"e-Patients," Chapter 3: Patient-Centered Networks: Connected Communities of Care

Chapter 2 ended with two pivotal observations: "Clinicians can no longer go it alone," and "The most effective way to improve healthcare is to make it more collaborative... In the chapters that follow, we offer more suggestions on how we might accomplish this." Chapter 3 begins this inquiry by exploring the trend that made the most difference to me, personally. The chapter starts by exploring the different purposes that have evolved for patient-centered communities.


3. Patient-Centered Networks: Connected Communities of Care

It's astounding how widespread e-patient behavior is, considering that hardly anyone I talk to even knows it's happening.

• Internet surrogates (peer caregivers (especially women) researching for another)
• "In the beginning, like most health professionals and researchers, my Pew colleagues and I assumed that patients would do their searching for themselves. So we were surprised to discover that more e-patients (81%) had gone online because a friend or family member had been diagnosed with a new illness than had searched the Net following a new diagnosis of their own (58%)."
• Pew research in 2006 found 93 million Americans seeking health information for themselves, another 42 million seeking information for their parents, and more.
  

• Helping patients & families deal with a new diagnosis: when people hear of a friend's crisis, they reach out with advice and useful information.
  
  
• Patient-centered support networks - a very different entity than the better-known disease-specific communities.
• I'm not in the book, but my CaringBridge friends are a perfect example. They'd get email notifications of each new post I made, and sometimes they'd forward the emails to others. In Web 2.0 terms, my support "went viral," and I got advice and support from people I'd never met or hadn't seen in decades.
  
  
• Web sites that support patient-centered online health networks: The public is now more aware of CarePages and CaringBridge, even moreso since this June's Associated Press story. But it was a very new topic in 2006.
  
  
• Why personal online health networks have received so little attention: Most people have considered the discussions very private. Not me, baby: put me out there. :)
  
  
• Providing continuing support for the incurable: "Professional medicine is often at its worst in providing continuing comfort and care for patients facing serious illnesses that are beyond the hope of cure. In such cases, the support and care patient-centered networks of family and friends provide can be a lifeline."
  
  
• What we can learn from patient-centered networks:
  
  
• "Patient networks are emerging as a new medical domain within which a wide variety of individuals and groups become valuable healthcare resources. Nearly all of those involved with patient-centered networks provide their services for free, and since patient-centered networks operate independently of the formal healthcare system, they are not constrained by that system's built-in limitations, inefficiencies, and defects." (emphasis added)
  
  
• "The importance of this form of communication should not be overlooked, since individual telephone calls and emails to a person's entire network of concerned individuals puts a huge burden on the patient or the caregiver."

The following is my observation, not taken from the published paper:

Look at how this dynamic is already disrupting where value arises in healthcare. (See the italics I added above.) Any student of economic earthquakes can see the signs: when a new source arises that

• adds significant value to an ecosystem
• is free
• and is not subject to the establishment's constraints,

...the convergence of forces can make for an explosive shift in everyone else's value proposition, everywhere else in the ecosystem. The White Paper doesn't say so, but having been through the gauntlet myself, and being a student of business change, the signs are clear enough for me.


----
Next: The surprisingly complex world of e-communities. (That illustrates what I just said: in an environment where something can be created and flourish for free, unconstrained, and where there's a need for it, it's going to evolve rapidly – becoming rich and complex, and what people want.)

"e-Patients," Chapter 2: Content, Connectivity, and Communityware

Continuing the series started in the previous post...

Chapter 2: Content, Connectivity, and Communityware – seven preliminary conclusions (full text wiki)

This chapter was my personal favorite, because it exploded so many myths and provided so much evidence that the change is already well underway.

Remember, I didn't read this until late January 2008, six months after my treatment had ended. When I read it, my immediate question to the e-patient working group was, "How the (#@$! could I have gone through last year without ever hearing about this?? We need to get the word out!" So here we are.

From the introduction:

"John Seely Brown... notes that when established experts first consider the effects of new information technologies and the cultural transformations they produce, they typically do so from within the cultural constraints of their established professional paradigm ... We were no exception. Our findings were so unexpected that we were forced to consider alternative points of view... But as Brown discovered, 'Really substantive innovations – the phone, the copier, the car, the PC, the Internet – drastically alter social practices.'"

The authors – mostly doctors, remember – said "Our most helpful insights came from a growing awareness that e-patients use the Internet in three fundamentally different ways: to access content, connect with others, and collaborate with others in ways never possible before."

See what I mean about how this had strong echos for me? They continue:

... many who have attempted to study or explain e-patients and many leaders in medical reform have overlooked, ignored, downplayed or even actively opposed some of the most innovative developments in modern medicine.

Presenting their findings, they said "We modestly suggest that the tentative conclusions below are no more 'anti-doctor' or 'anti-medicine' than the conclusions of Copernicus and Galileo were 'anti-astronomer.'" The preliminary conclusions:

1. e-patients have become valuable contributors, and providers should recognize them as such.
   
• "When clinicians acknowledge and support their patients' role in self-management ... they exhibit fewer symptoms, demonstrate better outcomes, and require less professional care."


2. The art of empowering patients is trickier than we thought.
• "We now know that empowering patients requires a change in their level of engagement, and in the absence of such changes, clinician-provided [information] has few, if any, positive effects."
  
  
3. We have underestimated patients' ability to provide useful online resources.
   • Fabulous story of the "best of the best" web sites for mental health, as determined by a doctor in that field, without knowing who runs them. Of the sixteen sites, it turned out that 10 were produced by patients, 5 by professionals, and 1 by a bunch of artists and researchers at Xerox PARC!
     
     
4. We have overestimated the hazards of imperfect online health information.
• This one's an eye-opener: in four years of looking for "death by googling," even with a fifty-euro bounty for each reported death(!), researchers found only one possible case.
  
• "[But] the Institute of Medicine estimates the number of hospital deaths due to medical errors at 44,000 to 98,000 annually" ... [and other researchers suggest more than twice as many]
• "We can only conclude, tentatively, that adopting the traditional passive patient role ... may be considerably more dangerous than attempting to learn about one's medical condition on the Internet." (emphasis added)
  
  
5. Whenever possible, healthcare should take place on the patient's turf. (Don't create a new platform they have to visit - take yourself wherever they're already meeting online.)
   
   
6. Clinicians can no longer go it alone.
• Another eye-popper: "Over the past century, medical information has increased exponentially ... but the capacity of the human brain has not. As Donald Lindberge, director of the National Library of Medicine, explains 'If I read and memorized two medical journal articles every night, by the end of a year I'd be 400 years behind."
• In contrast, when you or I have a desperate medical condition, we have all the time in the world to go deep and do every bit of research we can get our hands on. Think about that. What you expect of your doctor may shift - same for your interest in "participatory medicine."
  
  
7. The most effective way to improve healthcare is to make it more collaborative.
• "We cannot simply replace the old physician-centered model with a new patient-centered model... We must develop a new collaborative model that draws on the strengths of both systems. In the chapters that follow, we offer more suggestions on how we might accomplish this."
  

Next: Patient-Centered Networks: Connected Communities of Care

e-Patients: How they can help us heal healthcare, chapter 1

Regular readers know I often speak of "e-Patients: how they can help us heal healthcare," aka "the e-Patient White Paper." I urge people to read it, but at 126 pages, it takes a commitment.

So I'm going to serialize it into seven chapter summaries, in the form of seven blog posts. Here's the first.

e-Patients: How they can help us heal healthcare

Published in 2007 by the e-Patient Scholars Working Group,
completing the life work of Dr. Tom Ferguson

"[People] are suddenly nomadic gatherers of knowledge...
informed as never before...
involved in the social process as never before...
[as] we extend our central nervous system globally..."
--Marshall McLuhan, 1964 <==wow

Chapter 1: Hunters and Gatherers of Medical Information

This chapter lays the foundation for the body of the book, opening with two compelling stories of what we might today call "e-patient pioneers" - those individuals who, with no precedent, took matters into their own hands, embodying the e-patient idea that they (and you and I) have every right to know everything they can about their health - and sometimes they might even do a better job than the doctors.

Sections:

• Edward Murphy's incredible story of trying to get information about his condition - he had to impersonate his doctor (1994)
  
  
• "An unusual sloshing sound inside her head": Marian Sandmaier diagnoses her daughter's severe headaches, when two specialists had failed to (1999)
  
  
• Turning to Dr. Google: research from the Pew Center for the Internet & American Life, documenting that patient googling is now dominant: the great majority of Internet users look for medical information. (That seems obvious today, but it was radical and almost verboten when Tom Ferguson started his work.)
  
  
• Three types of e-patients - the well, the newly diagnosed, and the chronically ill - and more Pew research on the different ways they use the Internet
  
  
• "The Accepting, the Informed, the Involved, and the In Control": an intriguing way of viewing different people's Internet use based on their attitudes and how deeply in trouble they are.
  

In that last section, check out Group IV: "...believe in making their own medical choices... will often insist on managing their own medical tests and treatments as they think best... may attempt to help to keep their clinicians up to date on new treatments and studies.... may start, manage, or contribute to local support groups, online communities, blogs... " My my, which group am I in? :)

Next: Content, Connectivity, and Communityware - seven preliminary conclusions

Illness in the Age of 'e'

Dr. Danny Sands (my primary physician) and I have begun an initiative to share our story in the hope that both patients and medical professionals will see new possibilities for how healthcare delivery can be improved and even transformed using technology.

The title of our message is "Illness in the age of 'e': How Connected Technology Changes the Patient Experience." One medium for the message will be a medical journal article, which is in process. Another will be a session we're co-leading at the Connected Health Symposium at Harvard in October.

Earlier this month Danny gave his first public telling of our story, in a guest lecture at the University of Waterloo (Ontario). It was a webcast, broadcast live over the web - the room where he spoke was almost empty, which is kind of funny when you see it, but that's how webcasts work: many can watch live, and now it's available for free viewing.

It's a 45 minute talk, with introduction then Q&A. It requires Internet Explorer. Watch it here. There are no slides, so you can listen to it like a radio show if you like.

As you may know, Danny is one of the original pioneers in the use of doctor-patient emails. He's also a member of the e-patient scholars working group, which I joined this year. In addition to his work as a practicing physician, he teaches at Harvard Medical School and works for Cisco Systems. Busy guy, with a unique combination of perspectives. I'm glad to have him as my doctor.

A personal note: this is the first time I've seen Danny talk about the human, emotional side of being a doctor, caring at a personal level about how his patients are doing. I remember, almost too well, the urgent cell phone call I placed to him in January '07 just after Ginny and I saw the first images that revealed the cancer ... those moments when I realized I might be facing the end of my life very soon. He was so compassionate and caring. And we got to work.

We really hope that sharing our story will lead to positive changes in how patients and providers take advantage of technology to transform the experience of illness.

Comments welcome, below.

Steal these slides

I just stumbled across the "attic" of Tom Ferguson MD, who was the "George Washington of patient empowerment," as CNN put it this month, citing his work since 1975 to create a world of freedom and power for patients.

(That's you, in case you didn't notice. Thank him.)

Those familiar with the e-patient blog know about the white paper DocTom's team completed after his death in 2006. But I didn't know some of his earlier writings are around on www.DocTom.com, a modest web site. It includes a few old slide shows, sans speaker notes. But the good stuff is the images: you can get the drift.

My favorites (above) are #88 and #89 from his 2003 slides. Here's my narrative:

In the industrial age, the means of production and ability to create value were centralized in massive facilities. If you didn't own the factory, you didn't have freedom and power.

In the information age, those with access to information have access to power and can create value.

Those slides were made in 1995, when the Web had just been born, but they hit the nail on the head: today we have access to tremendous resources, and that empowers and enables us.

Please don't interpret these slides as meaning that in the world of the future there will be no doctors. That's idiotic. Rather, Tom's vision is that "we the people" have a lot more ability to contribute than was once thought. And both costs and quality can improve as a result.

Compelling evidence to support this was collected into the white paper (above). Further independent evidence from around the world is provided by the Patient Centered Primary Care Collaborative, about which I wrote in May.

Steal Tom's slides. Show them to others, put them in your decks when you give talks. And re-view the PCPCC slides, with their data on cost and quality. It's a new world out there - feed your head!

CNN's "Empowered Patient heroes" recognizes e-patient pioneers Tom Ferguson and Gilles Frydman

Cross-posted from the e-patients blog, where I'm an author.

Today's entry in the CNN.com "Empowered Patient" series, by medical correspondent Elizabeth Cohen, is titled Empowered heroes' hard lessons now help others:

This week, as we reflect on American heroes, we're saluting a few "patient empowerment" heroes, whose experiences with the health system have inspired them to help others.

I'm someone who has personally benefitted from the road these pioneers paved and lit, so I'm very glad to see this growing public awareness of their vital work.

The column's details page includes stories of ordinary people who, not unlike America's founders, had experiences that left them feeling that "we the people" could create a better reality with a new balance of power. They set out to create a newly empowered citizenry, and they did. Consider:

• About e-patient founder "Doc Tom" Ferguson, Cohen writes: "If there's a 'George Washington' of the empowered patient movement, it's Doctor Tom Ferguson. In 1975, at a time when many doctors were still viewed as all-knowing and infallible, Ferguson, a physician, author, and researcher, started writing about patients advocating for their own health care."


• Michael Cohen, whose work on medical errors thirty years ago led him to found the Institute for Safe Medical Practices.


• Gilles Frydman, whose experience with his wife's cancer in 1996 led him to form ACOR, the network of free cancer listservs that made such a difference for me during the peak of my cancer experience last year.
  
  
• Ysabel Duron, KRON news anchor whose 1998 encounter with Hodgkins Disease led her to notice (among many other things) that Latinos were largely missing from the cancer treatment scene; she founded Latinas Contra Cancer.
  
  
• Trisha Torry, whose incorrect cancer diagnosis in 2004 led her to found www.DiagKnowsis.com. She also runs patients.about.com.
  
  
• Victoria and Armando Nahum, whose son's 2006 death from an in-hospital infection has led them to form the Safe Care Campaign, teaching about preventing infection.

I want to point out a few things.

First, most of these people took a highly adverse experience and used it to create a new reality that had never existed before. To me this is a high expression of the human spirit.

Second, none of them did it for personal gain. This is people creating things for the public good.

Third - and perhaps most important on this Independence Day in America - although each of them is "just one person" (or couple) facing a massive establishment, think about the results we have today. It's commonplace to research one's own medical condition, doctors increasingly welcome such participation, people increasingly know it's their right to ask questions of their doctors (and the whole system), and more and more, people are banding together (especially on the Internet) to share their knowledge with others.

We still have a long way to go, but increasingly people are empowered to participate in their care.

I never knew Doc Tom, our "George Washington." He died before finishing his manifesto, "e-patients: how they can help us cure healthcare." Members of the e-Patient Scholars Working Group completed it in 2007 (PDF, wiki). The cover carries one more allusion to 1776: "I felt I was looking over Thomas Paine's shoulder."

When I first found this group in January, I said something about "the Sixties motto 'power to the people,' made real in the world." I guess it goes back farther than that. Thanks to all who've done the work so far - and thanks to CNN's Cohen for spreading the word.

Why I blog

This post is intended as an introduction for those who are new to me and want to understand the background for my views on the new world of healthcare.

My day job

I’m Director of Marketing Analytics for TimeTrade Systems, “Appointment Scheduling Experts.” We provide enterprise-scale SaaS appointment systems (customers) and a nifty, free, viral personal appointment inviter called TimeDriver, dubbed “the most unglamorously useful service” at DEMO ’08. My job is to bash on the e-marketing data, understanding search engine marketing as much as we can (it's all about helping people get what they want!), and run the CRM/SFA system. Oh, and I write.

I like to know what drives change, and I like it to be fact-based.

My cancer story

…is in a separate post. Short version, I suddenly faced death, went through a whirlwind of technology and treatment, survived, and returned with awareness and attitude.

Why do I blog?

I’ve had a lot of personal growth training from Landmark Education. During the crisis it helped me be awake and aware, in what some said was an almost Zen-like state of peace. (Not thrilled to have cancer, but at peace with what's so, and able to be clear-headed.)

As the story wound down, I was left profoundly aware that there was work for me to do, to take what I’d learned and bring it out into the world. Landmark is about expressing your true self: “The freedom to be at ease, regardless of circumstances. The power to be effective in the areas of life that matter most to you.” That's truth in advertising, and I saw that it's a self-expression for me to do this. (In other words, I can't not do it.)

I participated on the blog of Paul Levy, CEO of my hospital, long before I got sick. My handle there was Patient Dave. So I started my own blog, “New Life of Patient Dave,” at Thanksgiving, not knowing what I’d do with it.

How I became an e-Patient

In January I learned about the e-patients movement and met the people involved. I found people who’d already been developing the concepts I wanted to spread and had been gathering data to support it and make their case. I immediately “rebranded” myself e-Patient Dave: it’s who I am.

What’s an e-Patient?

E-patients are “enabled, engaged, equipped and empowered.” Many snapshot examples here. The term was coined by Dr. Tom Ferguson, a true visionary, who saw in the 1990s how the Internet would transform healthcare by enabling patients to be active partners in their own care. He saw this long before widespread broadband came about, and before any of today's "Health 2.0" tools existed. A true visionary.

If you want to understand the micromechanism of patients transforming healthcare, you must read “E‑Patients: How they can help us heal health care,” the e-patient white paper (PDF, wiki). If it were a Forrester report (147 pages) it would cost $10,000; it’s free. It's deep thinking that’s panned out, with real-life use cases and anecdotes.

Who’s in the e-Patient Scholars Working Group?

Extraordinary people who’ve been at this a long time, plus newbie me. I hesitate to name any one member, but two prolific contributors are Gilles Frydman (founder of ACOR) and Susannah Fox of the Pew Internet & American Life Project. Other world-changing members in the news recently: John Grohol’s Psych Central e-patient community just made Time’s 50 Best Websites 2008, and e-patient users at Joe & Terry Graedon’s People’s Pharmacy gathered the data that convinced the FDA there was a problem with the generic of Wellbutrin, which made the front page of the WSJ.

---

In my next post I’ll move into the business implications of what I learned while I spent a year as a patient then discovered the e-patient white paper. To get the most impact from the coming discussion, I urge you to read that paper too. It only takes a few hours – it's very well written. And aside from its business implications, it'll change your outlook on your own family's healthcare, which will be useful someday.

My cancer story - short version

I keep finding that I need to relate this year-long story in a short version. The full year-long journal is at bottom here. Here's the bulletized version.

• After a routine shoulder x-ray in January 2007, the doctor said “Get back in here; there’s something in your lung.” Out of nowhere I was found to have Stage IV (metastasized) Grade 4 (most aggressive) kidney cancer, throughout both lungs. Eventually we learned it was also in my thigh, ulna, skull and pelvis. Yet I had no symptoms.
  
  
• Desperately seeking information that could make a difference, I googled my ass off, identified my profile, and what I found was: “outlook is bleak,” “prognosis is grim,” “median survival time 24 weeks.” I scheduled myself into Bernie Siegel’s cancer patient weekend. I joined the ACOR kidney cancer list, started journaling on CaringBridge, and rallied family and friends. We updated my will.
  
  
• The ACOR community (active kidney cancer patients and supporters, always up on the newest information) was my best source of reliable information.
  
  
• I'm a strong believer in the power of how we interpret our experiences. My situation was scary, but I knew the question was "What can I do?" Regardless of the odds, I knew laughter helps health; I considered dropping out of chorus but my doctor said I should not start cancelling life activities I love ("It sends the wrong message, and the oxygen exchange will help you"); and then he said I needed to pack on some pounds to prepare for the battle ahead. So I declared my cancer strategy was to "Laugh, Sing, and Eat Like a Pig." That's what I titled my journal (below).
  
  
• Coincidentally, six weeks after diagnosis I visited WETA-TV in D.C. to talk about PatientSite. That week I got my first symptom: a sore leg, which turned out to be a bone metastasis: a massive met eroding my left femur. The kidney was removed in March (laparoscopically!)
  
  
• HDIL-2 therapy at Beth Israel Deaconess worked for me. I’m lucky; many people don’t qualify for it, and of those who do, only 20% respond. I did.
  
  
• Days before the treatment started, a tumor erupted from my tongue. Gross. I don’t want to think what that would have become if I hadn’t had that early detection. After the first week of treatment that tumor fell off.
  
  
• I continued researching, studying my radiology reports and lab results on PatientSite, and asking questions. Often I was wrong; being empowered didn’t make me an oncologist. Yet my phenomenal oncologist David McDermott and team said “I am happy to field your questions.” Tip: Arrogant doctors are “doctosaurs”; you don't need to put up with that anymore.
  
  
• I gave my PatientSite login to medically knowledgeable relatives, who supported me in knowing what was going on.
  
  
• In early May I fainted in the bathroom one morning and fell on the leg, which broke. Tip: before breaking a leg, you should faint, and wake up already in shock: no pain! Before you're out of shock, EMTs arrive and apply morphine! Pitfall: the ambulance ride to Boston, at rush hour, with powerful thigh muscles bouncing around and no bone to keep them in place. Solution: LaMaze-style breathing.
  
  
• I rented a mobility scooter and bought a Prius (has a big hatchback to hold the disassembled scooter) so I could return to work. (I couldn't rely heavily on crutches because the ulna metastasis threatened to break.) The leg’s now made of steel.
  
  
• In late June we passed the 24 week mark since diagnosis - the "median survival time" that I'd read about. I had a “What’s your drop dead date?” party at work; we blew razzberries at the cancer, and friends around the country did the same, at the same time.
  
  
• My e-community grew astoundingly. Over 100 people have posted comments and support. When an email says “Did you hear, our friend has cancer?” with a link to go see, support can go viral.
  
  
• My second round of HDIL-2, ending July 23 '07, was the last drop of treatment I’ve had. The near-deadly tumors had shrunk 66% before that round; they’ve shrunk another 75% since then, to 8% of their original size, with no more treatment. I am well. Update: make that 5%.
  
  
• I still worked at my day job, on and off during treatment, all summer 2007, returning to work full time in August. My company TimeTrade Appointment Systems was phenomenal; it’s a great place to work. My insurance company, Harvard Pilgrim, was astounding.
  
  
• It took a year after surgery for the leg to return to normal, but it's over. On July 4 I'll be on stage in Nashville with my chorus, competing at the world championships of men's barbershop harmony.
  

That’s the short version. The full text of my CaringBridge journal, "Laugh, Sing, and Eat Like a Pig" (500 pages), is available here. It's a potent example of Web 2.0 on the hoof.

CaringBridge story

This weekend the Associated Press is publishing a story about CaringBridge and a similar site, CarePages. It relates the experience of several users, including my community and family. For more information, see my CaringBridge journal.

Update 6/8: Scientific American's blog has this:

Blogging--It's Good for You
The therapeutic value of blogging becomes a focus of study

... A study in the February issue of the Oncologist reports that cancer patients who engaged in expressive writing just before treatment felt markedly better, mentally and physically, as compared with patients who did not. ...

Visitors: if you're looking for great resources for self-education on how to be an effective consumer in today's healthcare system, here's a post from my CaringBridge site a few weeks ago:

RESOURCES FOR INTERNET PATIENTS

As regular readers know, during this past year I've become a strong advocate of all the ways patients can improve their outcomes and their experience, becoming active participants in their care, especially by using the Internet.

Here are some resources:

• The E-Patients blog: E-patients are "empowered, engaged, equipped and enabled." This blog covers a wide range of topics about the new world of participatory medicine. If you're a patient or family in need, educate yourself by reading the wonderful "white paper" (manifesto) available on that site.


• A community support site, like CaringBridge. It saves you an enormous amount of time corresponding, and lets your supporters check in anytime instead of keeping up with emails.
   To see how it works, you can get the whole year's transcript (1/30/07 - 1/30/08) as a free download (one big file or single chapters), and read while you're sitting in waiting rooms. :)

On this blog I'm starting a beginner's guide to participatory medicine. It's my effort to share what I learned last year, with the intention that others can take a shortcut. In particular I recommend the chapter about "the five pillars of participatory medicine."

Those sites have many links to other web sites. Do your own exploring - see where it takes you.

And by all means, get out there and PARTICIPATE. In the world of blogging, that means you click the Comments link (or Guestbook, on CaringBridge), and enter questions or comments.

Be an e-patient: Ask what you want to know; say what you think.

Beth Israel Deaconess on ... Jeopardy??

One of my earliest posts on this blog was a thank-you to Dr. Drew Wagner, the amazing surgeon who removed my yucky-sticky-rude-tumored kidney, without cutting me wide open - just little tiny slits. Amazing.

In that post was a mention of the amazing simulation/training facility at his hospital (and mine), Beth Israel Deaconess. Well, today while chasing a link in the blog of that hospital's CEO, I came across this video clip: last December, their simulation center was featured on Jeopardy's Tournament of Champions!



And yes, they inflated my belly with that unnamed gas. (Yes, I have a bikini scar, and no, you may not see it.)

p.s. To be amazed at the openness of communication at that hospital, and the transparency they're bringing to the world of healthcare, go directly to that video site and page through the "More from this show" items on the right side. The video featured today is a real-life sample of how the hospital now approaches suggestions from workers at every level of the enterprise. What a beautiful example of empowering everyone, and the results it produces.