Running a hospital

Click here to see Pink Gloves

2009-11-23T09:30:00.001-05:00

I usually avoid posts with a commercial tilt, but this is a worthy exception. A note from a friend:

Emily Somers created, directed and choreographed this video in Portland last week for her Medline glove division as a fundraiser for breast cancer awareness. This was all her idea to help promote their new pink gloves. I don't know how she got so many employees, doctors and patients to participate, but it started to really catch on and they all had a lot of fun doing it.

When the video gets 1 million hits, Medline will be making a huge contribution to the hospital, as well as offering free mammograms for the community. Please check it out. It's an easy and great way to donate to a wonderful cause, and who hasn't been touched by breast cancer?

Sidney Borum auction reminder

2009-11-22T11:58:00.005-05:00

As you start thinking about holiday shopping after Thanksgiving, please give some thought to shopping at my online auction to benefit the Sidney Borum, Jr. Health Center.

There are already a lot of good items. Look here for a preview.

Several cash gift cards: You could use those as presents or to buy presents. Travel, books, golf equipment, and more. Inspirational speakers, too, for your business meetings or civic events.

More to come. Check back.

This auction runs from Dec. 1 at 6am to Dec. 7 at 8pm. Please tell your friends, and feel free to donate items if you would like, too.

In memoriam: Arnold Rosoff

2009-11-22T07:12:00.002-05:00

Arnold Rosoff, known to the world as an exceptional advertising executive, died this week at age 93. Arnold was a trustee and volunteer in our hospital.

Here's the most fitting tribute I have heard, from one of our nurses, Jane Wandel:

I wanted to share my memory of Arnold as an ED volunteer. He volunteered as an orderly and worked alongside the paid orderlies in the department - indistinguishable from them in terms of his role. In fact, it was many months before most of us on the staff realized that he was a hospital trustee. He was kind and quiet, gentle and humble. He ran specimens and pushed stretchers; he readily helped with the most menial and, at times, unpleasant jobs in the unit. He treated everyone - from housekeeper to attending physician - with enormous respect and kindness. We adored him.

US Healthcare Reform Photoshop Contest

2009-11-22T06:05:00.003-05:00

Dr. Wes announces the first (and perhaps only) US Healthcare Reform Photoshop Contest. Photographs in support or against the current efforts will be equally considered. The winner receives an iPod Touch. Get more details here.

How our staff gets high

2009-11-22T06:00:00.002-05:00

Mount Everest is the background. This was taken two weeks ago from Kala Patar in Nepal. The people are Margie Serrano, RN (nurse manager of Farr 6 and CVICU), Alan Lisbon MD (Executive Vice Chair, Anesthesia), and Judi Deveau RN, NP (cardiac surgery).

Evidence in Medicine

2009-11-20T18:03:00.000-05:00

A new blog by David Rind. Very timely.

We are eating ourselves to death

2009-11-20T15:42:00.001-05:00

I'm taking a risk of offending here, but I don't mean it that way at all. It could be written about much of this country.

This particular post is prompted by an AP story by Mike Strobbe, pointing out that rates of obesity in the United States are highest in the Southeast and Appalachia.

On my recent incoming flight to Kentucky, an MD from the area who was sitting next to me pointed out that I would notice a large number of people with high body-mass indices. I expressed surprise, and said, "You mean noticeably different?" He said, "Yes."

I mentioned this story upon arrival to a number of my hosts at UK, and they confirmed it. They attributed it to the diet in their part of the world, combined with an increasingly sedentary population. Still I wondered, "How different can it really be?"

Then I noticed the breakfast buffet at my talk (seen here). And then a friend sent me a picture of the breakfast she was served after delivering her baby, with eight pieces of bacon.

There is much talk of the cost of health care in America. That talk tends to focus on the costs of doctors and hospitals, but a growing determinant of that cost is the diet and exercise pattern of our culture. I have previously posted slides from the CDC showing this trend over time. Sure, Kentucky and some other states are in the lead, but the whole country is following suit.

If I had taken pictures of the meals available to waiting travelers at Boston's Logan Airport, you would see similar patterns. A single sandwich with 1500 calories. A 32-ounce drink from the soda fountain with hundreds more.

We are eating ourselves to death.

There is no billing code for compassion

2009-11-20T09:30:00.003-05:00

Our Dr. Amy Ship won the Campassionate Caregiver Award from the Kenneth B. Schwartz Center last night. The center conducts programs to educate, train and support caregivers in the art of compassionate health care. It received over 100 nominations for this award, which is designed to recognize people who have exemplified the practice of compassionate care to patients. Here is a background story from NECN television.

Amy's acceptance speech kept the audience in rapt attention. Here are some excerpts. I am hoping to be able to lead you to a video soon. One peak moment was when she emphasized the importance of primary care and bemoaned the current environment that often results in short, unsatisfactory visits. Noting that "there is no billing code for compassion," she called for a restoration of the proper role for primary care doctors.

Optimism? Other options?

2009-11-20T06:10:00.002-05:00

This New York Times story by Michael Grynbaum tells of a new transit pass in New York City that has the word "optimism" printed on the reverse. Why?

“God knows people want to feel good, they want to feel up, they want to feel positive,” said Christopher P. Boylan, who oversaw the project at the Metropolitan Transportation Authority. “If I can make a couple of customers smile a day, that’s nice.”

Shouldn't we be more flexible here in Boston? New York is so old. In this high tech town, where social media reigns and where everyone has a status bar on Facebook, shouldn't we have Charlie Cards that give us a choice on any given day?

Optimism, sure.

Next year, absoxlutely.

Still waiting (for my train/bus/trolley), clearly.

Wrong choice (for Monday morning quarterbacks), Patriotically.

Some choice, for Election Day.

Dim sum, for riding on Sunday.

Esplanade, for the Fourth of July.

Your ideas?

Donate Life New England

2009-11-19T11:30:00.005-05:00

BIDMC was just presented with this award for its role in promoting organ donations. The sponsor, Donate Life New England, coordinates organ donation programs throughout the region. It has a new website, as well as presence on social media like Facebook and Twitter, to get the word out about how important it is -- and easy it is -- to be an organ donor.

Many people think they have to wait for renewal of their driver's license to become an organ donor, but you can do it at any time. (I actually thought so, and then forgot to do it during my recent renewal!) You can do it on the website. It only takes a minute, and it will be legally binding. And, yes, you can revoke it at any time and also put various conditions in your record.

After going through the adventure below, I was moved to fill out the form. You never know.

Thanks for the rush!

2009-11-19T05:35:00.000-05:00

It has been a beautiful fall here in New England, and I have been taking some early morning bike rides. It is dark when I head out, so I have the full panoply of reflective gear and a clear and strong headlight. It is good to be seen by drivers in their cars.

In the picture, I am the "X" just making a right hand turn at a corner in which there is a rotary around which approaching cars from the opposite direction are supposed to go when making a left turn (top black line).

Except, this time, the guy driving a minivan at about 30 mph decides he is at Le Mans and choose to make the left turn by bypassing the rotary altogether and driving in the left lane and cutting the corner (lower line).

He finally wakes up and sees me and swerves and misses me by a foot. Never stopping. But accelerating off as he departs the scene.

I can't tell you how much I appreciated the adrenaline rush. I had been just a little chilly as I set out that day, and this event quickly warmed up my whole body.

A long day

2009-11-18T20:51:00.003-05:00

Even with enforced restrictions on duty hours, it can be a long day for residents. Next time, I hope this fellow can find a bed instead of a chair at the end of a corridor. He probably woke up feeling pretty stiff.

Tweeting while you talk?

2009-11-18T16:24:00.003-05:00

So, I have been doing a fair number of speeches lately, and you always wonder what people in the audience are thinking. Might they be publishing tweets with their opinions while you talk? Here is a humorous view from Marc Perry at The Chronicle for Higher Education.

Caught between mammograms

2009-11-18T11:58:00.001-05:00

Here is a great commentary by WBUR's Rachel Zimmerman about the uncertainties raised by recent articles about mammograms.

Dean Flier offers his views

2009-11-17T21:55:00.000-05:00

Harvard Medical School Dean Jeffrey Flier offers a thoughtful and honest perspective on the health care bills circulating in Congress in this Wall Street Journal op-ed. Jeff is not just an academic observer. He is an accomplished physician-researcher-educator with lots of experience in the trenches.

He must know that his column will raise the ire of those on one side or the other of the health care debate, and then what he says will likewise be used in the political debate. I am confident that he raises these issues because he senses a need for someone to speak directly and help our political leaders on both sides of the aisle do the right thing.

He starts with a plain-spoken summary: "As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade."

And then he leads to an important point: "Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true." Hmm, that sounds familiar and is strongly supported by everything I have heard. He continues, "So the overall effort will fail to qualify as reform."

But, for me, the major insight is this: "Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern."

And finally: "So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead."

Stories about Harvey Goldman, MD

2009-11-17T11:51:00.005-05:00

I reported in April on the death of Dr. Harvey Goldman, one of our beloved and esteemed colleagues (who loved baseball and is here seen with a Red Sox World Series trophy). Today, we honored this eminent pathologist with a memorial celebration and dedication of the Pathology Department Conference Room in his name. Speakers at the event included people from BIDMC, but also Fred Silva, Executive Vice President of the United States and Canadian Academy of Pathology, and Henry Appelman, Harvey's long-standing friend and colleague from the University of Michigan Medical School.

There were humorous and poignant remarks, too, from Robert Najarian, a gastrointestinal pathology fellow at BIDMC. He remarked that there were so many stories he had heard from residents and fellows that he felt badly he could not tell them all. I suggested we might give people a chance to tell those stories right here on this blog.

So, if you have studied or worked with Harvey at any point in your training or career and wish to offer stories or comments here for your friends, colleagues, and the world, please submit them.

The former Speaker speaks

2009-11-16T21:49:00.000-05:00

Here are some folks from around the country at the Press Ganey National Client Conference today in Maryland. The "clients" is this case are hospital and physician groups who employ Press Ganey to conduct surveys of their patients. Over 1700 people attended. I was invited to talk at one of the sessions about the issue of using transparency to help create a culture of quality and safety.

The keynote speaker was Newt Gingrinch, former Speaker of the US House of Representatives (fuzzy picture above). Mr. Gingrich and I agree on some things and not on others. For example, his behavior with regard to the issue of so-called "death panels" was, in my mind, despicable. And, even in this speech, he had tendency to introduce partisan divisiveness when not really necessary.

That being said, he made some good points. He implored those in attendance to engage in continuous process improvement in their hospitals and not await government action to improve the quality and safety and cost-effectiveness of patient care. Essential to those improvement programs, he noted, is accurate data about clinical results, with concomitant transparency of those outcomes.

You can review other aspects of his work and ideas at the Center for Health Transformation.

City Sourced, a great app idea

2009-11-16T17:23:00.003-05:00

I met a fellow today named David Kralik who is part of a new venture that has developed a wonderful iphone, Blackberry, etc. application called City Sourced. The idea is that, if you see something wrong in your town (a pothole, a broken street sign, or some other unsafe condition), you can immediately send a GPS-ed message with a picture of the problem to the municipality to inform them of the problem.

Just think, if I had had it this morning (and if I still had a Blackberry), I could have reported the problem I saw on the local transit system.

Art on the MBTA

2009-11-16T17:05:00.003-05:00

A short while back, I wrote about new uninformative signs and annoying audio messages on the local transit system. Having run a large public agency, I really understand and sympathize with the logistics involved in introducing a new system. But it seems to me that these folks are missing something: If your system is not ready for prime time, don't bring attention to it.

The previous loud message warning us not to be fare evaders has now been joined by a message urging us to follow the safety rules and regulations of the transit system -- as though we might know what those are. It was amusing to be told to be careful riding the escalators, since the stations at which this broadcast was delivered are at ground level.

This morning, too, we had a new feature. Check out the artwork portrayed on the sign. If you click to enlarge the photo, you can see a random pattern of energized LEDs. Thanks to the MBTA for offering this visual treat!

Market failure --> New entrants?

2009-11-15T06:45:00.006-05:00

This story by Rob Weisman in today's Boston Globe is about large insurance rate increases being faced by small businesses in Massachusetts. But, it is really about the lack of effective competition in the Massachusetts health care market, both on the provider side and the insurer side.

Although there are many contributors to rising health care costs in the state, one major one is the fact that the largest provider system is paid rates that far exceed the rest of the industry. This is the result of its market power and leverage over the insurance companies during rate negotiations. Yes, part of the problem is a fee-for-service payment regime that encourages overuse; but that is compounded when the dominant system's FFS rates are very high relative to the market. Why? Because it enables that system to recruit community physicians into its network at higher salaries, away from other systems. Those local doctors, in turn, refer their patients to the higher priced hospitals in that same network. This is a vicious cycle of higher rates, leading to network growth, leading to still more bargaining power, leading to higher rates.

Why do the insurers put up with this? Because there is a public perception, unsupported by clinical outcomes data, that the dominant provider must be part of any insurance plan's network. The plans, therefore, are afraid to leave those hospitals out of their insurance products. They also seem reluctant to create a market for insurance products that would charge customers a higher co-pay or add other features that would encourage the patients to go to lower-priced facilities.

The result: Utilization in the network served by the dominant provider grows at a rate exceeding the regional average. And because that utilization is reimbursed at a higher differential rate, the insurance company sees a huge cash outflow, and feels it necessary to raise rates -- especially to the market segment that has the fewest choices.

The second problem is a similar lack of competition in the insurance market itself. In any other industry, a competitor would enter the market and create a niche product -- a plan for small businesses and individuals, based on a limited high-quality, low-cost provider network.

National insurance companies have had a very small market presence in our state. Those who have thought about expanding their share of the Massachusetts market are probably concerned about the relative costs of doing so or about the ability of the insurers in this state to simply underprice their products. Well, we now see evidence that even the dominant insurer might feel it cannot afford to respond competitively to a new market entrant. That insurer, along with the others, is so persuaded of the market power of the dominant provider that it has been reluctant to take on that provider by leaving it out of its product mix or by including it at the premium price necessary to cover its costs.

A new entrant might feel differently and focus its efforts on a vulnerable market segment, one that would find a high-quality, low-cost network attractive. When you are fighting for your financial life as a small business or individual purchaser of insurance, you are more willing to make different kinds of choices. And, as a small business, you can more easily explain to your employees why you have done so.

To me, this seems like an opportunity for competition.

At the Saturday Club

2009-11-14T16:57:00.003-05:00

Rob Velella (the one on the left) wanted to commemorate the 200th birthday of Oliver Wendell Holmes, and so he wrote a one-act play called "At the Saturday Club." The Club, which still exists today, was founded in 1855 and was an informal gathering of the great writers and thinkers of that age. They met at Boston's Parker House for "extravagant meals and even more extravagant conversations."

This play begins in 1892, with Holmes being the last survivor of his generation of writers. In his mind, he travels back to 1860, where he revisits his old friends Henry Wadsworth Longfellow, James Russell Lowell, and Ralph Waldo Emerson. The dialog in the play is taken from the original words of these historical figures.

The play was performed this afternoon at the Massachusetts Historical Society.

Another great soccer season

2009-11-14T13:03:00.000-05:00

Another successful soccer season closed out today. Well, not quite. The last game was postponed because of bad weather, but the end-of-season party went as planned. We'll see next week whether we can extend the 7-1-1 record to 8-1-1. In the meantime, the girls and parents fought off the rainy weather blues with the above cake and lots of other goodies.

It was also a chance for me marvel again at how many of the girls' parents are doctors (both MDs and Ph.D.s.) They seem to be endemic to this city. They include the following specialties: psychiatry, internal medicine, infectious disease, endocrinology, neurology, nutrition and aging, and risk management to name a few. We are clearly ready for any medical emergencies that might occur on the field!

Right on Target from The Onion

2009-11-14T09:53:00.001-05:00

This is more true than you can imagine. It has happened to me many, many times during TV interviews.

How not to save energy

2009-11-14T05:53:00.006-05:00

The second US energy crisis occurred in 1979, after the Shah of Iran was deposed, and oil production in Iran plummeted from 6 million barrels per day to under 2MBD (black line in the chart to the right). Saudi Arabia and other OPEC countries increased production to try to offset this, but the results were uneven. While the overall reduction in supply was only 4 percent, panic resulted, leading to hoarding behavior and shortages.

President Carter responded to this with a package of energy legislation and his now-famous "malaise" speech, in which he discussed an American crisis of confidence and urged people to use less energy.

The most correct thing the President said in terms of energy policy was that "We often think of conservation only in terms of sacrifice. In fact it is the most painless and immediate way of rebuilding our nation's strength." But this lesson was soon lost as the government acted to equate conservation with deprivation.

An example is in the certificate above. The Emergency Building Temperature Restrictions were implemented the day after Carter's speech and set maximum temperature levels for public buildings in the heating season and minimum temperature levels in the cooling season, as well as maximum temperatures for hot water. Specifically, space heating was restricted to a maximum of 65 degrees Farenheit, hot water temperature to a maximum of 105 degrees F, and cooling temperature to a minimum of 78 degrees F.

The damage done to American's understanding of energy conservation was that a policy that could have been equated with efficiency, competitiveness, and improved comfort was instead seared into the public consciousness as sacrifice and discomfort. (It is no accident that the regulations were rescinded by President Reagan shortly after taking office.)

I had seen a similar portrayal during the first energy crisis in 1974, when the OPEC nations imposed an embargo on petroleum sales to the United States and other Israeli allies. Rogers Morton, Secretary of the Commerce at the time said, "Americans don't want to conserve energy. They want to win." At a private meeting at Harvard during that period, as an intense 25-year-old Deputy Director of the MA Energy Policy Office, I rather directly and perhaps a little rudely told Energy Czar Frank Zarb that he was dead wrong when he said that America had reached the limits of possible energy conservation.

Sure enough, investments in plant, equipment, and appliance over the years have changed the underlying structural relationship between energy use and GDP in the US and other countries, and they have done so while preserving and even enhancing the efficiency and comfort of American life.

But reminders persist. The certificate above is today posted in a building at MIT, no longer relevant or in force, but a shadow of a failed policy direction.

There is still tremendous potential for energy efficiency in America and the world, but only if we approach the problem in a way quite different from that adopted in 1979.

Atrius-BIDMC Relationship

2009-11-13T05:01:00.005-05:00

We announced yesterday an important partnership between the state's largest multispecialty group practice, Atrius Health, and BIDMC. This is a promising new relationship between a physician practice group and an academic medical center.

Here's the press release. Please note, in particular, the comments by Don Berwick, which help explain the context and significance of this.

While exciting to me, I also know that this will also require a lot of work to pull off, and I expect we will learn much from each other. I would also be happy to hear comments from my readers as to your experiences in similar ventures, and your advice to us to help make this a success.

ATRIUS HEALTH, BETH ISRAEL DEACONESS MEDICAL CENTER WORKING TO CREATE NEW HEALTH CARE MODEL

Atrius Health and Beth Israel Deaconess Medical Center are expanding their relationship to establish a new model of health care delivery between a large ambulatory multi-specialty practice and a leading academic medical center, according to Gene Lindsey, MD, president and CEO of Atrius Health.

The boards of directors from Atrius and BIDMC both voted Wednesday evening to build the expanded relationship. The first step will be that Harvard Vanguard internists from the Kenmore, Copley Square, and Post Office Square offices will send their patients who need emergency care or hospitalization to BIDMC. Over time, Atrius Health will also look to collaborate with BIDMC in ensuring hospital care for patients with more complex needs, including cardiovascular and oncology patients as well as other surgical specialties. The organizations will utilize electronic medical records to help coordinate patient care. Atrius Health will continue all of its existing hospital relationships to serve patients in communities it serves.

Guided by an overarching goal of patient-centered care, Atrius Health and BIDMC also envision a robust agenda of quality improvement and cost efficiency strategies. Both parties have a vision of working together far into the future. Additional details about joint clinical, quality, and cost reduction programs will be introduced over time.

This new expanded relationship comes amid the current statewide and national debate on cost control and health care reform, and the move toward global payments in Massachusetts. The collaboration will be built around a strong emphasis on primary care and a continuum of care from the ambulatory setting to the hospital and beyond.

“The goal is to demonstrate that by working together, the two organizations can provide the highest quality, best service, and lowest cost health care in the Commonwealth.” Lindsey said. “We have the utmost respect for the progress BIDMC has made towards eliminating preventable harm and doing so with transparency,” he added.

The collaboration is also part of a larger Atrius hospital strategy to work together to improve quality and reduce costs with hospitals that share their vision and want to work on lowering cost and improving quality. Atrius Health and BIDMC have a long history together and both were involved in the Blue Cross Blue Shield of Massachusetts LEAD program for process and quality improvement.

“We intend to establish the model for health care delivery in the Commonwealth,” said BIDMC President and CEO Paul Levy. “That model offers a full spectrum of health care services that are patient-centered, compassionate, integrated, and evidence-based. Fundamental to our model will be an emphasis on primary care, alignment of the organizations, and transparency. Atrius Health has demonstrated leadership in all these areas, which is why we are so excited to be working and learning together.”

“Almost for certain, the American health care system is on the threshold of a leap into a new era of integrated, coordinated care. Patients as individuals and society as a whole badly needs that leap to achieve better quality at lower total cost. That re-forming of care will require new, highly cooperative relationships between foresighted hospitals and progressive medical groups,” according to Don Berwick, MD, MPP, President and CEO, Institute for Healthcare Improvement. “I cannot think of two organizations better equipped to welcome that reinvention, and to succeed at it, than BIDMC and Atrius Health. Each has a strong and distinguished track record of innovation, and their combined efforts will blaze a trail for many others,” he added.

The goals of the new relationship follow many of goals and principles outlined by the Massachusetts Health Care Quality and Cost Council, the Massachusetts Payment Reform Commission, the Mayor’s Task Force on Improving Access to Primary Care in Boston, and the Institute for Healthcare Improvement (IHI), including: Putting primary care at the center of patient’s care; Making sure that physicians work together as a team with nurses, technicians, and other allied health professionals; Enhancing and further integrating electronic medical records; Advancing health equity and ensuring a diverse, culturally competent, interdisciplinary workforce; Preventing and reducing medical errors and being transparent about results; Improving the efficiency of health care delivery by continuous process improvement as exemplified by the Lean methodology; Empowering patient involvement in the design of the health care delivery system through advisory councils, secret shoppers, patient satisfaction surveys, and other mechanisms.

Harvard Vanguard and its predecessors have a long history with BIDMC. Harvard Community Health Plan originally formed as a combination of a Brigham & Women’s practice and a Beth Israel practice, and benefited from the relationships with both of these outstanding institutions. Today, Atrius Health has existing relationships with BIDMC for obstetrics and oncology.