Grand Rounds at Charlotte's Web

Welcome to this holiday edition of Grand Rounds! It's the time of year when friends and family gather, when stories are told and memories are made. But the winter weather and short days here in the northern hemisphere seem to prompt brevity in our everyday comings and goings. It seems like the right time to combine storytelling and brevity and channel Charlotte, one of the most masterful storytellers I met during a childhood spent with my nose in a book.

In keeping with Charlotte's knack for saying what she meant and meaning what she said succinctly, I've categorized this week's submissions using six words that describe quality healthcare. (They're borrowed--in ways I suspect would make Templeton the Rat proud--from the Institute of Medicine's report Crossing the Quality Chasm.) This week participants were asked to submit one word describing the inspiration or take-away lesson for their post, and you'll find their words woven into today's Grand Rounds.

I hope you enjoy the tale. And do take the opportunity this holiday season to revisit Charlotte's Web. Better yet, share it with the next generation. As we seek solutions to the vexing issues healthcare bloggers wrote about for this edition, we'll be needing new words, spun by young people whose imaginations are ignited.

The word used by the authors of Crossing the Quality Chasm to say that patients should not be injured from care intended to help them.

Last week The Blog of the Interdisciplinary Nursing Quality Research Initiative completed an ambitious commemorative series marking the 10th anniversary of To Err is Human. Since Florence dot com is, first and foremost, a real-time patient safety primer, I'm going to carefully letter my chosen word here: LEARN. And tell you to click on this link to access INQRI's lovely collection of stories, recollections, and sage advice.

Care does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic means.

Dr. Rich gets to the meat of the matter in  Let Us Shun The Obese this Holiday Season. Dr. Rich's heart of darkness post (key word: demonization) could have fit nicely in many dimensions of care, patient-centered and effective sprung to mind. But his astute observation that obesity is often rooted in genetics makes it fit best here.

In The Users' Guide to the Health Reform Galaxy, Bruce Siegel stays on message with his word: equity. But read this post to learn why an insider believes minority groups could lose ground if health reform is not "done right." Louise from the Colorado Health Insurance Insider says the word is flaws and writes Why Health Care Reform is Important.

Care based on scientific knowledge should be provided to all who could benefit and not provided to those not likely to benefit (avoiding underuse and overuse, respectively).

Amy Romano, CNM gets a blue ribbon in this category for maximin, a word I didn't know and one that would surely delight Charlotte. Amy wisely included a vintage PubMed link explaining her word, and she articulates her position in What SUVs Can Teach Us About Maternity Care. Paul Auerbach discusses The Canadian C-Spine Rule, with a take-away word of algorithm.  Allergy Notes offers up "allergy" as an index word for the post describing the difference between food sensitization and food allergy.

Rounding out this dimension of quality healthcare are those who prompt us to pay attention to the quality and accessibility of  high end data. Eve Harris offers transparency as the take-away lesson in Asking Dr. Science. Walter Jessen at Medpedia, an innovative 2.0 health information community, uses "reliable" to describe Medpedia Now Includes News & Analysis, Alerts, Q&A. And over at Clinical Cases and Images - Blog, we're reminded that it's also helpful to think. And rewarded with a thoughtful post, Medical Textbooks and Atlases Searchable on Google Books.

Care is provided in ways that are respectful of and responsive to individual patient preferences, needs, and values. It ensures that patient values guide all clinical decisions.

The ACP Internist offers Doctors, Ditch the Tie and Coat, an interesting piece about appearance (how patients' perceptions of providers are shaped by both culture and the providers' choice of attire). I found another new Charlotte-worthy word reading this post: zoris. (Check out the post to learn what it means if it's new to you, too.)

Laurie Edwards says the relativity factor is confounding when people with chronic diseases go about Learning to be a Primary Care Patient. Amy Tenderich winds up in the middle here, too, a welcome place according to her Wayback Wednesday post Oh, Glorious Middle. And Rachel's simply titled post is For Now. But the word she sent along, patience, may say even more about what patient-centered care really entails.

Jacqueline at Laika's MedLibLog captures the arachnoid spirit, giving her post a one word title: empathy. The post shows how much we long for care that considers more about who we are than our "chief complaint" often reveals. If Jacqueline had been in the mood to spin longer, she could have called this post, "What comes around, goes around!"

Developmentally appropriate care may mean calling on the healing power of friendship, something Nancy Brown points out in Helping Friends Who are Stressed and Depressed. In another part of the village, Barbara Kivowitz cautions that assumptions are not always helpful in Seven Myths about Couples and Illness. And Will Meek says the word is forgiveness and writes about it in How to Forgive.

One of the things I like best about the IOM's six dimensions of care is this: stakeholders don't always wind up tangled in their own little bitty egg sacs. Lock Up Doc offers the word transparency to explain her position on Should Patients With Borderline Personality Disorder Be Told Their Diagnosis? (It's a stance that also earns her a place in the coveted "patient-centered" category.) Curiosity earns The Happy Hospitalist a place here, too. (And his post Gynecological Exams: Best Done By Male or Female Gynecologists earns another label: funny.)

Dr Charles gives a nod to resilience in his post Hypochondriachal Heroism. And child psychiatrist An Ang Zhang explains something that makes healthcare delivery a challenge: Lying people. She says more in The Smartest Lie: Lord Winston; Super Doctors & The Dark Side. But At How to Cope with Pain, the word is contest! Visit for a holiday-inspired change of pace and see what's cooking! (Spoiler alert: It's not pork.)

The need to reduce waits and sometimes harmful delays for both those who receive and those who give care.

Kim, a future nursing student, writes revisiting my hospital stay. Although she sent patience along as her take-away, I've chosen to place her post here because omissions count in quality measures. Rats!

Harry Stern at InsureBlog is worrying about supply and demand, too. His post, More (Un?)Intended Consequence, projects doctor shortages and backs up rather glum predictions with data from the Association of American Medical Colleges. ACP Hospitalist echoes the concern, with a call-to-action word: need. The post is New York survey shows dire need for hospitalists, internists.  I'll take this opportunity to weave in a bit of Cavatican-style cheer: mid-levels.

  Avoiding waste (of equipment, supplies, ideas, and energy).

At Shoot Up or Put Up, Tim's NHS pharmacist guest blogs with Diabetics - Blight of GPs; Milk Cows of Pharmacists, explaining why people with diabetes should engage their pharmacists. (He gets a blue ribbon for including a farm animal in the post title.) And a wry, trans-continental laugh for his take-away word: Pharma-conomics. Dr. Wes offers a one-word take-away to describe a mixed blessing: patient-provider e-mail. And he articulates both "added value" and "be careful" features of this mode in The Inefficiency of Medical E-Mail.
 
Jessica Otte explains how hard it is sleep while completing an obstetrical rotation in No electric sheep for me: Sleep is fragmented. Medical residents and how much sleep they get impacts the efficiency of individual physicians and the system that depends upon them. Her word is delusion. (I think it's meant to describe her current sleep-impaired state. But the word may also describe conventional wisdom that allowed residents' hours to remain relatively unchecked in the latter part of the 20th century.)
 
Over at the Healthcare Business Blog, David Williams says Atul Gawande is too optimistic about healthcare cost control when he advances the idea that the future of healthcare reform may lie in the county extension office. Williams is serious: his take-away word is pessimism. Marya Zilberberg calls out Gawande for another reason: shortsightedness. It's explained in her post Can US agriculture reform inform the healthcare debate? She offers thoughtfulness as her word.
 
Joseph Kim's one word is "leaving," a topic that inspired his post, Should You Leave Clinical Medicine? Finally, Jolie Bookspan offers appreciation at this time of year, with some special "academy" awards.
 
Correction to information for the next edition of Grand Rounds! It will be hosted next week, 12/22 by Nancy Brown of Teen Health 411. Nancy will accept submissions (to brownn at pamfri dot org) until Sunday, 12/20/09 at midnight. The theme is "coming together."


Note: The descriptors of the IOM's Six Dimensions of Care are reproduced from pages 5 & 6 of the Executive Summary, Crossing the Quality Chasm.

Grand Rounds in a Word

This week in Orlando, the Institute for Healthcare Improvement (IHI) is hosting their annual conference, one built upon a single well-chosen word: Simplify. I'll be hosting Grand Rounds here next Tuesday, 12/15 and thought we'd continue the tradition of saying what we mean and meaning what we say in a word.

You're invited to share what's on your mind about any healthcare-related topic important to you. Just send the name of your post and a link to blynnolson at gmail. The only thing you have to do to ensure your post will be included is this: Pull out ONE word that explains what motivated your post or describes the "take-away" lesson you want readers to remember and send it along with your submission. I'll do the rest!

Looking forward to receiving "the word." Please submit by 12/13/09 at midnight EST.

Glad you're here but there are other interesting places to visit, too!

The Tuesday redirect I normally reserve for Grand Rounds is being shared this week. This signifies a warm endorsement of the INQRI blog which today launched a 10 day series commemorating the 10th anniversary of the IOM report To Err is Human. But it doesn't mean that you shouldn't visit Health Technology News (where a good laugh is in store for those who remember Seinfeld & Co's patient adventures).

I've been surprised that the topic of patient safety--measures to prevent inadvertent harm to people who seek care--has received so little mainstream media attention in this very long season of talk about healthcare and reform. The INQRI To Err is Human series is a great place to hear how patient safety intention and outcome are converging, with some of the patient safety advocates who have led the charge taking time out to assess progress.

Check out INQRI in the coming days. There's something for everyone. (Florence herself is learning new things there!)

Thank you, Grand Rounds!

A Thanksgiving edition of Grand Rounds is up this morning at Colorado Health Insurance Insider. One of my favorite posts comes from Laika's MedLibLog, where a web 2.0 savvy health librarian shares a list of scientific journals that she follows on Twitter.

Maybe Twitter lists like this speak to me because I remember what accessing quality medical information once looked like: finding time to go to the university library, scrounging around for change, countless hours spent looking for high-end resources, doing the bump and grind with a recalcitrant copy machine (so that the prized materials might be made readily accessible in places more welcoming than the nasty, drafty, dirty library). And leaving with the nagging sense that I probably missed the best things anyway.

People who think that Twitter is a place where bores report the outcome of their children's travel soccer games are missing it. There are bores in Health 2.0. (There are bores everywhere: The 2009 word of the year is unfriend and I suspect unfollow, what you do to bores on Twitter, will pop up next year.)

But the ability to piggyback onto lists used by medical librarians, gaining access to real time output from 90 (just a start, no doubt) scientific journals a health information practitioner relies on.... well, it's enough to make you drop your dimes.

When you let go of old ways of doing things, it's nice to find something as a useful as a "follow" button.

A Non-Clinical Grand Rounds

Dr. Joseph Kim is hosting Grand Rounds today at a blog devoted to exploring non-clinical medical careers. There's an interesting array of posts over there plus a chance to "shop around" the non-clinical world.

The only thing that made me wince when I took a quick look was that "patient safety" is near the top of the queue. From a blogger's point of view, this is good news, since posts placed high in the Grand Rounds narrative draw more hits to an author's blog. But from a patient safety standpoint, the perception that "patient safety" lives in the non-clinical world is a bad thing.

If you've every heard the expression, "your restaurant is only as as good as the last steak I ate there," you'll understand why. While many interests have a place at the table, the "sweet spot" in patient safety is at the point, often jagged and bleeding, where care is given and received.

There is certainly a science that informs patient safety and legitimate work to be done fostering a culture that recognizes and supports safe care. But if it's not visible at the front lines of care, it's not "patient safety."

"Code Boo" at Grand Rounds

Gina at Code Blog is hosting Grand Rounds today. The Halloween theme works for me since I'm always finding something scary to write about. (Check back tomorrow for a piece on the Northwest airliner that overshot Milwaukee by 150 miles because the pilots, ummmm, seem to have lacked sufficient redundancies.)

Car dating & cognitive dissonance at Grand Rounds

Here's a link to SharpBrains, where yesterday's host Alvaro Fernandez brought together Grand Rounds (a forum for medical bloggers) and Encephalon (a forum for people who blog about the brain and mind). Alvaro offers a tongue-in-cheek, "What a nice surprise! Hello. Nice to meet you" to both groups.

The introduction has already been made.

The need to recognize the inherent fallibility of humans (and design systems that are reliable in spite of the predictable faux pas humans make) was articulated nearly a decade ago in the first IOM report, To Err is Human. Alvaro's invitation, his need to suggest that healthcare professionals dip into the cognitive psychology well, is telling. It's surely part of the reason we've yet to post measurable gains in preventing inadvertent medical error.

It occurs to me that when introductions lead to a relationship, it's because both parties perceive a benefit. It's been ten years, and in the U.S, we're still discussing whether tired residents are really as tired as other tired people. And entertaining other intention-oriented ideas, like "Follow the 5 Rights." This suggests cognitive dissonance between the safety paradigm we have and the one we need. Apparently, "we're just not into you," SharpBrains.

Healthcare remains distinguished from other high consequence industries by the degree of personal vigilance we tolerate and rely on. No matter where you or your organization may be on the journey toward improving patient safety, you should agree to a second date with the folks who study the performance parameters of humans.

Applying lessons learned to healthcare workers and the systems used to deliver care is a necessary step in eradicating the public health problem called "medical error."

Participatory Healthcare at Grand Rounds

Grand Rounds is a "must visit" place today irrespective of whether you're a consumer, healthcare provider, or have another dog in the fight to improve healthcare. You'll find clear explanations of what "participatory healthcare" is and have a chance to assess how it's emerging.

One thing about participatory healthcare that jumps out at me is how well it aligns with the way I was taught to approach patient care when I was an undergrad nursing student in the mid '80's. That curriculum also came with a hefty dose of "change management" theory, something that drew disdain from the "where's the beef?" crowd and, unfortunately, didn't change much.

But what does seem to be changing things is the information revolution. Patient access to information, ideas, outcomes, and communication modalities is doing more than just shoring up foundational changes in "how we do things around here," (the easiest way to describe healthcare culture). These changes must occur to make the delivery of healthcare more reliable, more safe.

I see patient engagement as transformational, meaning we're likely to get somewhere better as a result of letting patients take the lead for part of the journey. So take a trip to Survive the Journey and see how far we've come.

When you do, you'll find that a number of the people who contributed to the participatory healthcare Grand Rounds appear on the inaugural list of "Top 25 Patient Safety Tweeps" I published last month, among them Dave DeBronkart (epatientDave), Amy Romano (midwifeamy), and John Sharp (JohnSharp). The experience of patients is central to efforts to improve patient safety. So are initiatives and incentives arising from clinicians, organizations, payors, industry partners, regulators, and academics. I'll publish an updated list this Friday, 10/16/09.

I welcome nominations of individuals or organizations from any of these categories for consideration on Safety Nurse's Top 25 Tweeps for Patient Safety list. The entity must have a current, active presence on Twitter. The volume of tweets is less important than the quality of patient safety information that's passed along.

Thanks for participating!

Tuesday Afternoon

I've been "chasing the clouds away" here in stormy Atlanta. But there are interesting things to report from other venues, too.

First, Grand Rounds, the weekly blogging carnival is celebrating its 6th anniversary at Residency Notes. Colin Son, a first year surgical resident, is surely one of the busiest people on earth. But he's making time to continue blogging and lending support to Grand Rounds. (Maybe this is a positive outcome of taming residents' work hours?) In any event, Colin featured the list of 25 Patient Safety Tweeps today, a nice indication that "patient safety" is hitting the radar screens of young professionals.

Residencies and patient safety were in evidence in other ways this week. I picked this up in Twitter feed:

@alinahsu: U of IL: residents must report 5 unsafe conds or near misses per year in order to move on. #ahrq09

(If you're learning how to "read" tweets, this message means that someone named @alinahsu believes that at the University of Illinois, residents must report unsafe conditions and near misses as a condition of satisfactory performance and to advance during their residency years.)

I wouldn't take the contents of any one tweet to the bank, but this one is a nice indicator of positive change in healthcare's reporting culture, coming from a field reporter. Social media (things like blogs, Twitter, and Facebook) are emerging as barometers of safety culture: Busy clinicians won't write a paper about things that please or annoy them, but they will drop a line or two. Here's an on-the-fly assessment about a usability issue, this one running at the top of a blog:

"Whatever the VA paid for these tablet computers that we use to consent patients, well it was too much. These things suck." — txmed

I spent a few hours this morning at Mercer University's School of Pharmacy, talking to 2nd and 3rd year students about culture and communication and how these things affect medication safety. And I'll take the online "thank you" from a pharmacy student with a newly minted Twitter account (@preventionjunky) as another positive sign that young professionals in the pipeline are going to be the tipping point in patient safety.

Finally, I had fun hosting "Bob the Nurse," the nurse action figure with too much time on his hands. Click on over to one of Keith Carlson's blogs to see how Bob Improves Drug Safety. I'm still laughing about his Zilactin walking stick.

Grand Rounds: "No Lie"

It's Tuesday, and another edition of Grand Rounds is up at Suture for a Living, a place where a plastic surgeon from Little Rock, AK talks about her passionate for sewing (and it's not just skin). This edition takes you around the world, to hear what others are saying about healthcare.

Wherever the good reads lead you this week, you won't find a place where healthcare is as out of control as what you'll find here in the United States. No lie.

Appreciative Inquiry: Grand Rounds

I've been thinking about writing a post about Appreciative Inquiry (AI), an analytic strategy that relies on seeing complex systems as "glasses half-full." This topic hasn't risen to the top of my queue yet, although one of my dearest nursing colleagues, Anne Challis, recently published a piece about the value of AI in RN retention in Nursing Management. (Anne's piece is worth tracking down, if only to see what a doggedly determined optimist can do with an employee's observation that "This job is a joy-sucking horror.")

I think "patient safety" might benefit from some AI treatment (or at least better PR). How, I've been wondering, will healthcare organizations more fully engage the citizens they serve with: "We kill fewer patients by mistake than our competitors"? And exactly who do we think wants to roll out of bed to work in that place?

So I was happy to see that Mark, of Medic999, chose "The time when it all fell into place," celebrating great catches, communication, and coordination of care for this week's Grand Rounds theme.

Today's Grand Rounds is worth visiting for another reason: You'll learn more about what care looks like from the perspective of first reponders and medics. This is valuable information for people interested in patient safety because fewer professional silos, less rigid hierarchies, and more effective communication across the continuum of care are things that improve outcomes. And that's good news for patients.

Enjoy Grand Rounds. And have a nice day.

Blog carnivals & car dating

I'm always on the lookout for stories, research, and information that says something about where we are in the quest to attain the IOM's "Big 6." (That would be healthcare that's safe, effective, timely, efficient, patient-centered, and equitable). This makes me something of a cheap date since pretty much everything about healthcare worth reading is going to take on at least one of these things.

So I screen a bit harder on the second date, looking for ideas and experiences that I find authentic and those that push me to reflect on these issues in a deeper way. Blog carnivals provide the "Readers Digest" version of what bloggers have written over the past week or so. Sometimes carnival hosts ask for posts on a particular topic, others just ask authors submit their favorites. I've found blog carnivals are a good place to go on a second date.

Here are two that published this week: Grand Rounds and Patients for a Moment. If you go, you'll find front line clinicians and patients telling stories about how the rubber meets the road in healthcare. They're authentic and, if you're like me, you'll probably find some that push you to think more about what, and why, you believe what you do about healthcare reform.

Grand Rounds: The oleaginous armor edition

Grand Rounds is up at The Covert Rationing Blog where you can get a check-up with Dr. Rich, healthcare's Stephen Colbert.

While you may not feel the need to find another source of information about healthcare reform, this one is worth checking out, if only to find out how "oleaginous armor" can be used in a sentence.

Get yourself a bag of Cheetos, mute the cable, put your feet up, and enjoy the read!

A salute to Grands Rounds (and other eye-catching things)

If you're following, or trying to find, reasonable points of view about healthcare reform--opinions that might be useful should you be forming one yourself--you're probably feeling a bit like Richard Gere in an "An Officer and a Gentleman" when Lou Gossett, Jr. hoses him. You've got nowhere else to go!

But wait. Forget that Lou Dobbs has been acting like Lou Gossett, Jr.

Click on over to Grand Rounds where Kim and her Gumby-esque friends share a lot of interesting things, the healthcare reform posts being a real find. You may feel like you're in a Fellini movie.

But if you're looking for the best reads, you've got nowhere else to go!

Grand Rounds visits the Tour de France

Tour on over to Grand Rounds, hosted today in Australia by Captain Atopic Degranulated. You'll get schooled on things cycling, plus have a chance to see who's wearing the yellow jersey, errr, white coat, in the blogosphere.

Healthcare reform is a hot topic, as stakeholders, most with big dogs in the fight, errr, race, jockey for position. One post to visit is It's About the Patients, Stupid where Mother Jones, RN reminds people why nurses remain the healthcare professionals most trusted by the American public.

Enjoy today's ride!

Grand Rounds & Health IT: The man behind the curtain is..... Forrest Gump?

Good reading awaits at this week's Grand Rounds, where Dr. Joseph Kim invited bloggers to share how IT is changing healthcare.

Healthcare is full of tech-facilitated miracles. I think health care technology's best successes so far lie in applications aimed at individuals. My daughter's cochlear implant is one great example.

A cochlear implant (CI) does not make my daughter a "hearing person." But it certainly gives her the opportunity to access sounds and to make meaning of them in a way that's very similar to what people with normal hearing can do.

Deaf people don't have surgery and wake up "hearing" any more than you buy a computer and become Bill Gates. To realize the full potential of a cochlear implant, a user learns to make meaningful use of the data the implant provides.

Implant users can hear--and grasp the significance of--a toilet flushing almost immediately. But understanding and mastering a complex battery of sounds--like syllables, words, and sentences--has a much longer learning curve. Gaining meaningful use of a cochlear implant also requires concomitant support that's not technical at all: early education for language acquisition and ongoing speech therapy.

Think about another IT-facilitated product that fosters miracles: digital radiography. A lay person can see that digital images are sharper, brighter, more precise than those on old-fashioned films. But knowing what's normal, what's a normal variation, and what requires follow-up takes education and experience, an intimacy with both the imaging device and the anatomy it captures. Like a CI, radiography only becomes meaningful when the data is interpreted, communicated, and factored into a larger whole.

System-level application of IT, a late-comer in healthcare, is likely on a similar journey toward meaningful use. Right now, I'd say health care stakeholders are hearing toilets flush and noticing that some things are brighter than others.

I think there's a lot of other things that could be said about that.

But since I'm feeling a little like Forrest Gump today, I think that's all I'm going to say.

Grand Rounds: Leveling the Field

Welcome to Grand Rounds! It's officially summertime, and Flo & Bo are taking you out to the ballgame! At Florence dot com, Bo, a seasoned nurse with an engineer's mind, channels Florence Nightingale, a systems thinker whose interest in public health and service gave rise to modern nursing. (Flo favors cricket, but this is Bo's gig.)

We make commentary about health, health care, and healing, a pursuit that, like baseball, often reveals motivated players, talented coaches, amazing facilities, and enthusiastic fans. But the game we follow is highly variable and outcomes don't always match the raw potential of the franchise. Maybe you have a team like this in your town?

Grand Rounds gave us an opportunity to ask people who blog about health care, "What's meaningful to you?" We were particularly interested in how IT solutions should be put to work to improve population health, individual health, and system efficiency.

We've appointed one of the USA's premier health care quality experts, Don Berwick, to be our honorary commissioner and have seated this week's submissions according to Berwick's four levels of interest. You'll find the experience of patients and families in the A position. The people and processes touching them are at Level B. Organizations where care is delivered are Level C, and other stakeholders and interests make noise from Level D.

The game is made all the more interesting because this group rarely stays in their assigned seats: players talk strategy; owners become players; players become owners; and fans have multiple allegiances. Got it? Good.

Now, let's play ball!

Throwing out the first pitch is e-Patient Dave who provides a compelling description of Meaningful Use: A pivotal definition of new-wave medical records systems. (Dave's vision may render advice for dealing with computer-related aches and pains obsolete, but if you need some while awaiting the "meaningful use" revolution, you can find it at Are Computers a Pain in the Neck (and Head)?)

Level A: The Players' Line-up

Laurie Edwards leads off with a hit Talking Health Reform with President Clinton. Edwards is a veteran patient-blogger determined to see patients' perspectives included in healthcare reform in a meaningful way.

Next up, Novel Patient shares how weighing the risks and benefits of potentially dangerous medication is a high-stakes wager for many patients in The Rituxan Gamble. It's early in the game, and we're reminded that, for many people, access to cutting-edge treatment is a hard-fought opportunity to bat, not the assurance of a run.

Batting 3rd is Amy Tenderich from DiabetesMine, the switch-hitter patient-entrepreneur, sharing submissions from this year's $10,000 DiabetesMine Design Challenge in Even More Bright Diabetes Ideas: A Little Help from Your Friends. Tenderich widens the players' circle, noting that her innovators frequently utilized patients' family and friends, valuable resources that have remained largely untapped in chronic disease management.

And in the power hitting position comes Duncan Cross, with a new blog round-up publishing patient-centered posts in Patients for a Moment: First-Ever Edition.

Next at bat:

Barbara Kivowitz takes a swing at discriminatory laws in Kept From a Dying Partner's bedside. What gets family into the game anyway?

Alison demos how new technology has made substantial improvements in her ability to manage diabetes, a claim she backs up with impressive data in her post Every picture tells a story.

Gold Glove Award Winners:

Dale Ann Micalizzi, a national champion for transparency and disclosure in the aftermath of her son's death, offers "The Power of Apology" by Dr. Marie Bismark." Dale writes, "After 8 years of searching for peace and answers, we received an apology last week from the physician who was an expert for the hospital and reviewed Justin's chart. The apology mattered and was appreciated beyond words even though it took so long."

Player/manager, WellRoundedType2 translates Changes in the way diabetes is diagnosed, for her team members, individuals she describes as interested in "Health at Every Size."

7th Inning Stretch:

Players' interests have been represented for a long time, and Disruptive Women in Healthcare introduces the May Man of the Month -- Charlie Inlander, who shares his lifelong experience as a patient advocate.

Bottom of the 9th:

Pinch-hitting for safe medication use and people at-risk for adverse drug events is Mona Johnson, with Anticholinergic medicines and memory loss.

Dean Moyer, someone with first-hand knowledge of back pain, offers a low tech method to obtain meaningful relief of neck pain in Neck Pain, Massage Therapy and Ice.

And Kerri Sparling, wearing number 6 (or Six Until Me), makes a fast call on a play, balancing the need for privacy with the urge to network in Do I Have the Right?

Level B: The trainers, managers, and coaches

Honorary team physician Daryl A. Rosenbaum MD wants players (and their parents!) to understand the limitations--and possible hazards--of mass production sports physicals in 10 Reasons Why Sports Physicals Need an Appointment.

Reality Rounds analyzes a case involving incarceration of an HIV+ pregnant patient in Get Ye to the Stockade, Ye Pregnant, HIV+ Wench! Knowledge of infectious disease, public policy, law, and a big dose of advocacy. If it's not an agent, it must be a nurse!

Catcher turned coach Amy Romano, MSN, CNM shares what happens when consumers and providers pursue evidence-based answers in "Flip Flop: How we (or at least Canada) went to routine cesarean for breech and back again in the era of evidence-based medicine."

Captain Atopic, a seasoned professional in the midst of changing roles in healthcare, reflects on his evolving perspective in Not My First Surgery. Flo & Bo appreciate the Captain's nod to how others see the game. Baseball culture, healthcare culture, it's all about culture.

Teen Health expert Nancy L. Brown, PhD shares survey results about teens' perceptions and offers advice for Giving Teens Purpose and Hope for the Future. (Bo, remembering teen behavior from her days as a perinatal nurse, is trying to figure out which base to have Dr. Brown coach. While this issue is taken to various stakeholder groups, go ahead and pass the link to Teen Health 411 along.)

Thrown out of the game?

The Jobbing Doctor reports the anonymity of bloggers is under threat in the UK by a combination of the London Times and a maverick judge in Who is the mystery man?

Back in the US, Evan Falchuk, writing for Team See First, advocates for accurate diagnosis of what ails health care as a necessary step for effecting meaningful reform in Some of My Best Friends are Doctors.

A Mom and Apple Pie Issue?

Dr. Linda Brodsky calls for stories related to gender inequality in health care for a multi-author book project in Hear Ye, Hear Ye!. Brodsky, another seasoned vet, puts questions of gender inequality and its impact on the quality of health care in the US in play.

Level C: The Organizations

CEO Paul Levy is Running a Hospital, a highly transparent one in Red Sox territory, where his blog is used for daily communication, shaping culture, opinions, and policy along the way. In Caller-Outer of the Month Award #6, he shares how the wisdom of frontline clinicians is utilized and recognized.

Rita Schwab effectively explains why the game should be understood by all people at all levels. Read past the opening nod to Health Care Risk Management Week and find a useful scorecard to help you determine if "patient safety" is a wild pitch or an intentional walk in the organizations you frequent.

The fitness of any organization is influenced by its infrastructure. Joseph Kim, MD, MPH shares findings from a research study, examining How many nursing homes use Electronic Health Records (EHRs)?

Level D: The Fans (and other interests that shape how the game is played)

Ever get to your seat at the ballpark and discover you (or someone in your party) has apparently offended the Ticketmaster God? Healthcare's another arena where people from very different places come to watch--and try to influence--how the game is played.

DrRich, a versatile manager-turner-agent, now with The Covert Rationing Blog, illustrates how mature medical technology (unlike mature consumer technology) often remains excessively expensive in Why Implantable Defibrillators Are Still So Expensive.

In The Economics of Health Care, Bob Vineyard of InsureBlog explores health care economics, advocating that reform measures include greater personal responsibility.

Louise and Jay, health insurance professionals, take a turn as players this inning, sharing what they know about Removing an Exclusion Rider on Our Policy in hopes of helping others. Alvaro Fernandez, of SharpBrains fame, is in the stands Debunking 10 Brain Training/Cognitive Health Myths.

Finally, The Cockroach Catcher's Dr Am Ang Zhang writes up Winter’s Tale: Blood, Entrails & Hansard and finds the collapsing of parliamentary record in a Shakespearean comedy to be a strong metaphor in the United Kingdom. (Bo sees the Curse of the Bambino being somewhat analogous on this side of the pond, although perhaps not a tale that portends health care woes in quite the same way.)

Thanks for coming, folks! This one's in the books. Next week, Grand Rounds is hosted at Edwin Leape.

Special thanks to my son, Luke Dixon, a real-time sports oracle and blogger at PucksNStuff, for providing enough baseball factoids to get this game played!

Grand Rounds: Searching for meaning

Flo & Bo are pleased to be hosting Grand Rounds, the weekly carnival showcasing the best of the medical blogosphere, on June 23rd.

Since healthcare is abuzz with talk about "meaningful use" this week, send us something you think is meaningful, and we'll fit the pieces together.

Submissions welcomed until 10 pm (EDT) on Sunday, June 21. Send to: blynnolson at gmail dot com & include "Grand Rounds" in the subject line. (This will help me differentiate what's meaningful to you from what's meaningful to the people who seem to think I've won the lottery when I peruse the Spam file.)

Here's the e-prescription:

• name of blog
• URL of blog
• title of post
• URL of post
• blog (or post) author
• twitter URL (if you tweet)
• brief description of what makes your post or perspective meaningful

See you next week!

Grand Rounds: More than good stories found

One of the things I like best about Grand Rounds is that I find inspiration to help bring my hodge-podge of loose thoughts and impressions together.

Healthcare reformers and activists have begun to focus on the $20 billion American Recovery and Reinvestment funds that--God-willing-and-the-creek-don't-rise--will make IT in healthcare "meaningful." The National Committee on Vital and Health Statistics' Report of Hearing on "Meaningful Use" of Health Information Technology captures multi-stakeholder concerns well. It's a worthwhile read about the realities we face in harnessing strong IT solutions to transform healthcare efficiency and outcomes.

I jumped at the chance to talk about meaningful use last week, both here and over at On Your Meds, the Medscape medication safety blog I write. Although I'm techy by nature, it doesn't take a specialist to see that the current state of IT often makes front line clinical people tie the horse to the Edsel's bumper to advance a care goal. (If you missed Gina's story a few weeks back, it's worth a read to sample just a few of the unintended consequences front line clinicians face when e-systems fail to communicate.) So I posted call-to-action pieces about meaningful use, advocating for IT outputs that would make patient data central and help get front line clinicians out of the manure.

Then I started reading what cutting edge e-patient advocates and health 2.0 innovators were saying about what "meaningful use" might really mean. E-patient Dave's remarkable story is one that has drawn attention to health IT's intention-outcome mismatch. The power of high-end patient involvement left me feeling that my "make it work for those on the line" approach was like suggesting we replace "Mr. Ed" with "Rachel Alexandra" on the bumper.

But today at Grand Rounds, I stumbled across the story of a man, and his family, movingly told through the fresh eyes of a soon-to-be nurse in Brain Death, Part 3. The patient and family in the story, especially when contrasted with e-patient Dave, show the vast continuum of abilities and circumstances of people in our care.

We most certainly need to get the horses off of the bumpers. But we also need to be certain that we advocate for models of care--which are ultimately what IT solutions support--that allow all kinds of horses to make it around the track.

Health care reform at Grand Rounds

Grand Rounds is hosted this week at Healthcare Technology News with a special edition focusing on Health Care Reform. Interesting reads about what ails--and what may fix healthcare--from a wide range of perspectives make a trip over to the tech blog today particularly worthwhile.

Florence dot com, busy contemplating a move to Wordpress didn't go to Grand Rounds this week, but her sister blog over at Medscape did. (At On Your Meds, the topic Flo & Bo took on--how to spend $20 billion for health IT in a meaningful fashion--also came up, but no mention of bodily fluids occurred during the making of that post!)

I think the role of the consumer in healthcare is one worth exploring, and Grand Rounds is a great place for front line health care providers to hear directly from them. Seeing people at their most vulnerable, and benchmarking patients by the capabilities of those who are unlikely to be effective self-advocates is yet another huge disadvantage of our "in sickness and in more sickness" model of care. People who bring the same sensibilities to managing healthcare they bring to other high-stakes endeavors should help set the bar for patient engagement, with default strategies made to protect patients when they cannot assume these functions. (If you've missed how I once saved myself from a significant warfarin overdose, you can find it here.)

My parents, retired teachers living in central Florida, have online access to their medical records via a portal in their physician's EMR. The system also churns out a printed and up-to-date medication list following each visit. In the land of IT possibilities, these are modest things to be enthused about, yet they represent cutting edge patient involvement in health records.

Enjoy Grand Rounds today! (Judge Judy will not be attending, no need to roll up your pant legs.)