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Yale, Van Gogh's "The Night Cafe" and Personal Property: What's Mine is Mine, and What's Yours is Mine

At Healthcare Renewal and at numerous other healthcare blogs, we write about academic and industry conflicts of interest, malfeasance, and other topics in the hopes that there are leaders within organizations who might correct the wrongs that result from such conflicts and behaviors. (That is, when it is not those same leaders behind the scandals in question.) Our efforts are based on the assumption (perhaps, more correctly, a hope) that the problems within organizations are not organic and ideological, and that they are in some fashion amenable to correction internally and externally via exposure to sunlight. What if we're wrong? A story caught my eye about my Medical Informatics alma mater. A Frenchman, Pierre Konowaloff, is suing Yale for return of a famous Van Gogh painting that was confiscated from his family in the early 1900's by totalitarians, psychopaths who created what proved to be one of the most oppressive and murderous regimes in history (the Soviet Union). In return, Mr. Konowaloff was countersued by Yale. Yale alleges that the confiscation of the painting by the Soviets was A-OK because "international law was not violated" [by the confiscation - ed.], therefore Yale has legitimate and unchallengeable dibs on the painting. "International law" was not violated? This response is beyond stunning. I had to retrieve my jaw from the floor after reading the story: <blockquote>Wall Street Journal June 3, 2009 <a href="http://online.wsj.com/article/SB124406037069082321.html">Yale Sued Over Van Gogh Painting Seized by Soviets</a> By JOSEPH PEREIRA A descendant of the onetime owner of a famed Van Gogh painting has sued Yale University in an effort to reclaim the artwork from the Ivy League school. In a lawsuit filed in U.S. District Court in New Haven, Conn., Pierre Konowaloff alleged that the university should have known the painting—"<a href="http://en.wikipedia.org/wiki/The_Night_Caf%C3%A9">The Night Café</a>"—had been confiscated from his great-grandfather, Ivan Morozov, a Russian industrialist and aristocrat, during the Communist takeover of Russia in the early 1900s. The 1888 painting was subsequently sold by the Soviet government to a European gallery. Stephen Carlton Clark, a Yale alumnus, bought the painting from a gallery in New York in the early 1930s and bequeathed it to Yale in 1961. In his suit, Mr. Konowaloff, who lives in France, accuses the university of engaging "in a policy of willful ignorance" that amounts to "art laundering," and asks the court to declare him the rightful owner. Aware of Mr. Konowaloff's intention to claim the painting, Yale filed a lawsuit of its own last March in federal court in New Haven. In its suit, Yale asserted ownership of "The Night Café," claiming that the nationalization of the painting by Communist Russia -- while at odds with capitalism -- did not violate international law. Yale stated in its lawsuit that "it was accepted at the time, as it is now, that the sales by the Soviet government were valid, as were later acquisitions of the paintings."</blockquote> In other words, rather than doing the right thing, Yale is claiming that the theft of personal property by the Soviets was OK by them. (While Yale is well known to have a culture far to the left and many of its leaders and faculty probably sympathize with communists, Hitler also "nationalized" the artwork and other property of individuals. Would Yale find those actions in accordance with "International law?" One can only wonder.) <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrSXZnfYXp1v75BtZHvc3nSFhg2zA9wb0vwtvfwCd3Hji13Ohnq78KunpBqHyaVGrhA_qkzf5VYOPgy2Hogq-3ViaaG43moo04CMNqY-6Ux7xjF0UjZie76n0B_q1NDAJn4n_u5VVPV7Wv/s1600-h/the_night_cafe.jpeg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5345054562162009938" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrSXZnfYXp1v75BtZHvc3nSFhg2zA9wb0vwtvfwCd3Hji13Ohnq78KunpBqHyaVGrhA_qkzf5VYOPgy2Hogq-3ViaaG43moo04CMNqY-6Ux7xjF0UjZie76n0B_q1NDAJn4n_u5VVPV7Wv/s320/the_night_cafe.jpeg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 313px; height: 254px;" /></a>Van Gogh's "The Night Cafe" </div> Now, if this were a one-off event, it would not be as illustrative of a systematic ethical decay that I fear exists in the hallowed Ivy halls. However, Yale has recently been fined $7.6 million after an investigation by NIH, NSF, DOD and others into misuse of research money by faculty. I wrote about that event at "<a href="http://hcrenewal.blogspot.com/2008/01/lux-et-veritas-or-trust-but-verify-yale.html">Lux et Veritas, or Trust But Verify? Yale discovers eDiscovery</a>", and the <a href="http://www.educause.edu/ir/library/powerpoint/csd5020.pps">powerpoint</a> from within Yale outlining the issues was eye-opening. Here is a synopsis of the outcome: <blockquote><a href="http://orda.siuc.edu/rm/36-02.pdf">Yale University Pays $7.6 Million to Resolve False Claims Act Allegations</a> (PDF) —excerpted from U.S. Dept. of Justice press release, Dec. 23, 2008 Yale University has entered into a civil settlement agreement with the federal government in which it will pay $7.6 million to resolve allegations that it violated the False Claims Act and the common law in the management of federally-funded research grants awarded to the university between January 2000 and December 2006. The grant awards were made by approximately 30 federal agencies and entities, including NIH, NSF, DOE, DOD, and NASA. The investigation focused on allegations involving two types of mischarges to federal grants. Both types of mischarges arose as violations of the basic principle that recipients of federal grants are allowed to charge to each grant account only “allocable” costs, which are costs that relate to the specific objectives of that grant project. The first allegation involved cost transfers and the requirement that costs transferred to a federal grant account must be allocable to that particular grant account. The settlement resolves allegations that some Yale researchers at times improperly transferred charges to a federal grant account to which those charges were not allocable. Researchers allegedly were motivated to carry out these wrongful transfers when the federal grant was near its expiration date and they needed to spend down the remaining grant funds. Federal regulations require that unspent grant funds be returned to the government. The second allegation involved salary charges and the requirement that charges to federal grant accounts for researcher time and effort must reflect actual time and effort spent on a particular grant. It was alleged that some Yale researchers submitted time and effort reports, for summer salary paid from federal grants, that wrongfully charged 100 percent of their summer effort to federal grants when, in fact, the researchers expended significant effort on unrelated work. Researchers allegedly were motivated to carry out these wrongful salary charges by the fact that they are not paid their academic-year salary by Yale during the summer. The only salary received by these researchers during the summer was the result of the effort they charged to federal grants. Absent the alleged grant mischarges, the researchers would not have been paid. The $7.6 million payment comprises two components: $3.8 million in actual damages for the false claims, and $3.8 million assessed as penalties for the false claims. </blockquote> Taxpayer money was used as they pleased until caught. What's mine is mine, and what's yours is mine.<div> </div><div>Yale's clinical operations have seen federal investigation once before which I wrote about at "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Insufficient%20IT%20management">Insufficient IT Management Depth Results in Justice Dept. Investigation, Millions of Dollars in Fines</a>." That story was more about IT incompetence rather than malfeasance, however. I've had my own personal experiences with these "what's mine is mine, and what's yours is mine" property-rights attitudes at Yale. Perry Miller, Director of Informatics, Kenneth Kidd, Professor of Genetics, and Carolyn Slayman, Deputy Dean for Academic and Scientific Affairs, waged a rather one-sided and extortionary battle to misappropriate my intellectual property, a computer program I'd authored as faculty, assisted by a lawyer in Yale's Office of General Counsel -- who for good measure was in fact unauthorized to practice law in Connecticut at that time. Ex-colleague faculty Richard Shiffman "purged" me, Stalin style, by telling recruiters who called that I didn't exist - one of those recruiters, unfortunately for him, happened to be a <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/protocol.jpg">detective I retained</a>. I wrote up the story in detail <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=%5Eyaleinf">at this site</a>. Dr. Kidd in particular was a principal in the now-defunct <a href="http://en.wikipedia.org/wiki/Human_Genome_Diversity_Project">Human Diversity Genome Project</a> in which he and others promised indigenous tribes their genetic materials would not be misappropriated for others' gain and profit. (I found that position risible considering my circumstances. Kidd's research raised further issues as I wrote at "<a href="http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html">Informed consent, exploitation and developing a SNP panel for forensic identification of individuals</a>.") University officials right up to President Richard Levin (in the WSJ recently <a href="http://online.wsj.com/article/SB124425383780391015.html">lamenting the decrease in the value of Yale's endowment</a> from $24 billion to $17 billion), said they could do nothing to help me, even though I was being badgered for my software and actually blackmailed (through denial of confirmation of my training and faculty time at Yale to potential employers).<div> You would think a university with an endowment in the billions of dollars could have protected its own junior faculty from senior faculty predators, and you'd also think it could return a Van Gogh to the heir of a man who had it stolen by thugs who later murdered tens of millions of their own citizens.<div> </div><div>Ironically, when I was Yale School of Medicine junior faculty in Yale Center for Medical Informatics, I was charged with teaching postdoctoral fellows about NIH ethics guidelines. The tenured senior faculty I was working for just didn't have the time.</div><div> </div><div>Now, I may simply be a "disgruntled former Yale faculty member" after nearly having my career destroyed by these people in what was the most disappointing experience in my life, bar none, but the pattern of "what's mine is mine, and what's yours is mine" seems to be all too commonplace in Yale's case. From Bloomberg's coverage of the same Van Gogh story:<div><div><div> <div style="margin-left: 40px;"> <a href="http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aqq9FKuy9sk8">Yale Sued Over Van Gogh Work By Man Claiming to be Russian Heir</a> </div> <div style="margin-left: 40px;">June 4, 2009 By Cary O’Reilly </div> <div style="margin-left: 40px;"> </div> <div style="margin-left: 40px;">... Konowaloff’s claim is the latest litigation accusing Yale of improperly possessing artwork or historic artifacts. The Republic of Peru sued Yale in December seeking a collection of artifacts excavated from Machu Picchu and other sites by university scientists and researchers. </div> <div style="margin-left: 40px;"> </div> I'd written about Machu Picchu <a href="http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html">here</a>: <blockquote>... Peripherally related in the scientific sense but perhaps closely related in the ethical and ideological sense, I've just discovered via a recent newspaper that Yale has some additional problems of late regarding property: "<a href="http://www.miamiherald.com/579/story/180105.html">Peru demands return of Machu Picchu treasures by Yale</a>", Miami Herald, July 25, 2007, by Tyler Bridges (now a Peruvian resident). Yale apparently went so far as to interpret the laws of a foreign nation, which is, of course, Yale's right as a sovereign entity, the People's Republic of Yale, it would seem: <blockquote style="font-family: arial;">Key documents include a 1912 Peruvian decree stating that Peru reserved the right to request the objects' return, and a 1916 letter that [Yale professor/explorer Bingham] wrote to the National Geographic Society about the artifacts from the 1914-15 expedition. ''Now they do not belong to us, but to the Peruvian government, who allowed us to take them out of the country on condition that they be returned in 18 months,'' Bingham wrote. Yale officials have said that Peruvian law in force in 1912 does not require the university to return objects from Bingham's expedition that year.</blockquote></blockquote> Perhaps less credible is this additional allegation from Bloomberg: <blockquote>... Yale and a secretive student society known as the Order of Skull & Bones were sued in February by the descendants of the 19th century Apache Indian warrior Geronimo. The family claims a group of Yale students may have stolen some of Geronimo’s remains in 1918 and taken them to Yale’s campus. The university denies the allegation and says it has no connection to Skull & Bones.</blockquote> Then there's Yale's <a href="http://www.opinionjournal.com/diary/?id=110008051">Taliban Man</a> incident per John Fund at the WSJ. The former deputy foreign secretary of the Taliban was taken as a student at Yale in 2006 while at the same time the school blocked ROTC training from its campus and argued for the right of its law school to exclude military recruiters. I fear other Ivy universities also lack a sense of basic ethics, both at the individual faculty level and collectively, i.e., including the leadership. I'd written about the ghastly events regarding the Duke lacrosse team affair at "<a href="http://hcrenewal.blogspot.com/2008/01/truly-disturbing-lawsuit-against-duke.html">A Truly Appalling Lawsuit Against Duke University</a>." Harvard Medical Schools's own ombud had written an article in JAMA in the late 1990's entitled "<a href="http://jama.ama-assn.org/cgi/content/full/280/3/216">Authorship: the coin of the realm, the source of complaints</a>", outlining the commonality of fights over IP between faculty and students, and admitted in a response to my <a href="http://jama.ama-assn.org/cgi/content/extract/281/2/135-a">Letter to the Editor</a> that this could not be prevented by administration (which in my view translates to, "the administration's worse than the faculty in this regard.") Others at Healthcare Renewal and related blogs have written about ethical lapses at other major universities as well. In summary, if both the majority of the faculty as well as the administration of our major universities never learned as children about respecting others' property, and pass these attitudes along to future academics and future captains of industry, the bloggers will be unable to teach them very much. We will continue on a course of periodic academic and industry healthcare (and other) scandals of increasing scale, along with the wasted talent, resources and opportunity these scandals represent. -- SS</div><div> </div><div>Addendum: after such a grim report, I thought I'd throw in something pleasant. Here is a friend I feed at the nearby park, one of six, in fact, Mute Swan cygnets (babies). The parents like me so much, they've offered me food in return - lovely clumps of fresh tender grass, which to them is a delicacy:</div><div> </div><div> </div><div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEih9VEKA4EPHbKAP_rYRLgo_L3UTXzuHBzr2iDzO9N_HJLh-TQ7IF5FgD6DDLUM2QUGPyW5OHmEHCSb21648a7m34yveSXK34niMUVNwKJAgh1VoJuVGmIT4h5KkCFPbYkpwwiQNX2hRse6/s1600-h/IMG_0482.JPG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5345126862280228034" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEih9VEKA4EPHbKAP_rYRLgo_L3UTXzuHBzr2iDzO9N_HJLh-TQ7IF5FgD6DDLUM2QUGPyW5OHmEHCSb21648a7m34yveSXK34niMUVNwKJAgh1VoJuVGmIT4h5KkCFPbYkpwwiQNX2hRse6/s320/IMG_0482.JPG" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 340px; height: 255px;" /></a></div><div style="text-align: center;">Cygnus olor - click to greatly enlarge these adorable fuzzballs <div style="text-align: left;">It's a great picture, but it's not a Van Gogh. Since I once worked at Yale, however, let's hope they don't claim the photo is theirs. -- SS 6/10/09 Addendum: Remarkably, there is apparently someone in the health IT community who was offended by the posting of the photo of the cygnet I feed (done, of course, as "comic relief"), as I have been informed. One can only wonder if violations of intellectual property and civil rights by universities, or patent safety concerns by faulty EHR's cause equal offense. </div></div></div></div></div></div></div>

Yale, Van Gogh's "The Night Cafe" and Personal Property: What's Mine is Mine, and What's Yours is Mine

At Healthcare Renewal and at numerous other healthcare blogs, we write about academic and industry conflicts of interest, malfeasance, and o...

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Design It Shelter Competition: Unleash your inner architect

Today, <a href="http://en.wikipedia.org/wiki/Frank_Lloyd_Wright">Frank Lloyd Wright</a>'s 142nd birthday, we're excited to announce the <a href="http://www.guggenheim.org/shelter">Design It: Shelter Competition</a>. Held by the <a href="http://www.guggenheim.org/">Guggenheim Museum</a> and <a href="http://sketchup.google.com/">Google SketchUp</a>, the competition is inspired by Wright's assignment for his apprentices at <a href="http://www.taliesin.edu/">Taliesin</a>: If you wanted to study to be an architect with Wright, you had to design and build a shelter in the desert outside of Phoenix, Arizona. Then you had to live and study in it. Unlike the Taliesin assignment, the shelters in this competition are virtual. To enter, use <a href="http://sketchup.google.com/">Google SketchUp</a> to design a small structure where someone might sleep and work. Your shelter should be created for a specific site anywhere in the world and geo-located in <a href="http://earth.google.com/">Google Earth</a>. It also should conform to <a href="http://www.guggenheim.org/new-york/education/sackler-center/design-it-shelter/how-to-enter">size constraints</a> and must not include running water, gas or electricity. When you're done with your design, upload it to the <a href="http://sketchup.google.com/3dwarehouse">Google 3D Warehouse</a>, then fill out the <a href="http://www.guggenheim.org/new-york/education/sackler-center/design-it-shelter/designit-competition-entry-form">submission form</a> on the Guggenheim website. Check out the video below to learn more: <object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/KIfC5zEAs4k&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/KIfC5zEAs4k&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="560" height="340"></embed></object> The deadline for submissions is August 23rd. You can find more details, including information about judging and prizes, on the the <a href="http://sketchupdate.blogspot.com/2009/06/announcing-design-it-shelter.html">Google SketchUp Blog</a> or the <a href="http://www.guggenheim.org/shelter">competition website</a>. Good luck! Posted by Aidan Chopra, SketchUp Product Evangelist

Design It Shelter Competition: Unleash your inner architect

Today, Frank Lloyd Wright 's 142nd birthday, we're excited to announce the Design It: Shelter Competition . Held by the Guggenheim M...

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Open letter to Mark Leavitt, Chairman, Certification Commission for Healthcare Information Technology on Penalties For Use of Non-"Certified" HIT

A remarkable Bill (ASSEMBLY, <a href="http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM">No. 3934</a>, STATE OF NEW JERSEY, 213th LEGISLATURE) has appeared in NJ that would prohibit the sale or use of healthcare IT not "certified" (i.e., feature-qualified) by the industry-founded and connected group "Certification Commission for Healthcare Information Technology" (CCHIT). The Bill calls for monetary <a href="http://en.wikipedia.org/wiki/Civil_penalty">civil penalties</a> for such sale or use: <blockquote>A civil penalty or civil fine is a term used to describe when a state entity or a governmental agency seeks monetary relief against an individual as restitution for wrongdoing by the individual. </blockquote> I previously wrote about CCHIT in a series of linked posts that start here: <a href="http://hcrenewal.blogspot.com/2009/02/very-troubling-post-about-cchit.html">A very troubling post about the CCHIT (Certification Commission for Healthcare Information Technology)</a>. I have now written the following open letter to Mark Leavitt, MD, PhD, Chairman, Certification Commission for Healthcare Information Technology. <blockquote>To: <a class="Addr" href="javascript:noop()" onclick="BuK('%22Mark%20Leavitt%22%20%3Cmleavitt%40cchit.org%3E')" title="Create new mail memo with this address">"Mark Leavitt"</a> <script> if (window.s_IsEditPrint && window.s_IsEditPrint == "1") wM(window.s_DocCreated);else wM(window.s_DisplayDate);</script>Date: Sunday, June 07, 2009 02:10PM<a class="Addr" href="javascript:noop()" onclick="BuK('%22Mark%20Leavitt%22%20%3Cmleavitt%40cchit.org%3E')" title="Create new mail memo with this address"><mleavitt@cchit.org></mleavitt@cchit.org></a> Cc: Robert O'Harrow, Jr., Washington Post, and various AMIA working group mailing lists (CIS - clinical info systems, POI - people & organizational issues, OS - Open Source, and ELSI - Ethics, Legal & Social Issues) June 7, 2009 Mark Leavitt, MD, PhD Chairman, Certification Commission for Healthcare Information Technology www.cchit.org [6/8/09 - contact info from www.markleavitt.com removed per critique in response below -ed.] <div style="margin-left: 40px;">Re: NJ HIT Bill at http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM by Assemblyman Harb Conaway, Jr., District 7, and Upendra Chivukula, District 17 </div> Dear Mark, The NJ Bill at <a href="http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM" target="blank">http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM </a> by Assemblyman Harb Conaway, Jr., District 7, and Upendra Chivukula, District 17, calls for making it a violation of law to sell HIT not "certified" by CCHIT . Penalties are called for. The bill states: <div style="margin-left: 40px;">... No person or entity, either directly or indirectly, shall sell, offer for sale, give, furnish, or otherwise distribute to any person or entity in this State a health information technology product that has not been certified by the Certification Commission for Healthcare Information Technology. </div> As used in this section, "health information technology product" means a system, program, application, or other product that is based upon technology which is used to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information. b. A person or entity that violates the provisions of subsection a. of this section shall be liable to a civil penalty of not less than $1,000 for the first violation, not less than $2,500 for the second violation, and $5,000 for the third and each subsequent violation, to be collected pursuant to the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). I and others find this bill remarkable. It really calls into focus the HIT community's concerns about CCHIT and its political connections, especially pursuant to the article " <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>" of May 16, 2009 in the Washington Post by Robert O'Harrow Jr. I therefore seek answers to the following questions: 1. Do you approve of the proposals in the bill at http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM ? 2. Did you, or anyone in a governance or leadership position at CCHIT, play a role in sponsorhip of this bill, through financial contributions, lobbying, advocacy for its proposals, and/or other means to prohibit sale of non-CCHIT certified HIT? 3. Did anyone with governance or leadership roles in CCHIT's founding or affiliated organizations (e.g,, HIMSS, CITL, and others) or business associates of such people, play a role in the bill's sponsorhip, through financial contributions, lobbying, advocacy for its proposals, and/or other means to prohibit sale of non-CCHIT certified HIT? 4. Did anyone (person or company) in the HIT industry, broadly speaking, who could directly profit from such a bill becoming law play a role in sponsorhip of, or advocacy for this bill? I believe candid and transparent answers to these questions are important in giving the HIT community confidence that CCHIT primarily serves the public interest, not interests of an HIT lobby. </blockquote> -- SS 6/8/09 Dr. Leavitt has candidly responded. I take his word on these issues at face value, having done business with him a bit over a decade ago (supporting the purchase of his company's EHR, Logician, for Christiana Care over the opposition of the IT department which preferred another vendor): <blockquote> From: "Mark Leavitt" <mleavitt@cchit.org> Date: 06/08/2009 02:51AM cc: cis-wg@mailman.amia.org, poi-wg@mailman.amia.org, os-wg@mailman.amia.org, els-wg@mailman.amia.org, oharrowr@washpost.com,sreber@cchit.org<cis-wg@mailman.amia.org><poi-wg@mailman.amia.org><os-wg@mailman.amia.org><els-wg@mailman.amia.org><oharrowr@washpost.com><sreber@cchit.org> Subject: RE: Bill to make illegal the sale or use of non-CCHIT "certified" systems </sreber@cchit.org></oharrowr@washpost.com></els-wg@mailman.amia.org></os-wg@mailman.amia.org></poi-wg@mailman.amia.org></cis-wg@mailman.amia.org></mleavitt@cchit.org><div dir="ltr" align="left">Scot, </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">Here are the answers to your questions: </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">1. No, I do not approve of this legislation -- which I'm reading for the first time in your email. Our goal, stated in almost every presentation I've given, and to which I've adhered in my leadership of the Commission, has always been to unlock positive incentives for health IT adoption. The bill does not fit that model at all, and it is a bad idea. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">2. Neither I personally, nor CCHIT as an organization, have lobbied, advocated, sponsored, or had anything to do with that bill. We were unaware of it until it started showing up on listserves Friday. The bill has never been mentioned in any of our Trustee, Commission, or staff meetings. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">3. Trustees, Commissioners, and Work Group members serve in a volunteer capacity at CCHIT. We require disclosure of conflicts of interest, but we do not monitor all activities in their 'day jobs' or other volunteer roles. "HIMSS, CITL, etc" are not affiliated with CCHIT, and we don't know about all their advocacy activities. I'm not privy to the information you seek. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">4. This question presumes that I would know everything that "anyone in the HIT industry, broadly speaking" has done regarding the bill. Naturally I do not have that knowledge either. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">Now that I've responded, the AMIA listserve members can stop reading here, while I go on to chat with Scot. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">Scot, in 15 years of medical training and practice followed by 25 years of healthcare informatics, I've encountered very few people -- and certainly no university professors -- who acted so disrespectfully toward me. Being a veteran of health IT, it's easy to find people who have worked with me or know me well, and to ask them about my integrity. Or to talk to some of the other 50 or so Commissioners who've served or the hundreds of work group volunteers. Shouldn't an informatics scientist do a modicum of research before undertaking a potentially harmful procedure such as attacking a person's or organization's reputation? Reading a news article by Mr O'Harrow does not qualify as due diligence. Would you let your informatics students get away with that before recommending a major, potentially disruptive or destructive IT project? </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">From your own blogging I see that your "early medical mentor, cardiothoracic surgery pioneer Victor P Satinsky, MD, believed in public embarrassment as a tool to fight bureaucracy and discrimination ." Well, that helps me understand. And your blogging about your frustration when you sought employment with a commercial EHR vendor <a href="http://hcrenewal.blogspot.com/2009/02/nextgen-and-vendordoctor-dialog-yet.html">http://hcrenewal.blogspot.com/2009/02/nextgen-and-vendordoctor-dialog-yet.html </a> explains even more. Knowing that, I forgive you for your tone and for inappropriately disclosing my home address and cell phone to everyone on these lists. I would be pleased to engage in a civil, rational debate with you along the lines of "EHRs -- do the benefits outweigh the risks?" C'mon out to the farm here sometime -- you know the address, and the dog's friendly -- or we could do it on the web. </div> <div dir="ltr" align="left"> </div> <div dir="ltr" align="left">Finally, my apologies to everyone on the mailing lists that Dr. Silverstein chose to include in his investigative journalism broadcast. If you object to his use of AMIA mailing lists for this kind of activity, you could let him know. </div> <div> </div> <div>Mark Leavitt, MD, PhD Chairman, CCHIT </div></blockquote> My response was simple: <blockquote>To: "Mark Leavitt" <mleavitt@cchit.org> Date: 06/08/2009 05:24PM cc: <cis-wg@mailman.amia.org>cis-wg@mailman.amia.org, poi-wg@mailman.amia.org, os-wg@mailman.amia.org, els-wg@mailman.amia.org, oharrowr@washpost.com,sreber@cchit.org<poi-wg@mailman.amia.org><os-wg@mailman.amia.org><els-wg@mailman.amia.org><oharrowr@washpost.com><sreber@cchit.org> Subject: RE: Bill to make illegal the sale or use of non-CCHIT "certified" systems Mark, I thank you for the answers to my questions. > Knowing that, I forgive you for your tone and for inappropriately disclosing my home address and cell phone to everyone on these lists. Mark, that information came from your page at <a href="http://www.markleavitt.com/">http://www.markleavitt.com/</a> which I found on a google seach for "Mark Leavitt." Image attached. I believed that to be your professional contact info. As to the rest of your response, you appear to attempt to discredit my arguments through ad hominem. I refer you to this page: <a href="http://www.nizkor.org/features/fallacies/ad-hominem.html" target="blank">http://www.nizkor.org/features/fallacies/ad-hominem.html </a> <div style="margin-left: 40px;">Translated from Latin to English , "Ad Hominem" means "against the man " or "against the person." An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting <input name="IL_MARKER" type="hidden">the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making <input name="IL_MARKER" type="hidden">the claim , her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim ). Second, this attack is taken to be evidence against <input name="IL_MARKER" type="hidden">the claim or argument the person in question is making (or presenting). This type of "argument" has the following form: </div><ol style="margin-left: 40px;"><li>Person A makes claim X. </li><li>Person B makes an attack on person A. </li><li>Therefore A's claim is false. </li></ol> The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of <input name="IL_MARKER" type="hidden">the claim being made (or the quality of the argument being made). Ad hominem, sadly, is not debate. Neither is <a href="http://www.nizkor.org/features/fallacies/appeal-to-authority.html" target="blank">appeal to authority </a>. Scot</sreber@cchit.org></oharrowr@washpost.com></els-wg@mailman.amia.org></os-wg@mailman.amia.org></poi-wg@mailman.amia.org></cis-wg@mailman.amia.org></mleavitt@cchit.org></blockquote> Truth be told, I actually offered no arguments in my email message. I was asking very probing questions with concern they would be ignored, or responded to with "spin" as <a href="http://www.hcrenewal.blogspot.com/2009/02/cchit-dissolved-involuntarily-in-april.html">here</a>, and their tone offended him. Fair enough. I was a bit disappointed, however, by the "<a href="http://www.quotationspage.com/quote/25317.html">The lady doth protest too much, methinks</a>" ad hominem embellishments to an otherwise candid and convincing response. Such are the risks of directness and <a href="http://hcrenewal.blogspot.com/2009/03/disruptive-innovators-at-healthcare.html">disruptive innovation</a>, however. -- SS 6/9 Addendum: Additional views on the NJ Bill are at ePatients.net at "<a href="http://e-patients.net/archives/2009/05/david-kibbe-mark-leavitt-openness-vs-opacity.html">David Kibbe & Mark Leavitt:Openness vs. Opacity</a>" and "<a href="http://e-patients.net/archives/2009/06/dossia-microsoft-healthvault-google-healthillegal-in-nj.html">Dossia, Microsoft HealthVault & Google Health: Illegal in NJ?</a>". There are some now-familiar themes regarding CCHIT civility in those posts. 6/10 Addendum: As a result of a link sent by a commenter, I am adding the post "<a href="http://www.hcplive.com/mdnglive/The_HIT_Realist/Kibbe_Leavitt">The Kibbe/Leavitt Rumble in the High Tech Jungle!</a>" to the list of interesting views in the 6/9 addendum above.

Open letter to Mark Leavitt, Chairman, Certification Commission for Healthcare Information Technology on Penalties For Use of Non-"Certified" HIT

A remarkable Bill (ASSEMBLY, No. 3934 , STATE OF NEW JERSEY, 213th LEGISLATURE) has appeared in NJ that would prohibit the sale or use of h...

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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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