Saturday, January 31, 2004

Information Technology and Health Care – Still a Poor Fit

The first time I ever used an e-ticket kiosk was at the George Bush International Airport in Houston. I remember looking across the lobby at the long row of agents checking in passengers with regular tickets and realizing that whoever invented the e-ticket had in mind making those positions unnecessary.

It also occurred to me that the airlines were not simply automating their established routines. Instead, they were using computer technology to perform a function in a new and more efficient way that would be impossible without it.

All of that was brought to mind by the January 27, 2004 AHA News Now (the daily internet news bulletin of the American Hospital Association), which reported as follows:

“Speaking at the World Health Care Congress meeting in Washington, [HHS Secretary] Thompson estimated....that more than $100 billion could be saved by hospitals and other health care providers annually if investments were made in improving information technology in the health care field, noting such an investment also would improve quality of care and reduce the paperwork burden for hospitals.”

A lot of people have been saying something like that for a long time. Unfortunately, doing things in new ways is something the health care industry finds it extraordinarily difficult to do. The guild system that characterizes the health professions, combined with the culture of medicine (in which a 99 to 1 vote is said to be a tie) and the entrenched tradition of professional independence, makes it impractical to consider any computer-enabled innovation that would eliminate large blocks of patient care work or transfer major clinical functions from higher to lower paid staff.

Slowly, slowly that is changing, but it has a long way to go before Secretary Thompson’s vision stands much chance of being realized. In the meantime, health care providers are apt to just overlay computers on their established way of doing things. The result will be that most of the money that gets spent in doing so will end up in the coffers of consultants and IT companies and the cost of care will more likely be increased than decreased.

Thursday, January 29, 2004

Can Small be Beautiful in Health Care?

Dan Ford’s story elicited the following from longtime association executive Bill Robinson, now retired:

“Re the misfortunes of Mr. Dan Ford, I am caused to wonder if the quality of healthcare, respecting the scientific limits of its time, might have been better when hospitals were a cottage industry.

"Modern Healthcare" reports that Tenet is about to sell 27 hospitals (in one fell swoop). Whatever does this sort of transaction have to do with caring for individuals - and in other reports informs us about the perilous circumstances of one Scrushy - same question.

But then, I'm of the view that primary and secondary education were better when schools had to be within walking distance, rather than these enormous "central" schools with student populations in the hundreds or thousands.

With huge size comes the perspective of handling volumes of "widgets", rather than students or patients.”

There may well be more here than the rantings of a grumpy old man. The hospital in my hometown of Harlan, Iowa runs an average daily census of about 20. It also has a foundation that employs the local physicians, some 8 to 10 in number, operates an emergency room and satellite clinics, has a CAT scanner and a fully digital x-ray department, performs the clinical functions of the county health department, includes the local mental health program, and does other things. Although Medicare is its major source of income, and although its Medicare rates are lower than those in the big cities, it makes money. The local people swear by it.

There was a time when we thought we ought to get rid of all these places. Maybe we need to think again.

Wednesday, January 28, 2004

What to we mean by “Cost?”

The following just in from Don Shropshire, friend and colleague since the 1960’s and President Emeritus of the Tucson Medical Center.

“Do solutions come harder because of a foggy focus? Costs? - unit prices; aggregate public and/or private expenditures; volume by demand through individual choice, public policy, or ‘system’ traditions; third party premiums; ignorance - or what? Compared to what? Increases or decreases to whom? Is a solution starting point getting on the same wave length among the talkers and the talkees?”

Good questions.

When we say costs are too high, what do we mean? Who has a definition to suggest?

Wednesday, January 21, 2004

Connecting the Dots

During the past few weeks, the press has carried three stories relating to health care that have a relationship worth recognizing.

The first appeared late in 2003 and dealt with the provisions of the recently passed Medicare Prescription Drug legislation that attempt to reduce costs by creating competition between Medicare and private managed care plans. (See, for example, the New York Times of November 28.)

The second came out early in January of 2004. It quoted the US Department of Health and Human Services as reporting that health care spending in the US had risen by 9.3 percent in 2002, reaching the levels of $5,440 per person and 14.9% of Gross Domestic Product – up from 13.3 percent in 2000 and 14.1 percent in 2001. The closest comparable figure in the developed world was 10.9 percent in Switzerland in 2001. (New York Times, January 9.)

Then on January 14, 2004 the Institute of Medicine issued a report claiming that there are 18,000 unnecessary deaths each year due to lack of health insurance and urging that steps be taken to assure that all Americans, including the 43 million now uninsured, have health insurance coverage by the year 2010.

“Connecting the dots;” i.e., taking these three stories together, effectively summarizes the core of today’s central health care issue, which is that while costs are too high and we have too many uninsured, the effect of insuring everybody would be to pump vast amounts of new money into the system, thereby inflating costs even further.

So the first thing that needs to happen is to bring costs under control.

Of course, quality is an issue, too. But the Total Quality Management movement of the 1980’s taught us that effective management discipline has the result of both reducing cost and improving quality. Exercising that kind of discipline is what the provider system must learn to do. Other industries have done it and health care can do it, too.

Whether the strategy embodied in the new Medicare law is the way to make this happen is a legitimate subject for debate. But those who don’t think so need to either suggest improvements or come up with something better.

Saturday, January 03, 2004

The Real World of Medical Errors

The following comes from Dan Ford, healthcare executive recruiter and fellow University of Chicago Alum. It is longer than my usual posting, but it seemed worth it in order to make the point that health care is more than an industry, that medical errors are more than statistics, that malpractice is more than a financial problem, and that system redesign involves more than laws and organization charts.

The material is excerpted from a paper Dan has given to healthcare risk managers and others. Anyone interested in the full paper should feel free to request it by contacting Dan at


He would be more than happy to oblige.

Herewith Dan’s report:


In 1991 our family had a tragedy in a hospital. My wife went into the hospital for a routine hysterectomy. She had a respiratory arrest caused by a morphine overdose with consequences as described below.

Diane Ford's "case" involved four hospitalizations, including four surgeries: 1) a hysterectomy and a colostomy; 2) a colostomy reversal; 3) a kinked colon; and 4) a fistula repair; with much follow-up therapy and medications. She now has and will have permanent brain damage – specifically, a short-term memory loss – for the rest of her life. She was 47 years old when this happened.

The details: On May 1, 1991, she went into the hospital voluntarily, at the recommendation of her physician, for a routine hysterectomy, following lots of bleeding. During that surgery, her colon was cut, and so the first surgery was followed by a second – a colostomy.

Twelve hours later in her room, she over-dosed on morphine given to her through the PCA pump. A student nurse was walking by her room, and heard a noise from her room that she said sounded like an elephant snoring. The code team was called. It took over 20 minutes to intubate her. That time frame caused a respiratory arrest, which caused permanent brain damage, and specifically a short-term memory loss. Narcan was not available at the bedside, nor easily accessible at the nurses’ station, if there at all. We don’t know how or what happened – we don’t know if it was equipment malfunction, medication miscalculation or what. The IV tubing was thrown away immediately after the respiratory arrest, so we were told. We have never been given an explanation, beyond some early speculation.

The colon was reversed in surgery two months later, in July. A kinked colon and a five-day hospitalization – no surgery – followed about five weeks later, in August. She then discovered bowel in her vagina because of a fistula. This fistula was later determined to have been caused by stray staples from the colostomy reversal. It was repaired, three months later in November, as it was not healing on its own. A very delicate surgery.

When we left the hospital, the only person to give us some help was the colostomy nurse, who gave very good instructions. Not a single person in the hospital gave me a suggestion on how to deal with someone with a short-term memory loss. A psychiatrist met with her the day before she was dismissed from the hospital. Her style was gruff and intense, and Diane did not like her. I understood why. On the way home I remembered we had a large white board in our basement from our days in the Amway business. I put that in our bedroom, where she lived for many months. That was her short-term memory.

During the two months of wearing the colostomy bag, Diane basically had no idea of why she had the bag, how to clean, or how to change it – hard to do with a short-term memory loss. My sister, who lived in the area, and a neighbor, were very kind and helpful, as were many, many other people outside of the hospital.

Every contact I made with area rehabilitation hospitals and therapists was initiated following my own research. Her original admitting physician simply did nothing, beyond the psychiatrist referral, even though I asked for help. I am not sure he ever picked up the phone to solicit counsel or referrals from anyone.

Her short-term memory loss is permanent. It did improve very slightly in the early stages.

In mid and late 1991, when I stopped feeling like a deer caught in the headlights, and had some things under minimum control with Diane and our children – teenagers at the time – and with my consulting work, I started asking pointed questions. Lots of why’s. At first we received nice and polite responses.

Things changed when I started asking more questions, and defenses went up. We were then turned over to a senior risk manager. It became very awkward. There were well-intentioned efforts to explain things, but the attitude was one of superiority. In simplistic terms it felt like: “We know best. Sorry your wife has brain damage. It happens.” I asked for and received a copy of the medical record. I asked for committee reports. That was denied. I knew it would be, but wanted to go on record as making the request.

We dealt mostly with one man who was in charge. There were two other family members on his staff. That seemed to me like an Interesting and questionable management philosophy and structure back then. When I think about it now, from my search consultant perspective, the hair on the back of my neck simply stands up. Where is the objectivity, the accountability, and the sense of responsibility?

The attitude of the risk manager was a mixture of gruffness, arrogance, condescension, insensitivity, antagonism, confrontation, lack of empathy, dismissive, and (I believe) occasional obfuscation. I initiated every conversation and meeting that we had. It was a constant feeling of being pushed into a black hole, of wishing we would go away. This risk manager told me frequently that his role was to save the hospital money, that his was not a philanthropic organization. In hindsight, I think he was carrying out his job as instructed, and to the best of his abilities, and personality.

I shared a story with him to try to get his attention. I told him that if I, hypothetically, as his neighbor, had backed into his car when backing out of my garage, that I had a responsibility to go over to his home, knock on his door, explain and apologize for what I had done, and take responsibility for making it right. I told him that no one ever did that.

His only response was that a hospital was much more complex than that. I responded that indeed it was, but the basic human principle was being ignored. He never responded or acknowledged. It was constant arguments and confrontations with him. He seemed to delight in that.

I also requested the involvement of the COO, who oversaw the hospital operations. He chose to never involve himself. One meeting he was supposed to be there, he did not show up. A message was delivered through the risk manager that he could handle it.

In 1991 Diane was a homemaker, a vibrant woman, and a mother of three children, Sarah 11, Jonathan 14, and Chris 17. She was active in our church – committees, choir, and educational involvement. She was attending McCormick Seminary as a part time student. She already had a masters degree in education, and was pursuing her second masters degree – in theology – when the respiratory event happened. Her life was full. She was a very bright, alert, loving, competent and responsible parent and wife, and friend of many. She loved to learn. She was a strong person, independent, by personality.

Today Diane lives is in an assisted living facility in Grand Rapids, Michigan, not far from Chris and Heidi, our son and his wife. Chris, now 30, was recently named her legal Conservator by a court here in Nashville, Tennessee, where Diane had been in an assisted-living facility in Franklin. Her brother and sister-in-law had been taking care of her financial and other responsibilities for three years. That ended because of her personality changes and perceptions of how things were being handled, which in her in mind are reality, thus causing frequent disagreements, and she not remembering from argument to argument. Prior to that, she had been in our home, and then a condo in the Chicago area.

Our marriage dissolved in the mid 90's. I literally ran out of give after three years of taking care of her needs, having watched her personality change enormously, and having a significant impact on those around her. For a year I talked with her about my feelings, not easy when she could not remember conversations from the day before.

My Christian vows are and were important, and I never thought this would happen. It did. I simply could not be the Old Testament Job. I care a great deal about her, and much of what I am doing relates to that. I am attempting to cause positive change so others are not treated and handled like she was, and like we were.

In the spring of 1993, after many months of attempting constructive dialogue with the hospital risk management, administration and the physicians involved, Diane and I decided to pursue a medical malpractice lawsuit. She could follow somewhat, but basically could not keep up with what was going on. All she knew was she was terribly wronged, and her life was turned upside down, to a very poor quality of life. I had told them early on I was not lawsuit-oriented, but to not under-estimate me.

In the final meeting we had with risk management, we were offered $100,000. We turned the offer down on the spot, with some pretty harsh words from me. It was an insult. The settlement offer was doubled a couple of months after initiating the lawsuit. That was declined, as well. This woman’s love of learning was destroyed. She has no ability to make a living. Her self-esteem was shattered. Her life changed terribly, and she needs to rely on others for support.

For 9 years the lawsuit meandered on, taking twists and turns. We settled last fall for a very nominal amount. Diane and her brother basically quit the lawsuit in early 2002. She could no longer emotionally handle the continued re-visiting of what had happened – to her brain, to her life, to her family, to her marriage, and to her future – and, to re-visit it with people she had likely grown to despise, because she had been treated so shabbily.

The final lawsuit settlement has a gag order on the dollar amount, interestingly enough. I cannot imagine why, but I shall respect that. When you go through a lawsuit, experiencing such awful emotions, you are expected to behave with reason and to act responsibly. A real tug and pull, believe me!

The defense attorneys played it textbook and classic – i.e., if you have a brain damaged patient, which on its own causes much dysfunctional life changes, and can cause the case to go on long enough, you may eventually wear us down, and we go away. They were right. They won. It was legal --- but not right, nor fair, nor did it fit the spirit of medicine. The hospital and doctors’ attorneys clearly used her brain damage and her resulting life changes as a lawsuit strategy. It happened on their watch, on their turf, under their responsibility.

This past September, I met with that same hospital’s risk management group, with today’s leadership. The former leadership is gone. Some in attendance were on the staff then and remembered the "case." I had initiated the meeting following a conversation last February with a professional friend, who is involved with the organization.

I was very candid about the last 12 years – in a constructive way – not intending to put anyone down, but being honest with my observations, facts and opinions. I told them about the last 12 years. They were surprised by the behavior, said many changes had been passed on to a number of hospitals affiliated with that hospital, as a result of that particular situation. One person apologized for the way we had been treated.

I was pleased and told them that. I also stated that it caused me some sadness, selfishly, and for Diane, and gave me a bit of a hollow feeling, because during that whole time we continued to be treated the way I describe in this presentation. I cannot yet put a label or handle on summarizing my emotions. The apparent tension, rather than blending, of the handling of the clinical and of the human side, keep coming to mind.

I did say it smacked of a double standard that, if things were that bad so as to cause so much change in multiple hospitals' procedures and guidelines, why not acknowledge to the patient, or victim, and basically "fess up."

Following that recent meeting with the risk management group, I wrote back an email – as I did not think of it at the time of the meeting – suggesting that, since I had received an apology for the way our family was handled, I thought it was more important to send an apology to Diane. I have not yet received a response. To my knowledge, it has not happened. I hope it will.

This recent meeting was the first positive interaction I had with the hospital representatives in 12 years. Again, I had initiated it.

1) I encourage you all to do the RIGHT THING, whatever that is, in a given situation. That is a term used frequently. It can never be over-used. You all know what is right, even if you receive different direction and counsel from your hospital senior leadership, insurance companies and legal counsel. Doing the right thing is a crucial cornerstone of life, including the handling of death and injury vignettes in hospitals. Hurting patients, and hurting caregivers and families, are not interested in hearing that your job is to protect the assets of the organization, or to save money. You are in a position to cause justice to happen. Do it!

2) The right thing for hospitals, doctors and other providers, to do is to TAKE RESPONSIBILITY FOR THEIR ACTIONS, as awkward as it might be. I encourage the involvement of the hospital CEO/COO whenever possible, so as to indicate the sincerity/genuineness involved, and to make "as right" as possible. Put your own ego’s aside, and do what it takes. I realize, of course, that a brain cannot be replaced. But, genuine efforts have to be made and the right messages sent.

3) I would suggest there is an ACCOUNTABILITY by providers to patients – plain and simple. To patients. Nothing terribly complicated.

4) TELL THE TRUTH. A year ago, I participated in a seminar of the joint fellowship programs of the Healthier Communities Fellowship and the Patient Safety Fellowship, of the Health Care Forum of AHA. We heard a speaker, Bill Grace, of the Center for Ethical Leadership, in Seattle, talk about two key leadership characteristics: 1) To tell the truth, and 2) To create hope. That has to start at the top of your hospital, with the board and your CEO. I encourage you to nudge and to cause that to also happen, if it is not happening.

5) REMOVE THE BARRIERS to constructive dialogue. Being defensive is human, but please work at being constructive.

6) Understand THE DEER IN THE HEADLIGHTS SYNDROME. You may have to have several meetings with patients and families, and to be sensitive to the timing. They may not really hear you the first time, or the second time. I have also grown to be more sensitive to the “deer in the headlights syndrome” that providers go through when experiencing a sentinel event.

7) Don’t ever forget THE HUMAN SIDE. I realize our experience is only one among thousands of such death and injury situations. My impression is that genuine efforts are being made to deal with the clinical piece. Please don’t forget there are human beings involved, with human needs. Cold and unfeeling attitudes will only build barriers. We always need to remember the dignity of human beings.

8) VALUES STATEMENT SHOULD INCLUDE ADVERSE OUTCOMES. When things run amok in a hospital, it is not a surprise. Bad things are going to happen. I would suggest that a hospital’s value statement adopt something like the following and that it not be a platitude: “To maintain honesty, integrity and accountability in our relationships with our patients, even in the face of adverse outcomes.” I invite and challenge you to encourage your own organization’s leadership to do this.

9) DEBRIEFING TEAM. Involve the patient and the family in your committees’ debriefings. Do away with the “CYA” attitude, and culture, if that exists.

10) Lastly, I would suggest you be PEACEMAKERS. I am in a small group Bible study in my church. A recent study of James 3: 13-18 really hit home. My faith is important to me. I don’t wish to offend anyone by referencing the Bible. It does have some pretty good guidelines for living.

Verses 17 and 18 of James 3 read as follows: “But the wisdom that comes from heaven is first of all pure; then peace-loving, considerate, submissive, full of mercy and good fruit, impartial and sincere. Peacemakers who sow in peace raise a harvest of righteousness.” I encourage and challenge you all to be PEACEMAKERS.

October and November, 2003

Building Barriers to Immunizing Children

The January 2, 2004 issue of the Harlan [Iowa] News-Advertiser carried an article announcing an immunization clinic for children to be held the following week in the county’s Home and Public Health Office, which is operated by the local hospital.

The following paragraph appeared in the middle of the article:

“The Iowa Department of Public Health, Bureau of Immunization is in charge of the vaccination program in the State of Iowa. Federal requirements and funding limits who is eligible to receive vaccinations through Public Health Clinics. Children without medical insurance may receive immunizations through this clinic. Children covered by hawk-i insurance are not eligible to receive immunizations through the Public Health Clinic and need to receive immunizations at a private clinic. Children covered by private health insurance that does not cover any of the vaccine cost may be served at this clinic. Children with health insurance that covers all or part of the vaccine cost need to receive immunizations through a private clinic. Children with Medicaid coverage may be served through the Public Health Immunization Clinics. There is no charge for immunizations, but donations are welcome.”

As it happens, Mrs. Wittrup and I received our flu vaccinations in Harlan last fall. They were given by the same hospital; i.e., the one that operates the county’s Home and Public Health Office. We went to the location announced in the newspaper, gave the clinic our Medicare number, got our shots, and that was that.

And we wonder why so many kids don’t get properly immunized.

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