Recently, MSNBC reported that a Rhode Island doctor is facing a $500 fine and must take a continuing education course after inadvertently revealing a patient's identity during a Facebook post meant to outline some of her clinical experiences. According to the article, the doctor did not directly identify the patient, but described his or her injuries in a fashion that allowed a third party to figure out the patient's identity.

In some ways, this is the perfect cautionary tale for hospitals and docs who, like everyone else, now reach their customers via tweets and status updates. Unlike some HIPAA breaches I've heard about—stories of medical students posting patient photos on Facebook abound—the doctor in question appears to have had no intent of making light of her patient's condition or exposing their identity. And my assumption is that the lightness of the penalty, doled out by Rhode Island's medical licensing board, reflects that lack of intent—although at least one of the hospitals where she has clinical privileges terminated those privileges following the incident.

But it does raise some concerns as hospitals and doctors increasingly market themselves on Twitter, Facebook and other social media vehicles, instead of through more traditional media and community relations outlets. Hospitals don't have much choice in the matter—every business is migrating from face-to-face interactions and exposure through newspapers and TV to real-time social media encounters with the general public, but I think some caution about the extent of exposure, and social media guidelines for staff, are imperative, especially as more hospitals use clinical encounters as a chance to promote their services via Twitter and live webcasts.

My sense is that we're still in a period of unsettled chaos with Twitter, Facebook and other social media forms, and that eventually, informal and legal boundaries will begin to self-police what is still a young form of communication. Until then, tweet with caution.

Can HIPAA and other privacy protections remain meaningful—and enforceable—in an era where every action is tweeted and where we're all encouraged to share every detail of our professional and private lives? And does your hospital have a Facebook or Twitter policy to handle the pitfalls of social media? E-mail your thoughts to hbush@healthforum.com.

You could get very dizzy watching all those revolving doors—the ones spinning people in and out of hospital executive suites these days.

Though the turnover rate of hospital CEOs dropped slightly in 2010—to 16 percent, from a 10-year high of 18 percent in 2009, according to the American College of Healthcare Executives—that's still a hectic pace, and it's bound to pick up as baby boomers stampede into retirement. Some 60 percent of hospital CEOs are over 55 and by some estimates, a jaw-dropping 75 percent of health care organization CEOs will retire in the next 10 years.

And don't expect the doors to suddenly stop revolving once the boomers are gone. Those Gen Xers now eyeing the corner office over the tops of their Facebook pages "do not seek jobs for life or the gold-watch or silver-tray trappings of longevity," warns a white paper from executive services firm B.E. Smith. As for Generation Y? They "tend to think that a good job lasts three to five years."

In other words, the days of the CEO-for-life are vanishing, if they really ever existed. Back in 2006, an ACHE survey found that only a tiny fraction—3.4 percent—had served at the same institution as CEO for more than 20 years. The median tenure of a hospital CEO was just 43 months.

If, as expected, that "churn" intensifies, it will be very hard on hospitals. "The loss of a CEO can cost a health care organization $1.5 million in severance, recruitment expenses and the new CEO's salary," write B.E. Smith's Zachary N. Beesher and Christine Ricci. Moreover, it often prompts others on the executive team to leave, and it delays construction projects, new equipment purchases, physician recruitment programs and new service development.

That's not all: If there's a whiff of instability at the top, staff morale and public perception suffer, and competitors might take advantage of the situation by trying to poach members of the medical staff.

All of which ought to be motivation enough for CEOs and board members now in place to keep a sharp eye out for young staffers or job candidates with leadership potential. They should also get very familiar with what those up-and-comers expect in their careers. The expectations are, to put it mildly, "nontraditional," a fact that might stick in some boomers' craws. But it's essential for the long-term viability of an organization to understand them, adapt accordingly and build a reputation as an attractive place for Gen Xers and Yers to work.

Here are some characteristics of younger professionals identified in the B.E. Smith report:

• Because they don't plan to stay with one organization forever, they "prefer benefits loaded on the front end or a flat salary out of which they can fund their own benefits."
• They respond well to 15-25 percent management or productivity incentives and bonuses.
• They will not work the long hours their predecessors put in, and they want flexible schedules to allow a balanced work-home life.
• They need "constant feedback on performance and one-on-one time with supervisors."
• They "relish prompt recognition, even if it involves a simple card, thank you or token of appreciation."
• They "quickly grasp new concepts and are avid users of technology."
• Coaching is advisable, preferably "a formalized process that uses professional coaches to achieve specific, measurable outcomes, holds both coach and student accountable and focuses not only on organizational goals, but also on personal development."

By the way, several recent surveys have found that far too few CEOs are paying any attention at all to leadership succession plans. That can't be good.

How is your hospital preparing for the next generation of leadership? Or is it? Let me know at bsantamour@healthforum.com. And look for my column every Tuesday in this space.

In the month since the 429-page proposed rule for Medicare's Accountable Care Organization program has gone public, and with a little more than 8 months remaining until the program starts in earnest in 2012, concerns from observers and interested parties have unsurprisingly piled up, a natural response to a major initiative hailed by its supporters as one of the keys to reducing long-term health care costs at the same time it improves overall health care outcomes.

The newest addition to the chorus of skeptics entered my inbox Friday—a new study out from the George Washington University School of Public Health warns that ACOs may not fully serve Medicare beneficiaries in underserved communities. The report points out that federally qualified health care centers, which currently serve 1.4 million Medicare beneficiaries among their 19 million low-income patients, are not allowed to form ACOs. In addition, the report argues that ACOs will be discouraged from even including health centers in their organization, "because of its prohibition of the assignment of FQHC Medicare patients to ACOs for shared savings purposes." 

The report notes some incentives designed to bolster FQHC participation in ACOs—including an increase in shared savings if an ACO includes an FQHC, and an exemption from some of the requirements related to shared savings thresholds if patients have at least one encounter with a health center. But it concludes that the impact of the rule will "exclude the poorest beneficiaries with the highest health risks," and will discourage hospitals from affiliating more closely with health centers.

Of course, this is the stage in any regulatory process—as CMS solicits feedback to the proposed rule before it finalizes it—when concerns by interested parties are meant to be raised, and hopefully addressed by CMS in some form or another. Texas-based VHA, a network of not-for profit health care providers, for instance, argued in a recent New England Journal of Medicine article that participating providers in ACOs may be underwhelmed by immediate financial results. The American Medical Association, meanwhile, is worried that not all physicians who want to join an ACO will be able to participate.

It's also a good time for would-be ACO players to get up to speed on what those 429 pages will mean for their particular institution, and tomorrow, the American Hospital Association is hosting a members-only town hall where hospitals can can hear from federal regulators and AHA experts on barriers to ACO participation and possible remedies—click here for more information.

In the meantime, I'd like to hear from you, the reader. Email your issue, concern or, pray tell, your unabashed enthusiasm for the proposed ACO rule to hbush@healthforum.com, and I'll feature some of the responses in an upcoming column, along with other feedback I've recently received on ACOs.

A new report from the Dartmouth Atlas finds that chronically ill Medicare patients are logging fewer hospital days and receiving more hospice care in the last six months of life, leading to a decline in the percentage of chronically ill patients who died in a hospital from 32.2 percent in 2003 to 28.1 percent in 2007. The report also found that chronically ill Medicare patients who are admitted to hospitals are spending more time in intensive care and receiving more visits from physicians.

Among the other key findings:

• The average patient logged 10.9 hospital days in the last six months of life in 2007, down from 11.3 days in 2003.


• 36.1 percent of chronically ill patients were treated by 10 or more doctors in 2007, up from 30.8 percent in 2003.


• Among 35 academic medical centers surveyed, 22 reported increases in the number of patients seeing 10 or more doctors in the last six months of life from 2003-2007.


• In 2007, chronically ill patients in Manhattan averaged 20.6 days in the hospital in their last six months of life, nearly four times higher than in Ogden, Utah, where those patients averaged 5.2 hospital days.

Read the full report here.

Tucked away in the Affordable Care Act is a provision that may give some rural hospitals a little bit of—and much needed—financial breathing room. The law expands the Rural Community Hospital Demonstration Project, which tests what happens when so-called tweener hospitals are paid on cost-based reimbursement. Tweeners are too big to be a critical access hospital, and thus are ineligible for cost-plus reimbursement, but too small to thrive under traditional Medicare PPS. The demonstration actually started in 2004 and was slated to fade into the sunset, but it was given an extra life thanks to the ACA.

CMS earlier this month started naming the 20 hospitals that will participate in the program, including Grinnell Regional Medical Center and four hospitals in Maine. Only time will tell how effective the program is in addressing the financial strain facing rural hospitals, a strain that is very likely to grow in the coming years. A new TrendWatch report released earlier this week by the American Hospital Association peers into the unique challenges facing rural hospitals in a post-recession, post-reform era. "The recent economic downturn put additional pressure on rural hospitals as they already operate with modest balance sheets," the report states, noting that rural Americans are more likely to be uninsured and have lower incomes than those in the city. While the ACA expands coverage to 32 million people, "many rural hospitals will have to make upfront investments in order to handle the influx of new patients." The report goes on to point out that "limited financial and workforce resources present significant ACA implementation challenges for rural hospitals. As more rural Americans gain access to health coverage through Medicaid and the commercial markets, rural hospitals will experience greater patient demand that may strain already limited staff and capital resources."

It's not all doom and gloom though. The TrendWatch points out that the ACA boosts aid and services to rural communities. For instance, $1.5 billion for the National Health Services Corp for scholarships and loan repayment for primary care practitioners who work in health professional shortage areas. The law also extends outpatient hold harmless provisions for rurals. Still, there's ample concern that rurals will not be able to fully participate in some of the law's most substantial delivery system reforms, including accountable care organizations and value-based purchasing.

I'd encourage you to take a look at the TrendWatch. It is an enlightening read about one of the nation's most critical safety nets.

Email your thoughts to mweinstock@healthforum.com.

After two years of buzz and hype, this week marks the beginning of attestation for CMS's Meaningful Use EHR incentive program for hospitals, doctors and other providers, and the health care blogosphere is full of discussion on how hospitals can meet at least 19 of the 24 meaningful use objectives for hospitals and, if all goes right, start receiving additional reimbursements later this year.

In my interviews and informal conversations this year, meaningful use is second only to ACOs in frequency as a topic—and in the breadth of opinions I've received from both boosters and skeptics. Unscientifically, I would say a majority of the folks I've talked to take the general view of William Bria, M.D., CMIO of Shriner's Hospitals for Children, who sees meaningful use as a once-in-a-lifetime opportunity for hospitals and docs to invest in IT in a way that will lead to real clinical changes.

"It's a clear signal that there's been enough discussion…that the practice of medicine and the use of information technology should be integrated," Bria told me in a recent interview.

That's the ideal result, of course, and having written about many a tricky or initially unsuccessful IT rollout, I know hospitals will have plenty of challenges to navigate with doctors, vendors and staff as they aim for meaningful use. And that's why, for at least the initial round of attestation that starts this week, many prominent health care systems are opting to wait on applying for meaningful use funding until they're confident of meeting the requirements.

Part of the reason for the caution that I've been hearing lately is the requirement that applicants demonstrate compliance for 365 days. In practice, that means that hospitals and systems seeking to enter the program this year have to be perfect from Oct. 1, 2011, to Oct. 1, 2012. Hospitals are also concerned about meeting Stage II meaningful use requirements, which CMS released in draft form earlier this year and will take effect for 2013 and 2014.

John Frownfelter, M.D., CMIO of inpatient services for Henry Ford Health System in Michigan, told me in a recent interview that concerns about complying for a full year starting in October led to Henry Ford's wait-and-see approach.

"If we were to attest this year and start with a 90-day period this year, which is what's required, the next fiscal year requires we're perfect for 365 days, and that begins Oct. 1," Frownfelter said. By waiting a year, Henry Ford and other systems that decide to wait remain in the program's grace period, and will still qualify for full meaningful use payments.

"Starting this year, it doesn't bring inherent value, as long as we're on a long-term track that's safe," Frownfelter said.

Of course, waiting on a large infusion of federal cash isn't something that all hospitals are in a position to do.

"Mid-market facilities…are really depending on that money to show up in order to fund the technology initiatives they're going after," Spencer Hamons, corporate project manager for the Yukon-Kuskokwim Health Corporation in Alaska and formerly a CIO at San Luis Valley Medical Center in Colorado, told me in a recent interview. Is your hospital system moving ahead with attestation this week, or have has a decision been made to hold off until 2012? Email your thoughts to hbush@healthforum.com.

Kids say the darnedest things. So do certain management types, though precociousness is not nearly as endearing in people who ought to know better. That's evident in some of the responses I got to my question about what health care leaders can do to overcome friction among staff members of different generations. Clearly, for many the first step is to take a close look in a well-lighted mirror. A few cases in point:

• "I've heard leaders in a group of people say, ‘Turn up your hearing aid, Barbara,' when a woman in her 60s asked that a question be repeated. And, ‘Let's hire the young one—young people will work harder. He's just waiting for Medicare to kick in so he can retire.'"

•"When I suggested to our CEO that we move the supplies closer to the patient rooms, he told me to ask the young people to get them if my legs couldn't handle it anymore."

•"In a board retreat, the younger generation of physicians and employees were criticized for not being as committed and not working as long hours—a bit disheartening to the two gen Xers in the room (me and our CFO), who consistently put in very long hours to ensure the success of our organizations."

•"Another supervisor was planning an after-work get-together for our staff and I overheard her tell one of the new nurses she didn't need to come because she must have better things to do with her young friends."

• "He's clueless," one executive said of a C-suite colleague with a chronic case of foot-in-mouth disease. "And then he's surprised when some of these incidents end up in HR."

The good news is that there are authentic leaders out there conscientiously trying to bridge the generational divide. And there's plenty of advice to go around for the rest:

•"Managers need to lead by example and examine their own prejudices."

•"Leaders need to recognize that they have biases like everyone else and not be afraid to put them on the table for discussion, using respect and pursuit of perfection principles."

•"Talk about it. Acknowledging that generational differences exist is the first step in bridging the gap."

•"They need to build off our common commitment to patient care so we can all see we're on the same team, we just play different positions."

•"They need to stop telling staff what to do and start encouraging staff to take ownership of how we work together."

•"Environments need to be created that foster and encourage partnership and collegiality."

•"Managers need to identify key leaders (younger and more mature staff) and have them model a behavior of partnership."

•"Communication should be adjusted to be maximally effective. A generation that texts and tweets will not want to read an article or listen to a lengthy discussion about a new change."

•Conversely, "Managers can't communicate with their workers through social media alone. Older workers might not be as conversant in it, and it isolates the manager from his staff and the staff from their colleagues. I've designated two e-mail- and Facebook-free days every month because face-to-face interaction and encouraging everybody to honestly participate in a conversation promotes trust, camaraderie and teamwork."

Encouragingly, writers from a number of different hospitals described panels of executives, middle managers, physicians and staff who have come together to first understand and then work to overcome the generational divide in their own units, departments and across whole organizations.

"Our employee diversity committee has begun a series of lunch and learn opportunities to build awareness and dialogue on issues of equity, inclusion, fairness and respect," one writer related. "One of our first topics, scheduled for May, is embracing generational differences."

Like the pizza for peace summit one reader shared a couple of weeks ago, a diversity committee sounds to me like a simple step in the right direction. Do you agree?

My column, touching directly or indirectly on generational issues affecting American health care, appears in this space every Tuesday. I appreciate hearing from readers about these or any topics of interest to folks who work in hospitals. Send your thoughts to bsantamour@healthforum.com.