healthy4u: NextGen

Two Opposing Views of EHR: InformaticMD vs. NextGen's Holder of "American Medical Informatics Certification for Health Information Technology"

The AMA's publication American Medical News recently quoted me following comments from IOM EHR Safety committee member Richard Cook in the Nov. 21, 2011 article "<a href="http://www.ama-assn.org/amednews/m/2011/11/21/psa1121.htm">IOM calls for monitoring and probe of health IT hazards</a>" by Kevin O'Reilly: <blockquote>... Not everyone on the panel agreed with delaying FDA regulation. [Per the IOM report on health IT safety released Nov. 10, 2011, see <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html">here</a> - ed.] Committee member Richard I. Cook, MD, filed a dissent in the report in which he recommended that health IT systems be regulated as class III medical devices. "It is quite remarkable that we're in this situation," said Dr. Cook, associate professor of anesthesia and critical care at the University of Chicago Pritzker School of Medicine. [Also, an expert in Medical Informatics - ed.] "It's not surprising that such adverse events are being found related to health IT, and it's not surprising that those promoting these systems have neither looked for them nor anticipated them. To make large-scale investments in these systems and only now be looking at the impact on patient safety borders on recklessness."Scot M. Silverstein, MD, agreed. "The bone I have to pick with the IOM report is that the action agenda is weak," said Dr. Silverstein, a consultant in medical informatics at the Drexel University College of Information Science and Technology in Pennsylvania. It is unethical to expand health IT so dramatically without understanding the precise nature of the risks it poses to patients, Dr. Silverstein said.</blockquote> Ironically, right below my statement was the following from HIT industry figure Charles Jarvis, blaming the user: <blockquote>Users faulted Leaders in the health IT industry also had their share of objections to some of the IOM panel's conclusions. "We don't think there's a great deal of data to substantiate that there are major safety problems with the majority of electronic health records systems in use today," said Charlie Jarvis, executive committee vice chair of the EHR Assn., a trade group that represents 46 organizations that supply most of the EMR systems implemented in medical practices. "These products are safe, dependable, time-tested and display a lot of the safety features we think are necessary to prevent problems going forward." Jarvis, also a vice president at the health IT firm <a href="http://www.nextgen.com/">NextGen</a>, said vendors and the government should work to help physicians and other health professional users understand systems, take advantage of their safety features and avoid errors. [Charitable translation: computers are infallible, so medical errors due to HIT are the user's fault, <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">the Sept. 2011 National Institute of Standards and Technology (NIST) report on usability</a> be damned. Clinicians should spend their valuable time learning to compensate for and then actually wading through <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experiences</a>. If only those stupid doctors and nurses would use our cybernetic miracle tools the way we want, the members of the EHR Association could be making even more money. Oh, and by the way, the NIST's concept of "use error" [1] is nonsense. - ed.]</blockquote> I presume the "EHR Assn." is the <a href="http://www.himssehra.org/ASP/index.asp">HIMSS EHR Association</a>, with <a href="http://www.himss.org/ASP/index.asp">HIMSS</a> itself being a gargantuan "cause-based, not-for-profit organization exclusively focused on providing global leadership for the optimal use of information technology and management systems for the betterment of healthcare":<blockquote> The HIMSS Electronic Health Record (EHR) Association is a trade association of Electronic Health Record (EHR) companies, addressing national efforts to create interoperable EHRs in hospital and ambulatory care settings. The EHR Association operates on the premise that the rapid, widespread adoption of EHRs will help improve the quality of patient care as well as the productivity and sustainability of the healthcare system. </blockquote> I observe that there are no conflicts of interest here that could cause Mr. Jarvis' stated opinions to be skewed towards the rights of computers and away from the rights of patients ... right? First, Mr. Jarvis makes a logical error related to the error illustrated in my earlier post today "<a href="http://hcrenewal.blogspot.com/2011/11/magical-thinking-on-health-it-from.html">Magical Thinking on Health IT from ModernMedicine.com</a>." His error is that of "proof by lack of evidence" [2]. No need to actually study the issue rigorously, despite repeated risk management-relevant incident reports (as opposed to the industry's preferred and highly erroneous term "anecdotes"). Just one recent, highly alarming example of an "anecdote" affecting probably tens of thousands of patients due to programming malpractice and grossly negligent quality assurance, at both vendor and end user hospitals, is illustrated <a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">here</a>. Since it's an "anecdote", perhaps Mr. Jarvis would agree there's nothing to see there, so we should all move along. (See the Aug. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things</a>" which puts the misuse of the "anecdotes" label in its proper place - the garbage can.) Not only is "proof by lack of evidence" in the face of hair-raising incident and defects reports (e.g., as in <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html">FDA's MAUDE database</a>) a prima facie logical fallacy unfitting in medicine, and in fact alien to medical ethics, but the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf">IOM report</a> specifically stated in no uncertain terms that nobody really knows the magnitude of the risks. This is due in part to numerous inhibitory factors in evidence diffusion. From the IOM report: <blockquote>... Several reasons health IT–related safety data are lacking include the absence of measures and a central repository (or linkages among decentralized repositories) to collect, analyze, and act on information related to safety of this technology. Another impediment to gathering safety data is contractual barriers (e.g., nondisclosure, confidentiality clauses) that can prevent users from sharing information about health IT–related adverse events. These barriers limit users’ abilities to share knowledge of risk-prone user interfaces, for instance through screenshots and descriptions of potentially unsafe processes. In addition, some vendors include language in their sales contracts and escape responsibility for errors or defects in their software (i.e., “hold harmless clauses”). The committee believes these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety.</blockquote> Imagine such a situation in, say, the pharmaceutical, automotive, aviation, or nuclear power industries. The responsible individuals would likely be hauled off to jail. However, this all may be irrelevant. After all, who can argue with the expert personal opinion of someone who holds "<a href="http://web.archive.org/web/20100103141103/http://nextgen.com/about-nextgen/leadership-structure.html#15">the American Medical Informatics Certification for Health Information Technology</a>?" That astonishing credential could conceivably elevate Mr. Jarvis' opinion over all others - even mine, with my meager background in the domain. I don't know if he still claims that credential, but he did as I described in my post about prior interactions with Mr. Jarvis and NextGen (dating back to 2004) in my Feb. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/02/nextgen-and-vendordoctor-dialog-yet.html">NextGen and Vendor/Doctor Dialog: Yet Another Patronizing EHR Company of Certified HIT Experts?</a>" I guess the fact I'd never heard of such a qualification represents my dearth of familiarity with the field of Medical Informatics and healthcare information technology. -- SS Notes: [1] “Use error” is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at <a href="http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf" rel="nofollow">http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf</a> (PDF). [2] Example of proof by lack of evidence, courtesy <a href="http://www.packetslut.co.uk/weblog/archives/00000053.htm">Scott Adams</a>: "I've never seen you drunk, so you must be one of those Amish people. " More on these issues is at the site "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties</a>."

Two Opposing Views of EHR: InformaticMD vs. NextGen's Holder of "American Medical Informatics Certification for Health Information Technology"

The AMA's publication American Medical News recently quoted me following comments from IOM EHR Safety committee member Richard Cook in ...

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NextGen and Vendor/Doctor Dialog: Yet Another Patronizing EHR Company of Certified HIT Experts?

<blockquote style="font-family:arial;">Note 6/9/09: To those reading this post via a link in an email from CCHIT's Mark Leavitt, see this June 7th post "<a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html">Open Letter to Mark Leavitt</a>" first. The link you are at now is several months old, one of many posts I've written over the years about the scarcity of leadership-level Medical Informatics-trained professionals in the health IT vendor world. I consider that issue contributory to EHR's often mission hostile user experience (my series on that topic is <a href="http://tinyurl.com/b28s74">here</a>), and ultimately deleterious to patient well-being. I also believe the HIT industry has put its own interests ahead of that of patients in its inattention to HIT safety and <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">rejection of accountability</a>. Additional views on the recent CCHIT NJ Bill are at ePatients.net at "<a href="http://e-patients.net/archives/2009/05/david-kibbe-mark-leavitt-openness-vs-opacity.html">David Kibbe & Mark Leavitt:Openness vs. Opacity</a>" and "<a href="http://e-patients.net/archives/2009/06/dossia-microsoft-healthvault-google-healthillegal-in-nj.html">Dossia, Microsoft HealthVault & Google Health: Illegal in NJ?</a>". There are some now-familiar themes regarding CCHIT civility in those posts. 6/10: As a result of a link sent by a commenter, I am adding the post "<a href="http://www.hcplive.com/mdnglive/The_HIT_Realist/Kibbe_Leavitt">The Kibbe/Leavitt Rumble in the High Tech Jungle!</a>" to the list of interesting views in the note above. -- SS</blockquote> My early medical mentor, cardiothoracic surgery pioneer <a style="font-family: arial;" href="http://mmp.cjp.com/pipermail/openheart-l/2005-June/002000.html">Victor P. Satinsky, MD</a>, believed in public embarrassment (a.k.a. "sunlight") as a tool to fight bureaucracy and discrimination. I quote him on that. He wanted his NSF summer science training progam (SSTP) 10th grade students at Hahnemann Hospital to actually picket a clothing distributor, for example, when that distributor did not deliver our white coats nor a refund in a timely manner. He also was highly politically incorrect, for example having gay activists speak to our group of 200 high school students about bias and discrimination, at a time in the early 1970's when such talks were frowned upon. He took grief for that. Yet fairness and "critical thinking always, or your patient's dead" were his mantras. Dr. Satinsky must be rolling in his grave at what has become of medicine due to the type of bureaucracy we cover here at Healthcare Renewal. He would probably be a healthcare blogger himself were he still alive. At "<a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/vendordoctor-dialog-on-healthcare-it.html">A Vendor/Doctor Dialog On Healthcare IT?</a>" I wrote that <blockquote>In response to my recent post to the American Medical Informatics Association's clinical information systems (CIS-WG) and organizational issues (POI-WG) workgroups about my <a href="http://hcrenewal.blogspot.com/2009/02/medinformaticsmd-in-wall-street-journal.html">WSJ letter to the editor</a>, Charles Jarvis, an AVP of Healthcare Industry and Government Relations at HIT vendor Nextgen.com thoughtfully suggested I "come and listen to how the government, providers, insurers and yes- HIT providers- can work together for the common good before drawing such strong conclusions." (Soothing blue font original - ed.) Dialog is a useful idea. I am always open to listening. However, dialog must be among equals in an atmosphere of complete transparency. Otherwise it is not dialog, it is politics. How can there be "dialog" in an environment where one side is able to squelch open discussion of the issues? ... p.s. in late 2003 after the <a href="http://www.businessweek.com/technology/content/nov2003/tc20031113_9818_tc119.htm">collapse of Merck's pipeline</a>, I wrote to your [NextGen's - ed.] CEO and HR department in Horsham about my availability to help in their EHR efforts. This was prior to the bulk of my writings on HIT difficulties. I did not so much as even get a response or inquiry, although I live thirty minutes away. Perhaps you could explore why your company showed no interest in perhaps the only formally trained medical informaticist in this area, and former CMIO of a major hospital in the region (Christiana Care).</blockquote> More on this below. I found Mr. Jarvis' patronizing "why don't you come and listen" line, sent in a nice soothing blue font, disturbing, since it's vendors (immune from liability and from intra-organization scrutiny even when events such as <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/healthcare-it-blamed-in-patient-death.html">this</a> and <a style="font-family: arial;" href="http://iig.umit.at/efmi/badinformatics.htm">these</a> occur), not physicians and physician informaticists, who need to do the listening. However, something else was at the back of my mind, and information saver that I am (I did run Merck Research Lab's science library and historical science archives department, after all), I checked my disk backups. What I found reflects something I've noted numerous times in the past. Interactions with HIT vendors - both their products and their people - have most often been quite annoying. Here is Mr. Jarvis' <a style="font-family: arial;" href="http://web.archive.org/web/20100103141103/http://nextgen.com/about-nextgen/leadership-structure.html#15">bio</a>: [Nov. 2011 editor's note - the bio disappeared from the original link; the link now points to archive.org] <blockquote face="arial"><h5>Charles Jarvis, Assistant Vice President, Healthcare Industry Services & Government Relations</h5> Charles W. Jarvis FACHE is Assistant Vice President for Healthcare Industry Services and Legislative Affairs – having been in this role since January 2005 [this date becomes relevant as below - ed.] Mr. Jarvis' responsibilities include community and partnership business development including overseeing the company grants and funding procurement program, government relations, new business planning, and educational efforts. Mr. Jarvis is active in the Electronic Health Record Vendor Association (EHRVA), currently holding the position of Chairman of the Government Affairs and Affiliated Organizations Workgroup.Prior to joining NextGen, Mr. Jarvis was in hospital and physician group practice management for 25 years in both the New Jersey and Massachusetts markets. Mr. Jarvis holds a Masters Degree in Business with a concentration in Health Administration [i.e., he took a few courses in health admin - ed.] from Temple University and a Bachelors Degree in Economics from the Wharton School of the University of Pennsylvania. [Common to the HIT industry and to observations on HC Renewal about HC leadership in general, I note no clinical experience or credentials - ed.] He is also a Fellow in the American College of Health Care Executives and holds the American Medical Informatics Certification for Health Information Technology [what is that? More below - ed.] </blockquote> Now, it was bad enough my earlier inquiries to the NextGen CEO were ignored. Far worse is the outcome of my application to NextGen for a position as Director of Industry Relations in late 2004: <blockquote>NextGen Healthcare is currently looking for an individual to manage our Industry Relationships. We are a rapidly growing, publicly held company looking for an aggressive, self-motivated individual who is seeking a challenging position with a top tier healthcare IT company. As the Director of Industry Relations, you will be responsible for managing industry relations. This will include relationship management with the consultant marketplace, medical societies, health plans, and our Value Added Resellers. Qualified candidates will have preferably healthcare IT background either as a project manager, consultant, marketing manager, or sales representative . Applicant must also be career oriented, professional, and organized, possess excellent oral and written communication skills and be detail oriented. Working knowledge of MS Excel, Word and PowerPoint a must. Local and national travel required.</blockquote> Here is the relevant email thread: <blockquote style="font-family: arial;">From NextGen: In a message dated 12/27/2004 9:04:43 A.M. Eastern Standard Time, JWong@nextgen.com writes: Hello Dr. Silverstein, We would like to schedule an interview for you the week of January 3, 2005. Would you please advise your schedule? I will be arranging an meeting with the president and one of our vice presidents. Please let me know what day and time are best. Thank you. Jennifer Wong Business Development Coordinator > NextGen Healthcare Information Systems, Inc. 795 Horsham Road Horsham, PA 19044 215.657.7010 (p) 215.657.7011 (f) jwong@nextgen.com Website - www.nextgen.com My reply back: From: ScotSilv@aol.com [mailto:ScotSilv@aol.com] Sent: Thursday, January 06, 2005 12:44 PM To: JWong@nextgen.com Subject: Re: Interview Hi Jennifer, I have been away for the New Year. I'm following up on getting an interview schedule set. I also left a voicemail. Regards, Scot NextGen gets back to me: In a message dated 1/10/2005 11:47:51 A.M. Eastern Standard Time, JWong@nextgen.com writes: Hi Dr. Silverstein, I have forwarded your resume internally to the appropriate persons. Thank you - you should be hearing from someone shortly. Thank you. Jennifer Wong Business Development Coordinator NextGen Healthcare Information Systems, Inc. 795 Horsham Road Horsham, PA 19044 215.657.7010 (p) 215.657.7011 (f) jwong@nextgen.com Website - www.nextgen.com My response after waiting, and waiting: From: ScotSilv@aol.com [mailto:ScotSilv@aol.com] Sent: Thursday, January 20, 2005 To: JWong@nextgen.com Subject: Re: Interview Dear Jennifer, I still await contact from NextGen. Please advise if this opportunity is still available. I am in conversation with other organizations and want to finalize my schedules. Sincerely, Scot </blockquote> Then ... silence. I never heard from the company again. (Dialog? What dialog? There does not appear to have been even fundamental respect.) In summary, an AVP who may very well have -- hypothetically speaking; I'd never heard of him before he responded to my recent workgroup posts -- made a decision about blowing me off as a Director in 2005 (he started in Jan. 2005) now tells me how I should "come and listen to how the government, providers, insurers and yes- HIT providers- can work together for the common good before drawing such strong conclusions." I can also add that NextGen did indeed hire a medical informaticist straight away from the same program I trained in, <a href="http://ycmi.med.yale.edu/research/rgraduates.html">Yale'</a>s, sometime after that person's completion of a postdoctoral fellowship in July 2006, as a "physician consultant." I had finished the fellowship in 1994 after a number of years of medical practice and by 2005 had quite a lot of <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about">applied and management experience</a> under my belt. (My current bio does not include my time as Medical Programs Manager for quasi-governmental agency <a href="http://www.septa.com/">SEPTA</a>, with much interaction with SEPTA Industrial Relations, and with federal regulators <a href="http://www.dot.gov/">DOT</a>, <a href="http://www.fra.dot.gov/">FRA</a>, <a href="http://www.nida.nih.gov/">NIDA</a> and others on health matters in the transportation industry, but it did then.) So, I was entirely blown off without so much as an explanation in 2005, but a new informatics trainee hired in 2006. This raises a number of questions. Hypothetically speaking, was this due to: <ul style="font-family: arial;"><li>Lack of recognition of my background, which included extensive clinical, medical informatics and EHR experience and working in a critical role in a quasi-governmental organization with links to several federal agencies?</li><li>Age discrimination? I was in my late 40's at the time.</li><li>Perhaps it was felt I had <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=leadership">too much experience for the organization</a>? </li><li>Hiring the young and relatively inexperienced on the basis of "cheap?"</li><li>My patient-centric advocacy views on HIT, as in, "the patient must be protected from defective HIT?"</li></ul> I am not making accusations in any way, only raising questions. Only the company knows the answers, of course, and it is their right to hire someone or not hire them or even have them in for interview. Even basic courtesy of followup with the professional community is optional. However, I rest my case regarding the really annoying nature of health IT vendors beyond just their often <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">poorly conceived products</a>, and their inability or unwillingness to tap experienced healthcare informatics professionals as I've written about before on HC Renewal. Finally, what is the "American Medical Informatics Certification for Health Information Technology?" claimed in Mr. Jarvis' biography? I have never heard of it before and a <a style="font-family: arial;" href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&q=American+Medical+Informatics+Certification+for+Health+Information+Technology&btnG=Google+Search">Google search</a> seems unrevealing. Could it be an overstated credential to impress stockholders and investors? (We in informatics strive for semantic clarity). AMIA does not "certify" anyone in informatics to my knowledge although they offer a short course in the <a style="font-family: arial;" href="http://www.amia.org/10x10">10x10</a> program that awards a "<a style="font-family: arial;" href="http://www.amia.org/10x10/students.asp">Certificate of Completion</a> in the 10x10 Program." I'm not aware of an American certification board in HIT. Is it like another <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2008/05/htrea-parallel-world-of-hit.html">Htraesian</a> informatics "certification", CPHIMS, as I described <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2008/04/is-himss-certified-professional-in.html">here</a>? Is it a certificate like <a style="font-family: arial;" href="http://www.drexel.com/online-degrees/information-sciences-degrees/cert-hci/index.aspx">this</a>, which students get after completing the intensive 3-course graduate program in an accredited university that I created? Perhaps something you get after completing one of <a style="font-family: arial;" href="http://www.nlm.nih.gov/ep/GrantTrainInstitute.html">these</a> programs, created and funded by Don Lindberg and other informatics pioneers, that I spent two years of my life in? Or perhaps it's more like <a style="font-family: arial;" href="http://www.healthitcertification.com/">this</a> three day 10 course miracle certification and button? "<a style="font-family: arial;" href="http://www.healthitcertification.com/regonsite.html">Consists of 10 course, two and a half days curriculum and CPEHR Certification Examination</a>" [is that like a 10 course meal? - ed.] Oh, I forgot. In healthcare informatics, <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/informatics-or-infomagic-health-it.html">everyone's an expert</a>. Finally, I guess I won't be applying to <a style="font-family: arial;" href="http://www.nextgen.com/">NextGen</a> again. They might blow me off. Again. -- SS

NextGen and Vendor/Doctor Dialog: Yet Another Patronizing EHR Company of Certified HIT Experts?

Note 6/9/09: To those reading this post via a link in an email from CCHIT's Mark Leavitt, see this June 7th post " Open Letter to M...

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