Local flavor for Google Suggest

Since the launch of Google Suggest <a href="http://googleblog.blogspot.com/2008/08/at-loss-for-words.html">last August</a>, you may already be used to the magic feeling of getting real-time suggestions just after typing a few keystrokes — that is, if you're searching on Google.com. But what if you're doing a search on Google in the U.K., India, Ireland or Australia?<br /><br />Today we're happy to announce the international launch of Google Suggest. We've localized our suggestions to account for various cultural and local factors to offer suggestions that look familiar to our users. For example, English users in different countries will get suggestions that feel natural:<br /><ul><li>If you type [liver] in the <a href="http://www.google.co.uk/">U.K.</a>, you're probably a Liverpool fan (but in the <a href="http://www.google.com/">U.S.</a> you'll get more suggestions about liver diseases):</li></ul><ul><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_7ZYqYi4xigk/SdKMDjCO-nI/AAAAAAAADdk/IWdgayCEJpA/s1600-h/uk-liver.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468102450084466" src="http://1.bp.blogspot.com/_7ZYqYi4xigk/SdKMDjCO-nI/AAAAAAAADdk/IWdgayCEJpA/s400/uk-liver.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 360px; height: 216px;" /></a><li>In <a href="http://www.google.com.au/">Australia</a>, typing [kan] will offer suggestions about Australia's most famous animal:</li></ul><ul><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_7ZYqYi4xigk/SdKMD1125vI/AAAAAAAADeE/93qjaM5Q6jA/s1600-h/au-kan.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468107498448626" src="http://2.bp.blogspot.com/_7ZYqYi4xigk/SdKMD1125vI/AAAAAAAADeE/93qjaM5Q6jA/s400/au-kan.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 359px; height: 214px;" /></a><li>In <a href="http://www.google.co.in/">India</a>, where the mobile phone market is exploding, it's no wonder that typing [no] leads to:</li></ul><ul><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_7ZYqYi4xigk/SdKMD5JuUsI/AAAAAAAADd0/fGZWABXZrwA/s1600-h/in-no.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468108387078850" src="http://2.bp.blogspot.com/_7ZYqYi4xigk/SdKMD5JuUsI/AAAAAAAADd0/fGZWABXZrwA/s400/in-no.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 361px; height: 214px;" /></a><li>In <a href="http://www.google.ie/">Ireland</a>, there are [pubs] everywhere:</li></ul><ul><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_7ZYqYi4xigk/SdKMD5TN2YI/AAAAAAAADd8/u5mMy5bMLig/s1600-h/ie-pubs.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468108426893698" src="http://1.bp.blogspot.com/_7ZYqYi4xigk/SdKMD5TN2YI/AAAAAAAADd8/u5mMy5bMLig/s400/ie-pubs.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 359px; height: 214px;" /></a><li>While in the <a href="http://www.google.mv/">Maldives</a>, typing [ato] leads to:</li></ul><ul><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://4.bp.blogspot.com/_7ZYqYi4xigk/SdKMDtTB99I/AAAAAAAADds/AFeK6Jltfl4/s1600-h/mv-ato.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468105204889554" src="http://4.bp.blogspot.com/_7ZYqYi4xigk/SdKMDtTB99I/AAAAAAAADds/AFeK6Jltfl4/s400/mv-ato.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 360px; height: 214px;" /></a></ul>Google Suggest now covers 155 domains in 51 languages. Special thanks go to the Suggest team in Israel for their hard work in making this a reality.<br /><br />So go ahead and start using Google Suggest wherever you are, and enjoy the special flavor of local suggestions.<br /><br /><span class="byline-author">Posted by David Kadouch, Product Manager</span>

Local flavor for Google Suggest

Since the launch of Google Suggest last August , you may already be used to the magic feeling of getting real-time suggestions just after ty...

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Analytics in Latin America

If you run an e-commerce site or use AdWords to direct traffic to your business' webpage, chances are you're interested in knowing what visitors to your site are clicking on, what content interests these potential customers and what avenues brought them there. The more you know about how people engage with your site, the better you are able to design successful advertising campaigns to help grow your business.<br /><br />In Latin America, online advertising is growing as more and more small businesses initiate an online presence and publicize their efforts through search and display advertising. But less than 5% of web properties throughout Latin America rely on analysis tools to improve their website's performance. Last week, our offices throughout the region hosted several Analytics-themed events to give agencies and other clients a better look at several Google measurement tools that provide people with the means to analyze their site's flow of data, interest and readership in order to build a better advertising campaign.<br /><br />In Mexico City, advertisers got together to learn about <a href="http://www.google.com/insights/search/#">Insights for Search</a>, <a href="http://adwords.blogspot.com/2008/06/introducing-google-ad-planner.html">Ad Planner</a>, <a href="http://googleblog.blogspot.com/2008/03/insight-into-youtube-videos.html">YouTube Insights</a>, <a href="http://www.google.com/analytics/">Analytics</a>, <a href="http://googlewebmastercentral.blogspot.com/2008/01/sitemaps-faqs.html">Sitemaps</a> and <a href="https://www.google.com/analytics/siteopt/splash">Website Optimizer</a>, as well as <a href="http://www.doubleclick.com/">DoubleClick</a> tools. Presentations were designed to give companies an in-depth look at the Google tools that can be helpful for planning their marketing budgets during an economic downturn. Being able to measure data on what content interests people and where consumers are searching for information can help advertisers be more selective about how they invest ad budget. Since the great majority of consumers go online for information before making a purchase, the goal of the seminar was to familiarize advertisers with tools that can increase the reach of their campaigns, while giving them a better idea of what works and what people are searching for.<br /><br />Meanwhile, our Analytics guru Avinash Kaushik visited São Paulo and Buenos Aires to speak to clients about web analytics and how to make the most of online marketing through analyzing metrics (check out his recent post on <a href="http://googleblog.blogspot.com/2009/02/stop-bouncing-tips-for-website-success.html">bounce rate</a> for related information). Avinash made web analytics fun and accessible with colloquial comparisons (referring sites as 'BFFs'), and demonstrated how to <a href="http://googleblog.blogspot.com/2009/03/make-sense-of-your-site-tips-for.html">optimize a website's performance</a> with changes in color and layout, among other things. He was accompanied by Google's Latin America managing director Alexandre Hohagen, Brazil's country manager Alex Dias, and Argentina's country manager Adriana Noreña at a succession of events revolving around web metrics and website optimization.<br /><br /><embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" flashvars="host=picasaweb.google.com&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FJoscelin.Cooper%2Falbumid%2F5317535977028402929%3Fkind%3Dphoto%26alt%3Drss" pluginspage="http://www.macromedia.com/go/getflashplayer" height="267" width="400"></embed><br /><br />The response and interest from customers and agencies to all of these events was indicative of the huge need for metrics and the ability to track ROI for their marketing investments, especially during these difficult times. For more information on Google Analytics tools, check out the <a href="http://analytics.blogspot.com/">Google Analytics Blog</a>, the <a href="http://websiteoptimizer.blogspot.com/">Website Optimizer Blog</a> and the <a href="http://conversionroom.blogspot.com/">Conversion Room blog</a>.<br /><br /><span class="byline-author">Posted by Alfonso Luna, Marketing Director, Latin America</span>

Analytics in Latin America

If you run an e-commerce site or use AdWords to direct traffic to your business' webpage, chances are you're interested in knowing w...

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Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

We have occasionally posted about the activities of for-profit contract research organizations (CROs). These are commercial entities that conduct human research, including clinical trials for pharmaceutical, biotechnology and device companies. More clinical research is being done by such CROs rather than by academic investigators. CROs seem to operate under the radar of most physicians, academics, and policy makers, but sometimes stories surface that raise questions about them.<br /><br />For example, we discussed the trials by SFBC International (now <a href="http://www.pharmanet.com/">PharmaNet Development Group</a>) in Miami that enrolled immigrants, often undocumented, under questionable circumstances and in Montreal that resulted in the transmission of active tuberculosis (see post <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-sfbc-internationals.html">here</a> and links backward); and the trial by <a href="http://www.parexel.com/">Parexel International </a>in London that put most of its subjects in intensive care (see post <a href="http://hcrenewal.blogspot.com/2006/08/parexel-blues-again.html">here</a>, with links backward). Last year, as we discussed <a href="http://hcrenewal.blogspot.com/2008/06/clinical-trials-torture-economy.html">here</a>, two articles questioning the ethics of research done under the auspices of CRO appeared in two major medical journals.<br /><br />In academia, human research is supposed to be overseen by institutional review boards (IRBs). Research done by CROs is also supposed to be overseen by IRBs, but the IRBs that do so are often also commercial. Despite concern that commercial IRBs may be tempted to lower their standards to get more business, commercial IRBs have flown even lower under the radar than have CROs. However, last week, a story appeared about how a "sting operation" tested one commercial IRB with amazing results. Here are excerpts from <a href="http://online.wsj.com/article/SB123811179572353181.html">the article by Alicia Mundy in the Wall Street Journal</a>,<br /><br /><blockquote><br />The sting, detailed at a House Energy and Commerce Committee hearing Thursday, involved the creation of a fictitious company and a fake medical device, a surgical adhesive gel. The sham firm then applied to three for-profit oversight groups -- called institutional review boards, or IRBs -- for approval to begin a clinical trial using their adhesive on human subjects.<br /><br />Two IRBs contacted by the GAO's sting operators -- Argus IRB of Arizona and Fox IRB of Illinois -- rejected the Adhesiabloc proposal because of unanswered safety questions.<br /><br />'We realized it was a terrible risk for the patient … It is the worst thing I have ever seen,' an Argus IRB reviewer said, according to a slide shown at the hearing.<br /><br /><a href="http://www.coastirb.com/">Coast IRB </a>LLC of Colorado Springs, Colo., did approve a study for the fictitious adhesive gel, 'Adhesiabloc.'<br /></blockquote><br /><br />The GAO also ran an experiment to see if the US Department of Health and Human Services (DHHS)would register a truly dubious commercial IRB<br /><br /><blockquote><br />The committee, working with the Government Accountability Office, Congress's investigatory arm, named the CEO of the fake IRB Truper Dawg, after a staffer's three-legged dog, now deceased. Other fake names included 'April Phuls' and 'Timothy Wittless,' which lawmakers said should have signaled irregularities to HHS. The department registered the IRB.<br /></blockquote><br /><br />On one hand, these anecdotes suggest, along with the stories discussed above, that CROs and the commercial IRBs that are supposed to oversee them deserve further scrutiny. Beyond that, one wonders if it is good for society for human research, including experiments involving drugs and devices, to be done by commercial firms dependent for their income on the companies that make these drugs and devices, overseen by other commercial firms also dependent on these same companies. The fundamental conflict is embodied by <a href="http://www.coastirb.com/page.asp?id=2&name=About">Coast IRB's self-description</a>:<br /><blockquote>as an advocate and a catalyst for an ever-stronger pharmaceutical industry, ethically and economically. </blockquote>which also<br /><br /><blockquote>recognizes the vital importance of our role in protecting individuals in all clinical studies and in continuously raising the bar on professional standards. </blockquote><br />How can the company be an "advocate" for the industry while simultaneously protecting the people exposed to the industry's still experimental drugs?<br /><br />See also <a href="http://www.gooznews.com/archives/001363.html">comments</a> on the GoozNews blog.

Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

We have occasionally posted about the activities of for-profit contract research organizations (CROs). These are commercial entities that co...

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Google's newest venture

Today we're excited to announce <a href="http://www.google.com/ventures">Google Ventures</a>, Google's new venture capital fund. This is Google's effort to take advantage of our resources to support innovation and encourage promising new technology companies. By borrowing the best practices of top-tier, financially focused venture capital firms and bringing to bear Google's unique technical expertise and brand, we think we can find young companies with truly awesome potential and encourage their development into successful businesses.<br /><br />At its core, Google Ventures is charged with finding and helping to develop exceptional start-ups. We'll be focusing on early stage investments across a diverse range of industries, including consumer Internet, software, clean-tech, bio-tech, health care and, no doubt, other areas we haven't thought of yet. Central to our effort will be our fellow Googlers, whom we view as a critically important resource to help educate us about potential investments areas and evaluate specific companies.<br /><br />Economically, times are tough, but great ideas come when they will. If anything, we think the current downturn is an ideal time to invest in nascent companies that have the chance to be the "next big thing," and we'll be working hard to find them. If you think you have the next big idea, or if you just want to to learn more, please see our website at <a href="http://www.google.com/ventures">www.google.com/ventures</a>.<br /><br /><span class="byline-author">Posted by Rich Miner and Bill Maris, Managing Partners, Google Ventures</span>

Google's newest venture

Today we're excited to announce Google Ventures , Google's new venture capital fund. This is Google's effort to take advantage ...

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Email in Indian languages

It's hard for me to imagine going without email for a day. It's such an easy and convenient way to communicate with my friends and family. However, there was one limitation that bothered me: my family members and friends who prefer to communicate in Hindi did not have an easy way to type and send email in their language of choice. I am extremely happy to announce the launch of a new feature in Gmail that makes it easy to type email in Indian languages.<br /><br />When you compose a new mail in Gmail, you should now see an icon with an Indian character, as the screenshot below shows. This feature is enabled by default for Gmail users in India. If you do not see this function enabled by default, you will need to go the "Settings" page and enable this option in the "Language" section.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_7ZYqYi4xigk/ScwgyDbQN7I/AAAAAAAADbk/of327m2z-b0/s1600-h/Picture+9.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317661304302876594" src="http://3.bp.blogspot.com/_7ZYqYi4xigk/ScwgyDbQN7I/AAAAAAAADbk/of327m2z-b0/s400/Picture+9.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 129px; height: 83px;" /></a>When you click the Indian languages icon, you can type words the way they sound in English and Gmail will automatically convert the word to its Indian local language equivalent. For example, if a Hindi speaker types "namaste" we will transliterate this to "नमस्ते." Similarly, "vanakkam" in Tamil will become "வணக்கம்." We currently support five Indian languages -- Hindi, Tamil, Telugu, Kannada and Malayalam -- and you can select the language of your choice from the drop-down list next to the icon.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_7ZYqYi4xigk/Scwg_D2m8hI/AAAAAAAADbs/aprsj9Zmo7s/s1600-h/Picture+10.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317661527755911698" src="http://1.bp.blogspot.com/_7ZYqYi4xigk/Scwg_D2m8hI/AAAAAAAADbs/aprsj9Zmo7s/s400/Picture+10.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 124px; height: 178px;" /></a>We built this new feature using Google's transliteration technology, which is also available on <a href="http://www.google.com/transliterate/indic/">Google India Labs</a>, <a href="http://www.orkut.com/Signup.aspx">Orkut</a>, <a href="https://www.google.com/accounts/ServiceLogin?service=blogger&continue=https%3A%2F%2Fwww.blogger.com%2Floginz%3Fd%3D%252Ftrans-enable.do%253Fr%253D926417%2526tlang%253Dhi%26a%3DADD_SERVICE_FLAG&alinsu=0&aplinsu=0&alwf=true&hl=en&ltmpl=hindi&skipvpage=true&rm=false&showra=1&fpui=2&naui=8">Blogger</a> and <a href="http://www.google.com/ig/adde?moduleurl=www.google.com/ig/modules/indic_transliteration.xml">iGoogle</a>. I hope you find this feature useful to communicate with those of your friends and family who prefer to write in their native language, and it will be available soon to businesses and schools using Google Apps. Now back to replying to all those Hindi emails I got from my family and friends today!<br /><br /><span class="byline-author">Posted by Chandramouli Mahadevan, Software Engineer</span>

Email in Indian languages

It's hard for me to imagine going without email for a day. It's such an easy and convenient way to communicate with my friends and ...

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Will The True Incidence of Healthcare IT-Caused Patient Adverse Outcomes Please Stand Up?

<span style=";font-family:arial;font-size:100%;" >The article </span><span style=";font-family:arial;font-size:100%;" ><a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians</a>, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278</span><span style=";font-family:arial;font-size:100%;" > (JAMA) has caused much discussion in healthcare IT circles.<br /><br />I have become aware of discussions centered on issues such as:<br /><br /></span><ul style="font-family:arial;"><li><span style="font-size:100%;">The factors besides vendor design flaws and defects that contribute to the unsafe and ineffective use of health information technology,</span></li></ul><ul style="font-family:arial;"><li><span style="font-size:100%;">The degree of effect caused by end user organization customizations,</span></li></ul><ul style="font-family:arial;"><li><span style="font-size:100%;">whether a focus on legal or regulatory action is misplaced</span><span style="font-size:100%;"> </span></li></ul><ul style="font-family:arial;"><li><span style="font-size:100%;">Whether such regulation could "stifle innovation", and</span></li></ul><ul style="font-family:arial;"><li><span style="font-size:100%;">Other interesting and stimulating related issues.<br /></span></li></ul><span style=";font-family:Default Sans Serif,Verdana,Arial,Helvetica,sans-serif;font-size:100%;" >These discussions miss the forest for the trees, unfortunately.<br /><br />They are all <span style="font-weight: bold;">speculation.</span><br /><br /></span><span style=";font-family:Default Sans Serif,Verdana,Arial,Helvetica,sans-serif;font-size:100%;" ><span style="font-family:arial;">I could just as easily </span></span><span style=";font-family:Default Sans Serif,Verdana,Arial,Helvetica,sans-serif;font-size:100%;" ><span style="font-family:arial;">- as a thought experiment - </span></span><span style=";font-family:Default Sans Serif,Verdana,Arial,Helvetica,sans-serif;font-size:100%;" ><span style="font-family:arial;">argue and rationally support a point of view that vendor defects, shortcomings, ill conceived user interfaces etc. are the greatest cause of HIT problems, that a sole focus on regulatory action is the best path, and that regulation would not stifle innovation but </span><span style="font-weight: bold;font-family:arial;" >promote </span><span style="font-family:arial;"> it by forcing complacent, lazy companies protected by the current status quo to become competitive, to hire the very best and brightest and most experienced who they now forgo as "too disruptive, too expensive, lack the latest programming skills", etc. </span><br /><br /><span style="font-family:arial;">None of this speculation really matters in the big scheme of things.</span><br /><br /><span style="font-family:arial;">What does matter is the fact that we now have before us a "grand confounder" - the anechoic effect caused by vendor contracting - that throws into doubt existing assumptions about HIT-caused errors.</span><br /><br /><span style="font-family:arial;">Who among us can now say what the number of physician observed defects really is, what the rate of HIT error really is?</span><br /><br /><span style="font-family:arial;">I've had several of my colleagues already tell me since the Koppel article that they know of HIT caused errors and even patient adverse consequences, but they are afraid to speak out. </span><span style="font-weight: bold;font-family:arial;" >What is the morbidity and mortality change associated with use of HIT vs. paper? </span><br /><br /><span style="font-family:arial;">Who really knows?</span><br /><br /><span style="font-family:arial;">There is a significant, perhaps high likelihood that the </span><span style="font-style: italic;font-family:arial;" >current state of HIT contracting</span><span style="font-family:arial;">, and the muting effect it creates, combined with fear of retaliation by potential objective HIT reporters (a.k.a. whistleblowers) </span><span style="font-weight: bold;font-family:arial;" >makes any such estimation highly questionable at best. </span><br /><br /><span style="font-family:arial;">Speculation is irrelevant. What we need is a </span><span style="font-weight: bold;font-family:arial;" >return to the rigor of medicine </span><span style="font-family:arial;"> - to science - in HIT itself.</span><br /><br /><span style="font-family:arial;">That can only happen in an environment where users are free(er) to share their observations and findings about HIT problems.</span><br /><br /><span style="font-family:arial;">Such one-sided, safety adverse HIT contractual clauses must end.</span><br /><br /><span style="font-family:arial;">-- SS</span><br /></span>

Will The True Incidence of Healthcare IT-Caused Patient Adverse Outcomes Please Stand Up?

The article Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians , Ro...

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The Retirement of a Generic Manager

A frequent theme on Health Care Renewal has been the adverse effects of health care leadership by <a href="http://hcrenewal.blogspot.com/2009/01/pfizerwyeth-merger-and-sacrificing.html">generic managers </a>with no background or experience in health care, and no intuitive understanding of its values. This type of leadership arose after some health care economists called for abolishing the <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-breaking-physicians.html">supposed physicians' "guild,"</a> and transferring power over health care to managers as a way to control health care costs. This has not lead to control of health care costs.<br /><br />The recent <a href="http://www.nytimes.com/2009/03/31/business/31wagoner.html">coverage by the New York Times </a>of the sudden retirement of the CEO of General Motors suggests that the notion that organizations should be run by generic managers is one whose time ought to be past. Wagoner presided over a dramatic decline in the fortunes of GM.<br /><blockquote><br />Mr. Wagoner presided over some of the biggest losses in G.M. history. In 2002, the company had predicted that it would earn $10 a share by the middle of the decade.<br /><br />Instead, G.M. lost $30.9 billion in 2008, when its per-share loss translated to more than $50 a share. G.M. stock, an economic bellwether that sold above $35 only three years ago, closed Friday at $3.62; it has fallen as low as $1.27 in the last year.<br /><br />In 1994, when he took charge of G.M.’s North American operations, the company made up 33.2 percent of auto sales in the United States.<br /><br />Last month, G.M. represented only 18.8 percent of American car and truck sales....<br /></blockquote><br /><br />The problem may have been, in part, that Mr Wagoner was never a "car guy."<br /><blockquote><br />'It’s a pretty unceremonious ending,' said John Casesa, an industry analyst and managing partner of the Casesa Shapiro Group. 'G.M. lost its way in the ’70s, but the company didn’t know it until 20 years late. The hole was much deeper than he realized when he became C.E.O.'<br /><br />And, Mr. Casesa said, <em>Mr. Wagoner’s finance background might have been a poor fit: 'The most successful auto companies are run by people who came out of the revenue-generating functions — manufacturing, design, marketing — making cars and selling cars.' Mr. Wagoner, the analyst said, 'skipped the whole apprenticeship that most auto C.E.O.’s experience.'<br /></em></blockquote><br /><br />The notion that a finance guy should run a car company makes not much more sense than the notion that a finance guy (or marketer, accountant, or lawyer) should run a hospital or a drug company. Yet now most health care organizations are run by such generic managers. Is it any wonder that while such generic managers have made a lot of money, they have been unsuccessful in controlling health care costs, much less solving any other aspect of the the health are crisis?

The Retirement of a Generic Manager

A frequent theme on Health Care Renewal has been the adverse effects of health care leadership by generic managers with no background or exp...

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Getting your Medicare records in Google Health

Google Health is working with the <a href="http://www.cms.hhs.gov/">Centers for Medicare and Medicaid Services (CMS)</a> on a pilot program in Arizona and Utah that lets Medicare beneficiaries import their Medicare claims data into Google Health.<br /><br />The pilot is one of several CMS programs to test out how the government can give beneficiaries secure access to their medical data online. Before I came to Google, I worked at the <a href="http://www.hhs.gov/" onclick="javascript: pageTracker._trackPageview('/outgoing/hhs.gov');">U.S. Department of Health and Human Services</a>, which houses CMS. At the time, the idea of giving beneficiaries access to their own Medicare claims data in electronic format was just that — an idea. Today, it's becoming a reality. And given the more than $19 billion investment the government is making in Health IT as part of the <a href="http://www.whitehouse.gov/the_press_office/arra_public_review/" onclick="javascript: pageTracker._trackPageview('/outgoing/whitehouse.gov/the_press_office/arra_public_review/');">stimulus package</a>, now is the perfect time.<br /><br />As a part-time caregiver to my mother who has a serious chronic illness and someone who just lost both elderly grandparents in the past four months to illness, I can see the benefit of having all of my family’s medical information organized in one place. When Google Health <a href="http://googleblog.blogspot.com/2008/05/peek-into-our-search-factory.html" onclick="javascript: pageTracker._trackPageview('/outgoing/googleblog.blogspot.com/2008/05/peek-into-our-search-factory.html');">launched</a> last year, I promptly set up accounts for my mother and both grandparents. But at the time, I found it frustrating that I was not able to access electronic copies of my grandparents' Medicare claims — where most of their medical data resided.<br /><br />The Medicare Arizona and Utah pilot is designed to give beneficiaries choice in the tools they use to manage their medical records online. Google Health is one of four personal health records (PHR) that beneficiaries can choose from. While only traditional fee-for-service (FFS) Medicare beneficiaries with a primary residence in Arizona and Utah are eligible to participate, this includes nearly 1.1 million beneficiaries living in those regions.<br /><br />For beneficiaries who choose to participate, it's important to know that Medicare does not have access to information in your Google Health Account — Medicare will only be sending data to your Account. Beneficiaries who participate in the pilot will still have access to data imported into their Google Health Accounts after the pilot concludes at the end of 2009. And with the recently launched Google Health <a href="http://googleblog.blogspot.com/2009/03/google-health-helping-you-better.html" onclick="javascript: pageTracker._trackPageview('/outgoing/googleblog.blogspot.com/2009/03/google-health-helping-you-better.html');">sharing feature</a>, any beneficiary enrolled in this pilot can now share this data with family members and doctors in their care network. <br /><br />If I had this type of electronic access to my grandparents' medical records during my family's medical crisis, it would have been a huge help to me. I applaud CMS for taking this big step towards empowering consumers with access to their own health records.<br /><br />If you're a Medicare beneficiary living in Arizona or Utah and are interested in participating in the pilot, you can <a href="http://www.google.com/intl/en-US/health/medicarephrchoice.html" onclick="javascript: pageTracker._trackPageview('/outgoing/google.com/intl/en-US/health/medicarephrchoice.html');">get started here</a>.<br /><br /><span class="byline-author">Posted by Missy Krasner, Product Marketing Manager, Google Health</span>

Getting your Medicare records in Google Health

Google Health is working with the Centers for Medicare and Medicaid Services (CMS) on a pilot program in Arizona and Utah that lets Medicar...

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Hedging the Future of the FDA?

A little while ago, we discussed the Obama administration's nomination for Commissioner of the US Food and Drug Administration (FDA), Dr Margaret Hamburg, focused on her current position as a director of Henry Schein Inc, a large distributor of medical products, including drugs and devices. There is another aspect of her nomination worthy of discussion, but which has not been publicly discussed. It has appeared almost as a footnote in a few reports of her nomination. For example, at the end of an <a href="http://www.chicagotribune.com/news/nationworld/chi-090311-margaret-hamburg-fda,0,4751083.story">article in the Chicago Tribune</a>,<br /><br /><blockquote>Hamburg is married to Peter Fitzhugh Brown, an artificial intelligence expert who is executive vice president and director of Renaissance Technologies, a privately owned hedge fund. </blockquote><br />In this time of financial meltdown, hedge funds are more frequently mentioned in the press. Hedge funds are a relatively new, and generally opaque presence in the financial world. Hedge funds apparently buy and sell stocks, bonds, commodities, financial instruments, and use a variety of investment strategies. Since health care accounts for over $2 trillion of the US economy, it seems possible that hedge funds might be involved in stocks, bonds, and the finances in general of health care corporations. We therefore wondered Mr Brown's position at the hedge fund management company Renaissance Technologies might have something to do with health care, particularly with health care corporations that make products regulated by the FDA. It turns out that this question has no simple answer.<br /><br />Hedge funds are often described as secretive and lightly regulated. This seems accurate, as it is not easy to find out much about their operations, strategy, holdings, or leadership. My usual Google searching tricks did not turn up much useful about Renaissance Technologies.<br /><br />Most helpful was a <a href="http://www.bloomberg.com/news/marketsmag/mm_0108_story1.html">2008 article in Bloomberg News</a>, which labeled the company as "the world's largest hedge fund manager." It was managing $35.4 billion in assets in September, 2007.<br /><br />The Bloomberg reporter's attempt to find out something about the company's strategies was a failure, summarized by his conclusion, "nobody knows precisely how the firm makes its millions." When the funds founder, Jim Simons, was asked what he can say about his trading strategy, he answered, "not much." The instruments he trades? - "everything." The strategies he uses? - "a lot."<br /><br />The only publicly available information about the company's holdings is in its 13F filings with the US Securities and Exchange Commission (SEC). The 2009 filing, covering 2008, is <a href="http://xml.10kwizard.com/filing_raw.php?repo=tenk&ipage=6134654">here</a>. The filing only covers long stock holdings at the end of the year. Lacking a research staff, I have not been able to go through the voluminous report in detail, but do note that the company at times invested in health care corporations from A ([Abbott Laboratories, valued at $88,909,000) to Z (Zimmer Holdings, $7,858,000).<br /><br />I had little luck finding out the role of Mr Brown within the company, and whether he has any personal responsibility for making decisions about investments in any health care corporations. But I did find that a prominent Renaissance Technologies fund, the Medallion Fund, worth $6 billion in July, 2007, is owned mostly by Renaissance Technologies employees, presumably including Mr Brown, not outside investors, "Medallion stopped taking new money from outside investors in 1993 and returned pretty much the last of their capital 12 years later. Today, the fund is run almost exclusively for the benefit of the Renaissance staff." Furthermore, most of Renaissance Technologies is now owned by its founder and a few top officers, including in particular, Peter Fitzhugh Brown, who the Bloomberg article reported as owning "5-10 percent."<br /><br />So, does Mr Brown's position in and partial ownership of Renaissance Technologies amount to a conflict of interest with respect to his wife's proposed position as Commissioner of the FDA? It is not clear. Mr Brown works for a company that manages billions of dollars, and likely a good chunk of that money is invested in instruments related to health care corporations. Mr Brown now presumably a goodly number of shares of the company's premier fund, and owns a substantial minority interest in the company as a whole. Hence he indirectly probably owns a substantial amount of such instruments. Whether he has any direct decision making responsibility for the buying and selling of such instruments is unclear.<br /><br />Therefore, it seems that Dr Hamburg actually has a "potential conflict of interest" arising out of her husband's role in Renaissance Technologies. In academic conflict of interest policies, that phrase often appears without a definition, perhaps to soften the words so often applied now to medical academics. But this seems to be a real instance in which it should be used.<br /><br />The shadows cast by the increasing opacity of the world of finance, now dominated as never before by organizations such as hedge funds that control large pools of investment about which regulations compel little disclosure, now seem to be darkening health care.<br /><br />In my humble opinion, the Senate hearings on Dr Hamburg's confirmation ought to determine whether this potential conflict is more than that. Furthermore, we need a broader dialogue about how to dispel the shadows and secrecy that the dark arts of finance have spread to health care.

Hedging the Future of the FDA?

A little while ago, we discussed the Obama administration's nomination for Commissioner of the US Food and Drug Administration (FDA), Dr...

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The 2009 Spelman College CS Olympiad

We've just sponsored the Seventh Annual <a href="http://www.spelman.edu/%7Esccso/">Spelman College Computer Science Olympiad</a> for the third consecutive year — something we were proud to do as part of our commitment to supporting computer science education and encouraging talented students from diverse backgrounds. This year, 22 teams from 12 Historically Black Colleges & Universities (HBCUs) or Association of Computer/Information Sciences and Engineering Departments at Minority Institutions (ADMI) participated in the Olympiad.<br /><br />One of the five events was the programming challenge, which for the second time was a <a href="http://www.google.com/webmasters/gadgets/">Google Gadgets</a> competition. Their task? To build an interactive, useful, and creative Google Gadget. Teams worked on their gadget concept and design prior to the Olympiad, and then brought their gadgets to a Friday night hack session, where Googlers and students worked together to debug the gadgets and make last-minute adjustments. At the conclusion of the workshop, teams presented their gadgets to a panel of three Googler judges, demonstrating gadget functionalities, discussing design challenges, and providing suggestions for how they would further refine their gadgets. Our judges were then faced with the tough task of deciding upon the winners:<br /><ul><li>First Place: Hampton University "2011"</li><li>Second Place: University of the District of Columbia "Firebirds"</li><li>Third Place: Norfolk State University "Green"</li></ul>Here's a look at Hampton University's first place gadget, a rendering of a game akin to tic-tac-toe called "Do Not Want."<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_7ZYqYi4xigk/Sc0aK0GapSI/AAAAAAAADcE/QKcTAosfR8s/s1600-h/donotwant.JPG"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317935508080993570" src="http://1.bp.blogspot.com/_7ZYqYi4xigk/Sc0aK0GapSI/AAAAAAAADcE/QKcTAosfR8s/s400/donotwant.JPG" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 352px;" /></a><br />Congratulations to all 22 teams!<br /><br /><span class="byline-author">Posted by Anna Davda, University Programs Specialist</span>

The 2009 Spelman College CS Olympiad

We've just sponsored the Seventh Annual Spelman College Computer Science Olympiad for the third consecutive year — something we were pr...

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An hour for the Earth

<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_7ZYqYi4xigk/Sc0AibUW5YI/AAAAAAAADb0/HA8srReDEr8/s1600-h/light+switch.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317907326443120002" src="http://3.bp.blogspot.com/_7ZYqYi4xigk/Sc0AibUW5YI/AAAAAAAADb0/HA8srReDEr8/s400/light+switch.jpg" style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 266px; height: 400px;" /></a><br />Cities around the world will participate in <a href="http://www.earthhour.org/home/">Earth Hour</a> on Saturday, turning off their lights to raise awareness for energy conservation.<br /><br />You might remember that <a href="http://www.google.com/intl/en/earthhour/">last year</a> we “turned the lights out” on the Google.com homepage during Earth Hour to symbolize our own <a href="http://www.google.com/green">commitment to sustainability</a>. We won’t be turning out the lights on our homepage again this year. Our users come first, and while we received lots of enthusiastic feedback last year, some found an all-black Google.com to be a little confusing. (Also, darkened screens don’t actually save energy — modern displays use the same amount of power <a href="http://googleblog.blogspot.com/2007/08/is-black-new-green.html">regardless of what they display</a>.) We are actively supporting this year's <a href="http://www.earthhour.org/home/">Vote Earth</a>, an Earth Hour 2009 initiative to gather one billion words to present at the <a href="http://en.cop15.dk/">United Nations Climate Change Conference</a> in Copenhagen in December of this year. Participants can share their opinions about climate change through the <a href="http://www.earthhour.org/home/#EarthConnect">Earth Connect</a> social platform which incorporates Google tools including <a href="http://maps.google.com/">Google Maps</a>, <a href="http://appengine.google.com/">App Engine</a>, <a href="http://www.google.com/friendconnect/">Friend Connect</a>, <a href="http://translate.google.com/">Google Translate</a>, <a href="http://www.blogger.com/">Blogger</a> and <a href="http://www.feedburner.com/">Feedburner</a>.<br /><br />After all, Earth Hour is about more than dimming lights; it’s about making a commitment to reduce energy consumption throughout the year. At Google, we take this commitment seriously and over the past twelve months we’ve worked hard to reduce Google’s own power use and to help others reduce theirs:<br /><ul><li>We remodeled our San Francisco office to achieve a <a href="http://googleblog.blogspot.com/2009/03/pot-o-leed-gold.html">Gold rating</a> by the <a href="http://www.usgbc.org/">U.S. Green Building Council's</a> LEED Green Building Rating System</li><li>Our engineers are working on a tool called <a href="http://www.google.com/powermeter">Google PowerMeter</a> that will show consumers home energy information almost in real time, right on their computer</li><li>We’ve designed the <a href="http://www.google.com/corporate/green/datacenters/">most efficient data centers</a> possible and are sharing some of our best practices with industry peers</li><li>In the fall we compiled tips and tricks to <a href="http://googleblog.blogspot.com/2008/10/is-your-house-haunted-by-high-energy.html">help our users save energy</a> (and money)</li><li>Our <a href="http://googleblog.blogspot.com/2008/06/plug-ins-converge-on-washington.html">summit on plug-in vehicles</a> in Washington was standing room only, with policy, technology, and energy experts all discussing an electric vehicle future<br /></li></ul>Google will continue to work hard this year to be as green as possible as a company, and we encourage others to take an hour on Saturday and commit to the Earth too. For some great ideas on ways you can save energy every hour of every day through computing efficiency, check out <a href="http://www.climatesaverscomputing.org/">Climate Savers Computing Initiative</a> and their recent video challenge: “<a href="http://www.powerdownfortheplanet.org/video/">Power Down for the Planet</a>.”<br /><br /><span class="byline-author">Posted by Bill Weihl, Green Energy Czar</span>

An hour for the Earth

Cities around the world will participate in Earth Hour on Saturday, turning off their lights to raise awareness for energy conservation. Yo...

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The Political Incorrectness of Discussing Conflicts of Interest in Medical Academia

<a href="http://www.boston.com/news/local/massachusetts/articles/2009/03/26/ethics_event_spawns_a_tussle_at_tufts/">From today's Boston Globe</a>,<br /><blockquote><br />Tufts University has withdrawn an invitation for a top aide to US Senator Charles E. Grassley to give the keynote speech at a conference on conflicts of interest in medicine and research, leading one conference organizer to pull out and question the university's commitment to academic freedom.<br /><br />The University-wide Committee on Ethics rescinded the invitation on March 13, according to e-mails obtained by the Globe. The messages said top Tufts officials refused to allow other administrators to be panelists at the meeting if Grassley's aide spoke, saying it was inappropriate to do so while Grassley is investigating ties between a Tufts professor and the drug industry.<br /><br />The senator, a Republican from Iowa, sent a letter on Feb. 17 to the president of Tufts, Lawrence S. Bacow, requesting detailed information on the relationship between a 'Dr. Boucher' and the pharmaceutical industry, including the amount and dates of all industry payments between January 2006 and December 2008. Dr. Helen Boucher is an infectious diseases specialist at the Tufts medical school.<br /><br />Spokeswoman Christine Fennelly first said in an e-mail that when Grassley declined the invitation, 'it was decided to refocus the symposium on a smaller scale, where the panelists would be faculty from Tufts University and affiliated faculty from Tufts Medical Center.'<br /><br />Later, when told that Krimsky's e-mails explicitly said the speaking offer was rescinded, she said the invitation to Grassley's aide had been withdrawn. 'Indeed . . . the administration felt it prudent to not engage someone from the Senator's office while we respond to the Senator's inquiry,' she wrote.<br /></blockquote><br /><br />One only has to browse the FIRE (Foundation for Individual Rights in Education) <a href="http://www.thefire.org/">web-site </a>to see the sad state of free speech and academic freedom in American universities. Most of the cases they discuss seem to involve barriers to presenting politically incorrect viewpoints on campus. FIRE has presented several cases involving dis-invitation of speakers with such views.<br /><br />On the other hand, on Health Care Renewal we have discussed our share of cases involving free speech and academic freedom in academic medicine. Most of these cases seem to involve barriers to presenting research results that turn out unfavorable to vested financial interests, particularly interests served by the promotion of particular health care products, like drugs or devices, or services.<br /><br />This case appears to be something of a hybrid. Like a number of cases discussed on the FIRE web-site, it involves the dis-invitation of a campus speaker whose viewpoint might not fit with that of the powers that be on campus. However, instead of causing offense because of his political positions, Mr Thacker seemed to cause offense because he has been involved in investigating conflicts of interest affecting medical academics. Thus, it seems that discussing such conflicts of interest has become politically incorrect. This seems to be a fairly blatant instantiation of the <a href="http://hcrenewal.blogspot.com/2007/08/bling-bling-poltical-correctness-and.html">anechoic effect</a>.<br /><br />See also <a href="http://carlatpsychiatry.blogspot.com/2009/03/tufts-blows-it.html">comments</a> by Dr Daniel Carlat on the Carlat Psychiatry Blog.<br /><br />ADDENDUM (31 March, 2009) - also see <a href="http://scienceblogs.com/effectmeasure/2009/03/more_on_conflicts_of_interest.php#more">comments</a> on the Effect Measure Blog.

The Political Incorrectness of Discussing Conflicts of Interest in Medical Academia

From today's Boston Globe , Tufts University has withdrawn an invitation for a top aide to US Senator Charles E. Grassley to give the ke...

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Changes to our sales and marketing organizations

Google has grown very quickly in a very short period of time. When companies grow that quickly it's almost impossible to get everything right—and we certainly didn't. In some areas we've created overlapping organizations which not only duplicate effort but also complicate the decision-making process. That makes our teams less effective and efficient than they should be. In addition, we over-invested in some areas in preparation for the growth trends we were experiencing at the time.<br /><br />So today we have informed Googlers that we plan to reduce the number of roles within our sales and marketing organizations by just under 200 globally. Making changes of this kind is never easy—and we recognize that the recession makes the timing even more difficult for the Googlers concerned. We did look at a number of different options but ultimately concluded that we had to restructure our organizations in order to improve our effectiveness and efficiency as a business. We will give each person time to try and find another position at Google, as well as outplacement support, and provide severance packages for those who leave the company. Finally, I would like to take this opportunity to thank everyone affected for all they have contributed to Google. <br /><br /><font class="byline-author">Posted by Omid Kordestani, Senior VP, Global Sales and Business Development</font>

Changes to our sales and marketing organizations

Google has grown very quickly in a very short period of time. When companies grow that quickly it's almost impossible to get everything...

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This Former Chief Medical Informatics Officer is Feeling a Bit Betrayed

<span style=";font-family:arial;font-size:100%;" >In thinking further about the "hold harmless" and "defects gag clause" originated by Health IT vendors and agreed to by hospital executives as I described at<span style="font-weight: bold;"> </span><a href="http://hcrenewal.blogspot.com/2009/03/health-it-hold-harmless-and-defects-gag.html">Have Hospital Executives Violated Their Fiduciary Responsibilities by Signing Such Contracts?</a>, I can state I feel a sense of (past) betrayal.<br /><br /></span><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;">Only now thanks to a Penn sociologist and a software consultant (plus the fortitude of JAMA, under some criticisms recently on other matters, in publishing this article) do we formally find out that hospitals have been literally "dumping" on physicians by signing contracts with the HIT vendors leaving the docs "holding the bag" for software errors and malfunctions, and gagging their organizations from openly talking about defects and problems. In other words, <span style="font-weight: bold;">physicians hold the risk, everyone else holds the money</span>.</span><br /><br /><span style="font-family:arial;">Actually, since EMR mostly benefits the </span><span style="font-weight: bold;font-family:arial;" >payers</span><span style="font-family:arial;">, I'd more correctly say hospital administrations have largely </span><span style="font-weight: bold;font-family:arial;" >sold physicians down the river, </span><span style="font-family:arial;">an act that echoes of contempt and betrayal let alone breach of fiduciary responsibility and the Joint Commission standards I believe apply as in the post linked above.<br /><br /></span></span><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;">It's not as if hospital administrations cannot negotiate these issues, nor are they forced to sign such provisions if vendors refuse to negotiate. They could send such vendors out the door. If this had been done as a routine by hospital executives, the health IT vendors would have been forced to give in years ago. Health IT was and is <span style="font-weight: bold;">not mandatory for operations</span>; the latest survey in NEJM indicates <a href="http://www.nytimes.com/2009/03/26/business/26health.html?_r=1">only ~9% of hospitals are using EMRs</a>.<br /><br />I also believe possible claims of ignorance and/or "we didn't read the fine print" don't fly. Hospital execs have the responsibility and duty to research such issues and read the fine print, or at the very least counsel did. In effect, at best the spinelessness of hospital administrations over the years may have spoiled the vendors to expect such concessions. (One also wonders about special "incentives" that might make hospital administrations weaker than they might otherwise be on such issues.)</span></span><br /><span style=";font-family:times new roman;font-size:100%;" ><br /><span style="font-family:arial;">Now I better understand perhaps why as CMIO/Director of Informatics at Christiana Care Health System in the late 1990's I never got to see the HIT contracts. </span><span style="font-family:arial;">I likely would have been a <span style="font-weight: bold;">lot less eager</span> to try to "sell" the EMR idea to the medical staff if I had been aware of the "vendor held harmless" provisions they faced if a software design problem or glitch in these immensely complex devices contributed to patient harm. I <span style="font-weight: bold;">also feel betrayed in my CMIO role</span> by not being informed of these contract provisions.<br /></span><br /><span style="font-family:arial;">I wonder how many former and present CMIO's out there are now thinking along the same lines.<br /><br /></span></span><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;">Ironically, as a Group Director at Merck Research Labs two years later I did review my department's informatics contracts, in fact I was required to, all several million dollars' worth, and in fact was involved in vendor negotiations (I had a personal grant of authority of $100,000 for smaller contracts). Pharma truly reveals hospitals for the IT backwater they are.</span></span><br /><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;"><br />Finally, there appears to be a mainstream media boycott of the Koppel/Kreda article. As of 1:30 PM EST March 26, Google news <a href="http://news.google.com/news?um=1&ned=us&hl=en&q=koppel+kreda">shows almost no coverage</a> except </span></span><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;">JAMA, ZDNet and Fox Business News. </span></span><span style=";font-family:times new roman;font-size:100%;" ><span style="font-family:arial;"> With Google <a href="http://www.google.com/search?hl=en&q=Health+Care+Information+Technology+Vendors%27+%22Hold+Harmless%22+Clause%3A&btnG=Search">web search</a>, I find mostly copies of the U. Penn press release, and links to a few blogs, including this one.<br /><br />I've previously noted this fascinating, Google-revealed phenomena about <a href="http://www.powerlineblog.com/archives/2006/09/015074.php">media noncoverage of politically inconvenient stories</a>.<br /><br />I've contacted the WSJ who printed my <a href="http://hcrenewal.blogspot.com/2009/02/medinformaticsmd-in-wall-street-journal.html">editorial letter</a> on Health IT last month. Perhaps they'll get the scoop on the issues raised by Koppel and Kreda.<br /><br /></span><span style="font-family:arial;">-- SS</span><br /><br /></span>

This Former Chief Medical Informatics Officer is Feeling a Bit Betrayed

In thinking further about the "hold harmless" and "defects gag clause" originated by Health IT vendors and agreed to by ...

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Health IT "Hold Harmless" and Defects Gag Clauses: Have Hospital Executives Violated Their Fiduciary Responsibilities By Signing Such Contracts?

<div style="text-align: justify;"><span style="font-style: italic;font-family:arial;font-size:85%;" ><span style="font-weight: bold;">July 2009 - Note</span>: also see my letter to the editor in JAMA on this same topic, </span><span style="font-style: italic;font-family:arial;font-size:100%;" ><span style="font-size:85%;">"Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards", published July 22, 2009, available online at <a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382">this link</a>.</span></span><br /></div><span style=";font-family:arial;font-size:100%;" ><br />Regarding healthcare IT "Hold Harmless" and Defects Gag Clauses as revealed by the JAMA article </span><span style=";font-family:arial;font-size:100%;" ><span><a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians</a></span></span><span style=";font-family:arial;font-size:100%;" > by Koppel and Kreda:</span><br /><br /><span style="font-family:arial;">Have hospital executives violated their fiduciary responsibilities by signing such contracts, and violated Joint Commission standards of hospital leadership conduct as well?</span><br /><blockquote style="font-style: italic;font-family:arial;"><span style="font-size:130%;"><br /><a href="http://www.infoplease.com/ce6/society/A0818616.html"><span class="title">Fiduciary</span></a> </span><span class="noindex" style="font-size:130%;"><span class="pron"> (fid<b>OO</b>'shēe"rē)</span></span><span style="font-size:130%;">, in law, a person who is obliged to discharge faithfully a responsibility of trust toward another. Among the common fiduciary relationships are guardian to ward, parent to child, lawyer to client, <span style="font-weight: bold;">corporate director to corporation</span>, trustee to trust, and business partner to business partner. In discharging a trust, the fiduciary must be </span><span style="font-weight: bold;font-size:130%;" >absolutely open and fair</span><span style="font-size:130%;">. Certain business methods that would be acceptable between independent parties dealing with one another “at arm's length” may expose a fiduciary to <span style="font-weight: bold;">liability for having abused a position of trust.</span></span></blockquote><br /><span style="font-family:arial;">Hospital management conduct is not bound by traditional business law only, just as physicians and other clinicians hold additional obligations. In both cases, obligations go beyond that of, say, a manager or worker at a McDonald's or a Wal-Mart. In healthcare <span style="font-weight: bold;">there are "special" third parties involved</span> with critical rights and responsibilities, namely, patients and clinicians.</span><br /><br /><span style="font-family:arial;">At </span><a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/03/health-care-information-technology.html">Health Care Information Technology Vendors' "Hold Harmless" Clause</a><span style="font-family:arial;"> I expressed great concern about the remarkable revelations in Koppel and Kreda's expose of arguably unethical and clearly inexcusable contracting practices by healthcare IT producers and vendors.</span><br /><br /><span style="font-family:arial;">The vendors have declared themselves off limits from liability even if patients die as a result of software defects and malfunctions, pushing that liability onto clinicians. Vendors have simultaneously declared themselves the Ministry of Information, Soviet style, on such defects.</span><br /><br /><span style="font-family:arial;">I also expressed my concern that the contractual suppression of information dissemination on health IT problems and defects may be one reason websites on health IT difficulties, such as the </span><a style="font-family: arial;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">site I started in 1998</a><span style="font-family:arial;"> (in fact cited by Koppel and Kreda) remain uncommon on the Web. This is despite my documentation of </span><span style="font-weight: bold;font-family:arial;" >continued, ongoing, world wide interest</span><span style="font-family:arial;"> in this topic (see my 2006 AMIA abstract on this issue </span><a style="font-family: arial;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/content/documents/AMIA2006_poster.pdf">here</a><span style="font-family:arial;">, PDF, and poster </span><a style="font-family: arial;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/content/documents/FINAL_Healthcare%20IT%20Failure_Oct_19_2006.ppt">here</a><span style="font-family:arial;">, PPT).</span><br /><br /><span style="font-family:arial;">It is not just the vendors who may be acting against the best interests of medical science and patient safety, however.</span><br /><br /><span style="font-family:arial;">It also seems to me that hospital executives, boards and counsel have fiduciary responsibilities, as well as obligations under principles of due diligence, Joint Commission and other regulatory guidelines, etc. to protect not just patients from defective technologies but also to </span><span style="font-weight: bold;font-family:arial;" >protect their staffs from unfair risks and legal liabilities. </span><span style="font-family:arial;">I note that these health IT contracts have apparently been signed willingly by hospital executives, </span><span style="font-weight: bold;font-family:arial;" >against the best interests</span><span style="font-family:arial;"> of patients and medical staffs. Nobody is holding a gun to their heads, and nobody is forbidding negotiation of terms.</span><br /><br /><span style="font-family:arial;">As a former CMIO/Director of Informatics I would never have signed such a contract. Period. (Of course, CMIO's and Directors of Informatics don't generally sign or even see health IT contracts, as they are </span><span style="font-style: italic;font-family:arial;" >Chiefs and Directors of Nothing.)</span><br /><br /><span style="font-family:arial;">Have hospital executives, boards of directors and counsel been violating their responsibilities and obligations every time they've signed a healthcare IT "hold vendors harmless, it's all on your docs" and "shhhh! keep the defects secret" contract? Have they abused their positions of trust?</span><br /><br /><span style="font-family:arial;">NIH research leaders and grant reviewers, as an example, consider seriously any problems with research that might place not just research subjects but also </span><span style="font-weight: bold;font-family:arial;" >investigators</span><span style="font-family:arial;"> at risk, medically, legally and otherwise. I perform this function on NIH study section panels.</span><br /><br /><span style="font-family:arial;">Let's look at the Joint Commission </span><span style="font-family:arial;">Hospital Accreditation Program </span><a style="font-family: arial;" href="http://www.jointcommission.org/Standards/SII/sii_hap_ld.htm">Leadership Chapter</a><span style="font-family:arial;">, and its standards for hospital leadership (</span><a style="font-family: arial;" href="http://www.jointcommission.org/NR/rdonlyres/D53206E8-D42B-416B-B887-491B6D5AA163/0/HAP_LD.pdf">link</a><span style="font-family:arial;">, PDF):</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Leadership</span><br />LD.01.03.01<br /><br /><span style="font-weight: bold;">Standard LD.01.03.01 </span><br />The governing body is ultimately accountable for the safety and quality of care, treatment, and services.<br /><br /><span style="font-weight: bold;">Rationale for LD.01.03.01 </span><br />The governing body’s ultimate responsibility for safety and quality derives from their legal responsibility and operational authority for [organization] performance. In this context, the governing body provides for internal structures and resources, including staff, that support safety and quality. </blockquote><br /><span style="font-family:arial;">The governing body has a legal responsibility for safety and quality, not just a moral obligation. One of the "internal structures" is healthcare IT that is safe and effective and that does not expose patients or staff to undue risks.</span><br /><br /><span style="font-family:arial;">How does signing "hold harmless" and "defects gag order" clauses with an HIT vendor serve such a purpose, exactly?</span><br /><br /><span style="font-family:arial;">Hospital executives </span><span style="font-weight: bold;font-family:arial;" >know, should know, or should have known</span><span style="font-family:arial;"> that such provisions would remove incentives for health IT vendors to produce the best products and to correct deficiencies rapidly, thus increasing risk to patients and clinicians.</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Elements of Performance for LD.01.03.01</span><br />5. The governing body provides for the resources needed to maintain safe, quality care, treatment, and services. </blockquote><br /><span style="font-family:arial;">One of those resources is health IT.</span><br /><span style="font-weight: bold;font-family:arial;" ><br /></span><blockquote style="font-family:arial;"><span style="font-weight: bold;">Standard LD.02.01.01<br /></span>The mission, vision, and goals of the [organization] support the safety and quality of care, treatment, and services.<br /><br /><span style="font-weight: bold;">Rationale for LD.02.01.01 </span><br />The primary responsibility of leaders is to provide for the safety and quality of care, treatment, and services. The purpose of the [organization]’s mission, vision, and goals, is to define how the [organization] will achieve safety and quality. The leaders are more likely to be aligned with the mission, vision, and goals when they create them together. The common purpose of the [organization] is most likely achieved when it is understood by all who work in or are served by the [organization]. </blockquote><br /><span style="font-family:arial;">How is a contract with an HIT vendor that calls for hiding defects in health IT and exposing staff to liability for defects in same serving the above purposes?</span><br /><blockquote style="font-family:arial;"><br /><span style="font-weight: bold;">Standard LD.02.03.01 </span><br />The governing body, senior managers and leaders of the organized medical staff regularly communicate with each other on issues of safety and quality. </blockquote><br /><span style="font-family:arial;">Does that include communication on health IT defects? Can a medical staff member ask to see a database of such defects when the hospital has signed a nondisclosure of defects agreement with an HIT vendor?</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Rationale for LD.02.03.01 </span><br />Leaders, who provide for safety and quality, must communicate with each other on matters affecting the [organization] and those it serves. </blockquote><br /><span style="font-family:arial;">I ask the same question as above.</span><br /><br /><blockquote style="font-family:arial;"><br /><span style="font-weight: bold;">Standard LD.03.01.01 </span><br />Leaders create and maintain a culture of safety and quality throughout the [organization]. </blockquote><br /><span style="font-family:arial;">Safety for whom, exactly? Patients, or patients and staff?</span><br /><br /><span style="font-family:arial;">How is exposing professional staff to undeserved liability from defective health IT serving the creation of a culture of safety and quality for them? How is suppressing information on health IT defects and problems helping patient safety and care quality?</span><br /><br /><span style="font-family:arial;">How is </span><span style="font-weight: bold;font-family:arial;" >lack of seeking informed consent</span><span style="font-family:arial;"> on health IT use from patients whose care is mediated by health IT devices with </span><span style="font-weight: bold;font-family:arial;" >known but undisclosable</span><span style="font-family:arial;"> </span><span style="font-weight: bold;font-family:arial;" >defects</span><span style="font-family:arial;"> creating a culture of quality?</span><br /><br /><span style="font-family:arial;">How is hiding such defects creating a culture of quality in the community's other hospitals, that may be considering purchase of the very same health IT?</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Standard LD.03.04.01</span><br />The [organization] <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">communicates information related to safety and quality to those who need it, including staff</span><span style="color: rgb(255, 0, 0);">,</span> licensed independent practitioners, <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[patient]s</span>, families, and <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">external interested parties. </span><br /><br /><span style="font-weight: bold;">Rationale for LD.03.04.01 </span><br />Effective communication is essential among individuals and groups within the [organization], and <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">between the [organization] and external parties</span>. <span style="font-weight: bold;">Poor communication often contributes to adverse events </span>and can compromise safety and quality of care, treatment, and services. Effective communication is timely, accurate, and usable by the audience. </blockquote><br /><span style="font-family:arial;">Are physicians and nurses explicitly informed by administration that clinicians are liable for bad outcomes due to software problems? Are they informed of the gag clause? Are patients informed of unremediated health IT defects existing at time of service?</span><br /><br /><span style="font-family:arial;">This standard seems a veritable smoking gun regarding breach of fiduciary responsibility and Joint Commission obligations when hospital leadership signs agreements specifically excluding the sharing information about health IT defects and complaints. </span><span style="font-weight: bold;font-family:arial;" >It is already known that hospitals maintain lists </span><span style="font-weight: bold;font-family:arial;" >of health IT defects</span><span style="font-family:arial;">, some in the thousands of items. </span><span style="font-family:arial;"> A number of the defects rise to the level of creating considerable risk to patients, and nobody is in a hurry to remediate them. (See my proposed although somewhat tongue in cheek "</span><span style="font-weight: bold;font-family:arial;" >HIT Informed Consent</span><span style="font-family:arial;">" that describes some of these known defect categories </span><a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/03/draft-patient-rights-statement-and.html">here</a><span style="font-family:arial;">).</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Standard LD.04.04.03 </span><br />New or modified services or processes are well-designed.<br /><br />... 3. The hospital's design of new or modified services or processes incorporates: <span style="font-weight: bold;">Information about potential risks to patients. </span><br /><br />4. The hospital's design of new or modified services or processes incorporates: Evidence-based information in the decision-making process. Note: For example, evidence-based information could include practice guidelines, successful practices, information from current literature, and clinical standards.<br /></blockquote><br /><span style="font-family:arial;">How does the contractual inability to communicate about health IT defects, which its executives willingly sign, serve this purpose?</span><br /><br /><blockquote style="font-family:arial;"><span style="font-weight: bold;">Standard LD.04.04.05 </span><br />The [organization] has an organization-wide, integrated [patient] safety program.<br /><br />... 12. <span style="font-weight: bold;">The hospital disseminates lessons learned</span> from root cause analyses, <span style="font-weight: bold;">system or process failures</span>, and the results of proactive risk assessments<span style="font-weight: bold;"> to all staff who provide services</span> for the specific situation.<br /></blockquote><br /><span style="font-family:arial;">Disseminates lessons learned, except when the HIT contract they've signed with a vendor forbids it, that is.</span><br /><br /><span style="font-family:arial;">The practices of the health IT industry, and the dealings of the hospital leadership with that industry, may in fact be a scandal of national (or international) proportions.</span><br /><br /><span style="font-family:arial;">I urge physicians and concerned others reading this to read the Univ. of PA press release "</span><span style="font-style: italic;font-family:arial;" >Why Are Healthcare Information Manufacturers Free of All Liability When Their Products Can Result in Medical Errors?</span><span style="font-family:arial;">" </span><a style="font-family: arial;" href="http://sev.prnewswire.com/null/20090324/DC8755624032009-1.html">here</a><span style="font-family:arial;">, obtain the JAMA article by Koppel and Kreda, and </span><span style="font-weight: bold;font-family:arial;" >call their congressional and other representatives</span><span style="font-family:arial;"> to have these self-serving industry practices that ignore protection of patients and practitioners from undue jeopardy stopped.</span><br /><br /><span style="font-family:arial;">I also believe any clinician under lawsuit related to hospital HIT malfunction, and/or patients harmed, should consider </span><span style="font-weight: bold;font-family:arial;" >suit against the management </span><span style="font-family:arial;">that signed the contracts allowing the defective IT's entry into the hospital and mandated clinicians to use the HIT.</span><br /><br /><span style="font-family:arial;">I, for one, already have begun discussing these issues with my representatives in Washington, and they've expressed great surprise at these revelations.</span><br /><br /><span style="font-family:arial;">-- SS</span>

Health IT "Hold Harmless" and Defects Gag Clauses: Have Hospital Executives Violated Their Fiduciary Responsibilities By Signing Such Contracts?

July 2009 - Note : also see my letter to the editor in JAMA on this same topic, "Health Care Information Technology, Hospital Responsib...

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iGoogle's got game... themes!

I'm happy to announce the launch of iGoogle game themes. These themes offer our users new iGoogle backdrops inspired by their favorite video games, including classics like "Mario" and "Mega Man" and new sensations like "Wii Sports" and "Spore." Like our <a title="iGoogle artist themes" href="http://googleblog.blogspot.com/2008/04/where-art-thou.html" id="m_na">iGoogle artist themes</a>, <a title="fashion and music themes" href="http://googleblog.blogspot.com/2008/09/more-eye-candy-for-igoogle.html" id="jc5v">fashion and music themes</a> and <a title="themes for causes" href="http://googleblog.blogspot.com/2008/12/creating-change-with-your-homepage.html" id="dqgk">themes for causes</a>, we hope that the game themes delight our users and reflect their personal interests. As you can imagine, these themes in particular have captivated our iGoogle software engineers who are gamers themselves. I'll now turn the post over to one of our engineers who worked closely on the project, Matthew Chan, for more details.<br /><br /><span style="font-weight: bold;">A gamer's POV</span><br /><br />I confess, I'm a game geek. My first experience with video games was spending hours and hours (not to mention my weekly allowance) playing "Donkey Kong" and "Galaga" at a nearby arcade until my fingers ached. These days I no longer have to ride my bike to the neighborhood arcade to play video games — I can do it in the comfort of my own home anytime I want! And even better... starting today, I can have images of my favorite childhood games right on my iGoogle page.<br /><br />iGoogle now has graphics from all sorts of games that I know will excite my fellow gamers. Picture your homepage with "Burnout" cars zooming in the background, Ryu from "Street Fighter" blasting hadoukens across your page, or rock stars jamming out to tunes from "Guitar Hero." It doesn't end there. For those of you who used to dream about completing the Triforce or getting out of tombs alive, choose from "Zelda" or "Tomb Raider." Want more? Try "Dungeons & Dragons," "The Sims 3," or "World of Warcraft" on for size.<br /><br />So come check out the new game themes (<a href="http://www.google.com/help/ig/gaming/">www.google.com/gamingthemes</a>) and choose your favorite one. If you can't decide, no worries. Just add the <a href="http://www.google.com/ig/directory?type=themes&url=skins/games_sampler.xml" id="wbrp" title="game theme of the day">game theme of the day</a> and enjoy seeing a different one on your iGoogle page every day.<br /><br />Here's a look at the themes in action:<br /><br /><object height="350" width="425"> <param name="movie" value="http://www.youtube.com/v/TzFPOHmrt2Q"> <embed src="http://www.youtube.com/v/TzFPOHmrt2Q" type="application/x-shockwave-flash" height="350" width="425"></embed> </object><br /><br /><span class="byline-author">Posted by Marissa Mayer, VP of Search Products and User Experience, and Matthew Chan, iGoogle engineer</span>

iGoogle's got game... themes!

I'm happy to announce the launch of iGoogle game themes. These themes offer our users new iGoogle backdrops inspired by their favorite v...

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Google, at your service

It used to be that creating a webpage was a pursuit reserved for the truly tech-savvy, requiring a geek's expertise in HTML, Java, or C++ coding.<br /><br />These days, it's a different story. Working with a <a href="http://en.wikipedia.org/wiki/Web_hosting_service">hosting service</a> has made things a great deal easier, as they can help you reserve a name for your site (www.[insertyournamehere].com), and they often provide tools to help get you set up, with minimal to zero programming experience required.<br /><br />Today, we're releasing <a href="http://www.google.com/webmasters/provider/">Google Services for Websites</a>, a few more tools that your hosting company can now enable to help you improve your website. This expanded program includes Webmaster Tools, AdSense, Custom Search, and Site Search, making it easier to drive traffic to your site, monetize your site through the Google ad network, and add various search capabilities to help your visitors find information on your site faster.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://3.bp.blogspot.com/_7ZYqYi4xigk/ScqyZDtONxI/AAAAAAAADbc/urIdmLxTM4Q/s1600-h/Fatcow.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317258453625747218" src="http://3.bp.blogspot.com/_7ZYqYi4xigk/ScqyZDtONxI/AAAAAAAADbc/urIdmLxTM4Q/s400/Fatcow.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 329px;" /></a><br />For more information, check out our <a href="http://googleenterprise.blogspot.com/2009/03/google-services-for-websites-expands-to.html">Enterprise Blog</a>, <a href="http://googlewebmastercentral.blogspot.com/2009/03/making-more-tools-available-with-just.html">Webmasters Blog</a> and <a href="http://googlecustomsearch.blogspot.com/2009/03/google-services-for-websites-includes.html">Custom Search Blog</a>. And if your hosting service doesn't have Google Services for Websites yet, send them to <a href="http://www.google.com/webmasters/provider/">this page</a>. We hope you find these new tools helpful.<br /><br /><span class="byline-author">Posted by Rajat Mukherjee, Group Product Manager</span>

Google, at your service

It used to be that creating a webpage was a pursuit reserved for the truly tech-savvy, requiring a geek's expertise in HTML, Java, or C+...

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Google's 2009 EMEA Faculty Summit

Our <a href="http://maps.google.com/maps?q=Brandschenkestrasse+110+8002+Z%C3%BCrich+Switzerland&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&split=0&gl=us&ei=ZszHSdWIDYKOsQPen6HgBg&sa=X&oi=geocode_result&resnum=1&ct=title">Zurich office</a> was proud to host Google's second annual EMEA (Europe, Middle East, and Africa regions) Faculty Summit last month. Eighty leading academics joined us from 66 universities in 24 countries for this three-day event.<br /><br />The Faculty Summit's purpose is to increase collaboration between key universities and our engineering teams. This year, we organised more than 40 talks and presentations, plus panels, networking and social events to help our guests learn more about Google's work in their regions. In return, Googlers gained valuable insight into challenges faced by the region's universities and new developments in the academic world. Event highlights included a keynote by leading cryptographer and Turing Award winner Adi Shamir on the topic of privacy and security as related to cloud computing. Further discussion centered on topics ranging from the power and limitations of cryptographic technology to usability issues introduced by security requirements, with some debate over the balance between preventing abuse and identifying and reporting abusers.<br /><br /><a href="http://www.google.com/corporate/execs.html#spector">Alfred Spector</a> (VP of Research), Jeff Walz (University Relations) and I spoke about Google's engineering efforts and the impact of our university relations initiatives, with much discussion focusing on our involvement in the Arab and African regions. Rapidly expanding markets in the Middle East and Africa represent a major engineering challenge for us, and we are eager to continue collaboration with leading academic attendees from the region well beyond the Summit. We were pleased to welcome representatives from the Al Arabiya news channel, who highlighted this topic in a recent broadcast. We also heard from Google 'Research Award' and 'CS4HS' (Computer Science for High School) grant recipients and EMEA-based academics spending long-term sabbaticals at Google, who described their experiences over the past year.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_7ZYqYi4xigk/Scpcjuji0wI/AAAAAAAADbU/TVAcLoHktqA/s1600-h/_mg_6766.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5317164078926582530" src="http://1.bp.blogspot.com/_7ZYqYi4xigk/Scpcjuji0wI/AAAAAAAADbU/TVAcLoHktqA/s400/_mg_6766.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 267px;" /></a><br />This year also saw new additions to the Faculty Summit agenda, including a networking session allowing academics to discuss collaboration options one-on-one with specific Google engineers. This session spurred a great deal of activity — for instance, multiple Googlers are booked to deliver guest lectures at external events and universities and several attendees have been invited to present their findings on research ranging from 'Software Visualisation' to 'Mobile Agile Testing' at Google engineering offices across EMEA. We plan to make these networking sessions a focal point at future Faculty Summits!<br /><br />I'd like to thank the organising team for their help in planning and executing this important event for the second year running. The 2009 EMEA Faculty Summit proved to be an incisive and informative event resulting in new academic and industrial collaborations. We look forward to reporting back on these synergies as they develop over the next year!<br /><br /><span class="byline-author">Posted by Nelson Mattos, VP of Engineering</span>

Google's 2009 EMEA Faculty Summit

Our Zurich office was proud to host Google's second annual EMEA (Europe, Middle East, and Africa regions) Faculty Summit last month. Ei...

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BLOGSCAN - The Mysterious Disappearance of a Report Critical of Industry Funding of CME

<span style="color:#006600;">On the Carlat Psychiatry Blog, Dr Daniel Carlat </span><a href="http://carlatpsychiatry.blogspot.com/2009/03/ama-ethics-and-404-not-found.html"><span style="color:#006600;">discussed</span></a><span style="color:#006600;"> the mysterious disappearance of a report by the AMA's Council on Ethical and Judicial Affairs (CEJA) which recommended the end of commercial funding of continuing medical education (CME). The report was tabled, and is now no longer available on the AMA web-site. (Although, it has not completely vanished off the webs. See the comments on Dr Carlat's post.) Meanwhile, the AMA has posted a series of "fact sheets" from their </span><a href="http://www.ama-assn.org/ama/pub/education-careers/continuing-medical-education/events/national-task-force-cme-provider-industry.shtml"><span style="color:#006600;">National Task Force on CME Provider/Industry Collaboration</span></a><span style="color:#006600;"> which seem notably friendly to "collaboration" among educators and industry. </span>

BLOGSCAN - The Mysterious Disappearance of a Report Critical of Industry Funding of CME

On the Carlat Psychiatry Blog, Dr Daniel Carlat discussed the mysterious disappearance of a report by the AMA's Council on Ethical and ...

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Citizen participation that scales: a call to action

At Google we hold weekly <a href="http://en.wikipedia.org/wiki/Town_hall_meeting">town hall</a>-style meetings with our founders, CEO, and guest speakers, which always feature a Q&A session. Managing Q&A is a unique challenge with an audience of thousands, in offices around the world, who inevitably want to ask more questions than we have time to answer. To help address this challenge, we developed <a href="http://moderator.appspot.com/">Google Moderator</a>, built on <a href="http://code.google.com/appengine/">App Engine</a>.<br /><br />Moderator gives participants a way to submit questions and vote for the ones they want answered. And thanks to the scale that App Engine provides, this application can now support tens of thousands of people at once. This gives everyone the chance to be heard in a way that gives priority to the issues that matter most to the broader group.<br /><br /><a href="http://www.youtube.com/watch?v=hjJm_Hzc6Yg">As you may have heard</a>, the White House is hosting an online town hall meeting on Thursday and has asked people to submit questions for the president and vote on which ones they think he should answer.<br /><br />We think technology can be a force for greater accountability and access between citizens and their elected officials. We're excited that the White House has chosen to use the power of cloud-based applications like Google Moderator and App Engine to scale the president's direct dialogue with the American people.<br /><br />To take part in this experiment in citizen participation, please visit: <a href="http://whitehouse.gov/OpenForQuestions">http://WhiteHouse.gov/OpenForQuestions</a><br /><br /><span class="byline-author">Posted by Vic Gundotra, Vice President, Engineering</span>

Citizen participation that scales: a call to action

At Google we hold weekly town hall -style meetings with our founders, CEO, and guest speakers, which always feature a Q&A session. Manag...

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Health Care Information Technology Vendors' "Hold Harmless" Clause - The Largest IT Industry Abuse Ever?

Dear fellow physicians, nurses and other clinicians:<br /><br />You thought frivolous medical malpractice suits were a problem?<br /><br />Guess what:<br /><br />It's worse. Along with your patients you are nonconsented beta testers and experimental subjects of the health IT industry, and <span style="font-weight: bold;">potential victims of the computer industry's arrogance and dysfunctio</span><span style="font-weight: bold;">n</span>.<br /><br />In the remarkable article <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians</a>, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009;301(12):1276-1278, we learn that:<br /><br /><blockquote style="font-family:arial;"><span style="font-size:130%;"><span style="font-family:arial;">Healthcare information technology (HIT) vendors enjoy a contractual and legal structure that <span style="font-weight: bold;">renders them virtually liability-free</span>—“held harmless” is the term-of-art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device <span style="font-weight: bold;">shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics</span>, even when these HIT users are strictly following vendor instructions...HIT vendors are not responsible for errors their systems introduce in patient treatment because physicians, nurses, pharmacists, and healthcare technicians should be able to identify—and correct—any errors generated by software faults. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[Yes - we're all knowing magicians with the power to read minds, infer incorrect lab values via therapeutic touch, and possess encyclopedic knowledge in our heads at all times. This raises the question: if we are that omniscient to be able to identify and correct software faults with 100 percent accuracy to avoid patient harm, then why do we need electronic medical records at all? - ed.]</span></span></span><br /></blockquote><br />Also see the Univ. of Pennsylvania press release "<span style="font-weight: bold;">Why Are Healthcare Information Manufacturers Free of All Liability When Their Products Can Result in Medical Errors?</span>" <a href="http://sev.prnewswire.com/null/20090324/DC8755624032009-1.html">here</a>.<br /><br />In the new Koppel and Kreda JAMA article we also learn that:<br /><br /><blockquote style="font-family:arial;"><span style="font-size:130%;">HIT implementations are massively complex, and are fraught with delays, errors, resistance, work process redesign, frustration, and outright failure. Healthcare facilities <span style="font-weight: bold;">cannot predict the myriad scenarios</span> in which software failures could result in patient harm and liability, and they are not likely to be knowledgeable a priori about frequent vendor updates.</span></blockquote><br />We additionally learn that:<br /><br /><blockquote style="font-family:arial;"><span style="font-size:130%;">The significant disparity between buyers and sellers in knowledge and resources [about healthcare IT problems] is profound and consequential. Vendors retain company confidential knowledge about designs, faults, software-operations, and glitches. Their counsel have crafted contractual terms <span style="font-weight: bold;">that absolve them of liability and other punitive strictures while compelling users’ non-disclosure of their systems’ problematic, or even disastrous, software faults.</span></span><span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);font-size:130%;" ><br /><br />[This is simply astonishing. In other words, health IT customers and users have a gag order imposed on them regarding software faults and defects, while clinicians -- through their ingenuity, their labor in finding defect workarounds, and their liability -- serve (as I've written) as captive beta testers and an insurance company for HIT vendors - ed.]</span><br /></blockquote><br />These observations are nothing short of astonishing. They do help explain, however, the near silence of hospitals and their executives regarding healthcare IT faults, an observation I made in this 2006 AMIA presentation about the scarcity of such information:<br /><br /><span style="font-weight: bold;"></span><blockquote style="font-family:arial;"><span style="font-weight: bold;font-size:130%;" >Access Patterns to a Website on Healthcare IT Failure</span><span style="font-size:130%;"> (</span><span style="font-size:130%;"><b style=""><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/content/documents/AMIA2006_poster.pdf">Abstract</a></b> [<span class="SpellE">pdf</span>], <b style=""><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/content/documents/FINAL_Healthcare%20IT%20Failure_Oct_19_2006.ppt">Poster</a></b> [<span class="SpellE">ppt</span>].)</span></blockquote><br />The Joint Commission also made this observation in their Dec. 2008 <a href="http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm">Sentinel Events Alert on Health IT</a>:<br /><br /><span id="plcMain"><blockquote><span style="font-family:arial;">There is a dearth of data on the incidence of adverse events directly caused by HIT overall.</span> </blockquote></span><br />The new JAMA article may also explain why HIT is so often done so poorly as to present a <span style="font-weight: bold;">mission hostile user experience</span>, as I started to write about a decade ago at my healthcare IT difficulties website <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/">here</a>, as I outlined in an eight part series starting <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">here</a>, as the American College of Physician Executives noted <a href="http://hcrenewal.blogspot.com/2009/03/health-it-industry-out-of-control.html">here</a>, as the National Research Council noted <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">here</a> ("Current Approaches to US Healthcare IT are Insufficient"), and as many others noted as well:<br /><br /><blockquote style="font-family:arial;"><span style="font-size:130%;">Healthcare IT News (3/10, Merrill) reported, a survey conducted by the American College of Physician Executives found "that although more physician leaders are using healthcare information technology, they still find it </span><span style="font-weight: bold;font-size:130%;" >clunky and unresponsive to their needs</span><span style="font-size:130%;">." The survey of 1,000 ACPE members "revealed that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems. </span><span style="font-weight: bold;font-size:130%;" >Many said involving clinicians at the planning stages would pre-empt many of the problems that crop up later."</span><span style="font-size:130%;"> </span><span style="font-size:130%;"> One respondent noted that "systems are chosen according to administrative criteria rather than what physicians need."</span></blockquote><br />Without accountability, a manufacturer is unmotivated to produce quality products at the expense of profits. They become complacent and lazy. This is an excellent reason why major HIT applications are as abhorrent as they are and violate so many fundamental principles of human computer interaction and resilience engineering.<br /><br />It can also explain why talent management within the vendors is biased against hiring medical informatics experts, who would resist intellectual laziness of their non-informatics profit oriented (and unaccountable) counterparts.<br /><br />Koppel and Kreda note that such stipulations defeat patient safety efforts and are contrary to the principles of evidence based medicine. I can add that such stipulations are contrary to the principles of <span style="font-weight: bold;">good engineering</span>.<br /><br />These stipulations further instantiate my observation that <span style="font-weight: bold;">h</span><span style="font-weight: bold;">ealth IT lacks the rigor of medical science itself</span>, its major Achilles heel. This is one reason why I believe a national HIT initiative at this point in time is going to be, <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm">as in the UK</a>, nothing short of an expensive debacle.<br /><br />The existence of "hold harmless" clauses and gag orders raises many questions:<br /><br /><ul><li>Clinical supervisors of other physicians are indeed practicing medicine. Are Health IT vendors in fact <span style="font-weight: bold;">practicing medicine by cybernetic proxy</span> via these IT systems? </li><li>Aren't the vendors' own claims of revolutionary healthcare quality improvements mediated via EMR's, alerts and reminders, clinical decision support, etc., malfunctions of which physicians may be held liable, <span style="font-weight: bold;">prima facie evidence that the vendors are in fact practicing medicine by proxy?<br /></span></li><li>Should not these purveyors of cybernetic (i.e., virtual) medical devices <span style="font-weight: bold;">be held accountable</span> for their products, as in the pharmaceutical and the non-cybernetic (i.e., physical) medical device industries?<span style="font-weight: bold;"><br /></span></li><li>How did such a situation regarding critical healthcare devices arise?</li><li>In what other healthcare or other technology intensive industries, if any, do similar conditions exist, and what are the repercussions?<br /></li><li>How long has this situation existed?</li><li>Why is it tolerated by clinicians?</li><li>Why is it tolerated by clinical leaders?</li><li>Why is it tolerated by medical professional societies, such as the AMA, the ACPE, etc., supposedly representing their members' interests?</li><li>Why is it tolerated by hospitals and their executive leadership and boards of directors?</li><li>Why is it tolerated by IS departments in hospitals?</li><li>Why is it tolerated by hospital general counsel?</li><li>Are there possible civil tort/RICO (racketeering)/criminal implications regarding patients injured by defective health IT where defects were known but not disclosed?</li><li>Is not such a protective arrangement prima facie evidence that this technology is indeed experimental, with patients and clinicians as unconsented experimental subjects?<br /></li><li>Why is it tolerated by our government?</li></ul><br />Regarding the last point, the Obama administration has promised an atmosphere of national accountability and responsibility. Why, then, has it simultaneously employed the coercive force of government (payment penalties for HIT non adopters after the absurdly short period of five years from now, 2014) to push <span style="font-weight: bold;">an exploratory medical device from an unaccountable industry of unproven ROI</span> at a cost of tens of billions of dollars on to the medical profession? This reality raises another question as I suggested in my <a href="http://hcrenewal.blogspot.com/2009/02/medinformaticsmd-in-wall-street-journal.html">WSJ Letter to the Editor</a> of February 18, 2009. I wrote:<br /><br /><p></p><blockquote style="font-family:arial;"><p><span style="font-size:130%;">Dear Wall Street Journal:</span></p><p><span style="font-size:130%;">You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.</span></p> <p><span style="font-size:130%;">I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.</span></p></blockquote><p></p><br />In other words, was the administration misled by the health IT industry? I believe it might have been.<br /><br />As an example, Mr. Obama's healthcare IT policy campaign adviser <a href="http://blogs.wsj.com/health/2009/01/26/allscripts-ceo-urges-one-two-punch-on-electronic-medical-records/">per the WSJ</a> Glen Tullman, CEO of HIT vendor AllScripts and Board member of the industry-created government contractor CCHIT ("Certification Commission for Healthcare IT"), probably didn't tell Mr. Obama his company was selling goods that did not function properly. (Here is a link to my organization's <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf">Civil Complaint against AllScripts</a>, PDF). We apparently cannot know how many other organizations had their own complaints that might not have made it into litigation, due to the aforementioned gag orders. (Ironically, I found out about the lawsuit at my own organization only through an anonymous comment at the HIT gossip site <a href="http://histalk.blog-city.com/news_051607.htm">HISTalk</a>.)<br /><br />Incidentally, by matter of pure speculation, I was not permitted involvement in that implementation despite having been a pioneering CMIO at a larger healthcare system years prior and the only formally educated medical informaticist at my organization. My writings on health IT dysfunction were well known to the IT staff and likely the vendor after a short web search; it would have been in the vendors' interests to keep me away from sales and implementation of known deficient health IT. Again, this is simply speculation.<br /><br />On the other hand, I am aware of major healthcare organizations with "portfolios" of hundreds or thousands of issues and defects awaiting remediation, and CMIO's struggling against cavalier bureaucracies who want the doctors even in critical care areas to live with the problems, and vendors who are not in a hurry to fix their products.<br /><br />Some of the problems rise to the level of critical with regard to patient safety. Under contract, the problems <span style="font-weight: bold;">cannot be disclosed to the public</span>, to patients whose care might fall under the aegis of these systems, or to other healthcare organizations seeking the same systems. I hope to be a plaintiff's witness when the inevitable lawsuits for patient injury place such capricious vendor, hospital and IT leadership on the witness stand.<br /><br />Finally, in fairness the JAMA article discusses issues beyond the vendors' control such as misuse or poor training done by the host organization using the IT.<br /><br />Possible remedies to the situation of unaccountability for the outcomes of HIT misdesign, malfunction and other defects are outlined in the article. See it or the press release at the above links if you lack JAMA access.<br /><br />As I've written numerous times on this site, due to the implications and especially now due to the revelation that the <span style="font-weight: bold;">scarcity of adverse events information related to HIT is probably by design</span>, I favor stringent health IT regulation <a href="http://hcrenewal.blogspot.com/2009/03/lets-deregulate-pharma-information.html">as in pharmaceutical IT</a>.<br /><br />Whatever happens, however, I know this. For the sake of patient safety:<br /><span style="font-size:130%;"><br /></span><div style="text-align: left;"><span style="font-size:100%;"><span style="font-weight: bold; color: rgb(255, 0, 0);">This </span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">s</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">orry, a</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">busive </span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">a</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">nd </span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">i</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">nexcusable </span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">t</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">ravesty </span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;">m</span><span style="font-weight: bold;">ust </span><span style="font-weight: bold;">e</span><span style="font-weight: bold;">nd</span><span style="font-weight: bold;"> ...</span></span><span style="color: rgb(255, 0, 0);font-size:100%;" ><span style="font-weight: bold;"> now.</span></span><br /></div><br />Finally, to health IT vendors, as my early medical mentor, pioneering cardiovascular surgeon and educator Victor P. Satinsky, MD might have said:<br /><br />If you can't take the heat of the responsibilities of clinical medicine, then <span style="font-weight: bold;">get out of our kitchen.</span><br /><br />-- SS

Health Care Information Technology Vendors' "Hold Harmless" Clause - The Largest IT Industry Abuse Ever?

Dear fellow physicians, nurses and other clinicians: You thought frivolous medical malpractice suits were a problem? Guess what: It's wo...

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