healthy4u: HIMSS

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics - "EHRs: The Real Story",  pg. 18-27, Feb. 10, 2014, available <a href="http://www.cci.drexel.edu/faculty/ssilverstein/EHRs_Real_Story_Medical%20Economics.pdf">here</a> (PDF). Full issue at <a href="http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf">http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf</a> - it is large, 12 MB: <blockquote class="tr_bq">... "Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research f rm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs."</blockquote> Here are other key findings from this national survey: <ul><li>73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice. </li></ul><ul><li>67% of physicians dislike the functionality of their EHR systems. </li></ul><ul><li>Nearly half of physicians believe the cost of these systems is too high. </li></ul><ul><li>45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse. </li></ul><ul><li>65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as signifcant.</li></ul><ul><li>About 69% of respondents said that coordination of care with hospitals has not improved.</li></ul><ul><li>Nearly 38% of respondents doubt their system will be viable in five years. </li></ul><ul><li>74% of respondents believe their vendors will be in business over the next 5 years.</li></ul> <div>My own views are: While some might dismiss such surveys as well as reports of harms as "anecdotes" (those same persons conflating scientific discovery with risk management, see <a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=LYQ0kvWIAEGlr6MBedQBY4tGF9IZCNEIO-wCybP0fwH6J_hSfD2Oiv3jiryTYaXcgidWN-ajWas.&URL=http%3a%2f%2fhcrenewal.blogspot.com%2f2011%2f08%2ffrom-senior-clinician-down-under.html" target="_blank"></a><a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html</a>), I observe that such articles/surveys are increasing in frequency the past few years and are coming from reasonably capable observers - clinicians - .unlike, say, a Fox News survey of pedestrians on complex political matters. Another physician survey is here:  <a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html.</a> Here's an interesting ad hoc survey of nurses:  <a href="http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html">http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html</a>. . This is not what the Medical Informatics pioneers intended, and is not due to physicians being Luddites (a topic I addressed at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>). In my opinion, organizations that have the expertise to change the current trajectory of this technology such as the American Medical Informatics Association (<a href="http://www.amia.org/">AMIA</a>) needs to leave its tweed-jacket academic comfort zone and become more proactive - or perhaps I should say aggressive - in combating the industry status quo.  </div><div></div><div> The health IT industry trade associations such as <a href="http://www.himss.org/">HIMSS</a> have no such qualms about aggressively and shamelessly pushing their version of EHR utopia, an agenda that has led to massive profits for the industry... but to clinician survey results such as above.  And to injured and dead patients.</div><div></div><div> -- SS </div>

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics - "EHRs: The Real Story" , pg. 18-27, Feb. 10, 2014, available here (PDF). Full issue at http://medicale...

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Texas Medical Association slams ONC Healthcare IT safety plan

The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality and patient care risks: <blockquote class="tr_bq">FierceHealth IT today</blockquote><div style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><div class="gmail_quote"> <blockquote><a href="http://links.mkt1985.com/ctt?kn=167&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__S4c8UaRxIHMoxpErecFsKw" target="_blank">Texas Medical Association slams ONC safety plan</a></blockquote><blockquote><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" width="31"></td><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" valign="bottom" width="150">By Dan Bowman</td><td style="color: #888888; font-family: Verdana, Arial; font-size: 9px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" valign="bottom"> </td></tr></tbody></table></blockquote><blockquote><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td style="font-family: arial, sans-serif; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div><div>The <a href="http://links.mkt1985.com/ctt?kn=57&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__kdmrdIyd6sIcVcFLYphXQ" target="_blank">health IT safety action plan proposed by the Office of the National Coordinator for Health IT</a> in December is not specific enough to succeed, according to recent comments made by the Texas Medical Association. In its <a href="http://links.mkt1985.com/ctt?kn=92&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_assets_fiercemarkets_com__roPjbL4h6p1at3aX94znog" target="_blank">letter</a> to National Coordinator for Health IT Farzad Mostashari, TMA said that responsibility for the plan "lacks focus," and should be overseen by a "highly visible HIT Safety Czar.</div><div> </div><div>TMA also called setting mandatory deadlines and developing a "robust" reporting and learning system imperative to the success of the plan, saying that the plan's current reliance on voluntary reporting and funding represents a "fundamental weakness."</div><div> </div><div>"TMA believes that significant patient safety risks exist now, and new ones will emerge in the next one to two years as many [electronic health record] and other HIT vendors merge or go out of business," the letter said.</div><div> </div><div>Additionally, the group expressed doubts about a code of conduct proposed to keep vendors in line as far as ensuring cooperation with safety organizations for adverse event reporting. "TMA is concerned that this will not materially affect industry accountability and generate the changes that are needed," the letter said. "For example, what if a developer does not comply with said code of conduct? There is no penalty or impetus for change."</div><div> </div><div>The American Medical Association was a bit less harsh in its <a href="http://links.mkt1985.com/ctt?kn=190&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_ama_assn_org_resources_do_kLlOCnendmgZnkafWC36A" target="_blank">assessment</a> of ONC's plan. It supports most of the ideas outlined in the plan, although it called for more research to be done on the impact of electronic health record use regarding patient safety in the ambulatory setting.</div><div> </div><div>"Physicians are concerned about potential liabilities from EHR system design and software flaws, as well as lack of interoperability among EHR systems that could result in incomplete or missing information, which may lead to errors in patient diagnosis and treatment," the AMA letter said. "In addition, the impact that EHRs have on physician practice workflows can lead to unintended consequences. Those impacts are the result of how the software is developed."</div><div> </div><div><a href="http://links.mkt1985.com/ctt?kn=5&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__fdelaLMvtjHW1QKrOUvegg" target="_blank">HIMSS said in its letter to Mostashari</a> that it wants to see more provider-vendor cooperation when it comes to investigation of patient safety events, as well as usability, while the AHA said in its letter that its stakeholders would like to see more of a focus on a single, national approach to matching patients with their records with a goal of patient safety.</div><div> </div><div>The <a href="http://links.mkt1985.com/ctt?kn=146&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__Uy2fglIMzJM3HSXPTivQVg" target="_blank">College of Healthcare Information Management Executives, meanwhile, said that the plan needs to be facilitated</a> by stakeholders not directly under government control.</div><div> </div><div>To learn more: - here's the TMA <a href="http://links.mkt1985.com/ctt?kn=92&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_assets_fiercemarkets_com__roPjbL4h6p1at3aX94znog" target="_blank">letter</a> (.pdf) - read the AMA <a href="http://links.mkt1985.com/ctt?kn=190&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_ama_assn_org_resources_do_kLlOCnendmgZnkafWC36A" target="_blank">letter</a> (.pdf)</div><div> </div><div>Related Articles:<a href="http://links.mkt1985.com/ctt?kn=5&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__fdelaLMvtjHW1QKrOUvegg" target="_blank">HIMSS, AHA support ONC's patient safety plan</a> <a href="http://links.mkt1985.com/ctt?kn=146&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__Uy2fglIMzJM3HSXPTivQVg" target="_blank">CHIME: ONC's role in health IT safety plan 'overstated'</a> <a href="http://links.mkt1985.com/ctt?kn=57&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__kdmrdIyd6sIcVcFLYphXQ" target="_blank">HHS issues health IT safety action plan</a></div></div></td></tr></tbody></table></blockquote></div></div><div style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><div class="gmail_quote"> The TMA and AMA letters linked above are worth reading in their entirety. I note, with little surprise, the "softer" stances (e.g., self-policing vs. government oversight) taken by industry-dominated bodies such as HIMSS and CHIME. On the other hand, I find the AMA's "less harsh" views somewhat disappointing.  Their letter is welcome, and more research needs to be done as to risks in ambulatory settings (and inpatient settings as well).  However, the delays in action during the research are of concern. Where patient safety is concerned, fast action is a top priority.  Patients, needless to say, have more rights than computers and their sellers. -- SS </div></div>

Texas Medical Association slams ONC Healthcare IT safety plan

The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality a...

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The HIT Scam

Worth a read - <h1 class="post-title"><a href="http://healthblog.ncpa.org/the-hit-scam/" rel="bookmark" title="Permanent Link to The HIT Scam">The HIT Scam</a> By Greg Scandlen</h1><h1 class="post-title">Notable in the piece are these observations: </h1><blockquote class="tr_bq"><h1 class="post-title"> ... even the editors of the <a href="http://www.washingtonpost.com/opinions/the-rush-to-digitize-patient-records-has-not-cut-costs/2013/01/14/09d90096-5c2d-11e2-beee-6e38f5215402_story.html?hpid=z3">Washington Post</a> have come to agree the whole [national health IT] project was a fiasco — but only after we wasted $27 billion of taxpayer money. </h1>Yet, those who are enriching themselves on the $27 billion are just happy as clams over the program. John Hoyt, the Executive Vice President of the Healthcare Information and Management Systems Society (HIMSS) was quoted in a recent Health Change Bulletin as saying − <div style="padding-left: 30px;">This data suggests that the HITECH portion of the 2009 stimulus law is achieving its intended result of encouraging increased implementation and meaningful use of electronic health records among hospitals. Facilities…are laying the groundwork for interoperability to occur. Stage 6 and Stage 7 hospitals are fully prepared for provider-to-provider or facility-to-facility interoperability, as well as increasing the provider or facility’s ability to provide electronic health data reporting to public health and immunization registries to support population health review and syndromic surveillance.</div><div style="padding-left: 30px;"> </div>There, aren’t you greatly reassured? By the way, the New York Times piece cited above reported that – <div style="padding-left: 30px;">RAND’s <a href="http://www.rand.org/pubs/monographs/MG408.html" title="Abstract of the report.">2005 report</a> was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.</div><div style="padding-left: 30px;"> </div>No doubt the companies that paid for the RAND study are also members of HIMSS. And General Electric certainly has what might be called a “special” relationship with President Obama.</blockquote><h1 class="post-title">I've been writing on similar issues for more than a decade.</h1><h1 class="post-title">It's well past the time when the same rigor that applies to pharma and medical devices be applied to the health IT sector.  And the marketing hype, along with bad health IT, abolished.</h1><h1 class="post-title">-- SS  </h1> <a href="http://healthblog.ncpa.org/author/gscandlen/" rel="author" title="Posts by Greg Scandlen"></a>

The HIT Scam

Worth a read - The HIT Scam By Greg Scandlen Notable in the pi ece are these observations: ... even the editors of the Washington Post ...

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Good HIT, Bad HIT, HIMSS And Reckless Technology Advocacy: Will This Hurt President Obama?

HIMSS, the <a href="http://www.himss.org/" target="_blank">Health Information Systems Management Society</a>, is the large vendor trade group representing healthcare IT sellers. At the HIMSS blog entitled "Health IT is an essential element to transform the Nation’s healthcare system" (<a href="http://blog.himss.org/2012/10/05/health-it-is-an-essential-element-to-transform-the-nations-healthcare-system/" target="_blank">link</a>), <a class="url fn n" href="http://blog.himss.org/author/carlamsmith/" rel="author" title="View all posts by Carla M Smith, MA, CNM, FHIMSS">Carla M Smith, MA, CNM, FHIMSS</a> writes this with regard to the House  <a href="http://waysandmeans.house.gov/news/documentsingle.aspx?DocumentID=310498">letter</a> to HHS Secretary Sebelius asking her to suspend payments for the EHR Incentive Payments authorized in the American Recovery & Reinvestment Act of 2009: <blockquote class="tr_bq">HIMSS opposes halting the Meaningful Use EHR Incentive Program. Health IT is an essential, foundational element of any meaningful transformation of the Nation’s healthcare delivery system.  </blockquote> (Of course, not mentioned is "transformed" into what, exactly; this utopian ideation is a topic for another time.) A chart is then presented as to "how US civilian hospitals have, since the first incentive payments were made in second quarter, 2011, matured in their use of health IT."  Then this statement is made: <blockquote class="tr_bq">Healthcare providers are adopting certified EHRs and using them for meaningful purposes; thus, achieving Congressional intent to improve the quality, safety, and cost-effectiveness of care in U.S. </blockquote> Really?  (See my Feb. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html" target="_blank">Hospitals and Doctors Use Health IT at Their Own Risk - Even if Certified</a>.") This non-evidence based, amoral advocacy by HIMSS for health IT may cost the President the November election.  HIMSS has beguiled the president into similar unquestioning advocacy for the technology in its present form, which his opponents are now (rightfully) seizing upon as in the House letter. The reckless mistakes made by HIMSS and their advocates include these two: 1.   The unquestioned belief that this expensive technology would save billions of dollars in healthcare costs, instead of depleting precious healthcare resources better spent on, say, improvement of healthcare services for the poor. 2.  More importantly, the appallingly naïve belief that any health IT is good health IT, and that any health IT is only capable of good, not bad. HIMSS has thus failed to recognize - or perhaps worse, recognized but recklessly ignored - the profound difference between good health IT (GHIT) and bad health IT (BHIT). As I defined at my <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">teaching site on Medical Informatics</a>: <blockquote class="tr_bq">Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </blockquote> I am an advocate of the former, and an opponent of the latter. Bad health IT is prevalent in 2012 due to lack of meaningful quality control, software validation, usability standards and testing, and regulation of any type - a situation HIMSS long favored.   (The failed National Programme for HIT [NPfIT] in the NHS <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=granger_speaks_out" target="_blank">learned this the hard way</a>, as will Australians <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">needing emergency care</a>, I predict.) Put bluntly, in the end BHIT maims and kills patients, squanders precious healthcare resources, and drains the treasury into IT industry pockets (see my Oct. 3, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/10/honesty-and-good-sense-on-electronic.html">Honesty and Good Sense on Electronic Medical Records From Down Under"</a> and this query link on <a href="http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20risks" target="_blank">health IT risks</a>).  Further, the failure to recognize that the technology's downsides need to be understood and remediated before national deployment occurs and under controlled conditions, not after (which uses patients as non-consenting experimental subjects for software debugging), speaks to gross corporate negligence on the part of HIMSS.  It's not as if they did not have advance warning of all of healthcare IT's deficiencies.  BHIT also permits record alterations after the fact that may be to <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">conceal medical error</a>.  I am aware of numerous instances of such alterations, fortunately caught by critical-thinking, detail-minded attorneys.  However, like health IT harms, the incidences of known alteration attempts likely reflect the "tip of the iceberg." HIMSS and its fellow travelers have thus led this administration down the Garden Path of health IT perdition. I warned of this in a Feb. 18, 2009 Wall Street Journal <a href="http://online.wsj.com/article/SB123492035330205101.html">letter to the editor:</a> <blockquote class="tr_bq">Dear Wall Street Journal: 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. 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. For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors. [That project, the NPfIT in the NHS, has now been abandoned - ed.] HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine. The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker. I can only hope patients get something worthwhile for the $20 billion. Scot Silverstein, MD </blockquote> Mr. President, again, quite bluntly, the health IT industry took you for a ride, and the damage is done and is continuing due to lack of any meaningful health IT post market surveillance.   (As I wrote <a href="http://hcrenewal.blogspot.com/2012/10/house-ways-and-means-notes-ehrs-not.html" target="_blank">here</a>, the untoward results have already been used against the current administration, with more perhaps to follow.) In the U.S. we have the 1938 <a href="http://www.fda.gov/regulatoryinformation/legislation/federalfooddrugandcosmeticactfdcact/default.htm" target="_blank">Federal Food, Drug, and Cosmetic Act</a> (FD&C Act) in place: <blockquote class="tr_bq">The introduction of this act was influenced by the death of more than 100 patients due to a <a href="http://en.wikipedia.org/wiki/Sulfanilamide" title="Sulfanilamide">sulfanilamide</a> medication where <a href="http://en.wikipedia.org/wiki/Diethylene_glycol" title="Diethylene glycol">diethylene glycol</a> was used to dissolve the drug and make a liquid form.<a href="http://en.wikipedia.org/wiki/Federal_Food,_Drug,_and_Cosmetic_Act#cite_note-3">  </a>See <a class="mw-redirect" href="http://en.wikipedia.org/wiki/Elixir_Sulfanilamide_disaster" title="Elixir Sulfanilamide disaster">Elixir Sulfanilamide disaster</a>. It replaced the earlier <a href="http://en.wikipedia.org/wiki/Pure_Food_and_Drug_Act" title="Pure Food and Drug Act">Pure Food and Drug Act</a> of 1906. </blockquote> It should be honored, not ignored via special accommodation to the health IT industry and its trade group. HITECH also needs to be put in dormancy until the problems with these <a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html" target="_blank">unregulated medical devices</a> get worked out in relatively small, controlled settings to minimize risk, with patient informed consent.  This is in accord with human rights documents dating at least to the <a href="http://en.wikipedia.org/wiki/Nuremberg_Code" target="_blank">Nuremberg Code</a>, as in any new, experimental or partly-experimental medical device, pharmaceutical, or therapy. -- SS

Good HIT, Bad HIT, HIMSS And Reckless Technology Advocacy: Will This Hurt President Obama?

HIMSS, the Health Information Systems Management Society , is the large vendor trade group representing healthcare IT sellers. At the HIMSS ...

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HIMSS Senior Vice President on Medical Ethics: Ignore Health IT Downsides for the Greater Good

The Health Information Management Systems Society (<a href="http://www.himss.org/" target="_blank">HIMSS</a>) is the large health IT vendor trade group in the U.S.  At a Sept. 21, 2012 <a href="http://blog.himss.org/2012/09/21/will-health-it-increase-fraud-and-abuse/" target="_blank">HIMSS blog post</a>, <a href="http://blog.himss.org/author/jcasillas2/" target="_blank">John Casillas</a>, Senior Vice President of HIMSS Financial-Centered Systems and HIMSS Medical Banking Project dismisses concerns about health IT with the refrain: <blockquote class="tr_bq">... To argue that the existence of something good for healthcare in many other ways, such as having the right information at the point of care when it’s needed, is actually bad because outliers use it to misrepresent claims activity is deeply flawed. Through the best use of health IT and management systems, we have the opportunity to improve the quality of care, reduce medical errors and increase patient safety. Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records. Surely, no one can argue paper records are the path forward. Name one other industry where this is the case. I can’t. Let’s not let the errors of a few become the enemy of good.</blockquote> The ethics of these statements from a non-clinician are particularly perverse. The statement "Don’t let the arguments of some cast a cloud over the critical importance and achievement of digitizing patient health records" is particularly troubling. When those "some" include organizations such as FDA (see FDA Internal 2010 memo on HIT risks, <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">link</a>) and IOM's Committee on Patient Safety and Health Information Technology (see 2012 report on health IT safety, <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">link</a>) both stating that harms are definite but magnitude unknown due to systematic impediments to collecting the data, and the ECRI Institute having had health IT in its "top ten healthcare technology risks" for several years running, <a href="http://hcrenewal.blogspot.com/2012/03/ecri-institutes-top-health-technology.html" target="_blank">link</a>, the dismissal of "clouds" is unethical on its face. These reports indicate that nobody knows if today's EHRs improve or worsen outcomes over good paper record systems or not.  The evidence is certainly conflicting (see <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html" target="_blank">here</a>). It also means that the current hyper-enthusiasm to roll out this software nationwide in its present state could very likely be at the expense of the unfortunate patients who find themselves as roadkill on the way to the unregulated health IT utopia. That's not medicine, that's perverse human subjects experimentation without safeguards or consent. As a HC Renewal reader noted: <blockquote class="tr_bq">Astounding hubris, although it does seem to be effective.  Such is PC hubris.  Who could ever call for reducing the budget of the NIH that is intended to improve health.  Has health improved?  No. So why does a group with spotty successes if not outright failure never get cut?  It’s not the results, it’s the mission that deserves the funding.  So it’s not the reality of HIT, it’s the promise, the mission, that gets the support.  Never mind the outcome, it’s bound to improve with the continued support of the mission.</blockquote> Is this HIMSS VP aware of these reports?  Does he even care? Does he believe patients harmed or killed as a result of bad health IT (and I know of a number of cases personally through my advocacy work, including, horribly, infants and the elderly) are gladly sacrificing themselves for the greater good of IT progress? It's difficult to draw any other conclusion from health IT excuses such as proffered, other than he and HIMSS simply don't care about unintended consequences of health IT. Regarding "Surely, no one can argue paper records are the path forward" - well, yes, I can.  (Not the path 'forward', but the path for now, at least, until health IT is debugged and its adoption and effects better understood).  And I did so argue, at my recent posts "<a href="http://hcrenewal.blogspot.com/2012/09/good-health-it-v-bad-health-it-paper-is.html" target="_blank">Good Health IT v. Bad Health IT: Paper is Better Than The Latter</a>" and "<a href="http://hcrenewal.blogspot.com/2012/09/a-reason-to-refuse-use-of-ehrs-in-your.html" target="_blank">A Good Reason to Refuse Use of Today's EHR's in Your Health Care, and Demand Paper</a>".  I wrote: <blockquote class="tr_bq">I opine that the elephant in the living room of health IT discussions is that bad health IT is infrequently, if ever, made a major issue in healthcare policy discussions. I also opine that bad health IT is far worse, in terms of diluting and decreasing the quality and privacy of healthcare, than a very good or even average paper-based record-keeping and ordering system.   This is a simple concept, but I believe it needs to be stated explicitly.  </blockquote> A "path forward" that does not take into account these issues is the path forward of the <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiastic technophile</a> who either deliberately ignores or is blinded to technology's downsides, ethical issues, and repeated local and mass failures. If today's health IT is not ready for national rollout, e.g., causes harms of unknown magnitude (e.g., see <a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">this query link</a>), results in massive breaches of security as the "Good Reason" post above, and mayhem such as <a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">at this link</a>, then: The best - and most ethical - option is to slow down HIT implementation and allow paper-based organizations and clinicians to continue to resort to paper until these issues are resolved.  Resolution needs to occur in lab or experimental clinical settings without putting patients at risk - and with their informed consent. Anything else is akin to the medical experimentation abuses of the past that led to current research subjects protections such as the "<a href="http://grants.nih.gov/grants/policy/hs/ethical_guidelines.htm" target="_blank">Ethical Guidelines & Regulations</a>" used by NIH. -- SS

HIMSS Senior Vice President on Medical Ethics: Ignore Health IT Downsides for the Greater Good

The Health Information Management Systems Society ( HIMSS ) is the large health IT vendor trade group in the U.S. At a Sept. 21, 2012 HIMSS...

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HIMSS Annual Meeting in Las Vegas - Fitting for People Who Gamble With People's Lives to Make a Buck?

The setting for the Feb. 2012 annual meeting of <a href="http://www.himssconference.org/">HIMSS</a> (the Health Information Management Systems Society, the gargantuan health IT trade group), ongoing as of this writing, is the Venetian Sands Expo Center in Las Vegas, NV. Judging by the pictures posted at the HisTALK blog <a href="http://histalk2.com/2012/02/21/himss-22112/">here</a> of the event, now ongoing, it seems to be one big, happy party: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5ZvHKibjTPjNNCRYqlAywA333MHS3Pc9ZX0G3YI8yIN9ZwuFK359McJLNSt7Vi3V293fzipOvXMLhOp-wFtsE-ua-8dX1nm1LGTJ0u1wqP_VvcgGYi-1RRVb5EuVMhCiiDWCNJubpPlii/s1600/dice.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5711969678677442594" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5ZvHKibjTPjNNCRYqlAywA333MHS3Pc9ZX0G3YI8yIN9ZwuFK359McJLNSt7Vi3V293fzipOvXMLhOp-wFtsE-ua-8dX1nm1LGTJ0u1wqP_VvcgGYi-1RRVb5EuVMhCiiDWCNJubpPlii/s320/dice.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 181px; height: 242px;" /></a>Rolling the dice at HIMSS 2012, Las Vegas. </div> This is ironically apopos for an organization whose leaders <a href="http://hcrenewal.blogspot.com/2010/07/barry-chaiken-md-mph-lets-be-patient.html">beg for special accommodation</a> for a technology they know their industry has not learned how to "do right" after decades of profiteering (at patient's expense), thus gambling with live, unconsenting people as the poker chips: <blockquote> Barry Chaiken, former HIMSS Chairman of the Board, <a href="http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/">July 2010 interview</a>: "We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better." [While the systems remain in use on live, unconsenting patients - ed.] </blockquote> It is difficult to imagine such a statement coming from the aviation, nuclear energy or other lives-at-risk industries. HIMSS 2012 really seems to be a fun party. Even Elvis was in attendance: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7I5Qubd3bi5K8MvyKluWflkJ9a-gKte8HHrVJkn1hUhG1OO63e_egpDg5ZNhaHZyl73PD5a4TYiZ2YSPJo7xcpdAXYs2MASN-poBgh3JQjGj7UtaIY9nCivXNVRz5iJK_tQ08MWyqIIi1/s1600/elvis.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5711969880801128546" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7I5Qubd3bi5K8MvyKluWflkJ9a-gKte8HHrVJkn1hUhG1OO63e_egpDg5ZNhaHZyl73PD5a4TYiZ2YSPJo7xcpdAXYs2MASN-poBgh3JQjGj7UtaIY9nCivXNVRz5iJK_tQ08MWyqIIi1/s320/elvis.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 181px; height: 242px;" /></a>Elvis, a fitting icon for an industry trade show on health IT? <a href="http://en.wikipedia.org/wiki/Elvis_Presley">Journalist Tony Scherman wr</a><a href="http://en.wikipedia.org/wiki/Elvis_Presley">ote</a> that by early 1977, "Elvis Presley had become a grotesque caricature of his sleek, energetic former self. Hugely overweight, his mind dulled by the pharmacopoeia he daily ingested, he was barely able to pull himself through his abbreviated concerts." </div> Sounds like what the commercial health IT sector has done to the good intentions and well-thought out applications created by the health IT pioneers. I note that <a href="http://en.wikipedia.org/wiki/Prostitution_in_Nevada">prostitution is legal in Las Vegas</a> as well. This allows making money from objectification of human beings, although at least the latter give consent to the exploitation of their bodies. Final thought: What was missing from HIMSS was the ED EHR Slot Machine of Risk. (From my March 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>.") <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcU1f1u1xxTYzAFs-kQfsH8mbfXmMmM1y_N6NJyqUe84mGs7L1iES7gq9kDC1Sor-Ou5voVcgAigLNV7MDtghk4cj_BBu55iz2SAxUMcr_c6FBjgjcRLOEv_sTCeLSWdeS80MCINk5tAjJ/s1600/winner.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5711973402090193266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcU1f1u1xxTYzAFs-kQfsH8mbfXmMmM1y_N6NJyqUe84mGs7L1iES7gq9kDC1Sor-Ou5voVcgAigLNV7MDtghk4cj_BBu55iz2SAxUMcr_c6FBjgjcRLOEv_sTCeLSWdeS80MCINk5tAjJ/s320/winner.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 320px; height: 240px;" /></a>The ED EHR Slot Machine. Click to enlarge. You've hit the ED EHR mis-processing jackpot! Perhaps today is a good day to die... </div> -- SS

HIMSS Annual Meeting in Las Vegas - Fitting for People Who Gamble With People's Lives to Make a Buck?

The setting for the Feb. 2012 annual meeting of HIMSS (the Health Information Management Systems Society, the gargantuan health IT trade gr...

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HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating" (June 2009) that I wrote about in a Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/unintended-errors-with-ehr-based-result.html">Unintended errors with EHR-based result management: a case series, and a special pleading for health IT</a>" with a new report: <a href="http://www.himss.org/ASP/ContentRedirector.asp?ContentID=76349"></a><blockquote><a style="font-weight: bold;" href="http://www.himss.org/ASP/ContentRedirector.asp?ContentID=76349">Promoting Usability in Health Organizations: Usability Maturity Model</a> (PDF, Feb. 2011)</blockquote> I knew I was in for a heaping helping of gobbledygook after reading the title itself: “Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model” A “Healthcare Usability Maturity Model” is a clue that what follows will take simplicity, and expend considerable ink to tangle it into a mess of process mysticism, buzzwords, paradigms, very pretty charts, and other Master-of-the-Obvious-made-to-look-sophisticated, destined-for-the-dusty-shelf consultant report. That is largely what follows. See for yourself.This passage in the Executive Summary is pathognomonic of the amoral, money-over-blood, patients-as-guinea-pigs mentality that inhabits the commercial health IT sector. I find it particularly revealing and revolting: <blockquote> ... Leaders may be reluctant to incorporate usability principles and practices [in a safety-critical technology increasingly mediating all aspects of medical care delivery - ed.] because of perceptions that these methods may slow development and product fielding. However, data exist on usability return on investment (ROI), outlining the value of adopting usability in health organizations. </blockquote> Excuse me? It takes proof of "ROI" to convince these companies to produce usable (which subsumes the concept of "safe") health IT? This is as cold-blooded a calculus as it gets. This is <a href="http://en.wikipedia.org/wiki/Ford_Pinto">Ford Pinto</a> material:<blockquote>... Critics alleged that the vehicle's lack of reinforcing structure between the rear panel and the tank meant the tank would be pushed forward and punctured by the protruding bolts of the <a href="http://en.wikipedia.org/wiki/Differential_%28mechanics%29" title="Differential (mechanics)" class="mw-redirect">differential</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-fordpintocase-14">[15]</a> [by a rear end collision of only 20 mph/32 km/h, causing a fire - ed.]— making the car less safe than its contemporaries.According to a 1977 <a href="http://en.wikipedia.org/wiki/Mother_Jones_%28magazine%29" title="Mother Jones (magazine)">Mother Jones</a> article, Ford allegedly was aware of the design flaw, refused to pay for a redesign, and decided it would be cheaper to pay off possible lawsuits for resulting deaths. The magazine obtained a <a href="http://en.wikipedia.org/wiki/Cost-benefit_analysis">cost-benefit analysis</a> that it said Ford had used to compare the cost of an $11 repair against the monetary value of a human life—what became known as the Ford Pinto Memo.<a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-50worst-12">[13]</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-mother-15">[16]</a><a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-16">[17]</a> An example of a Pinto rear-end accident that led to a lawsuit was the 1972 accident that killed Lilly Gray and severely burned 13-year old Richard Grimshaw. The accident resulted in the court case <a href="http://en.wikipedia.org/wiki/Grimshaw_v._Ford_Motor_Co.">Grimshaw v. Ford Motor Co.</a>,<a href="http://en.wikipedia.org/wiki/Ford_Pinto#cite_note-17">[18]</a> in which the California Court of Appeal for the Fourth Appellate District upheld compensatory <a href="http://en.wikipedia.org/wiki/Damages">damages</a> of $2.5 million and <a href="http://en.wikipedia.org/wiki/Punitive_damages">punitive damages</a> of $3.5 million against Ford, partially because Ford had been aware of the design defects before production but had decided against changing the design. [In more recent years, others said the Ford Pinto scandal was not clear-cut, but health IT unusability increasing odds for medical errors is clear-cut - ed.] </blockquote> <blockquote> </blockquote> Why are these companies and their leadership getting to play God - in a field such as Medicine? <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtYbO9i2jbJhyyQoyesX24vy99i7HmbRi1kxfdWEEBWLpTmLP96_JrM5JI86qwUPQj1Ty9do51aSnNSRNA8dohgaxoRq-xqmtV_BNVjW4U6Bq42Yw3K2gnwf5tK7_mxnnVqOj9KN9r1y6W/s1600/cp.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5579924020893002882" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtYbO9i2jbJhyyQoyesX24vy99i7HmbRi1kxfdWEEBWLpTmLP96_JrM5JI86qwUPQj1Ty9do51aSnNSRNA8dohgaxoRq-xqmtV_BNVjW4U6Bq42Yw3K2gnwf5tK7_mxnnVqOj9KN9r1y6W/s320/cp.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 128px; height: 181px;" /></a>Usability? Those Luddite doctors and crummy patients will get usability over my - er, their - dead bodies, if I don't profit handsomely from it. Finally, I have several meta-observations about this new report: <ul><li>We don't need a "usability maturity model." We need USABILITY. We need the common and longstanding knowledge of software usability in other mission critical sectors to be applied on the development whiteboard and usability testing labs (if any!) at HIT vendors. </li></ul><ul><li>Why is it that health IT usability has to be written about, basically as if from the grade school level, in 2011 - some sixty years into the “computer revolution?” Do we still write treatises on why it’s wise to use sterile technique and good lighting in operating rooms? What is the major malfunction in this industry? </li></ul><ul><li>Why is this treatise not entitled “Promoting Usability in Health IT Vendor Development Shops: A Vendor Responsibility Model”?</li></ul><ul><li>The frequent use of the terminology "user experience" as applied to healthcare IT in this report struck my eye. It has been adopted in this report, but was uncommon regarding health IT until recently, as in my posts about the health IT <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience.</a> </li></ul>The terminology is conspicuously absent in the aforementioned earlier 2009 HIMSS report. It would not take Sherlock Holmes to theorize that I might be an <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&biw=1024&bih=578&q=healthcare+IT+user+experience&btnG=Google+Search#sclient=psy&hl=en&client=firefox-a&hs=q9q&rls=org.mozilla:en-US%3Aofficial&channel=s&biw=1024&bih=578&tbs=ww:1&q=%22mission+hostile+user+experience%22&aq=f&aqi=&aql=&oq=&pbx=1&bav=on.2,or.&fp=6c13b9433fbb516b">unattributed contributor</a> to the new 2011 HIMSS report. If anyone knows differently, I'd be interested to hear about it.-- SS <blockquote> </blockquote>

HIMSS and Healthcare IT: We Don't Need A "Usability Maturity Model." We Need - USABILITY - and Less of Cold-Blooded Calculus

Health IT industry consortium HIMSS has followed up its Master of the Obvious, 50-years-too-late paper " Defining and Testing EMR Usabi...

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HITECH and Funding Cuts: The Battle Begins

At "<a href="http://hcrenewal.blogspot.com/2011/01/us-house-of-representatives-proposes-to.html">US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH</a>" I predicted this: <blockquote>... I have no financial conflicts of interest regarding HITECH or health IT to weep about. Others do, and it's not hard to predict their financial interests will push them to oppose repeal "by any means necessary." The next few months should be an interesting time in the politics of healthcare IT. A replacement HITECH act that's "HI" on research and caution, but not so "HIGH" on stealth, coercion and euphoria (i.e., as on mind altering substances) would be welcomed. </blockquote> The battle's already begun. At "<a href="http://www.fiercehealthit.com/story/meaningful-use-incentives-jeopardized-gop-bill/2011-01-28">Meaningful Use incentives jeopardized by GOP bill</a>", Jan. 28, 2011 by at Dan Bowman at FierceHealthIT.com, views exactly as I expected have begun being proffered by the industry: <div style="border: medium none; text-align: left; background-color: transparent; color: rgb(0, 0, 0); overflow: hidden; text-decoration: none;"> <blockquote>... All of that [possibility of HITECH funding termination] has HIMSS Vice President for government relations Dave Roberts just a little on edge, reports Healthcare IT News. "We're trying to tell people that this process is going on. This is only one body [of Congress]. Don't let this be a concern," he said. But "if this is a new way of thinking, that could be concerning. So I think that while this particular bill may not pass, it's something that has to be watched closely." Patti Dodgren, CEO of <a href="http://www.hielix.com/">Hielix</a>--which helps to facilitate electronic health information exchanges across the U.S., shares Roberts' view. [Any possible conflicts of interest towards full-speed-ahead-damn-the-torpedoes health IT diffusion in that role, I ask? - ed.] "Just the suggestion of repealing HITECH stimulus funds for physicians...is short-sighted at best, and threatens the very progress that is already beginning to be realized within the industry to move our healthcare system into the 20th [yes, 20th] Century," Dodgren told FierceHealthIT. "All this bill serves to do is strengthen the cynics of health IT. [Translation: "short sighted" and "cynic" = those more interested in taking the time to do health IT "<a style="font-style: italic; font-weight: bold;" href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">right</a>" and in patient rights and patient well being, than in personal gain - ed.] We work with thousands of physicians and state government healthcare officials who have worked tirelessly over the past months to achieve the benefits that healthcare IT promises [no, Ms. Dodgren, they haven't, actually; you and they have merely encouraged a rushed, cavalier and reckless rollout (of a technology even HIMSS' former Chairman of the Board, a physician, admitted is not ready), damaging - not helping - health IT's prospects. See below - ed.], and this bill is a disservice to them and to the healthcare industry." </blockquote>It may be a "disservice" to those who stand to profit from the health IT industry, but it's a great service to the healthcare industry and to the patients it serves. I didn't really need to look, as experience at HC Renewal has proven time and again about the healthcare pundits, but the credentials of someone making such claims about health IT are not impressive IMO. From an <a href="http://www.linkedin.com/in/pattidodgen">online bio</a>, Ms. Dodgren holds the illustrious "CPHIMS" certification that I wrote about at my April 2008 post "<a href="http://hcrenewal.blogspot.com/2008/04/is-himss-certified-professional-in.html">Is the HIMSS Certified Professional in Healthcare Information and Management Systems stamp substantive, or just alphabet soup?</a>". After 8 years as Director Budgeting & Financial Systems at (now-defunct) Digital Equipment Corp. (DEC) and 4 years as Senior Business Analyst at Dun & Bradstreet, she has been a "change management professional" for twenty years who "co-founded a management consulting practice which specializes in the application of change management principles to health information technology." I note no medical (or medical informatics) training or experience. My reply to these people is as follows, as posted in a FierceHealthIT comment: <div style="border: medium none; text-align: left; background-color: transparent; color: rgb(0, 0, 0); overflow: hidden; text-decoration: none;"> <div class="submitted"></div><blockquote><div class="submitted">By S Silverstein MD | Posted 7:09pm | January 30, 2011 Patti Dodgren and Dave Roberts seem to favor continuation of a risky and even harmful national medical experiment that does not even have the fundamental decency to seek patient informed consent. See <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html">http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html</a> for examples of some of the risks. The former Board Chair of HIMSS, Barry Chaiken, MD, MPH, FHIMSS said it best in July 2010:</div> <div class="content"> <blockquote><a href="http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/">http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/</a> ... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.</blockquote> Let the industry learn the responsible way, not on patients' and physicians' blood, sweat and tears through way-too-early national initiatives that will only add to the $14 trillion national debt (<a href="http://www.usdebtclock.org/">http://www.usdebtclock.org/</a>), and throw some of the money into industry pockets.</div></blockquote><div class="content"></div> </div>Franky, as a physician with no financial conflict-of-interest axes to grind, I am increasingly disgusted with the cavalier, money-grubbing attitudes of the health IT industry and its pundits. Their attitudes and behaviors represent a poster study of healthcare industry at its worst. This latter fact is not lost on me as I speak with government representatives seeking to improve medical drug/device watchdog legislation, and to attorneys looking to protect patients from harm or gain recompense for those already injured as a result of faulty IT. -- SS </div>

HITECH and Funding Cuts: The Battle Begins

At " US House of Representatives Proposes to Defund Largest Non-Consented Medical Experiment in U.S. History: HITECH " I predict...

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Barry Chaiken, MD, MPH: "Let's be patient" with experimental devices that harm patients

At an <a href="http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/">interview</a> of Barry Chaiken, MD, MPH, FHIMSS, former Chairman of the Board of health IT trade group <a href="http://www.himss.org/">HIMSS</a> and chief medical officer of <a href="http://www.imprivata.com/">Imprivata</a>, a company specializing in healthcare IT security, Chaiken pleads for the following special accommodations for Health IT relative to other medical sectors: <blockquote>... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better. [Why are the health IT applications bad to begin with, I ask? - ed.] </blockquote> I note the following. <ul><li>If 'we're' still learning (and I don't include people with genuine clinical computing expertise in that subgroup, but it does include the plethora of amateurs in the commercial health IT industry), then the technology is experimental.</li><li>Worse, it's unregulated - a major special accommodation in and of itself. </li><li>These sentiments about "being patient" would be appropriate - if the subjects of this experimental technology that vendors need to be "given a chance" to make better were experimental lab rats.</li></ul> Instead, the subjects of the experimental technology are unwitting, unconsenting human beings, who are being used as experimental test subjects for software development, and being put at risk, injured and indeed <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=maude_death">killed</a> by the disruptions these experimental technologies cause. Under these realities, the position presented by Chaiken is, in my opinion, ethically perverse. That such sentiments come from someone who holds the MD degree and who I assume took the Hippocratic oath in some form is stunning. In the health IT industry, "<a href="http://en.wikipedia.org/wiki/Primum_non_nocere">Primum non nocere</a>" seems to have been replaced with "Kybernetik über alle." Further, the commercial health IT vendors have had the good part of five decades to "get it right." How long is long enough? Their software is unavailable for detailed evaluation and open critique of the user experience by impartial experts, unlike open source EHR's like VistA CPRS, demo version available <a href="http://www.ehealth.va.gov/EHEALTH/CPRS_demo.asp">at this link</a> where anyone can: <ul><li>Download the latest version of CPRS today and get access to new features including graphing functionality</li><li>Use the software as if you were a provider by entering orders, entering documentation, retrieving reports (and graphs) and viewing alerts and notifications that help with decision support</li><li>Learn first hand how VA’s electronic health record system works</li></ul> Personally, I've had to use stealth simply to obtain and post graphical representations of some simply inexcusable commercial HIT interface sins (<a href="http://www.tinyurl.com/hostileuserexper">link</a>). Why should a secretive industry be given additional special accommodation? Dr. Chaiken goes on to state: <blockquote>Let’s hold them accountable if they don’t [make the applications better]. Absolutely, hold them accountable if they don’t; and the marketplace, I hope, will be able to make those choices and hold them accountable when they don’t. But, we’re still learning.</blockquote> Again, I'm not sure who the "we're" refers to, but "holding companies accountable" will not really help victims of the experiments who are seriously injured or killed. A better solution, as I have written on this blog (such as at my Nov. 2008 post "<a href="http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html">Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans</a>?" and at other sites as well: Protect patients. Constrain the health IT experiment temporally and geographically, and apply the laws, customs and regulations of medical experimentation until this industry "has learned" whatever lessons Chaiken thinks they need to learn, e.g., from decades of Medical Informatics, Social Informatics, Computer Science, HCI and other research. None of these fields - last time I looked - are classified or protected intellectual property. Share information on patient adverse outcomes and near misses, instead of concealing them and contractually gagging users from openly speaking about problems. That would be the ethical approach. Further, how many more decades should we wait for the health IT industry to figure out how to look for better leaders beyond the "school of hard knocks" bias that's existed for at least the past decade? How many substandard health IT leaders were placed in hospitals the past few decades as a result of outrageous attitudes like these below from the major recrutiers, centered on spreading the wealth? <blockquote>I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman. Healthcare Informatics, "Who's Growing CIO's." [No, that line about 'being consumed with patient care issues' as a strike against health IT leadership didn't come from a Scott Adams business-idiot parody cartoon - ed.] </blockquote> As in clinical medicine itself, if you're going to be anywhere near patient care and making decisions affecting its delivery, a degree damn well "gets you something." At about the same time the above appeared in Healthcare Informatics, a generalist IT recruiter wrote me <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/opinions1.htm#anon1">this</a>: <blockquote> ... What is happening to MDs trying to change careers is providing a window into broader issues about professionals in society today - narrow training, pigeonholing in the marketplace, difficulty making lateral and cross-industry transition, what a handicap it is to be creative, entrepreneurial, or cross-disciplinary in the current marketplace, and the wasted intellectual capital represented by the high caliber of individuals who can't find ways to fruitfully plug themselves into the marketplace. I continue to be amazed at this general phenomenon...the remarkable quality of a number of candidates I've met, and the lack of recruiters' ability to get them in the door of good companies. The interesting part of the story is that when I am able to get access to high level execs in some of these companies (not just IT, but devices, pharmaceuticals, etc. also) they are dismayed at the quality of those that they hire. They know that something is wrong in how the recruitment process is working. (eg, one of the major device cos. just devoted the time of 1 FTE in Human Resources to 'finding innovative ways of identifying and recruiting good talent into the company.')</blockquote> Whose fault were the outrageous, deleterious hiring practices prevalent in this industry that contributed materially to its production of substandard products, hiring practices that persist to this day? (See example <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=leadership">here</a>.) Why should we be "patient", and "give them [yet more chances] to figure out the right way to do this", and why should patients permit themselves to continue to be guinea pigs to such a sloppy, cavalier industry? I note that Chaiken's credentials appear to fit the template, as colleague Roy Poses describes at various posts including <a href="http://hcrenewal.blogspot.com/2010/07/not-your-average-joes-health-plan.html">here</a>, of an "executive isolated from the real world of health care" and member of the <a href="http://hcrenewal.blogspot.com/search/label/superclass">superclass</a>. From the interview linked above: <blockquote> ... According to your LinkedIn profile, you’re CMO for Imprivata, CMIO for Symphony Corporation, and CMO of DocsNetwork. You’re on a couple of advisory boards, you own a vineyard, and you just finished your term as chair of the HIMSS board.</blockquote> Perhaps that helps explain the mantra of "computers [and profit] first, patients second." Finally, in answer to my own question above "Why are the health IT applications bad to begin with", I suggest complacency, incompetence, willful ignorance, and negligence (including <a href="http://legal-dictionary.thefreedictionary.com/Criminal+Negligence">criminal negligence</a>) as possible answers. -- SS Addendum: The following in today's WSJ caught my eye ("<a href="http://online.wsj.com/article/SB10001424052748703720504575377061515304900.html">What we've learned from the Gulf spill</a>", Michio Kaku, July 20, 2010): <blockquote>The nagging question is: Why did it take so long? Why couldn't they have capped the leak months ago? For three agonizing months, BP's engineers and executives were essentially making things up as they went along, conducting a billion dollar science project with the American people as guinea pigs. The basic science of stopping oil leaks at 5,000 feet below sea level should have been done years ago.</blockquote> Concepts are similar. With just a few edits, we have this: <blockquote>The nagging question is: Why is it taking so long? Why couldn't they have learned to create useful health IT decades ago? For at least thirty agonizing years, Health IT vendors' engineers and executives were essentially making things up as they went along, conducting a multibillion dollar science project with the American people as guinea pigs. The basic science of producing safe, effective, usable health IT should have been done years ago.</blockquote> -- SS

Barry Chaiken, MD, MPH: "Let's be patient" with experimental devices that harm patients

At an interview of Barry Chaiken, MD, MPH, FHIMSS, former Chairman of the Board of health IT trade group HIMSS and chief medical officer o...

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Is H. Stephen Lieber, CEO of HIT Industry Trade Group HIMSS, Misinformed or Simply Lying?

In the Wall Street Journal article today entitled "<a href="http://online.wsj.com/article/SB10001424052748704259304575043572008622004.html?mod=WSJ_Tech_RIGHTTopCarousel">Can Technology Cure Health Care?</a>" by erstwhile WSJ reporter Jacob Goldstein, H. Stephen Lieber, CEO of the health IT trade group <a href="http://www.himss.org/">HIMSS</a> disputes the idea that "electronic medical records systems focus on billing [and other administrative tasks] at the expense of patient care" and says: <blockquote>[These systems] are "primarily designed for improving clinical outcomes, and a secondary benefit is that they improve administrative efficiencies." </blockquote>Is Mr. Lieber misinformed, or worse, could he simply be lying?In fact, these systems do neither of these things, as repeated studies are showing such as I aggregated in "2009 a Pivotal Year in Healthcare IT" at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=2009">http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=2009</a>, and as in this new 2010 study report in Health Affairs: <a href="http://content.healthaffairs.org/cgi/content/abstract/29/4/639?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=jha&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT" target="_blank">Electronic Health Records' Limited Successes Suggest More Targeted Uses</a> The team, led by Harvard Medical School professor Catherine M. DesRoches, surveyed more than 3,000 U.S. community hospitals to assess factors such as inpatient costs and mortality and readmission rates. Here are their findings:<blockquote>Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care. ... the researchers determined that the technological systems, as currently implemented, do not have a significant impact on improving care and reducing costs, DesRoches said. </blockquote>A key phrase is "as currently implemented." To that, I'd add "as currently designed under the leadership of the HIT industry", which is to say, poorly. I commented on this report in my prior post "Yet Another Study Shows Health IT Does Not Bat The Ball Out of the Park; And, is HIT an Issue of States' Rights?" <a href="http://hcrenewal.blogspot.com/2010/04/yet-another-study-shows-health-it-does.html">at this link</a>. These results are also in line with the 2009 National Research Council report, the highest scientific authority in the U.S. that involved Octo Barnett and other health IT pioneers. The NRC report calls <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">current approaches to health IT "insufficient"</a> and calls for major redesign of health IT to support clinicians' cognitive needs. From the NRC report:<blockquote>Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient. </blockquote>And this was from the country's most advanced centers in terms of healthcare IT. As to cost savings, there's the Nov. 2009 “<a style="font-weight: bold;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf">Hospital Computing and the Costs and Quality of Care: A National Study</a>” (Amer J Med 123:1; 40-46) by Himmelstein and Woolhandler at Harvard Medical School, that also concluded “as currently implemented, hospital computing might [very] modestly improve process measures of quality but not administrative or overall costs." There's also the June 2009 <a href="http://www.wharton.upenn.edu/">Wharton School of Business</a> article "Information Technology: Not a Cure for the High Cost of Health Care" that I wrote about <a href="http://hcrenewal.blogspot.com/2009/06/wharton-on-healthcare-it-can-i-go-home.html">at this HC Renewal post</a>.Typical of the recalcitrant, recidivist IT industry, Lieber goes on to blame doctors:<blockquote>"... there is a resistance on the part of some to recognize the professional clinical advantage that these systems give them, many default to 'This is designed for billing, not clinical outcomes.'" </blockquote>Never does he consider that doctors might have good reasons to avoid the technology - as in, to protect the lives of the patients in their trust. (When they see user-hostile HIT products from major vendors such as <a href="http://ww.tinyurl.com/hostileuserexper">these</a>, who can blame them?) He then waves off "glitches" - the kind that result in untold clinician inconvenience and disruption, and have resulted in an unknown but <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=FDA_iceberg">"tip of the iceberg"</a> rate of patient injury and death per the FDA - by stating that:<blockquote>"There is a range of systems out there, just as in any kind of product line, ranging from poor to mediocre to excellent." </blockquote>His merchant computing, <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">card tabulator/data processing</a> mindset reveals itself in this statement. Unfortunately, health IT, as in other medical devices, IS NOT JUST ANY KIND OF PRODUCT LINE. Malfunctions and poor design do not simply cause a truckload of candy bars to be delivered to the wrong merchant.As in pharma and other medical devices, when trade group leaders of the HIT medical device companies are unaware of current research, dismiss it, and blame end users, or simply are liars, that industry deserves serious academic and governmental scrutiny. -- SS

Is H. Stephen Lieber, CEO of HIT Industry Trade Group HIMSS, Misinformed or Simply Lying?

In the Wall Street Journal article today entitled " Can Technology Cure Health Care? " by erstwhile WSJ reporter Jacob Goldstein, ...

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CCHIT Has Company

It appears CCHIT, an offspring of the large HIT trade association HIMSS, won't get its wish for Health IT Certification hegemony. I think the outcome of a multidisciplinary HIT policy workgroup's deliberations on this issue reasonable: <h2 face="Georgia,'Times New Roman',Times,serif" size="1.333em" style="border-width: 0px; margin: 0em 0.5em; padding: 0.05em 0em; outline-width: 0px; font-weight: bold; font-style: inherit; vertical-align: baseline; line-height: 1.15em;"></h2> <blockquote>Aug. 17, 2009 iHealthBeat.org <a style="font-weight: bold;" href="http://www.ihealthbeat.org/Articles/2009/8/17/Policy-Committee-OKs-Plan-To-Establish-Multiple-EHR-Certifiers.aspx">Policy Committee OKs Plan To Establish Multiple EHR Certifiers</a> On Friday, the [HHS] Health IT Policy Committee adopted recommendations that called for multiple entities to certify electronic health record systems, Health Data Management reports. The committee's certification and adoption work group issued the recommendations (Goedert [1], Health Data Management , 8/14). To receive official certification, EHR systems must meet a minimum set of criteria and achieve the "meaningful use" objectives of the federal economic stimulus package. Under the stimulus law, health care providers who demonstrate meaningful use of EHRs will receive Medicare and Medicaid incentive payments (O'Harrow, Washington Post , 8/15). Recommendations The work group recommended that: * Certification criteria allow for open-source software; * Certification processes should let health care organizations qualify for EHR subsidies under Stark Law exceptions that allow organizations to subsidize the cost of EHRs for physicians; * Certification should last for four years; * Multiple groups perform HHS certification under a single set of criteria; * The National Institute for Standards and Technology should participate in accreditation and certification decisions; * The Office of the National Coordinator for Health IT should define certification criteria; * ONC should create an accreditation process for certification groups; * Officials develop alternative certification processes for self-developed software; and * Vendors are required to receive certification from only one group ( Health Data Management , 8/14). The work group said it envisions the establishment of 10 to 12 different EHR certification groups, in addition to the Certification Commission for Health IT (Manos, Healthcare IT News , 8/14). The recommendations now go to HHS for consideration ( Health Data Management, 8/14).</blockquote> The workgroup said CCHIT is too closely aligned with the health IT industry, noted that the industry trade group HIMSS helped found CCHIT, and noted that CCHIT's members includes several people with ties to HIMSS and health IT companies. They were clearly uncomfortable with the potential conflicts of interest, especially if CCHIT gained sole responsibility for HIT "certification." [A term I put in quotes since it really is "features qualification" at this point, not certification such as a physician receives after passing Specialty Boards - ed.] Having been on the receiving end of CCHIT bullying myself ("<a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html">Open letter to Mark Leavitt, Chairman, Certification Commission for Healthcare Information Technology on Penalties For Use of Non-Certified HIT</a>"), it's clear most Americans don't like bullies, especially bullying from powerful lobbying organizations such as HIMSS and its progeny. (It's also become clear they don't like 1000+ page healthcare reform plans shoved, unread, down their throats by political bullies.) By the way, since the July 21, 2009 publication of my JAMA letter "<a href="http://hcrenewal.blogspot.com/2009/07/health-care-information-technology.html">Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards</a>" and Koppel and Kreda's reply, pointing out the terrible situation that HIT "defects nondisclosure" and "hold harmless" clauses create for hospital executives, physicians and patients, I have heard from the Joint Commission, but not from HIMSS. Perhaps HIMSS leadership believes I have nothing worthy to add to the discussion. (Perhaps another 'Open Letter' is called for.) -- SS

CCHIT Has Company

It appears CCHIT, an offspring of the large HIT trade association HIMSS, won't get its wish for Health IT Certification hegemony. I thi...

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HIMSS: Hospital CIO's Should Not Only Manage Healthcare IT, But Also Biomedical Engineering

I have written in the past about the territoriality of the IT department in hospitals, observing that the departments I was exposed to seemed more political than the clinical departments themselves. This territoriality came at the expense of clinicians' and patients' best interests. This phenomenon seems to go beyond the confines of the hospital IT shop, perhaps as a manifestation of the IT culture. For example: Other have observed - unapprovingly so - how the health IT trade group HIMSS, via a <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html">massive lobbying effort</a> and via its offspring, the CCHIT, has sought to gain hegemony over health IT through a "certification" process, a service for which CCHIT desires to be the sole provider. It's become worse. Now control over biomedical instrumentation (which includes such safety critical devices as ventilators, cardiac and other physiologic monitors, heart-lung machines, radiological devices, etc.) is sought. <div dir="ltr" align="left">In the June 2009 HIMSS analytics report "Devices in Hospitals" (<a href="http://www.himssanalytics.org/docs/HA_MedDevices.pdf">link to PDF</a>): <a href="http://www.himssanalytics.org/docs/HA_MedDevices.pdf"> </a></div> Page 7: <div style="margin-left: 40px;"> ... It appears that the IS department [a.k.a. IT department, or Management Information Systems department - ed.] is becoming the key support department for interfaced intelligent medical devices. This is a natural extension as IS departments build and support a cadre of interfaces to improve the collection and use of data within the hospital. </div> Then at the end of the report, in the Conclusion, a leap of logic of gargantuan proportions: <div style="margin-left: 40px;"> What is less clear at this time is whether the biomedical operations will be placed under the IS department for management. We believe that it should be , ala the movement of responsibility for telecommunications to the CIO when telecommunications and information technologies merged in the last 15 years . </div> Au contraire ... it is very clear to those who know what they're doing that this is a very bad analogy and suggests HIMSS does not understand the vast differences between the discipline and functions of biomedical engineering, versus the IT department role of management of computer and other ICT's (information and communications technologies). I find this astonishing. Having done a clerkship in biomedical engineering in medical school, and being somewhat knowledgeable about electronics as an <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformatic1/ham.htm">FCC-licensed radio amateur</a> at the Extra class (highest certification attainable by a series of FCC examinations), I find the HIMSS Analytics position risible and dangerous. It suggests a desire to expand territory even further into an area for which CIO's and hospital IT personnel are even less qualified - indeed, far less qualified - than clinical IT. Apparently, CCHIT wants to have hegemony over "certification" of clinical IT, and the parent organization HIMSS through its research arm opines IT should also take over "medical devices" (while still excluding clinical IT from that categorization to avoid regulation, of course).As I first asked <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">over ten years ago</a> after observing IT personnel in hospitals : <blockquote> Who, exactly, are the IT personnel in hospitals, and what, exactly, in their backgrounds qualifies them for major involvement in clinical affairs, let alone leadership roles regarding safety-critical clinical devices?</blockquote> Perhaps the Joint Commission, FDA, and other regulators need to start asking the same question.-- SS

HIMSS: Hospital CIO's Should Not Only Manage Healthcare IT, But Also Biomedical Engineering

I have written in the past about the territoriality of the IT department in hospitals, observing that the departments I was exposed to seeme...

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