healthy4u

Outrageous extremely overpriced ridiculously simple EMR interfaces

This in from a 2005 college graduate working in healthcare IT for almost 3 years, with a technical background only, who has found my <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">site on HIT difficulties</a>. This person's been working with several hospitals and hospital groups to create interfaces to practices and labs as well as master patient index services. This HIT worker writes: <blockquote style="font-family:arial;">"...one other thing that I think should be covered is the outrageous extremely overpriced ridiculously simple (I opted to use as many adjectives that came to mind) task of creating an interface in an EMR. After doing a few interfaces myself and working with about a dozen or so EMR vendors the cost is ridiculous for the amount of work they actually do. The average cost that I've seen is about $4,000 to $6,000 USD, I've seen some that are 'free' I'll explain this one later, some upwards of $40,000+ and some in the realm of a few hundred. Under this secret shroud of "everything is complicated and takes tons of people and costs an arm and a leg" is really a two person job that takes about three to four hours, or even less if you know what you're doing. To create an interface between two systems one person configures their application to listen on a socket, and the other to configure the application to connect to an IP and a specific socket. This of course assumes the two systems are maintained by two different people. There is more that goes into creating an interface sure, but from an EMR point of view its two people. I've configured a [Big Vendor] interface with the vendor in 30 minutes. [Big Vendor] charges I think the number was $3,500 to $4,000 for the "Labor charge", [Big Vendor] is the 'free' one once you purchase the application you can create as many interfaces as you want. I've yet to meet a physician, nurse or office assistant that have the know-how to create an interface. Other EMR's charge per interface as if paying $15,000 for the application wasn't enough a physician must spend another $4,000 to $6,000 for a stinking interface! Yes its important that they have it but WOW! - $4,000 to $6,000 for 30 minutes of work? Some are longer, some interfaces require more configuration's which isn't much, most any worthwhile application already has default configurations and interfaces so one could load those and not go too far over 30 minutes of work, certainly not longer than a few hours though. Thinking of a typical practice that I've encountered, there are three general feeds: 1. General Labs - This interface would send over your microbiologies,blood tests etc. 2. Transcriptions - This interface would send over, well, transcriptions anything dictated. 3. Radiology - This interface would send over all your radiology transcriptions with the added feature of being able to handle images. Not that I've actually seen one in action, these are all just claims right now. The sheer size of radiology images dissuades labs from sending them over the system because of bandwidth issues, also because not many interfaces currently support DICOM, or one system in the flow doesn't support DICOM. So, if we take one of the larger EMR's, your eCW's, GE's, Misys's, Allscripts et cetera, the cost for one of these systems range from $12,000 to $15,000 that I've seen for a small practice. Then if you take the $4000 (lets be nice and give EMR's the lower number) at three interfaces for a total of $12,000 we have a system that costs $24,000 to $27,000. That's ridiculously insane for a broken system that somewhat works. Another thing that has always got me wound up with looking at these costs are that the EMR's know their application best, they know how the HL7 data should look, but they have no way of mapping the HL7 to be compliant with their systems. So I'm forced to map it for them, I'm lucky if they have specs, and if they do they're likely out dated (I have yet to receive a spec that was not out of date by the way). Reverse engineering an application's interpretation of HL7 is insane. To be fair, some vendors do offer though to do the mapping, then again they also charged $40,000+. I've tinkered with EMR systems when I can, some were nice, some were trash, most were trash. These applications work and look great for me, but lets face it, I'm no clinician I don't understand most of what is on the screen, I can fumble around though and figure things out. These applications are designed and developed by engineers, these applicationsonly make sense to engineers. These systems are pure trash. Here's to taking down the shroud and smoke screen HIT has put up the past couple decades. Feel free to post this in its entirety if it will help take down the smoke screen. </blockquote> Having been a CMIO, I can vouch for these expense levels charged for interfaces that I knew, also being a computer professional, were quite simple to code. -- SS

Outrageous extremely overpriced ridiculously simple EMR interfaces

This in from a 2005 college graduate working in healthcare IT for almost 3 years, with a technical background only, who has found my site on...

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The Malpractices of the Multitudes: the HIT Mission Hostile User Experience, Part 8

More on the origin of this post's title, penned in 1836, below. (Note: Part 1 of this series is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">here</a>, part 2 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">here</a>, part 3 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_24.html">here</a>, part 4 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html">here</a>, part 5 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_27.html">here</a>, part 6 is <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">here</a>, part 7 is <a href="http://hcrenewal.blogspot.com/2009/03/information-technology-makes-healthcare.html">here</a>, and part 8 is <a href="http://hcrenewal.blogspot.com/2009/03/malpractices-of-multitudes-mission.html">here</a>. 2011 addendums: a post that can be considered part 9 is <a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">here</a>, part 10 is <a href="http://hcrenewal.blogspot.com/2011/12/ehr-mission-hostile-user-experience.html">here</a>.) This post is part 8 of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at major medical centers. These devices provide a decidedly mission hostile user experience, yet with an almost religious fervor are being touted as cybernetic miracles to cure healthcare's ills. <blockquote>April 2011 addendum: see what might be considered part 9 <a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">at this link</a>.</blockquote> My college is a member of the <a href="http://www.ischools.org/">iSchool</a> consortium, consisting of schools of information science and technology (notably, not "information technology and science"). <blockquote>The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications.</blockquote> Note the "as well as." Note the primary focus, and that which is secondary. This philosophy parallels that of Medical Informatics well. This probably sounds like Martian to many in the healthcare and perhaps the broader business IT sector. One of my colleagues on reviewing this HIT series had this to say: <blockquote style="font-family: arial;"> It's really nice to hear that for once IT professionals have been able to successfully repeat the development lifecycle for healthcare information systems: <ul><li>Fail to understand the problem -></li></ul><ul><li>create a fragmentary and inaccurate requirements definition -></li></ul><ul><li>design an ambiguous, ignorant and risk-laden user interface -></li></ul><ul><li>pull all the misguided notions together with baling wire and call it a design-></li></ul><ul><li>translate the "design" into an executable form, adding and subtracting design elements at random -></li></ul><ul><li>observe the first output from the system and declare it ready for the healthcare professionals. fini</li></ul> Did I miss anything?</blockquote> I believe he captured the essense of today's HIT vendor market well. Here are examples of screen displays of vital patient information, displays that force clinicians to go on wild goose chases and seem designed by true neophytes to the field of information presentation and user interaction design. This is not to single out any one vendor. Many vendor products have deficiencies. See this display of something as simple (one would think) as blood pressures: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmvltC6XKg9_afHVtZV2WZ0TvHAEIQpEvXBBWRHkdj_uuUXFofKZ2vd0m7pZL6Y4fvgSG6IAvDZi-01x6FXwiJkE_qXeJklZRtWJlnhM31qXTn9IAN3SoBIXy4f96AVCypr5rGSyeAt_N9/s1600-h/bp1.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309109363406374482" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmvltC6XKg9_afHVtZV2WZ0TvHAEIQpEvXBBWRHkdj_uuUXFofKZ2vd0m7pZL6Y4fvgSG6IAvDZi-01x6FXwiJkE_qXeJklZRtWJlnhM31qXTn9IAN3SoBIXy4f96AVCypr5rGSyeAt_N9/s320/bp1.jpg" style="cursor: pointer; display: block; height: 269px; margin: 0px auto 10px; text-align: center; width: 429px;" /></a>(click to enlarge) <div style="text-align: left;"> Note the following: <ul><li>Diastolic blood pressures in the left column;</li><li>Systolic blood pressures in the roight column;</li><li>An adventure to match them by date;</li><li>No column headers at top.</li></ul> Which value goes with which? How much energy does it use up to scroll around and connect the two? This display is so poorly conceived, one wonders why it was included at all in a production system. There's more. Let's troll for data, shall we? See the blood oxygen saturation level, circled? <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu905SrE7UWqih06dfekAG55ypw5xED6AUaRoRY0-Wjr3odjrpQwAA0mFgxu_zx5a8LbhNks40uBeNXXNv2_yvqiAWSrOj2hUKa0wQfBvya9VrIq6Me0IhzX8dvcpx_eos6H6JZaND5VxJ/s1600-h/pulseox1.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309111713343813090" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu905SrE7UWqih06dfekAG55ypw5xED6AUaRoRY0-Wjr3odjrpQwAA0mFgxu_zx5a8LbhNks40uBeNXXNv2_yvqiAWSrOj2hUKa0wQfBvya9VrIq6Me0IhzX8dvcpx_eos6H6JZaND5VxJ/s320/pulseox1.jpg" style="cursor: pointer; display: block; height: 317px; margin: 0px auto 10px; text-align: center; width: 433px;" /></a>(click to enlarge)</div> What percentage oxygen was this patient receiving? It's not there! Where is it? Scroll down ... <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3mRxHdhg82E8YHmARGw4DK8MJSWJAmfPNBNaoZgRgTjdTu5E39LXvMM9uzmnJcBMEIzZAcEHf_OSMzFghi2teoOZoTIIRKiWgkSMon2E6SjcYik8-YLh70lTnjAAL6RTh5Yoyw1aI5E6M/s1600-h/pulseox2.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309112826374552962" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3mRxHdhg82E8YHmARGw4DK8MJSWJAmfPNBNaoZgRgTjdTu5E39LXvMM9uzmnJcBMEIzZAcEHf_OSMzFghi2teoOZoTIIRKiWgkSMon2E6SjcYik8-YLh70lTnjAAL6RTh5Yoyw1aI5E6M/s320/pulseox2.jpg" style="cursor: pointer; display: block; height: 342px; margin: 0px auto 10px; text-align: center; width: 412px;" /></a>(click to enlarge)</div> ... and down ... <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifM6KQKapHXEeScoAmiSvodQhpSkZ5RwkVCT_sWpAGAeD9yi47aTcHPd-ZyA69UxpnnG-8cZx0d-7Pe5iKgUBtkV0rqsckNYHiOZNhyphenhyphenEwiVTVxezg5MLgUJCSD1DiMSgelxAPUVUER64wD/s1600-h/pulseox3.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309114210505780354" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifM6KQKapHXEeScoAmiSvodQhpSkZ5RwkVCT_sWpAGAeD9yi47aTcHPd-ZyA69UxpnnG-8cZx0d-7Pe5iKgUBtkV0rqsckNYHiOZNhyphenhyphenEwiVTVxezg5MLgUJCSD1DiMSgelxAPUVUER64wD/s320/pulseox3.jpg" style="cursor: pointer; display: block; height: 336px; margin: 0px auto 10px; text-align: center; width: 403px;" /></a>(click to enlarge) <div style="text-align: left;"> Our answer, at last! Circled. Of course, the corresponding pulse oximetry is now off the screen. How much attention would it have taken to present the two together? How much coding would it have taken with today's computers, that execute billions of instructions per second, to dynamically condense the presentation of information, eliminating the absolutely empty cells between the two values? Similar isses are noted for other biomedically coupled values, such as coumadin dose and blood thinning value (INR). Screw matching those up, and as my mentor Victor P. Satinsky, MD might have said, your patient's dead. Speaking about information sparsity, how's this display? <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2u2XuKF_6ev1jaMi8nrl9NHK2pZueIvVWxEmRvdR9YewzNfU43HZ3A9hvThFc08qRN9cwz1moU_AVZVg3f52lM9m2SWdIZxbdfDrPLopxlzU10V7AF_u1QD4LpqbT3aiLRk0A3vX16Piv/s1600-h/sparse.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309115566446043474" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2u2XuKF_6ev1jaMi8nrl9NHK2pZueIvVWxEmRvdR9YewzNfU43HZ3A9hvThFc08qRN9cwz1moU_AVZVg3f52lM9m2SWdIZxbdfDrPLopxlzU10V7AF_u1QD4LpqbT3aiLRk0A3vX16Piv/s320/sparse.jpg" style="cursor: pointer; display: block; height: 311px; margin: 0px auto 10px; text-align: center; width: 428px;" /></a>(click to enlarge) <div style="text-align: left;">There's one value in the entire screen. What a waste. How much difficulty would it have been to simply present the one row, automatically? The EHR disperses and fragments vital patient information. How, exactly, is this is supposed to make clinicians more efficient and less error prone? I am only presenting the easiest to present problems, easiest that is in a static medium such as a blog. If presented dynamically, we find with some EHR's, for example, that it takes 50 or so mouse clicks across various screens and drop down lists and drop boxes to enter 5 common diagnoses. It takes selecting from multiple hierarchical lists and buttons across four different screens, multiple times repetitively, to find out how well a patient is eating. Here is simple advice from J Gen Intern Med 2009; 24(1):21-26. <blockquote> It is imperative that usability principles are embedded in CPOE design to avoid • overly complex screens • poor grouping of like terms • an inflexible human-computer interface • mis-use of clinician time</blockquote> Do the HIT vendors actually read such advice? I wonder. Medical Informatics reminds me of dentistry in its early days. B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to Medical Informatics in our present age: <blockquote face="arial">The word "dentist" has been so infamously abused by ignorant pretenders, and is in general so indifferently understood, that I cannot forbear giving what I conceive to be its original meaning: viz, the profession of one who undertakes and is capable not only of cleaning, extracting, replacing by transplantation and making artificial teeth, but can also from his knowledge of dentistry, preserve those that remain in good condition, prevent in a very great degree, those that are loose, or those that are in a decayed state, from being further injured, and can guard against the several diseases, to which the teeth, gums and mouth are liable, a knowledge none but those regularly instructed, and who have had a long, and extensive practice, can possibly attain, but which is absolutely necessary, to complete the character of a Surgeon Dentist.</blockquote> Hardly anyone spoke out. More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to Medical Informatics and healthcare IT: <blockquote style="font-family: arial;"> One thing is certain, this profession must either rise or sink. If means are not taken to suppress and discountenance the malpractices of the multitude of incompetent persons, who are pressing into it, merely for the sake of its emoluments, it must sink, - for the few competent and well educated men, who are now upholding it, will abandon a disreputable profession, in a country of enterprise like ours, and turn their attention to some other calling more congenial to the feelings of honorable and enlightened men.</blockquote> I understand that point of view. And with that, I end this series. -- SS </div></div></div></div></div></div>

The Malpractices of the Multitudes: the HIT Mission Hostile User Experience, Part 8

More on the origin of this post's title, penned in 1836, below. ( Note: Part 1 of this series is here , part 2 is here , part 3 is h...

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Lilly: "I were referred to me as person who specializes in pharmaceutical based informatics and wanted to reach out to me."

At "<a href="http://hcrenewal.blogspot.com/2009/01/what-me-worry-lilly-fined-over-zyprexa.html">What, Me Worry? Lilly Fined Over Zyprexa, Should Be Fined For eRecruitment Inanity As Well?</a>", I wrote about a very bizarre eRecruiting message I received from Eli Lilly: <blockquote face="arial"> In just about the most bizarre and inane recruiting email I think I've ever received, this unsolicited gem came in to my professional email account. This is at least the second time I received this identical message in the past few weeks.</blockquote> It began with "Dear MD." Click on the above link to see that solicitation. I didn't think it could get much worse than that. I was wrong. This just in, exactly as received (emphases mine): <blockquote style="font-family: arial;"> From: Hank Gehron <hank.gehron@rightthinginc.com> Sent: Tue, 3 Mar 2009 7:45 am Subject: Your Help Is Requested for a Eli Lilly Career Opportunity! (Discovery Informatics Director at Indianapolis) </hank.gehron@rightthinginc.com> <div align="left">I am a member of the Staffing Team at Eli Lilly. I were referred to me as person who specializes in pharmaceutical based informatics. I wanted to reach out to me, to see if you maybe able to recommend anyone that could qualify for the below position. [Perhaps I should recommend my grade school English teacher to go over this solicitation with a big red marking pencil? - ed.] </div> <div align="left">For more than 130 years, Eli Lilly and Company has been dedicated to meeting the health care needs of people in the United States and around the world. We address these needs primarily by developing innovative medicines-investing a higher percentage of our sales in research and development than any other major pharmaceutical company. If you are interested in being considered for employment with a "Best in Class" Pharmaceutical company, please review the following opportunity. </div> <div align="left">Please feel free to call me with any questions; or perhaps you may know of someone that could qualify. </div> <div align="left">Your consideration is most appreciated. </div> <div align="left">Hank Gehron, MBA, SPHR Lilly Talent Acquisition Team / RightThing Recruiting Process Outsourcing work. 610-263-3030 Ext. 4450, Country Code 001 blackberry. 610-836-1856 <a href="mailto:hank.gehron@rightthinginc.com">hank.gehron@rightthinginc.com </a> </div></blockquote><div align="left"> </div> Then there are the "requirements": <blockquote>MINIMUM REQUIREMENTS: M.S. or Ph.D. in Biology, Chemistry, or related Computational sciences Minimum of 8-10 years experience in biotech or pharma industry Minimum of 3-5 years managing/leading Informatics teams Strong understanding of genomic, proteomic, expression, and imaging platforms. Experience in the specifications, design, development, and deployment of bioinformatics, chemo-informatics, and translational informatics tools and analysis to support research portfolio. </blockquote> Note no call for formal medical or medical informatics training, as this position is not really "Discovery Informatics" (which would encompass medical informatics), it is primarily bioinformatics or "gene stuff." I commented on that field at "Has Bioinformatics Hit a Hard Wall of Stagnation?" <a href="http://hcrenewal.blogspot.com/2009/01/has-bioinformatics-hit-hard-wall-of.html">here</a>. I will not comment further, only asking a simple question: Is this a company you would want to work for or that inspires confidence in its ability to produce safe medicines? <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeS0Pj1l05PAku7KWlbhjKs48DG1jASdsevfMGhNGjW78zANl7Ehe1GfBSqbGggcqm0MOmu3-D-xr3o3ExkXl0nl1yQtd3CANbRQm8szR_4r3ju985uje9z5XsTVk7Ek-Pa5MSQRWiJrHA/s1600-h/alfred_e_neuman.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5309060942816173682" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeS0Pj1l05PAku7KWlbhjKs48DG1jASdsevfMGhNGjW78zANl7Ehe1GfBSqbGggcqm0MOmu3-D-xr3o3ExkXl0nl1yQtd3CANbRQm8szR_4r3ju985uje9z5XsTVk7Ek-Pa5MSQRWiJrHA/s320/alfred_e_neuman.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 125px; height: 163px;" /></a>What? Me worry about talking good with grammar? </div> -- SS

Lilly: "I were referred to me as person who specializes in pharmaceutical based informatics and wanted to reach out to me."

At " What, Me Worry? Lilly Fined Over Zyprexa, Should Be Fined For eRecruitment Inanity As Well? ", I wrote about a very bizarre...

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Meet the New Boss, Same as the Old Boss? - Health Care Reform to be Lead by a Director of Boston Scientific, Cerner, and Medco

Today we learned that President Obama has announced his new picks for Secretary of Health and Human Services and for Director of the White House Office for Health Reform. The choice of Nancy-Ann DeParle for the latter position raises some issues. The NY Times <a href="http://www.nytimes.com/2009/03/03/us/politics/03health.html">provides some background</a>: <blockquote> He also named Nancy-Ann DeParle to coordinate health policy for the administration. Her position, counselor to the president and director of the White House Office for Health Reform, is not subject to Senate confirmation. Ms. DeParle was commissioner of the Tennessee Department of Human Services from 1987 to 1989. Under President Bill Clinton, from 1997 to 2000, she was administrator of the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services. Since then, she has gained extensive experience in the business world. That experience, though seen as an asset by many, prompted questions from some of the people vetting personnel for Mr. Obama, supporters of Ms. DeParle said. Ms. DeParle has been a director of large health care companies including Medco Health Solutions, a pharmacy benefit manager; Cerner, a supplier of health information technology, including electronic medical records; Boston Scientific, a medical device company; DaVita, which runs kidney dialysis centers; and Triad Hospitals. </blockquote> In addition, <a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/03/02/AR2009030200371.html">according to the Washington Post</a>, <blockquote> DeParle, 52, was previously commissioner of the Department of Human Services in Tennessee. During the Clinton administration, she worked in the Office of Management and Budget and later oversaw Medicare and Medicaid as the administrator of the Health Care Financing Administration. DeParle currently is managing director of CCMP Capital, a private equity firm. She also serves on the boards of several firms related to health care. A White House spokesman said she is in the process of resigning all those positions. </blockquote> Administration spokespeople apparently brushed aside any questions about Ms DeParle's conflicts of interest. A <a href="http://www.nytimes.com/2009/03/03/us/politics/03czar.html">separate article in the NY Times </a>noted: <blockquote> In picking Nancy-Ann DeParle to champion an overhaul of the nation’s health system, President Obama selected someone with deep roots in the Washington bureaucracy, an intimate familiarity with health policy and respect on both sides of the political aisle — not to mention degrees from Harvard Law School and Oxford University. But in putting Ms. DeParle in charge of an issue that has bedeviled presidents for decades, Mr. Obama also chose to overlook Ms. DeParle’s business ties to companies that have a direct stake in the health care debate. In announcing her appointment Monday as the director of the White House Office of Health Reform, Mr. Obama expressed 'absolute confidence' in Ms. DeParle, who ran the agency that oversaw Medicare and Medicaid during the Clinton administration. But the White House instantly faced questions about whether her appointment was skirting the spirit, if not the letter, of the president’s tough conflict-of-interest policy. Since leaving the Clinton administration, Ms. DeParle has been managing director of a private equity firm, CCMP Capital, and a board member of companies like Boston Scientific, Cerner and Medco Health Solutions. White House officials said Ms. DeParle was severing ties with those companies and would recuse herself from participating in any matter that was 'directly or substantially' related to former clients or employers. 'It is our view, and the view of counsel here, that the incidence of that will be very low,' an administration official said of the need for Ms. DeParle to recuse herself from decisions. The official, who was not authorized to speak publicly, said Ms. DeParle would be working mostly with federal agencies and lawmakers, and not directly with companies. </blockquote> MedInformaticsMD just <a href="http://hcrenewal.blogspot.com/2009/03/cerner-board-member-as-healthcare-czar.html">posted</a> about his concerns specifically vis a vis Ms DeParle's current position as a leader of Cerner. My main concern here is that Ms DeParle's ties to multiple health care corporations are so strong as to jeopardize her ability to be the new leader of health care reform for the whole country. To review, Ms DeParle is currently a member of the boards of three health care corporations, Boston Scientific, Cerner, and Medco. As we have <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">discussed</a> many times previously, a corporate director has a legal obligation to advance the profits and financial fortunes of the corporation he or she serves. As Robert AG Monks put it, corporate directors are supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. <a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986">Corporate Governance</a>, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] As compensation for that loyalty, corporate directors are usually exceedingly well-paid for the nominal hours they spend in their meetings. In particular, per <a href="http://ccbn.10kwizard.com/xml/download.php?repo=tenk&ipage=5545615&format=PDF">the company's 2008 proxy statement</a>, in 2007, Ms DeParle received $160,338 in total compensation from Boston Scientific, and held 62,020 of its shares. Further, per <a href="http://library.corporate-ir.net/library/11/118/118401/items/287619/CERN_2008proxy.pdf">the Cerner 2008 proxy statement</a>, in 2007 she received $195,051 from that company, and held 27,000 of its shares. Ms DeParle was just elected to the Medco board in 2008, so her compensation and stock holdings were not listed in <a href="http://ccbn.10kwizard.com/xml/download.php?repo=tenk&ipage=5588519&format=PDF">that year's proxy statement</a>, but presumably her total compensation would mirror what other directors received in 2007: a retainer of $50,000, and an annual grant of shares and options worth $175,000 at the time it would be granted. Given her previous obligation of "unyielding loyalty"to and generous compensation from major health care corporations, it might be hard to suddenly be indifferent to their interests. Of course, a White House spokesperson pledged that Ms DeParle would "recuse herself from any matter that was 'directly or substantially' related to former clients or employers." The problem is that most of the issues that might come up in discussions of health care reform might be directly and substantially related to the interests of the companies Ms DeParle now leads. For example, one obvious way to control costs in a reformed health care system would be to reduce the current reimbursement system's bias in favor of procedures over cognition. Boston Scientific makes much of its money selling devices that are used during such procedures. Any general shifting of reimbursement more in favor of cognition rather than procedures could reduce Boston Scientific's profits, profits which Ms DeParle is currently sworn to protect. So would Ms DeParle recuse herself from all discussions of reimbursement? I submit that if Ms DeParle recused herself from discussion of all issues that might affect the interests of Boston Scientific, Cerner, and Medco, let alone the private corporations she directs whose interests might be less easy to define, and let alone the corporations which she used to direct, she would have very little to do in her new position. On the other hand, were Ms DeParle to be an active Director of the White House Office of Health Care Reform, would the reform be in the interests of all the US people, or in the interests from the large and powerful corporations whose interests she was so recently pledged to protect? Does this new appointment truly reflect President Obama's statement that he did not come to Washington "to work for the powerful and well-connected interests who have run this city for too long?"

Meet the New Boss, Same as the Old Boss? - Health Care Reform to be Lead by a Director of Boston Scientific, Cerner, and Medco

Today we learned that President Obama has announced his new picks for Secretary of Health and Human Services and for Director of the White H...

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Cerner board member as Healthcare Czar

President Obama has declared that National Electronic Health Records are essential to curing healthcare's ills. From <a href="http://www.msnbc.msn.com/id/29466833/" style="font-family: arial;">MSNBC</a>: <blockquote style="font-family:arial;">WASHINGTON - President Barack Obama will name former Clinton administration health official Nancy-Ann DeParle on Monday to lead the newly created White House Office on Health Reform, a U.S. official said.DeParle, a former administrator of what is now the Centers for Medicare and Medicaid Services, will lead the White House office charged with coordinating Obama's ambitious healthcare reform efforts with Congress. </blockquote>From the <a href="http://www.nytimes.com/2009/03/03/us/politics/03czar.html?ref=us" style="font-family: arial;">NY Times:</a> <blockquote style="font-family:arial;">WASHINGTON — In picking Nancy-Ann DeParle to champion an overhaul of the nation’s health system, <a href="http://topics.nytimes.com/top/reference/timestopics/people/o/barack_obama/index.html?inline=nyt-per" title="More articles about Barack Obama.">President Obama</a> selected someone with deep roots in the Washington bureaucracy, an intimate familiarity with health policy and respect on both sides of the political aisle — not to mention degrees from <a href="http://topics.nytimes.com/top/reference/timestopics/organizations/h/harvard_university/index.html?inline=nyt-org" title="More articles about Harvard University.">Harvard</a> Law School and <a href="http://topics.nytimes.com/top/reference/timestopics/organizations/o/oxford_university/index.html?inline=nyt-org" title="More articles about Oxford University">Oxford University</a>. But in putting Ms. DeParle in charge of an issue that has bedeviled presidents for decades, Mr. Obama also chose to overlook Ms. DeParle’s business ties to companies that have a direct stake in the health care debate.</blockquote> From <a href="http://www.cerner.com/public/Cerner_2.asp?id=27436" style="font-family: arial;">Cerner Corp</a>, one of the largest vendors of Health IT: <blockquote style="font-family:arial;"> Nancy-Ann DeParle was appointed to Cerner Corporation's Board of Directors in May 2001.</blockquote> From the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=granger_speaks_out" style="font-family: arial;">former head of the UK's Connecting For Health</a> National HIT program: "Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that Cerner has put in recently is appalling ... Cerner and prime contractor Fujitsu had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome -identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."<o:p></o:p> From <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm" style="font-family: arial;"> The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee, Jan 2009:</a> <blockquote style="font-family:arial;">... 5 The termination of Fujitsu's contract has caused uncertainty among Trusts in the South and new deployments have stopped. One option being considered for new deployments is for Trusts to have a choice of either Lorenzo provided through CSC or the [Cerner] Millennium system provided through BT. There are, however, considerable problems with existing deployments of [Cerner] Millennium and serious concerns about the prospects for future deployments of Lorenzo. Before the new arrangements for the South are finalised, the Department should assess whether it would be wise for Trusts in the South to adopt these systems. Should either of the Local Service Providers take on additional commitments relating to the South, the Department should take particular care to assess the implications of the extra workload for the quality of services to Trusts in the Local Service Providers' existing areas of responsibility. 6 The Programme is not providing value for money at present because there have been few successful deployments of the [Cerner] Millennium system and none of Lorenzo in any Acute Trust. Trusts cannot be expected to take on the burden of deploying care records systems that do not work effectively. Unless the position on care records system deployments improves appreciably in the very near future (i.e. within the next six months), the Department should assess the financial case for allowing Trusts to put forward applications for central funding for alternative systems compatible with the objectives of the Programme.</blockquote> This appointment appears to my untrained eye, on the surface, to be a problem, even with typical promises that these conflicts of interest will not affect decisions. From the NY Times article: <blockquote style="font-family: arial;">White House officials said Ms. DeParle was severing ties with those companies and would recuse herself from participating in any matter that was “directly or substantially” related to former clients or employers.</blockquote> That is a relief - somewhat. This HIT company is likely to make huge profits in coming years. Will Ms. DePerle give up all financial stakes in this company and industry she and/or her family may hold such as stock, options and other tangibles? In a more general sense, can we as a country really trust such statements from business and government leaders any more? Should we? The <a href="http://www.dcexaminer.com/opinion/Obamas-HIT-will-likely-be-a-miss-40512247.html" style="font-family: arial;">Washington and San Francisco Examiners</a> have it about right in this common sense-filled editorial in which I am cited (I played no part in its appearance): <div id="article_inner" style="font-family:arial;"> <blockquote><h1>America’s foray into HIT will likely be a miss</h1> Examiner editorial 3/2/09 There is a provision of the $878 billion stimulus package rushed through Congress for $20 billion to develop a centralized national health information technology system. Proponents claim HIT will save $77 billion during the next 15 years and greatly reduce medical errors. Who could possibly object to that? Well, for starters, ask health care providers in Britain’s National Health Service, who have been trying to get their HIT system to work properly for the past five years. The cost of NHS’ HIT has escalated to six times the original estimate — the U.S. equivalent of $18.4 billion — to serve just 30,000 physicians in 300 state-run hospitals, a fraction of the health care providers in the United States. In January, Public Accounts Chairman Edward Leigh reported to fellow members of Parliament that essential systems are late or, when deployed, do not meet expectations of clinical staff. HIT is such a mess that Leigh recommended funding alternative systems if matters don’t improve within the next six months. But even if HIT is eventually junked, British taxpayers will still have to pay for it. The National Academies of Science noted that much of the electronic medical data collected in the U.S. is used mainly to comply with regulations or to defend against lawsuits, rather than to improve patient care. A large 2003-04 study of 1.8 billion ambulatory patients discovered that the use of electronic health records provided no difference in 14 of 17 quality-care indicators, produced significantly better care in just two and worse care in one. And, a summary of 33 studies done in Europe between 1985 and 2009 found that HIT actually causes a significant number of medical errors. After spending billions of dollars during the past three decades, only 4 percent of U.S. physicians have a fully functional HIT system, according to Drexel University biomedical informatics professor Scot Silverstein — and its not because doctors don’t want to use technology. These expensive systems are just not designed for their extremely complex and highly specialized needs. In an open letter to President Barack Obama, Silverstein said HIT is an experiment that’s unproven on a large scale. Computers in hospitals have also been linked to the spread of MRSA, a deadly antibiotic-resistant staph infection. Yet, the same federal government that can’t keep its own military veterans’ medical records secure is bound and determined to spend $20 billion in a top-down, centralized effort that has a very good chance of messing up yours.</blockquote> </div> This raises several questions: <ul><li>Was Ms. DeParle as a board member at Cerner acting definitively when complaints such as those from the UK came in? And perhaps do a google search on terms such as <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&q=healthcare+IT+failure&btnG=Google+Search">healthcare IT failure</a>? </li></ul><ul><li>Will Ms. DeParle support or oppose <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/regulation_and_oversight_hoffman.pdf">needed federal regulation</a> of an industry in which she holds (held) a Board Membership? </li></ul><ul><li>With (former) board members of HIT companies whose products apparently caused the UK's CfH program to cry "uncle" now in positions of ultimate power over U.S. healthcare, and with an administration locked into irrational exuberance over HIT, should physicians in the U.S. also look forward to a forced cybernetic dystopia as at my series <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">starting here</a>?</li></ul> Finally, this is not a piece against our President. He is not, nor expected to be, an expert in information technology and healthcare informatics. I actually feel sorry for him. I feel sorry for him in letting reactionary and opportunistic corporate elements of the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=ecosystem">healthcare IT ecosystem</a> lead him to make calls for full national HIT, along with penalties for nonadoption of this experimental and often defective technology, on the hyperaggressive, absurd and in fact damaging timeframe of five years, by 2014. See "<a href="http://www.jamia.org/cgi/content/short/13/1/106" style="font-family: arial;">Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless?</a>" by Ford et al. And parroting the industry line, declaring with full confidence that Health IT will improve quality and decrease healthcare costs. The evidence on both issues is, let's just say, far more contradictory and questionable than the evidence that VIOXX kills people. -- SS

Cerner board member as Healthcare Czar

President Obama has declared that National Electronic Health Records are essential to curing healthcare's ills. From MSNBC : WASHINGTON ...

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Chatting away on iGoogle...

I'm a creature of habit. My morning routine consists of going to my desk with coffee mug in hand and checking my email, reading the news and updating my to-do list. One place I can do all of that without having to go to multiple websites is <a href="http://www.google.com/ig">iGoogle</a>. Having the ability to work on email right on my iGoogle page has been awesome, but I simply couldn't get the same Gmail experience without the chat feature. So we got together with the iGoogle team several months back to talk about how to integrate a chat feature on iGoogle, and since then, we've been running experiments with a small number of iGoogle users and have also been using it internally. We're pleased to announce that starting today we are extending the feature to a larger set of iGoogle users. Similar to the chat feature on Gmail, people will be able to send instant messages to their colleagues, friends and family straight from their iGoogle page. We've made this easy. If you're already a Gmail chat user, all your current chat settings will apply to iGoogle, so things will work the way you like in both places. But even more exciting is that you'll even be able to chat with friends who don't yet have a Gmail address — any email address will do. All you have to do is invite them as a chat buddy, and if they accept your invitation and sign up for iGoogle with their personal email account, their name becomes just a click away right on your page. Don't want to be bothered while you're checking out the latest news or reading your emails? You have a couple of options to hid the chat feature. You can either click the chat “options” link and selecting “hide chat,” or sign off completely by selecting "sign out of chat." It's worth noting that this feature may have some kinks, so we ask for your patience as we work through them. Here at Google, it's common practice for us to involve our users as early possible so we can make sure we get it right. We'll also be rolling this feature out slowly, so if you don't see it on your iGoogle page and you simply can't wait to check it out, feel free to opt in by going to <a href="http://www.google.com/ig/v2invite">www.google.com/ig/v2invite</a>. Currently, iGoogle chat is rolling out in English for our U.S. users. But don't worry, the feature is coming soon for other iGoogle supported languages and countries. You can check out our <a href="http://www.google.com/support/websearch/bin/answer.py?hl=en&answer=126293">Help Center</a> for more information on how it works, and as always, we are interested in hearing any <a href="http://www.google.com/support/forum/p/Web+Search?hl=en">feedback</a> you have. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKjvyZBIxJtgIjoeD_9PGUSbUmj1qbllA3PKPr8NCKEwLx8paAjOmglD81-OD6E2UWefoIlUecTX3xU4l6p8kKCo8vRKWO5Szb0FQYDXRne1sDcoXkE8UtAaIAPE3BxnV6medSICBJt3rg/s1600-h/iGoogle+chat.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5307652875888870546" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKjvyZBIxJtgIjoeD_9PGUSbUmj1qbllA3PKPr8NCKEwLx8paAjOmglD81-OD6E2UWefoIlUecTX3xU4l6p8kKCo8vRKWO5Szb0FQYDXRne1sDcoXkE8UtAaIAPE3BxnV6medSICBJt3rg/s400/iGoogle+chat.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 294px;" /></a> Posted by Rhett Robinson, Google Talk Engineer

Chatting away on iGoogle...

I'm a creature of habit. My morning routine consists of going to my desk with coffee mug in hand and checking my email, reading the news...

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A $4.3 Million Dollar CEO for a Not-For-Profit Health Care Insurance Corporation

The US stock markets are at lows unseen for more than 10 years, unemployment is rising, around the world national deficits are increasing, and times are tough for ostensibly not-for-profit Blue Cross and Blue Shield of Massachusetts, the state's largest health care insurer/ managed care organization. <a href="http://www.boston.com/business/healthcare/articles/2009/02/28/blue_cross_ceos_pay_rose_26/">Per the Boston Globe</a>: <blockquote> Blue Cross-Blue Shield's business was affected by the stock market decline, the recession, and the increasing cost of medical care. Membership at the state's largest health plan declined about 40,000 to just over 3 million. 'The decline in membership had an impact on results,' said chief financial officer Allen Maltz. 'In addition, many of our customers changed their benefits plans to products that have much lower margins.' Blue Cross-Blue Shield insures employees of national companies that have locations outside Massachusetts, Maltz said, and those customers accounted for some of the drop-off in membership. Maltz said Blue Cross-Blue Shield aims for a profit margin of between 1.5 and 2 percent. Last year's margin was almost zero. The firm had operating income from its medical claims business of just $1.6 million. A new state assessment on reserves lowered income by $21 million, Maltz said. Revenue was flat at $6.7 billion, and medical claims were also unchanged at $6 billion. Like most health insurers, Blue Cross-Blue Shield also relies on investment income, which fell 28 percent to $111 million. Maltz said the firm managed to avoid losses in the market by investing primarily in bonds and avoiding derivative securities that have declined precipitously in value. </blockquote> Well, things are tough all over. But they are apparently not so tough for Blue Cross Blue Shield's CEO: <blockquote> The salary and bonus paid to Cleve L. Killingsworth, chairman and chief executive of Blue Cross and Blue Shield of Massachusetts, increased 26 percent last year, to $3.5 million, even though the health insurer's membership declined and its net income fell 49 percent. Based on previous years' retirement benefits - which Blue Cross-Blue Shield did not report for 2008 - Killingsworth's total pay package was likely about $4.3 million, making him by far the highest paid healthcare executive in Massachusetts. </blockquote> And what was the justification for Killingworth's stellar pay? <blockquote> Salaries at Blue Cross-Blue Shield were inflated by a complex executive bonus plan in which senior officials get bonuses based on a rolling average of the previous three years. 'These executives and the company performed and exceeded our expectations,' said Jay McQuaide, a Blue Cross-Blue Shield spokesman. 'They earned these incentives.' The key metrics in the incentive plan are membership and net profit, he said. </blockquote> The company's board of directors did not do badly either. Unlike most boards of not-for-profit corporations, this one was paid: <blockquote> The insurer's board members also received a 33 percent increase in base pay, from $30,000 a year to $40,000. Most earn far more because of payments for attending meetings and serving on committees. </blockquote> Finally, <a href="http://www.bostonherald.com/business/general/view.bg?articleid=1155201&srvc=home&position=1">according to the Boston Herald</a>, other executives did quite nicely too: <blockquote> Bay State health insurance bosses continued to rake in multimillion-dollar compensation packages last year as the state and its taxpayers struggled to pay ever-increasing health-care costs. Data filed yesterday with the state’s Division of Insurance shows that Blue Cross Blue Shield of Massachusetts, the state’s largest HMO, doled out million-dollar pay packages to five executives, while Harvard Pilgrim Health Care paid its two highest-ranking executives a total of $2.7 million. Blue Cross’ top earner is Peter Meade, who retired last spring as executive vice president of corporate affairs. Meade took home $4 million, a sum that includes retirement benefits accrued during his 12 years at the HMO. </blockquote> It's just amazing that with all their talk about "pay for performance," top executives of health care organizations seem to make huge sums year in and year out, regardless of their organization's performance. (As an aside, how could someone say that the company's pay for performance "main metrics" were membership and net profit, when both fell, yet the CEO's pay rose?) There was a brilliant discussion of the culture that lead to this sad state of affairs <a href="http://www.timesonline.co.uk/tol/comment/columnists/minette_marrin/article5822151.ece">in the Times (UK) by Minette Marrin</a>. It was about British bankers, but it just as well could have been about American health care executives: <blockquote> The filthy rich, as Peter Mandelson affectionately calls them, are different. It is not just that they’re rich but that there’s something about being extremely rich that blurs ordinary perspective in all but the most exceptional people. Power may corrupt, but extreme wealth blinds and deafens. I first came across the filthy rich just after I was married and went to live in Hong Kong in the 1970s. Leaving poverty-stricken Britain, my husband and I joined a gold rush of bankers and brokers to what was then still a crown colony. What we saw was wealth and conspicuous consumption beyond the wildest dreams of avarice. Though we weren’t extremely highly paid, we spent a lot of time with people who were. Some were entrepreneurs and others were employees of banks and trading houses that, as today, offered them ways of making megabucks. Soon it became obvious that being very rich is like catching an insidious virus. Some people are able to resist it, but with most people the super-riches virus burrows into your nervous system for life. It blurs your perspective, weakens your grasp on reality and changes your identity into someone who is entitled to be very rich. </blockquote> Ms Marrin's description of "plutocratic blindness" seems to apply to a CEO of a so-called not-for-profit organization who could claim more than $4 million in a year in which the global economy collapsed, and his own organization did rather badly by any financial measure. This passage by Ms Marrin seems applicable to the Blue Cross Blue Shield Board who approved this disproportionate pay package: <blockquote> But I do know things are done quite differently on the parallel planet inhabited by the filthy rich. Remuneration boards unselfconsciously award each other astonishing packages, wrapped up in euphemism. </blockquote> The lack of selfconsciousness in this case may have been driven by the board's familiarity with how things used to be done in the American financial sector. A quarter of the board's members are leaders in that sector (see post <a href="http://hcrenewal.blogspot.com/2009/01/to-whom-did-scorpions-in-bottle-owe.html">here</a>). Let me close with Ms Marrin's suggested solution: <blockquote> The filthy rich culture that has developed in the past 20 years is sick. It needs strong medicine, fresh air, open windows. Above all, what’s needed is a cold dose of fear – fear of failing, of being sacked and of losing the lovely money. Here is an excellent antidote to greed. </blockquote>

A $4.3 Million Dollar CEO for a Not-For-Profit Health Care Insurance Corporation

The US stock markets are at lows unseen for more than 10 years, unemployment is rising, around the world national deficits are increasing, a...

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