Should you spring clean your solar panels?

Ever since we assembled a 1.6 MW solar panel installation at our headquarters in Mountain View in 2007, we've been wondering, "Does cleaning the solar panels make them more effective?" We thought it might, but we needed to be sure. So we analyzed the mountains of data that we collect about the energy that these panels produce — after rain, after cleaning and at different times of the year.

We have two different sets of solar panels on our campus — completely flat ones installed on carports, and rooftop ones that are tilted.

Since the carport solar panels have no tilt, rain doesn't do a good job of rinsing off the dirt they collect. (Also, our carports are situated across from a sand field, which doesn't help the situation.) We cleaned these panels for the first time after they had been in operation for 15 months, and their energy output doubled overnight. When we cleaned them again eight months later, their output instantly increased by 36 percent. In fact, we found that cleaning these panels is the #1 way to maximize the energy they produce. As a result, we've added the carport solar panels to our spring cleaning checklist.

The rooftop solar panels are a different story. Our data indicates that rain does a sufficient job of cleaning the tilted solar panels. Some dirt does accumulate in the corners, but the resulting reduction in energy output is fairly small — and cleaning tilted panels does not significantly increase their energy production. So for now, we'll let Mother Nature take care of cleaning our rooftop panels.

Accumulated dirt in the corners of a rooftop solar panel

We've also been crunching numbers on dollars-and-cents; the more energy our panels produce, the sooner we'll be paid back by our solar investment. Our analysis now predicts that Google's system will pay for itself in about six and a half years, which is even better than we initially expected.

If you want to learn more about our solar study, check out these slides showing the effects that seasonality, tilt, dirt, particulate matter, rain and cleaning have on Google's solar energy output. We hope you solar panel owners out there can tailor our analysis to the specifics of your own installation to produce some extra energy of your own!

Posted by Winnie Lam, Senior Product Manager

Search Options now on Google Images

A few months ago when we announced the Search Options panel, we promised that you would soon see similar functionality across our other search properties. Today we are rolling out Search Options for Google Images.

This new feature offers quick access to existing tools, including search by color and image type. Color search will find images that are only in color or only in black and white, or even images that contain a specific color, such as red, pink, or green. Type search is a great way to narrow down your results if you are looking for a specific kind of image, such as a photo, clip art, line drawing or face.

We've also revamped our size search. In addition to choosing from commonly searched-for sizes, now you can search for an exact image size or any image larger than a certain size. You can find images of practically any size, including 70 megapixels or more.



The new layout makes it faster and easier to combine and toggle between options. It also makes it easier for us to add additional image search options in the future, so keep your eyes peeled. Just click "Show options..." in the blue bar on the search results page to try out any of these tools.

Posted by Ken Dauber, Software Engineer, and Nate Smith, Associate Product Manager

BLOGSCAN - More on Senate Hearings on Industry Funded CME

There has been considerable coverage of the remarkable hearings by the US Senate Special Committee on Aging on industry funded continuing medical education (CME). See reporting by Dr Daniel Carlat on the Carlat Psychiatry Blog, and by the Prescription Project on their Postscript Blog. See also the comments by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog. Some key points were that the Senators failed to see why physicians cannot afford to pay for their own CME, and therefore must depend on corporate funding to support; and the Senators failed to buy the argument that medical progress vitally depends on health care corporations paying for and influencing the education physicians get.

Bloggers Can Spread the Word, Just Not About the Sponsors' Competitors

The internet, social media, web 2.0 etc have changed how important health care issues are discussed. So, it is not surprising that big health care organizations are trying to use these new media to promote their messages. New media, however, are no more immune from the effects of conflicts of interest than are old media.

An article from corporate communications company Ragan.com about how the American Heart Association (AHA) is using bloggers to get people interested in a heart-healthy diet and exercise program illustrates how even "civilian" bloggers can get caught up in the web of conflicts of interest that pervades health care. The background is:

Keeping track of the conversations on the array of social media networks can gobble up your workday. So why not find someone else to do it for you?

The American Heart Association did just that, approaching four established bloggers with a proposal: Write about our new campaign, Go Red For Women: BetterU, and we’ll link to your blog from our site. BetterU is a 12-week online nutrition and fitness program to improve heart health among women.

The blogs appear to be working. They’ve helped drive traffic to Go Red/BetterU since the program’s June 1 launch.

It did seem that the AHA went to considerable effort to make sure they had recruited just the right bloggers.

The AHA researched potential candidates with the help of agencies Edelman PR and Edelman Digital. After a month-and-a-half, they settled on four bloggers: Joshilyn, Nyasha, Stacey, and Nadia.

The criteria: The bloggers had to be female, have an enthusiastic following, be diverse in age and ethnicity, and have a high Technorati rating. Most important, their content and advertising had to align with the association’s values, says Director of Marketing Anu Gandhi.

'You’re really ultimately picking a spokesperson for Go Red for Women and the larger American Heart Association,' [senior manager for cause communications Megan] Lozito says. 'That’s a really important process for us — that it be correct and that it be the right people. So we spent a lot of time getting to know those ladies and making sure our mission would be aligned.'

More interesting was the values with which the bloggers were supposed to align, particularly those relating to the program's corporate sponsors (see the logos at the bottom right of the BetterU web-site).

From there, the association brought the bloggers to the Dallas headquarters for a full health screening at The Cooper Institute, a photo session, a preview of the BetterU program, and some message training.

Although the BetterU bloggers got some message training in Dallas, Gandhi says AHA has been hands off when it comes to what they can and can’t say about the program.

The bloggers are asked to post once a week about BetterU and follow basic guidelines—no profanity, no defamation, no writing about nor condoning any medications or treatments. She says they also ask bloggers not to talk about competitors of AHA’s two national sponsors: Macy’s and Merck Pharmaceuticals.

I would suspect that the explicit instruction not to favor Merck's competitors would also remind the bloggers not not do say anything that might make the giant pharmaceutical company unhappy.

Eight weeks into the program, they haven’t had any problems.

'There are things we don’t want them to write, like profanity, but that’s also part of the vetting in the beginning,' Lozito says. 'We wanted to find people who believe in our mission, who speak to the same type of audience, but at the same time we want them to have their own flavor and own tone, because it’s a blog.'

So the bloggers recruited by the AHA may be happy, since they now have a big organization's web-site driving traffic to their blogs. The AHA may be happy, since the bloggers can spread the word about their BetterU program. I imagine the marketers at Merck may be happy too, since the bloggers have been warned about the need to keep the corporate sponsors happy. However, what may be good for all the parties in this transaction may not be so good for the general public, as another opportunity for uninhibited, honest discussion of health care issues has been lost.

This is an explicit example of the adverse effects of commercial funding of not-for-profit disease advocacy groups. Corporate sponsors may not expect anything as gross as advertising in return for their money. However, they may expect something more subtle, a generally favorable attitude toward the sponsor, at least the disinclination to say anything that might put the sponsor in a negative light. After all, politeness requires that we be nice to the people who are nice to us. But being nice to sponsors may not be so nice for the people that a health care not-for-profit organization is supposed to serve.

PS - for those who like science fiction, see the preview of the new version of "V," in which Anna, the leader of the Visitors, an invasion force disguised as human-appearing, benign aliens, warns her television interviewer,

Just be sure not to ask anything that would put us in a negative light.

I now pronounce you monetized: a YouTube video case study

(Cross-posted from the YouTube Biz Blog)

Last week the world watched in wonder as Jill Peterson and Kevin Heinz's wedding party transformed a familiar and predictable tradition into something spontaneous and just flat-out fun. The video, set to R&B star Chris Brown's hypnotic dance jam "Forever," became an overnight sensation, accumulating more than 10 million views on YouTube in less than one week. But as with all great YouTube videos, there's more to this story than simple view counts.

At YouTube, we have sophisticated content management tools in place to help rights holders control their content on our site. The rights holders for "Forever" used these tools to claim and monetize the song, as well as to start running Click-to-Buy links over the video, giving viewers the opportunity to purchase the music track on Amazon and iTunes. As a result, the rights holders were able to capitalize on the massive wave of popularity generated by "JK Wedding Entrance Dance" — in the last week, searches for "Chris Brown Forever" on YouTube have skyrocketed, making it one of the most popular queries on the site:


This traffic is also very engaged — the click-through rate (CTR) on the "JK Wedding Entrance" video is 2x the average of other Click-to-Buy overlays on the site. And this newfound interest in downloading "Forever" goes beyond the viral video itself: "JK Wedding Entrance" also appears to have influenced the official "Forever" music video, which saw its Click-to-Buy CTR increase by 2.5x in the last week.

So, what does all of this mean? Despite compelling data and studies around consumer purchasing habits, many still question the promotional and bottom-line business value sites like YouTube provide artists. But in the last week, over a year after its release, Chris Brown's "Forever" has again rocketed up the charts, reaching as high as #4 on the iTunes singles chart and #3 on Amazon's best selling MP3 list. We've seen similar successes in the past with partners like Monty Python.

One of our main goals at YouTube is to help content creators effectively make money from the distribution of their content online. That they can do so in a way that brings artists and our community together to create fun, spontaneous and inspiring works, is one of the best and most exciting things about YouTube.

Posted by Chris LaRosa, Technical Account Manager, and Ali Sandler, Music Partner Manager

BLOGSCAN - Live-Blogging Senate Hearing on Conflicts of Interest and Continuing Medical Education

Dr Daniel Carlat is live-blogging the US Senate Special Committee on Aging hearing on conflicts of interest and continuing medical education on the Carlat Psychiatry Blog, and so is Prof Margaret Soltan on the University Diaries.

Polly Want a Million (Plus)

We have frequently posted about attempts to justify financial relationships among physicians and medical academics on one hand, and pharmaceutical, biotechnology, device and other health care corporations, on the other. Some defenders of such relationships now have gone so far as to start their own society, whose meeting was covered and commented on by fellow "pharmascolds," including Dr Daniel Carlat and Dr Howard Brody. The usual justification of these relationships is that they are necessary for "innovation" and the onward progress of medical science, education, and care. I have yet to see any logic or evidence to back up these assertions, nor have I seen anyone defend these relationships who does not also have personal financial relationships of their own with health care corporations. (See examples here, here, and here.)

Meanwhile, cases of individual physicians and academics whose lucrative relationships with industry seem to generate huge conflicts of interest continue to surface. The latest example ferreted out by investigators working for US Senator Charles Grassley (R - Iowa) is that of Dr David Polly. (Recall that Dr Polly was one of the strongest defenders of Dr Thomas Kuklo, who was accused of falsifying clinical research results in a way that seemed to favor the product of his own corporate benefactor [see post here].)

The main points were reported by David Armstrong and Thomas M Burton in the Wall Street Journal,

In May 2006, University of Minnesota spine surgeon David Polly urged a Senate committee to fund research into the severe arm, leg and spine injuries suffered by soldiers in Iraq and elsewhere.

Dr. Polly told the committee he was testifying on behalf of the American Academy of Orthopaedic Surgeons and referenced his prior work caring for soldiers as a surgeon at the Walter Reed Army Medical Center.

What Dr. Polly didn't disclose during his testimony was that his trip to Washington was paid for by Medtronic Inc., the big medical-device maker whose bone growth product, called Infuse, has been used to treat soldiers, according to company records.

Dr. Polly and colleagues in Minnesota subsequently received a $466,644 Department of Defense grant for a two-year study beginning in February 2007 to evaluate Infuse in cases where an injury is also infected, according to the university.

Dr. Polly was paid $1.14 million by Medtronic for consulting services from 2004 to 2007.

Details of Dr. Polly's consultant billing were provided by Medtronic to Sen. Charles Grassley, an Iowa Republican who has been scrutinizing the relationship between academics and industry.

Although there have now been many reported cases of medical academics who collected large payments from health care corporations, the services they provided in exchange for the money have not always been very clear. Defenders of financial relationships among physicians and medical academics and industry have argued that most payments were for valuable research, education, or health care activities. However, Senator Grassley's office provided the details of Dr Polly's invoices, and several of the news articles so far described what he did for the money. Per the Wall Street Journal article,

In total, Dr. Polly billed Medtronic for more than $50,000 in lobbying-related costs. He made trips to Washington in 2005 and 2006 and called on several members of Congress, according to the records.

According to billing records, Dr. Polly's billing rate was $4,750 for an eight-hour day in 2007, and he billed as many as 13,000 minutes a quarter -- or 216 hours over three months. In some months, he conducted at least some Medtronic business on nearly every day.

His consulting log indicates that on one occasion he spent one minute to wake up a Medtronic executive, although he listed 'no charge' for that service. He did bill Medtronic for the 30 minutes he spent in the car with that executive after waking him up.

An accompanying post on the Wall Street Journal Health Blog provided more information:

Did you ever wonder what doctors do to earn big consulting contracts from medical device companies and pharmaceutical concerns?

Records released by Medtronic to Sen. Charles Grassley, a longtime critic of the ties between academics and and health-care companies, provide a rare and detailed glimpse into the daily billings of a consultant — in this case, spine surgeon David Polly of the University of Minnesota.

Polly collected more than $1 million in four years of work for Medtronic, according to the records, which you can take a look at here.

The services he provided were many, but among them, Polly was paid to write articles for medical journals; write a chapter in a book and a book outline; recruit patients for publicity efforts; attend Medtronic national sales meetings; travel to conferences in Japan, Paris and elsewhere; lead training and educational sessions for physicians; and lobby Congress.

Polly also billed for at least two phone calls with Medtronic CEO William Hawkins as well as charging the company $2,000 when Mr. Hawkins visited an operating room. In October, 2003, he billed the company $12,000 for attending a medical meeting of the North American Spine Society, at $4,000 a day.

There are also scores of entries for work billed in five-minute increments, usually to send email or return phone calls. The bill for each five-minute charge? $49.48 a pop.

So did the $1.2 million Medtronic spent on Dr Polly's services inspire any "innovation?" Did it lead to any scientific progress or improved health care? I am not sure.

It is clear, however, that a good chunk of this money went to support marketing, advocacy, and lobbying. The items in bold italics above were clearly in support of marketing, advocacy and lobbying, not science, medical education, or patient care. (To give Dr Polly the benefit of a doubt, some other items listed above could have been related to research, education, or patient care, although this is not indisputable.)

So the case of Dr Polly corroborates my deep skepticism of the financial relationships among physicians and medical academics on one hand, and corporations that sell health care goods and services on the other. We "pharmascolds," - a preferable term might be health care skeptics - suspect that many of these relationships are really about stealth marketing and advocacy. The companies often pay to market their products and services, or advocate positions to the companies' advantage, but prefer that their salespeople and advocates are cloaked in academic guises, and wreathed in the rarefied aura of respected academic institutions. (Note that some of us are just as skeptical about relationships among academic institutions and other health care not-for-profit organizations on one hand, and such corporations on the other, for analogous reasons.)

While the leadership of our formerly distinguished medical academic institutions remains infiltrated, if not dominated by people earning many thousands of dollars from health care corporations, I must remain skeptical about how much of these institutions supposedly academic output is actually stealth marketing and stealth health policy advocacy.

At the very least, medical academics, medical academic institutions, and other health care not-for-profits or NGOs should reveal in detail what payments they get from companies selling health care products or services, and how these payments could relate to the companies' marketing or lobbying efforts. In the US, some such disclosure would be mandated by the proposed "Sunshine" legislation now being considered by the US Congress. (By the way, note that this problem is hardly confined to the US, and needs global, not just American attention.)

However, physicians (at least physicians in full-time private practice, academic positions, and employed by mission-oriented not for profit organizations) should go further, and consider whether receiving industry money is worth the ongoing damage it does to our professionalism and our professional reputations. Medical schools, universities, health care foundations, disease advocacy groups, and other health care not-for-profits and NGOs should also go further, and consider whether receiving industry money is worth the ongoing damage it does to their missions, and their institutional reputations.

See also comments by Prof Margaret Soltan on the University Diaries blog.

Wyeth: Ghostwritten Papers Fake, But Accurate

It looks like Wyeth has lost its battle to keep secret its practices regarding ghostwriting of scientific papers. The issue in question is whether ghostwriting contributed to excessive prescription of post-menopausal hormones and increased the incidence of breast cancer:

Posted on Sun, Jul. 26, 2009
Philadelphia Inquirer

Wyeth told to release documents on ghostwriting

Associated Press

LITTLE ROCK, Ark. - A federal judge has ordered the unsealing of thousands of pages of documents pertaining to the ghostwriting practices of Wyeth Pharmaceuticals, which is being sued over hormone-replacement drugs.

U.S. District Judge Bill Wilson ordered the papers unsealed Friday at the request of a medical journal and the New York Times. Plaintiffs' attorneys presented the papers earlier at trial to show that Wyeth routinely hired medical-writing firms to ghostwrite articles that appeared in seemingly objective medical journals but included only the name of a scientific researcher as the author.

Of course, in addition to the violation of accepted practices of authorship, such as specified by NIH and the International Committee of Medical Journal Editors, among others, such lucky authors get to "count" such papers in their academic portfolios, presumably also in violation of their own institutional policies and guidelines for fair attribution and intellectual honesty, e.g., here. Ghostwriting may also skew the tenure process, providing advantages to the unscrupulous academic over the ethical scientist or scholar. (One wonders about the true percentage of the massive number of papers claimed by some medical academics actually written by the putative first author.)

The ruling came in a case that involves about 8,000 lawsuits that have been combined before Wilson. The lawsuits focus on whether Wyeth hormone-therapy drugs Prempro and Premarin, used to treat symptoms of menopause, have caused breast cancer in some women.

The New Jersey drugmaker, which has major operations in the Philadelphia area, had already turned over the documents, which it says concern about 40 articles in medical journals and other publications, to Sen. Charles Grassley (R., Iowa).

How is evidence based medicine possible if just one drug company has sponsored ghostwritten articles in 40 medical journals and other publications? What is the "total mass" of questionable articles now infecting the literature?

Grassley sought them last year without a subpoena as part of a congressional investigation into drug-industry influence on doctors.

The documents were shown to jurors at trial but have otherwise been unavailable publicly.

Plaintiffs say ghostwriting is when a drug company conjures up the concept for an article that will counteract criticism of a drug or embellish its benefits, hires a professional writing company to draft a manuscript conveying the company's message, retains a physician to sign off as the author, and finds a publisher to unwittingly publish the work.

There are several layers of dishonesty in this activity, including foreknowledge of scientific deception through fraudulent misrepresentation of authorship by the pharma, dishonesty of the physician who "signs off" as first author, and misrepresentation by the pharma, the writing company and the physician about provenance of the article to scientific publishers.

Drug firms disseminate their ghostwritten articles to their sales representatives, who present the articles to physicians as independent proof that the companies' drugs are safe and effective.

Wyeth attorney Stephen Urbanczyk acknowledged that the articles were part of a marketing effort. But he said that they were also fair, balanced, and scientific.

What business does a lawyer have lecturing the public that the articles were a dishonest marketing effort masquerading as legitimate science, but were "fair and scientific?" How does he know? In addition, the "fake but accurate" excuse is getting quite shopworn. Hopefully, Sen. Grassley will approach ending this ghostwriting practice with vigor.

In fact, this raises another issue. I have written that management of pharma by those lacking biomedical bona fides is, by definition, mismanagement. This is a case in point. Wyeth's President, Board Chair and CEO Bernard Poussot lacks biomedical credentials. Harry Truman said "the buck stops here", but a in the case of scientific ghostwriting, CEO's such as Poussot cannot vouch firsthand for the accuracy and fairness of their company's science. He lacks the expertise. The buck does not stop at his desk; he is dependent on scientific underlings in such matters.

This affair is another instantiation of my belief that pharma is best led by those with relevant scientific expertise such as Merck under clinician-scientist Dr. Roy Vagelos. (It is perhaps not coincidental that Merck became a shadow of its former self under non-scientist Raymond Gilmartin.)

Wyeth, the world's No. 12 pharmaceutical company by sales, is being bought this fall by No. 1 drugmaker Pfizer.

How appropriate, as Pfizer is led by the former top lawyer for McDonald's and Boston Chicken, bringing to life my "If you've run McDonald's, you can run anything" metaphor. If a wise investor were to take a bearish position on a stock, this merged company would be an excellent candidate.

Finally, another ghostwriter of sorts recently died, Sandford Dody (1918-2009). Dody anonymously penned best selling autobiographies of actresses Bette Davis and Helen Hayes, among many other notables. Such ghostwriting is essentially victimless, as opposed to its counterpart in the scientific domain. However, Mr. Dody had an astute observation about the practice, even when there was no trail of diseased or dead bodies.

Per the WSJ article "A Ghostwriter Who Struggled to Accept Life in the Shadows":

... Mr. Dody, who died July 4 at the age of 90, found the work spiritually destructive. "After all," he wrote, "how does one become a ghost without dying a little?"

In the case of biomedical ghostwriting, the conspirators all "die a little" in purveying their intellectual dishonesty on a trusting public.

It's too bad some of that same public also dies, and not just a little, as wages of professorial ghostwriting sins.

The acknowledgements are where minor contributions and reviews get placed in an ethically-attributed scientific paper. Anyone who does not understand this, or rationalizes "honorary authorship" or similar workarounds to meaningful attribution does not belong in science.

Finally, scientific ghostwriting must stop. I also believe its conspirators should be excluded from receiving public money for research and excluded from the biomedical literature for a good, long period of time.

-- SS

Are the Health Plans of the Very Rich Different from Yours and Mine?

Yesterday, the New York Times published an intriguing story about "Cadillac" (that is, expensive) health insurance plans,

Goldman Sachs is one of the nation’s richest banks, and hundreds of top Goldman employees have a health care package to match — one of the 'gold-plated Cadillac' plans cited by those involved in the health care debate in Washington.

Goldman’s 400 or so managing directors and its top executive officers participate in the bank’s executive medical and dental program as part of their benefits, according to documents filed with the Securities and Exchange Commission. The program generally costs the bank $40,543 in premiums annually for each participant’s family.

Those taking part in the plan include the company’s chief executive, Lloyd C. Blankfein, and four other top officers, as well as managing directors, whose base salary is $600,000.

Goldman’s medical coverage entered the health care discussion on Sunday when David Axelrod, senior adviser to President Obama, cited the Goldman program as an example of the expensive benefits the administration might consider taxing to help pay for its health care program.

'The president actually was asked this the other day by Jim Lehrer, and what he said was that this was an intriguing idea to put an excise tax on high-end health care policies like the ones that the executives at Goldman Sachs have, the $40,000 policies,' Mr. Axelrod said.

A proposal by Senator John F. Kerry, Democrat of Massachusetts, would impose an excise tax on the insurers that issue policies like Goldman’s, with the expectation that the insurers would pass along most, if not all, of the cost to employers who buy the plans.

Leaders of the Senate Finance Committee, which is working on bipartisan version of the health care legislation in Congress, had long expressed interest in taxing some employer-provided benefits — a move many budget experts say would help slow the steep rise in health costs.

Negotiators have not yet determined the value of the plans that would set off a tax on the insurance companies; the numbers under discussion range from $20,000 to $40,000 annually, a senior administration official said.

The lower end of that range would increase the amount of money the tax would raise but would also hit some middle-class workers, whose unions in some cases negotiated robust health benefits in lieu of pay increases. Typical employer-provided plans cost $13,000 to $20,000 per family, depending on the location and the age of the plan participants.

A health care package costing $40,000 or more a year would generally have no co-payments or deductibles, according to Paul Fronstin, an analyst at the Employee Benefit Research Institute, a Washington nonprofit that studies benefits. It would also have no limits on doctors or procedures, no restrictions on pre-existing conditions and no requirements for referrals.

Few people have such policies, Mr. Fronstin said. 'It would only be top executives who run big businesses, mainly people in the C suite,' said Mr. Fronstin, referring to companies’ chief officers.

It was not clear from this article how many top corporate executives have such plans, and whether leaders of other kinds of organizations, like large not-for-profits, also have them.

My main concern about such plans is not how much they contribute to top corporate leaders' compensation packages. Such packages are generally already so outrageously huge that providing $40,000 rather than $13,000 worth of health insurance is a trivial increase. My concern is not that plan recipients' demands for health care will collectively increase health care costs, because they include only a tiny portion of the population.

My main concern, instead, is how much these plans further insulate already cocooned top executives from the vicissitudes of daily life, particularly related to coping with our current dysfunctional health care system. What benefits executive health care plans provide is not clear, but presumably they insulate executives from having to deal with the managed care/ health insurance bureaucracy which frustrates patients seeking particular services, but not necessarily the most expensive, or least beneficial services. Such executives might thus not have gut level appreciation of how dysfunctional the health care system has become for even insured patients. Since top executives often are disproportionately influential members of the "superclass," their disconnection from the realities of dysfunctional health care is likely to translate into little real support by the powers that be for meaningful health care reform. There support may be further retarded by the influence of their fellow superclass members whose personal fortunes depend on the status quo in health care.

Real improvement of health care may depend on finding leaders who have better understanding of the plight of real people.

Announcing the 10 Days in Google Books game

Which infamous book thief got caught stealing from the Chicago Public Library and was later acquitted on grounds of insanity? How many European cities are mentioned in Karen Fowler's "The Jane Austen Book Club?" And can you figure out what curious objects Dorothy is picking from a tree in this illustration from Frank Baum's "Ozma of Oz?"


Stumped? Find the answers to these and other fun questions in the 10 Days in Google Books game. Each day, we'll ask you five trivia questions on a different theme. Search Google Books to find the answers with hints to help you along the way. After you answer each day's questions, you can enter a contest to win a Sony Reader. If you enjoy the game, come back the next day for another set of questions — and another chance to win.


For official rules, including prize descriptions, visit http://books.google.com/game. (Please note: Some books may not be available in full view to those outside the United States.) The first 20,000 people to play the game will also receive commemorative Google Books laptop stickers. So all you bookworms out there, start playing now!

Posted by Hicham Alaoui, Associate Product Marketing Manager, Google Books

BLOGSCAN - Reports from the ACRE Meeting

The proceedings at the first meeting of the benignly titled Association of Clinical Researchers and Educators (ACRE) was chronicled on the Carlat Psychiatry Blog here, and on Postscript, the Prescription Project blog here. ACRE, founded by Dr Thomas Stossel (see relevant post here on the sorts of arguments Dr Stossel has made), was founded to defend academics who are paid on the side by drug, biotechnology, and device companies from the complaints of the "pharmascolds." What I found most troubling was that the conference was officially opened by Dr Jeffrey Flier, the Dean of the Harvard medical school, implying a medical school endorsement of this group, and featured presentations by the presidents of the American Association of Clinical Endocrinologists, and the American Society of Hypertension, implying endorsement by these medical societies. But also see the comments by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog that there may be a silver lining to this cloud.

How "Independent" a Source of Health Care Reform Data?

This week, a Washington Post article discussed who provides the data being cited in the ongoing US debate about health care reform.

The political battle over health-care reform is waged largely with numbers, and few number-crunchers have shaped the debate as much as the Lewin Group, a consulting firm whose research has been widely cited by opponents of a public insurance option.

To Rep. Eric Cantor (Va.), the House Republican whip, it is 'the nonpartisan Lewin Group.' To Republicans on the House Ways and Means Committee, it is an 'independent research firm.' To Sen. Orrin G. Hatch (Utah), the second-ranking Republican on the pivotal Finance Committee, it is 'well known as one of the most nonpartisan groups in the country.'

But how independent is the Lewin group?

Generally left unsaid amid all the citations is that the Lewin Group is wholly owned by UnitedHealth Group, one of the nation's largest insurers.

More specifically, the Lewin Group is part of Ingenix, a UnitedHealth subsidiary that was accused by the New York attorney general and the American Medical Association of helping insurers shift medical expenses to consumers by distributing skewed data. Ingenix supplied UnitedHealth and other insurers with data that allegedly understated the 'reasonable and customary' doctor fees that insurers use to determine how much they will reimburse consumers for out-of-network care.

In January, UnitedHealth agreed to a $50 million settlement with the New York attorney general and a $350 million settlement with the AMA, covering conduct going back as far as 1994.

Ingenix's chief executive, Andrew Slavitt, said the company's data was never biased, but Ingenix nonetheless agreed to exit that particular line of business. 'The data didn't have the appearance of independence that's necessary for it to be useful,' Slavitt said.

Lewin Group Vice President John Sheils said his firm had nothing to do with the Ingenix reimbursement data. Lewin has gone through 'a terribly difficult adjustment' since it was bought by UnitedHealth in 2007, he said, because the corporate ownership 'does create the appearance of a conflict of interest.'

'It hasn't affected . . . the work we do, and I think people who know me know that I am not a good liar,' Sheils said.

Is it only an appearance of conflict, and how objective is the Lewin Group's work?

Lewin's clients include the government and groups with a variety of perspectives, including the Commonwealth Fund and the Heritage Foundation. A February report by the firm contained information that could be used to argue for a national system known as single-payer, the approach most threatening to insurers, Sheils noted.

But not all of Lewin's reports see the light of day. 'Let's just say, sometimes studies come out that don't show exactly what the client wants to see. And in those instances, they have [the] option to bury the study,' Sheils said.

So, in summary, a group providing ostensibly "independent" data and opinions about an important health care policy debate is actually a subsidiary of a commercial managed care organization/ health care insurance company which clearly has vested interests in certain policy options. While the consulting group apparently struggles to be objective, its top leader reported that is fashions its reports at the behest of its clients, and that clients can "bury" reports that offend them, possibly because they do not serve their vested interests.

It is not surprising that participants in the current, noisy debate about health care reform, like many other health policy debates, have vested interests, and that their positions are likely to promote these interests. However, what should at least be disturbing is how often those with vested interests try to appear to be disinterested and independent. Should we trust "independent" voices that actually are conflicted, or those who cite "independent" views that actually come from interested parties?

By the way, we first posted about the Lewin Group's actual status as an Ingenix, and hence UnitedHealth subsidiary here in January, 2009, and first posted about how its contribution to the current health care reform debate was being touted as independent here in April, 2009. That a news organization with the status of the Washington Post is now picking up this story suggests a little optimism that the anechoic effect might be weakening.

Physicians Down Under Get Direct About Danger of Bad HIT

Too often, physicians acquiese to demands by hospital executives that they adjust to and use health IT, even if that health IT is flawed. This is despite the fact that liability for patient care resides with the physicians, not the HIT vendor or executives.

Several physicians Down Under have had enough:

Doctors issue deadly warning
Daily Examiner, Grafton, Australia
David Bancroft | 23rd July 2009

It seems incredible that a patient record system that aims to improve treatment could kill people [not so incredible to the informed - e.g., see "Bad Informatics Can Kill" - ed.], but that is a claim being made about a new system that is almost certainly going to be introduced into the Grafton Base Hospital next week.

Earlier this month, leading health officials from the Lismore Base Hospital wrote to the North Coast Area Health Service (NCAHS) claiming a new Surginet electronic medical record system that had been operating in the hospital for several months would 'inevitably' lead to the death of patients.

But the health service said changes had been made to the Surginet electronic medical record (EMR) system since the concerns were raised by the four senior clinicians on July 2, and the system had been operating 'satisfactorily' in Sydney without patient concerns being raised. ["Without concerns raised" does not mean they do not exist - ed.]

In their letter to NCAHS chief executive officer Chris Crawford, which was copied to the Minister for Health John Della Bosca, the four medical specialists said there had been recurring problems over several months and 'these have not improved'.

“This has resulted in unnecessary compromise of patient safety,” they wrote.

“There have been repeated well demonstrated cases of near miss disasters due to these problems. [Will patients be as lucky the next time? - ed.]

“We believe that negative patient outcomes, including death, will inevitably result from the continuing use of this system.

“Surginet is fundamentally flawed.

“New technology should: improve the quality of our work; help us to be more efficient, and; make routine tasks easier.

“EMR Surginet does none of these; in fact it has had the opposite effect.

“We believe that the Surginet EMR system is unsafe and will result in patient morbidity and mortality.”

Surginet was to be implemented at the Grafton Base Hospital yesterday, but after concerns were raised with the area health service, implementation was delayed until next Wednesday.

A health service spokesman said the implementation had been delayed so the software producers, Cerner [an American company behind the HIT products that caused difficulty in the UK - see the UK House of Commons report here, esp. points 5 and 6 - ed.], could speak with Grafton surgeons and anaesthetists prior to the implementation about any concerns they may have.

“NCAHS takes any concerns raised about patient safety seriously and is addressing these,” the spokesman said.

“It should be emphasised that Surginet is operating satisfactorily in Sydney hospitals without patient safety concerns being raised. [Again, that does not mean they do not exist; clinicians may be afraid to speak out and working furiously to establish workarounds to problems - ed.]

“It is a system used worldwide that can be adapted to accommodate local work practices in NSW hospitals. ["Can be adapted" - anything "can be adapted". But has this application actually been adapted to the culture in NSW hospitals? - ed.]

“Arrangements are being made for discussions to be held with the department heads by representatives of the EMR project team and Cerner.”

The spokesman said Surginet had recently been introduced at the Maclean Hospital and there had been no complaints and the NCAHS had actually received a letter of thanks from the hospital. [A letter of thanks from whom at the hospital, exactly, and based on what substantive claims? - ed.]

Such discrepancies between one hospital and the next regarding HIT require critical evaluation - erring on the side of patient safety, not IT vendor convenience. Considering the aforementioned UK House of Commons report and the "near miss disasters" mentioned by the Australian physicians, such due diligence is mandatory in my opinion.

Further, American physicians can probably learn from these Australian counterparts in being vocal about HIT problems.

-- SS

Inquiry to Joint Commission on points I raised in my July 22, 2009 JAMA letter on HIT

As I posted here, my letter "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in JAMA on July 22, 2009. A preview of the letter can be seen here, or a full version here if you subscribe to JAMA.

This JAMA letter covered some of the same points I addressed extensively at my Drexel HIT website essay "Hold Harmless and Keep Defects Secret Clauses", including the major point that hospital executives signing HIT "Hold Harmless" and "Defects Nondisclosure" contracts are in violation of Joint Commission standards for conduct related to safety, and in violation of their fiduciary responsibilities towards patient and employee safety and freedom from undue liability.

I've sent the following inquiry to Paul M. Schyve, M.D., Senior Vice President, The Joint Commission:

July 24, 2009

Paul M. Schyve, M.D.
Senior Vice President
The Joint Commission
schyve@jointcommission.org

Cc: MChassin@jointcommission.org, otrippi@jointcommission.org

Dear Dr. Schyve,

In testimony to the House Committee on Veterans' Affairs on July 22, 2009 at this link , you state:

... The Joint Commission has established standards that require the hospital to:

• Create a culture in which adverse events are reported and evaluated for underlying ("root") causes, and preventative actions are taken.
• Identify high-risk processes and prospectively determine their possible modes of failure, the effects of those failures, and the actions that will prevent the failures or mitigate their effects.
• Establish a culture of safety throughout the hospital. This accreditation standard became effective January 1, 2009, although its purpose and expectations were publicized for over a year in advance.

In my JAMA letter to the editor of July 22, 2009 entitled " Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" ( link ), I point out that the Hold Harmless and Defects Nondisclosure clauses signed by hospital executives in contracting for healthcare information technology (such as CPOE and EHR systems) are in violation of Joint Commission safety standards, as well as hospital executive fiduciary responsibilities to patients and clinicians. These clinical IT systems can and do cause medical errors and patient harm.

My letter was in response to Koppel and Kreda's March 25, 2009 article " Health Care Information Technology Vendors' "Hold Harmless" Clause: Implications for Patients and Clinicians ", JAMA. 2009;301(12):1276-1278.

I am interested in the Joint Commission's response to the issues I raise.

I await a response.

-- SS

Announcing the 2009 Google Online Marketing Challenge winners

This year we held the second Google Online Marketing Challenge — a global university competition, launched last year, that gives undergraduate and post-graduate students hands-on exposure to online marketing. Working with their professors, teams receive the equivalent of US$200 to spend on Google AdWords advertising, then work with a local business to devise an effective online marketing campaign. Teams are given three weeks to mastermind the strategy before submitting a campaign report to an international judging panel of professors.

This year's Challenge was bigger and better in every way — more teams, more students, more universities and a significant improvement in the quality of campaigns and reports. We're thrilled to report that 2,187 teams took part from across 57 countries, representing a 36% increase in participation from last year. The Challenge continues to develop as one of the world’s biggest university competitions.

We're excited today to announce the results. Our global winners come from Deakin University, Australia and were taught by Chia Yao Lee and Bardo Fraunholz. The team of Andrew Kidd, Richard Blakely, Kevin Fung, Clinton Hinze, Katalin Kish and Howard Lien worked with a local kids play center, www.littletigrrs.com.au, to create a well-crafted campaign that highly impressed our judges.

Clockwise from top left: Richard Blakely, Chia Yao Lee (professor), Katalin Kish, Kevin Fung, Bardo Fraunholz (professor), Howard Lien, Andrew Kidd, Fiona and Mike (from Little Tigrrs), Clinton Hinze and Mick, The Big Hearted Tiger

Team spokesman Andrew Kidd gave us some insight into their winning campaign:

"After discussions with the business owners, we decided we needed to conduct three separate campaigns. One would promote the play center to customers outside a 10 kilometre geographic radius, another would attract more mothers' groups to the center, and the third one would attract more party and group event bookings. Visitors to their website more than doubled compared with the same period last year. We knew we had developed a strong campaign — but to win the global competition is outstanding."

The team and their professor are off to Mountain View, California for a tour of the Googleplex. To help in their ongoing studies, each team member will also receive an Apple MacBook Pro.

There were also three regional winners: for the Americas, the winning team comes from James Madison University in the U.S., while a team from the Warsaw School of Economics in Poland won for Europe, the Middle East and Africa. In the Asia Pacific region, the winners come from the International College of Management in Sydney, Australia. Here are more details about our winners.

We developed the Challenge to benefit everyone involved. We're delighted that thousands of small businesses around the world have seen their online presence improved in just three weeks. Professors tell us that the Challenge has allowed them to deliver a unique, practical teaching and learning exercise. For those students that took part, we hope they have developed some useful online marketing skills which they can use when they graduate and enter the workforce.

For anyone interested in competing in the 2010 Challenge, formal registrations will open later this year, but in the meantime you can register your interest.

Posted by Lee Hunter, Product Marketing Manager

Google Latitude on your iPhone

Earlier this year we announced Google Latitude, a service that lets you and your friends share your locations with each other. You control who gets to see your location and where on the map you appear to others. Today, we're releasing Google Latitude for iPhone and iPod touch, available in the Safari browser.

Visit google.com/latitude from your device to start using Latitude. Add a bookmark to your home screen to quickly launch Latitude. Just open Latitude in Safari and tap the + icon > Add to Home Screen > Add. For more details, check out the Google Mobile Blog.


Posted by Marc Wilson, Software Engineer

It's a bird...it's a plane...it's iGoogle comics themes!

We have always been excited to introduce design flair and whimsy to our user experience, especially on our homepage. Be it through our special holiday logos or special themes for our iGoogle users, we like to open up our homepage as a canvas for artists to express themselves and reach their fans and Google users around the world. Today, I'm particularly excited to announce the new comics themes for iGoogle, just in time for Comic-Con's 40th anniversary.

The themes showcase the amazingly diverse world of comics. Browse our gallery (www.google.com/comicsthemes) to choose from nostalgic comic strips like Peanuts, iconic heroes like Batman and Iron Man, or alternative comics greats like Dan Clowes, author of the graphic novel, "Ghost World." The dozens of themes represent talented artists from around the world including Rumiko Takahashi from Japan and Lewis Trondheim of France.

To offer his unique perspective as one of the world's most accomplished comics artists, I'm pleased to introduce guest author Jim Lee. In addition to being a recognized industry veteran, he also drew today's beautiful homepage logo incorporating some of DC Comics' most famous characters.

During his 20 year career, Jim has worked with DC and Marvel Comics, co-founded Image Comics and also WildStorm Comics – one of our iGoogle themes. His Batman, Superman, X-Men, Iron Man, Fantastic Four and WildC.A.T.s issues have sold millions of copies. Jim is a recipient of the Harvey Award, Golden Panel Award and is widely respected for his contributions as an artist, a creator and a publisher of comics.

An artist's POV by Jim Lee

Even as the world of comics evolves and embraces a new digital era, it doesn't change the universal, international appeal of the unique art form that is created through the simple marriage of word and picture. I'm excited to have been chosen to help launch this wonderful project. But I'm more elated, both as a professional and as a fan, that so many different types of comics have been chosen to be part of the iGoogle comics themes launch. From the mainstream superhero world of DC that I work in to the mainstays of the newspaper funnies from my childhood, to the Tokyopop manga titles I collect with my teenage daughters to the esoteric and more literary works of Dan Clowes and Gene Yang, two of my favorites; I think the breadth of choices available demonstrates the amazing diversity and the fundamental vitality of the stories comics can tell.


Posted by Marissa Mayer, Vice President of Search Products and User Experience, and Jim Lee, Comics Creator/Publisher

Pseudo-Evidence Based Medicine Threatens Health Care Reform Based on "What Works"

As I posted yesterday, the increasingly noisy debate about health care reform in the US has not dealt much with the issues we often discuss on Health Care Renewal. These include problems in how health care organizations are led which threaten physicians' and other health care professionals' core values using tactics including perverse incentives, deception, and intimidation.
Last night, however, President Obama held a news conference mostly devoted to health care issues, in which he stressed the importance of changing not just how health insurance works, but how health care decisions are made. As Newsweek's "The Gaggle" blog reported,

Can I guarantee that there are going to be no changes in the health care delivery system? No. The whole point of this is to try to encourage changes that work for the American people and make them healthier. The government already is making some of these decisions. More importantly, insurance companies right now are making those decisions. And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works, because that's not how it's working right now.

So what the President seems to be advocating is making health care more evidence-based, perhaps in the formal sense of evidence-based medicine.

As a card-carrying evidence-based medicine advocate, I certainly agree, but let me reiterate that evidence-based medicine is not just medicine based on some sort of evidence. As Dr David Sackett, and colleagues wrote [Sackett DL, Rosenberg WM, Muir Gray JA, Haynes RB, Richardson WS. Evidence-based medicine; what it is and what it isn't. BMJ 1996; 312: 71-72. Link here. ]

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

Furthermore,

Evidence based medicine is not 'cookbook' medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.

One can find other definitions of EBM, but nearly all emphasize that the approach is designed to appropriately apply results from the best clinical research, critically reviewed, to the individual patient, taking into account that patient's clinical characteristics and personal values.

So far, so good. I believe the proper application of "real" (as described above) evidence-based medicine has the potential to improve patient outcomes while moderating health care costs. However, we have pointed out how problems arising from concentration and abuse of power in health care threaten the evidence-based medical ideal.

First, there are major problems with the development of the sort of clinical research evidence required by the EBM process. We have discussed how clinical research is frequently manipulated by those with vested interests in producing results that favor the products or services that they sell. The critical review process inherent in EBM is meant to cope with less than optimally designed and implemented research. However, the process was designed to cope with honest mistakes and inevitable trade-offs, not deliberate manipulation by vested interests.

Worse, we have discussed how vested interests may engineer the suppression of research when manipulation fails to produce the desired results. The EBM process assumes that the research on which decisions should be based is an unbiased sample of research that was done (and done to advance science, not commercial or ideological interests). When research whose results are unwanted by vested interests is suppressed, the resulting distortion of the evidence base may irretrievably bias the EBM process.

Finally, we have posted about how vested interests have distorted the discussion, dissemination, and teaching of the results of clinical research. They may develop systematic stealth marketing campaigns, often employing supposed "key opinion leaders," who are paid on the side by marketers, and using "medical education and communication companies"as marketing fronts whose publication strategies include deceptive tactics such as "ghost-writing."

Thus, a rising tide of "pseudo-evidence based medicine" threatens to overwhelm even the most conscientious physicians trying to practice evidence-based medicine.

So, while I applaud President Obama's advocacy of reforming health care to emphasize what the best evidence suggests really works, I do not think this effort will get far unless we deal with the rising tide of pseudo-evidence based medicine. As a minimum, we need full and detailed disclosure of all the relationships among vested interests and medical research and education, and a much greater role for research and education that is not subsidized by corporations bent on using research and education to market their products and services.

State, City Settle Case Alleging Medicaid Fraud

We have posted on a variety of settlements of cases alleging health care fraud, but this one has a new twist, as reported by the NY Times,

New York State and New York City officials agreed this week to repay the federal government for more than half a billion dollars in improper Medicaid claims, averting a potential court battle but adding more red ink to the state’s and city’s finances.

The settlement, which federal officials said was the largest recovery of Medicaid funds in history, ends a lengthy dispute with the federal government over whether school districts around the state improperly sought Medicaid payments for speech therapy and other services dating to the early 1990s.

Under the agreement, which was announced Tuesday, the city will repay about $100 million. The state will pay about $332 million in 10 installments over the next five and a half years and will also give up $107.9 million worth of Medicaid claims now owed by the federal government.

Though neither city nor state officials are required to admit wrongdoing under the agreement, it does require the state’s Department of Education to submit to independent monitoring of its Medicaid-financed programs.

Since the 1980s, Medicaid has helped school districts pay for the cost of services like speech therapy and psychological counseling for schoolchildren, including the cost of transportation to therapists’ offices. School districts in New York have been among the most aggressive in the country in seeking such aid: one federal study found that New York accounted for 44 percent of all student health services.

Those lawsuits, filed under the federal False Claims Act, spurred several audits by the Department of Health and Human Services of city and state programs that finance speech therapy and other programs for disabled children. Those audits found substantial potential for fraud, reporting that a vast majority of the claims submitted did not meet federal requirements, and that in many cases there was no evidence that the services had actually been provided.

This may be the first settlement of health care fraud allegations we have discussed in which all the involved parties were government agencies.

The current fervent debate in the US about health care reform has focused on ever rising health care costs. However, this debate has largely ignored the ethics of health care, and the sorts of leadership of health care organizations that has lead to rampant and costly mischief, of which this case is just the latest example. How can we control costs while so many health care leaders are seeking every angle to make more money, whatever the consequences?

Digital activism on YouTube

(This is the second of a series of posts from YouTube's news and politics blog, Citizentube. -Ed.)

Activism today isn't limited to picket lines and marches on the Mall — people have taken their movements to the web, and YouTube has become an important platform for exposure. Every day, people use YouTube to fight for causes, whether they're hunger-striking celebrities like Mia Farrow, or 9-year-olds trying to save the neighborhood kickball lot from destruction. On Citizentube, our YouTube blog that chronicles the way people use video to change the world, we've seen digital activists use YouTube in three basic ways: to shine a light on issues that need more exposure, to drive action around causes they care about, and to create connections between people and organizations that share their desire to make a difference.

Some of the most compelling videos we see are those that spotlight important issues that aren't being covered in the mainstream media. Witness, a nonprofit organization whose mission is to document human rights abuses around the world through video, offers an excellent example — this video from their YouTube channel chronicles the clashes between the Burmese military and rural ethnic minorities. Invisiblepeople.tv, a relative newcomer to YouTube, is taking a similar approach by tackling a more domestic issue: homelessness. This summer, the group is traveling across America to document the real, unedited stories of people living on the streets, in tent communes and in cars — and posting all of the footage to their YouTube channel. And of course we've seen protesters in Iran, China and elsewhere use YouTube to amplify their causes far beyond national borders.

Other individuals and nonprofits are using YouTube as a direct advocacy tool, experimenting with ways to drive action from their videos to a particular cause. And we're building new products to make it even easier for them to do this effectively. For example, in March, we launched a tool called "Call to Action," which allows nonprofit organizations to drive traffic from an in-video overlay to an off-site page where they can collect donations, signatures or email addresses. Shortly after launch, to commemorate World Water Day, we featured a video from charity:water on the YouTube homepage that used a call-to-action overlay to encourage YouTube users to donate money to build wells and provide clean, safe drinking water for those who don't have it. Through YouTube, charity:water was able to raise over $10,000 in one day — enough to build two brand-new wells in the Central African Republic and give over 150 people clean drinking water for 20 years.

Yet some of the most innovative uses of YouTube for digital activism are those that leverage the communities that exist on YouTube around particular causes. YouTube is inherently a social experience and many of our users are hungry to partner and collaborate with others who share their passions. Last December, popular YouTube users the Vlogbrothers launched the "Project for Awesome," a campaign which asked fellow budding change-makers to make videos about their favorite charities. Over 1,200 people joined the effort to promote their cause of choice. And just a few weeks ago, in partnership with President Obama's launch of serve.gov, we created "Video Volunteers", a new platform on YouTube which connects nonprofits that lack video resources with proven video-makers who want to use their skills to do good. There are already hundreds of posts from nonprofits seeking help on the Video Volunteers YouTube channel, so if you're interested in creating a video for an organization, head over to the channel now and find a cause you care about.

Activism is constantly evolving on YouTube, so we'll keep posting fresh accounts of how citizens and nonprofits are changing the world, one video at a time, on Citizentube.

Posted by Ramya Raghavan, YouTube Nonprofits & Activism

What Health Care Reformers Don't Discuss

Health care reform is now the big health care story in the US. Discussion of various health care reform proposals regularly lead in print and electronic media. Yet we have been very quiet here on Health Care Renewal about health care reform.

I personally have written little, because it seems to me that hardly any of the discussion swirling around relates to the concerns we discuss on this blog. We write about the bad effects of continuing concentration and abuse of power in health care on physicians' and other health care professionals' core values. We note instances of ill-informed, incompetent, self-interested, conflicted, or even corrupt leaders of health care organizations. We discuss how problems with the governance of health care organizations allow such leadership. We comment on instances in which bad leaders use tactics such as deception, creation of perverse incentives, and intimidation. And we address how all this can lead to higher costs, decreasing access, poor patient outcomes, and demoralized professionals.

For example, just in this month, July, 2009, we posted about:

How Trusted Health Care Institutions are Lead by the Conflicted

• One of the largest and most respected medical societies gets three times as much income from the pharmaceutical, biotechnology and device industries as from membership dues, and its current generously salaried president just asks the public to "trust us, we're doctors" (link here);
• The White House health care reform czar just stepped off the board of directors of a health care corporation accused of "ruthless" behavior and making patients feel they are only equivalent to "dollars" (link here);
• An award-winning show on public television featured remarks favoring drug treatment of psychiatric illness by an academic "key opinion leader" without disclosing his multiple financial ties to the pharmaceutical industry (link here);
• A state legislator pleaded guilty to selling his services to an academic medical center (link here);
  

Health Care Leaders Do Not Share Physicians' Traditional Values

• Leaders of the university that employs the academic "key opinion leader" mentioned above intimidated another of its professors because he wrote a blog critical of the pharmaceutical industry (link here);
• A study showed that primary care doctors burn out not just because they think their pay is low, but because they work in "chaotic" environments, lead by people who do not inspire trust and whose values are not aligned with those of the physicians (link here);

And our archives, going back now to the end of 2004, include much more.

For the most part, however, these are not the issues discussed in the great health care reform debate.

There does seem to be, at the margins, some discussion of a few productive approaches, which deserve credit. These include the Sunshine bill, which would improve disclosure of conflicts of interest generated by health care corporations' payments to health care professionals and academics; the push to support some comparative effectiveness research; and some attempts to address the perverse incentives built into the system used by Medicare to pay physicians. It is not clear, however, whether these efforts are going to get very far, and in any case, they remain peripheral to fervent discussions of health care financing, which seems to be the only topic of interest to most would-be health care reformers.

I believe that the US health care reform will not produce good results if it fails to address the issues we discuss on Health Care Renewal.

But discussion of them, of course, may threaten many with vested interests, and lots of people who have been made rich and powerful by the current system.

So look forward to endless debates about whether the "public option" for health insurance is a good or bad idea, but nothing about how the insurance industry is lead, much less how pharmaceutical, biotechnology, device companies, hospitals and academic medical centers, medical not-for-profit organizations, health care information technology companies, and government agencies are lead, and how bad leadership facilitated by bad governance will continue to make things worse.

JAMA letter: "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards"

My letter "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in JAMA yesterday. A preview of the letter can be seen here, or a full version here if you subscribe to JAMA.

The letter was in response to Koppel and Kreda's groundbreaking March 2009 JAMA article "Health Care Information Technology Vendors' Hold Harmless Clause: Implications for Patients and Clinicians."

The JAMA letter covered some of the same points I addressed extensively at my Drexel HIT website essay "Hold Harmless and Keep Defects Secret Clauses", including the major point that hospital executives signing such contracts are in violation of Joint Commission standards for conduct related to safety, and in violation of their fiduciary responsibilities towards patient and employee safety and freedom from undue liability. In the Drexel website essay I also noted that:

... these stipulations [hold harmless and gag clauses in contracts] further instantiate my observation that health IT lacks the rigor of medical science itself, its major Achilles heel.

Koppel and Kreda note in their JAMA reply to my JAMA letter that:

Dr Silverstein's letter adds context to our Commentary on HIT vendors' self-protective "hold harmless" clauses while introducing an important discussion about hospitals' and vendors' possible violations of Joint Commission standards. We agree with Silverstein about the misapplication of the standard business software contracting model.

Of interest, the American Medical Informatics Association (AMIA) had authored a reply to Koppel and Kreda quite different than mine, which for a time appeared on their national website (www.jamia.org) but was later withdrawn apparently due to concerns that such a letter might be viewed as an official organizational position. It was entitled "Response to Commentary in JAMA -- Ross Koppel, David Kreda" and can be read in its entirety here.

The AMIA response piece concluded:

"While we support increased transparency around error disclosure, the belief that the best approach to increase the safety and effectiveness of EHR systems is by legal regulation of system vendors is misplaced. Such an approach would stifle innovation and not achieve the desired goals. At a minimum equal attention needs to be given to the role that provider organizations bring to configuration, management and oversight of the software and related processes."

In fact, Koppel and Kreda addressed the provider side issues extensively in their article.

Of interest, JAMA did not publish the AMIA response but instead published mine. Perhaps it's because JAMA felt I had something important to say, as opposed to simply making excuses for HIT vendors and valuing prevention of "stifling of innovation" over hospital leadership's safety and fiduciary obligations to patients and staff.

"The belief that the best approach to improving HIT safety is via regulation is misplaced?" (Misplaced how, exactly?) Tell that to the airline or public transit or pharma or the medical device industries. Or to the public whose care is increasingly dependent upon these HIT systems.

It is my firm opinion that "innovation" done recklessly, in secrecy, without accountability, and via exploitation is not innovation at all.

-- SS

July 23 addendum:

Dr. Koppel has forwarded to me a letter he and Mr. Kreda submitted to AMIA in response to AMIA's aforementioned critique of his March 2009 JAMA "Hold Harmless Clause" article. Koppel and Kreda's letter, "On the AMIA Response to Commentary in JAMA by Ross Koppel and David Kreda" can be read here (MS Word .doc format).

Highlights:

... Where the AMIA authors disagree with us is the emphasis placed on errors produced in the coupling. [The coupling of healthcare organization and software, i.e., alterations and customizations beyond the control of the software vendor - ed.] We say a vast number or errors are generated in the marriage. But they say we have essentially ignored how many errors are created by doctors and hospitals seeking to consummate their relationship with HIT systems in situ ...

... A brief recap of our JAMA commentary seems in order. We wrote about: (1) the HIT vendor “non-disclosure” clauses that prevent clinicians from sharing information about errors generated from faulty software; (2) the clauses that remove all vendor responsibility for errors in their systems – and place all responsibility on clinicians and hospitals (the “hold harmless/learned intermediary” clauses); (3) the need to protect vendors from responsibilities for errors introduced when hospitals implement HIT or when untrained or incompetent clinicians use the HIT; and (4) the need for more balanced contracts that are fair to clinicians and hospitals ...

... Given that we addressed the non-software issues we are said to have ignored, we are not sure why our JAMA commentary earned the response it received on official AMIA letterhead. We hope, therefore that this letter can further a longer conversation about the many ways to make clinical IT software and its implementation better. Nonetheless, we stand by our statement that the imbalance in incentives we described in our JAMA Commentary is a structural obstacle that on balance hurts improving the clinical part of clinical IT.

Read the whole thing at the link above. (I placed Koppel and Kreda's response to AMIA on my faculty server. The response, to the best of my knowledge, was not published by AMIA itself.)

-- SS