Thursday, December 30, 2010

Our new website with Upstate

Community General Hospital and Upstate Medical University have started a combined website, a joint project to help keep everyone informed as we plan to combine the two hospitals in 2011.

Happy new year!

Tuesday, December 28, 2010

Medicine's limits, and patient needs

There was a small, important article in Bloomberg News last week by David Klein, the CEO of Excellus, the large BlueCross BlueShield insurer in Upstate New York.

Mr. Klein discusses lessons learned during his wife's battle with cancer. He speaks plainly about what must be a very confounding and very emotional period in their life together. He notes that sometimes "clear answers don't exist" in medicine, despite the best research and despite the care of able practitioners.

David Klein's article emphasizes both the human and the humane: respect for the art of medicine, not just its scientific content, and the importance of emotional and spiritual support in patient care.

These are important reminders for professionals and lay people alike.

Friday, December 24, 2010

Today's poinsettias

The poinsettia plants being delivered to patients today remind me of the generosity of Morris Berman, one of the founders of Community General Hospital.

When he was alive, Morey Berman, a prominent Syracuse attorney, would call Community General Hospital each December and request that poinsettias be given to any patient who was otherwise without flowers over the holiday season.

"Send the bill to me," Morey would say, but he never wanted credit for the gift. "Just enclose a card saying, 'Happy holidays from the Board of Directors.'"

That's how I first met Morey. I was usually the guy receiving his call, and I would work with nurses to identify patients and make arrangements for the flowers.

As a young lawyer, Morey Berman chaired the 1957 study that resulted in a new Community Hospital of Greater Syracuse opening on Onondaga Hill in 1963. I wrote about this history a few years ago.

Morey's brother, Dr. Leon Berman, was President of Community's Medical Staff (1965-1967), and Morey served as Chairman of the Board of Directors (1970-1973). What a remarkable family that produced these siblings!

This morning, when I saw the poinsettia plants filling a conference room at the Community General Foundation, I remembered Morey Berman and his thoughtfulness for hospital patients. In the years since his death, an anonymous donor has continued the poinsettia tradition at Community in Morey Berman's memory.

Sunday, December 19, 2010

Holiday tea

My thanks to all who made the annual Holiday Tea so enjoyable last week, especially the Food Service and Human Resource Departments. Those departments work each year so that the rest of the Community General Hospital family can enjoy the season and one another's company.

Saturday, December 18, 2010

ACOs as "inside baseball"

Local hospitals and physician groups are talking about accountable care organizations (ACOs), the somewhat mythical structures that are envisioned in the Protection and Affordable Care Act (PPACA), also known as "health care reform."

I say "somewhat mythical" because ACOs do not actually exist. . . at least, not yet.

PPACA encourages providers to form ACOs so they can benefit by sharing a percentage of savings they generate for Medicare. An ACO, according to PPACA, is “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in Medicare’s traditional fee-for-service program.”

The Centers for Medicare and Medicaid (CMS) says that ACOs may be started by physicians, by medical group practices, or by medical practice networks. They may be partnerships or joint ventures involving hospitals and physicians, or it may involve hospitals employing physicians.

I recently posted comments about hospitals that have bought medical practices to "align physician and hospital performance" for health care reform. Purchasing medical practices is a likely step toward the formation of ACOs in Central New York.

CMS says it will establish the ACO program one year from now -- on January 1, 2012. Right now ACO polices and standards are in the developmental stage. CMS has asked for public comments about ACO characteristics and functions. At a workshop in October, CMS (with the FTC and the OIG) promised to develop safe harbors for ACO structures. “Safe harbors” are legal structures that have automatic clearance from government anti-trust laws.

One of the confusing things about ACOs, as I understand them, is their invisibility to beneficiaries and patients. The providers who join an ACO would not apparently have to tell their patients about it. Nor would any patient be obligated to seek care only from the ACO providers.

ACOs are expected to save money by better care coordination, such as preventive care, early treatment, avoiding duplicate tests, etc. But Medicare beneficiaries would not know that their care is being coordinated within an ACO network. As CMS explains, “[a]ssignment [of the individual to an ACO] will be invisible to the beneficiary, and will not affect their guaranteed benefits or choice of doctor. A beneficiary may continue to seek services from the physicians and other providers of their choice, whether or not the physician or provider is a part of an ACO.”

Although not “enrolled” in an ACO, beneficiaries would somehow be “assigned” to one. Exactly how assignment might work is the subject to public comment – see the recent Federal Register (November 17, 2010).

It may seem that managed care plans, which have been around for decades, offer models for ACOs. But is that the case? Beneficiaries who are enrolled in managed care plans know it. They have "gatekeepers" who actively or passively coordinate their care, determining whether care is covered and which providers are eligible to provide the care. Managed care also presumably confers a vale for individual beneficiaries through lower premiums or co-pays.

If I understand the ACO concept correctly, providers will be responsible for the cost of all the care beneficiaries receive

- even if those beneficiaries don't know their care is being coordinated within an ACO network;

- even if beneficiaries are not obligated to get their care from the ACO's providers; and

- even if beneficiaries experience no personal advantage by being assigned to an ACO.

A recent white paper about the 30-year experience of managed care in California suggests that “efforts to apply care coordination techniques to the open choice . . . environment have not been successful.”

The author James Robinson, Director of the Center for Health Technology, recently told Modern Health care magazine that beneficiary choice poses a major obstacle to care coordination. He called it "the biggest challenge to ACOs. . .”

Discussing ACOs may seem a bit like talking inside baseball. This is an active topic within the health care industry. Decisions about player changes shape next year's baseball season. Watching CMS decision-making will help us understand the impact of ACOs on Medicare services and costs.


Saturday, December 11, 2010

Remembering Bastogne

December 13. That is the date that begins the story told by Dr. John Prior about his experiences in Bastogne, Belgium in 1944.

A few years ago I posted Dr. Prior's
memoir about the Battle of the Bulge. This is a fitting time of year to recall his story.

I recently heard about this episode in history from
Martin King, a British author who is finishing a book about Bastogne, based on the experience of Augusta Chiwy.

Ms. Chiwy is one of the nurses who worked with Dr. Prior when their aid station in Bastogne took a direct hit from a German fighter-bomber on Christmas eve, 1944. Thirty American soldiers died in the aid station, along with one of the nurses, Renee Lemarie.

Augusta Chiwy survived the blast and is still living.

Dr. Prior passed away in Syracuse, NY at age 90 in 2007.

That's a young Captain John Prior, pictured at right, when he served with the Medical Battalion of the 10th Armored Division. At left is Dr. Prior in the 1980's as Chairman of Pathology at Community General Hospital. He also served as President of the Onondaga County Medical Society at the time.

Episode 6 of the HBO television series Band of Brothers includes scenes in the aid station in Bastogne, and both Augusta Chiwy and Renee Lemarie are portrayed briefly in the dramatization (but not Dr. Prior).

Mr. King wrote me that Dr. Prior features prominently in his book about Augusta Chiwy. "The lives of Dr. Prior, Augusta and Renee Lemaire will always be inextricably linked due to the sequence of events that occurred in Bastogne during WWII," Mr. King said.

"I can't emphasize enough the major role that Dr.Prior played with the 10th Armored division . . . . His bravery and tenacity saved literally hundreds of US lives. Augusta remembers him with great affection."

That's a photo of Augusta Chiwy, at right, as a young woman. Below is a brief video about her that was made recently by Mr. King. I look forward to reading his book when it is published.

Monday, December 6, 2010

Dr. Joe Smith, 1946-2010

Dr. Joe Smith died Saturday.

Joe suffered much these past two years, a consequence of the accident that left him paralyzed in 2008. He was in and out of the hospital frequently, and it was easy to get discouraged. He acknowledges being discouraged -- and also being extremely grateful -- in his last, inspiring message. It was posted yesterday on the website of Syracuse Orthopedic Surgeons (SOS).

Joe was supported by a great family, especially his wife Carol, and his children. Carol cared unselfishly for Joe though all the difficulties. Joe was also supported by his friends, a loyal and steady tribe, many of whom have known him from childhood. They stayed in touch, visiting him, offering words of encouragement, helping the family.

When he retired as an orthopedic surgeon in 2005, Dr. Smith was a larger-than-life figure, having succeeded Dr. Bob Lockwood as Chair of Orthopedics. He was honored with an award from the Community General Foundation, and he served on the Community General Board of Directors.

After retirement, Joe loved to work in his garden. It was an avocation he shared with his father-in-law, about whom Joe always spoke with much affection and respect. Joe often brought a box of fresh vegetables when we met for lunch at Luigi’s Restaurant on Valley Drive. Luigi's was one of his favorite haunts.

Last January at the dedication of Community’s new Center for Orthopedics, speaker after speaker paid tribute to Joe, whose leadership helped shape orthopedic excellence at the hospital. Later that day, I gave a DVD copy of the dedication ceremony to State Senator John DeFrancisco, Joe’s high school classmate and lifelong friend. He took the disc with him when he visited Joe the following day. It was great that Joe was able to hear the words spoken in his honor and to see the new Center, “but it was very bittersweet to sit and watch it with him,” the Senator later told me.

“If you are reading or listening to this,” Joe writes in his final message, “I am no longer present in this world but hopefully moved on to a better spiritual place. I’d like to thank you, I’d like to thank everyone for their help and consideration and especially their love.”

Our thoughts are with you, Joe, and with Carol, your family and your friends.

Tuesday, November 23, 2010

Our thanks this year

The Thanksgiving quilt is being displayed throughout Community General Hospital. This is a graphic tapestry displaying expressions of gratitude by employees, volunteers, and other members of the Community family.

Leading the things for which we are thankful, as in past years, are the love of family and friends (almost one-half of all comments), our jobs and coworkers (about one-fifth), and our faith, life, and health (about one-fifth).

Others are thankful for men and women in military service, for our doctors, for Community's partnership with Upstate Medical University, for the Syracuse University football team's bowl prospects -- as well as for baseball, for ice cream, for doe permits, and for the copier machines!

There are three Thanksgiving quilts posted throughout the hospital so be sure to see them all. You can read the individual comments by clicking on each of the three displayed here.

This is the fourth year we've displayed the quilts at Community General, and we borrowed the idea from Peter McGinn, past President of UHS in Binghamton, NY.

Sunday, November 14, 2010

Dr. McCabe and I meet at Community

Dr. John McCabe and I held a series of meetings with Community General Hospital employees last week. Our thanks to all who attended, asked questions and offered comments.

Each meeting began with my introduction of Dr. McCabe, who is not known to most employees. Dr. McCabe briefly reviewed his background, and he talked about his philosophy of hospital management: to employ capable people and to provide the resources to help them do their jobs. He acknowledged the technical and professional expertise of hospital employees. He said he understands and appreciates that patient care depends on each individual’s competence and caring.

I told employees who attended the meetings that Dr. McCabe and I have worked closely together throughout the summer and fall, and we have developed mutual confidence and respect.

I briefly reviewed the reasons why Community is interested in combining with Upstate University Hospital as referenced in comments about discussions with Upstate and buying medical practices.

I reviewed some of changes that are expected to affect hospitals and doctors, and I reminded employees about the areas our Board of Directors has determined to be important: the need for future investment in facilities and medical technology, the need for more options and opportunities to work with physicians, and the need for larger scale operations to achieve greater efficiencies and access to resources.

I said that Community's Board is interested in the future role of the hospital in providing quality care to the populations we have traditionally served through emergency, inpatient and outpatient services. Community’s goal is to build upon the traditional assets developed over decades, namely, the private medical staff, the skilled work force, and the property, plant, and equipment.

Dr. McCabe said that Upstate has similar and complementary goals. Upstate has a very high occupancy rate, upwards of 90% -- and Upstate is growing. As a result, Upstate needs more acute care beds, and Community has acute care capacity. The ways in which Community’s physical infrastructure and its licensed capacity can help address Upstate’s growing needs are being actively explored. He said the goal is to have a single hospital with two campuses.

Upstate’s educational role will expand in the future as more physicians, midlevel practitioners, and allied health professionals are needed. The Community campus would maintain a separate identity within the Upstate system and would participate in Upstate’s academic role. The extent of educational involvement would vary, depending on the clinical service and the interest of private practice physicians and health practitioners.

Dr. McCabe said Upstate recognizes the role and importance of the private, voluntary medical staff at Community and seeks to foster such private practice. In areas where services can be improved by a combination of private staff and university physicians, Upstate is willing to cooperate – examples include the current hospitalist service and cardiology coverage. If private practice is not able to provide a service, Upstate would do so (for example, intensivist services).

How to bring together the two medical staffs has not yet been determined, and initial meetings have been held with Community physicians to begin considering the issues. More work will be done in this area over the next several months.

Upstate has made significant progress in conducting due diligence on Community General. “Due diligence” is the process of investigation and discovery that two parties undertake before they enter a transaction, such as a merger, acquisition, or joint venture. Over the summer months Community and Upstate shared various documents with each other, allowing attorneys, accountants, and other experts to understand and evaluate business practice, finances, legal contracts, property conditions, etc. Dr. McCabe estimated that Upstate has reviewed more than one quarter million pages of Community's documents and has not found obstacles to the planned combination.

Research and analysis continue in the areas of clinical services and workforce. There are various models for consideration, and Upstate is actively examining them. Dr. McCabe and I met with representatives of 1199SEIU earlier this month to hear their interests and concerns, and Dr. McCabe said that he has had a similar meeting recently with the representatives of the unions active at Upstate.

Dr. McCabe said the timeframe for combining the hospitals is next year, possibly by mid-year. This is, of course, subject to the extensive review and approval process involving various government regulatory departments. This would include Certificate of Need (CON) approval by the state Department of Health. When the project is approved in 2011, the process of combining hospitals would begin. This process would likely take place over a period of years.

There were a number of questions from employees. These ranged from “What will happen to my position if the two hospitals come together?” to “Would you continue to be interested in a consolidation if the federal government slows down or stops health care reform?”

In the first case, it is too early to say how positions might be organized. This relates to the study of clinical services and workforce needs that remains to be completed. In general, the combination is likely to make the Community campus more busy, not less busy -- and that would be good for jobs.

To the second question, the answer is “Yes, even without federal health reform, the hospitals’ combination makes sense.” The economic forces facing hospitals and doctors are well underway and are likely to continue, despite what the next Congress may or may not do in the next year or two.

Dr. McCabe and I heard many encouraging comments about preparing for the future challenges and opportunities. I appreciate the good attendance and the constructive comments from employees.

The Community family made Dr. McCabe feel welcome, and he was pleased to hear good comments about the Upstate-affiliated physicians who have joined Community's medical staff this year.

Saturday, November 13, 2010

It's official

Community General Hospital has been officially re-accredited by the Joint Commission.

This means our hospital operates in conformance with policies and procedures that meet accreditation standards.

As previously reported, the accreditation survey identified areas where Community could improve. Community's staff addressed each and every area within the time frames required, and the Joint Commission issued its certificate this week, dating from the time of our site survey.

Friday, November 12, 2010

Their good work in Tela

It's a wonderful thing that Dr. Tom Haher and Physician Assistant Steve Keib did recently. They both returned from a week of humanitarian work in Tela, Honduras.

Before they left, they stocked up on supplies and materials from Community, which were put to good use in helping care for children at Hospital Tela. The family income in Tela is only a few hundred dollars a month, and Dr. Haher has been part of a voluntary program to bring medical care to Tela for 15 years.

That's Dr. Haher kneeling in front of Community's logo with Steve Keib third from left. Both are part of Syracuse Orthopedic Specialists in Syracuse, NY.

Sunday, November 7, 2010

Employee meetings tomorrow

Since the poster appeared last week, several have asked me,"What's the big announcement?"

No big announcement -- just a progress report on the journey Community General and Upstate University Hospitals are making to become a combined hospital.

This round of meetings gives employees the opportunity to meet Dr. John McCabe, the President and CEO of University Hospital, and to hear him discuss our progress.

NOTE: Because of a conflict, Dr. McCabe will not be able to attend the 2 p.m. meeting, as planned. The other meetings will proceed as scheduled.

Dr. McCabe was appointed President & CEO at University Hospital and Senior Vice President for Hospital Affairs at Upstate Medical University in August 2009. He has been at Upstate for more than two decades and developed its Emergency Medicine residency training program. Dr. McCabe served as Dean at Upstate Medical University for six years in the 1990s. His national leadership positions include serving as Chair of the Board of Directors of the American Board of Medical Specialties, the organization that oversees the certification of physician specialists in the United States.

Dr. McCabe has served as editor of the journal, Resuscitation. He is a Past President of the American College of Emergency Physicians. He has served as a member of the American Board of Emergency Medicine since 1996 and is on its Board of Directors.

Dr. McCabe attended medical school at the SUNY Upstate Medical University, completed his internship at the Charles F. Kettering Medical Center in Kettering, Ohio, completed his residency in Emergency Medicine at Wright State University School of Medicine in Dayton, Ohio.

For those who cannot attend the meetings, I will provide a recap in several days.

Friday, November 5, 2010

Buying medical practices

Today's Post-Standard carries a story about St. Joseph's Hospital buying a primary care practice. This comes on the heels of a story in September about Crouse Hospital's practice acquisition.

So the question is: "Will Community General Hospital be buying practices too?"

The issue is not practice acquisition per se. The issue is developing alignment strategies to help hospitals and doctors work more effectively in the future.

Many changes are expected in health care, and Community's strategy is to seek a merger partner - Upstate University Hospital - to help meet those changes.

▪ New York hospitals, with physical plants that are among the oldest in the country, need to make investments as they replace aging infrastructures, purchase medical technology, and develop electronic medical records. To be economical, such investments need to be spread over a large base of operations. Preparing for the future is largely a question of having sufficient scale to undertake such investments. This means being larger than a stand-alone hospital.

▪ Hospitals in New York generally have weaker financial operations than most of the country. And Medicare payments will be reduced dramatically in the coming years so hospitals have to become more efficient. Syracuse hospitals are already among the most efficient statewide so, again, hospitals face issues of scale, of spreading their fixed costs over operations that are sufficiently large.

▪ Hospitals and doctors will need to better coordinate care, not just hospital care but wellness care and prevention, access to primary care and specialty doctors, and transitions among outpatient, hospital, and post-hospital services – in other words, we will need more integrated delivery systems.

Through Community's merger planning, we expect to enhance the ability of private practitioners to care for patients. But we realize not all physicians will remain in private practice in the future, nor will all doctors coming from residency training want to join private practices. Our affiliation with Upstate will bring Community more options for doctors.

Employing many physicians is a huge task, a huge investment, and a huge risk for a stand-alone hospital. Hospitals in Syracuse and elsewhere have failed at this before.

That’s why Community is developing the initiative with Upstate, with its larger base, its broader specialty panel, and its established employment opportunities – at the same time we continue to work with private practitioners.

Saturday, October 23, 2010

Wow, Fall Harvest Gala tops $300,000

The photo shows the lobby of the Hotel Syracuse yesterday evening. That's the logo of Community General Hospital, as ice sculpture, in the center. The occasion was the Community General Foundation's Fall Harvest Gala where three individuals and organizations were recognized for their service to community.

Dr. David Halleran (in photo below, at right) was honored for his service to Community General Hospital and its Medical Staff. Specifically cited were his work as a surgeon, his humanity in caring for patients, and his focus on collaboration as a physician leader.

Also recognized was Onondaga Community College and its President Dr. Debbie Sydow (third from right) for the excellence of OCC's School of Nursing and its important role in our community.

Saluted for corporate citizenship was Excellus BlueCross BlueShield of Central New York, which has long supported health education, health planning, and quality improvement initiatives within the community. Receiving the accolade for Excellus was Dr. Arthur Vercillo, Regional President (fourth from left).

A special gift of $56,000 was presented by the Auxiliary to Community General Hospital by its President. John Stafford (at left).

With the Auxiliary, the Foundation raised $302,000!

I sincerely thank all who made the 2010 Gala such a success:

Diamond Sponsor

Platium Sponsors
Laboratory Alliance of CNY LLC

Gold Sponsors
Advanced OB-GYN
Bond Schoeneck & King PLLC
Upstate Medical University
Welch Allyn

Silver Sponsors
Colon Rectal Associates
ConMed Corporation
Crouse Radio9logy Associates
Dr. David Halleran
Onondaga Hill Pathology
Practice Resources LLC & FamilyCare Medical Group PC
Realty USA
Rural Metro medical Services
Dr. & Mrs. Edward Schoenheit
SOS Syracuse Orthopedic Specialoists
Visual technologies

Also much appreciated were the many Bronze, Copper, and Patron Sponsors, along with individual donors. Your generosity is greatly appreciated! Thanks also to Foundation Chair Scott Matukas, Byrne Dairy (second from left), and Gala Committee co-chairs Rebecca Norr-Hartman, Welch Allyn (third from left) and Mark Re, RealtyUSA (second from right).

Friday, October 15, 2010

Go SU!

Community General Hospital employees salute Syracuse University!

Saturday, October 2, 2010

Bacterium, beware

At a recent meeting of Community General Hospital's Quality Committee, Chairman Dr. David Tyler made the following comment after Sue Chamberlain concluded her report on infection control:

"If I were a bacterium, I would be very scared to see Sue in my neighborhood."

Sue Chamberlain, Community's Director of Infection Control Program at Community General Hospital will be honored November 1 by the Onondaga County Medical Society.

I have written many times about infection rates. Thanks to Sue -- and her colleague Dr. Mitch Brodey, Infectious Disease Officer -- Community's infection rates are well controlled, and our compliance with surgical infection protocols is strong.

The hospital's staff posts immunization rates that are among the best in the county, and compliance with hand washing policies by employees and physicians are consistently well above average.

Sue is routinely consulted for her infection control experience by the Department of Health and by other hospitals -- and now she will be honored by the Medical Society

I thank the Medical Society for recognizing Sue for her expertise and accomplishments.

Monday, September 13, 2010

Community at the Cookoff!

Community General Hospital's team took first place in the United Way's Kickoff Cookoff! last week at the CNY Regional Market. The winning entry was a chocolate-banana-graham cracker icebox cake (recipe, below).

Community took first-place Cookoff! honors in 2004 with the "famed Friday" macaroni & cheese. Since then, our team has settled for second place finishes with chili (2005), chicken wings (2006), and Jello prism dessert (2009).

That's Community's team in the photo with their bucket hats, tie-died shirts, and the Big Banana (really, John Carnowski). Others in the photo are, from left: Hector Ramos, Pauline Warboy, Mark Siegel, Judy Piedmonte, Jeanne Waldron, Tracey Fenner, and Kristin Schofield.

Here is how to make the chocolate-banana-graham-cracker icebox cake:

Makes one 5-by-10-inch cake
Serves 8 to 10.
• 15 ounces milk chocolate, chopped
• 5 large egg yolks
• Salt
• 3 cups heavy cream
• 20 graham cracker sheets
• 4 or 5 ripe bananas, very thinly sliced lengthwise
• Garnish: whipped cream

1. Line a 5-by-10-inch loaf pan with plastic wrap. Place chocolate in a heatproof bowl. Place yolks and a pinch of salt in another heatproof bowl.

2. Bring cream to a simmer in a medium saucepan. Slowly pour cream into bowl with yolks, whisking constantly; return mixture to saucepan set over low heat. Cook, stirring constantly, until mixture is thick enough to coat the back of a wooden spoon, about 8 minutes (mixture should not come to a boil). Immediately strain through a fine sieve set over chocolate; stir until chocolate melts and is smooth. Refrigerate, stirring occasionally, until thick, about 4 hours.

3. Spread 1 cup chocolate mixture evenly into bottom of loaf pan. Top with a layer of 4 graham crackers, trimmed to fit. Spread 1/2 cup chocolate over tops, and cover with some bananas. Spread 1/2 cup chocolate over bananas, and top with a layer of 4 trimmed graham crackers. Repeat with remaining chocolate, bananas, and graham crackers until you reach the top of the pan; finish with graham crackers.

4. Cover with plastic wrap, and refrigerate overnight. Uncover, and turn out onto a serving platter. Remove plastic wrap. Garnish with whipped cream, and cut into slices.

Saturday, September 11, 2010

Saturday, September 4, 2010

Medicare's "flawed formula"

Dr. David Page recently had a call-to-arms message in the Post-Standard. He spoke about a pending 30% cut in payments doctors receive for taking care of Medicare patients. Here are excerpts from Dr. Page's letter-to-the-editor.
America’s 46 million elderly and disabled patients, as well as military families, are at the center of what once was a yearly battle to preserve their access to health care. This year, that struggle became a quarterly — and at times a monthly — skirmish that has damaged Medicare’s credibility among patients and their doctors.

At the core of this struggle is a flawed formula that controls what Medicare pays physicians for the care of elderly and disabled patients.

* * *

By law, the formula required Medicare to slash physician payment by more than 21 percent this year. Congress knew such a cut would devastate elderly and disabled patients’ access to health care. So legislators have stumbled through this year — at first delaying the pay cut for a few weeks, then allowing the cut to take effect for a few weeks, then stepping in to pass a temporary, retroactive pay fix, then allowing the cut to take effect again before passing a second, temporary, retroactive fix.

This latest fix — without another Congressional intervention — will end Nov. 30. Worse, physicians will face a 30 percent pay cut next year.

This unrelenting threat is destabilizing the Medicare system for patients whose doctors — particularly primary care doctors — work in small- and medium-sized practices, often in underserved areas and with small or no operating margins.

* * *

No other sector of the health care system is routinely subjected to this variability and uncertainty. It’s time to end the month-to-month uncertainty that undermines patients’ confidence in Medicare and disrupts physicians’ ability to provide ongoing care. It’s time to infuse some stability into a system on which more than 46 million Americans depend.
Dr. Page is a family physician who practices in Camillus, NY. A long time member of the Medical Staff at Community General Hospital, he serves on the hospital's Board of Directors. He is President of the FamilyCare Medical Group, PC, which was honored last year by the Community General Foundation. Dr. Page is Vice President of the Onondaga County Medical Society.

Friday, September 3, 2010

Again, Community has low rates of infection

Earlier this week the New York State Department of Health reported infection rates for hospitals statewide.

Community General Hospital has again posted low infection rates when compared with other hospitals, both statewide and locally.

For colon surgery infections, Community had statically significant low rates of infections. For hip infections and central line-associated blood stream infections (CLABSI), Community's infection rates were well below the state average. The charts below show CGH's infection rates in comparison with the three other non-federal Syracuse hospitals, labeled A, B, and C.

The source of these data is the Department of Health's report Hospital-Acquired Infections, New York 2009.

Ice cream for volunteers

Each year some 475 volunteers donate about 55,000 hours of service at Community General Hospital.

Community's staff recently acknowledged the everyday contributions of volunteers with a late summer ice cream treat.

Thank you, volunteers.

Sunday, August 22, 2010

Our welcome message

Tomorrow you will see a new advertisement from Community, welcoming some physicians from Upstate University Hospital to Community's medical staff. It does not mean the Upstate doctors have left their University responsibilities, only that they are now serving patients at Community too.

The idea for the message came from a Community-affiliated doctor who said that, although physicians are well aware of the presence of Upstate doctors on Community's medical staff, some patients may not be. It is impressive how many Upstate doctors now work under contracts with the Community General Hospital.

The most recent physicians to join Community's medical staff are specialists in intensive care medicine, called intensivists. They joined the staff and started working in Community's ICU this month. They followed a number of hospitalists from Upstate, who began work at Community in July.

Since 2008 Community has been served by University Emergency Physicians, the same group of emergency care specialists who practice in University Hospital downtown. Several years before that, Community welcomed to its staff specialists in rehabilitative medicine from Upstate. These professionals provide care and medical direction at the only two acute rehabilitation services in Syracuse -- at Community General and at University Hospitals.

Each of these arrangements has been made on a case-by-case basis as the need and opportunity for specialty care has arisen. The Upstate additions enhance and broaden Community's services. They do not supplant or replace them. Nor do these additions mean that the proposed merger with Upstate is a "done deal." The merger is a complex process that is still being studied.

Could there be additional instances where Community’s subspecialty depth is enhanced by physicians from Upstate? The answer is "yes," but Community does not intend to add physicians merely for the sake of doing so. These service relationships are intended to be supportive of Community's doctors in their private practices, and not as interfering with or displacing their practices.

We welcome the presence at Community of Upstate physicians, who have demonstrated an ability to cooperate and broaden coverage in patient care situations while the broader merger issues are under discussion.

Saturday, August 14, 2010

Our "final exam"

Everyone knows what it is like to prepare for a final exam. The last minute cram sessions. The study lists. Classmates challenging one another with questions and answers in late night study groups. But it's a rare person who can make up in a few cram sessions for studies otherwise neglected during a semester's classes.

This week was a kind of final exam for Community General Hospital. The examiners were on-site surveyors from the Joint Commission, the body that accredits hospitals. Yes, we have been cramming for this examination for some time, but it is not a test you can study for short-term. You have to be following the polices and processes every day in order to meet accreditation standards.

We did not know the date of our examination. But we knew that Community was due for a survey in 2010.

Last Tuesday morning the surveyors arrived on campus unannounced for the four-day examination. Throughout the week they met with patients and caregivers, they reviewed our policies and processes, observed a surgical procedure, reviewed performance data, and they met with board members, physicians, nurses and support staff.

The Joint Commission has four categories of scoring:

1. There is an immediate threat to life.

2. Specific situations prompt a preliminary accreditation denial or make an accreditation conditional.

3. There is a direct impact on safety or quality

4. There is an indirect impact on safety or quality.

First, I am glad to say that Community did well. Although we won't have the final results for ten days, it appears we will receive a full three-year renewal of our accreditation.

Second, we learned a lot.

It is not strange to say that our learning continued, even during this "final exam." The surveyors score the hospital on what they find, grouping the findings into the four categories summarized above.

But the point of the survey is not only to check off "wrong answers." It is also a collaborative process, and that means surveyors suggest ways to achieve better results. They told us what other hospitals are doing, and they gave us examples.

In some cases, the surveyors asked us for copies of policies, forms, or data displays that they thought were effective and could benefit others. I was happy to hear that Community demonstrated good team work and showed evidence of good patient care. But we are far from perfect.

The surveyors cited Community for seven direct findings and for 12 indirect findings. We have six to eight weeks to address these issues, depending on whether it is a direct or indirect finding.

Here are the surveyors' findings in areas that have direct impacts on safety or quality:

Managing safety: Documentation of weekly checks of emergency eye wash stations was missing in two areas. There were several instances where call-alarm pull-cords were wrapped around grab bars. And a red bag (infectious waste) was improperly left in a patient care corridor in one area.

Managing hazardous materials: In two cases, employees were not able to respond immediately to questions about what to do in the event of a formaldehyde spill. (Formaldehyde is toxic chemical compound.) Also, rooftop exhaust fans were not identified with bioharzard labels.

Utility risk management: Electrical junction boxes were not properly covered in several locations, and proper room ventilation was not checked in a procedure room earlier this year when such checks were done on all operating rooms.

Medical equipment: The daily check of a backpack containing emergency supplies was not documented, and checking an emergency cart in another area was not documented on three different days.

Construction safety: The hospital's policy did not require temporary sign placement when an emergency egress route is temporarily changed during construction.

Emergency exits: The sliding doors at main entrances had manufacturer-installed locking devices that compromised the breakaway feature in an emergency. Also, surveyors noted several instances where equipment in hallways partially obstructed corridors.

Informed consent: There were two instances where the informed consent process was incomplete. In one case documentation did not include a patent's likelihood of achieving his or her goals. In another, the risks, benefits, and side-effects of alternatives were not documented.
In a few cases we were able to make changes on-the spot, such as the roof vent labels, junction box covers, and breakaway door switches. Other changes will take time, and we have Joint Commission deadlines.

There is work to do as a result of these survey results, and next week we start with a meeting of the Board of Directors. The survey shows how well we are doing things, but the real goal is to get better, and our "final exam" will help us do that.

Sunday, August 8, 2010

Community this summer

Community's Division of External Affairs took advantage of the cherry picker (aka hydraladder) that was on campus last week for seasonal maintenance on lighting fixtures and other high elevation work.
This panoramic view of Community General Hospital is a composite of several images taken on August 6 by Dan Cameron, Community's graphic designer.

Saturday, July 31, 2010

Patient satisfaction at the 75th percentile

This week we celebrated impressive improvements in Community General Hospital's patient satisfaction scores . . . across the board.

There were free sundaes in the cafeteria on Wednesday, and Chris Stryker, Chief Nursing Officer, and her Directors Nancy Thompson, Lyn Pittinger, and Cathy North brought ice cream to night staff in various departments.

The graph shows Community's overall patient satisfaction rating, as posted in the hospital this week.

The Press Ganey survey scores (second quarter, 2010) show patients overall rating of the hospital at 86.4%, a statistically significant improvement over previous scores. That score puts Community at the 75th percentile for hospitals of our size nationally and for hospitals in our Central New York comparison area.

The overall rating reflects improving patient satisfaction in all areas, including these statistically significant gains:

▪ Satisfaction with nursing care and communication -- 89.9%, up over two percentage points
▪ Satisfaction with doctors care and communication -- 88.7%, up over two points
▪ Satisfaction with the handling of personal issues -- 87.0%, up over two points
▪ Satisfaction with hospital accommodations -- 81.4%, up over four points

We've seen the improvements coming as we track the changes from week-to-week and quarter-to-quarter.

Improved patient satisfaction has also been evident in the HCAHPS* scores the federal government posts on its Hospital Compare website. I talked about the HCAHPS improvements in employee meetings last May.

It's great to know that patients see improved value from our caring and in our hospital environment. Congratulations to Community's employees, to our management team, and to our medical staff.

- - -

* HCAHPS stands for "Hospital Consumer Assessment of Healthcare Providers and Systems." HCAHPS track and report the opinion of Medicare patients at hospitals across the nation.

Saturday, July 24, 2010

A remarkable man

In about two hours, there will be a funeral in Williamsville, NY for an 88-year old Italian immigrant who came to America during the Great Depression, who was a decorated World War II fighter pilot, and who became a noted test pilot.

Nello Infanti was the father of Steven Infanti, who is Chairman of the Board at Community General Hospital. I never met Mr. Infanti, but I feel I know him from stories Steve has told over the years. He was a remarkable man.

▪ During World War II, Nello Infanti flew 63 combat missions in a P-38 over Africa, Europe, and Russia.

He received the Distinguished Flying Cross and the Air Medal with Seven Oak Leaf Clusters.

▪ He earned an Aeronautical Engineering Degree from Rennsselaer Polytecnic Institute, plus many hours of post graduate studies at the University of Buffalo and Edwards Air Force Base.

▪ He worked for 40 years at the Cornell Aeronautical Laboratory and became its Chief Test Pilot in 1963. Mr. Infanti flew over 100 types of aircraft, many highly classified.

▪ He trained over over 800 test pilots, more than 40 of whom became astronauts. He flew with Neil Armstrong and Buz Aldrin. He also flew all the X-15 pilots, shuttle, B-1, B-2 and F-17 pilots.

▪ Mr. Infanti was a Fellow in the Society of Experimental Test Pilots.

There is a report about this remarkable man in the Buffalo News, along with his obituary.

I extend my condolences to Steve Infanti, to his mother Louise, and to the entire family.

Sunday, July 18, 2010

How are we doin'?

My 'round-the-clock meetings with employees were well attended last Wednesday and Thursday.

Understandably, many were not able to attend so I am posting a summary of my slide presentation here.

Community's occupancy has been quite high recently, and I very much appreciate all that employees and physicians are doing to provide patient care and services during these hot summer days.

As you'll see from the meeting material, occupancy is not the only thing that is "up" -- there are improvements in quality, patient satisfaction, renovations, etc.

Wednesday, June 30, 2010

Our discussions with SUNY Upstate

In late May, I announced that Community was interested in discussing a potential affiliation with SUNY Upstate University Hospital. Yesterday, I reported on the progress we have made in discussions with Upstate.

Here is the text of a memo I sent to members of the Community General family:

On Thursday, June 24, the Community General Hospital board of directors voted to approve a letter of intent that identifies CGH’s desire to negotiate a merger with Upstate University Hospital. I am very pleased to report that the ongoing discussions with University Hospital’s leadership have been productive. The potential benefits of a merger are encouraging for each facility, and more importantly, for the Central New York community.

This afternoon the SUNY Board of Trustees approved a resolution to support SUNY Upstate Medical University’s acquisition of Community General Hospital. As such, Community General Hospital would partner with Upstate University Hospital and expand Upstate Medical University’s clinical presence in the Syracuse area. The approval of the resolution today demonstrates SUNY’s commitment to improving the health care resources in the Syracuse area. CGH’s strategic plan to become part of a larger health system took a significant step forward because of the action by the SUNY trustees.

CGH and Upstate have drafted a vision and set of principles for the proposed relationship. Key among these is respect for the voluntary medical staff at CGH. These principles were reviewed at the semi-annual meeting of the CGH medical staff on June 12, 2010.

Planning committees related to finance, communications, and operations are currently being established with representatives from Upstate and CGH, while medical staff representatives are expected to begin discussions soon regarding clinical service improvements. In addition, Upstate has retained PricewaterhouseCoopers to develop a business plan for the proposed merged entity.

There are many parts to any new relationship, and our potential affiliation with Upstate is no different. A tremendous amount of progress has been made in a short period of time, and representatives from both institutions are working efficiently, but carefully, to establish the most comprehensive health care system for the community at large.

I will continue to keep the CGH family updated as additional details become available in the coming weeks and months. I thank you for your continued hard work and dedication to CGH and the patients we serve.

Saturday, June 26, 2010

This year it was Bill's Tourney

Last week -- the 26th anniversary of the Community General Foundation Pro-Am Golf Tournament -- was held in memory of Bill Towsley.

Until his death on March 10, Bill was the Business Manager of IBEW Local Union #43. He was also a member of the Foundation Board and a long-time friend of Community General Hospital.

More than 200 people attended the Pro-Am on June 18 at the Shenandoah Golf Club at the Turning Stone Resort under picture-perfect skies.

Bill's son Ken played in the IBEW #43 foursome, and all his children attended the award ceremonies at the end of play. They are Ken (with Jen), Billie (with Sarah), Tracy (with Tate), and Jennifer (with Jeremy). It was a wonderful and emotional end to a great day.

That's Don Morgan in the photo, at right. He is the Business Manger of IBEW Local Union #43, and with him are NECA Manager Marilyn Oppedisano and Pat Costello, Assistant Business Manager/ President of the Local.

This year's Pro-Am was supported by more than 90 local and national companies. It is Central New York's only charitable pro-am style tournament. Special thanks go to the Central New York PGA and its executive Alan Seamans for all the help and support in putting together this annual event.

Since its inception the Community General Foundation Pro-Am has raised over $2.2 million in support of Community General Hospital. Greg Cohen, senior vice president of EBS-RMSCO, Inc., and co-chair of the 2010 Golf Committee, announced that this year's Pro-Am was the most successful yet, raising some $170,000. He said this was the result of "tremendous generosity" from the sponsors. My thanks to Greg and to Jim Aiello, who also co-chaired the Golf Committee.

In the closing ceremonies, Greg officially announced the Pro-Am's new name: The Towsley Pro-Am to Benefit the Community General Foundation. Under Bill's leadership, Local #43 donated more than $80,000 to Pro-Am over the past nine years.

Bill passed away on March 10 after a courageous battle with cancer. He discussed the illness with me a number of times. Bill made no secret of the battle he was in, and he was as tough, as straightforward, and as honest in facing cancer as he was in his life as a labor leader.

I told Bill I admired his stoicism about the illness, and I allowed that "it must be tough for you sometimes, Bill."

"Sure it is," he said. "Sometimes you wake up in the middle of the night. You can't help but think about things. But what are you going to do? You've got to face this thing and get on with your life."

On the day he died, a reporter called to ask my recollections of Bill. I told her stories about how I met him and how Bill and the IBEW supported a number of charities. At one point I described Bill as applying "gentle pressure" as he fought to make sure that firms using union labor were included in the competitive bidding process for construction jobs.

"You're the first person I've heard use the word 'gentle' in the same sentence as Bill Towsley," said the reporter.

I knew Bill as someone unapologetic about his union interests, one who was practical and forthright in pursuing his goals, one who was interested in the community, and one who stood by his friends.

At Bill's calling hours, I ran into a prominent elected official coming out of the Edward J. Ryan Funeral Home as I joined the hundreds-long waiting line going in. "We lost a good man," I said.

"He was a good one alright," said the official, "but he didn't hesitate to yell at me."

"Oh, he could yell at me too," I said. "But he was smart, he was a straight shooter, and he had a big heart."

I couldn't be prouder that the Pro-Am is now named for Bill and that in its first year the Towsley Tourney topped previous records for the Community General Foundation. I'd like to acknowledge and thank the sponsors of the 2010 Pro-Am, including:
Presenting Sponsor
IBEW Local 43/ NECA

Course Sponsor

Cart Sponsors
Syracuse Orthopedic Specialists
Welch Allyn

Pro Sponsor
Crouse Radiology Associates

Lunch Sponsors
Alliance Bank
Bond, Schoeneck & King PLLC

Buffalo Hospital Supply
Burns Bros Contractors

Carrier Corporation
Empower FCU
Fust Charles Chambers
Honeywell, Inc.
Key Bank

M.S. Kennedy Corporation
Mackenzie Hughes, LLP
Practice Resource
Rural Metro

Upstate Emergency Medicine

Tuesday, June 22, 2010

Remembering Bev Lippert

Kristin Schofield, Community's Director of Volunteer Services, sent the following remembrance of Bev Lippert, who died unexpectedly yesterday:
Our volunteers and staff are deeply saddened by the loss of our volunteer Beverly Lippert. Bev was killed in a car accident yesterday morning, June 21.

Beverly was a long time employee and retiree of CGH. She loved to tell stories of how she was the employee who ordered all of the first supplies for the Nursery when we first opened. She made all the decisions what to purchase and where to put it. If you walk to the cafeteria and see the photo from the 60’s of a nurse tending to a newborn baby you will see Bev at her finest, doing what she loved, clad in her nursing whites and her cap. She was a very dedicated nurse who cared for several current staff members when they had babies (as well as some staff members who were the babies themselves).

After retirement, Bev continued at CGH as a volunteer, Auxilian and was a current Auxiliary board member. Many of you may recognize Bev as Mimi’s handler. Mimi was her toy poodle that, for years, she brought to the nursing floors to visit patients. Bev also gave many hours as a volunteer at the Diagnostic Desk on Thursday mornings. As of June 17, the last day she volunteered with us, she had given over 4,800 hours to volunteer service.

Calling hours will be tomorrow at Buranich Funeral Home in Camillus from 4 – 7pm and the funeral will be held Thursday at 10 am in the Fairmount Community Church.
Bev did not have any immediate family members but made a lot of friends CGH in the 47 years she was associated with us and considered us her family. She will be missed and remembered fondly. Please keep her in your thoughts.
Thank you, Kristin, for remembering Bev and her part in the CGH family. Bev was a true caring professional.

You can read the obituary in today's Post-Standard.

Monday, May 24, 2010

A broader look at affiliation

On May 19, I sent the following announcement to Community General family:

Yesterday, the CGH board of directors decided it was in the best interests of the community to examine more than one option for hospital affiliation. Accordingly, the board did not proceed to the next step of the merger planning process with Crouse Hospital. CGH remains interested in continuing strategic planning with Crouse, but not on an exclusive basis. Therefore, the board exercised its right to dissolve the Memorandum of Understanding (MOU), which required exclusive joint planning.

Upstate University Hospital has recently provided CGH with an alternative strategic proposal, which is well-developed and comprehensive. The CGH board believes it is in the best interests of the community to examine all options when considering the community’s long-term needs for health care quality, service and access to care.

As details of this become clearer, I will, of course, provide additional information to the CGH family about these important issues.

We have much to be proud of - our medical staff, our employees, our facilities and the support of the community-at-large. We have demonstrated excellence in many areas. We continue to plan the best way to improve upon these assets as we prepare for the many changes to come in health care delivery, technology and finance.

I thank you for your continued hard work and dedication to CGH.

Sunday, May 16, 2010

If you missed it . . .

Several employees have asked for copies of the presentation I gave at 'round-the-clock employee meetings earlier this month.

Thanks to brainshark, I am able to do so here. Click on the presentation, below, to see the slides and hear my narration.

Thursday, May 13, 2010

Appreciation day

Yesterday Community saluted its employees, physicians, volunteers, and associates with an Appreciation Day picnic in the cafeteria.

Buffet servings were free for all shifts, and management topped off the meal by serving ice cream sundaes.

Employees received a Community General Hospital coffee mug as a token of appreciation.

The annual festivity acknowledges and thanks health care workers for their 24/ 7 service to patients and community. Thank you!

Saturday, May 8, 2010

Our employee meetings

As I do from time to time, I held ’round-the clock meetings for employees on May 6. Naturally, a lot of the discussion focused on the impact of the federal health care reform legislation as it affects hospitals, as well as on the status of Community General Hospital's merger discussions with Crouse Hospital.

Health care reform legislation

I summarized the effects of the health care reform legislation – admittedly, at a very high level – on consumers, hospitals, and other organizations. For consumers, health care coverage will become more available, and an estimated 30 million individuals could be added to insurance rolls. Individuals will not be excluded from purchasing health insurance because of pre-existing health conditions, nor will there be any lifetime caps on what insurance pays for care and treatment. Adult children, up to the age of 26, will be able to have coverage under their parents’ insurance plans. This information has been generally well-covered in the news media.

I also talked about the impact of health care reform legislation on hospitals, specifically about the $196 billion reduction in Medicare and Medicaid payments to hospitals over the next ten years. There will be new taxes on medical devices and on brand-name pharmaceuticals ($31 billion over ten years), as well as the new taxes on health insurance coverage itself ($57 billion during the period). These are examples of increased costs hospitals will have to pay for the goods and services they buy.

The hospital association has translated the $196 billion nationwide reduction into the impact on each hospital in New York State. Because of the new legislation, the four hospitals in Syracuse, NY, will receive $424 million less from Medicare and Medicaid over ten years. These are huge numbers, and they are hard to imagine in the current context.

These reductions in revenue are expected to be offset to some extent by revenue from individuals who will have health coverage, thanks to the legislation. It is very unlikely, however, that the revenue from the newly insured will come close to offsetting the reduced hospital payments that are forecast.

Overall the health care reform law will be a transformative force affecting the way health care is provided in our society.

Our merger talks

In this context I discussed the merger talks currently underway between Community General and Crouse Hospitals. I compared the forces acting on Community (such as, higher state taxes, the needs of physicians and medical groups, and pension costs) with some of the forces affecting Central New York generally (such as, flat population growth, an aging population, and Medicaid cutbacks). Recognizing these forces and anticipating the impact of federal health reform legislation, last January Community and Crouse entered an agreement to plan a merger, if feasible.

Moody’s, the financial analysis company, recently predicted that, as a result of federal legislation, non-for-profit hospitals will find it more difficult to borrow funds and that more hospitals will look for opportunities to consolidate.

Community and Crouse are, in fact, considering the advantages of creating a larger hospital that operates two campuses. The advantages could include the better ability to work with physicians, potentially better access to capital, more efficiency, and the ability to avoid duplicate investments. In interviews with consultants earlier this year, physicians from both hospitals suggested various ideas, and the consultants have been considering these. The consultants are getting close to a recommendation for both hospitals to consider.

Assuming both hospital boards adopt a structure recommended by the consultants, there will still be a number of steps remaining before the merger process is done. These include implementation planning with clinicians, filing a Hart Scott Rodino document with the Federal Trade Commission, and preparing a Certificate of Need (CON) application for New York State. In addition, both hospitals would have to complete “due diligence,” a process in which each hospital examines the other’s business in detail, considering such things as financial performance, business contracts, tax issues, pension obligations, property ownership, etc. The time frame for these activities could be another year or so.

Our financial performance

I also reviewed Community's financial performance through the first quarter of 2010.

I was pleased to report that through March, Community is operating in the black and on-budget (see the chart below). This is significantly better financial performance than we experienced in 2009 in the first quarter.

Patient satisfaction

I discussed patient satisfaction and showed how Community's most recent HCAHPS scores – as self-reported by Medicare patients – have improved in every category.

The HCAHPS survey measures the percentage of Medicare patients who report that nurses and doctors “always” communicate well, that their pain is “always” well-controlled, and that their rooms are “always” well-cleaned. Community does well in comparison with other Syracuse hospitals – we have the highest scores in three of ten categories and the second highest scores in another five categories. And . . . Community's HCAHPS scores improved in the most recent 12-month period (see the chart, below).

Improvements to come

I talked about improvements being made to patient rooms on several units. The sixth floor renovation (orthopedics) has been completed, and room improvements are underway on Three West. Furthermore, we have begun to update rooms on Four West and, when finished in late summer, the patients and staff from Two West will relocate to Four West to take advantage of the updated and larger rooms. Following that, we will make improvements to the GYN rooms on Two East.

The new health information exchange

Community will become the first hospital in Syracuse this year to link to the health information exchange (HIE) being developed by the Health Advancement Collaborative of Central New York (HAC-CNY).

The HIE will initially link all four Syracuse hospitals, through the Internet, with five primary care physician groups, representing several hundred physicians. By next year doctors and hospitals on this fledgling network will be able to exchange patient-specific data with the consent of the patients themselves. As more physician practices join the exchange, HAC-CNY will link to other networks through the State Health Information Network of New York (SHIN-NY). The idea is to make individual patient information readily available to any of that individual’s caregivers. Naturally, there are demanding security and patient privacy requirements for this to function.

Employees had a number of questions and suggestions during the meetings, and I appreciated the opportunity to speak with so many of you.