Wednesday, April 28, 2010

Who is this guy and what is he holding in his hands?

There are two types of people.  There are those who believe, rather passionately, that Apple products are better.  Much better.  And then there are those who don't like to consider themselves Kool-Aid drinkers and consider the "Apple is Better" mantra to be nothing more than expert marketing induced hype.  Regarding Apple products, I became a Born Again in 2002, but that's a story for another post.

I've written on this blog (example, here) that the new iPad is a marvel, an innovation and... more importantly... a change agent.  That it will help usher in an entirely new digital era in ways that are different and even more striking than the manner in which personal computers and cellphones have done so thus far.

My own long awaited iPad arrives on Friday and I'll keep you posted on whether this really is a game changer or not, based on my own personal experiences and the anticipated quest to make this replace paper (and newspapers, books, ipods, magazines, and eventually, a laptop).

So, who is that gentleman holding an iPad in the photo above?  It's Russian President Medvedev.  For more insight, I think you'll find the following video to be quite illuminating:

From Louise

New Yorker runs a contest where readers are asked to supply the caption for a sketch, such as the one above.  Though Louise, my niece, did not win... we all thought this was pretty good.  Louise just turned 8...

Tuesday, April 27, 2010

Home Care as Cash Cow aka The Peril of the Broad Brush

There’s nothing wrong with the profit incentive. In fact, it drives innovation, sparks economic growth and prosperity and improves the lives of many who benefit from the creation of jobs and opportunity.  Furthermore, profit margins allow for investment and invention and often dramatically improve quality and efficiency of processes and systems.

There’s nothing wrong with the profit incentive.


I attended the annual Visiting Nurse Associations of America meeting in Orlando last week and took serious note of the fact that home care is the only segment in the industry that experienced a funding cut as a result of the recently passed health care reform law. Glass-is-half-full types said that it could have been much worse, and very nearly was, but the rest of us wondered why an industry segment that has so compellingly and consistently demonstrated value in improving lives and cutting costs by keeping patients independent and at home (i.e., out of much more costly settings) could experience a fate such as this.

Well, the reason is simple and it involves public officials painting across the entire home care industry with one broad brush. For-profits and not-for-profits are all spilled into the same large bucket and marked with the "excessive profit" label.

Medicare pays reasonably. For the most part, nobody else does. If you are for-profit oriented and choose your patient/payer mix, then you choose wisely. If you are mission oriented and take care of everyone, regardless of their ability to pay or the reimbursement policies of their insurance company (government or otherwise), then you pay very close attention to things like the proposed $40b Medicare funding cuts.

In today’s Wall Street Journal, Barbara Martinez points out the significant profits of some of the large for-profit home care companies. One of the companies mentioned experienced a stock value increase from $1 to $60 over the past decade. The piece is full of similar “success stories”. Not bad if your goal is to drive profits. Concerning if your goal is to provide efficient, high quality care to those who need it the most.

Here’s the damning part:
Medicare reimbursements for the entire home health-care industry are coming under increased scrutiny. The federal agency that advises Congress on Medicare payment issues, the Medicare Payment Advisory Commission, or MedPAC, warned last month that home health "overpayments contribute to the insolvency" of the Medicare trust fund as well as premium increases that beneficiaries must pay.
There’s nothing wrong with the profit incentive. But if participating organizations are able to selectively choose which patients to serve, leaving only non- or under-paying patients to others, then the forecasted cuts to Medicare payments will prove difficult for the for-profits and fatal for the not-for-profits.

At the Visiting Nurse Association of Boston, we have believed (for 125 years in fact) that everyone deserves high quality home care services. That everyone deserves to be treated with dignity and respect and very skillfully delivered care. That compassion knows no profit margin.

Broad brushes will harm safety net providers and jeopardize the mission of responsible home care agencies. Broad brushes will defeat what organizations such as this one have fought hard to build. And broad brushes should be avoided at all costs…

Saturday, April 24, 2010

What if...

... you're walking through a dense woods and the sun breaks through perfectly... and you only have the camera in your cellphone?

You take the pictures anyways and then boost the saturation and contrast, sharpen slightly and convert to black & white.

Thursday, April 22, 2010 reports impact of reform on DV

The Family Violence Prevention Fund ( is reporting the favorable impact of the recently passed health reform law on domestic violence.  Prior to the passage of the law, health insurers (in eight states plus the District of Columbia) could deny coverage to victims of domestic violence because they deem their abuse to be a preexisting condition.  Per FVPF President Esta Soler: "We've fought for many years at the state and federal levels for laws that outlaw discrimination on the basis of domestic and sexual violence.  We are delighted that lawmakers have now addressed insurance discrimination against victims of domestic violence."

The new law also includes funding for the expansion of home visitation programs that provide health care and social supports to pregnant women and new mothers.  These programs have demonstrated great success in reducing the incidence of child abuse.  Additionally, the new law also establishes grants for organizations to provide intervention and supportive services, including housing, vocation counseling and group counseling for pregnant women and teens who are victims.

The U.S. Centers for Disease Control and Prevention reports that women experience two million injuries from intimate partner violence each year.

99 year old gets her first computer - an iPad

On this blog, I've been touting Apple's new tablet device as a true game changer.  Here's further proof:

VNA of Boston Hospice Medical Director Meets President Obama

Reprinted from a VNA Hospice Care communication:

VNA Hospice Care's Medical Director, Dr. James L. Baker, recently met President Barack Obama. He joined Governor Deval Patrick, Vicki Kennedy, and several other dignitaries at the April 1st invitation only event at the Opera House during the President's visit to Boston.  Dr. Baker said that "It was an honor to have this opportunity to meet with key leaders of the Democratic Party, particularly President Obama, now that the Health Care Reform Act was passed.  The evening made it possible to foster personal relationships with the leaders who will guide health care for the coming decades.  "Ultimately, I hope to bring Hospice and Palliative Medicine to the attention of our legislators at both the local and National level, and help guide the way to better care for the most vulnerable patients in our society."

The fundraising event was attended by about one hundred, including the Democratic leaders, policy makers, and invited guests.  Dr. Baker said that there was a sense that the monumental effort to bring about health care reform left the group somewhat battle weary, but all were aware that the real work was yet to begin.  Discussion centered upon "Where do we go from here, how should we best re-group, and how are we going to get the job done right?"

Dr. Baker and President Obama, who both attended Occidental College in Los Angeles, shared laughs about their college days.  Dr. Baker later went on to O.U.H.S.C., then residency at the University of Massachusetts, graduate school at Johns Hopkins, and Fellowship at Harvard Medical School.

He joined the faculty of Harvard Medical School in 1997, and remained faculty there until 2007.  After having completed his Fellowship at Mass General Hospital, Brigham and Women's, and Dana-Farber, he served as a consultant in Palliative Medicine at Beth Israel Deaconess before joining VNA Hospice Care of Boston as full time Medical Director.  He is one of the few hospice Medical Directors who is certified in Hospice and Palliative Medicine by the American Board of Hospice and Palliative Medicine (ABHPM).  He is also board certified in Emergency Medicine, and has taught that specialty for many years.

Recently, Dr. Baker was also asked to join the American Academy of Hospice and Palliative Medicine Health Policy Task Force, and in that capacity he hopes to help further the health care policy agenda of AAHPM at the national level.

Dr. Baker is passionate about hospice care and continues to take every opportunity to talk about progress that has been made in palliative medicine, and specifically all that VNA Hospice Care has to offer to referring physicians. As such he has recently met with Mount Auburn Cambridge Independent Practice Association (MACIPA) physicians and will also speak to physicians at Winchester Hospital in the near future. Please call VNA Hospice Care at 781-569-2888 or e-mail or if you would like to schedule Dr. Baker to meet with your physician group or for grand rounds regarding advances in Hospice care and opportunities for collaboration.

Wednesday, April 21, 2010

5 Questions From the Road

There was a time when I was constantly in hotels, but business travel has thankfully become more scarce.  Having spent some time on the road over the past few weeks, I have come up with 5 pressing questions regarding hotel living.

  1. The hotel soaps now all seem to have shea butter.  There's much mention of shea butter.  What is shea butter and should I be happy that my soap has butter in it?  If I come into a room and see a label that indicates an ingredient of I-Can't-Believe-It's-Not-Shea-Butter, should I be disappointed?
  2. Why are the electrical sockets always hidden and full?  When I travel, I need to recharge my laptop, ipod, cellphone and camera battery.  But the sockets are always behind the furniture and low, down by the floor.  And it seems I always have to decide whether I want to lose the use of a lamp, the alarm clock or the TV in order to plug my stuff in.  Would adding an extension panel be so difficult?
  3. The in room coffee makers.  Every room now has one but do you actually know anyone who has ever used it?  The packet of coffee in my room could be used to swat at and seriously hurt a well proportioned feral cat.  I'm sure it's been sitting in the bin for a decade.
  4. If I walk into my local McDonald's and spend $2, I can sit there and access free wifi for seven hours straight.  Here in my several hundred dollar per night hotel room, I need to pay $10 for a day of internet usage.  Why?
  5. Shampoos now seem to feature eucalyptus and menthol.  Frankly, this is more than my sensitive scalp can tolerate as a burning head doesn't appeal to me.  If I wanted to rub Vicks VapoRub into my hair, I'd simply do that.  Whatever happened to shampoos that smell like flowers?
More serious trip reports are forthcoming.

Anybody remember these guys?

I'm seeing them this coming Friday night.

Their first album was exceptional, start to finish.  Second album also good and this time, critically acclaimed as well.  But, achieving success on your sophomore effort in the music business is tough plus record company woes buried them.  Later albums were full of beautifully crafted songs such as this one... most of which are undiscovered still.

Looking forward to Friday night.

The Happiest Place on Earth!

Says so in the brochure...

Here's Exhibit A.  Skies like this don't exist at home.

Monday, April 19, 2010

How NOT to play

Excerpts from DC presentation

I received a few emails and comments regarding this post and the fact that I photographed (unflatteringly) a copy of my remarks for the meeting I recently attended in Washington DC. I was asked if I would be willing to share the text. Here are some excerpts (it was meant to be delivered without reading directly from the page, so I veered off at times… here are the high points):

Good Afternoon and thank you for this opportunity.

My name is Rey Spadoni and I am the president of the VNA of Boston… and I am proud to state that we are now celebrating our 125th straight year of providing care to individuals in their homes in the Greater Boston area…

For 125 years, we have provided care all over the Boston area, including in some of the toughest neighborhoods and housing developments in the city. I myself have worked in the health care industry in Boston for almost 30 years and can say without hesitation that our nurses and physical therapists consistently go to places no one else will. And we take care of everyone, regardless of their payer, or any other, status. I would prefer to comment to you here today that such distinctions no longer matter in our society, but they do. Regardless of them, however, our organization treats everyone the same. With compassion, and respect, and state-of-the-art medical care services.

Our patients are, for the most part, very sick… the average age is about 70 for non- maternal child health services and 60 years of age, on average, overall. And they are sicker now than they were even just five years ago as hospitals are increasingly getting people out of the hospital faster. At the acute care hospital where I worked, we routinely discharged patients who just a few years ago would have been considered too sick to go home. And so, sicker patients are going home and we are increasingly being called upon to go provide care to them.

I mentioned that I have been in this field for 30 years. That has included serving as an acute care hospital executive, an HMO executive, I ran an inner city community health center and worked for a large physician group practice. Those types of settings are vital to the health care system, but I can say without doubt that the provision of high quality health care services in the home helps to keep patients in their homes longer… and out of those far more costly settings. When home care is done right, it is a bargain.

The fact is that the services we provide are an exceptional financial deal for the Federal government: we provide the highest quality care… at the lowest possible cost to the Medicare program for people needing post acute care services.

And that is just what we do for Medicare.

We also take care of a lot of Medicaid clients, which is a tremendous challenge, not only because they often come to us with complex social and economic circumstances that complicate their medical care, but also because the state who sets Medicaid payment rules consistently pays us at levels below our costs…

As has been discussed, the health care reform law that just passed includes some graduated reductions in Medicare payments to home health over the next few years. These have us concerned, not only in terms of how they will impact us in the long-term and our ability to care for our elder clients, but also on our ability to recruit and compete for nurses in a very tough medical marketplace in Boston…

It has us immediately concerned because, as has been discussed, the health care reform bill rightly includes some provisions and incentives for states to stop spending as much money on nursing home care and be more creative in terms of home based services. These are goals that we support on behalf of our patients who would prefer to stay at home with us rather than be in an institution. The data is compelling: patients who stay at home longer experience better health outcomes, it costs the Federal government less, and patients’ quality of life and personal dignity is enhanced.

But as I mentioned previously, right now at the VNA of Boston, which is already a significant safety net provider for the Commonwealth of Massachusetts for people needing long term care, we currently lose… on every nursing visit we make to a Medicaid client. And the Home Care Alliance has similar data for agencies in Lawrence, New Bedford and Springfield.

I come here today not specifically to ask Congress to help make state Medicaid payers become better payers for long-term community services, though that would obviously be appreciated.

What I am asking that you understand a few things broadly, and do a few things specifically.

First, please understand that how MEDPAC characterizes home health profits and home care in general is not indicative of the bottom line for a lot of agencies such as the VNA of Boston. I hope you can appreciate that we have a different story to tell. Please know that you cannot paint all home health agencies together with one broad brush. Not everyone strives to maintain the highest standards of measurable outcomes. Not everyone goes into every neighborhood to care for patients. Not everyone cares… for everyone. But, for organizations such as ours, we simply cannot sustain any further cuts than those already proposed and still continue to do what we do.

Second, please understand that home care agencies are the solution to many of the problems of health care costs we all saw and debated in the recent health care reform effort. I mentioned previously that I have worked in the hospital, insurance and physician group practice industries and I can assure you from my own experience that home care works. That home care makes sense. That it is a very important part of the solution. Please help us to preserve it.

Specifically, we need support with the complex issue of deciding who pays for home care when someone is dually eligible for Medicare and Medicaid. Without going into great detail here, home care agencies are stuck in an administratively costly tussle between states and the Federal government on this. In your packets is a letter signed by many in the Massachusetts delegation asking CMS to fix this. If they won’t do it administratively, we need your help with a legislative change. Lisa and Congressman McGovern have been leading the fight on this… and this is one we should be able to resolve.

Thank you for this opportunity today. Thank you for your past support. I hope you will remember one thing from my remarks and that is that home care is a viable mechanism to reduce costs and to improve quality. But not every home care agency is the same. On behalf of the ones who care for everyone in their service areas, the ones who are motivated by their missions, and the ones who effectively keep people out of more costly settings… we do need your help.

Thank you.

Saturday, April 17, 2010

An apology for Tro Lo Lo Lo...

This guy has it all...

I dare you to watch a minute of this and not be completely creeped out.

The Copy


The Orlando Sentinel reported on this a few weeks ago, but I just caught wind of it now.  Dr. Jack Cassell, a Mount Dora, Florida, urologist posted this on this door.  It reads: "If you voted for Obama, seek urologic care elsewhere.  Changes to your healthcare begin right now, not in four years."

What exactly begins right now, I might ask the urologist?

Per Dr. Cassell, he is not refusing care ("seek care elsewhere" might suggest otherwise) "because that would be unethical."

Everyone in DC last week (opponents and supporters) acknowledged that the new law is extremely complicated and that the work of implementation, including drafting thousands of new regulations, begins soon.  There are a lot of mandates and high arching goals, but the work of defining procedure and impact hasn't yet begun in earnest.  The politicization process is... clearly... well under way.

Wednesday, April 14, 2010

Miscellany from the Capitol City

I just attended the National Association for Home Care & Hospice Annual March on Washington. For those of you from obscure places like Buraydah, Saudi Arabia and Flekkefjord, Norway, this is me pictured with Senator Scott Brown (R-MA).  If you're from those places, see if you can guess which one is the U.S. Senator.  Hint: he's not wearing the goofy red name badge.

These days were dedicated to meeting with our delegation and advocating on behalf of home care and hospice, not really about drinking coffee and sitting in hotel ballrooms listening to experts talk about strategies for growing volumes or optimizing reimbursements for services, though there was some of that too.  Here, in no particular order, are some thoughts from the past four days.

  • There was a great deal of discussion about how partisan a society we've become.  My suspicion has been that we've always been a fairly partisan society, though the experts here have concluded that it's worse now than ever.  I wonder if majority parties always feel as though partisanship is "worse now than ever."
  • Paul Begala (Democratic strategist, Clinton advisor, CNN analyst) said that: "Demonizing Obama will fail, just as demonizing Reagan did."  Begala noted that liberals have tried for decades now to discredit Ronald Reagan but "it's just not sticking."  He predicts a similar fate for those who criticize the current President.
  • More from Begala:
    • Obama is "fundamentally a moderate" and "a pragmatist" despite his opponents' attempts to paint him as an extreme left winger.
    • Some free advice for Republicans: Move to the center and don't be defined by the Glenn Becks and Sarah Palins.  He predicts the emergence of a new centrist from the Republican party who will gain control of the party.  Without this, it will remain adrift.
    • Fox News is "killing" CNN, resulting in a major emphasis at the network to be "balanced".
    • When he teaches his Georgetown law students, he tells them to: "read something beyond your comfort zone."  Jeb Bush was once asked what he reads from the opposing side and he was able to quickly name publications, writers, and websites from the left.  Begala said: "I'll put my money on Jeb."
  • David Plouffe, Democratic strategist and President Obama's 2008 Presidential Campaign manager, addressed the group.  Here are the high points:
    • Demographic trends strongly favor the Democratic party, including the growth in Latino and African American populations as well as the fact that younger voters are increasingly involved and increasingly voting.  All those factors bode well for future elections for Democrats.
    • Partisan politics have become about self-interest, not about what's best for the U.S.  Some Republicans are "reaching across" and favoring Democratic initiatives.  They will be demonized in upcoming elections and specifically targeted by the Tea Party Movement.  
    • Communication is all about mobile devices now as we increasingly get all of our information from them.  The Obama campaign was the first in history to capitalize on this phenomenon.  Don't mistake the growing number of twenty and thirty year olds who have entered the workforce with computer skills as the sole driving force here; increasingly, people in their sixties and seventies are going on-line, often times for many hours per day.
    • FDR's Fireside Chats routinely secured an 80% radio audience.  Today's biggest presidential addresses garner a tiny fraction of that audience, partly because our focus today is not singularly on a world war... and also because we obtain our information about presidential addresses via television, re-broadcasts on hulu and youtube, via twitter feeds, on-line forums, etc.  The key here is that increasingly we are getting our information via second- and third-hand sources.  In the past, we needed to worry about securing communication channels.  Now, we worry about that and making sure we have secured the help of opinion leaders as well.
    • Video is king.  Websites need to have video and lots of it.  It gives people a reason to go back to the site and for those in the health and not-for-profit sectors, telling your story via video feeds is "the future."
  • Some of the traditional and (over-) generalized assumptions that Democrats support health care issues and Republicans oppose it were turned upside down.  Some of the loudest applause went to champions such as Susan Collins (R-ME) and John Thune (R-SD).  There was one interesting moment when Chuck Grassley (R-IA) gave a stirring anti-health reform speech, setting the tone for what will be a highly contentious implementation process.
  • Senator John Kerry (D-MA), long a champion of home care, spoke of his own recent health issues and need for home care, citing a deep appreciation for the role home care plays in keeping individuals out of the hospital.
  • Senator Scott Brown (R-MA), still in his start-up phase, will hopefully also become a champion.  More to come on this point...
  • There was a rousing protest outside the hotel this morning (who needs an alarm clock when there's booming Vietnamese language chanting from a series of loudspeakers that can do the job?) against Nguyen Tan Dung (don't quote me on that) who was apparently staying in the hotel.  The protestors did not wish good things upon Mr. Tan Dung and his family.

The last of the painted images...

If you've seen some of the posts from Washington DC, you'll know that I was experimenting with a new HDR (high dynamic range) technique, not necessarily a difficult one, though utilizing a point and shoot compact camera handheld is something that is quite difficult.  I'm not in love with the technique as it produces a "painterly" effect which can be quite take-it-or-leave-it.  Also, I'm not traveling with the ideal computer set-up for post processing, so it wasn't possible to manipulate the final versions as much as I would have liked.

More realistic photos are forthcoming...

Waiting for a Train

Monday, April 12, 2010

Four from the break in DC

Try the "Otuk Otuk", you'll love it...

The appearance isn't much to write home about, but the food was amazing.

I learned today that Washington DC does not have many Chinese restaurants and when I saw this Malaysian joint, I thought that it seemed close enough.  As you can see from the signs on the door, a lot of official sounding places have concluded that this one is alright, so I thought, alright.

Satay, delicious.  Curry puff, fantastic.  But the kicker was the Otuk Otuk.  I'm 90% sure that's what it's called.  It's a meaty substance wrapped in a green leaf and I didn't try eating the leaf because that was fairly uninviting.  The food inside was good.  Very, very hard to place, though.  I've narrowed it down to land creature.

Washington DC's Malaysia Kopitiam.  Highly recommended.

Note: If this is the final post on this blog, then you'll know perhaps things didn't pan out so well...

"iPad to the Rescue" AKA "The iPad Disaster"

Given my recent post about how the Apple iPad will move us toward a (nearly) paperless society, you'll note that I'm looking forward to receiving mine as soon as the 3G versions ship (still estimated as "late April").  

There have been a few times since being here in DC that I wished that I could have traveled with my future companion.  I had some prepared remarks for meetings on Capitol Hill and printed them out before leaving home yesterday morning.  Because I continue to work on them, I'm left with a set of sheets full of handwritten edits, cross outs and newly added text.  I can't easily print out a new version here and so I've been contemplating how this might have gone had I actually had an iPad with me.  I would have been able to make changes right on the device and then bring it with me to the podium today.  I could easily scroll through my notes for reference whenever I needed to make sure I was hitting the main points.  Who needs printing, I thought?  Who needs paper?  iPad to the rescue.

Well... wouldn't you know...

This morning, before heading via cab to the House office building, I decided to look at my notes one more time.  I placed them down on the glass top desk in the hotel room, whereupon sat my newly purchased "Ethos" Starbucks brand water bottle full of moisture from condensation.  I hadn't noticed the fairly decent sized puddle that I squarely placed the notes into.  A half hour later when I returned, I noticed the mess and saw many of my edits running down the page on the soggy sheets.  I decided to try to dry them out by the window, as this Blackberry photo shows.

Now had that been an iPad resting in a puddle for a half hour... total and complete disaster.

I can only hope my forthcoming actual field reports are more about rescue than about disaster.

Sunday, April 11, 2010

Is paper dead?

The Star Trek tricorder.  I always wanted one.  And with each progressive series and movie in that famous entertainment franchise, the devices became sleeker and seemed to be able to do more and more.  By "The Next Generation", Captain Picard carried a thin slate that seemed to replace any hint of paper anywhere.  Information streamed to it.  He could communicate with it.  It was just like... well, like an Apple iPad.

And so now, with the advent of real life tricorders, will all of us, like the crew of the Enterprise, forego all paper for such a thin slate?  My sense is: not quite yet.  But the reason is not necessarily what you think.

In terms of pure functionality, I believe the Apple iPad gets us 90% of the way to a paperless society.  90% of anything that any of us can do on a piece of paper, we can do better on an iPad, because of course an iPad can do much, much more.  And as I mentioned recently (see here), there are new tools emerging which seriously challenge the reign of paper, which originated back in Egypt with papyrus (about 2400 BC).  But why not 100% of the way there?  Well, there are times when you need paper to write on in places where batteries can't be recharged or weather conditions (tropical rain forests, icy climes) won't be kind to electronic devices.  But in the 90% scenario, an iPad will work just fine.

So, what's the real barrier then?  I suggest it's cultural and that we're only roughly 30% of the way there. Folks, myself included, like to take notes on pda type devices and laptops.  We like to look up information electronically and we prefer reading a blog or news coming from an RSS feed rather than having to pick up a last century style newspaper (shudder).  But, we always look suspicious when doing so.  As though we're not paying attention because we're playing an online version of Battleship (B4... you sank my destroyer!) or checking emails or posting on Facebook or whatever.  Recently, I was in a large group meeting and when someone cited a figure in a presentation that I suspected was incorrect, I popped open my Macbook and looked up the information.  The top lifted, I called up a file, I checked it out and then popped the top back down.  20 seconds tops.  But I received feedback later that I appeared as though I was disinterested in the actual discussion at hand.  Au contraire.

The Apple iPad is the first tricorder-like device that stands a chance at changing this cultural dynamic.  It will take early adopters and then a normalization phenomenon (as happened with GPS devices, cellphones, fax machines, telephones, automobiles, papyrus...) for people get used to the idea that those toting a device are, in fact, present and available.  When this happens (over the next five years), then paper's days will surely be numbered.

Now I have to get back to the meeting I'm in.

A8.  Hit.

Blogging from the train

It occurred to me as I typed the title of this post that as recently as 10 years ago, the phrase "blogging from the train" would probably have been met with a curious "doing what from a train?"  The term blog wasn't as widely used or understood just a decade ago, never mind the idea of actually being able to do so from a moving vehicle.  But now that wifi and fast 3G connections are prevalent, I suppose it's possible to blog from just about anywhere.

In honor of that fact, I'm now blogging to you live from a charging Amtrak train headed to Washington DC.  I'm spending the next four days at the National Association for Home Care & Hospice annual "March on DC" where we'll have an opportunity to present to members of our congressional delegation and their staffs on issues pertaining to our industry.  I'll have an opportunity to talk about the Visiting Nurse Association of Boston and the likely impact of proposed changes to Medicare reimbursements over the next few years.  I'll cut to the chase - it's not good.

The schedule is quite full, so I don't know whether I'll have any opportunity to blog real time or whether it will have to wait until I'm on the Acela Express headed back toward Boston.  In any event, I'll let you know how it goes.

A quick note about the photo above.  I shot it quickly with my little point & shoot camera and upon full screen inspection, the shot appeared dull and unexciting.  Which means it cried out for some computer manipulation.  Thought I'd give it a classic charcoal effect.

Why a train to DC?  Though it takes a bit more time, the hassle factor is substantially less than flying in my experience.  Because it's a Sunday and the first meeting is not until 3:00 today, I have the luxury of time. And in my experience, when you factor in dealing with the ever increasing challenges of air travel, including airport transfers, security, etc., and the fact that the end-to-end train stations are quite close to home and destination, the time it takes to go via train is only fractionally greater.  Coupled with the availability of wifi internet and big, spacious seats, it's a more civilized way to go.

UPDATE:  Seconds before hitting the "Publish Post" button, a booming voice just announced that "car 6 is disabled", meaning that we're headed back to the last station to ditch it.  This gives us an approximately one hour delay.  So much for civilized...

Thursday, April 8, 2010

THE killer app for iPad

The alternate title for this post is: "A glimpse at the future."

PCs had been around for a while but not many people thought they needed one.  But then the "killer app" appeared and then everyone wanted one.  That app?  The Spreadsheet (namely Visicalc).  The Mac was languishing as a failed product idea... until its killer app fueled its famous growth.  That app?  Desktop publishing (namely Pagemaker).

Now that we have a new platform which has sold hundreds of thousands of units in its first few days, often sight unseen by its buyers, many are speculating on whether there is an iPad killer app.  Cases are being made that the killer app relates to media distribution, namely electronic delivery of tv shows and movies.  Others are saying that it's electronic books.  Others believe it's a collection of regular desktop and laptop apps that can now simply be used on a smaller, lighter and more intuitive device.

But I wonder if the answer to this question pertains to note taking, that thing we all do when we got to meetings, class, get ready to go food shopping, plan out our weekends... you get the point.  I'm a big note taker and have been using the amazing program Evernote for a long time.  It's a great way to store information, all kinds of information, on your phone, PC, or Mac.  The magical Evernote "cloud" keeps everything in sync so that all you enter at your home Mac will appear perfectly the next day at your work PC.  Being able to quickly look up information on your Blackberry or iPhone is invaluable and something I've found I can't live without.

Enter the new Evernote for iPad.  This 3 minute video will bore non-techies to tears and the kerplunky music will get under your skin.  Despite all that, however, I suggest that what you're about to see right here represents the future...

Wednesday, April 7, 2010


Nurse 1935 #2

(Visiting Nurse Association of Boston Photo – 1935)

I was merely a visitor there.  I had the luxury and benefit of being able to descend down the long flights toward the car and eventually into my own more comfortable reality.  I was only a guest. 

During my first month with the Visiting Nurse Association of Boston, I did what most of our new employees do: I visited homes with several of our talented and deeply committed clinicians.  I wrote here on several occasions about those early experiences (those specific posts, in fact, inspired the creation of this blog), none of which were more moving than the MCH visits.  MCH is our Maternal Child Health program, which is focused on caring for newborns and their moms.  Typically, this care is directed toward children with multiple health challenges and problems… and families who are often completely overwhelmed by them.  On those visits, I had the privilege of witnessing awesome care and compassion and even though I had the liberty of an exit, for me, it still felt overwhelming.

As per our website:

The VNAB MCH program is comprised of highly skilled obstetrical and pediatric nurses who provide home care services to women with high-risk pregnancies, premature infants, children with acute, chronic or terminal illnesses’ as well as early maternity discharge.

The MCH Team intervenes at critical junctures in a family’s life and has the opportunity to be in a setting no other members of the health care team are likely to enter—the patient's home.

Examples of VNAB MCH TEAM referrals include:

  • High-risk prenatal and postpartum care
  • High-risk infants, including prematurity, NAS
  • Infants or children with cardiac anomalies
  • Infants with feeding problems
  • Breastfeeding difficulties
  • Early Maternity Discharge visits
  • C-Section wound care
  • High-risk teen moms and infants
  • Children and adolescents with cancer
  • Children and adolescents with diabetes or asthma
  • Environmental assessment for asthma triggers

Recently, Maria Dunn, manager of the MCH program at VNAB, presented to the senior team our newly developed MCH program focused on caring for babies with congenital heart defects.  The program is specifically designed to improve outcomes for these babies and prevent unnecessary re-hospitalizations.

To that end, we’re collaborating with several Boston area health care organizations, launching new pre-op and post-op standards of care, and ensuring consistent and high levels of competency for all staff via formal certification processes.

Though we’ve been stepping into homes and caring for infants and their mothers for 125 years, our organization continues to develop and launch modern, state-of-the-art programs for the communities we serve.

For more information, please send us an email at

Same picture, this time in B&W

I was so inspired by the work of this guy, that I decided to grab a recent photo and attempt to render it in black & white to similar effect.

Does it work?


Tuesday, April 6, 2010


Rushing by and looked up.  Pointed my tiny point and shoot camera in this direction and clicked.  It was raining pink flowers and spring is here.

“Now What?” asks Dr. Gawande

atul-gawande (photo courtesy of Reflective Design)

Atul Gawande, Brigham & Women’s Hospital surgeon, Harvard School of Public Health professor, and author for The New Yorker and other publications asks a simple question: AND NOW WHAT?

I once commented here on a brilliant piece by Dr. Gawande regarding the wildly high medical costs in McAllen, Texas and suggested that anyone who would like to become educated on this issue ought to read this particular work.  It’s illuminating and balanced and can be found by clicking here.

Now, given the passage of the health reform law and the mounting public pressure and likely political response to quash it, this physician author offers some perspective… and history… in the latest The New Yorker.  Here’s the link.


  • We have much to learn from the 1965 passage of the Medicare bill and the raucous build-up and aftermath.  Physicians, hospital and others were convinced it would be the end of the U.S.  It wasn’t.
  • The Patient Protection and Affordable Care Act (you know it as “ObamaCare”) could, in the author’s words, “prove as momentous as Medicare.”  But, there are some key differences:
    • The phase-in will be much slower this time
    • No key groups are specifically against it (as the docs and hospitals were in 1965); rather, this is about overall public opinion and political battling
  • The primary argument against the new law is that we can’t afford it.  Dr. Gawande suggests that the best way to “protect reform” is to prove that assertion wrong.  When Medicare came into existence, health care spending was six percent of the GNP.  Today, it’s 18 percent.  Left unchecked, we can’t sustain this continued increase and it will likely negatively impact our future economy in dramatic and harsh ways.
  • And here’s the most important point (and one I’ve made on this blog): the new law does not pretend to solve all the problems.  Rather, it creates new mechanisms and forum in which we can, together (and subject to public input and political processes) more effectively address them.

The anti-reform chorus continues to chant that this is about government takeover of health care.  But I see quite a bit in the package about public empowerment and private sector partnerships designed to fix what’s currently broken.

There may be good reasons to kill reform, but fear of a government take-over and ultimate affordability are not highest on that list.

Monday, April 5, 2010


Thank you DonnaT

I know a Donna T., but I have absolutely no idea whether the one who suggested "the third word" (see post here) is her or not.

In any event, in the post linked above, I mentioned that the tag line for this blog was missing a third word.  It presently (for another 5 minutes anyways) reads: "home care, images, etc." and I've been contemplated what to replace "etc." with.

DonnaT commented on the post and suggested "home care, images, impressions" and it works.

So, thank you DonnaT, wherever you are.

Friday, April 2, 2010

The iPad is everywhere!

2apr10oub24tletterIt's not technically out until tomorrow (the wifi version anyways), but the iPad is making its way around various media outlets and meeting with a great deal of critical acclaim.

And Dave seems to really like his.

Good day...