healthy4u: Mismanagement

Masters of the Obvious at Athens Regional Medical Center: Lack of clinician input, training, common sense created problems with Athens Regional electronic records system - but mostly lack of common sense

<div style="text-align: center;">(Note: also see my earlier May 26, 2014 post at <a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html</a>)</div> My early medical mentor, Dr. Victor P. Satinsky, had disdain for those whom he called "Masters of the Obvious", who proffered profound words of wisdom that were in fact common-sensical or well-accepted, as if they'd invented those words personally. I think it's fair to say that after countless publications dating back decades, pointing out the essential role of clinical leadership in the development of clinical tools such as healthcare information technology systems, that such involvement is now a standard of care that reasonable hospital leadership would mandate when spending tens of millions of dollars on potentially injurious or lethal systems. Yet the physician revolt at Athens Regional Medical Center appears to be a result of its most senior leadership not keeping IT leadership on an appropriately short leash (a phenomenon that falls under the topical heading of "severe mismanagement"): <blockquote class="tr_bq"><a href="http://onlineathens.com/local-news/2014-06-14/lack-input-training-created-problems-athens-regional-electronic-records-system">http://onlineathens.com/local-news/2014-06-14/lack-input-training-created-problems-athens-regional-electronic-records-system</a>  Lack of input, training created problems with Athens Regional electronic records system By Kelsey Cochran Athens Banner-Herald Updated Sunday, June 15, 2014  More input in the way Athens Regional Health Systems’ electronic health records system was implemented should have come from the clinicians who use it every day, and fewer decisions should have been made by the hospital’s information technology department, a top hospital administrator and two vice presidents of system vendor Cerner Corp. said this week, in the wake of criticism of the system by a number of physicians. ... Although some daily users of the system were involved in the planning and design process from the beginning, Cerner Vice President Michael Robin, who has worked closely with ARMC since the deal was first made, said his team noticed midway through its implementation that the hospital system’s IT team was leading the project, which is "atypical" of Cerner clients like ARMC, he said. </blockquote> First, I don't think that IT team control of health IT projects is all that unusual.   Clinicians, even medical informaticists with cross-disciplinary expertise, rarely are more than "internal consultants" who may be ignored, as opposed to true leaders with executive presence and authority (e.g., control of budgets, grants of authority, and IT staff performance evaluation, hire and fire authority). Second, where was the Board of Directors?  They were ultimately responsible for allowing the IT leadership in at a level beyond their collective heads. Third, it's just a bit odd that the leader of the (failed) $20 billion National Programme for IT in the NHS, Richard Granger, said almost exactly the same thing about listening to end-users ca. 2007 (see <a href="http://hcrenewal.blogspot.com/2007/07/clinical-it-mayhem-is-good-for-it.html">http://hcrenewal.blogspot.com/2007/07/clinical-it-mayhem-is-good-for-it.html</a>).  I as well as numerous other authors had similar observations, in some cases dating to the 1960's.  For example,  see my essays, some dating to the late 1990s at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases</a>, and Dr. Donald Lindberg's quotes from 1969 at the page below from Morris Collen's book "A History of Medical Informatics in the United States 1950-1990." <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcn4aLX1NGS_wG4FsSop81xaYmy9OeDKeiW-6qndwAvRWTmR6Sa4pwXyBuG02j4jKhifXdjSbcCcLcFngrkv6lYcip-V6DQvXzAsPCHdqMity4UopLN1lptK4OjgvBQIMUurTDLVb4l7Jr/s1600/collen168.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcn4aLX1NGS_wG4FsSop81xaYmy9OeDKeiW-6qndwAvRWTmR6Sa4pwXyBuG02j4jKhifXdjSbcCcLcFngrkv6lYcip-V6DQvXzAsPCHdqMity4UopLN1lptK4OjgvBQIMUurTDLVb4l7Jr/s1600/collen168.jpg" width="210" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">EHR pioneer Dr. Donald A.B. Lindberg (<a href="http://www.nlm.nih.gov/od/roster/lindberg.html">http://www.nlm.nih.gov/od/roster/lindberg.html</a>), 1969:  "Computer engineering experts per se have virtually no idea of the real problems of medical or even of hospital practice, and furthermore have consistently underestimated the complexity of the problems ... in no cases can these jobs be done, simply because they have not been defined with a physician as the continuing major contributor and user of the information." (Click to enlarge)</td></tr></tbody></table> The essential nature of clinicians actually having input (and at a leadership level) into the design and implementation of clinical tools such as health IT is patently obvious.  Only in the perverse control-mentality of business information technology (a.k.a. MIS or management information systems, see <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html</a> for the possible pre-electronic computer, tabulator-based roots of that culture) could such a precept even be questioned, let alone ignored. <blockquote class="tr_bq"> ... Moore, who took over as administrative lead on the electronic health record system after Thaw resigned, said some of the issues outlined in the physicians’ letter were real, and some were “theoretical.”</blockquote> Translation: some of the complaints were accidents waiting to happen. <blockquote class="tr_bq">..."To the best of our knowledge, there was not patient harm or patient death.” </blockquote> In other words, this is yet another story where the common, feel-good and ignorant refrain "but patient care has not been compromised" has reared its ugly head.  (I've made this type of claim a topical header at this blog.  See query link <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised</a> for others.) Assuming that's true - note that the impact of bad health IT can be delayed due to delayed effects of bad or missing information - this statement is, let me be impolite, vacuous on its face. <div class="headword" id="headword"><blockquote class="tr_bq"><h2>vac·u·ous (<a href="http://www.merriam-webster.com/dictionary/vacuous">http://www.merriam-webster.com/dictionary/vacuous</a>)</h2>adjective \ˈva-kyə-wəs\ </blockquote><div class="ld_on_collegiate"><blockquote><div class="bottom_entry">: having or showing a lack of intelligence or serious thought : lacking meaning, importance, or substance</div></blockquote></div></div> It seems some simple facts apparently need to be explained to these geniuses.   I'll put it in caps just to make sure they understand some basic issues: <ul><li>A HOSPITAL IS NOT A PLACE FOR RISKY INFORMATION TECHNOLOGY EXPERIMENTATION.   UNNECESSARY RISK IN HEALTHCARE IS A VERY, VERY BAD THING. </li></ul><ul><li>THE GOAL OF HOSPITALS IS NOT TO SUBJECT PATIENTS TO RISK VIA MISMANAGEMENT OF HEALTHCARE IT, AND THEN PROCLAIM "NOBODY WAS INJURED OR KILLED" AFTER THE PERPETRATORS OF THE MISMANAGEMENT ARE UPROOTED. </li></ul><ul><li>CLINICIANS DO NOT TOIL IN HOSPITALS TAKING CARE OF SICK PATIENTS SO THAT INFORMATION TECHNOLOGY PERSONNEL CAN HAVE COMFY JOBS AND COOL COMPUTERS.</li></ul> One wonders if these points might be above the intellectual pay grade of those running hospitals - including boards - in 2014. If nobody was injured or killed, it was due to happenstance, not due to appropriate due diligence and adherence to the standards of care essential in this healthcare sector - that is, healthcare information technology. Depending on happenstance is not a good healthcare management strategy. -- SS

Masters of the Obvious at Athens Regional Medical Center: Lack of clinician input, training, common sense created problems with Athens Regional electronic records system - but mostly lack of common sense

(Note: also see my earlier May 26, 2014 post at http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html)My early medical mentor, Dr. Victor P. Satinsky, had disdain for those wh…

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16 Jun 2014

Sickness in the Information Technology Sector: Technical problems, discord plagued Maryland health care site

Eye-opening, ground-level, no-holds-barred accounts of IT mismanagement and mayhem are too rare, considering the stakes in 2013.  The behind-the-scenes crap that goes on needs a great deal of sunlight. Below is such an account of great merit, in the Baltimore Sun. First, I note physicians and nurses are generally able to collaborate to take care of sick patients.  They are natural "team players"; taking care of patients is their professional calling.  I did it all the time in my patient care years, especially in critical care settings, where lack of collaboration with colleagues could lead to dead patients. IT personnel are another species entirely.  It's all about territory, competition, self-promotion, empire-building, drinking from the ever-flowing fountain of money, etc.; process matters more than results; and to hell with the end users, let alone patients. Here is, in macro form, the Fifty Shades of Mass Dysfunction I've often encountered when my professional work intersected with IT personnel, whether in hospitals or industry.  And I was supposed to simply "shut up" about this crap - i.e., go along to get along: <blockquote class="tr_bq">Technical problems, discord plagued Maryland health care site <a href="http://www.baltimoresun.com/health/bs-hs-exchange-woes-20131207,0,6559272.story" target="_blank">http://www.baltimoresun.com/health/bs-hs-exchange-woes-20131207,0,6559272.story</a>  By <a href="http://bio.tribune.com/MeredithCohn" target="_blank">Meredith Cohn</a> and Andrea K. Walker, The Baltimore Sun 10:50 p.m. EST, December 7, 2013 Although state officials have provided the public scant detail about the troubled launch of Maryland's version of <a href="http://www.baltimoresun.com/topic/health/healthcare-laws/affordable-care-act-%28obamacare%29-EVGAP00039.topic" target="_blank" title="Affordable Care Act (Obamacare)">Obamacare</a>, emails and documents show that the project was beset behind the scenes for months by an array of technical issues, warring contractors and other problems. Since Maryland's online health exchange opened Oct. 1 for people to buy insurance under the Affordable Care Act — and immediately crashed — the two main companies in charge of the website have taken their fight to court, a corporate project manager was replaced and a high-powered consulting firm was quietly brought in to restore order. Though state officials initially said the crash of the online exchange was an unexpected and fixable problem, emails and documents obtained by The Baltimore Sun through state open-records laws outline serious issues before and after the launch. The revelations came just days before Rebecca Pearce, the head of the exchange, resigned. State officials announced that move Friday night and pulled Carolyn Quattrocki from the governor's health reform office to serve as an interim replacement</blockquote> I am going to reproduce some paragraphs that show just how chaotic are the processes - in any health IT endeavor, whether they be for the exchanges that are essential to getting insured, or to the hospital IT systems that are essential to getting out of the hospital in something other than a pine box. Emphases mine: <blockquote class="tr_bq">Just two weeks before the launch, Pearce visited the prime contractor's <a href="http://www.baltimoresun.com/topic/us/maryland/anne-arundel-county/linthicum-PLGEO100100602070000.topic" target="_blank" title="Linthicum">Linthicum</a> headquarters and found a room of empty seats. She fired off an email questioning the company's commitment to resolve problems and reminding the contractors of what was at stake: "Tonight, I am begging. I don't know how else to say it: we have got to make this a reality." Despite her proddings, in-fighting between contractor Noridian Healthcare Solutions and a key subcontractor, EngagePoint Inc., disintegrated amid finger-pointing and accusations in court papers. At one point, after Noridian severed contractual ties between the companies but continued to ask for help, EngagePoint CEO Pradeep Goel emailed Noridian officials: "Are you people on <a href="http://www.baltimoresun.com/topic/health/drugs-medicines/cocaine-HEDAR00190.topic" target="_blank" title="Cocaine">crack cocaine</a>?"</blockquote> Contractors, subcontractors, all offering "solutions" in healthcare and all likely to have not a single soul on board with anything beyond a merchant-computing background. And nice, friendly questions amongst the friendly, collaborative finger-pointing and accusations typical of the IT world when mass mayhem occurs. And a begging boss?  How lovely. <blockquote class="tr_bq">... Pearce, who was hired in 2011 at a salary of $175,000, declined to comment on problems surrounding the exchange or her resignation.  [If I were her I would have resigned out of disgust with these idiots.  Oh wait - I did leave IT positions for reasons, in part, like that  - ed.] The emails provided by the state covered the two weeks before and after the website launch. They give only a limited behind-the-scenes view of creating and launching the exchange. Officials withheld an unknown number of emails, saying state law exempts them from disclosure because they involved the decision-making process of high-ranking executive officials. The troubles in Maryland mirror problems faced by other state exchanges, as well as the federal portal providing insurance options to consumers in 36 states.</blockquote>  Emails withheld under claims of legal privilege means we'll never know all the dirt. <blockquote class="tr_bq">... In Maryland, Sharfstein said the complexity was compounded because of an aging state <a href="http://www.baltimoresun.com/topic/health/government-health-care/medicaid-HEPRG00001.topic" target="_blank" title="Medicaid">Medicaid</a> computer system that needed to be integrated into the exchange. Officials also chose to customize existing technology that proved tougher to retrofit than expected, he said. "Unlike buying a book online from <a href="http://www.baltimoresun.com/topic/economy-business-finance/amazon.com-inc.-ORCRP000672.topic" target="_blank" title="Amazon.com Inc.">Amazon</a>, this process is more akin to applying for a passport, buying a home, and receiving an individually calculated tax credit all through a single web portal," O'Malley said Friday night. "We had more user glitches and user problems than we had hoped. "A longer testing period might have allowed us to prioritize and address more of these problems before the launch date. Time and ultimate success will tell whether the decision to purchase off-the-shelf software and employ multiple contractor entities were good or bad decisions."</blockquote> "Hope" is not a proper project management technique of which I am aware, especially in a project of the admitted complexity as this one. "Tougher to retrofit than expected?" Expected by whom?  IT "experts" who believe in unicorns and the tooth fairy?  I point out that in medicine, such mistakes are called "malpractice." A longer testing period might have allowed us to address more problems?  But they went live anyway? <blockquote class="tr_bq">... In early 2012, the state gave a $71 million contract to develop the website to a Noridian-led team that included Curam Software, <a href="http://www.baltimoresun.com/topic/economy-business-finance/ibm-ORCRP008000.topic" target="_blank" title="IBM">IBM</a> and Connecture. To save time in creating the exchange, the Maryland legislature exempted the contract from the normal procurement process, and North Dakota-based Noridian outscored three other bidders. Sharfstein said Noridian will likely remain at work in its Linthicum offices beyond its contract's year-end expiration. The company has already been paid about $57 million but the state contract allows penalties for delays. State officials declined to comment on whether any penalties will be sought. Noridian is ultimately responsible for delivering the system, Sharfstein said. EngagePoint, which is based in Calverton, was not included in the original contract and appeared to have been hired without the exchange's knowledge, officials said. The state first learned of the companies' "deep strains" in the three months before the website launched, according to documents in U.S. District Court in Baltimore. The issues disputed included accounting, project management, intellectual property and payment. Emails offer a glimpse at how their differences affected efforts to build the site and then fix post-launch problems. Pearce repeatedly questioned the contractors' commitment to the project after Gov. Martin O'Malley announced on national TV that Maryland's site would go live on time. On Sept. 22, after Sen. <a href="http://www.baltimoresun.com/topic/politics/government/barbara-a.-mikulski-PEPLT004501.topic" target="_blank" title="Barbara A. Mikulski">Barbara Mikulski</a> echoed the governor in publicly applauding Maryland's readiness, Pearce wrote the contractors: "It's time to get this right. Now. Period." Noridian was also criticizing the subcontractor it hired. On Sept. 25, Noridian's project manager wrote to Goel, complaining that EngagePoint refused to perform critical work: "EngagePoint is responsible for 'designing and implementing [an exchange] system,'" the project manager wrote. The 8 a.m. launch was supposed to allow the estimated 800,000 uninsured Marylanders to sign in and browse 45 plans from six insurers. Officials had warned of "bumps in the road," but the site crashed in minutes. ... "As the executives in charge of this program, I would like to understand from you exactly what is happening with the project and what you are doing to address the issues," she wrote to the contractors at 7:56 a.m. on Oct. 2. By 4:10 p.m., she questioned why 85,000 people had hit the "get started" button, but there fewer than 500 accounts had been created. About a half-hour later, she wrote to the contractors, "Can you please provide an update on what is going on right now? Who is on site? What has anyone learned?" Some of the companies' emails focused on achievements rather than dwelling on worsening problems. Noridian CEO Tom McGraw wrote to state officials on Oct. 4, "We have seen increases in all aspects of the system performance over the last several hours and anticipate that these will start showing in the next report." But four days later McGraw notified state officials that the project manager was being replaced.</blockquote> Conflict, favoritism, fighting, "it's not my job", lies, spin, stonewalling, strife ... chaos. "Efforts to build the site and then fix post-launch problems" is also typical of the IT world.  In health IT, especially clinical IT, those harmed or killed during the "fixing" process are considered a necessary sacrifice, a "bump in the road." <blockquote class="tr_bq">... Paul von Ebers, CEO of Noridian Mutual Insurance Co., Noridian's parent company, wrote on Oct. 10 that the consultants "expressed concern with ongoing coordination issues between the Noridian and EngagePoint teams." He requested a meeting to resolve "working differences" between the companies. This was days before Noridian fired EngagePoint, sparking the angry email exchanges and dueling lawsuits between the companies. Noridian then sought to hire EngagePoint workers; EngagePoint sued and was met with a counter-suit. "We are expected to do piecemeal work for Noridian after contract termination because you just woke up and decided you don't know what you are doing?" Goel wrote Oct. 26. "We are not going to respond to ridiculous emails from Noridian demanding our team members show up for work after being escorted out of the office."</blockquote> That's the path to progress:  firing subcontractors and attempting to steal their employees, and lawsuits and countersuits. I could go on, but read the entire postmortem account (itself rare in large IT projects) at the Baltimore Sun link above. Some of the de-identified cases at my academic site on health IT difficulties reflect this type of discord; some are mine personally such as at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU</a> , <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story</a> and <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cultures%20of%20mismanagement%20toxic%20to%20healthcare%20quality">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cultures%20of%20mismanagement%20toxic%20to%20healthcare%20quality</a>. I was expected to "go along to get along" with this BS, and was deemed "not a team player" when I spoke up for enduser (clinician) and ultimate customer (patient) rights. In summary, the IT world is demonstrably dysfunctional, with the types of conflict as in the Baltimore Sun story more the rule than the exception, especially where healthcare is concerned.  Good, relatively brief resources for better understanding these issues are the following papers: <blockquote class="tr_bq"> Social Informatics.  An introductory essay entitled “Learning from Social Informatics” by R. Kling at the University of Indiana can be found <a href="https://web.archive.org/web/20100310084838/http://rkcsi.indiana.edu/archive/SI/Arts/SI_report_Aug_14.pdf">at this link</a> (PDF).  The book “Understanding And Communicating Social Informatics” by Kling, Rosenbaum & Sawyer, Information Today, 2005 (Amazon.com link <a href="http://www.amazon.com/Understanding-Communicating-Social-Informatics-Communication/dp/1573872288/ref=sr_1_1/102-9749119-8288920?ie=UTF8&s=books&qid=1174318804&sr=8-1">here</a>) was based on this essay. Pessimism, Computer Failure, and Information Systems Development in the Public Sector.  (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand).  Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.  <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Goldfinch_pessimism_PAR.pdf">link</a>to pdf <div class="MsoNormal" style="margin-right: 20.4pt;"> </div>“Defensive climate in the computer science classroom” by Barker et al., Univ. of Denver.  Link <a href="http://portal.acm.org/citation.cfm?id=563354&coll=portal&dl=ACM">here</a>(subscription required).  May help explain the control-seeking culture of IT personnel.   As part of an NSF-funded IT workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.</blockquote> If a person thinks this technology will "revolutionize" healthcare anytime soon, considering the "people issues" involved let alone the technical ones, then that person is either hopelessly naïve, or needs a mental health evaluation (colloquially, "needs their head examined"). -- SS

Sickness in the Information Technology Sector: Technical problems, discord plagued Maryland health care site

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09 Dec 2013

The Adventures of the Purloined Bequest, the Resident Heiress, and the Hidden Hospital System

The game is afoot again.  A series of recent articles in the media described a series of cases whose mysterious interrelationships Sherlock Holmes might have appreciated. The Purloined Bequest A singular <a href="http://online.wsj.com/article/SB10001424127887324324404579045331810905304.html">article </a>in the Wall Street Journal, entitled "Judge Rules in Case of Fortune Tied to Buffett," first made this case explicit, but some background is required to understand it. The story focused on Long Island College Hospital, in Cobble Hill, Brooklyn, New York.  [Full disclosure: this story got my attention particularly because I grew up nearby in Brooklyn, and was born at that hospital, which was also the local hospital my parents often used.]   LICH has long been the major community hospital for downtown Brooklyn. The story appeared to begin in 2011, per the WSJ, <blockquote class="tr_bq"> In 2011, Judge [Carolyn] Demarest approved the merger of LICH and SUNY Downstate on the condition it would keep the charitable hospital going. As part of the deal, the hospital transferred properties to Downstate estimated to be worth as much as $1 billion collectively, according to a previous court order.</blockquote> The merger was supposed to keep LICH in operation as a community hospital and provider of acute care to the poor.  However, things did not work out.  This year, however, Downstate announced plans to shut the hospital, leading to protests from Brooklyn residents and local politicians. <blockquote class="tr_bq">'It is clear that the premise upon which this Court authorized the transfer of assets has been defeated,' Justice Demarest wrote in her Aug. 20 decision, adding that Downstate had breached its contractual obligations. She cited a 'legal and moral responsibility' to correct her earlier error in approving the merger. She directed Downstate to return all assets to the hospital's previous owner, Continuum Health Partners Inc., which subsequently said it couldn't take the reins. The court is expected to review other proposals. </blockquote> The judge also discovered that hospital management had been raiding an large endowment fund intended for other purposes, <blockquote class="tr_bq">A New York state judge ruled this week that a struggling Brooklyn hospital must repay tens of millions of dollars it borrowed from an endowment set up by early investors with billionaire Warren Buffett. The ruling aims to rectify the previous use of the money by Long Island College Hospital, which is hurting financially and was scheduled to close. Mr. Buffett in July told The Wall Street Journal that his late friends, Donald and Mildred Othmer, would have felt 'betrayed' at the way the funds were spent.</blockquote> Apparently, <blockquote class="tr_bq"> The Othmers, natives of Omaha, Neb., who later lived in Brooklyn, were longtime friends of Mr. Buffett's, and each invested $25,000 with the billionaire in 1961. When they died—he in 1995 and she in 1998—they gave away a fortune estimated at $780 million, including the $135 million permanent endowment for the hospital. The Othmer wills stipulated the interest on the endowment could be used for operating expenses but the principal should be held 'in perpetuity.' In a series of court-approved transactions that began in 2000, the hospital borrowed from the funds repeatedly to meet short-term obligations and cover debts. The hospital argued that the money was necessary to keep the hospital afloat, which it said the Othmers would have wanted. The transfers depleted most of the endowment, a result that came to light after the Journal wrote about the situation in July.</blockquote> <a href="http://www.nytimes.com/2013/08/21/nyregion/judge-rejects-long-island-college-hospitals-ownership-deal.html">New York Times</a> and <a href="http://www.brooklyneagle.com/articles/dead-lich-could-net-suny-100-million">Brooklyn Daily Eagle</a> articles focused on the question of whether SUNY/ Downstate intended to close the hospital so it could sell its apparently valuable real estate assets in a now fashionable neighborhood, but not on how the hospital fell into these dire straits. There seem to be some lingering questions - -  If the losses and borrowing began in 2000, or earlier, who was responsible for them, given the current owners have only been in place since 2011? Note that the phrasing in the article above ("the hospital argued that the money was necessary to keep the hospital afloat") suggested that before SUNY took over, the hospital was independent.  However, the article mentioned, albeit only briefly in passing, that the hospital had a previous owner, Continuum Health Partners Inc. -  How were the losses explained when they occurred, and what was the rationale for  borrowing from restricted endowment as a response, instead of, for example, direct efforts to minimize losses or increase capital and revenue? Note that the article implied that when SUNY acquired LICH, it acquired some very valuable real estate.  Why did the previous management of LICH not consider selling off some of this real estate to resolve its debts? -  Did mismanagement of the hospital lead to excess losses, and did borrowing funds from the principle of the hospital's endowment to offset these losses amounted to more mismanagement?   Meanwhile, a second even more bizarre story about another New York City hospital almost simultaneously got media attention. The Resident Heiress The case first made it into the media in 2012, when the tabloid New York Post <a href="http://nypost.com/2012/09/02/beth-israel-medical-center-shook-down-heiress-huguette-clark-for-13-million-relatives-say/">reported</a>, <blockquote class="tr_bq">Beth Israel Medical Center milked reclusive copper heiress Huguette Clark for more than $13 million in fees, donations and even a priceless painting during her 20-year stay as a patient — and greedy executives angled for $125 million more, her relatives allege in shocking new court filings over Clark’s estate. The alleged shakedown was illuminated in an e-mail in which hospital board member and former CEO Dr. Robert Newman referred to Clark as 'the biggest bucks contributing potential we’ve ever had,' according to court papers. He told a colleague her 'potential has been overwhelming[ly] unrealized.' At one point, he suggested to Clark that she pay nearly one-third of her estimated $400 million fortune to keep the now-shuttered Beth Israel North on the Upper East Side open so she could keep living in the room she had refused to leave for 15 years despite being in good physical health, the papers allege. But instead of addressing Clark’s crippling anxiety, hospital honchos played on her fears, engaging in 'a concentrated effort, orchestrated at the highest board and executive levels,' to get her money, court documents obtained by The Post allege. Clark’s death last year at age 104 set off a battle over her estate. Her distant relatives claim lawyer Wallace Bock, accountant Irving Kamsler, private-duty nurse Hadassah Peri and the Beth Israel administrators manipulated the feeble Clark for her money. The nurse, who received cash and gifts from Clark, stands to inherit nearly $34 million and Clark’s priceless doll collection in the now-disputed will. Beth Israel is to get $1 million. The Paris-born Clark inherited her money from her father, William, a rail and mining baron and former US senator whose wealth rivaled the Rockefellers’. She went to Beth Israel North in 1991, when she was 85, after a doctor found her emaciated and ill in one of her three sprawling Fifth Avenue apartments. She spent the last two decades of her life in dismal hospital rooms with the shades drawn and door shut even though there was 'no medical basis for keeping her' past the first few months, documents show. Clark was 'the perfect patient' for the hospital, her relatives charge, noting, 'She required no medical care, possessed enormous wealth, paid over $800 a day for her room, and became progressively more dependent on the hospital.' 'Beth Israel had a plan to subtly, but ever so persistently, court Huguette for the purpose of garnering gifts and ultimately do a will in favor of the hospital,' court papers claim.</blockquote> This case also seems to be about wealthy donors and hospital executives.  Yet what makes it most bizarre are the circumstance of Ms Clark's hospital stay.  As a former intern, resident, fellow, and teaching hospital attending, I can attest that most hospital administrators are concerned, if not obsessed, with discharging patients quickly.  Hospital stays are currently paid by most insurers according to the patients' diagnoses, but not their length of stay.  Long stays cost hospitals money.  Furthermore, unnecessarily long stays use up resources that could better serve acutely ill and injured patients.  Yet Ms Clark stayed an astounding 20 plus years, without any obvious medical rationale.  No hospital official contested the fact that Ms Clark stayed that long in the NY Post article. Furthermore, in a 2013 New York Times <a href="http://www.nytimes.com/2013/05/30/nyregion/hospital-caring-for-an-heiress-pressed-her-to-give-lavishly.html">article,</a> the hospital's lawyer, defending a parallel attempt to recover the money donated to the hospital, wrote <blockquote class="tr_bq"> Beth Israel had provided Mrs. Clark with 'a well-attended home where she was able to live out her days in security, relative good health and comfort, and with the pleasures of human company.' Besides, he said, the amount of money she gave to Beth Israel was “not very large considering her vast wealth.”</blockquote> Furthermore, a member of the Beth Israel fund-raising staff wrote in a memo disclosed during litigation, <blockquote class="tr_bq"> She was well enough by then to go home to her spacious apartment at Fifth Avenue and 72nd Street, overlooking Central Park, Ms. [Cynthia L] Cromer said, but 'she asked if she might stay in the hospital longer: she feels comfortable and safe, and her apartment is being renovated.'</blockquote> Never mind that the fundamental mission of the hospital is to provide acute care for the sick and injured, not to provide comfortable retirement housing. But hospital managers are apparently on record acknowledging that the hospital was basically providing Ms Clark with services that are normally available in a retirement community, not services that acute care hospitals normally provide anyone   There is no evidence that the hospital ever provided similar services to any other patients.  The obvious mystery, then, is - why no one at the hospital, no doctor, nurse, or manager, or no visitor, regulator, accrediting agency, insurer ever questioned why the hospital was providing a long-term residence to a former patient? No answer to the question has appeared in any coverage I have seen of this case, including a September, 2013,.NY Times followup <a href="http://www.nytimes.com/2013/09/15/nyregion/the-two-wills-of-the-heiress-huguette-clark.html">article</a> on the occasion of the case nearing trial.  In the absence of a creditable explanation for this strange distortion of the hospital mission, - is there any other conclusion than that its purpose was to extract a large amount of money from a vulnerable, rich, but no longer acutely ill former patient? This would suggest an unusual but monumentally unethical kind of hospital mismanagement. So we have two recent stories about major, unusual, apparently severe mismanagement by hospital executives.  These stories were reported as if they were independent. However, buried in the original NY Post article, but unmentioned in either of the major NY Times articles, however, was a hint of how this case and that above of the purloined inheritance appeared to be linked. The Hidden Hospital System The NY Post article referred thus to the Beth Israel CEO who allegedly pushed Ms Clark for contributions, <blockquote class="tr_bq"> Newman, former CEO of Continuum Health Partners, Beth Israel’s parent organization, took the unusual step of offering to help Clark complete a will so 'some faceless bureaucrat of the government' wouldn’t get his hands on her estate, court papers say.</blockquote> Quick Watson, did you see that? Continuum Health Partners was the "parent organization" of Beth Israel Hospital during at least some of the time Ms Clark was in residence there.  Continuum Health Partners also was the "previous owner" of Long Island College Hospital during at least some of the time it apparently was suffering large losses and its endowment was being depleted.  So were both these stories really about the same organization, the same hospital system? Digging a little further, per its <a href="http://www.linkedin.com/company/continuum-health-partners/products">own LinkedIn page</a>, <blockquote class="tr_bq"> Continuum Health Partners, Inc. was formed in 1997 as a partnership of three venerable institutions — Beth Israel Medical Center, St. Luke's Hospital, and Roosevelt Hospital.</blockquote> So while the hospital system did not exist when Ms Clark first entered Beth Israel Hospital, the heiress' "care" was under the control of the organization apparently from 1997 to the day she died. Furthermore, as noted in a 2011 Chronicle of Higher Education article, <a href="http://www.innovativeresourcesgroup.com/archive/89-latest-and-greatest/314-from-mergers-that-didnt-stick-lessons-emerge-for-other-charities">available from </a>Innovative Resources Group Inc, <blockquote class="tr_bq"> If there was a honeymoon after the merger of Long Island College Hospital, in Brooklyn, with Continuum Health Partners, in New York in 1998, few remember it. The bickering began early and dragged on for years, but divorce didn’t seem inevitable until the doctors went public.</blockquote> So the hospital system called Continuum Health Partners took over Long Island College Hospital in 1998 and held it for 13 years.  Furthermore, apparently LICH was part of Continuum Health Partners during the time when its losses rose and the Othmer bequest was depleted.  For example, from the CHE article, <blockquote class="tr_bq">  Several physicians told a crowd gathered outside the hospital’s entrance in 2008 that Continuum had withheld money from the 150-year-old institution, needlessly cutting patient services and endangering the hospital’s future.</blockquote> Also in 2008, the Brooklyn Heights Blog <a href="http://brooklynheightsblog.com/archives/3845">reported</a> this response to a question about finances from the Continuum Health Partners CEO, Stanley Bazenoff, <blockquote class="tr_bq"> LICH faces an immediate fiscal crisis. Unless action is taken quickly, he said, LICH will not have cash on hand to meet payrolls and other current expenses. He ascribed LICH’s problem to three factors. First, the hospital carries a heavy debt burden–approximately $150 million in long-term bonds financed through the New York State Dormitory Authority and $25 million in short-term commercial paper–which results in annual debt service (including interest and amortization) cost of approximately $22 million. Second, LICH has an operating deficit, presently about $40 million on an annual basis,...</blockquote> Denis Hamill, a columnist for the New York Daily News, made this accusation in a February, 2013, <a href="http://www.nydailynews.com/new-york/hamill-lich-merged-death-article-1.1266344">editorial</a>: <blockquote class="tr_bq">Under Continuum, the once-profitable LICH ran up $300 million in debt from pure administrative malpractice. And then Brezenoff brokered the smelly SUNY Downstate merger, with state taxpayers absorbing the $300 million debt.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> So it certainly looks like there is an argument that Continuum Health Partners, under its CEO, Stanley Bazenoff, was responsible for the manipulation of pseudo-patient and rich heiress Hughette Clark to secure a large donation, and the nearly simultaneous depletion of Long Island College Hospital's finances, including a large bequest that was supposed to be untouchable.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Not surprisingly, Mr Bazenoff, described by Mr Hamill as <blockquote class="tr_bq">a ruthless powerbroker ... whose nickname at LICH is Darth Vader </blockquote> and <blockquote class="tr_bq">a quintessential member of what muckraker Jack Newfield called The Permanent Government of New York  </blockquote> also seems to have gotten rich in his position as leader of Continuum Health Partners, along with his other top managers.   The blog LICH Watch <a href="http://lichwatch.blogspot.com/2011/03/salary-scandal-at-hospitals.html">found</a> these results from the system's 2009 IRS 990 report,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">here are some highlights, figures for Continuum employees who, hm, earned more than a million dollars for the year: Chandra Sen, MD, $2,109,204 Stanley Brezenoff, $2,014,413 Kathryn C. Meyer, Esq. $1,049,807 John Collura, $1,307,556 Gail Donovan, $1,365,354</blockquote>  A 2011 New York Post <a href="http://nypost.com/2011/03/16/nonprofit-hosp-bigs-megabucks/">article</a> stated,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq"> Stan Brezenoff, CEO of Continuum Health Partners, overseeing such hospitals as Beth Israel, St. Luke’s and Roosevelt, pulled in about $3.5 million. </blockquote>  So this leads to yet more mysteries, first about the individual cases when viewed as occurring within one large hospital system:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">-  Why were Long Island College Hospital's finances addressed as if it were an independent entity, when it was in fact just a subsidiary of Continuum Health Partners? </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> -  Why was Continuum Health Partners role in the hospital's enlarging debt and depleting endowment not discussed?</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> Similarly,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> -  Why was the bizarre treatment of Hughette Clark attributed to "Beth Israel executives," but not Continuum Health Executives, when Beth Israel was also just a subsidiary of Continuum Health? </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Then there is the larger mystery,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> -  Why have these two cases been discussed as completely independent, when they appear to be part of a pattern of conduct by Continuum Health Partners management? </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Summary</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">While we continue to see cases, some amazingly bizarre, suggesting mismanagement and unethical management of hospitals and hospital systems, there seems to be an amazing lack of curiosity about how they occurred and what their implications may be.  This lack of curiosity is so profound that no one seems to have noticed that two vivid and strange cases getting prominent media notice in the same city and the same time involved the same large hospital system. </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Health care organizations seem to become ever larger.  Such enlarging organizations can concentrate their power, dominate their "markets," and hence increase their revenues and the compensation of their top hired managers.  Without any countervailing force, they push seemingly inexorably towards oligopoly and then monopoly.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Furthermore, the cases of the purloined bequest and the resident heiress show that ever larger organizations with ever more complex structures are ever better at hiding the accountability of their top hired managers.  We have previously noted, e.g. <a href="http://hcrenewal.blogspot.com/2010/10/glaxosmithkline-subsidiary-pleads.html">a case</a> in which a subsidiary of GlaxoSmithKline pleaded guilty to crimes involving production of adulterated drugs, thus shielding GSK and its management from responsibility, how subsidiaries of large corporations may plead guilty to crimes, thus absolving their parent organizations and its managers of any blame. In the current cases, it seems that somehow a large health care system was able to avoid accountability by letting its component hospitals appear to be independent.  Yet it is the larger system that was booking the revenue and making millionaires out of its hired managers.  This seems to show how concentration of power into ever more complex organizations can be used to enhance the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, making mismanagement and those accountable for it ever more obscure. </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">As we have said until blue in our collective faces, if we do not hold the real leaders of health care accountable for their actions and the actions of their organizations on their watches, we can expect continued misbehavior, and hence continued health care dysfunction.   </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div> It's appropriate to conclude with this, a video of Jeremy Brett in A Scandal in Bohemia, from the first season of the show as first shown on PBS. <iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/shLYcUVOMb4?list=PL2VjH97HFEqmNfN8aQ5qiv90kPM7ncZ7U" width="560"></iframe>

The Adventures of the Purloined Bequest, the Resident Heiress, and the Hidden Hospital System

The game is afoot again. A series of recent articles in the media described a series of cases whose mysterious interrelationships Sherlock Holmes might have appreciated.The Purloined BequestA singula…

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19 Sep 2013

Calling Dr. Moe, Dr. Larry and Dr. Curly: Advocate Medical Breach of Four Million Patient Records, and No Encryption

At my Oct. 2011 post "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure" (<a href="http://hcrenewal.blogspot.com/2011/10/still-more-ehr-chaos-pandemonium-bedlam.html">http://hcrenewal.blogspot.com/2011/10/still-more-ehr-chaos-pandemonium-bedlam.html</a>) I thought I'd seen the worst. Yet another post to add to the category of medical record privacy/confidentiality/security (<a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy),</a> however: <blockquote class="tr_bq"><a href="http://www.healthcareinfosecurity.com/advocate-medical-breach-no-encryption-a-6021">Advocate Medical Breach: No Encryption?</a> Computer Theft Raises Questions About Unencrypted Devices By Marianne Kolbasuk McGee, August 27, 2013. The recent theft of four unencrypted desktop computers from a Chicago area physician group practice may result in the second biggest healthcare <a href="http://www.healthcareinfosecurity.com/breach-response-c-324">breach</a> ever reported to federal regulators. But the bigger issue is: Why do breaches involving unencrypted computer devices still occur? According to the Department of Health and Human Services' "wall of shame" website listing 646 breaches impacting 500 or more individuals since September 2009, more than half of the incidents involved lost or stolen unencrypted devices. Incidents involving data secured by encryption do not have to be reported to HHS. ... The four unencrypted but password-protected computers [passwords on PC's are bypassable by smart teenagers - ed.] stolen during a burglary in July from an office of <a href="http://www.healthcareinfosecurity.com/breach-may-affect-4-million-patients-a-6018">Advocate Medical Group</a> in Illinois may have exposed information of about 4 million patients, according to an Advocate spokesman. </blockquote> 4 million is about 1.3 percent of the entire U.S. population (about <a href="https://www.google.com/search?q=us%20population">313.9 million</a> in 2012) ... on just four desktop computers. Try that with paper ... As to the subtitle of the article, "Computer Theft Raises Questions About Unencrypted Devices", I've written on that issue before.  I'd noted questions like that are remarkable considering both MacOS and Windows have built-in, readily available encryption, the latter for a few extra $ for the "deluxe version" (see  <a class="" data-reactid=".r[2a5gp].[1][4][1]{comment10200246430313520_4728545}.[0].{right}.[0].{left}.[0].[0].[0][2].[0].[1]" href="http://en.wikipedia.org/wiki/FileVault" rel="nofollow" target="_blank">http://en.wikipedia.org/wiki/FileVault</a> and <a class="" data-reactid=".r[2a5gp].[1][4][1]{comment10200246430313520_4728545}.[0].{right}.[0].{left}.[0].[0].[0][2].[0].[3]" href="http://en.wikipedia.org/wiki/Bitlocker" rel="nofollow" target="_blank">http://en.wikipedia.org/wiki/Bitlocker</a>).   Perhaps the best explanation in 2013 for unencrypted desktop PC's containing millions of confidential medical records is this picture, symbolic of the apparent attitudes of corporate and IT management on health IT security: <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnAsw6PW67gX6YJJIVtd1hEp5nCpuf5Re_XG0rDd2AJELzlw8B5pV9bvBxHPXa6DhmesPxvPoc8c_n3Y3u2s3Ki1GxEUgZ_jzbex53lu7i4-pc6eS4SKXr6axDPCCVSmKPpHg_UAPThsnN/s1600/stooges+police300px.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnAsw6PW67gX6YJJIVtd1hEp5nCpuf5Re_XG0rDd2AJELzlw8B5pV9bvBxHPXa6DhmesPxvPoc8c_n3Y3u2s3Ki1GxEUgZ_jzbex53lu7i4-pc6eS4SKXr6axDPCCVSmKPpHg_UAPThsnN/s1600/stooges+police300px.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Encryption?  We don't need no encryption.  We got triple protection already!</td></tr></tbody></table> -- SS

Calling Dr. Moe, Dr. Larry and Dr. Curly: Advocate Medical Breach of Four Million Patient Records, and No Encryption

At my Oct. 2011 post "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure" (http://hcrenewal.blogspot.com/2011/10/still-more-ehr-…

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28 Aug 2013

IT Specialist and the job he wouldn't take: hospital management's health IT "plan" is a checklist for failure

Received unsolicited on June 14, 2013 from a computer professional whose identity I am redacting.  Posted with his permission: <blockquote class="tr_bq"><div>Dr. Silverstein,</div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">Thank you very much for the many insights and helpful references provided on your "Contemporary Issues in Medical Informatics" (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</a>) web site! In performing my due diligence for a position as an IT Director at a small rural hospital, I have come across your writings. </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I originally applied for this position in the hopes of leveraging my IT, project management, compliance and security experience to gain new expertise in healthcare IT. After my initial phone interview with the "CIO" and HR Director, at which I discovered that I would have the responsibility to implement a poorly conceived new EMR project, without the authority or resources to make it successful, additional red flags were raised which required further research. This led me to you.  </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I cannot help but chuckle at the organizational, social and project management dysfunctions in medical IT, as described in your "Ten Critical Rules for Applied Informatics..."  (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=tenrules">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=tenrules</a>).   I have encountered similar dysfunctions in the world of military and commercial IT.  With a little tweaking, your lessons learned are applicable across a wide range of IT disciplines and a good reminder of how to avoid IT project and career failures and achieve successes.</div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">Yet, I understand and have come to appreciate your thesis that medical IT is fundamentally different from business IT. Even though I am convinced that I could do better than most, I have concluded that it is probably wiser for a competent healthcare informaticist to lead HIT implementation projects. I wonder how many such competent informaticists there can be! Unfortunately, since I have no background in medicine, it is probably a little late for me to become one. </div><div style="background-color: transparent; color: black; font-style: normal;"> </div><div style="background-color: transparent; color: black; font-style: normal;">I certainly will not engage in this particular opportunity. What I know of the hospital management's "plan" at this point is a checklist for failure. The reality of this rural hospital, and apparently thousands of similar situations, is unnecessarily and depressingly tragic for patients and clinical professionals. I appreciate your crusade to raise the bar for healthcare IT, and therefore IT in general. Thank you for saving me from jumping in to an untenable situation.</div></blockquote> Ironically, and sadly, this letter is similar to others I have received dating to 1999.  Little has changed in nearly 15 years, except that with the rush to implement this unregulated, experimental technology thanks to the HITECH Act, there's likely going to be a lot more patient harm, especially at smaller hospitals new to this endeavor. -- SS

IT Specialist and the job he wouldn't take: hospital management's health IT "plan" is a checklist for failure

Received unsolicited on June 14, 2013 from a computer professional whose identity I am redacting. Posted with his permission:Dr. Silverstein,Thank you very much for the many insights and helpful refe…

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17 Jun 2013

Hospital Retaliation Against Outspoken Physician Reaches New Levels - La Cosa Nostra Levels, That Is

Physicians, take note: <blockquote class="tr_bq">The Advisory Board Company Feb. 14, 2013   <a href="http://www.advisory.com/Daily-Briefing/2013/02/15/Jury-Hospital-CEO-framed-physician-by-planting-gun" target="_blank">Hospital Framed Physician; Planted a Gun </a> A jury has ordered a California hospital chain to pay physician Michael Fitzgibbons $5.7 million after its former CEO allegedly framed him by planting a gun in his car. In 2006, Fitzgibbons—an infectious disease specialist and former chief of staff at Western Medical Center—was arrested in the hospital parking lot after police found a pair of black gloves and a handgun in his car. Police questioned Fitzgibbons and searched his car after an anonymous 9-1-1 call claimed that the doctor had brandished the gun in traffic. DNA evidence from the gloves and gun exonerated Fitzgibbons, and he was never charged. However, the arrest followed a series of disagreements between Fitzgibbons and the leadership of Integrated Healthcare Holdings Incorporated (IHHI), which owned the Santa Ana hospital. Fitzgibbons and his attorney—Ted Mathews—alleged that IHHI's then-CEO, Bruce Mogel, had framed Fitzgibbons in an effort to silence him. Specifically, Mathews said that the frame was part of Mogel's attempt to "humble" Fitzgibbons after the doctor won a legal victory over IHHI in June 2006. During the trial, former IHHI President Larry Anderson testified that Mogel had instructed him to create a $10,000 contract for a "scary guy" named Mikey Delgado immediately after Fitzgibbon's legal victory. The contract was for unnecessary work on the health system's website. In his testimony, Anderson said he realized after Fitzgibbons was arrested that the contract was actually for the frame. Mathews told the jury that the $10,000 was used to "[get] Dr. Fitz set up." IHHI's board learned of the $10,000 contract during Anderson's deposition in 2008. Instead of firing Mogel, the board awarded him an eight-month consultancy worth $43,750 per month, Mathews says. This showed that IHHI board "knew what Mogel did to Dr. Fitzgibbons," Mathews told the jury, adding, "They ratified it, and they gave him a golden handshake goodbye.</blockquote> The article notes Board acquiescence. Two questions come to mind: 1.  Have the involved people been permanently removed from positions of authority in healthcaree? 2.  Have the persons involved been charges criminally? <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilmYlDXF0wtZWXy1i_Qce5WGtXzfJhnM2jwPUoB_AD06s_waEqlZyWng7l078AfCON-jrqQwmzZ-npxbJ3w66ZsTv53A1dbmrREys3idjEO9K6iBwgPffmubMHGPIwfO81GDQVOGmlFo3d/s1600/goldfinger-54.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilmYlDXF0wtZWXy1i_Qce5WGtXzfJhnM2jwPUoB_AD06s_waEqlZyWng7l078AfCON-jrqQwmzZ-npxbJ3w66ZsTv53A1dbmrREys3idjEO9K6iBwgPffmubMHGPIwfO81GDQVOGmlFo3d/s320/goldfinger-54.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><a href="http://www.youtube.com/watch?v=QtkFmufS6k8" target="_blank">Shocking.  Positively shocking.</a></td></tr></tbody></table> -- SS

Hospital Retaliation Against Outspoken Physician Reaches New Levels - La Cosa Nostra Levels, That Is

Physicians, take note: The Advisory Board CompanyFeb. 14, 2013 Hospital Framed Physician; Planted a Gun A jury has ordered a California hospital chain to pay physician Michael Fitzgibbons $5.7 milli…

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28 Feb 2013

A Right Royal Mess: EHRs and Royal Berkshire NHS Foundation Trust

Almost every theme I've written about for the past 15 years, at this blog and at my teaching site (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">link</a>) regarding health IT mismanagement is present here: <blockquote class="tr_bq"><a href="http://www.ehi.co.uk/insight/analysis/1033/a-right-royal-mess" target="_blank">A Right Royal Mess</a>      ehealth INSIDER 12 February 2013 Newly released reports on Royal Berkshire NHS Foundation Trust’s implementation of Cerner Millennium show that many crucial issues were not addressed prior to go-live; and that the trust is continuing to face considerable operational and financial issues because of the system. Rebecca Todd reports.</blockquote> Read it at the link above. I feel this scenario is being repeated in many countries, including the U.S., with many different vendor products.  The industry's pathologies and self-serving memes are difficult to overcome. As Orwell said:  "To see what is in front of one's nose needs a constant struggle." But don't worry...you're perfectly safe.  Computers, after all, improve healthcare and are entirely beneficent, according to the pundits.  Every untoward event is a mere "anecdote." -- SS Addendum 2/15/13:  just to illustrate my point, there's also this: <blockquote class="tr_bq"><a href="http://www.ehi.co.uk/news/EHI/8392/monitor-blasts-rotherham%27s-epr-programme" target="_blank">Monitor blasts Rotherham's EPR programme</a> ehealth INSIDER 15 February 2013 Lis Evenstad  The Rotherham NHS Foundation Trust has been found in significant breach of its terms of authorisation by Monitor, with its electronic patient record implementation identified as a key issue. The trust this month admitted it was facing "persistant serious issues" with the deployment of its Meditech EPR including "clinician and staff acceptance and usability" ... “The trust has not managed EPR implementation in an effective way and significant operational and financial risks will remain until the trust has a robust and operationally effective EPR system." ... “It is unclear whether the trust has sufficient visibility over operational performance and quality issues, including incidents of patient harm,” it adds.</blockquote> -- SS

A Right Royal Mess: EHRs and Royal Berkshire NHS Foundation Trust

Almost every theme I've written about for the past 15 years, at this blog and at my teaching site (link) regarding health IT mismanagement is present here:A Right Royal Mess ehealth INSIDER12 Febr…

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15 Feb 2013

University of Virginia, GE settle $47M suit over EMR implementation

<div style="font-family: Arial,Helvetica,sans-serif;">The following <a href="http://en.wikipedia.org/wiki/Keystone_Cops" target="_blank">Keystone Kops</a> story of healthcare IT dysfunction brings to life (like the old GE slogan) the types of mismanagement I've written about at my site "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">Common Examples of Healthcare IT Difficulties</a>": <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJnqmNlxwEPMOvgNMQJ6pEYVooYmTIMJWPpxjEul3OQVEsysKIM7xwO4_tzhHf7rx3oNCp6csJTM5MD85R-FHDpQZd1siQDfq87uvqwTsebW59Vk4ZxInDr4G3I7lzLBaTL-j-JZqx6b-Y/s1600/ge.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="215" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJnqmNlxwEPMOvgNMQJ6pEYVooYmTIMJWPpxjEul3OQVEsysKIM7xwO4_tzhHf7rx3oNCp6csJTM5MD85R-FHDpQZd1siQDfq87uvqwTsebW59Vk4ZxInDr4G3I7lzLBaTL-j-JZqx6b-Y/s320/ge.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">From 1982 <a href="http://www.youtube.com/watch?v=w3PXucLotXk" target="_blank">GE commercial</a> - "We Bring Good Things to Life"</td></tr></tbody></table></div><table border="0" cellpadding="0" cellspacing="0" style="font-family: Arial,Helvetica,sans-serif;"><tbody><tr><td width="31"> </td><td style="color: #888888;" valign="bottom" width="150"> </td><td style="color: #888888;" valign="bottom"> </td></tr></tbody></table><div style="font-family: Arial,Helvetica,sans-serif;">Clown pun not intentional - but perhaps apropos, not just with reference to GE but to U. Va's health IT leadership team as well.  It seems both parties might have had a role in this debacle (see additional links in the article below).</div> <blockquote class="tr_bq"><div style="font-family: Arial,Helvetica,sans-serif;"><a href="http://www.fierceemr.com/story/university-virginia-ge-settle-47-million-suit-over-emr-implementation/2012-07-13" target="_blank">University of Virginia, GE settle $47M suit over EMR implementation</a></div><div style="font-family: Arial,Helvetica,sans-serif;">FierceEMR.com July 13, 2012</div><div style="font-family: Arial,Helvetica,sans-serif;">By Dan Bowman</div><div style="font-family: Arial,Helvetica,sans-serif;"> </div></blockquote><table border="0" cellpadding="0" cellspacing="0" style="font-family: Arial,Helvetica,sans-serif;"><tbody><tr><td><blockquote>The University of Virginia this week reportedly has settled a $47 million civil suit against GE Healthcare over what it believes was sloppy--and ultimately incomplete--development and implementation of an electronic medical record system. The case, which originally was filed in 2009, had been set to go to trial this week. When FierceHealthIT checked on Friday, the case had yet to be entered into the circuit court clerk's records. In 1999, UVa hired IDX Systems Corporation to develop an integrated healthcare information management system, <a href="http://links.mkt1985.com/ctt?kn=111&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0" name="13888ff9baf6844c_www2_dailyprogress_com_ne_ojbtUcKYEdHkW8fhhvBA" target="_blank" title="http://links.mkt1985.com/ctt?kn=111&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0">according to</a> The Daily Progress. Amendments to the contract in 2002 divided the project into four phases, with the first two focusing on implementation of the records management software, and the last two focusing on billing and logistics. After acquiring IDX in 2006, GE was tasked with hitting the milestones outlined through Phase 2 by June 2008; UVa claims it never did, and in February 2009 asked for a refund of more than $20 million. At that time, UVa also awarded a $60 million contract to Epic to perform the same tasks, <a href="http://links.mkt1985.com/ctt?kn=88&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0" name="13888ff9baf6844c_c_ville_com_Article_UVA_U_pJZwjnBkM2Ve8wKqxP6EA" target="_blank" title="http://links.mkt1985.com/ctt?kn=88&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0">according to</a> C-Ville.com [see note 1]. GE swiped back, blaming UVa for the delays in implementation, and saying that by going with Epic, the school "failed to perform its obligations under the agreement, breaching its contract," according to a filing obtained by the Daily Progress. The case isn't too surprising, considering that <a href="http://links.mkt1985.com/ctt?kn=135&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0" name="13888ff9baf6844c_fierceemr_com_story_klas__X16Dr3aQkEYX6712RPz2w" target="_blank" title="http://links.mkt1985.com/ctt?kn=135&ms=NDIwOTU3NwS2&r=MTg5MTY1NTQxNjMS1&b=0&j=MTI3NzcwMzAyS0&mt=1&rt=0">GE Healthcare has had issues since purchasing IDX</a>. In a KLAS report from August 2010, author Kent Gale said there was a "downward trend in GE's meeting commitments" to its customers.</blockquote> Besides what was undoubtedly a huge waste of money and resources, what is missing from this story is the possible impact of this debacle on patient care.  Not "hitting the milestones" of phase 1 and 2 ("focusing on implementation of the records management software") and peforming "sloppy and incomplete" work can probably be translated as having had "bull in a china shop" effects on records management. Perhaps the morbidity and mortality rates at U. Va during the period of EHR mayhem need to be examined. -- SS Notes: [1] From the link to C-Ville.com:  "According to UVA’s complaint, the deal dates to 1999, when UVA contracted with tech firm IDX to develop an electronic medical record system, or EMR, for its hospital. But problems started early, UVA claimed, with IDX failing to hit milestones on the multi-phase project. When technology company GE took over IDX in 2006, the parties got together to rework the contract. But UVA said the issues continued, and it ultimately pulled the plug, saying GE failed to meet its obligations. GE, meanwhile, claimed it was UVA that broke contract. The two parties had agreed to work together on the complicated project, according to the company’s counterclaim. UVA was to act as a development partner, collecting and processing two decades’ worth of patient data and building and testing the system. But the medical center didn’t hold up its end of the bargain, said GE, making it impossible for the company to stay on schedule." </td></tr></tbody></table>

University of Virginia, GE settle $47M suit over EMR implementation

The following Keystone Kops story of healthcare IT dysfunction brings to life (like the old GE slogan) the types of mismanagement I've written about at my site "Common Examples of Healthcare IT Diffic…

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16 Jul 2012

To all physicians: Fools hiring amateurs, to control you and land you in court?

Health IT systems will be/are used to control you - a medical professional - in your treatment of patients, and could land you in court if they contribute to your making a medical mistake. They could also land you in a <a href="http://hcrenewal.blogspot.com/2009/10/sham-peer-review-could-this-bad-faith.html">sham peer review</a> for being a "disruptive" physician if you complain about a poor EHR. Here's an example of who gets hired to run such systems. Note the "Education" and "Qualifications Knowledge, Skills, and Abilities Required" I bolded.This job description is not atypical of many "clinical informatics" job descriptions: <blockquote style="font-family:arial;">HCAClinical Informaticist(Job Number: 25388-35620)https://hca.taleo.net/careersection/0hca/jobdetail.ftl?lang=en&job=1112401&src=JB-11444 <div> <div>More About HCA.....</div> <ul><li>HCA has been Recognized in Computerworld Magazine's Top 100 Workplaces to work for Information Technology Professionals for the 3rd consecutive year, coming in this year at #32.</li><li>HCA has been recognized by the Ethisphere Institute as one of the 2011 World's Most Ethical Companies.</li></ul> </div>Summary of Duties <blockquote>The Clinical Informaticist is accountable for driving successful adoption and clinical process optimization of clinical information systems. This is done through the application Clinical Adoption Methodology, incorporating best practice and evidence-based knowledge. Utilizes the knowledge and skills of clinical practice to determine clinical functions that are suitable for computer application and to ensure the information systems are consistent with professional standards of clinical practice. Acts on behalf of the Director of Applications in absence of said director.</blockquote> Duties Include But Are Not Limited To <ul><li>Facilitates knowledge of current state, desired state, and gap analysis of core clinical processes that are enabled by clinical information technology, being mindful of operational requirements/ constraints and conflicts. Works collaboratively with QA to evaluate outcomes, and opportunities for improvement.</li><li>Maintains a trusting and effective relationship with all customers. Assists clinical managers in identifying information systems needs and project management related to information systems.</li><li>Maintains membership or consultation to appropriate committees, work groups or task forces as needed to facilitate the ongoing process of the design, implementation, and revision of the automated and manual components of the clinical information system. Conducts meetings and presentations, effectively and professionally.</li><li>Maintains a current knowledge of a) trends and issues in health care, nursing practice, healthcare informatics, regulatory/accreditation requirements; b) organizational policies and procedures related to clinical practice and the legal implications of the clinical information system; c) structure and hierarchy of the organization.</li><li>Functionality expertise for clinical applications supporting core patient care processes and their relationship to other organizational information systems.</li><li>Works closely with counterparts in appropriate user organizations to ensure consistent and effective use of technology resources and optimization of installed applications and sustainability.</li><li>Adheres to Code of Conduct and Mission & Value Statement. Understands the personal obligation to report any activity that appears to violate applicable laws, rules regulations or the Code of Conduct itself. Maintains confidentiality, promotes system security to promote compliance.</li><li>As facility-care-area based position must learn and comply with System and facility safety policies and rules; must use appropriate safety equipment and procedures at all times; must immediately report all unsafe conditions to supervisors; must be familiar with all safety features of equipment, tools or materials encompassed by job duties; and must check with supervisors (prior to job performance) if there is a question as to the safe procedure to be used for any job function.</li><li>Participate in special projects as needed and performs other duties as assigned.</li></ul> Qualifications Knowledge, Skills, and Abilities Required <ul style="font-weight: bold;"><li>Membership in an appropriate organization is required (HIMSS, AMIA, for example) that is specifically targeted to informatics in healthcare</li><li>Working knowledge of Microsoft Office products (WORD, EXCEL, PowerPoint, Project Plan, and VISIO)</li><li>Strong oral, written, and interpersonal communication skills; strong analysis/problem solving and critical thinking; strong leadership, facilitation and coaching skills; current knowledge of patient care practices; clinical expertise; ability to work in multi-disciplinary teams.</li></ul> <blockquote style="font-weight: bold;">Preferred:</blockquote> <ul style="font-weight: bold;"><li>Knowledge and skill in selection, implementation, and training of clinical information systems</li><li>Project management skills</li><li>Previous experience utilizing Meditech documentation system</li><li>Previous experience with Quality Improvement initiatives and clinical process re-engineering</li></ul> Education <ul style="font-weight: bold;"><li>BSN or Bachelors degree in other Allied Health Professional degree from an accredited college</li><li>Current (10/08) department incumbents must achieve Bachelors requirement by 12/31/2012</li></ul></blockquote> Wow... BSN, allied health bachelors, or "must achieve Bachelor's by 12/31/12"? Some (at best) MBA-level fool wrote this 'description' for the hiring of some amateur with a BS - or no degree - to perform functions that will seriously affect how you, with 4 years college, four years med school, PGY internship, residency, perhaps fellowship or other post doctoral experience, perform your profession?Your kids may have more professional education and qualifications than your hospital's "health computing experts." Fantastic. I add this:Health IT cannot be made to work properly - ever - when being mismanaged by fools and amateurs.-- SS

To all physicians: Fools hiring amateurs, to control you and land you in court?

Health IT systems will be/are used to control you - a medical professional - in your treatment of patients, and could land you in court if they contribute to your making a medical mistake.They could…

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18 Mar 2012

What is Life is Really Like in Pharma? - These xtranormal Video Cartoons Come Close.

Sadly, the 'xtranormal' video cartoons at the following URL capture all too well what life is like in the pharmaceutical industry - buzzwords, neologisms, nouns turned into verbs, new paradigms, team players - and per the site, endless inane "initiatives" and related threats to sanity. I've been there; while a parody, these videos are uncomfortably close to reality. <a href="http://www.youtube.com/user/ZombieSymmetry/feed"> http://www.youtube.com/user/ZombieSymmetry/feed</a> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOjW3ZHtixsCfG9CBqzXYLcqBNdPxJfgRiMWhP1TfVsbPKNV6NDp0c-JUoAgxIMPsWulXxYRPYLY-gj7lra6MFhMEeztKzp0-SCnEJXtxVUCA56iMar4JHzQEluGSW11Qq3_GrgN-Rn7a9/s1600/future_of_pharma.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5704053254550054114" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOjW3ZHtixsCfG9CBqzXYLcqBNdPxJfgRiMWhP1TfVsbPKNV6NDp0c-JUoAgxIMPsWulXxYRPYLY-gj7lra6MFhMEeztKzp0-SCnEJXtxVUCA56iMar4JHzQEluGSW11Qq3_GrgN-Rn7a9/s320/future_of_pharma.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 382px; height: 260px;" /></a></div><div style="text-align: center;">"I'll have to ideate on that for awhile, Mike" </div> Even sadder are managers who believe their own babble. -- SS

What is Life is Really Like in Pharma? - These xtranormal Video Cartoons Come Close.

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31 Jan 2012

"Barbarians at the Gate" - Making Private Equity Less Private, and Understanding Its Effects on Health Care

One good byproduct of the tumultuous everlasting 2012 campaign for the US presidency has been to shed light on a number of political and economic issues that had previously been ignored, especially those relating to the global financial crisis or great recession.  In turn, many of these issues may be relevant to our understanding of our ongoing health care dysfunction.  The latest issue to achieve prominence was the nature of private equity firms.  Current presidential contender Mitt Romney used to work for Bain Capital, a private equity group.  As we discussed <a href="http://hcrenewal.blogspot.com/2012/01/us-presidential-candidates-financial.html">here</a>, Bain Capital owned a variety of companies, including some important health care corporations.  More importantly, attacks on Mr Romney's record at Bain by other candidates have lead to a broader discussion of the nature of private equity.  This discussion is very relevant to health care, since private equity firms have taken over a number of important health care corporations, and more recently, have begun to take over formerly non-profit health care organizations. Therefore, we will summarize what has become known about private equity, and then consider its implications for health care. Understanding Private Equity as Re-Branded Leveraged Buy-Out Firms - Private Equity Firms are Just Re-Branded Leveraged Buyout Firms The first good statement to this effect I found was by Merrill Goozner in the Fiscal Times(1): <blockquote>Private equity is actually a misnomer, since the modus operandi of those investors is no different than the leveraged buyout firms that pioneered junk-bond financing in the 1980s. </blockquote> As reported by the Los Angeles Times(2): <blockquote>'Being known as a leveraged-buyout-deal shop wasn't the most attractive label out there,' said Colin Blaydon, director of the Center for Private Equity and Entrepreneurship at Dartmouth's Tuck School of Business. 'Private equity has a much nicer ring to it.'</blockquote> In fact, according to Forbes columnist Robert Lenzer,(3) the famed investor Warren Buffet called this re-branding <blockquote>'Orwellian': Buffett wrote that 'private equity' is a 'name that turns facts upside-down: A purchase of a business by these firms almost invariably results in dramatic reductions in the equity portion of the acquiree’s capital structure compared to that previously existing.'</blockquote> I must admit I always thought private equity firms simply collected large amounts of capital from investors, then used the pooled capital to buy out troubled firms. I assumed that because these investors therefore had a large personal stake in these firms, they would want to increase at least their financial value. I also thought that leveraged buy-out firms ceased to exist after all the bad press they got in the 1980s. It turns out I was wrong on all counts. Probably, a lot of other peoples' beliefs about private equity were similarly wrong. Once the equation of private equity and leveraged buyout firms is made, understanding what they do and its implications are easier. - Leveraging the Buy-Out The modus operandi of leveraged buyout firms is to make their purchases of troubled corporations mainly with borrowed money. As Merrill Goozner put it(1), <blockquote>Private equity firms generally finance anywhere from 60 to 90 percent of their purchases with borrowed cash. </blockquote> Note that, <blockquote>Interest payments on those debts are treated just like any other expense, and are therefore deductible from earnings.</blockquote> - Then Leveraging the Acquired Company If this leveraging were the only leveraging done in a leveraged buy-out, the implications might not be that big, except for the acquiring firm. After all, when the leveraged buy-out firm borrows the money, it then becomes obligated to pay it back. However, then comes the tricks. One important trick was described in the following example by economist Dean Baker on the Beat the Press blog(4), <blockquote>To take a simple example, suppose a public company (let's call it Gingrich Inc.), has $1 billion a year in profits. If Gingrich Inc. paid taxes at the full 35 percent rate (fat chance), it would have $650 million [thanks Robert] a year to either keep as retained earnings or to pay out as dividends to its shareholders. Now suppose that a PE company (we'll call it Romney Capital) steps in. The current price to earnings ratio in the stock market is around 14, so Gingrich Inc. would have a pre-takeover market value of approximately $9.2 billion (14*$650 million). Romney Capital then arranges for Gingrich Inc. to borrow $6 billion which it pays out as a dividend to itself. This means that the Romney Capital has just gotten back almost two-thirds of its investment.</blockquote> A somewhat less vivid description of the process appeared in a post by Robert K Lifton on the Huffington Post(5): <blockquote>Most often, in order to increase the return on capital invested by the fund, the fund will borrow a significant portion of the purchase price of the business. And sometimes, if it can, the fund will take back as a distribution immediately upon closing the purchase of the business, a portion of its investment in the purchase price, reducing its own investment and enhancing its return on the investment left in the business. This distribution may come from the company's existing cashable assets or from money that the company is caused to borrow.</blockquote> Thus, it appears that while the leveraged buy-out (or private equity) firm borrowed money to finance the purchase of a company, it can almost immediately get out of its obligation to pay off that loan, by making the acquired company its own loan, and using proceeds from that to end the LBO firm's debt. The leverage, and the obligation to pay back a debt has almost magically been transferred from the LBO or private equity firm to the acquired company. That has big implications, as Lifton wrote(5): <blockquote>This additional leverage also creates additional risk; if things don't go right the business will not be able to pay the carrying costs of the debt, the lender will take over the business and the fund will lose its investment. Sometimes, that results in the acquired company placed in bankruptcy proceedings either to liquidate its assets to pay off the debt or to restructure, a process Bain also experienced. </blockquote> - Selling Assets to Further Reduce the Private Equity Firm's Debt LBO firms have another trick up their collective sleeves. As Dean Baker continued his example(4), <blockquote>Now suppose that the Romney Capital arranges to sell off some of Gingrich Inc.'s assets, such as real estate or a highly profitable subsidiary, and then uses the proceeds to make a payment to the Romney Capital rather than leaving the money under the control of Gingrich Inc. Such sales may allow Romney Capital to recoup the rest of its investment and possibly more.</blockquote> Of course, the result is <blockquote>Gingrich Inc. is then left as a highly indebted company with few assets. In this story, Romney Capital may have earned a substantial profit on a limited investment (it recouped most of its money almost immediately when it loaded Gingrich Inc. with debt), without doing anything to improve the operation of Gingrich Inc. If Gingrich Inc. manages to stay in business and generate profits, then this will increase the return. Romney Capital may be able to resell the company and treat the whole sale price as profit. On the other hand, if Gingrich Inc. goes bankrupt, this will primarily be a problem for creditors, since Romney Capital has already gotten its investment back. In effect, Romney Capital might have secured large gains entirely by financial engineering, while creating no value whatsoever.</blockquote> Let me underscore that. The LBO model (now also the private equity model) enables the acquiring LBO firm to avoid any losses, by shifting all the risk and obligations to the acquired firms. This puts these firms at considerable jeopardy. - Tactics to Prepare Acquired Firms for Sale Of course, LBO/ private equity firms want to do more than not lose money. To make real money, they must be able to sell off the firms they acquire. To do so, they must make these firms, or their components, seem attractive, at least in the short term. To do this, they employ a standard set of tactics out of the generic management playbook. So, per the LA Times(2), <blockquote>layoffs are part of the playbook that elite investment firms use to squeeze cash out of struggling companies. </blockquote> Also, per Lifton(5), <blockquote>To increase the profits of the acquired company, the fund may reduce the number of employees, reduce pay levels or curtail work time.</blockquote> In addition, per Josh Barro writing for the Forbe blog(6), other tactics can include <blockquote>downsizing, increased automation, offshoring, and the like. </blockquote> - The Private Equity/ Leveraged Buy-Out Version of the Anechoic Effect It is striking that while Mitt Romney worked at Bain Capital in the last century, and private equity has been around, if not growing, since then, the current presidential campaign seems to be the first occasion which prompted any real public discussion about the nature of private equity, and its significance for the larger political economy. Thus private equity/ LBO seem to have been anechoic for a very long time (like much about how our current health care system operates seems to be <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>.) This version of the anechoic effect seems to have been deliberately created by the private equity/ LBO firms. A Washington Post commentary(7) quoted Mitt Romney, <blockquote>You know I think it's fine to talk about those things in quiet rooms,...</blockquote> As a New York Times story(8) put it, these firms are lead by <blockquote>a group of Wall Street executives who prefer to operate out of the spotlight</blockquote> A story in Politico(9) called private equity/ leveraged buy-out firms <blockquote>one of the most secretive redoubts of the American economy</blockquote> The article went on to suggest that these firms may well have something to hide: <blockquote>Josh Kosman, author of 'The Buyout of America: How Private Equity Is Destroying Jobs and Killing the American Economy.' [said] 'Most private equity firms are because once you look behind the numbers, there is much they don’t want you to see.'</blockquote> Furthermore, <blockquote>Private equity companies often tend to have confidentiality agreements with their investors (Bain would not comment on what agreements it has). Several equity experts interviewed for this story thought any disclosures from Bain were likely to spook its investors. The private equity business model is based on taking companies out of the public markets, where reporting requirements are strict and investors punishing, making changes that will hopefully make them more profitable and then selling them or taking them public through an IPO. The part that happens behind the curtain is not always pretty, and private equity firms have learned over the years that it’s hard to tell a complicated story in the media. The goal of private equity is to keep things private. 'It’s had very little consciousness in the political realm until Romney came along because these guys are smart enough not to try to become Treasury secretaries,' said Bill Cohan, a former Wall Street banker-turned-investigative journalist who wrote 'Money and Power: How Goldman Sachs Came To Rule The World.'</blockquote> In addition, Dean Baker suggested that the confidentiality is used to hide how private equity/ leveraged buy-out firms remove capital from acquired companies(4), <blockquote>The sort of asset stripping described here, which harms creditors by taking away potential collateral for their loans, violates the law. However it is extremely difficult to prevent, especially with private equity companies that have to make few public disclosures.</blockquote> Thus secrecy/ confidentiality/ deception should be regarded as one of the main tactics used by private equity/ leveraged buy-out firms. Implications for Health Care Mitt Romney's candidacy has generated a surprising amount of discussion about the effects of private equity/ leveraged buy-out firms on the political economy. Many are worried that despite his claims, such firms cause more job loss than job creation. In the Huffington Post(10), Robert Creamer wrote that private equity/ LBOs have contributed to the sense that ordinary people who play by the rules suffer while well-connected insiders prosper: <blockquote>It just doesn't make sense to them that a relatively tiny number of people -- who don't build a product or create a service -- can make massive amounts of money, while ordinary people who work hard and play by the rules see their incomes flat-line. Their view is simple. They create cars, or food, or houses or computers -- or they provide police protection, or care for sick people, or teach our kids. Why should they be asked to sacrifice when guys who basically gamble for a living -- as Wall Street speculators -- make incomprehensibly large sums of money?</blockquote> There seems to be a good argument that the tactics used by private equity/ leveraged buy-out firms might be bad for the general political economy. Moreover, these firms often take over health care corporations, drug and device companies, health care information technology companies, health insurance companies, for-profit hospital chains, etc. There is reason to think that their standard tactics used on such targets are likely to be particularly bad for health care. Many health care corporations depend on a long-term view to be successes. To develop new products, drug, device, and health care IT companies must pursue research and development projects that take years. All health care companies depend on highly trained, specialized workers and professionals. To sustain these sorts of employees requires a long-term attention to their development. So private equity/ leveraged buy-out firms' short-term focus, transfer of debt and risk to the acquired companies, and emphasis on short-term generic management cutting costs techniques including lay-offs, outsourcing, etc clash with the sophisticated long-term focus these companies require. These health care organizations often require the complex interplay of many components. Private equity/ leveraged buy-out firms' efforts to sequester and sell particular assets may disturb this complex system. Health care quality, and successful research and development require transparency. Extreme emphasis on secrecy by private equity/ leveraged buy-out firms threatens such transparency. Even more pointed concerns may arise when private equity/ leveraged buy-out firms endeavor to take over non-profit health care organizations. We plan to discuss these in a subsequent post. The NY Times(g) noted that in the 1980s, leveraged buy-out firms <blockquote>were branded as 'barbarians at the gate' - the title of a book [by Burrough and Helyar, link <a href="http://www.amazon.com/Barbarians-Gate-Fall-RJR-Nabisco/dp/0060536357">here</a>] about the takeover of RJR Nabisco by Kohlberg Kravis Roberts.</blockquote> Now 30 years later we are finally having a conversation about the role of these firms in the greater political economy. We in health care should be having a parallel discusion about their role in our sphere. I submit that their role was not likely productive. Since health care should not merely be looked upon as a means to make money, but as a public good, we ought to be talking about how to restrain private equity/ leveraged buy-out firms from doing it more damage. References 1. Goozner M. Private equity's edge: buy now, deduct taxes later.  Fiscal Times, Jan 9, 2012.  Link <a href="http://www.thefiscaltimes.com/Articles/2012/01/09/Private-Equitys-Edge-Buy-Now-Deduct-Taxes-Later.aspx">here</a>. 2, Hamilton W. Private equity industry: a bad rep, but is it deserved. Los Angeles Times, Jan 12, 2012. Link <a href="http://articles.latimes.com/2012/jan/12/business/la-fi-private-equity-20120112">here</a>. 3. Lenzer R. Why Warren Buffet disdains the private equity crowd. Forbes, Jan 14, 2012. Link <a href="http://www.forbes.com/sites/robertlenzner/2012/01/14/why-warren-buffett-loathes-the-private-equity-crowd">here</a>. 4. Baker D. NPR does fluff piece for private equity. Beat the Press, Jan 13, 2012. Link <a href="http://www.cepr.net/index.php/blogs/beat-the-press/npr-does-fluff-piece-for-private-equity">here</a>. 5. Lifton RK. Mitt Romney and Bain Capital: understanding the reality. Huffington Post, Jan 13, 2012. Link <a href="http://www.huffingtonpost.com/robert-k-lifton/mitt-romney-bain-capital_b_1205157.html">here</a>. 6. Barro J. The discussion we should be having about Bain. Forbes, Jan 12, 2012. Link <a href="http://www.forbes.com/sites/joshbarro/2012/01/12/the-discussion-we-should-be-having-about-bain">here</a>. 7, Robinson E. Reexamining the myth of no-fault capitalism. Washington Post, Jan 16, 2012. Link <a href="http://www.washingtonpost.com/opinions/reexamining-the-myth-of-no-fault-capitalism/2012/01/16/gIQAvKO13P_story.html">here</a>. 8. Lattman P, Lowrey A. As Romney advances, private equity becomes part of the debate. New York Times, Jan 10, 2012. Link <a href="http://www.nytimes.com/2012/01/11/business/as-romney-campaign-advances-private-equity-becomes-part-of-the-debate.html">here</a>. 9. Hagey K. Mitt Romney's Bain Capital days: a black box. Politico, Jan 11, 2012. Link <a href="http://www.politico.com/news/stories/0112/71344.html">here</a>. 10 Creamer R. Why the Bain Capital controversy is so damaging to GOP chances this fall. Huffington Post, Jan 16, 2012. Link <a href="http://www.huffingtonpost.com/robert-creamer/why-the-bain-capital-cont_b_1208678.html">here</a>.

"Barbarians at the Gate" - Making Private Equity Less Private, and Understanding Its Effects on Health Care

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18 Jan 2012

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