Natural Disaster Response on WIHI

May 16, 2013: Reliable Practices for Responding to Natural Disasters:
Lessons from North Shore-LIJ and Hurricane Sandy
(2:00 PM - 3:00 PM ET)

Featuring:

Mark P. Jarrett, MD, MBA, Chief Quality Officer, North Shore-LIJ Health System
Mark J. Solazzo, MBA, Executive Vice President and Chief Operating Officer, North Shore –LIJ Health System 
Joseph Cabral, MS, Senior Vice President, Chief Human Resources Officer, North Shore-LIJ Health System

Hurricane Sandy first struck the Caribbean and then the entire East Coast of the United States at the end of October 2012. The storm smacked into New York and New Jersey especially hard, impacting millions. The story of how the largest health care system in the region, North Shore–LIJ, operated throughout to ensure patients and staff were protected and supported, under fierce circumstances, is one that communities and hospitals everywhere can learn from. This is our focus for the May 16, 2013, WIHI: Reliable Practices for Responding to Natural Disasters: Lessons from North Shore-LIJ and Hurricane Sandy, featuring three leaders from NS-LIJ who were responsible for every kind of decision imaginable before, during, and after the storm.

Some of the decisions included transferring hundreds of nursing home residents out of harm’s way, taking in patients from other hospitals, assisting at area shelters, buying up fuel for ambulances, and opening up a resource center for hospital staff whose homes and neighborhoods had been torn apart and flooded. One of the back stories to NS-LIJ’s response is the degree to which it was built upon critical lessons learned during Hurricane Irene, a year before. In 2009, there was the H1N1 outbreak. In each instance, the health system did things well, and saw where it fell short; now that Hurricane Sandy has come and gone, this same type of assessment continues.

Health care organizations and first responders must prepare for many types of crises and disasters. Reflecting on the recent Boston Marathon bombings, which killed three and seriously injured over 200 (NEJM, April 24, 2013), authors Arthur Kellermann and Kobi Pelag write, “The best way hospitals can prepare is to base their response on a strong foundation of daily health care delivery.” So, routine and reliably safe practices, guided by continuous quality improvement, is lesson one for emergency planning. WIHI host Madge Kaplan invites you to bring your experiences and your interest to this timely discussion on May 16.

Please click here to enroll.

Big Blue pushes accessibility, with help from others

Back in the late 1970s, when I was Director of the Arkansas Department of Energy, the state disabilities commission ran an awareness event in which corporate and governmental leaders were given a disability for the day and were expected to try to carry out their work and personal functions.  You might be given heavily fogged glasses to be partially sighted; or you might be confined to a wheelchair; or (in my case) you were given earmuffs that severely limited your ability to hear.  At the end of the day, we all met to discuss what we had learned.  My observation was that the disabilities tended to isolate people from "normal" social and business intercourse with other people.  The result was that talented, skilled, and intelligent people were foreclosed from full participation.  I remember saying, "What a waste to society" in terms of capabilities that were being lost.

The world has changed somewhat.  In the United States, the Americans with Disabilities Act was signed into law in 1990.  Later in that decade, the United States required federal agencies to purchase electronic and information technology that was accessible to people with disabilities.  Other countries have similar laws requiring public accommodation for people with disabilities and similar requirements for integration of accessibility standards into computers and the like.  All of that is a good thing.

 But I think an equally important thing is happening now, in that technological changes are making it possible for disabled people to have more and better accessibility at work, home, and play.  I learned this week that IBM has demonstrated a particular commitment to this field.  While there is a clear business reason for many of their activities, their initial interest was philanthropic and several programs remain so.

I was intrigued by many of the company's activities, but one aspect in particular resonated with a message you have often read on this blog and on those of other patient advocates in the health care system.  We have been asserting that health care providers, researchers, and related service providers should be patient-driven.  We aim to encourage and establish true partnerships between those who provide health care services and those who use those services.  To date, the health care system has been slow to adopt this philosophy.

Look in contrast, at a portion of the IBM accessibility workplan:

To help IBM gain a deeper understanding and foster an accessible environment, IBM forms external relationships with leading experts on accessibility. These relationships help IBM understand specific issues and collaborate with key constituents to continually drive accessibility into mainstream IT.

• Understand how people with disabilities and seniors need information presented to them.
• Work with advocates to gain better understanding of their needs in the market.
• Demonstrate the value of integrating accessibility practices into businesses and communities through collaboration with advocates and early adopter clients.

Imagine if your hospital were to have a parallel portion of its workplan:

To help our hospital gain a deeper understanding and foster a patient-driven environment, we form external relationships with leading patient advocates and experts. These relationships help us understand specific issues and collaborate with key constituents to continually drive a partnership with our patients into our mainstream care delivery system.

• Understand how people with diverse medical conditions and demographic characteristics need information presented to them.
• Work with advocates to gain better understanding of their needs in the market.
• Demonstrate the value of integrating patient-driven practices into health care related entities and communities through collaboration with advocates and early adopter partners.

MedStar, Contra Costa, and a few others are taking this seriously.  Many others are just going through the motions or not even trying. This is a topic deserving attention by hospital boards of trustees, who should hold management accountable for adopting a philosophy and building the infrastructure to make such collaboration the norm.

Regina + Dave = Something else!

I feel grateful to know @ReginaHolliday (Regina Holliday) and to watch her use her artistry and her language as one of the world's most important patient advocates.  I also enjoyed watching today on her blog as she gently took apart someone who was trying to commercialize that advocacy role.  Among other things, she advised:

A word of advice: Don’t ever ask a patient activist how you can take advantage in the realm of patients…

She went further, and her article would have been enough, but then the first comment by e-Patient Dave deBronkart piles on with a blistering response that is worth a blog post in itself.  Directed at the person who wrote to Regina, he said:

Wake up and get a clue. (I'm being blunt because your situation is critical, as in ICU critical.) You just got $50,000 of marketing consulting from Regina Holliday. (I mean that literally. If you'd engaged a PR firm for $50,000 . . .  it would be worth every cent.)

If you feel defensive, squelch it and learn, buddy. Take every single word Regina said as gold. Or, really, honestly, non-snarky: find a different industry. This ain't appliances and iPhones.

Whew, these patient folks have gotten uppity, no?  I think it is great.

"It's not our job."

Some people were criticizing me the other day when I suggested that CMS was wasting its time by publishing hospital chargemaster data while neglecting its real responsibilities.  "Why are you so hard on them?" was the typical comment.

Why?  Because the agency is neglecting important duties, tasks that could actually improve the quality and safety of patient care.

Well, just a few days later, Pro Publica makes the case so strongly that I will just quote excerpts from their report:

An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive. Federal officials have done little to detect or deter these hazardous prescribing patterns.

How does CMS respond?

"CMS's payments don't go to physicians, don't go to pharmacies. They go to plans, which is how our oversight framework has been established," Jonathan Blum, the agency's director of Medicare, said in an interview. The philosophy "really has been to defer to physicians" about whether a drug is medically necessary, he said.

Other disagree.

Asked repeatedly to cite which provision in the law limits their oversight of prescribers, CMS officials could not do so.

The Office of the Inspector General of the Department of Health and Human Services has repeatedly criticized CMS for its failure to police the program, known as Part D. In report after report, the inspector general has advised CMS officials to be more vigilant. Yet the agency has rejected several key recommendations as unnecessary or overreaching.

Other experts in prescription drug monitoring also said Medicare should use its data to identify troubling prescribing patterns and take steps to investigate or restrict unsafe practitioners. That's what state Medicaid programs for the poor routinely do.

"For Medicare to just turn a blind eye and refuse to look at data in front of them . . . it's just beyond comprehension," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

"They're putting their patients at risk."

Brava to Tejal and NPSF!

The Board of Directors of the National Patient Safety Foundation have done a very, very good thing in appointing Tejal K. Gandhi to become the Foundation’s next president.  Tejal brings a wealth of experience in the field.  After 10 year as executive director of quality and safety at Brigham and Women’s Hospital, she moved on to chief quality and safety officer the entire Partners Healthcare System.

I had a chance to see Tejal in action as we served together at the Risk Managament Foundation. She was invariably thoughtful and well prepared and diligent in pursuing sensible quality and safety improvements throughout the Harvard system. Beyond that, she exhibits a warm and modest demeanor that will hold her in good stead and generate support and involvement among medical professionals as she pushes hard to achieve the "so much work to do to ensure the safest care for all patients."

The Orange Line

I am very pleased to announce the publication of The Orange Line, A Woman's Guide to Integrating Career, Family and Life.  Here's the review I wrote for it:

I am confident that when people look back a decade from now they will view publication of The Orange Line as a watershed event.  In the book, authors Jodi Detjen, Michelle Waters, and Kelly Watson challenge women to confront assumptions they have that surround and limit their personal and professional lives.  While the authors issue this challenge with empathy and caring, they never lose sight of its underlying message: The power of change lies within.  The authors' advice is not easy, and their book has no place for self-pity or excuses for blaming "the system."  Indeed, it may create some discomfort for some women as they internalize its messages. But The Orange Line gives hope to all of us who believe that women's integration of work and family is the key to a successful society.

Here's my neighbor and friend Jodi showing off the recently arrived book on a perfect spring day in front of a beautifully flowering apple tree!

And now presenting . . . robotic lap choles!

As a non-medical person, I was so excited when I could say "laparoscopic cholecystectomy" without pausing or tripping over all the syllables.  In English, this is a surgery to remove a gall bladder using laparoscopic instruments through holes in the abdomen instead of cutting it open.  Lap choles, for short, are among the most routine and safest surgical procedures.  The folks at USC note:

Laparoscopic cholecystectomy is a very safe operation. The overall complication rate is less than 2%. The complication rate for laparoscopic gallbladder surgery is similar to the complication rate for traditional open gallbladder surgery when performed by a properly trained surgeon. Many thousands of laparoscopic cholecystectomy have been performed in the USA and this operation has an excellent safety record.

An article on Medscape notes:

Laparoscopic cholecystectomy has rapidly become the procedure of choice for routine gallbladder removal and has become the most common major abdominal procedure performed in Western countries. LC decreases postoperative pain, decreases need for postoperative analgesia, shortens hospital stay from 1 week to less than 24 hours, and returns the patient to full activity within 1 week compared to 1 month after open cholecystectomy (OC).

In 1990, 10% of cholecystectomies were being performed laparoscopically. By 1995, 10 years after the introduction of LC, close to 80% of cholecystectomies were being performed laparoscopically. 

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

So, what do you do if you are a robotic surgery device company that has saturated the marketplace for robot-assisted prostate surgery and if the president of the American College of Obstetricians and Gynecologists has said:

Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. 

Answer:  You try to create a demand for robot lap choles. You drool as you read the last line of the quote above:

In 2008, 750,000 patients underwent cholecystectomy in the United States; in 90% of these patients, the operation was done laparoscopically.

This is huge compared even to the 90,000 radical prostatectomies that are undertaken each year, where you have grabbed 70,000 of the total.

Just imagine if we could get doctors and hospitals to buy our robot to do a portion of those.  

Let's even make a video and have a doctor and a patient make unsupported assertions about the relative benefits compared to the excellent safety record of traditional lap choles.  The narrator says, "Having gall bladder surgery is a lot easier."  "It's a lot better," says the patient.

A few months later, the surgeon, Dr. Babak Eghbalieh, announces: "As of February 1st, 2013, the Robotic Surgery Program at CRMC [Community Regional Medical Center in central California] will be the fourth busiest Single Site Robotic Gallbladder surgery in the west coast of US!!"

Where do these videos come from?  No production credits are provided, but if you watch the next one, you'll see (starting at 59 seconds), an lengthy insertion of visual material from the company that produces the robot.



The patient notes, "Everybody was so friendly."

Useless noise from CMS

What on earth did CMS have in mind when it released the FY2011 chargemasters for America's hospitals?  Well, according to one report:

The public release of the data is part of an effort by Medicare to increase transparency in the health system. 

“Historically, the mission of our agency has been to pay claims,” said Deputy Medicare Administrator Jonathan Blum. “We’ll continue to pay claims, but our mission has also shifted to be a trusted source in the marketplace for information. We want to provide more clarity and transparency on charge data.”

CMS explains:

Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service.

This is a case where the release of bad data is worse than having no data at all.

A hospital's chargemaster is an archaic fiction, a way previously used to allocate the joint and common costs of the hospital to particular services.  It does not serve as the basis for how much a hospital is paid by Medicare.  It does not serve as the basis for how much a hospital is paid by Medicaid.  It does not serve as the basis for how much a hospital is paid by private insurers.

Further because of federal and state prohibitions against balance billing of patients (i.e., the difference between the amount paid by an insurer and the amount of the charge), it also provides no basis to consumers that means anything at all.

But it sure creates a stir to be able to say: "For joint replacements, which are the most common hospital procedure for Medicare patients, prices ranged from a low of $5,304 in Ada, Okla., to $223,373 in Monterey, Calif. The average charge across the 427,207 Medicare patients’ joint replacements was $52,063."

For the record, Medicare pays hospitals based on a formula that takes into account the difference in overall wages and prices in different parts of the country.  There are also adjustments for rural hospitals.  There are also adjustments for academic centers to pay for residency training. The chargemaster employed by a hospital is not a consideration in the establishment of these federally determined rates.

Likewise, Medicaid rates are based on a state-determined formula.

Likewise, private insurance companies often base their hospital and physician rates off the Medicare formula, or have their own approach (often not even related to the hospital's actual costs).  Very, very few have rates based on "a percentage of charges."

I don't know what CMS really hoped to accomplish in the way of transparency by publishing out-of-date, irrelevant data.  But such behavior is consistent with CMS publishing out-of-date, irrelevant clinical outcome data.

Transparency, CMS style.

CMS says that the recent release of information is "part of the Obama administration’s work to make our health care system more affordable and accountable."  Oh, wait, this is the same president who had a photo-op with a robotic surgery company that has made its fortune by marketing high cost clinical equipment that lacks clinical evidence to support its relative efficacy.  This is the same president who compared hospital readmissions to going to an auto mechanic and having to bring your car back for re-repair, who doesn't seem to understand the unintended consequences of poorly design federal payment penalty strategies.

Meanwhile, CMS fails to take action to solve the well established and recognized problems in its own rate structure that encourage the medical arms race.  Even Mr. Obama's former adviser wonders why the agency won't or can't solve that kind of problem.

When Brent James advises doctors "Don't wait for Washington," he knows of what he speaks.  Improvement in the health care system will not come from confused and politically conflicted federal officials.  The challenge is whether it will come from the health care professions, or whether we will start heading down an inexorably declining slope towards higher costs, poorer quality, and (quiet) rationing of services.

Creating an insatiable appetite for improvement

John S. Toussaint and Leonard L. Berry masterfully set forth the essence of Lean in an article entitled, "The Promise of Lean in Health Care."

Lean is not a program; it is not a set of quality improvement tools; it is not a quick fix; it is not a responsibility that can be delegated. Rather, Lean is a cultural transformation that changes how an organization works; no one stays on the sidelines in the quest to discover how to improve the daily work. It requires new habits, new skills, and often a new attitude throughout the organization from senior management to front-line service providers. Lean is a journey, not a destination. Unlike specific programs, Lean has no finish line. Creating a culture of Lean is to create an insatiable appetite for improvement; there is no turning back. As Lean consultant Joan Wellman states,“With Lean, you will keep changing your definition of what ‘good’ is."

Mayo Foundation for Medical Education and Research: Mayo Clin Proc. 2013;88(1):74-8.

Now on e-books: How a Blog Held Off the Most Powerful Union in America

I'm pleased to be able to offer my new book on all e-book platforms.  Just go to this Smashwords page, and you can find the whole gamut of options, from Apple iPad/iBooks, Nook, Sony Reader, Kobo, to most e-reading apps including Stanza, Aldiko, Adobe Digital Editions, and others. You can find the Kindle version there, too, but also over at Amazon.  If you'd like, there is a free sample for sampling!

Of course, the paper version is still available at Amazon, too.

@EricTopol says, "Show me the data!"

Many of us were excited when it was announced in February that Eric Topol would be the new editor-in-chief at Medscape.  I think big things are in store.  He recently wrote:

Medicine is . . . poised for its biggest shakeup ever as it transforms to a more precise, individualized, and democratized model. My charge at Medscape is to help capture this excitement, the changes and opportunities, along with the challenges and the need for validation. Medscape will be expanding its breadth of coverage in areas that will be rebooting, which include not only diagnostics, imaging, and medical devices but also the operational aspects of office visits, hospitals, and medical informatics.

We intend to take Medscape to the next level, one that embraces the need for change and zooms in on the ways to get there -- the ways to provide better, more efficient care for your patients.

But what really gets me excited about Eric's sense of purpose is this slightly reworked video from Jerry Maguire.

The thoroughbreds were in MD, not KY

As I headed to BWI airport early Friday morning, my seatmate turned and asked if I was staying on the flight to connect to Louisville, to watch the Kentucky Derby.  "No," I replied, "I'm going to Maryland to watch the real thoroughbreds in action."  A quizzical look was the response.

I was headed to a meeting of MedStar Health's Patient and Family Advisory Council for Quality and Safety, convened by Dr. David Mayer, Vice President, Quality and Safety.  With strong suport from the system's CEO and Board, David is leading a system-wide effort to make the Medstar hospitals the best in the nation for quality, safety, and transparency.  He decided to enable a strong voice for the patients and has recruited the ultimate dream team for the PFAC.

Here's the list:

Michael Millenson (photo at right)

Patty Skolnik (photo at right, with Michael)

Armando Nahum

Victoria Nahum

Martin Hatlie

Rosemary Gibson (top photo)

Carol Hemmelgarn (top photo, with Rosemary)

Sorrel King (below, left)

Helen Haskell (bottom photo)

Those of you who have been following this field know that this is the Who's Who of internationally acknowledged experts in patient advocacy.  Sadly, many of the group came to this field because of family tragedies, loved ones killed by preventable medical errors.  They have channeled their grief into a commitment to help others avoid what they have been through.  In so doing, they have also become experts in process improvement, root cause analysis, behavior science, and the like.   

David put the group through their paces, with an extensive and intensive agenda.  They, in turn, did the same for David and his team, asking probing and difficult questions and making programmatic suggestions to enhance the MedStar effort.  This is no rubber-stamp body!

In memoriam: Ricardo Portillo

You probably haven't heard of Mr. Portillo, of Murray, Utah.  Here are excerpts and pictures from the AP:

A Utah soccer referee who slipped into a coma after being punched by a teenage player during a game a week ago died Saturday night, police said.

Ricardo Portillo, 46, of Salt Lake City passed away at the hospital, where he was being treated following an assault, Unified police spokesman Justin Hoyal said.

Police have accused a 17-year-old player in a recreational soccer league of punching Portillo after the man called a foul on him and issued him a yellow card.

"The suspect was close to Portillo and punched him once in the face as a result of the call," Hoyal said in a press release.

The teenager was playing goalie . . . when Ricardo Portillo issued him a yellow card for pushing an opposing forward trying to score a goal.

The teenager, quite a bit heavier than Portillo, began arguing with the referee, then unleashed a punch to his face. Portillo seemed fine at first, then asked to be held because he felt dizzy. He sat down and started vomiting blood, triggering his friend to call an ambulance.

When police arrived around noon, the teenager was gone and Portillo was laying on the ground in the fetal position. . . . He was considered to be in fair condition when they took him to the Intermountain Medical Center.

But when Portillo arrived to the hospital, he slipped into a coma with swelling in his brain.

There's just too much wrong here. One life lost. Many others will be in turmoil for years to come.  Here are Mr. Portillo's daughters Johana and Ana:

Sometimes things like this happen because of bad chemistry in the moment, and that may have been the case here.  Not that it excuses the behavior.

But sometimes things happen like this because a coach has not set a proper standard of behavior for his players--particularly at this age, where testosterone levels are apt to surge.  A short story, fortunately not in this category.  I recently was an assistant referee in a game with 16-year-old boys.  There were some scuffles on the field, and one team felt particularly (but not justifiably) aggrieved by the fact that the referee did not call as many fouls as they felt were warranted.  As the boys returned to their bench after the game, several complained to their coach about the referee, and the coach said, "I can't say anything as long as he has my (coach ID) card."

In others words, "You are right to be upset.  I would have yelled at the referee, but he would have sanctioned me."  What a standard of behavior!  How about, "The referee calls it as he sees it, and our job is to just play a fair game."

Referees who officiate at youth games in all sports do so for the love of the game and for the chance to enable children to have a pleasant experience that promotes individual and team development.  When violence occurs as a result of one immature and uncontrolled child, that is tragic.  When anger occurs as a result as a result of the poor example of a misguided coach, he or she has failed in exercising proper leadership with the children who are his or her charges.

This story was not from The Onion

It was not my plan to publish another post on this topic for some time, but you'll soon see why I felt compelled to.

As I was writing my recent piece about the potential financial slide of a private-equity-owned health care system, I never, ever, ever considered that part of the workout of such a system might be to sue an insurance company in another state for a terminated buy-out deal of another hospital.

And yet here it is.  Here are excerpts from Robert Weisman's report in the Boston Globe (not The Onion):

Steward Health Care System, which terminated an agreement to buy a Woonsocket, R.I., hospital last fall, charged in a lawsuit Wednesday that Rhode Island’s largest health insurance company blocked the deal by failing to negotiate reasonable health care payments.

In a complaint filed in state Superior Court in Providence, Steward, which runs a chain of hospitals and doctors groups across Eastern Massachusetts, alleged Blue Cross & Blue Shield of Rhode Island engaged in anticompetitive practices and interfered with prospective contractual relations to thwart Boston-based Steward’s proposed acquisition of Landmark Medical Center.

Steward, owned by the New York private equity firm Cerberus Capital Management, demanded a trial by jury and asked for Blue Cross & Blue Shield to pay unspecified financial damages as well as reimburse its attorneys’ fees involved in taking the court action.

The collapse of Steward’s deal to take over Landmark marked a setback in the health care chain’s efforts to build a national for-profit hospital and physician network.

But while it has negotiated with financially troubled hospitals in Florida and Maine, in addition to Landmark, it has yet to complete an out-of-state deal.

Aging in Place on WIHI

May 2, 2013: Home for Life, Aging, and Aging in Place

2:00 - 3:00 PM ET

Featuring:
Sharon J. King, Principal, Starfield Consulting Ltd. & Special Advisor, South Georgian Bay Collaborative
Mimi Toomey, Director, Policy Analysis and Development, Administration for Community Living, US Department of Health and Human Services

With the aging of the population in many countries, where are the best ideas going to come from to help older people remain in their communities, and among the friends and families — and other seniors — they know best? How can we shift mindsets and models from ones that include endless and expensive health care interventions to a vision that factors in the role that supportive people and support services can play further upstream — to reduce isolation and loneliness, to ensure good nutrition and management of chronic health issues, to prevent avoidable hospitalizations?

On the May 2 WIHI: Home for Life, Aging, and Aging in Place, we’re going take a stab at some answers. We’re going to travel to South Georgian Bay, a community along the Severn River in Ontario, where six organizations have come together to create a web of resources called Home for Life, focused on the growing population that’s over 65. Anchored by volunteers, a 211 system to initiate and engage services, and a “back to the village” vision that also includes empowering older individuals with computers and new technologies, Home for Life isn’t just another in a long string of well- intentioned social service initiatives. WIHI guest Sharon King, one of its creators, believes Home for Life should be studied, measured, and monitored for its effectiveness. She’s hopeful they’re on to something in Canada that can be adapted elsewhere.

How does this look to Mimi Toomey from her perch at the US government’s Administration for Community Living? With over 25 years of experience developing policies to support aging populations, is this the kind of “break the mold,” more cost-effective experimentation that communities in the US need to tap into, too? Do we have similar examples popping up that we need to learn more about? Probably so. If we’re going to get out from under headlines and reports that focus exclusively on aging as unaffordable for society most of all, we need fresh ideas and compassionate innovation. That’s why WIHI host Madge Kaplan hopes you’ll join the discussion on May 2.

What, me boisterous?

@BGlennWrites (Brandon Glenn), writing at Medical Economics, names me as "perhaps Epic's most boisterous critic" because of two columns I have written about the firm's taxpayer-supported rise to dominance in the EHR field.  I don't think so, at least compared to people I have talked to in the industry, but if I did deserve that sobriquet before Brandon's article, he now deserves the honor.

The points he makes about why Epic's dominance could stifle EHR and health care IT innovation are cogent.  Here are some excerpts:

If Epic (already based on an antiquated technology – MUMPS) decides to maintain an essentially closed system, and to drive all innovation internally, this could prove stultifying, limiting the development of novel ideas, and forcing the many high-profile adopters of Epic to accept stagnation or pay the staggering costs of switching," wrote physician-scientist David Shaywitz in Forbes.

In other words, the "closed" nature of Epic's systems - coupled with its dominant market position - could mean that Epic ends up setting the defacto standards for EHR systems, effectively stifling innovations that its competitors might develop in the EHR market. That, in turn, could lead to Epic's big hospital customers - and those hospitals' patients - being frozen out from advances in EHR technology.

Health IT analyst John Moore of Chilmark Research predicts that's exactly what'll happen. Writing at The Health Care Blog, Moore said Epic is operating on a model that "will ultimately hinder healthcare organizations’ ability to rapidly innovate and respond to market changes. Epic simply will not be able to move fast enough and their customers will struggle as a result."

I don't claim to have the IT expertise of these people. I have witnessed the normal trend of a dominant player in a marketplace to squelch innovation, regardless of the sector.  Brandon's article now has me even more worried.

Boston College MBA students pose the questions

I've been invited to lecture at many business schools around the country, but tonight's experience at Boston College was pleasantly unique.  Here were the instructions I received from faculy member Stephen Bookbinder:

The class requires NO preparation from you. You just show up at 7:00 pm on April 30 for about 60 to 90 minutes and the students are prepared to ask you questions about your career and your experiences as the leader of BIDMC.  They will have used publicly available information to learn about the hospital industry, BIDMC and you to prepare for the class and anything else you might like them to read.  They will prepare an interview guide in advance and they will ask questions such as: describe a great mentor, tough decisions you had to make, how you created a leadership team,  etc. They will be graded on the quality of the interaction they establish with you and their ability to make the best use of the time they have with you.  They will also have to write a short paper on what they learned and can apply in the future.

 
So I showed up properly unprepared and responded first to Janet, Leigh, and Andy (above) and then to Colin, Brian, and Patrick (below).

For me, the time flew by.  The questions were excellent.  The students had clearly prepared throughly and coordinated the topics among themselves.  (How refreshing compared to certain press conferences I have gone to!)  On that front, I am certain that their classmates gave them a good grade.  I'm hoping the students allow me to publish excerpts from their forthcoming papers so you can all share their observations in a couple of weeks.

An investment banker asks a question

This is a true story.  An investment banker friend, very astute as to the issues surrounding private equity investments but not so familiar with health care, was confused.  He laid out the scenario as he saw it and then asked me the final question.

He said: You run a private equity firm and you are awash in cash, looking to create a portfolio of interesting investments that will satisfy your funders.  You see that the US government has passed the health reform act, assuring insurance coverage to a large percentage of the population.  You wonder if you can apply private equity principles to this sector.  What are those principles?  Get into a situation in which there are not likely to be a lot of bidders; satisfy political entities and other constituencies who might be concerned about the viability of the acquired firm and therefore view you as the "white knight;" put in place a hard-driving CEO; leverage your equity component with a healthy dose of debt; focus on extracting as much cash as possible from the business; take actions to grow the top line of the firm, as well as EBIDTA, so that you will be able to present a colorable story to future investors as to the company's growth potential; and then flip the business in an IPO or to another private equity firm after a few years.

Coincidentally, you learn that a faith-based hospital chain is having financial troubles.  Among other things, the institution faces a hangover of employee pension obligations and has been forced to underfund renewal and replacement and other capital improvements.  The religious organization that owns the system is unfamiliar with the operation of  health care facilities and views the system as a financial and operational drain not central to its mission.  For reasons of control, though, it created a governance structure that gives little authority to the hospital chain's board of trustees.  Further, its CEO is keen to arrange a sale of the hospital system to a private equity firm to show that he can create a vibrant business proposition.

So your private equity firm offers to buy the property, making promises to regulators and stakeholders in the community.  Few objections are raised and the deal is approved.  The private equity firm, new to health care, gives an unprecedented level of authority and autonomy to the CEO.  He rewards your confidence by executing the key elements of the business plan.  Assets are sold for short term gain, with little concern for the downstream costs: After all, the hospital properties will be flipped in a few years anyway.  The hospital system's laboratories are sold to a private laboratory service company, in return for a long-term contract to use that company.  Real estate is sold and leased back.  The system agrees to a front-end-loaded risk-based reimbursement contract with the largest private insurer, one that calls for substantial reductions from the trend of medical expenses in future years.  Physician practices in the community are purchased at above-market prices to create an increased flow of referral business to the hospitals.

The partners of your private equity firm have some concerns, but not enough to act.  The new corporate headquarters for the hospital system seems a bit large and luxurious.  Very high prices are paid to recruit tertiary care specialists into the hospital system.  For the high acuity services that this hospital system cannot deliver, patients are being sent to the highest cost hospital in the region instead of equally competent, but lower cost, alternatives. Also, experienced senior level executives that are recruited leave soon after arriving, either being fired or choosing to take lower paid jobs elsewhere. Insiders are promoted to replace them. 

But then the money falters.  Revenues take a tumble and days in accounts receivable grow during an extended transition to a new centralized billing system that was designed to take the place of the billing systems run by each hospital.  The risk contract with the insurer starts to limit annual price increases.  Medicare and Medicaid rates are constrained by the federal and state government.  Top line revenues fall, EBIDTA falls, cash flow falls.  Finally, the private equity partners are nervous.

They turn off the spigot and impose cash constraints on the system.  Normal maintenance of building systems is deferred.  Medical equipment expenses, too, are kept to a minimum.

The private equity firm searches for a new person who will be told to fix things, and quickly.  When he arrives, he will realize that the previous decisions that were made are now starting to burden the system with unavoidable operating costs and revenue constraints.  The only place to save money is on staffing.  He must make dramatic cuts in the upper management levels but will also be forced to make other cuts in the clinical support and lower administrative staff. Band-aid capital spending will be permitted when unsafe conditions exist, but the hospitals will start to fall behind on upgrades of important medical equipment and devices.  He will be in a race against the clock.  Can he hold it together long enough to permit the investors to get a return in the flip?  Finally, he will realize that closing one of the hospitals has to be part of the answer.  Investors will be relieved when he does so, but the community and governmental constituencies that supported the initial acquisition will get worried.

My colleague surmised that it would be around this time that regulators would begin to understand that the corporate guarantees that might stand behind the private equity firm's acquisition of the hospital system are a nullity.  The owners' resources are legally separated from those of the hospital system.  It would take years of litigation to pierce that corporate veil.  Thus, the commitments that have been made to the governmental and private constituents in the community are supported solely by the financial resources of the hospital system itself.  But that hospital system faces high debt service costs and obligations, other long-term cost commitments, and increasingly difficult revenue restrictions.

It would be around this time, he figured, that the capital markets would get wind of the fact that this hospital system cannot generate a risk-adjusted equity return that is commensurate with other industries.  An exit strategy that was predicted on a flip through an initial public offering or sale to another private equity firm would looking less and less viable

His question to me, "What would happen next?  Don't we need these hospitals to be in good condition to serve the public?"

My answer:  Assuming my friend's scenario is correct, pressure will build--from the employee unions, from the doctors, and from the legislators and municipal officials who were promised job preservation and growth in income taxes, sales taxes, and property taxes.  Behind the scenes, the dominant provider organization in the state--the only organization with sufficient cash flow to remediate the poor state of these decapitalized properties--would let the governor and others know that, because of its "concern for the public," it will "reluctantly" take over several of these distressed properties, but only "if it is asked."  The deal is struck, and the dominant provider finds itself owning facilities in several new regions in the state, broadening and enhancing its market power.

At that point, people throughout the region would sit and wonder, "Where did all the money go?"  Investors in the private equity fund would be less concerned:  They received their cash flow for several years.  Even though the exit strategy didn't work out as hoped, this hospital system investment is just a small component of a diversified portfolio managed by the private equity firm.

"Oh, " he said, shaking his head, "I was afraid of that."

Rushdie on moral courage

Salman Rushdie, who knows of such things in away most of us will never experience, asks the question in a New York Times article, "Whither Moral Courage?"  Some excerpts:

We find it easier, in these confused times, to admire physical bravery than moral courage — the courage of the life of the mind, or of public figures.

Even more strangely, we have become suspicious of those who take a stand against the abuses of power or dogma.

It was not always so. The writers and intellectuals who opposed Communism, Solzhenitsyn, Sakharov and the rest, were widely esteemed for their stand. ... As recently as 1989, the image of a man carrying two shopping bags and defying the tanks of Tiananmen Square became, almost at once, a global symbol of courage.

Then, it seems, things changed. The “Tank Man” has been largely forgotten in China, while the pro-democracy protesters, including those who died in the massacre of June 3 and 4, have been successfully redescribed by the Chinese authorities as counterrevolutionaries. The battle for redescription continues, obscuring or at least confusing our understanding of how “courageous” people should be judged.

Two years ago in Pakistan, the former governor of Punjab, Salman Taseer, defended a Christian woman, Asia Bibi, wrongly sentenced to death under the country’s draconian blasphemy law; for this he was murdered by one of his own security guards. The guard, Mumtaz Qadri, was widely praised and showered with rose petals when he appeared in court. The dead Mr. Taseer was widely criticized, and public opinion turned against him. His courage was obliterated by religious passions. The murderer was called a hero.

This new idea — that writers, scholars and artists who stand against orthodoxy or bigotry are to blame for upsetting people — is spreading fast, even to countries like India that once prided themselves on their freedoms.

America isn’t immune from this trend. ... Out-of-step intellectuals like Noam Chomsky and the deceased Edward Said have often been dismissed as crazy extremists, “anti-American" ... One may disagree with Mr. Chomsky’s critiques of America but it ought still to be possible to recognize the courage it takes to stand up and bellow them into the face of American power.

It’s a vexing time for those of us who believe in the right of artists, intellectuals and ordinary, affronted citizens to push boundaries and take risks and so, at times, to change the way we see the world. There’s nothing to be done but to go on restating the importance of this kind of courage, and to try to make sure that these oppressed individuals ... are seen for what they are: men and women standing on the front line of liberty. How to do this? Sign the petitions against their treatment, join the protests. Speak up. Every little bit counts. 

One of the best

My UK friend and colleague Isam Osman posted this note on Facebook today:

Yesterday the Sudan lost one of its great medical pioneers Prof Ahmed Abdel Aziz Yacoub FRCS , FRCP FACS. One of the first Cardiac Surgeons in Africa, he was the medical educator who established modern surgery in Sudan. He was a charismatic leader, a gifted surgeon, a loving father and staunch advocate for the poor and suffering Sudanese patient. He taught generations of doctors both the ethics and art of surgery. After retirement he went back to study, acquiring a Law degree and subsequent Phd from London University in Islamic Medical Jurisprudence. No mean feat in ones 70's! I pray that he is min ahl Jana rahimihu Allah. 

This certainly seems like a wonderful person.  As I commented, this is a good reminder that not all the "best" doctors reside in American and European academic medical centers.

I was prompted to say that because, several years ago, a local medical school here in Boston said that its purpose was "To create and nurture a community of the best people committed to leadership in alleviating human suffering caused by disease."  A worthy purpose, I thought at the time, but how pretentious to imply that it would comprise "the best people."  As Isam's note reminds us, there are devoted and committed people throughout the world.