healthy4u

Get the picture

If a picture is worth a thousand words, then Google Image Search is now worth 1 trillion, 187 billion, 63 million words. Yes, that's right, math majors; we've updated our image index, and now offer users precisely 1.18763 billion newly updated images of <a href="http://images.google.com/images?hl=en&lr=&output=search&q=purple+flowers">purple flowers</a>, <a href="http://images.google.com/images?q=lamborghinis&amp;hl=en&lr=&output=search">Lamborghinis</a> and <a href="http://images.google.com/images?q=wallpapers&hl=en&lr=&rls=GGLD,GGLD:2004-06,GGLD:en&sa=N&tab=wi">whatever else you care to look at</a>. In fact, we're so excited about the quality and comprehensiveness of our updated image index, we've even begun sprinkling a few images into the regular Google.com search results for certain search terms. If you do a Google web search for, say, <a href="http://www.google.com/search?hl=en&q=sunsets">sunsets</a>, <a href="http://www.google.com/search?hl=en&lr=&q=Mount+St.+Helens&btnG=Search">Mount St. Helens</a>, or other queries for which our algorithms think pictures might be relevant results, you may see a few pictures at the top of your search results page, along with a link to complete image search results for that query. You can try out our new image index by clicking the "Images" link on Google.com, or by going directly to the <a href="http://www.google.com/imghp?hl=en&amp;tab=wi&q=">Google Image Search page</a>. Go ahead and feast your eyes. Radhika Malpani Tech Lead

Get the picture

If a picture is worth a thousand words, then Google Image Search is now worth 1 trillion, 187 billion, 63 million words. Yes, that's rig...

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Another Homicide

Another Homicide

There seems to be a tiny time-cluster of health care officials facing homicide charges, a new low for health care. (See the previous posting...

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Malpractice Crisis in Ireland: Physicians to Vote On Industrial Action

Although this blog has had a distinctly American flavor, we believe that the general problems we discuss know no national boundaries. (By the way, we'd be happy to welcome some bloggers from outside the US.) For example, those who think that the malpractice insurance situation is bad in the US should see stories <a href="http://www.limerickpost.ie/dailynews.elive?id=6021&category=Daily-Mon">here</a> and <a href="http://www.ireland.com/newspaper/front/2005/0207/2362756787HM1HEALTH.html">here</a> from Ireland. Although Ireland has a national health service, Irish hospital-based physicians (consultants) still face the risk of malpractice law-suits. Now Irish hospital consultants are ready to vote for an "industrial action," i.e., a doctor's strike, over malpractice insurance issues. Apparently, the Irish government developed a new system of malpractice coverage, but which did not include coverage for liabilities incurred before last February. The former source of many physicians' coverage of this "tail" (in the US parlance), is no longer available. So physicians have no source, other than own pocket, of payment for expenses occured to defend lawsuits arising from events before last February, and no insurance for any damages they might have to pay.

Malpractice Crisis in Ireland: Physicians to Vote On Industrial Action

Although this blog has had a distinctly American flavor, we believe that the general problems we discuss know no national boundaries. (By th...

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CVS tied to R.I. lawmakers

I am aware that Rhode Island has had its share of healthcare problems in the insurance sector. Here's another angle to the dangers of allowing those involved making a living from healthcare parasitically to curry favor from those who set or enforce the rules for society (i.e., politicians, also usually with no healthcare credentials). I am the son of a small, independent pharmacist in Philadelphia who opened his first store in the early 1950's. I worked for my father as a teen and literally watched the takeover of his profession by large corporate interests as chain drugstores started dotting the landscape, including directly across the street from his venerable <a href="http://home.aol.com/ku3e/lumar.jpg">Lumar Pharmacy</a>, Somerton (far Northeast Philadelphia). -- SS CVS tied to R.I. lawmakers The drugstore chain's dealings led to the state Senate president's resignation. By Michael Mello, Associated Press PROVIDENCE, R.I. - From the University of Rhode Island's sparkling Ryan Center, named after CVS Corp.'s top executive, to the familiar red signs that dot the landscape, the nation's second-largest drugstore chain is a clear economic force in the nation's smallest state. Yet CVS's behind-the-scenes political clout may be even stronger. A furor has erupted at the Statehouse over the recent disclosure that CVS - Rhode Island's largest private employer - had secret business dealings with some lawmakers. The uproar has spurred the resignation of the state Senate president and led to an investigation by the Rhode Island attorney general - himself a former CVS lobbyist. Activist groups are demanding tighter disclosure laws. Others want to replace the state's part-time legislature with a full-time one, so that lawmakers are less likely to hold down outside jobs that could create conflicts of interest. Republican Gov. Don Carcieri, meanwhile, wants a special commission to investigate corporate influence in government. "We have a huge crisis of confidence in the public's mind," he said last week. The governor's concern goes beyond CVS to recent ethics complaints involving other firms, including Blue Cross & Blue Shield of Rhode Island, the state's largest insurer. Also, two executives connected to the Lincoln Park dog track and gambling hall have been indicted on charges of conspiring to pay a bribe of up to $4.5 million to the House speaker's law firm in 2000 and 2001 for help in winning approval for more video slot machines and blocking a proposed casino. Rep. John Harwood, who is no longer speaker, has denied any wrongdoing and has not been charged. Few, if any, companies are as tightly woven into the fabric of the state as CVS. Cofounded by Woonsocket native Stanley Goldstein, CVS opened its first store in 1963 in Lowell, Mass. The Fortune 100 company now has about 4,200 stores in 32 states and the District of Columbia. It has dozens of stores in the Philadelphia area. Its corporate headquarters are in Woonsocket, and it employs about 5,200 people in Rhode Island. CVS has long been lauded for its philanthropic efforts, including an annual charity golf tournament. The company and its chief executive officer, Tom Ryan, donated at least $4 million to help build the state university's sports arena. But critics say the goodwill generated by the company's good citizenship has been erased by the secret business relationships with Democratic Senate President William Irons and Sen. John Celona, who was chairman of a committee overseeing the health-care industry. "I can't trust them," Democratic State Sen. Leonidas Raptakis said of CVS. "Why didn't they come out and tell the public of this hidden agenda?" Irons, an insurance broker, received $70,000 in commissions over two years as the broker on a CVS employee health-insurance policy, according to federal documents. And Celona acknowledged he was being paid $1,000 a month by CVS as a consultant when a bill opposed by CVS died in his committee. The bill would have relaxed the exclusive relationship Blue Cross has with CVS and certain other pharmacies, and allowed patients to get their prescriptions filled at drugstores including Walgreens. Celona has since stepped down from the chairmanship, and CVS's competitors are again pushing the bill. CVS said in a statement that it violated no state laws but is adopting new procedures that "will hold CVS to a higher standard of conduct than that required by Rhode Island state law or regulation." Some of the financial arrangements were brought to light by the Providence Journal. Because Rhode Island lawmakers are part-time, they are not barred from working for CVS or any other company. Lawmakers must report the names of their employers, though not the exact amounts they are paid. Celona and Irons could be fined for not disclosing their business relationships. Criminal investigators are looking deeper, to see if businesses have bought influence with lawmakers. Celona and Irons both declined interview requests. Rhode Island Attorney General Patrick Lynch is heading the investigation along with state police. He has resisted calls to remove himself and appoint a special prosecutor because of his own past connections to CVS. CVS also is named in an ethics complaint against Republican State Rep. William McManus, a business analyst for the company. McManus is accused of improperly speaking against a bill to allow the sale of medications imported from Canada. The Rhode Island legislature typically meets six months a year in the late afternoons, and includes teachers, lawyers, restaurant owners, firefighters, insurance agents and farmers. Most of the lawmakers make $12,063 a year. Democratic Sen. Joseph Polisena said Rhode Island needed a full-time legislature. "As we have seen in a number of instances, there can be unfortunate results when members of the part-time General Assembly serve two masters - the citizens in their districts and their regular, full-time jobs," he said. But having full-time legislatures can lead to complaints, too - namely, that the lawmakers are too focused on reelection. "If it is their primary source of income, then it becomes a job that's important for them to hold onto, then they'll make decisions in the interest of getting reelected," said Karl Kurtz of the National Conference of State Legislatures.

CVS tied to R.I. lawmakers

I am aware that Rhode Island has had its share of healthcare problems in the insurance sector. Here's another angle to the dangers of al...

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"There is Always a Hidden Agenda" - Alleged Cover Up of Research Abuses at the VA

In January, we <a href="http://hcrenewal.blogspot.com/2005/01/those-government-health-care-blues.html">posted the story </a>of malfeasance at the Stratton Veterans Affairs (VA) Medical Center in Albany. Today, <a href="http://www.nytimes.com/2005/02/06/nyregion/06vets.html?hp&ex=1107752400&amp;en=1f9bb82504a0e363&ei=5094&partner=homepage">the NY Times published a major piece of investigative reporting </a>on the affair, which now appears to be larger and more troubling than it did last month. Then, the focus was on research coordinator Paul Kornak. Kornak was apparently hired despite having lost medical licenses in several states due to forged credentials, and a felony fraud conviction in Pennsylvania. Although Kornak apparently never completed medical training, the Stratton VAMC allowed him to perform physical examinations and identify himself as "doctor." The FDA found that Kornak had falsified patients' medical records in several drug studies, allowing patients to enroll in studies even though they should have been excluded. Kornak plead guilty to fraud and negligent homicide for the death of one patient in a chemotherapy study. However, problems at Stratton predated Kornak's arrival. In the 1990's, two pharmacists repeatedly complained of major violations of research protocols, including enrollment of patients without consent, enrollment of patients who should have been excluded, and giving patients treatments not included in protocols. In response, the pharmacists were targeted by VA internal investigations, although none ever found any wrong-doing. An investigation of research at the hospital, conducted by Dr. Thomass Ferro, was allegedly rigged by administrators to find nothing wrong. Said Dr. Ferro, "there is always a hidden agenda to exonerate or convict in these internal investigations. In this case it was to exonerate." So Ferro did a cursory investigation, and even after he then "watered down" his finidings, his superiors edited his report to remove even "minor discrepancies." Furthermore, how the VA responded on the national level to the problems at Stratton was even more troubling. When problems there first were noticed in 2003, the new VA Chief of Research and Development, Dr. Nelda Wray, ordered a nation-wide review of VA research. She halted research altogether at Fargo, ND, where there were problems with the Institutional Review Board. She ordered credentials checks on and ethics training for all researchers. But by2004, Dr. Wray, in turn was accused of ethics problems, and was <a href="http://www.biomedcentral.com/news/20040326/03">forced out of her position</a>. Her lawyer charged the investigation was "an easy and convenient way to stop sorely needed reforms." Some major points: - The response of the VA to staff complaints about research at the Stratton VAMC was apparently to punish the whistle-blowers, and cover up the complaints. This is all too reminiscent of the cases of physicians punished for complaining about quality, detailed in the landmark investigative series in the Pittsburgh Post-Gazette, <a href="http://www.post-gazette.com/pg/03299/234499.stm">The Cost of Courage</a>. - This response allowed wrong-doing to continue, resulting in, according to a court of law, the death of at least one patient. - Thus, this case suggests how bad leadership of a medical organization can not only harm the research process, or suppress research results, but also directly harm patients. - Furthermore, the allegations made by Dr. Wray's lawyers, if true, suggest that the problems go much deeper, or higher than the administration of one VA hospital. Coupled with all the other stories we have been reporting, about not only the VA, but the NIH and the FDA at the federal level, about numerous for-profit companies, and not-for-profit hospitals and managed care organizations, this underscores how we need to get serious about restoring integrity to the leadership of health care organizations.

"There is Always a Hidden Agenda" - Alleged Cover Up of Research Abuses at the VA

In January, we posted the story of malfeasance at the Stratton Veterans Affairs (VA) Medical Center in Albany. Today, the NY Times published...

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End of the Anechoic Effect: Editorial Reaction to the New NIH Rules

The announcement of the <a href="http://hcrenewal.blogspot.com/2005/02/nih-seeks-higher-standard-better-late.html">change in NIH conflict of interest rules </a>has created quite a bit of press, maybe finally signaling the end of the <a href="http://hcrenewal.blogspot.com/2004/12/anechoic-effect-and-conflicts-of.html">"anechoic effect"</a> for this particular story. Oddly enough, the old way of doing business at the NIH has found a few prominent apologists, echoing the troubling reaction by NIH staff <a href="http://hcrenewal.blogspot.com/2005/02/pogo-at-nih.html">I discussed yesterday. </a> For example, see the <a href="http://www.washingtonpost.com/wp-dyn/articles/A62214-2005Feb3.html">commentary by Steven Pearlstein in the Washington Post</a>. Here are a few quotes with my comments. "A Massachusetts politician once told me, over lunch at Boston's Locke-Ober cafe, that most systems work best when lubricated with a bit of moral ambiguity." As a Rhode Island resident, I didn't think this was a promising start for a discussion of ethics and research. The moral ambiguity of many politicians has fueled considerable cynicism about politics in general. "I'm not sure I see the wisdom of drawing a 'bright line,' ... between NIH scientistis doing basic research and commercial enterprises that build upon that research. " This is a false dichotomy, but seems to be a prevalent argument against the new standards. The false dichotomy is between major financial entanglements with pharma and biotechnology firms and no contact at all with such firms. NIH staff don't need to be paid huge consulting fees over and above their full-time salaries, or hold stock or collect stock options in pharmaceutical and biotech companies to work collaboratively with industry. "What purpose is served by preventing them (NIH staff) from making a buck by sharing that informal knowledge with profit-making companies?" The purpose is not having them feel beholden to the profit-making companies for all those bucks they make on the side. But again, why should people who work full-time for the NIH, and get six-figure salaries from the government, need to also "make a buck" from these companies? "A surprising number of people violated those [existing] rules [requiring disclosing conflicts of interest]. But rather than coping with that by dealing harshly and publicly with a few of the worse offenders, the NIH brass have now caved in to pressure from Capitol Hill to prohibit drug and biotech-related investments and commercial entanglements by their researchers." It is true that no one has yet dealt harshly with the NIH leaders who made the most money from consulting fees and stock options while supposedly working full time for Uncle Sam. Actually it is not true that the rules prohibit biotech-related investments by NIH staff, since they can still invest indirectly through, for example, mutual funds. Why is it bad in this case to listen to the opinion of Congress? "But the right question is not whether we should stomp out every last bit of such 'corruption,' but whether the price is worth it. Having a fuzzy line, and giving administrators some flexibility in enforcing it, was probably better for medicine, better for the biotech industry, and certainly better for the Washington economy." There has been very little research on the effects of conflicts of interest and corruption affecting the leaders of health care organizations, so there is no good data about what might be good for "medicine" or the public. However, it seems reasonable to hypothesize that commerical entanglements are bad because they may sway such NIH leaders, who have considerable power over what science gets done and how it is reported, in favor of their outside benefactors, leading to biased science, biased interpretation of science, and biased science policy. Furthermore, the knowledge that some NIH leaders may be beholden to commercial vested interests outside of the NIH threatens the credibility of all NIH sponsored research, the credibility of the NIH research priorities, and the credibility of NIH efforts to translate and disseminate research results. Finally, knowing that some NIH leaders are financially benefiting from conflicts of interest may clearly demoralize NIH staff, NIH-supported scientists, and researchers seeking NIH support who do not have such conflicts. Similar was <a href="http://www.forbes.com/columnists/free_forbes/2005/0214/040.html">the commentary in Forbes by Thomas P. Stossel MD</a>. "In the real world, these restrictions (on conflicts of interest) address nearly nonexistent scientific corruption and ultimately impede medical progress by depriving pharmaceutical companies of access to biomedical scholars." See my comments above. Since there have been few relevant studies, it's not clear how much corruption there is. Again, biomedical companies can easily get access to and collaborate with scholars without paying them personally for consulting or handing them stock options. "How did financial conflicts-of-interest rules get to be such a big deal? One reason is that the gatekeepers of the medical literature believe it is. Editors of high-profile medical journals vilify the pharmaceutical industry..." Funny, I have seen criticism that medical journals have been too cozy with that industry. Note that for Stossel the bogey-man seems to be journal editors, while for Pearlstein it was "Capitol Hill." "The public wants trustworthy science, and it can get that without new ethical rules. Even more, it wants results - lives saved - and it can't get those if commercial sponsorship of research is made difficult, if not impossible." Again, why should the public will find research more trustworthy if the researcher is getting paid on the side by industry? Again, note the false dichotomy. Industry can certainly sponsor research done at academic organizations by research grants without paying researchers consulting fees in addition to their full-time salaries. For contrast, see <a href="http://www.philly.com/mld/inquirer/10811695.htm">the editorial in the Philadelphia Inquirer</a>. My favorite quotes were: "The NIH staffers' outside work involved paid consulting, teaching, speaking or writing for private health-care firms - with drugmakes bankrolling many of the deals. Financial arrangements like these, allowed since, 1995, pose a huge conflict for all the 6,000-plus NIH scientists. How so? Because NIH officials' day jobs position them to promote or aid these firms through grants, contracts, and approvals." "As a group, NIH scientists pulled in millions of dollars in consulting and other fees. With that kind of money at stake, to whose interests were they most attuned - the publics', or their second employers'? "Institutes' officials must monitor whether an exodus of talent occurs. If so, the correct remedy is better pay - not watering down ethical core standards." 'Nuff said.

End of the Anechoic Effect: Editorial Reaction to the New NIH Rules

The announcement of the change in NIH conflict of interest rules has created quite a bit of press, maybe finally signaling the end of the ...

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Major medical center thrashes for clinical IT leadership

Major medical center in Philadelphia, Temple University, thrashes around for clinical IT leadership. <a href="http://www.amia.org/jobexch/jobs/posting.asp?jid=710">This ad</a>, regarding a "a seven-year, enterprise-wide Information Technology strategic plan" for clinical IT and process redesign, was posted again on the job exchange area of the American Medical Informatics Association. It has many hallmarks of the lack of awareness of sociotechnical issues in clinical IT and of the role of Healthcare Informatics professionals in studying and <a href="http://home.aol.com/medinformaticsmd/failurecases.htm">preventing costly errors experienced by other medical centers</a>, and of facilitating change. <blockquote>"The ideal candidate will have a Bachelor’s degree; a Master’s is preferred [in what, exactly, is unclear-SS]. Significant IT skills [why don't I see "Medical Informatics" or clinical medicine training anywhere? - SS] with 8-10 years in managing a CIS Implementation Process in a large, complex academic medical center or multi-hospital health system is also required....The Director must have a demonstrated, successful track record in Operations Improvement, Clinical Work Redesign, Benchmarking and results monitoring as well as strong project management skills. The ability to conduct educational training and coaching on project management, change management and Operations Improvement analysis is also essential."</blockquote>This position also has the hallmark of a "Director of Nothing" position, lacking executive presense and credibility with medical staff - especially tough medical specialists such as surgeons, invasive cardiologists, and the like:<blockquote>The Operations Improvement Director/Clinical Work Redesign will provide support, leadership and guidance to all system entities’ OI Teams during the implementation process. He/she will serve as a Team Leader and Major Change Agent leading multiple Redesign Teams. </blockquote>With a bachelor's or master's degree in field that is unspecified, such a person is likely going to have a very hard time convincing the medical staff of several major academic hospitals to acquiese to major work changes affecting how they practice medicine, for example. A summary of some of these issues is at the page "<a href="http://home.aol.com/informaticsmd/job1.htm">Ten critical rules about job structure and reporting for applied informatics positions</a>", authored by me in 1998 or so.<a href="http://home.aol.com/scotsilv/biography.htm">My background</a> was, for example, deemed unsuitable for this role when I inquired last year, despite the fact that I'd successfully led evaluation, acquisition and implementation of both vendor-acquired clinical IT (e.g., the Logician EMR), and personally led custom development of advanced <a href="http://members.aol.com/scotsilv/invascard.htm">subspecialty IT</a> (e.g., in Invasive Cardiology), in large (1500 bed) multi-hospital medical centers. The rejection was on the basis of "not having enough clinical process redesign experience." Not even called for an interview; the rejection was paper-based.Others with formal training and experience in Healthcare Informatics, with training and background similar to mine, were likely also rejected. This posting is a repeat on a primary site for NIH-program Informatics recruiting, namely, the website of the American Medical Informatics Association. It is a sad phenomenon to watch this apparent thrashing, essentially reflecting an "informatics immaturity", over and over again throughout a period dating back at least 12 years in my case, when I was an NIH Postdoctoral Fellow in Medical Informatics. Perhaps I should not complain. The pioneers in clinical IT began noting these issues 30+ years ago.It's also possible that resumes of those with formal Medical Informatics credentials scare the daylights out of some people in large medical centers -- for example, IT personnel with no clinical training or experience, and "Medical Instamaticists" (e.g., clinicians whose credentials in information technology amount to novice or intermediate-level tinkering as per this <a href="http://home.aol.com/informaticsmd/taxonomy1.txt">taxonomy of informatics skills</a>). The NIH has tried to introduce a cadre of specialists to make EMR implementation more efficient but even after more than a decade of dedicated funding for programs at some of the country's best universities, the word has not gotten out as well as it should have. In the end, patients (and taxpayers) <a href="http://www.sptimes.com/2004/02/19/Tampabay/Senator_hears_out_Bay.shtml">pay the price for errors in clinical IT implementation</a> - sometimes spectacularly so.As Roy Poses' correspondent notes below regarding leadership of <a href="http://hcrenewal.blogspot.com/2005/02/new-ceo-for-independence-blue-cross.html">Independence Blue Cross</a> of Pennsylvania:<blockquote>"What you're seeing is typical of most businesses. This seems to me to be the result of some myopic views taught in B-schools; "you don't have to know 'THE' business, just how to run 'A' business." Similarly, some folks think just because they can "do anything," they can run a business. I'm trying to convince them that "it ain't necessarily so." </blockquote>This myopia seems to permeate down far below the C-officer level in the so-called "<a href="http://www.amazon.com/exec/obidos/tg/detail/-/0787959707/qid=1107466486/sr=8-2/ref=sr_8_xs_ap_i2_xgl14/102-0163203-7198542?v=glance&s=books&n=507846">healthcare system</a>" in the U.S.I hope I'm wrong, but the Internist-learned pattern detection algorithms in my grey matter sense a long and arduous implementation process at Temple. That public money may be spent on this seven-year project (Temple University is a state-funded school) is a real issue. -- SS

Major medical center thrashes for clinical IT leadership

Major medical center in Philadelphia, Temple University, thrashes around for clinical IT leadership. This ad , regarding a "a seven-yea...

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