Monday, March 30, 2015

Crushed between two elephants

Here's a fascinating story about a developing trend. It's by Jordan Shapiro at the St. Louis Post-Dispatch and is presented over at Kaiser Health News. (KHN, by the way, is one of just a few go-to media outlets when you want to know what's really happening in health care.)

Jordan explains:

UnitedHealthcare, which covers approximately one-fourth of Missourians, has changed the way it handles something known as “balance billing” — the difference between the provider’s charge and the amount allowed by the insurer. The insurer’s move this year, designed to force down costs, means the insurer won’t pay the bills of some emergency room physicians and other specialists even though they work for hospitals in the UnitedHealthcare network. That could leave a customer with health insurance coverage stuck with thousands of dollars in unexpected expenses.

UnitedHealthcare previously would pay almost all of the bill from the emergency room doctors who performed services at an in-network hospital. But now UnitedHealthcare says it would scale back how much it would pay. It will now only pay the prevailing out-of-network rate, leaving the remainder of the bill to patients.

UnitedHealthcare blames the hospitals that contract out their emergency care to other providers who may or may not be in the insurer’s network.

It feels like the battle of the titans, with consumers getting crushed in the middle. As KHN's Jay Hancock noted on Twitter:

"What happens when Big Insurance plays the heavy with Big Hospitals? Consumers get screwed."

More than a Hallmark moment

I'm such a cynic about National ** Day (where ** is some profession or other.)  I really believe that most of these "holidays" were created to sell greeting cards, and maybe also roses and candy.  I also think that days like National Secretary's Day, for example, are pretty insulting, in that every day of the year should be cause for appreciation of people and their professions.

So it was with a touch of sarcasm that I posted on Facebook and Twitter the following query:

It's National Doctors Day. How do you plan to celebrate? Kiss your PCP? Send a Hallmark card? Pay your co-pay at time of visit? Adhere to a prescription? File an advance directive?

Who would have thought that this would prompted a cascade of true appreciation?  So very sweet.  Here's a sample:

Say a silent thank you to all the doctors I've worked with over the years and a special thanks to the one who figured out what I needed when I was at my lowest.

Remember what an amazing neurologist and heart surgeon I had at BIDMC.

I have the privilege of working at BIDMC and will say thank you to all the "white coats" and even the residents I come across today as they are the doctors of tomorrow once they pass their Boards!

Simply say, thank you. Most don't hear it enough, especially these days.

Don't kiss your PCP-do a fist bump and a big thank you.

See your doc as a human who also carries a heavy burden. Treat them as such. Offer a hug and encouragement.

And, finally!

First, I'll remind them that nurses have helped get them where they are today, and that our week comes in May! Next, I think I'll schedule my annual mammogram and eye exam to help boost my PCP's quality scores. 

Sunday, March 29, 2015

Art in Giving

The Rachel Molly Markoff Foundation is a small organization, created in memory of a young girl who died from brain cancer, dedicated to funding research in pediatric cancers and helping families cope with childhood cancer..  The foundation has engaged in an innovative way to raise money, called Art in Giving.

It's a simple concept.  If you are, say, the developer of a new office building, hospital, research laboratory, or university, you likely have a budget to purchase art to decorate the walls and hallways.  Instead of buying your art through regular channels, you meet with one of the volunteer curators who work with Art in Giving, and they help you find art from their catalog.  The artists have agreed to donate half of the price of the paintings or sculpture to the Markoff Foundation.

Here's a three minute video that describes it all.

Please contact the foundation if you have a new or older building or office or laboratory that might want to be a participant in this worthwhile program.

Lots of drugs with no physical exam

You see all kinds of things on Facebook.  For example, people are remarkably free with their medical information.  Still, some stories just call for more information.

Take this one.  What struck me was the phrase: "Lots of drugs with no physical exam." I'm no doctor, but I just wonder if that would be the norm?  What do you think?

A female in her 30s first writes from the emergency room of a local hospital:

Apparently my migraine isn't a migraine when my blood pressure is 151/112!

Five hours later, she files this report:

Discharged with a BP of 156/97 s/p phenagrin, compazine, 8mg ZOFRAN IVP, 4 mg Morphine IVP, 4mg Klonopin, 3mg Ativan. Migraine is now a headache and I am apparently stable for discharge. Lots of drugs with no physical exam. Just wondering what's going on as the pharmacodynamics are working away and since these drugs have been in for about 45min. What the pharmacokinetics have it out for me for the rest of the day. 

Who is placing bets on my vitals this am?

Friday, March 27, 2015

Documenting the work-around on the T

In great measure due to previous posts, I now seem to be the designated Twitter recipient of photos of MBTA personnel dealing with the problem of Green Line train doors that get stuck on the platform and can't close.

Here's the latest tweet with the accompanying picture above:

#MBTA employees physically shutting the doors. 

Thanks to @daisy and @chippy_the_hero for their diligence.

So we can document the work-around, while noting that there has been no systemic fix to the problem even though it regularly disrupts service.

"Targeted hurting" by drones

Sometimes I wonder if I am living in the right century.  I read this article about "the coming revolution of drone warfare" and was doing fine till I came to this paragraph:

Finally, lethal drones may make possible a new form of high-tech coercion: targeted hurting. Targeted terrorist-killing operations are designed to take an enemy off the battlefield. Targeted hurting could be designed to change any enemy’s behavior—by destroying selectively the family members, friends, associates, villages or capabilities that the enemy holds most dear.

Is this just the geopolitical environment in which we find ourselves or is the author (as suggested by a friend) a psychopath. If the former, wow.  If the latter, why does she get space in the Wall Street Journal?

Bigger is better? Not so fast!

Here's a useful report from the Leonard Davis Institute of Health Economics at the University of Pennsylvania:

A new study by LDI Senior Fellow Lawton Burns and colleagues challenges the conventional wisdom about the societal benefits and comparative advantages of integrated delivery networks (IDNs).  A literature review and detailed analysis of financial and quality indicators found “scant evidence” of improved quality, lower cost per case, or greater societal benefit.  From the abstract:

Looking at the benefits to society, the authors found that there is evidence that IDNs have raised physician costs, hospital prices and per capita medical care spending; looking at the benefits to the providers, the evidence also showed that greater investments in IDN development are associated with lower operating margins and return on capital. As part of this report, the authors conducted a new analysis of 15 of the largest IDNs in the country. While data on hospital performance at the IDN level are scant, the authors found no relationship between the degree of hospital market concentration and IDN operating profits, between the size of the IDN’s bed complement or its net collected revenues and operating profits, no difference in clinical quality or safety scores between the IDN’s flagship hospital and its major in-market competitor, higher costs of care in the IDN’s flagship hospital versus its in-market competitor, and higher costs of care when more of the flagship hospital’s revenues were at risk.

In a related piece at Modern Healthcare, the authors conclude:

After decades of strenuous policy advocacy, it is still not clear that, in the case of the IDN, the whole is greater than the sum of its parts, or that policymakers should be encouraging further IDN formation.

I share the authors' skepticism about this direction in health care policy.

Wednesday, March 25, 2015

Valuing introverts

Please take a look at a new article I posted at the athenahealth Health Leadership Forum.  I welcome comments there and here.

WWI and the Middle East

Back in January, I had a chance to hear and meet Scott Anderson, author of Lawrence in Arabia, at the Jaipur Literature Festival.  Now, as I finally get around to reading the book, I find myself jolted upright by many of its stories and observations.  Here’s a short section (from pages 150-152 in the book) about how an outlying corner of World War I came to symbolize something far larger.  I fear we also see in this section how the implications of those decisions went beyond that moment in history, being formative to the situation in which we find ourselves today.

A perverse mind-set had settled in among the warring European powers by that autumn of 1915.  To understand this mind-set, one had to appreciate the paralysis that held over the larger map of the war. [Here he describes the stalemate on all fronts and the loss of millions of lives.] Given this stunning lack of progress earned at such horrific cost, it might seem reasonable to imagine that the thoughts of the various warring nations would now turn to peace, to trying to find some way out of the mess.  Instead, precisely the opposite was happening.  

It’s a question that has faced peoples and nations at war since the beginning of time, and usually produced a terrible answer: in contemplating all the lives already lost, the treasure squandered, how ever to admit it was for nothing? Since such an admission is unthinkable, and the status quo untenable, the only option left is to escalate.  Thus among the warring states in Europe at the end of 1915 it was no longer a matter of satisfying what had brought them into the conflict in the first place—and in many cases, those reasons had been shockingly trivial—but to expand beyond them, the acceptable terms for peace not lowered, but raised.  The conflict was no longer about playing for small advantage against one’s imperial rivals, but about hobbling them forever, ensuring that they might never again have the capability to wage such a devastating and pointless war.  

But defeating one’s enemies is only half the game; for a war to be truly justifiable one has to materially gain.  In modern European custom, that need had been sated by the payment of war reparations into the victor’s coffers, the grabbing of a disputed province here or there, but that seemed rather picayune in view of this conflict’s costs. Instead, all the slaughter was to be justified by a new golden age of empire, the victors far richer, far grander than before. Naturally, this simply propelled the cycle to its logical, murderous conclusion. When contemplating all to be conferred upon the eventual winners, and all to be taken from the losers, how to possible quit now?
 

No, what was required was greater commitment—more soldiers, more money, more loss—to be redeemed when victory finally came with more territory, more wealth, more power. For the Entente powers of Great Britain, France, and Russia there really was only one place that offered the prospect of redemption on the scale required: the fractured and varied lands of the Ottoman Empire.
 
For all three powers, the war in the Middle East was now to become about satisfying their imperial cravings—desiderata, as it was politely known—they had long harbored.  (For Russia, Constantinople; for France, Syria; for Britain, the land approaches to India, its “jewel in the crown.)

Then there was the religious factor. All three of the principal Entente powers were devoutly Christian nations is 1915, and even after six hundred years it still grated on many that the Christian Holy land lay in Muslim hands.  In carving up the Ottoman Empire there was finally the chance to replay the Crusades to a happier ending.
 
There was a diplomatic need for the allies to codify these imperialist imperatives, leading to the Sykes-Picot Agreement. “In just a few days of meetings in early January 1916, two midlevel diplomats cobbled together a future map of the Middle East,” deciding how these lands were to be divided after the war.

On such arrogance and folly--and on such tenuous strands--were built the foundations for many of today’s problems in a contentious part of the world.

Managers for care improvement on WIHI

Madge Kaplan writes:

The next WIHI broadcast — The Managers and Management We Need to Improve Care — will take place on Thursday, March 26, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • David Munch, MD, Senior Vice President and Chief Clinical Officer, Healthcare Performance Partners
  • Stephanie Calcasola, MSN, RN-BC, Director of Quality and Medical Management, Baystate Medical Center
  • Kedar Mate, MD, Senior Vice President, Institute for Healthcare Improvement (IHI)
Health care leaders have an incredibly important role to play in driving improvement initiatives in their organizations. So do people on the frontlines of care. What we aren’t as articulate about is the role that middle managers play. You know, the people with the job titles of House Supervisor or Shift Supervisor or Team Lead or Manager of the PACU (Post Anesthesia Care Unit). A growing number of experts say we can’t afford to ignore that people in these jobs are essential to improvement, too. 
One of those experts is Dr. David Munch, who will help lead our discussion on the March 26 WIHI: The Managers and Management We Need to Improve Care. Dave Munch will be joined by IHI’s senior innovation and improvement capability expert, Dr. Kedar Mate, and Baystate Medical Center’s Stephanie Calcasola. All three will help us look at what middle managers do, now, on behalf of quality improvement – and what they could do more of, if their contributions and unique positioning in the organization were better utilized and understood. Especially when it comes to making improvement endeavors operational and sustainable.

Dave Munch recently wrote a blog post about this topic for ihi.org that we invite you to read ahead of the March 12 show. He’s also pointed us to some interesting research that suggests, among other things, that senior leader support for the middle management team helps build managers’ confidence and commitment to drive change and ignites enthusiasm across the organization.

No one’s capabilities and talent should be wasted when it comes to improving health and health care for those we serve. We know you agree. So, join us on March 26! You can enroll for the broadcast here

Tuesday, March 24, 2015

Do they think that an acknowledgement is the same as a solution?

A posting on Twitter, in reply to mine of last week about a persistent problem on our transit system.

This, plus the comments I received on the problem from Universal Hub readers, suggest that a solution is a long time off.

So if it is not going to get fixed, or perhaps can't get fixed, why does the person at the T who responds to customer call-outs reply with this kind of message:

Thanks for reporting this.  We've forwarded it to our supervisors and will look into this door issue, now.

Do they think that an acknowledgement is the same as a solution?  Why don't they just tell the truth instead?

Golly, it feels like how complaints are handled in some hospitals!

Oops, wrong side again.

Someone once said that there are two types of surgeons, those who have operated on the wrong side, and those who will do so.  The persistence of wrong site surgeries (worldwide) is striking, especially given the existence of the so-called Universal Protocol that is supposed to eliminate them.

What to do?  Plug away.  As each case occurs, do a full analysis of what went wrong and why, and then teach all those involved in this arena in the hospital.  Engage in a just culture, understanding that if it happened to one well intentioned surgeon, it could easily happen to someone else.  Look for the underlying systemic flaws.

Here's an example of one such review, held in a hospital in the UK, held without blame and with all participating.  In my mind, it represents an excellent summary of this particular case and provided useful results for the hospital and its staff.

After Action Review
Never Event Wrong side surgery 

What was expected :

Patient was admitted for Right sided percutaneous intervention. Patient expected to come in, have the correct procedure by doctor A under sedation and go home the same day. 

What actually happened:

Doctor A at the team huddle in the morning felt that his list might overrun due to a complex case on the list. He asked doctor B in the next theatre who had a light list if he could help by doing a case or two. Doctor B agreed.

Patient came from ward to Doctor B’s list for the procedure to be undertaken by another practitioner on behalf of Doctor B. Patient was consented in the anaesthetic room by the other practitioner.

Side of procedure not marked by consenting practioner.

Patient went into theatre and placed prone on table and sedation commenced. WHO Time-out took place after sedation commenced. Surgical site marking tick box in the Sign In ticked as done.

The Practitioner then proceeded to invasively treat the wrong side percutaneously.

No one in the team noticed error.

Patient returned to the ward only to notice that plaster over injection site was on the wrong side. Flagged it up with the Nurse who informed the treating team. Team came to ward and after checking agreed there had been a mistake. Patient returned to theatre to have the correct site treated by Doctor A under LA. Patient informed under duty of candour of mistake. 

Why the difference:

1.Unexpected patient on the list operated on by a different team.

2.Operation site not marked.

3.The Team felt that better concentration by all during Time-out might have helped. They feel that it is often the case that not everyone actually pauses and pay attention completely during time-out. Anesthetist was concentrating on the patient’s airway as sedation has already started.

4.The Surgical Site tick box on the Sign In was ticked as done even though this was not the case because ‘Doctor B never marks operation side’. Staff assumed that it was therefore all right to do so. The Practitioner who did the procedure marks all his patients except those that he does for Doctor B in order to avoid any ‘unnecessary remarks’. 

What lessons can be  learned

1.      All patients having interventional procedures to a bilaterally symmetrical organ or part of the body should be marked at the time of consent with a marking pen that will not wash off with alcohol based skin preparation.

2.      If the patient is not marked the procedure should not be undertaken until such a time as the person who consented the patient marks the appropriate side. All or any member of the team should feel empowered to ‘call this out’. Bilateral procedure sites should have a mark on each side.

3.      If the patient is not marked it should not be documented that this has been done in the WHO Sign in and staff should feel empowered to decline to start the procedure.

4.      Sedation should not be started until Time-Out is completed to allow the whole team to pause and concentrate.

5.      During Time Out all activity should stop to allow complete focus of the whole team on the checklist prior to commencement of the operation.

Monday, March 23, 2015

How can we do so poorly?

Chistian Gausvik, one of our Telluride Patient Safety Camp participants last summer, sent me a note on Facebook:

Wanted to share a piece with you that I recently had the somewhat unfortunate inspiration to write.

He titled it "7 Months Out." Excerpts:

In the same 7 months since I left the conference my grandfather has been struggling with constant symptoms that seem obviously to point to a bladder or prostate cancer. Following along as a family member I can see the frustrations our system causes. He’s a sharp guy and my family is well educated – though not medical professionals – and still everyone (myself included) has been confused through the entire journey. Assured it was a bladder infection he pressed on through several rounds of antibiotics eventually undergoing a bladder scope and further blood testing. All the while never informed of any possibility beyond a unitary tract infection. He encountered physicians in the hospital and outpatient setting nearly a dozen times throughout these months. The communication and hand off between doctors was poor, the system was muddled with confusion and communication was nonexistent.

After 4 rounds of attempting to treat the symptoms as a UTI, after an X-ray, a scope and multiple sets of blood work and still no answers we switched providers. A repeat of the initial scope revealed a very high grade anterior prostate cancer – understandably missed by routine screening but unforgivably missed by 7 months of encounters with the healthcare system. Seven months of taking pills, having side effects, of changing his lifestyle, of making appointments, of collecting medical bills and finally a repeat of a test that was initially done months prior reveals the diagnosis that should have been obvious all along. 

How can we do so poorly? We do not communicate well, we do not follow patients well and we just don’t always take good care of people.

It terrifies me that I am working my way towards a career in a system that does such a poor job at times, because I only want to do the best to treat my patients in the best possible way. I won’t let it terrify me though, rather inspire me to do better, to communicate, to listen, to speak up, to find and learn from errors. I will do better.

RI Marijuana policy: Not so fine, says Fine

ConvergenceRI offers a disproportionate number of engaging and thoughtful health care stories--disproportionate because of its small size as a media organization and the small size of its home market.  Here's the latest, an excellent interview with the outgoing head of the state's Department of Health, Michael Fine.  The headline:

Outgoing director of the R.I. Department of Health offers his candid views on the state’s need to own its addiction problem, to stand on science, to invest in research, and to admit that its social policy on marijuana has been a disaster. 

Here are some excerpts (and a link to the video):

We are living some big lies. To a certain extent, intelligent public discourse depends on us telling the truth. What the science does is, it gives us access to the truth.

It’s pretty clear to me that our social policy about marijuana has been a dismal failure. You can still buy, I’m told, marijuana in every boys room or girls room in every high school in the state. That’s a big issue. We have, according to the evidence, more marijuana use in Rhode Island than any other state in the country.

Marijuana isn’t a single substance, there are multiple substances contained in the smokes and the edibles. Clinical research is critical if we’re going to make marijuana a truly medical process, so that we can understand dose and frequency and duration.

What we do with medical marijuana and its authorization is not a medical process. It’s a substance whose strength we don’t know, whose impact on the individual we don’t understand. The good news is that we’re helping the suffering of people; the bad news is that it is not a medical process. It asks physicians to do something that they aren’t specifically trained to do.

There is a legitimate argument [that can be made] that [legalization, regulation and taxation] is a reasonable social policy. …There are things we need to be thinking about if we [are to] do it.
…How we can make sure that we use any tax money that’s being raised to really fund substance abuse treatment [and recovery programs].
The evidence suggests that there is going to be a side effect of increased use. We need to do our very best to make sure that adolescents don’t have access to this drug. Because, clearly, there is good evidence that shows the relationship between marijuana use among adolescents and a number of adverse outcomes.”

Sunday, March 22, 2015

How teenagers spend time together

Sign of the times.

In appreciation: Nicole Freedman

Nicole Freedman, bicycle czarina here in Boston for seven years, is headed off to Seattle to lead their Active Transportation initiative. Almost single-handedly, she transformed a very bicycle unfriendly city into one that--subject to the limits of a cow-path formed streetscape--is much more conducive to urban wheelers.  As she notes in her farewell letter:

I am proud of how much we have accomplished together for cycling here in Boston. Since launching we have added 92 miles of bike lanes and nearly 2,000 bike racks. We have an award winning Community Biking Program which has donated 4,015 bikes and trained 23,000 youth. And of course, the New Balance Hubway system has become a new Boston institution.

I first met Nicole when she was visiting a patient in our hospital.  She was introduced to me by our Chief of Medicine, Mark Zeidel, a family friend.  Mayor Thomas Menino later offered her a position in his admininstration, and she got to work quickly.

A few months later, she came to me wondering how she might get the Boston area hospitals to contribute to Hubway,  a series of bike rental depots to be located at key points throughout the city.  "How much is each bike stand?" I asked.  It was $100,000.

Understanding the competitive nature of our industry, I said, "I can guarantee participation by every hospital in town."  She looked stunned.  I said, "We'll fund two stands on our two campuses. All you have to do is call the CEO or COO at every other hospital and tell them that BIDMC has committed to the Mayor's new bike program.  They will immediately join in."  Sure enough, within two weeks, she had enough commitments to proceed with the program, anchored by bike stands at the city's hospitals.


One of Nicole's key programs was Hub on Wheels, a daylong biking romp through neighborhoods of the city.  It attracted thousands of riders.  After participating the first year, I realized that it had insufficient medical coverage along the route, so we volunteered to set up tents with doctors and nurses at key locations, along with ambulances donated by Cataldo Ambulance Service.  We also fielded a team of riders from the hospital staff, including that very Dr. Zeidel (seen left, in yellow slicker) who had made the initial introduction.

We were encouraged to do all this by Nicole's vibrant energy, enthusiasm, and good humor.  Others throughout the city likewise pitched in to help or participate.  Even Mayor Menino was seen on a bicycle, although he confided to me that he was, er, less than comfortable sitting on a bike for an extended period of time.  (I'll pass on the exact terminology he used!)  In short, Nicole demonstrated what one committed person can achieve for an urban area.  We all wish her well in Seattle!

Making "precision medicine" personal

Here's a short and sweet article by Zachary Berger and Dave deBronkart about "precision medicine."  The upshot:

Let’s not forget there’s more to a person than their physical selves: people have preferences, and their values vary. We assert that the ideal treatment is personalized to both our cells and our selves.

Only through shared deliberation by patient and health care provider does “precision medicine” become personal. Innovating new treatments is laudable but misguided unless patients identify what is at stake for them in current treatment gaps. Precision genomic research falls short of its potential if the risks and benefits of gene therapies aren’t in accord with the patient’s priorities.

As President Obama encourages precision medicine, he should support recognition of patient preference, and involvement in decisions, as part of this initiative, to ensure that “precision” medicine is not just “personalized” but personal. We say: blend the nuance of self with the nuance of cell.

Saturday, March 21, 2015

In memoriam: Stacy Duckett

Stacy Duckett, the Corporate Secretary of the Southwest Power Pool, died this week in Arkansas after a long fight with brain cancer.  Given my current involvement in the New England electric power grid, you might think that I knew her through that channel.  But it actually goes way back.

In a previous life, I was energy secretary for Bill Clinton during his first term as Governor.  In October 1979, our first daughter Rebecca was born at New Baptist Hospital.  After a few months, we needed some babysitting help, and my deputy, Cherry Duckett, said that her daughter Stacy would be happy to oblige.  She was about 16 at the time.

So we met this young woman, who was already showing the depth of character that would characterize her for years to come.  Inevitably polite and kind in that Southern kind of way, she also offered a deep intelligence and curiosity about the world, and was an excellent conversationalist, even as a teenager.  She also displayed a marvelous irreverence about the world that was refreshing and very funny.

Her primary part-time job (beyond babysitting) was serving frozen yogurt at the outlet of a start-up company called TCBY.  She was working at the company's first store, in west Little Rock's Marketplace Shopping Center.  According to this story, she was the first TCBY employee not a member of the founder's family, the Hickingbothams, when she began working at the store in high school. "Duckett soon moved to the corporate office, and she worked at TCBY full-time while getting her law degree."

"It's not something you recommend for everybody," she said at age 35. "It requires self-discipline and focus."

Something she had in abundance.

I guess the family recognized her talent after she received a law degree from the University of Arkansas at Little Rock School of Law, as she "rose in ranks to become a vice president and assistant general counsel to the yogurt giant."

The article also notes:

Outside the office, Duckett has served as president of the Home Team, Youth Home Inc.'s volunteer organization. She served on the 1997 race committee for Race for the Cure. She also teaches Sunday school at Trinity United Methodist Church. 

I followed all this from afar and then was pleasantly surprised to find that our lives were again overlapping.  After I joined the board of the New England electric power grid, I learned that she was general counsel to the Southwest Power Pool, having joined the organization in 2000.  As noted here, "she joined SPP as an attorney in the transmission and regulatory policy group, quickly assumed project management responsibilities, was named Director, Corporate Affairs, and served as General Counsel" before taking her last position.

We had a chance for short reunion a couple of years ago at an inter-regional meeting. At the time, her cancer had let up a bit, and she was in good spirits and cogent, but she knew it was going to come back. Mainly, she wanted to talk about how Rebecca, her former charge, was doing. When I showed her the pictures, she beamed with pride.

My condolences to her lovely family and all who have had the pleasure of her company during an all-too-short life.

Kill the SGR

One of the best examples of misnomers in government policy is the sustainable growth rate (SGR) formula that's supposed to automatically adjust Medicare physician compensation (mainly downward) each year.

The formula is flawed and so every year, there is an incredible effort by doctors and people in Congress to postpone its effect.  This creates the usual Washington work-around, in that the savings that would otherwise arise from the SGR disappear, and, under Congressional rules, the money has to be made up elsewhere.  That offset never really happens, but a postponement always takes place to avoid the disaster of reducing doctors' compensation.  Sometimes the "patch" lasts a year, sometime just a few weeks while Congress kicks the can down the road.

Well now, there is a bipartisan (yes, bipartisan!) effort to repeal the damn thing.  The AMA is on the case, sending out a gazillion emails to possible supporters. The House is expected to vote on the proposal next week, before the March 31 expiration date of the current patch.

I don't know whether the proposed solution is the best possible, but it is not time to let the perfect be the enemy of the good:  It is time to eliminate this odd provision in the law.

Update on OpenBiome

I was curious to know about the progress of the non-profit fecal microbiota transplant (FMT) company OpenBiome since I last visited them on this blog in December 2013. So, I inquired of Mark Smith and James Burgess, who gave this heartening report:

Thanks for checking in! The past year has been a very interesting and rewarding one for us. You wrote the first story ever about OpenBiome and started a media cascade that ended with coverage in the New York Times and beyond. We've experienced rapid growth and are working with over 230 hospitals in 43 states and have provided treatments for over 2800 recurrent C. difficile patients at this point. 

In addition to enabling care for C. difficile patients, we have also worked to support a number of clinical trials investigating the use of FMT for new indications. Many are still in the planning phases or have just recently been approved by the FDA and are preparing to initiate recruitment, but we're supporting studies of FMT in Ulcerative Colitis, Crohn's and IBS. We're also discussing studies for more exotic conditions, although none have moved beyond ideation at this point. There's an awful lot of hype in this space so we've been cautious about moving too quickly. C. difficile remains the only condition that we know benefits from FMT.

Over the past year, we have also been testing and developing an encapsulated formulation that should reduce procedure related costs and risks for treatment of C. difficile, while enabling long term maintenance therapy for the investigation of chronic conditions where a single dose is unlikely to provide lasting benefit. Capsules will also enable more robust blinding during placebo controlled trials.

Looking to the future, the long-term regulation of FMT remains an important open question. We have advocated that stool should be regulated with its own custom screening and processing requirements like blood products, while synthetic cocktails composed of well-defined, pure cultures of bacteria should be regulated as biological drugs. In the long-term, we are confident that this synthetic approach will replace natural stool (certainly for the treatment of C. difficile), but until then we think OpenBiome has an important role to play in the public health system both by enabling care for otherwise intractable cases of C. difficile and supporting research into new applications for FMT. 

Indeed, based on a cost effectiveness study by Ashwin Ananthakrishnan's group at MGH, each FMT saves the healthcare system $17K in direct treatment costs, putting our savings to the system at close to $50 million. However, this assumes FMT is delivered using the traditional directed donor approach rather than the more efficient universal donor model that we employ, so the true savings are likely considerably higher. Carolyn Edelstein has been doing a deeper dive into these numbers and is working with folks at the Harvard School of Public Health to conduct a more realistic assessment. We think these economic consequences should be considered as regulatory decisions are made, especially given that the costs of biologics are likely to be much higher than the material that we provide today for $250 per treatment.

In memoriam: Charles Button

I had heard great things about Charlies Button when I headed over to run the Massachusetts Water Resources Authority in 1987.  He was at the Boston Water and Sewer Commission, and I needed to build our team to carry out the $4 billion Boston Harbor Cleanup.  We met on City Hall Plaza and walked around talking about his experience, while I made the pitch to come on over.

He wasn't playing hard to get, but he turned me down flat.  The issue was that our agency--off to some false starts--had not yet proved that it was serious about creating a strong enough organization to carry out this massive project.  The last thing he was going to do was join a place that did not have the commitment and resources in place to succeed.  He was waiting for a sign that we were for real.

He got that sign after we purchased the Quincy shipyard for $50 million for a project laydown area, got our Board to commit to an 80-person project management team, and designated Richard Fox to run the project.  Dick said he was going to make another run at Charlie, and, sure enough, he joined our team.

You can read about this fellow's extensive accomplishments in this obituary.  If it has something to do with the region's wastewater infrastructure for over 40 years, he had a hand in it.  But as in all such matters, it is not what he did that we now remember, but how he did it.  He was the ultimate engineering professional, prudently and methodically considering the options to solve a problem, unswayed by passions of the day, understanding that the physical infrastructure he was building was being designed to last for decades. His clients were the public.  Sure he was dealing in steel and concrete, but underlying the fabrication of structures was a desire to do the best for the people of Boston and the metropolitan area.

Finally, there was his demeanor.  Understated, listening more than talking, thinking before opining,  respectful of elected officials but unafraid to engage in quiet forcefulness to persuade them with the facts, and always ready to find humor in the situation and letting a wry smile appear on his face. Whether Charlie was talking or listening, we always turned to him with trust: His judgement, commitment to the public good, and integrity were never, ever in doubt.  Millions of people in this region--for decades to come--will owe him a debt of gratitude.  It was a privilege and pleasure to know him.

Friday, March 20, 2015

A lesson from Dr. Dolittle to the MBTA


Many of us grew up with the Dr. Dolittle books.  He was famous for being able to talk with the animals, but his adventures went far and wide.  In one book, Doctor Dolittle's Post Office, he organizes a postal service for a small African country.  Following his directions, they carefully put up post boxes throughout the country and mail slots in their doors. People post their letters, but then they wonder why delivery does not follow.  Of course, it's because he and they have both forgotten to include the infrastructure needed to empty the mailboxes and sort and deliver the mail.  All is solved in the end, and the mail does go through--delivered by large and small birds, depending on the weight of the letter or parcel.

It is in this spirit that I turn to our local transit system. Our poor MBTA ("The T') has gotten hammered this winter and essentially shut down during the snow storms.  Much of this failure was due to persistent underinvestment by the state government in the system, something that I hope will be remedied in the future.  But--as in any complex organization--there were and are also patterns of behavior and design of work flow that impede process improvement.  My buddy Steve Spear describes some of these and antidotes in a recent article.  He notes:

Long and short, the Legislature will be debating budgetary actions to prevent future system collapses. That said, the executive branch will not only have to spend that money wisely but also have to develop these dynamic capabilities to assure that it is put to the best and most effective use.

It . . . means developing an eye to detect even micro aberrations from [the] ideal and investigating the root cause of disruptions, so countermeasures can be developed and their recurrence prevented.

I want to relate one example of these work flow problems now, not to poke fun or ascribe blame, but to provide an example for both the transit system and other organizations.

With the advent of Twitter, it becomes possible to report service problems in real time to @MBTA, and it is a sign of the system's alertness that you almost always get a rapid response thanking you for your tweet and telling you that your concern has been forwarded to supervisors who will work on the issue.

Then what happens?  Well, here's where it feels like the early days of Dr. Dolittle's post office.  I appreciate that someone is monitoring Twitter, but there seems that there's "many a slip 'twixt the cup and the lip" after the message arrives on that person's screen.  

I was riding the Green Line in February when the door of our car got stuck on the passenger platform.  The train was delayed, causing a backup in traffic.  The driver actually had to leave her post twice and give the door a mighty shove from the outside to get it unstuck.

How could that be, I thought? These cars have been in service for years, and the height of the platform has not changed.  So I figured it was some misalignment of the door.  So, I sent a tweet to @MBTA.


Our dialogue is above.  Read from the bottom up.

Upon leaving the train at my destination, I mentioned something to the driver about the oddness of the occurrence and she noted that it had happened before from time to time.

I thought nothing of it, sure that the problem would be solved. Until yesterday.  Precisely the same thing happened. A friend sent me this note with the accompanying photo:

Car #3806B. Single car D line train headed outbound, stuck at Copley station because the door wouldn't close as it kept getting stuck on the platform. 


You can see the failure mode in the photo.  That little piece of rubber at the bottom of the door hangs down too low and gets caught on the passenger tread of the platform  The door gets jammed and cannot close.

My friend and I both reported problems with cars in the 3800 series.  I see here that these were built by Breda in the period 1997 to 2007.  I'm not going to try to do a root cause analysis, but I'm willing to bet--based on our very limited sample--that if we were to look at other cars from this series, we'd see the potential for similar problems.  If so, that would suggest that a minor fix to the bottom of the doors could help keep the trains running.

Or maybe there's some other cause and some other solution.  The point is that Steve Spear is exactly right.  The MBTA needs to get better at "developing the eye to detect even micro aberrations from [the] ideal and investigating the root cause of disruptions, so countermeasures can be developed and their recurrence prevented."  Or as Dr. Dolittle might suggest, let's figure out how to deliver the mail to someone who will read and act on it.

And before you health care people chortle at "The T" and get too self-satisfied with your own organizations, let's reflect on the all too pervasive need for hospitals to do the same.

Thursday, March 19, 2015

America says, "Let MDs share my data--for free!"

Every now and then, the wisdom of the American people shines forth, especially if you phrase a relevant question in an understandable manner. Check out the lede from this story:

Nearly 75 percent of American adults surveyed believe it is very important that their critical health information should be easily shared between physicians, hospitals and other health care providers, according to a survey released today by the Society of Participatory Medicine and conducted by ORC International.

"What this survey points out is that when critical health information can't be shared across medical practices and hospitals, patients are put at risk," said Daniel Z. Sands, MD, MPH, co-founder and co-chair of the Society of Participatory Medicine and a practicing physician.  

The survey also revealed that 87 percent of respondents are overwhelmingly against any fees being charged to either healthcare providers or patients for the transfer of critical health information.

Hint:  This is where state Attorneys General and the US government should be working hand in hand to make sure this happens.  Right now, it is being observed in the breach.

Huh? HUH?

I've written at length about the push given to capitated contracts by Blue Cross Blue Shield of Massachusetts--and have suggested a number of public interest-related questions about this corporate policy.

The company doesn't like it to be called capitation. You decide.  Here's the short summary from an article in Health Affairs:

Its principal elements are a five-year term; an annual global budget based on each group’s historical per member per month spending; a quality-based system of performance bonuses; and regular reports from Blue Cross on the group’s spending, service use, and quality of care. 

Ok, so let's just call it capitation with the potential for some bonuses based on tracking sixty-four measures (thirty-two each for inpatient care and for ambulatory or outpatient care) covering the process of care.  Why do I call it capitation? Because it is.

And I'm also not going to comment on whether tracking 64 separate quality metrics can actually influence doctor and nurse day-to-day behavior on the floors, the ORs, and in the ICUs to improve quality over what would occur anyway.

That's not what brings me back to the topic today.  It is this line from the same article:

Although the medical groups each have an annual global budget, Blue Cross pays them fee-for-service throughout the year. All payments for medical care are debited against the group’s budget, whether the services are delivered by providers inside an Alternative Quality Contract group or by unaffiliated providers. At the end of each year, Blue Cross conducts a reconciliation exercise with each group, paying it any money left in the budget or recouping what the provider spent over the agreed-upon global budget. 

Read that again: "Blue Cross pays them fee-for-service throughout the year."

Now, BCBS of MA has been going around the state (and the country) for many years decrying the use of fee for service--and yet it maintains this underlying billing system.

It must costs millions of dollars each year to process the claims from provider groups and compile this information in this form.  Simple question:  Why is it necessary?  Why not just send a check each month for 1/12 of the annual budget?  There is simply no need to do a reconciliation.  If the provider group beats the budget, they keep the money.  If they exceed the budget, they absorb the loss.

Is there some information need that BCBS is providing?  Well, no.  Maintaining the FFS fiction clearly is not necessary to inform the provider organizations of the quantity of work they've done.  They already know what work they are doing.  (In fact, they use that information for internal transfer pricing purposes to compensate their individual doctors and hospitals.)  In short, the providers already have it within their sole power to analyze activity levels and choose or not choose to make changes in clinical patterns to achieve greater efficiency and quality. 

Why doesn't the "insurer" here act to reduce transaction costs?  (I call it an "insurer" because it has essentially shed its risk-taking function.)  Maybe the answer is that, if the "insurer" always gets to keep a fixed percentage of the premium dollar for administrative costs, it might as well incur those costs.

Or maybe it's just some form of corporate paternalism, indicating the company's fundamental lack of trust and faith in the provider organizations.  If I had a choice where to put my trust, I know which I would choose.

Wednesday, March 18, 2015

Monitoring stress of patients in ICUs

Here's a link to an intriguing paper produced by Julia Somerdin, a participant in the MIT System Design and Management program.

She states the challenge:

A cost-effective, reliable, and real-time information system for monitoring the stress of patients in intensive care units (ICUs) is missing from current ICU systems. This presents an important opportunity because [among other things]:
  • ICU patients, often unable to report on their stress and pain levels, rely primarily on nurses' training and knowledge—yet, because nurses can visit patients only periodically, pain can only be assessed intermittently;
  • Pain and stress ratings are often subjective, even guesswork, and nurses treating the same patients often disagree with each other because of their varying levels of training and experience.
She offers an approach:

ICU Cam enables non-invasive monitoring of stress and pain using a remote smart camera mounted on top of a patient's bed. Its capabilities include:
  • remotely measuring stress during complex dexterity tasks, such as surgery; and
  • transfer of reliable real-time results to physicians via data visualization.
With these tools:

The embedded software system consists of four modules:
  1. Camera server-side data collection and processing
  2. Networking module for Wi-Fi transmission
  3. Client-side data receiver
  4. Graphical user interface that provides data regeneration and interpretation.
With these results:

During lab testing, ICU Cam measured heart rate and heart rate variability with over 96 percent accuracy. Additional benefits may include:
  • Early detection of pain to help doctors provide early relief to patients incapable of self-reporting;
  • Reduced length of ICU stay, resulting in substantial savings for hospitals and insurance companies; and
  • Increased ICU efficiency and reduced nurse workload.
I'm sure she'd like to know your reactions to all this!  Please comment here.

Monday, March 16, 2015

A video that should be required viewing in Colorado

Regular readers may have picked up on the fact that e-Patient Dave deBronkart and I are friends, dating back to our time as classmates at MIT.  He has a classic story from the 1960s that is familiar to his friends, but now it is available for the world to hear.

Go to this site and start the video at minute 11.

I love how he brings the story around to the them of his speech, letting patients help.  But I also just love the story.  It should be required viewing in Colorado as part of the marijuana education efforts there.

Sunday, March 15, 2015

An NHS GP asks, "How long do I continue to push my luck?"

David Shepherd has been a GP with the National Health Service for over two decades and also trains doctors in that profession.  He recently published this story:

I made a serious drug error last year. There, I said it - confession is good for the soul. Fortunately, no one was harmed but this was the first time in 23 years as a GP that I got it that badly wrong. The story is worth telling in detail as it contains important lessons for me, my practice and the wider NHS.

 In a nutshell I prescribed an antibiotic (No, that wasn't the sin – there was a genuine indication!) to a frail patient in a care home whose records unambiguously contained a correctly coded allergy to that drug. The drug was prescribed, dispensed and the full course given before the error came to light. Had the patient had a significant reaction, in his/her frail state, it could easily have caused death or hospital admission.

David has a thoughtful protocol he applies regularly: 

This has served me well for 23 years.

As we review the rest of the article, we come to see that the cause of the error appears to be being over-extended and tired: 

In August 2014 I experienced one of the busiest days I have known in general practice. I worked from 7:45am, foot continuously on the accelerator, until after 6:30pm with no break for coffee or lunch or tea. I probably managed to pass urine once. For the first time in 22 years I was unable to complete the work I needed to do that day before being late for our Partnership meeting that evening. It was a 13.5 hour day and I cycled home exhausted. I slept fitfully and woke early, my mind racing with the events of the previous day and thoughts for the coming one.

The fateful visit occurred later the same day, at the end of another full-on morning with no break and no lunch, with only a few minutes to get back to the surgery to lead the meeting. The patient, who I knew well, was acutely ill and needed a prescription. In my rush . . . I missed the drug allergy on my patient printout. I can’t remember whether I checked and just missed it or whether I just didn't check. 

I rushed back to people waiting for me and the meeting went well. Then with my mind buzzing I set about catching up with all the tasks and letters and path results that had come in that morning and afternoon and the work I had been unable to complete the previous day. I wrote up the visit. The computer warned me about the drug interaction but I flicked through ignoring it along with all the other non-clinically relevant warnings that come up.

The realization was delayed: 

A week later I was reviewing the patient’s notes for some reason and to my horror realised what had happened. I printed out the visit slip – yes the allergy was there. I tried re-issuing the drug – yes the computer did warn me. The really scary thing is that despite being a conscientious GP for 22 years, despite predicting that something like this would happen (though not to me!) and despite teaching safe prescribing habits to GP registrars for 15 years, I did not realise what was happening at the time. I was just overloaded and hitting me so I'm more careful in future isn't necessarily going to help.

As I have reported: 

Terry Fairbanks (Director of the National Center for Human Factors Engineering in Healthcare) notes that most errors are skill-based errors, or errors that occur when you are in automatic mode, doing tasks that you have done over and over--indeed tasks at which you are expert. 

He explains, "When you are in skills-based mode, you don't think about the task you are about to do. Signs don't work! Education and labeling don't work when you are in skills-based mode. Most medical errors are in the things we do every day."

Accordingly, vigilance and training are not the answer to skill-based errors. Neither is punishment:

"While discipline and punishment has a role when there is reckless behavior, applying discipline to skill-based errors will drive reporting underground and will kill improvement."


Being tired and stressed can be a contributing factor, as was the case here. And David uses this story to make a case for a more rational patient loads for NHS GPs:

Much is made of learning from the airline industry in making the NHS safer. However, NHSE, DoH and the government are not credible in this matter. The current contractual arrangements mean that there is no point beyond which a GP cannot be pushed and NHSE is quite intent to keep on pushing. This is in stark contrast to flight crew safety rules which "recognize the universality of factors that lead to fatigue in most individuals and regulates these factors to ensure that flight crew members in passenger operations do not accumulate dangerous amounts of fatigue.  Fatigue threatens aviation safety because it increases the risk of pilot error."

It is absurd that GPs are trusted to decide on the patient with chest pain in front of them and on commissioning for populations but are denied the ability to decide on a safe workload in their own practices.  

He concludes with a warning:

And if no solution is forthcoming, General Practice will have crossed, by NHSE’s action, from ‘if’ serious patient harm occurs to ‘when’ but it will be the GP who is hung out to dry. I find myself asking a question I never dreamt I’d ask, ‘Is it ethical to be a GP?’ Should I continue to work within this system, knowing there is a real chance of inadvertently harming a patient, when it deliberately and incompetently denies me the means to minimise that risk? 

So how long do I continue to push my luck?

Saturday, March 14, 2015

HemOnc.org offers value

Way back in 2012, I wrote about a wiki Peter Yang created to share clinical knowledge about his field. I was pleased to receive this update from him:

Thank you again for previously supporting our efforts at HemOnc.org to create a collaborative free hematology/oncology reference. We're excited that ASCO's Journal of Oncology Practice just published a manuscript we submitted about the website, which is still going strong and being regularly updated after over 3 years. 

That article notes:

From its inception in November 2011, HemOnc.org has grown rapidly and most recently has detailed information on 383 drugs and 1,298 distinct chemotherapy regimens (not counting variants) in 92 disease subtypes. There are regularly more than 2,000 visitors per week from the United States and international locations. A user evaluation demonstrated that users find the site useful, usable, and recommendable.  

Future enhancements, including more metadata about drugs and increasingly detailed efficacy and toxicity information, will continue to improve the value of the resource.


Congratulations to this team for a job well done and for their contributions to so many people around the world!