Health Business Blog

Dennis Pointer, a governance expert and professor at the School of Public Health and Community Medicine at the University of Washington, has authored a helpful e-book for directors of non-profit health care organizations. You can download the 43-page document for free.

Navigating the Boardroom, 40 Maxims… Things You Must Know and Do to Be a Great Director is organized in a simple format. Each maxim is stated in a few words, e.g., “Understand board topography” and then explained with a few paragraphs, anecdotes and the occasional illustration. At the end of each maxim is a set of bullet-pointed “directorship keys,” with the practical implications of the maxims for board members.

I read the book and it’s a lot more practical and specific than others I’ve read recently. (In particular I suggest avoiding Good Governance for Nonprofits, which dedicates essentially all of its 200+ pages to advocating that boards develop a Board Policies Manual. The Nonprofit Board Answer Book from BoardSource is better.)

We interact with many non-profit and for-profit health care boards in our consulting practice and I also serve on some, so I found myself looking at the maxims from a few perspectives.

In general the advice is quite conservative, as the author acknowledges. Pointer goes beyond the usual warnings about avoiding conflicts of interest to add some related points:

• #33 Don’t engage in personal financial dealings with other directors or executives
• #34 Never do non-governance work for the organization
• #35 Keep your personal relationship with the CEO at arms-length
• #36 Provide the CEO with advice and counsel, but be careful

He includes some sound advice that other good governance consultants usually include but that I frequently see ignored:

• #14 Don’t represent narrow interests or constituencies. (He could have added that boards should avoid tokenism, e.g., it’s not a good idead to appoint a “young member” to the board and then expect him or her to act as the representative for all young people.)
• #19 If you’re the board chair, learn how to run effective and efficient meetings
• #32 Argue in the board room, lock arms when you leave it

And he also has some good maxims that I haven’t seen expressed so explicitly elsewhere

• #10 Serve your apprenticeship, but do so quickly
• #18 Develop (or enhance) your healthcare organization-specific financial literacy
• #30 Don’t make individual requests of the CEO and executive team members

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Check out Diabetes Mine, where the 2nd Annual DiabetesMine Design Challenge is getting underway. A year ago, blogger Amy Tenderich posted an Open Letter to Steve Jobs asking him to apply the consumer design genius that brought us the iPod, Mac and iPhone to the fertile area of diabetes devices. That letter sparked a variety of conversations, ideas, and publicity.

This year Amy decided to formalize the process into a competition, and in doing so she’s taken things up several notches:

• She has enlisted MedGadget as co-host, and attracted support from IDEO and Cory and Justin Oringer
• There are cash prizes and other inducements
• The entries are to be submitted to the DiabetesMine channel on YouTube and follow a set of guidelines

Entries will be judged on three criteria:

• Efficiency
• Clinical efficacy
• Aesthetics

The deadline is May 26, so get started!

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Physicians and nurses in a Delaware command center will monitor intensive care unit (ICU) patients in six Maryland hospitals as part of the Maryland eCare initiative. From the Washington Post:

The program, funded with a $3 million grant, “allows us to provide the same high level of care at 2 in the morning as we provide at 2 in the afternoon,” said Maryland eCare Director Marc T. Zubrow, director of critical care medicine at Wilmington’s Christiana Care Health System, where the critical care doctors will be based. “It’s about crisis prevention rather than crisis response.”

A video camera and computer terminal positioned in a patient’s room will send vital signs, test results and information about patient responsiveness to Wilmington, where a doctor and several nurses will view the data and photographs on high-resolution computer monitors.

If command center staff members see the patient’s health deteriorating, they can communicate with nurses to provide medicine or additional tests…

The technology, known as eICU, was developed by Baltimore-based Visicu, a medical technology company, and is used in about 200 hospitals throughout the country.

This initiative is interesting in its own right, because it’s extending the telemedicine concept beyond its typical bounds. However, the implications are potentially quite profound:

• If people are comfortable with the idea of monitoring ICU patients from 50 or 100 miles away, they should be equally comfortable with a distance of 5000 or 10,000 miles. The communications links are just as good to Asia as they are to Delaware, so why not have doctors and nurses there monitoring the ICU? Actually, it could be better. When it’s 2 am in Maryland (and Delaware) it’s 2 pm in Singapore and Manila, when people are wide awake. What’s more, labor costs are a lot lower. At this point the barriers are more regulatory in nature than anything else.
• The concept could and should be extended to the emergency department as well. We increasingly hear that specialists, such as neurologists, are refusing to take call in emergency departments. With modern communications technology much of what a neurologist does could be done remotely. At a minimum it could cut down on the number of in-person staff needed.
• Younger physicians are increasingly seeking to limit their total number of hours at work. (The Wall Street Journal wrote about it today.) That’s a change from the medicine-is-everything attitude of earlier generations and it’s exacerbating the shortage of staff. On average, female physicians want to work fewer hours than men, especially those that want to have kids. Perhaps there’s an opportunity to tap into some underutilized resources by providing telemedicine work for stay-at-home moms and dads.

Radiology has paved the way with the “nighthawk” concept, and while there are definite advantages to in-person care, more specialties than one might initially expect can conduct at least some of their patient care activities remotely.

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The Global Healthcare Investing Conference opens in Cleveland tomorrow, April 30. The Cleveland Plain Dealer will liveblog seminars, post audio of interviews with investors and entrepreneurs, and publish breaking news during the two-day conference. Tune in if you have the chance.

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Check out Grand Rounds at Doc Gurley. This one is a special Grand Rounds Smack Down edition that is not to be missed.

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I’m quoted in the latest edition of Dubai’s Medical Times, Middle East, about the rise of the Internet as a force in medical tourism. See Casting Your Net.

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Last week I posted about Aimee, a web-based tool that allows patients and physicians to understand the radiation exposure they’re receiving from various medical scans. The site also suggests alternative scans that may be more appropriate (and less expensive) in specific situations. I also interviewed the CEO of SafeMed, a company whose real-time clinical decision support software provides patient-specific guidance on imaging and other tests at the point-of-care.

A MedPage Today article provides a reminder of why such tools are so important. See Physician Self-Referring Linked to Spike in Imaging Use.

Physician self-referral for CT, MRI, and PET scans accounts for much of the large recent increase in overall usage of these technologies in California, said a researcher here.

Overall utilization of MRI scans in California increased by about half from 2000 to 2004, but scans performed by physicians who billed for the procedures themselves rose as much as 374% among some patient groups, reported Jean M. Mitchell, Ph.D., of Georgetown University in the May issue of Medical Care…

Dr. Mitchell said the most likely explanation for the dramatic increases in self-referred imaging was financial.

“For many cases, use of an advanced imaging procedure in lieu of a less expensive diagnostic procedure results in higher revenues (profits) to the provider without any commensurate improvements in outcomes or quality,” she wrote.

The AuntMinnie article I cited listed a variety of criticisms and quibbles from physicians about Aimee, one of which was that the tool is provided by a cost containment company that has a financial interest in imaging utilization. It’s a bit like the pot calling the kettle black.

I expect that all of this will evolve to a model where providers deploy SafeMed and similar tools, which contain protocols and decision rules that both providers and payers can accept. That will reduce the friction between payers and physicians while improving outcomes and safety for patients and lowering costs along the way. That era can’t arrive too soon as far as I’m concerned.

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RNCentral has compiled a list of 25 tips to help protect yourself from medical errors. My personal favorites are:

• #2 Ask questions –you need to know what’s going on
• #4 Don’t forget the details –small details can matter, and your caregiver should be interested
• #16 More isn’t always better –the context here is surgery, but I would expand the scope of this advice
• #22 Follow up on your test results –don’t assume no news is good news
• #25 Ask a family member or friend to be there –I recommend a doctor if possible

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SoftwareAdvice.com has posted 5 Ways Physicians Can Profit from Using an EMR. The list is pretty good:

1. Stop paying staff to manage paper –imagine being able to find information as easily as you can do on Google
2. Reduce malpractice premiums –improved documentation helps the defense at trials and can also improve follow-up with patients
3. Stop downcoding and submit claims with confidence –although it’s important to make sure what gets put into the EHR is truthful
4. Participate in pay-for-performance programs –which are much more feasible with electronic records
5. Get your EMR purchase subsidized –your local hospital may be willing to foot the bill: up to 85 percent

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Patients turn to Internet for medical solutions in Africa Business Daily covers ground that is familiar to US readers:

• Patients are increasingly using the Internet to research medical conditions
• Physicians view this behavior as a mixed blessing: on the one hand some patients are better informed, on the other hand patients may come in with a lot of misinformation that the physician has to spend time correcting
• Some physicians are spending more time keeping up to date because patients who come in are better informed than they are
• Face time with physicians is only about 10 minutes per visit

The article is about patients in Kenya; one has to assume that these patients are middle class. Still, it points out an important truth: as long as people have uncensored Internet access (and understand written English) they can use all the sites that an American or other rich country resident can. Sure, not all the information is relevant, but much of it is.

There’s a chronic shortage of medical personnel in Africa and it’s not going to get a lot better anytime soon. On the other hand, access to the Internet is growing fast: partly through laptop and desktop computers, but also through cell phones. Finding ways for scarce and expensive doctors and nurses to leverage online medical information and decision support tools will be a key to improving access to quality health care for poor countries in all parts of the world.

Health 2.0 companies might also want to look to contributors from outside the rich countries. Although such contributors won’t be highly valued by advertisers and other sponsors, they are certainly capable of generating valuable content that can enhance the value of the site overall. I haven’t seen many Health 2.0 companies pursuing such a strategy explicitly, but I expect that to change within a year or so.

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