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October 17, 2011

Washington Hospitals Sue Over Cruel and Unusual Medicaid ED Visit Limits

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I’ve heard of some draconian budget-cutting measures, but the following, proposed by officials in Washington state, just about takes the cake. Good to see that the state’s hospitals, along with its doctors, are rightfully attempting to slam the door shut onMedicaid planners’ obscene antics.

A new state plan in Washington proposes to limit payment for Medicaid patients’ emergency department visits, on the extremely dubious assumption that such patients can self-diagnose whether they ought to be there in the first place. Not only is this program unlikely to save any real money (unless you count the money saved by not having to care for dead beneficiaries), it assumes that emergency department staffers are adding useless layers of expertise so often that their services should be choked back dramatically. The truth is, there’s boatloads of evidence that the poor aren’t the biggest users of ED services for non-emergent conditions, but I suppose these state penny-pinches wouldn’t be bothered by the facts.

Get this. The state’s Medicaid folks want to cover only three “non-emergency” visits per year — enough of a disincentive to prevent people from going in the first place — but it doesn’t end there. The plan would classify more than  700 diagnoses as “non-emergent,” including (wait for it) chest pain, abdominal pain and breathing problems.  So, I take it that pregnant women, infants, children, the disabled and the mentally ill are supposed to decide with a home thermometer and a bit of prayer whether they’re actually in danger?

According to the folks suing the state, which include the state medical association, hospital association and chapter of the American College of Emergency Physicians, this program not only endangers patients, but also has thrown a cloud of smoke around payment issues. Specifically, the plaintiffs argue that the state is threatening patients that they’ll be billed directly, while EMTALA and state charity care laws prohibit patient billing.

Folks, if I were a hospital executive, I’d be suing to avoid legal and political messes that will arise here, sure. But I’d be sick to my gut about what such rules would mean to real people, too. I truly hope that’s what the suing hospitals have in mind.


June 4, 2011

Hospital EMR actually works

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As some of you may know — if you read the blog — I recently had an experience which set a fine example as to how much health IT can help hospitals when deployed well and supported by smart training. In short, a family member just had an effective, focused trip through a hugely busy ED, largely due, I believe to the technology it uses.

The hospital has deployed the Picis electronic document management system, along, seemingly, with traffic control modules, to strip much of the fat away from a patient’s trip through the ED.

With staff clicking away happily, patients moving in and out promptly and physicians having easy access to patient histories, med lists test results and more in one easy-to-access place, I saw a pretty neat ballet in place.

The truth is, however, that this seems to be an exception rather than the rule. Far more  hospitals I’ve visited seem to have taken a heavy-handed, training-light approach to introducing their EMR.  (One facility had installed screensavers on staff desktops that read “Cerner is coming.” I can’t imagine this gave any employees a big thrill, or helped them get prepared.)

Actually, when I passed through the same facility later, I saw flustered-looking nurses trying desperately to get simple transactions done, forming an insecure cluster together as they tried to help a colleague enter some observations. Thaaaat didn’t give me a nice, secure feeling about the hospital’s odds of making clinical mistakes.

I hate to say this, but I think the odds of a hospital IT department changing its culture enough to truly support EMR users is pretty darned small. My guess is that it will take several years before hospitals have a clue as to how to handle the big, huge change management process their EMR produces. Good luck, guys.



April 28, 2011

There’s no good excuse for stifling physician-owned hospitals

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When health reform was passed, part of the law forbid physician-owned hospitals from expanding or undertaking new construction.  The rules affected roughly 300 hospitals in 34 states, offering services ranging from acute care, women’s, rehabilitation and psychiatric care.

You won’t be surprised to hear that the trade group representing such hospitals, Physician Hospitals of America, continues to fight for removal of this restriction, found in section 6001 of the Patient Protection and Affordable Care Act.

I’ve got to say I’m with the PHA on this one. Why on earth must we block the development of physician-owned hospitals?  Yes, there have been a couple of horror stories where specialty physician-owned hospitals –lacking an emergency department — failed to address patient needs.

But from where I sit, those stories are no more common, proportionately, than they are amongst traditional acute care hospitals. Besides, if the main concern legislators had was emergency department care, they could have mandated that all physician-owned facilities have one.

No, it’s clear that physician-owned hospitals make traditionally-structured facilities nervous, and that they’ve worked hard to put them in their place.  Other than protecting the profit stream for themselves, however, I don’t think they have a leg to stand on.




April 18, 2011

Google takes over hospital industry, CMS in private leveraged buyout

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Read the headline?  Those are things that just aren’t going to happen, right?

Well, I’m pretty sure the things that we can expect for the next few years will end up looking just about that strange when we read about them a decade later.

My personal faves are a) Accountable care organizations dominate U.S. healthcare system, b) Most hospitals are connected to doctors via EMR and c)  Emergency departments no longer swamped with uninsured patients.

Anyone else want to volunteer “future headlines” — stuff that might come true but seems impossible at the moment? Or stuff that should happen but just can’t?  Sarcastic or serious, your choice.

So, you got your crystal ball out?  I’ll publish all of your predictions, crazy or not. 🙂


December 13, 2010

Bigger, better, faster hospitals are a great idea

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Nagoya City University Hospital in Kawasumi

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The other day, I read a tweet from the estimable Matthew Holt in which he summarized what hospitals have been telling him.  In short, they seem to want bigger, badder, newer facilities.  In fact, if I recall correctly, they feel they’re in deep mud if they don’t get these  upgrades and/or new facilities soon.

OK, usually I take such statements with a grain or two of salt. After all, who  — in any industry — doesn’t want the latest and greatest, from the toys we squabble over on up into adulthood?  But in this case, I think we should be taking Holt’s feedback quite seriously.

After all, despite the fact that I’m not an architect, hospital CEO, designer  or any variation on same, I can immediately think of a few very important reasons for a massive buildout of hospitals to improve care and meet today’s process standards:

*  Shared rooms are right out.  There are already a fair number of hospitals (no stats to hand but this IS happening) who are converting all shared rooms to single rooms within their facility.  Their main rationale is infection control, but I think they’re also hoping to streamline the care process by allowing nurses to think rationally, about one patient a time.

*  Older physical plants are a huge liability. When you’ve got a house full of sick people, the last thing you want is a drip from that 20 year old pipe, asbestos to remediate, mold in ancient ducts and so on.  While maintenance will be an issue for any facility, we’ve learned a lot since the first wave of current hospitals were built. Let’s get rid of ’em ASAP.

*  If you’ve ever owned a house from the 70s (and I have) you know that they leak air conditioning and heat out at a ferocious rate.  Sure, you can weatherstrip and insulate and hang curtains to seal out air from the windows, but eventually, it starts to cost so much that it’s a big waste.  A new place — or hospital — is much cheaper over the long run.

*  And while they’re at it, hospitals newly-designed hospitals can be planned with green energy usage in mind — a trick which might not work out in a clumsy plant from decades a ago.  That not only helps to save the earth, it can save big bucks too.  Again, I don’t have a case study handy but Google “green hospitals” and  you’ll find some heartening stories.

* Oh, and I almost forgot…old hospitals can be a nightmare for techs to work around.  Whether you’re talking about simply making sure Wi-Fi gets to every corner of the building or rolling out an EMR, nobody needs to live with design flaws from the 60s.

So, though I’m surprised to say it, it seems to me that bigger, better, faster hospitals are indeed what the doctor ordered.  We’re not talking self-glorifying projects approved by boards to prove they’ve got the juice to make it happen, we’re talking simply about getting with the times.   Let’s hope plenty of hospitals find the means to do so.


November 21, 2010

Would you feel safe in this ugly lobby?

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A patient having his blood pressure taken by a...

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Folks, I’ll never forget that night.  Led gently by my worried husband, who was a bit concerned about my ability to keep breathing, I walked into the lobby of a mid-sized, plain-vanilla 100-odd bed community hospital in my neighborhood.

I already knew, from phone calls to my PCP, that I probably had pneumonia. And I knew that while I probably didn’t need an admission, I definitely needed a hand.  My temp was 104, my cough was in the Black Plague range  and I could barely walk.

So, then medical reality collided with nice, warm, compassionate medical theory.  The details aren’t important — basically, since the ED staff had nowhere appropriate to put me while I waited, and demanded I wear a mask I simply could not tolerate  — I ended up sitting on the floor inside the glass box between the outside and inside doors to the facility.  At least the cold from the winter night kept my temp down a bit.

I’m sorry, but I absolutely cannot fathom why even a not-so-rich community hospital can’t do more to make very, very uncomfortable and scared people feel safe when they enter an ED door.

Why are hospitals spending SO much energy advertising their abbreviated ED wait times?  Customer service, right? Well, guys, I can assure you that it makes more sense to start with EDs that aren’t a nightmare to visit. Get people through quickly? Sure. But for the time they’re in the lobby, much less in case, make that time welcoming and safe.

Yes, I realize not every hospital will spend enough to put Pottery Barn-style couches and deluxe coffee and tea service out there, but what bothers me is that comfort doesn’t seem to be anyone’s aspiration when patients arrive.

The nursing staff in the emergency departments I’ve visited are largely abrupt and impatient, refusing to make the slightest human connection with patients.  The lobbies themselves stack uncomfortable institutional chairs and horrible lighting on top of one another in a graceless manner which rivals sitting in the New York City subway at 2AM.  And if you want food or drink you often have to go on a hunting expedition you’re in no position to conduct.

My take? This is not acceptable. No. Not for a second.  I don’t want to hear any excuses about it.

If your hospital can’t afford high-toned decor, maybe get a volunteer to serve as a concierge to help make people comfortable. Rent a goddamned cot or two for patients who aren’t dying but feel like they want to.  Provide some hot liquids, for Christ’s sake — it’s not going tap out the budget for a mid-sized community hospital.  Remind your front-desk nurses that people are in pain, and base part of their pay on the reports you get from patients.

You know, evidence is piling up that patient satisfaction correlates pretty strongly with profit.  If compassion and common sense aren’t enough to convince the hold outs that it’s time for them to make their front door inviting, I guess nothing will.


So many blank spots on the clinical data map!

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Emergency medical technicians evacuating an in...

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EMTs collect a lot of data on their trip to the emergency department — and usually, data treating ED physicians will want pretty badly when they see the patient. But in virtually every case, most of that critical info transfer takes place on paper or in a hurried conversation amidst much noise and distraction.

Community medical centers collect as much data on patients as private primary care practices do,  but how often are they connected with hospitals — even those that have done a big ambulatory EMR rollout?

And what about blood banks?   Independent clinical labs like LabCorp.?  School medical offices?  Is anyone paying attention to their data, or is it just being ignored?

Look, I don’t mean to be a dunce here. It’s not as though hospitals and medical practices are sitting around buffing their nails and waiting for something to happen, data-connection wise.

But it’s worth remembering, despite the labor involved in hooking up hospitals and primary care practices, that there are data leakage everywhere.  Until we look the flow of data more wholistically, whole workflows will be designed as though such relationships didn’t even exist — and that’s a Bad Thing.

I say, start with the EMT data, as it’s the closest to the point of care, but regardless of how you expand your clinical data source map, expand it. Otherwise, you’ll be left with a nasty information design problem and finding a workaround will be a nighmare.  Think about it.

(This editorial’s content draws on a speech given by Vivian Funkhouser of  Motorola at a trade show held last week by Everything Channel.)

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July 9, 2010

Passing the buck, or, why PCPs *are* the problem

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Look, let me say up front that I’m very sympathetic to primary care practices.  I mean, truly.  My family is lucky enough to have access to a small, intimate primary care practice, and I kid you not, I love those folks.

All that being said, I just had an experience which tells me that changing PCP business models are creating a very, very large problem.

What of my experience?  Well, in theory, it was no big deal.  I called in after hours to ask about a family medical problem which worried me, and asked for a bit of guidance.   I was just concerned enough about a family member’s health to see a bit of extra help.

The response I got was another matter. Rather than asking why I had called after regular practice hours, and what my concerns were, the clinician taking call said (more or less verbatim): “Well, I didn’t see (Jill) yesterday when you brought her in, so I have no idea what’s going on with her. Take her to the ED if you want, but I can’t help you.”  I was silent for a bit, shocked by her rudeness (she’s usually very helpful), then said “If that’s what you think” and hung up.

Because I know enough to avoid the ED whenever possible, I held off, and things turned out fine. But this encounter raised a few questions which trouble me deeply:

*  Let me get this straight: Are patients supposed to go to the ED first these days so as not to inconvenience their PCP?

*  If they do contact an on-call PCP, should they be afraid that their call will be “unsuitable” or not worth addressing?

*  Has the whole notion of taking call deteriorated so much that PCPs covering the night shift will only talk to patients they’ve seen recently?  If so, they’re nudging many, many patients to the ED who might otherwise just need a word or two.

For many years, the ED was the pressure point in the whole health system, with ED administrators secretly hoping to avoid uninsured GOMER (Get out of My Emergency Room) patients. (Yes, not very sensitive terminology.)

Now, the problem seems DCAHs (Don’t Call After Hours).  Greviously-stressed care practices just aren’t prepared to absorb the costs of after-hours care or even telephone advice, and it’s throwing the system out of balance in a new way.

As things stand, the exploding primary care clinician shortage just keeps getting worse and the need for patients to have medical homes is climbing. Pile these issues on top of the already overloaded primary care business — in which margins are so bad that practices are adding day spas, for heaven’s sake — and you’ve got real trouble.

Ultimately, I think all of these problems are going to be resolved, and I’m very clear that PCP practices want to help. In the mean time, someone’s going to have to do a better job of fielding the 5PM to 9AM gap in care.  Telemedicine, urgent care centers and retail clinics are making a dent, but they can only make a dent in the problem.   This is a very big deal, and it’s only going to get bigger.


June 22, 2010

Broadcasting ED wait times: Smart or risky?

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     Today, I write to y’all from the lovely city of Richmond, VA,  a lovely colonial-era town which blends striking 18th-century row homes with dazzling modern palaces of light and tinted glass. Among those businesses with a shining presence in downtown Richmond are a handful of established hospitals, and they play to the modern city-dweller.

Several HCA hospitals, including those in in Richmond, have put the latest hospital marketing tool into place — a service which lets patients know how long the wait time will be if they visit the facility’s emergency department.  This is happening elsewhere in the country, too, and my read is that it’s likely to pop up more often.

HCA hospitals provide the “door-to-provider” time, or the time from the patient’s arrival to the time he or she is seen by a doctor, physician’s assistant or nurse practitioner. Cell phone users can use the system by texting “ER” to 23000.  Other facilities have developed iPhone applications allowing patients to get a read on ED conditions.

This “check your wait time” thing sounds good to me, when I think like a patient at least. But I also see some serious downsides to this practice: 1)  It encourages people to think of the ED as a primary care setting, where timeliness is key, 2) it could encourage inappropriate behavior.  

Also, isn’t it possible that stressing brief wait times will expectations that emergency care can operate like a dry cleaner or a McDonald’s? 

Bottom line: I like creative marketing as much as the next guy, but this doesn’t feel right. Maybe I’m just too cynical. What do you think?

June 13, 2010

Video: Violence at an NYC hospital

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 Knowing hospital violence is getting worse may be discomfiting — but it’s easy to say “that only happens to other facilities.”  So here’s a more visceral way to take in the message.

In this video, a local television station offers a report on the escalating violence faced by New York City’s St. Barnabas Hospital.

Sure,  St. Barnabas is an urban hospital in the Bronx. And maybe the crime rate in its catchment area is higher than, say, a cushy suburban neighborhood.  But violent people are everywhere.

So, here way have another reminder to take action. What can hospitals do, today, to keep their facilities safe?