vote to increase taxes or fees, which go into effect immediately. Yet the investments that result from that vote take years to be felt in improved services or facilities. Those who vote “yes” get no credit. Indeed, they are likely to be assigned blame and criticized for raising taxes or fees by a public that does not trust they are necessary.

Kevin Harrington, the former president of the Massachusetts Senate, once gave a detailed description of the mechanics of this dynamic on Beacon Hill. Harrington was elected in 1959, when the Metropolitan District Commission was in charge of the region’s water and sewer system. At the time, all MDC expenditures approved by the Legisla­ture would be assigned to the cities and towns in the district and collected from the public through property taxes. Harrington related how engineers from the agency would come before the Legisla­ture’s Natural Resources Committee seeking money because the plants taking care of sewage were obsolete.

“And then politics raised its ugly head,” Har­rington said when I sat down with him more than a decade ago to try to make sense of how the political establishment deals with infrastructure projects. “It’s so simple, so plain, and so sad—the representatives and senators that were inside of the MDC district would come to those of us who were not in the district, and they would say, ‘Please don’t vote for this money. Our local mayors, our city councilors, and alderman and selectman don’t want their property taxes to go up.’ So I would say in my stupidity, ‘Of course, I’ll vote with you.’”

The metropolitan area transit system is the current poster child for this built-in dynamic that leads us to put off infrastructure investments....

MITSS seeks nominees for Annual HOPE Award

Reposted from Medically Induced Trauma Support Services:

Nominations are now being accepted for the Fourth Annual MITSS HOPE Award. The HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner of the award will receive a $5,000 cash prize to continue their work.

The sponsor of the 2011 HOPE Award is RL Solutions.

Submissions are due by September 16th, 2011, and the award will be presented at the MITSS 10th Annual Dinner and Fundraiser to be held on Tuesday, November 1st, 2011, at the Westin Copley Place, Boston, Massachusetts.

Take this opportunity to nominate someone who is doing great work. Note that self-nominations will be acceptable. Visit http://www.mitsshopeaward.org/ for eligibility criteria and submission requirements, to download a nomination form, check out past winners, and much, much more!

Is there a Piazza in medicine's future?

One of the holy grails of clinical information systems is to build decision support programs that would provide doctors with real time advice during the care of patients. The industry is moving along in this realm. The idea is to mine the clinical data in a hospital's records to look for patterns that would make the practice of medicine more evidence-based.

That is all to the good and will likely bear fruit. But let's think differently and explore the potential value of social networking in helping out clinicians.

I'm drawn to this idea by an article in yesterday's New York Times, entitled "Homework help site has a social networking twist." The story is about a start-up company called Piazza, created by a young woman who found herself alone while other students collaborated on engineering problem sets.

When Pooja Nath was an undergraduate at the Indian Institute of Technology Kanpur, an elite engineering school in India, she felt isolated. She was one of the few women on campus. While her male classmates collaborated on problem sets, Ms. Nath toiled in the computer lab alone.

The experience as a young woman in that culture formed the foundation of her start-up....

Students post questions to their course page, which peers and educators can then respond to. Instructors moderate the discussion, endorse the best responses and track the popularity of questions in real time. Responses are also color-coded, so students can easily identify the instructor’s comments.

Although there are rival services, like Blackboard, an education software company, Piazza’s platform is specifically designed to speed response times. The site is supported by a system of notification alerts, and the average question on Piazza will receive an answer in 14 minutes.

OK, I know clinical decision-making is different from getting the right answer on a homework assignment. Wait, is it all that different?

Students post questions to their course page, which peers and educators can then respond to. Instructors moderate the discussion, endorse the best responses and track the popularity of questions in real time. Responses are also color-coded, so students can easily identify the instructor’s comments.

What if a clinician had access to a cadre of like-minded clinicians and posed questions and got answers in real time? We can imagine this at different levels. Think of medical students on rotation, performing patient histories. They are not allowed to actually treat the patients, but what if they wanted to test their diagnostic and prescriptive skills, by quickly tossing questions to the medical world version of Piazza and seeing how well they have analyzed the situation? Participants could include other medical students and the course instructors.

Ditto for residents, except they actually deliver care as well as analyzing patients. And, of course, ditto for attending physicians as well.

In short, decision support systems do not need to be based on mining computerized databases. They could, in addition, be based on mining the experiential database of thousands of clinicians.

Snooping curtailed

Medscape Medical News reports that the federal government has called off its mystery shopper survey of primary care practices, the subject of my blog post here.

Reacting to accusations of both snooping and wasting money, the federal government announced today that it is suspending a proposed plan to have "mystery shoppers" seek appointments with physicians to determine how easy or hard it is to access primary care, especially for someone covered by Medicare or Medicaid.

The explanation:

In response to all the flak, an HHS spokesperson announced today that the study is on hold.

"After reviewing feedback received during the public comment period, we have determined that now is not the time to move forward with this research project," the HHS spokesperson said in a statement. "Instead, we will pursue other initiatives that build on our efforts to increase access to health care providers nationwide."

I am not sure which is more troubling, that the idea emerged in the first place or that the government is so wimpy about its convictions that it backed off so easily in the face of criticism.

Central Mass homegrown fireworks

Here's a little Independence Day fireworks treat. In addition to the big city displays, people all across the country in rural areas also have their own shows. The one below is from a lake in Central Massachusetts last night. Residents on all sides of the lake set off their fireworks for the better part of an hour-and-a-half. The video shows just four minutes worth to give you a sense of the view across the lake, as well as some closer explosions, complete with double images from the water's reflection.

Thomas Jefferson hoped that Americans would celebrate the Fourth of July — what he called "the great birthday of our Republic" — to "refresh our collections of [our] rights, and undiminished devotion to them."

John Adams said, in a letter to Abigail Adams on July 3, 1776:

The day will be most memorable in the history of America. I am apt to believe that it will be celebrated by succeeding generations as the great anniversary festival…It ought to be solemnized with pomp and parade…bonfires and illuminations (fireworks) from one end of this continent to the other, from this time forward forevermore.

Both men died on July 4, 1826.

If you cannot see the video, click here.