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Indiana Power Surge: The Hospital Computing Backwater And The Need to Reform IT Before IT Reforms Medicine

In the three part series "<a href="http://hcrenewal.blogspot.com/2009/02/hospital-it-backwater-20-billion-abyss.html">Healthcare IT Backwater: The $20 Billion Abyss?</a>" I lamented that hospitals are often an IT backwater, and the backwater mentality would severely hamper efforts to "reform healthcare" via IT: <blockquote><dl><dt class="hwrd"><a href="http://www.merriam-webster.com/dictionary/backwater">Merriam-Webster</a>:</dt><dt class="hwrd"> </dt><dt class="hwrd">Main Entry: back·wa·ter <a class="audio" href="http://www.merriam-webster.com/cgi-bin/audio.pl?backwa04.wav=backwater%27" onclick=" popWin('/cgi-bin/audio.pl?backwa04.wav=backwater'); return false; "><img alt=" Listen to the pronunciation of backwater" src="http://www.merriam-webster.com/images/audio.gif" title=" Listen to the pronunciation of backwater" /></a></dt><dt class="pron">Pronunciation: \-ˌwȯ-tər, -ˌwä-\</dt><dt class="pron">Function: noun</dt><dt class="func">Date: 1629</dt></dl>- an isolated or <a class="formulaic" href="http://www.merriam-webster.com/dictionary/backward">backward</a> place or condition</blockquote> Computing is not a hospitals' core competency, salaries for IT personnel are usually lower than in other industries, and talent mismanagement in hospitals is far worse than in other sectors where IT is critical (e.g., health IT recruiters retained by hospitals have traditionally been generalists, or worse, recruiters with attitudes <a href="http://hcrenewal.blogspot.com/2008/09/correcting-historical-misinformation.html">such as this</a>): <blockquote>I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in <st1:place st="on"><st1:city st="on">San Rafael</st1:city>, <st1:state st="on">California</st1:state></st1:place> about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, <st1:place st="on"><st1:city st="on">Northbrook</st1:city>, <st1:state st="on">Illinois</st1:state></st1:place>, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.</blockquote><o:p></o:p> <o:p> </o:p> The end result of the hospital IT backwater mentality is stories such as this: <blockquote>Indystar.com <a href="http://www.indystar.com/apps/pbcs.dll/article?AID=/20090603/LOCAL18/906030346">Hospital is forced to turn away patients</a> Methodist Hospital went "on diversion" early Tuesday for the first time in its 100-plus years, sending ambulances that came to its doors to other hospitals.The diversion lasted until about 3 a.m., Wide said. A power surge knocked out Clarian Health's computer system Monday afternoon, derailing the hospitals' ability to access electronic health records for patients, said Clarian spokesman James Wide. Staff members at Methodist and Indiana University Hospital had to enter patients' records by hand. By about 1 a.m. Tuesday, a backlog of paperwork led Methodist and IU hospitals to stop accepting patients who arrived by ambulance. Walk-in patients were still accepted. The diversion lasted until about 3 a.m., Wide said.</blockquote> This raises a number of questions: <ul><li>Which power system "surged?" Shouldn't hospitals be protected from such "surges?" </li><li>Was any other equipment "knocked out?" CCU/ICU monitors? Ventilators? Heart-lung machines? If so, why were they not protected? If they were not knocked out but the EHR was, why? </li><li>What computers, exactly, were knocked out? Does not sound like the workstations, which would be rebooted quickly. Therefore must have been data center servers...and if so... </li><li>Why were the EHR servers vulnerable to "power surges"? </li><li>Or was this EHR a remote hosted ASP arrangement and did the surge occur at the service provider...in which case, the above question also applies? </li><li>Where were the backup systems? Were there backup systems? </li><li>Who performed the "backlog of paperwork?" Was it clinicians backloading the paper data into the system? -- in which case a power surge would have turned doctors into the world's most highly trained data entry clerks? </li></ul><div> </div>Of course, there was the usual refrain by non-clinical management, as I wrote at "<a href="http://hcrenewal.blogspot.com/2009/05/health-it-failure-never-puts-patients.html">Health IT Failure Never Puts Patients at Risk</a>", that such outages are just minor blips on the radar. In another account of this story: <blockquote>WTHR.com Eyewitness News <a href="http://www.wthr.com/Global/story.asp?S=10461766&nav=menu188_2">Power surge forces hospitals to divert new patients</a> Updated: June 2, 2009 07:57 AM Indianapolis - Methodist and Indiana University Hospitals are back open and accepting new patients. Monday around 3:45pm a massive power surge hit the hospitals crashing their computer system. IPL responded quickly to assist with bringing the system back online. In the meantime, the hospitals began doing things on paper, like patient charting, that had been done by computer. There was no disruption in patient care, however, around 1am Tuesday both hospitals decided to stop taking new patients [that's not a "disruption in patient care?" - ed.] As of 3:15am most of the primary care system was back up and running and Methodist starting taking some new patients. I.U. Hospital continued to divert patients for some time. As of 7:00am all patient primary care systems were up and running and both hospitals were completely open to new patients. Officials say there will be no impact on elective surgery Tuesday.</blockquote> Here is the candid translation of the statement that "There was no disruption in patient care" by a total EHR crash, making records and probably CPOE unavailable and forcing clinicians and administrative assistants back to paper and pencil (fortunately, paper charts and pencils require at most only a flashlight and hand-cranked sharpener for read and write access): <blockquote>"By the grace of God, no patients were harmed (that we know about in the confusion right now, or will admit to even if we did know) among our own patients or those diverted, in the chaos that ensued after the HIT systems went down from a power surge that we should not have been susceptible to in the first place."</blockquote> As I wrote in Part 2 of the aforementioned series, I reiterate that HIT should be treated as experimental, not as a drop-in panacea for healthcare's ills. In its present state is is perhaps as likely to exacerbate those ills. This is probably not technology that should be deployed en masse at present. We cannot afford as a society to learn how to do this by trial and error. -- SS

Indiana Power Surge: The Hospital Computing Backwater And The Need to Reform IT Before IT Reforms Medicine

In the three part series " Healthcare IT Backwater: The $20 Billion Abyss? " I lamented that hospitals are often an IT backwater, ...

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Was a Private Equity Takeover of Bausch and Lomb Meant to Conceal Its Legal Settlements of Cases of Eye Infections?

This week, the Associated Press <a href="http://www.google.com/hostednews/ap/article/ALeqM5jz3TMuH6bomvVkjjZcYoABBjQYGgD98HAO4G1">reported</a> on yet another way health care corporations may keep information that reflects poorly on their products out of public view. The story involved fungal eye infections that particularly afflicted users of a specific contact lens cleaning solution: <blockquote> More than 700 lens wearers in the United States and Asia say they were exposed to a potentially blinding infection known as Fusarium keratitis while using ReNu with MoistureLoc, a new-formula multipurpose solution for cleaning, storing and moistening soft contact lenses. Sometimes, the damage was irreparable. Seven people in Florida, Maryland, New York, Oregon, Tennessee and West Virginia had to have an eye removed. At least 60 more Americans needed vision-saving corneal transplants. The U.S. Centers for Disease Control and Prevention confirmed 180 cases in 35 states from June 2005 through September 2006, when the agency's dedicated surveillance stopped, according to Dr. Benjamin Park, a CDC epidemiologist. CDC continued to hear of sporadic, unconfirmed cases in the months after MoistureLoc was withdrawn, Park said. 'Surveillance usually captures the tip of the iceberg and sometimes it captures a larger tip than other times,' Park said in an interview. Among out-of-court settlements reached in May was a potential bellwether case brought by Andrea Martin, a Broadway actress and comedienne whose eye was scarred. In Colorado, a corneal transplant ended a race-car driver's career. In Baltimore, a chimney-sweep business owner who lost an eye got hooked on painkillers. Leading eye doctors and government scientists concluded that MoistureLoc, launched in 2004 with novel disinfectant and moisturizing ingredients, was the only lens solution that contributed to the outbreak. Yet the mechanics of how it caused the problem are still not fully clear. </blockquote> AP alleged that Bausch and Lomb kept the cases out of public view by using a previously unknown (at least to me) strategy: <blockquote> Contact lens maker Bausch & Lomb Inc. had an overriding reason for going private in 2007: It wanted to handle a devastating recall of its flagship lens cleaner, its chief executive said, 'without a lot of outside distraction.' Over the past year, away from the glare of public scrutiny, the optical products company has quietly settled nearly 600 fungal-infection lawsuits — with dozens more individual claims yet to be resolved. The cost so far: Upward of $250 million. With some fungal lawsuits still unresolved, the prospect of Bausch & Lomb's health care nightmare being aired in court has not entirely faded — which heartens some lawyers and doctors. 'The truth has been very carefully buried, and it appears to have been buried going back to the beginnings of the outbreak,' said Dr. Arthur Epstein, who was chairman of the American Optometric Association's contact lens and cornea section during the highly publicized crisis. 'All settlements were predicated on silence about the clinical findings and blame and so forth. My hope was that what actually happened would become part of public record in a courtroom. That way, we'd be able to learn from it and move on and make sure it never happened again.' When Bausch & Lomb was acquired by private equity firm Warburg Pincus for $3.67 billion in October 2007, Chief Executive Ronald Zarrella said the deal would allow the company 'to pursue the growth path we were on ... without a lot of outside distraction.'Zarrella retired last year. 'hey can do all this out of the public eye — guys like me aren't sitting there scrutinizing the financial impact of every single settlement,'said analyst Jeff Johnson of Robert W. Baird & Co. in Milwaukee. 'you can completely focus on your brand and on doing what's right by the patient.'</blockquote> So, if I understand this correctly, after Warburg Pincus took the company private, it was no longer required to file certain reports with the US Securities and Exchange Commission (SEC), including reports that would have had to acknowledge the multiple settlements the company made of cases alleging adverse effects of its contact lens solution. What is striking is the allegation by the AP that "taking the company" private was a strategy meant to conceal the settlements of these cases, (rather than a strategy implemented to fulfill other aims, which had the side effect of diminishing reporting of these cases' results.) Again, I am hardly an expert, but relatively opaque private equity firms like Warburg Pincus seem to have become increasingly influential in the US economy, and to have an increasing role in health care. In 2007, we had <a href="http://hcrenewal.blogspot.com/2007/09/web-of-deception-ensnares-us-nursing.html">posted</a> how private equity firms running nursing homes, including Warburg Pincus, seemed to contribute to the opacity of their operations. More recently, we <a href="http://hcrenewal.blogspot.com/2009/04/hedge-fund-u.html">posted</a> about how leaders of private equity, and of other kinds of firms in the finance arena, seem to also increasingly be leaders to which medical schools report. One final note... A quick tour through the Warburg Pincus website reveals how involved the firm is in health care. The firm <a href="http://www.warburgpincus.com/industries/healthcare/Default.aspx">claimed</a> that as a "direct equity investor in healthcare for more than 30 years, Warburg Pincus has invested more than $4 billion in approximately 120 healthcare companies." Furthermore, the firm seems quite intertwined with the leadership of academic medicine. It has a Life Sciences Advisory Board, of which three of four members are current leaders in academic medicine. The most prominent, Dr Michael Rosenblatt, Dean of the Tufts University School of Medicine, did not disclose this relationship in several versions of his biography published on the university web-site. (See the Tufts administration version <a href="http://provost.tufts.edu/1174149600661/Provost-Page-prov2w_1174149601058.html">here</a>, and the Tufts Medical Center version <a href="http://www.tuftsmedicalcenter.org/OurServices/EndocrinologyandDiabetes/MichaelRosenblattMD">here</a>.) Oh, what a tangled web we have weaved in health care, a web that continually frustrates transparency and makes it hard to figure out who was responsible for what when things go wrong.

Was a Private Equity Takeover of Bausch and Lomb Meant to Conceal Its Legal Settlements of Cases of Eye Infections?

This week, the Associated Press reported on yet another way health care corporations may keep information that reflects poorly on their pro...

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Picasa Web Albums stays big, gets faster

I use <a href="http://picasa.google.com/">Picasa</a> to manage the photos on my computer in part because it's the fastest way to manage all of the pictures I take. When I started working on <a href="http://picasaweb.google.com/">Picasa Web Albums</a>, the speed and responsiveness of the desktop program were a tough act to follow. Typically, when you move your photos from the desktop to the web, you have to choose between viewing high resolution photos that take forever to download, and tiny photos that lack any detail. For Picasa Web Albums, we thought we could do better. We chose to show large images, the very biggest we can fit into your browser window. If you open up a slideshow or full-screen view, we can fill your entire monitor. But it wasn't snappy enough for us, so we had a choice to make: either use smaller images, make the Internet faster, or make our code smarter. We think large images are important, because seeing a photo's little details can make a big difference, and as much as we wanted to, making the whole Internet faster was a little impractical in the short term. So we went deep into the code and gave it a thorough tune-up. The results, I hope, speak for themselves. Take a look at any album or slideshow on Picasa Web (<a href="http://picasaweb.google.com/startled/MesaVerdeNationalPark#5343594568426354866">here's one of mine</a>) and you should notice that browsing photos is significantly faster. Give <a href="http://picasaweb.google.com/startled/MesaVerdeNationalPark#slideshow/5343594568426354866">full-screen</a> mode a try to see even bigger photos. If you've got a reasonable connection to the Internet, you should be able to hold down one of the arrow keys and zip through the entire album at a pretty good clip, flip-book style. Of course, while you could zoom past entire albums at ludicrous speed, we hope you'll enjoying spending your time looking at the photos themselves, rather than navigating between them. Posted by Shawn Brenneman, Software Engineer

Picasa Web Albums stays big, gets faster

I use Picasa to manage the photos on my computer in part because it's the fastest way to manage all of the pictures I take. When I star...

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If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?

The publication "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</a>" on May 16 2009 in the Washington Post (my comments <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html">here</a>) exposes a massive lobby that has grossly over-represented the benefits of healthcare IT, committed a cross-disciplinary invasion of medicine, and created a myth about HIT's supposed transformative powers in curing healthcare's ills. Since its publication in the Post I have become concerned that the research literature that exists extolling healthcare IT may be tainted by corporate influence. The phenomenon of tainted biomedical literature is certainly familiar to readers of Healthcare Renewal and other medical blogs regarding pharmaceuticals and medical devices. Electronic health records systems can facilitate, not revolutionize, medicine when led by competent experts cross-trained to a meaningful extent (i.e., graduate level or beyond) in both clinical medicine and information science and technology, e.g., biomedical informatics professionals. Even these professionals must often expend much effort in "managing the mismanagement" by incompetent and/or conflicted IT and hospital leadership. (An example of a tightly run and highly specialized project in a high risk medical subspecialty that did have tangible clinical and some financial returns, via identification of poorly performing medical devices -- not something the medical device industry cares for -- is <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">here</a>. This type of project is not easily portable.) Making yet another case for how the concept of national electronic health records is probably a bad idea at this point in time with respect to our understanding of health IT and its social-technical interactions and challenges, it appears the military's EHR system AHLTA is simply a disaster. [Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.] All of the preventable elements I've <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">written about</a> are present: unreliability to due inadequate attention to resilience engineering, a <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a>, time-wasting, demoralization of clinicians, and a cornucopia of other predictable (to informatics experts) consequences when health IT is managed by anyone other than experts. Just as our economy and culture are now falling apart at the seams as a result of decades of mismanagement and corruption, from micro to macro levels, in most domains (borrowing a phrase from Rev. Jeremiah Wright, "the chickens are coming home to roost"), so the wages of incompetence and corruption in healthcare and healthcare IT are rearing their ugly head. This is the situation in the setting of a relatively constrained patient population (primarily active military personnel and families): <blockquote><a href="http://www.usmedicine.com/articles/electronic-records-system-unreliable-difficult-to-use-service-officials-tell-congress.html">U.S. Medicine - the Voice of Federal Medicine</a>May 2009Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress - By Sandra BasuWASHINGTON—AHLTA, the Department of Defense’s $4 million [sic - that should be $4 billion - ed.] electronic medical record system, continues to be difficult for military physicians to use, according to top military health leaders who spoke at a House Armed Services subcommittee hearing at the end of March. At a Congressional hearing titled “AHLTA is ‘Intolerable,’ Where do we go from here?” top Department of Defense and service leaders told members that medical personnel are hampered by an electronic medical record system that, among other issues, is slow, difficult to use, unreliable and frequently crashes.“Being the first service to vigorously support the fielding of AHLTA five years ago, we faced a near mutiny of our healthcare providers, our doctors, our nurse practitioners, physician assistants and others last summer,” Army Surgeon General Lt. Gen. Eric Schoomaker, MC, USA, told committee members at a joint hearing held by the Military Personnel Subcommittee and the Terrorism, Unconventional Threats and Capabilities Subcommittee. Committee members also voiced concern about how the system was impacting provider morale and patient care. “The committee has heard from military doctors and nurses who use AHLTA that it is unreliable, difficult to use and has decreased the number of patients they can see each day. We have also heard that medical professionals leave the military because of their frustration with AHLTA,” said Rep. Joe Wilson, R.-S.C., ranking member of the Military Personnel Subcommittee of the House Armed Services Committee. </blockquote> Difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse? Yes: <blockquote>A Troubled SystemAHLTA is currently deployed worldwide to 70 hospitals, 410 clinics and 6 dental clinics. In addition, the system is used in 14 theater hospitals and 208 forward resuscitative sites. While Army, Navy and Air Forcer medical leaders who testified all stressed the importance of an electronic medical record [perhaps due to lobby influence and myth-making? - ed.], they all expressed frustrations with AHLTA. Dr. Schoomaker told committee members that medical personnel, particularly specialists, often “spend as much or more time working around the system as they do with the system.” He said that the services are still not effectively able to seamlessly access complete data of patients from the battlefield between the military treatment facilities and the Department of Defense and the Veteran’s Administration. Last year he said he knew he had a problem when he asked a physician who is a self-described “super user” of the system whether she was a “super fan” of the system and she responded that she was not. “When our best and most faithful users of AHLTA could not admit to being fans of the system, I knew we were really having serious problems,” Dr. Schoomaker said.</blockquote> When the Army's Surgeon General observes that clinicians "spend as much or more time working around the system as they do with the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT. Who said it's a powerful tool to improve healthcare and reduce costs? Who said it's ready for national dissemination? What conflicts do such individuals have with the health IT industry? <blockquote>He blamed the system’s failures on a lack of a clear-cut strategy for implementing AHLTA—a problem he believes still exists. “In my opinion, the failures of AHLTA can be attributed to the overall lack of a clear, actionable strategy and poor execution from its genesis. As a result of the MHS’s lack of an information management/information technology strategy up to this point, theArmy Medical Department has been largely frustrated by a number of obstacles that continue to impede the system’s capabilities and functionality,” he said. He also said that the services should have a greater input in decision making regarding AHLTA. “Military health system information technology investments and solutions should be transparent to the services sitting here at the table and should be jointly governed, meaning that we with service input are treated as principal customer clients of the system and that we are heard and acted upon promptly,” he said.</blockquote> As a faculty member in a College of Information Science and Technology where undergraduates and graduate students are taught the importance of information science and consideration of the needs of end users as a primary enabler of IT success, how can there be a "lack of an information management/information technology" strategy in this national health IT project? How can there have been a lack of input into decision making by the services in the development and deployment of AHLTA? <blockquote>Leaders from the Navy and Air Force detailed the challenges that their personnel face in using AHLTA. “Almost all of the providers I spoke to relate to the system going down unexpectedly, recently at least once a week,” Navy Deputy Surgeon General Rear. Adm. Thomas R. Cullison, MC, USN, told committee members. He added that while no one would like to return to paper records, providers are “largely dissatisfied” with the system and that the system slows down their clinic time. “Most of our providers say they have to stay later in the afternoon to finish up notes simply because it slows down clinic time,” he said. Air Force Deputy Surgeon General Maj. Gen. Charles Bruce Green, USAF, MC, told the committee that Air Force primary care physicians spend about 40 percent of their time working with AHLTA versus 60 percent of their time with patients. On the other hand, specialists are “working around the system trying to find new solutions,” since the system does not address the needs unique to their practices. In his written testimony, Dr. Green said that the problems associated with AHLTA have resulted in “low productivity and provider morale.” </blockquote> Forty percent of clinician time spent tinkering with balky computers? This should be astonishing to any reader unfamiliar with these issues, and an eye opener to our governmental representatives not just regarding the military, but regarding the entire lobby-promoted scheme to force clinicians to adopt HIT by 2014 or suffer financial penalties. Specialists "working around" the system (thus risking the <a href="http://hcrenewal.blogspot.com/2008/06/business-v-clinical-computing.html">dangers of workarounds</a> of HIT deficiencies observed by Koppel and others) because it does not meet the needs of their subspecialties? No surprises here. After reading about issues in development of domain specific healthcare information systems for high risk subspecialties (such as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">here</a>), it should be obvious that the business IT-dominated health IT industry as it currently exists cannot fill such needs. More importantly, I feel the AHLTA project is an illustration of what will be reproduced, thousands or tens of thousands of times over, in hospitals and physician practices all over this country as we proceed in a national EHR initiative based on false premises borne of the health IT lobby. <blockquote>The Problem Then-Assistant Secretary of Defense for Health Affairs S. Ward Casscells, M.D., told committee members that many of the problems that AHLTA has suffered have been “self-inflicted wounds,” due to software contracts with vendors that were “poorly written.” “We have had, over the past decade, contracts that were poorly written from the standpoint of performance, they have loopholes in them that permitted delays. We have, in some instances, lax oversight of some of these contracts,” he said.</blockquote> Unbelievable. Hospitals sign HIT contracts putting all liability for system defects on clinicians, and that gag them from disclosing defects outside their organizations. The military's HIT contracts apparently had additional flaws that are probably pervasive in the commercial sector as well. <blockquote>... In moving forward to rectify AHLTA problems, DoD has adopted a Unified Strategy Regional Distribtion Approach, a three-phased plan for reshaping the electronic health system. In written testimony, Dr. Casscells explained this strategy seeks to “improve provider satisfaction, improve reliability and strengthen data sharing throughout DoD and Department of Veterans Affairs healthcare delivery continuum and with private healthcare providers.” The first phase of the approach will focus on “stabilizing performance, reliability and the core infrastructure,” of the system according to Casscell’s written testimony. "I want to be wary of overpromising. We have done that in the past [indeed, the entire HIT industry has massively overpromised for decades - ed.], but I am excited about this. I think there is a chance here that we can once again be leaders for the nation in electronic health records, as was the case several decades ago. I would like to think that a year or two from now, you will agree with me that AHLTA has gone from intolerable to indispensible,” Dr. Casscells told committee members. Tommy J. Morris, acting director in DoD’s office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness Programs, said that the only service that nonconcurred with their proposed blueprint to overhaul AHLTA was the Army [not exactly an unimportant stakeholder - ed.] Dr. Schoomaker, on his part, challenged the notion that there was actually a “strategy” in place for rectifying AHLTA. “Mr. Morris has got a plan, he does not have a strategy. We asked for a strategy. A plan is just one element of a larger strategy. We asked for a strategy and our involvement in that strategy, so with respect, that is what we in a sense partially nonconcurred with,” Dr. Schoomaker said.</blockquote> "I've got a plan." How familiar a refrain that is in a time of mass societal mismanagement. If I were a politician examining health IT, I'd really start looking into how our government became convinced health IT was not only a worthwhile investment, but an "economic stimulus." As with our <a href="http://hcrenewal.blogspot.com/2009/05/canadian-health-it-ripoff-is-anyone-in.html">friends up north</a>, it seems to be primarily a stimulus for poseurs and dyscompetents to come out of the woodwork, disrupt healthcare providers, and then collect massive fees for the "favor." In consideration of the above, I ask: If the military, with its internal discipline and ability to take over entire modern countries with just a few thousand soldiers lost, and its constrained patient population (active military personnel and families generally free of complex and chronic illnesses) can't get electronic health records right, why would anyone think inept and sometimes corrupt EHR companies, dyscompetent hospital IT departments, and <a href="http://hcrenewal.blogspot.com/2009/03/health-it-hold-harmless-and-defects-gag.html">reckless and cavalier hospital executives</a> can? I reiterate my concerns that the "AHLTA experience" will become all too familiar to hospitals and physician practices throughout this country, unless sanity and rationality is restored to our thinking about health IT. -- SS

If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?

The publication " The Machinery Behind Healthcare Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billio...

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Square your search results with Google Squared

Some information is easy to find. If you want to learn the rules of golf, you can search Google for [golf rules] and we'll return a list of relevant web sites right at the top. But not all your information needs are that simple. Some questions can be more complex, requiring you to visit ten, perhaps twenty websites to research and collect what you need. For instance, I'm a big fan of roller coasters. In the past I've used Google to search for information about roller coasters, such as which ones are the tallest, fastest, and have the most loops. Finding this information used to take multiple searches — I'd find roller coaster sizes on one website, heights on another, and speeds on a third. By manually comparing the sites, I could get the information I was looking for, but it took some time. With <a href="http://www.google.com/squared">Google Squared</a>, a new feature just released in Google Labs, I can find my roller coaster facts almost instantly. <div> Google Squared is an experimental search tool that collects facts from the web and presents them in an organized collection, similar to a spreadsheet. If you search for [roller coasters], Google Squared builds a square with rows for each of several specific roller coasters and columns for corresponding facts, such as image, height and maximum speed. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKpXjS35u0BzResS4M6oNooL96fDQxu3myeneE1V16l3ZxGLWhuFCuWGK34cOxM_RGcovwL_DNUI2momghoQYmIC5kYtmqOJ1BH2KgsZmUXoF7PsfBNlY5ACj1gtDb2s0r_67932wQkehq/s1600-h/RollerCoastersSquare.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5343231429610916146" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKpXjS35u0BzResS4M6oNooL96fDQxu3myeneE1V16l3ZxGLWhuFCuWGK34cOxM_RGcovwL_DNUI2momghoQYmIC5kYtmqOJ1BH2KgsZmUXoF7PsfBNlY5ACj1gtDb2s0r_67932wQkehq/s400/RollerCoastersSquare.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 280px;" /></a> </div><div>While gathering facts from across the Internet is relatively easy (albeit tedious) for humans to do, it's far more difficult for computers to do automatically. Google Squared is a first step towards solving that challenge. It essentially searches the web to find the types of facts you might be interested in, extracts them and presents them in a meaningful way. This technology is by no means perfect. That's why we designed Google Squared to be conversational, enabling you to respond to the initial result and get a better answer. If there's another row or column you'd like to see, you can add it and Google Squared will automatically attempt to fetch and fill in the relevant facts for you. As you remove rows and columns you don't like, Google Squared will get a fresh idea of what you're interested in and suggest new rows and columns to add. See it in action in the video below: <object height="295" width="480"><param name="movie" value="http://www.youtube.com/v/__INtIXNLmI&hl=en&fs=1"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/__INtIXNLmI&hl=en&fs=1" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="295"></embed></object> If you click on any fact, you'll see the sources Google Squared gathered it from as well as a list of other possible values that you can investigate. So even if your square isn't perfect at the beginning, it's easy to work with Google Squared to get a better answer in no time. Once you've got a square you're happy with, you can save it and come back to it later. To give Google Squared a whirl, try searching for [planets] or [romantic movies]. You can try out <a href="http://www.google.com/squared">Google Squared</a> now in Google Labs. Posted by Alex Komoroske, Associate Product Manager for Google Squared</div>

Square your search results with Google Squared

Some information is easy to find. If you want to learn the rules of golf, you can search Google for [golf rules] and we'll return a list...

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Tour the homepages of your favorite celebrities

Have you ever wondered what celebrities do when they use the web? Today, we're announcing the new <a href="http://www.google.com/igshowcase">iGoogle Showcase</a>, which allows you to see and share the homepages of some of your favorite icons. These 30 preeminent people, including <a href="http://www.google.com/intl/en_us/help/ig/showcase/dave_matthews.html">Dave Matthews</a>, <a href="http://www.google.com/intl/en_us/help/ig/showcase/rachael_ray.html">Rachael Ray</a> and <a href="http://www.google.com/intl/en_us/help/ig/showcase/katie_couric.html">Katie Couric</a>, are sharing their iGoogle pages with you in full so you can get a glimpse into their interests and how they experience the web. The iGoogle Showcase allows you to either add a celebrity's entire iGoogle page to your own, or browse through the collection and choose different gadgets and themes from several pages. For example, you might select <a href="http://www.google.com/intl/en_us/help/ig/showcase/al_gore.html">Al Gore's iGoogle page</a> for his preferred theme and gadgets for keeping up on the latest media news, supporting the Alliance for Climate protection cause or browsing through photos from National Geographic. <object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/TAEXRq9wlhY&hl=en&fs=1"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/TAEXRq9wlhY&hl=en&fs=1" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="560" height="340"></embed></object> In addition, many of our celebrity partners have created their own custom iGoogle gadgets to easily connect with their fans every day. If you're a <a href="http://www.google.com/intl/en_us/help/ig/showcase/ryan_seacrest.html">Ryan Seacrest</a> fan, his new gadget can help you keep up with all the latest entertainment news. You can follow his tweets, watch exclusive videos, listen to radio interviews, and view his photo albums. <a href="http://www.google.com/intl/en_us/help/ig/showcase/donald_trump.html">Donald Trump</a> offers advice to entrepreneurs, <a href="http://www.google.com/intl/en_us/help/ig/showcase/martha_stewart.html">Martha Stewart</a> shares recipes and tips, and <a href="http://www.google.com/intl/en_us/help/ig/showcase/anderson_cooper.html">Anderson Cooper</a> delivers headline news and extras from his CNN show AC360. To get any one of our celebrity themes or gadgets on your own iGoogle page, visit the <a href="http://google.com/igshowcase">iGoogle Showcase</a>. We've all heard about "six degrees of separation," but now, some of your favorite stars are just a few clicks away. Posted by Marissa Mayer, Vice President, Search Products and User Experience

Tour the homepages of your favorite celebrities

Have you ever wondered what celebrities do when they use the web? Today, we're announcing the new iGoogle Showcase , which allows you t...

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"Man's Best Hospital," Run by the Boss of a MECC (Medical Education and Communications Company)?

In January, 2009 we <a href="http://hcrenewal.blogspot.com/2009/01/to-whom-did-scorpions-in-bottle-owe.html">posted</a> about how the CEO of Blue Cross Blue Shield (BCBS) of Massachusetts and of Partners HealthCare, made a secret oral agreement that BCBS would pay Partners at a higher rate than that given to other hospitals. Why BCBS would want to pay so much to this one hospital system was never clear. Partners does include some extremely prestigious hospitals, including the Brigham and Womens Hospital, and the Massachusetts General Hospital, ("Man's Best Hospital" in the House of God), but there are some other very prestigious teaching hospitals in Boston that were not blessed by BCBS' largess. We speculated about one possible cause: the leadership of the two organizations may have felt they had more in common with each other than with the constituencies of their own organizations. A few leaders of each organization had direct ties to the other. Many leaders of both organizations were simultaneously leaders of finance, the same sector that has brought us what is now called the Great Recession. Leadership of both organizations had conflicted loyalties. The organizations' CEOs at the time, and many members of their boards had divided loyalties and apparent conflicts of interest. For example, Jack Connors, the chair of the Partners HealthCare board, <a href="http://www.adclub.org/2008_Legends/jack.html">is also </a>the Chairman Emeritus of marketing communications company Hill, Holliday, Connors, Cosmopoulos Inc, whose clients include pharmaceutical and pharmacy benefits manager CVS / Caremark, and is also a member of the board of directors of Covidien, a medical device company. The Boston Globe just published <a href="http://www.boston.com/business/healthcare/articles/2009/05/31/partners_leader_questioned_on_outside_ties/">a report </a>that Mr Connors had even more intense conflicts that had not heretofore been made public. <blockquote>He's chairman of New England's largest healthcare company, and that position atop Partners HealthCare has tested the limits of Jack Connors's considerable corporate dexterity. Though he has no background in medicine, Connors has been Partners' chief overseer, champion, and its most public face for 13 years. [One board member] is the cofounder and chairman emeritus of Partners' advertising firm. That would be Jack Connors. And that potential point of conflict has been disclosed.... But to the chagrin of some former board members, never brought up for board review was Connors's stake in a leading medical education firm whose sale in 2004 made Connors a very wealthy man. Nor has the board notified public officials of Connors's ownership of a fledgling home healthcare firm that has directly solicited Partners' hospitals for business. Connors and top Partners officials defended the decision not to publicly disclose Connors's potential conflicts, saying that because Partners did not directly contract with either of Connors's firms there were no conflicts to report. Connors also defended his right to be an entrepreneur in the healthcare business while also chairing Partners' board, and strongly denied ever using his position for personal or financial advantage. The larger company, M/C Communications, grew to become the biggest commercial provider of continuing education to physicians in the decade between its inception in 1994 and when Connors sold it in 2004. It profited hugely from an exclusive commercial relationship it maintained with Harvard Medical School, whose faculty teach at seminars the company holds. Partners' signature institutions, Massachusetts General Hospital and Brigham and Women's Hospital, are major teaching affiliates of Harvard Medical School. In addition, M/C Communications benefited financially from millions of dollars in sponsorship revenue paid it from major pharmaceutical firms eager to play to this professional audience. Connors said he was under no obligation to disclose his ownership of M/C Communications to the Partners board. He said that while there is an 'affiliation' between Harvard Medical School and the two Partners hospitals, there is no formal contract between them. Connors said he informed Partners executives of his ownership of M/C Communications, and that they determined it did not warrant disclosure to the full Partners board. 'There is no contract between Partners and Harvard,' Partners said in a statement to the Globe. Connors made a name for himself as an executive with Hill, Holliday, Connors, Cosmopulos, the Boston advertising company that he helped found and guided throughout a long career. Less well known is that he made most of his fortune from M/C Communications, which he sold to Bain Capital for $450 million in 2004. The sale was the largest of a private healthcare-related company in Massachusetts that year, according to TM Capital Corp., an investment banking company. Connors, who led an investor group that bought the firm outright for $13 million in 2000, made about $250 million from its sale. After his 2004 windfall, he founded a company that helps elderly patients readjust to life at home after a hospitalization. That company, Dovetail Health, has - Connors acknowledged - solicited business from hospitals owned by Partners. And Connors confirmed that after Dovetail executives failed to convince Blue Cross Blue Shield of Massachusetts to contract with the firm, he personally spoke to the giant insurer's president, Cleve L. Killingsworth, on Dovetail's behalf. Partners and Blue Cross Blue Shield regularly negotiate over $2.5 billion worth of medical business a year. Connors acknowledged in an interview that it might have appeared 'inappropriate' to some for him to pitch Killingsworth. But he said the conversation stemmed from a shared belief that new ways must be found to reduce frequent return trips of elderly patients to the hospital. More recently, however, he said he does not believe his approach to Killingsworth was inappropriate. </blockquote>So let's try to recap this. While Jack Connors has been chairman of the board of Partners HealthCare, the largest and most prestigious hospital system in Massachusetts, he also ran an advertising agency that did business with Partners, and has been on the board of Covidien, a medical device company. Both of these relationships he disclosed to his fellow board members, although no one seemed troubled by them. However, while a Partners board member, Connors was also the founder, and ultimately profited very handsomely from the sale of M/C Communications. M/C Communications apparently begat <a href="http://www.mc-comm.com/live/MCHCGateway.html">M/C Holding Corporation</a>, which in turn owns M/C Communications and Pri-Med Institute LLC. M/C Communications now <a href="http://www.mc-comm.com/live/MC/">describes itself </a>as " established in 1994 and has become a leading provider of medical education event management solutions for health care professionals and others around the globe." M/C Communications runs <a href="http://www.pri-med.com/pmo/Home.aspx">Pri-Med</a>, which is <a href="http://www.pri-med.com/industry/">described</a> thus: "Pri-Med is a platform for science and medicine that includes meetings, resources, online, and new media tools designed to meet the information and education needs of today’s practicing physician." Pri-Med <a href="http://www.pri-med.com/industry/conference.htm">markets itself to industry</a>, presumably the pharmaceutical, biotechnology, and device industry, "Sixty percent of doctors’ offices restrict rep access, making it more challenging than ever to get in front of your customers. But with Pri-Med, you get to meet clinicians in a professional environment where they seek you out. More than 66% of attendees say they come to Pri-Med events to meet you, industry representatives." So Connors' company was a medical education and communication company (MECC), which provided what appeared to be educational programs to physicians that in fact were also sold to the health care industry as marketing opportunities. So Partners HealthCare, which includes two of the world's most prestigious teaching hospitals, has been run by the boss of a MECC? Say it ain't so. Not only did Connors own a company that had an exclusive contractual relationship (as described above) with the Harvard faculty who staff the main Partners HealthCare hospitals, that company was engaged in marketing the products of sponsoring drug and device companies disguised as education. Finally, Connors denied that this presented any kind of conflict of interest, because Partners HealthCare has no explicit contract, just an "affiliation" with Harvard Medical School. Finally, just to ice the cake, Connors' latest venture is a home health care company that did business with Partners, and tried to do business with BCBS, spearheaded by Connors' direct conversations with the BCBS CEO. Jack Connors thus seems to have just become the latest poster boy for leaders of health care organizations who put their personal financial interests ahead of their responsibilities to those organizations, and function as a power elite whose collective interests trump those of the constituents of the organizations they run. Quoting <a href="http://www.boardsource.org/Knowledge.asp?ID=3.364">from BoardSource</a>, the main duties of the leader of any US not-for-profit are: <blockquote> Duty of Care The duty of care describes the level of competence that is expected of a board member, and is commonly expressed as the duty of 'care that an ordinarily prudent person would exercise in a like position and under similar circumstances.' This means that a board member owes the duty to exercise reasonable care when he or she makes a decision as a steward of the organization. Duty of Loyalty The duty of loyalty is a standard of faithfulness; a board member must give undivided allegiance when making decisions affecting the organization. This means that a board member can never use information obtained as a member for personal gain, but must act in the best interests of the organization. Duty of Obedience The duty of obedience requires board members to be faithful to the organization's mission. They are not permitted to act in a way that is inconsistent with the central goals of the organization. A basis for this rule lies in the public's trust that the organization will manage donated funds to fulfill the organization's mission. </blockquote> By leading companies that did direct business with Partners and its staff, and failing to disclose that he was doing so to his fellow Partners board members, Connors appeared to have violated the Duty of Loyalty. By running a MECC that helps drug and device companies market to physicians in the guise of education, using faculty from the academic teaching hospitals that he lead, Connors seems to have mocked the mission of the academic hospitals within Partners, and thus appeared to violate the Duty of Obedience. This episode certainly does suggest that health care, and the organizations involved in this case, are lead by an "old-boy network," as one person interviewed for the Globe article suggested. More than just an old-boy network, they seem to be lead by chummy members of the power elite whose collective personal interests supersede the missions of the organizations they are supposed to steward. When this happens, is it any surprise that health care becomes less accessible, more expensive, and of lower quality? Yet challenging the power elite that are increasingly revealed as controlling much of health care seems to be something that one cannot talk about when discussing health care reform. However, failing to address this problem will likely doom any effort, no matter how well intentioned, to improve health care. Hat tip to and see <a href="http://alison-bass.blogspot.com/2009/06/fish-rots-from-top-conflicts-of.html">comments</a> by Alison Bass on the Alison Bass Blog. ADDENDUM (3 June, 2009) - See also <a href="http://carlatpsychiatry.blogspot.com/2009/06/harvard-med-school-jack-connors-and.html">comments</a> by Dr Daniel Carlat on the Carlat Psychiatry Blog.

"Man's Best Hospital," Run by the Boss of a MECC (Medical Education and Communications Company)?

In January, 2009 we posted about how the CEO of Blue Cross Blue Shield (BCBS) of Massachusetts and of Partners HealthCare, made a secret or...

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