A Letter from the RUC, and My Reply

The vast amounts spent in the US on health care have not translated into access for many patients, consistently excellent quality of care, and signiticantly improved outcomes. While we spend all this money, the primary care and generalist practitioners on the front lines are increasingly embattled and disgruntled, and their numbers are rapidly thinning. One problem may be the pattern of fees paid to physicians. Fees paid to physicians not only influence costs directly, but provide incentives for physician decision making about what tests and treatments patients receive. We have posted several times, most recently in February, 2009, <a href="http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html">here</a>, about how the US Medicare system sets fees paid to physicians.<br /><br />Since health care reform is now a hot topic in the US, there has been increasing discussion of the plight of primary care and generalist practitioners, but little consideration of how it arose. What we wrote in February was (with updated links):<br /><br /><br /><blockquote><br />As we have discussed, the US Medicare system determines what it pays physicians using the <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/overview-of-rbrvs.shtml">Resource Based Relative Value System (RBRVS)</a>. This system determines the pay for every kind of medical encounter according to a complex formula that is supposed to account for physicians' time and effort, physicians' practice expense, and the cost of malpractice insurance. The components of physicians' effort assessed are, in turn, technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient.<br /><br />To keep the system, which was started in 1990, current, requires addition of new kinds of encounters, which means encounters involving new kinds of procedures, and updating of the estimates of various components, including physicians' time and effort. To do so, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the RBRVS Update Committee (RUC). The <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.shtml">RUC</a> is a private committee of the AMA, touted as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments. However, the identities of RUC members are secret, as are the proceedings of the group.<br /><br />This opaque and unaccountable process has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for "cognitive" medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation. The effects of the RUC have been amplified by the unexplained tendency of commercial managed care and health insurance to track the RBRVS system when making their own payments to physicians.<br /><br />For further details about the RUC, see these posts on Health Care Renewal (<a href="http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html">here</a>, <a href="http://hcrenewal.blogspot.com/2007/12/is-sustainable-growth-rate-main-problem.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/05/payments-for-patient-centered-medical.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2008/12/no-such-ruc-new-england-journal-takes.html">here</a>) and important articles by Bodenheimer et al,(1) and Goodson.(2) By the way, why the US Center for Medicare and Medicaid Services (CMS) relies de facto exclusively on the RUC to control the RBRVS system, and why the AMA made the RUC into a secret organization apparently beholden only to the organization's proceduralist members are unanswered questions. </blockquote><br /><br />The next month, Dr William L Rich III, and Dr Barbary Levy, the Chair and Chair-Elect of the RUC, wrote me a letter to "point out several blatant inaccuracies within your blog entry that severely misrepresent the nature and work of the AMA / Specialty Society RVS Update Committee (RUC)." They then asked me to "retract or correct the inaccurate statements within the aforementioned blog immediately." However, the letter did not specify the supposedly inaccurate statements within the blog post. So, my email response noted that "the letter contains no detail about the alleged 'inaccurate statements.' If you define them, we will certainly consider your views." I never got a reply to this message, therefore thinking the matter to be closed, and I saw at that time no reason to make the exchange public.<br /><br />Apparently, the matter was not closed. A few days ago, two anonymous comments were appended to the post. They stated that my letter had appeared on the AMA web-site, <a href="http://www.ama-assn.org/ama1/pub/upload/mm/380/posesresponse.pdf">here</a>. So it is now public. The comments did not say, and I have so far not been able to find out when the letter was posted, and what its context is within the AMA web-site, including any indication that I had already replied to it in private.<br /><br />Despite these irregularities, however, given that the AMA apparently has chosen to make the letter public, I believe I ought to respond publicly.<br /><br /><strong>"Blatant Inaccuracies?"</strong><br /><br />Dr Rich and Dr Levy wrote:<br /><br /><br /><blockquote><br />We would like to take this opportunity to point out several blatant inaccuracies within your blog entry that severely misrepresent the nature and work of the AMA / Specialty Society RBRVS Update Committee (RUC). We request you retract or correct the inaccurate statements within the aforementioned blog immediately.<br /></blockquote><br /><br />First, as I noted above, the letter never specified which of my statements the letter writers considered "blatant inaccuracies." If there are any specific statements of fact in the post above (or any other post I write) that can be shown to be inaccurate, I will correct or retract them. However, I do not believe the letter by Dr Rich and Dr Levy demonstrated any particular statements of mine to be blatantly inaccurate.<br /><br /><strong>The Obscurity of the RUC Membership</strong><br /><br />The letter stated:<br /><br /><br /><blockquote><br />The RUC does not operate in the shadows.<br /></blockquote><br /><br />One of my major criticisms of the RUC was that it is opaque. Before I wrote my first post on the RUC, I tried to determine its membership by searching the AMA web-site, easily available AMA publications, and the web. I could find lists of past members, but no current list. In addition, I asked RUC staff by email whether they could provide me the list, or an easy way to access it. They would or could not do so, and the highest ranking staffer I contacted wrote, "we do not give out the RUC members' contact information. We attempt to shield the RUC from lobbying by industry or others." Only after these inquiries did I dub the RUC membership "secret."<br /><br />Dr Rich and Dr Levy suggested that it is not quite secret. It stated that "a list of the individual members of the RUC is published in the AMA publication, Medicare RBRVS 2009: The Physicians Guide." This publication is available from the AMA <a href="https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1170041">here</a> for a mere $71.95. However, the book is not on the web, or in my local or university library, and I have no other way to easily access it.<br /><br />Additionally, although the letter stated, "any individual may solicit AMA staff directly or a specialty society to learn the names of the members of the RUC," the letter was not accompanied by any communication from AMA staff containing this information.<br /><br />Thus, to date, I still do not know who the members of the RUC are. If the letter authors had wanted to show that the membership of the RUC was not meant to be obscure, they could easily have sent me the list with their letter, appended a copy of the pages of the book which contained the list, or asked their staff to provide this information. They chose not to do so. So, while the RUC membership may not be exactly secret, it remains obscure, only barely public, and relatively inaccessible.<br /><br /><strong>The Secrecy of RUC Proceedings</strong><br /><br />Furthermore, to support its contention that "the RUC does not operate in the shadows," the letter stated that<br /><br /><br /><blockquote><br />any individual may attend a RUC meeting upon: (1) the invitation of and notification by a relevant specialty society; (2) an express invitation by the chair of the RUC; or (3) the approval of a written request to attend; and a review of conflicts and potential conflicts of interest.<br /></blockquote><br /><br />This does not mean that RUC meetings are open, or that their proceedings are public. Instead, as Goodson(2) noted, RUC "meetings are closed to outside observers except by invitation of the chair." Furthermore, he stated, "<em>proceedings are proprietary and therefore not publicly available for review</em>."<br /><br />The letter also personally invited me to attend "the next meeting of the RUC, which will take place April 23-26, 2009 in Chicago." In retrospect, this invitation did not appear serious, since it was never repeated or expanded after my email reply to the March letter.<br /><br />Nor did the invitation include any assurance that I could make anything about this meeting public. I had learned from a previous RUC attendee who will remain anonymous that attendees are obligated to sign non-disclosure agreements. Signing such an agreement might jeopardize my further ability to write anything of substance about the RUC. Furthermore, making all meeting attendees sign non-disclosure agreements effectively makes the meeting secret.<br /><br /><strong>The RUC and Primary Care</strong><br /><br />Dr Rich and Dr Levy asserted that:<br /><br /><br /><blockquote><br />Your publication irrationally and unreasonably paints the RUC as the perpetrator of all physician payment policies that have negatively affected primary care.<br /></blockquote><br /><br />Furthermore, they argued that the RUC has been good for primary care and cognitive practice:<br /><br /><br /><blockquote><br />The RUC has made several recommendations that positively benefit cognitive and non-procedural physician specialties.<br /></blockquote><br /><br />My opinions about the RUC's influence on payments to physicians, and the decline of primary care and generalist and cognitive practice are hardly original. My previous posts were clearly based on evidence and discussion from references 1-4. Let me summarize these arguments, using direct quotes from these references, which perusal of the original articles would reveal are not taken out of context.<br /><br /><em>Primary and generalist practice is threatened by the current payment system.</em><br /><br />From Bodenheimer et al(1):<br /><br /><br /><blockquote><br />Incomes of primary care physicians are well below those of many specialists, and the primary care–specialty income gap is widening.<br /><br />... the lower income of primary care physicians is a major factor leading U.S. medical students to reject primary care careers.<br /><br />Primary care practice is not viable without a substantial increase in the resources available to primary care physicians.<br /></blockquote><br /><br />From Goodson(2):<br /><br /><br /><blockquote><br />Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale.<br /><br />Current reimbursement incentives substantially favor procedures and technical interventions and offer financial advantages for expensive care, thereby encouraging specialty services.<br /><br />The continued and sustained incentives for medical graduates to choose higher-paying specialty careers and for those physicians in specialty careers to increase income through highly compensated professional activities have been associated with the dwindling of the generalist workforce. The lack of incentives for medical graduates to choose generalist careers in internal medicine, family medicine, and pediatrics has had a profound effect on the workforce mix and, ultimately, US health care expenditures.<br /></blockquote><br /><br /><br /><em>The RUC has been the major influence on the physician payment system leading to these problems</em>.<br /><br />From Bodenheimer et al(1):<br /><br /><br /><blockquote><br />In summary, the RUC process favors increases in procedural and imaging reimbursement for 3 reasons: specialty society influence in proposing RVU increases, the specialist-heavy RUC membership, and the desire of RUC specialists to avoid increases in evaluation and management RVUs. With their ability to create new codes and influence RVU updates, many procedural specialists can influence fees in a way that observers find to substantially overvalue procedural and imaging services. Moreover, high fees may encourage physicians to increase the volume of profitable services, leading to even higher income gains and greater spending growth.<br /></blockquote><br /><br />From Goodson(2):<br /><br /><br /><blockquote><br />The RUC has powerfully influenced CMS decision making and, as a result, is a powerful force in the US medical economy. Furthermore, by creating and maintaining incentives for more and more specialty care and by failing to accurately and continuously assess the practice expense RVUs, the decisions of CMS have fueled health care inflation. Doing so has affected the competitiveness of US corporations in the global market by contributing to years of double-digit health care inflation that have consistently increased the costs of manufacturing and business in the United States over the last decades.<br /><br />The current mechanism fails to provide sufficient checks and balances and is skewed and dysfunctional.<br /><br />The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery.<br /></blockquote><br /><br />Dr Rich and Dr Levy are entitled to their opinions, but I would argue that there is considerable evidence and opinion suggesting that the current dysfunctional physician payment system is a major cause of the decline of primary care and cognitive practice, and simultaneous rise in health care costs and decline in health care access in the US. Furthermore, there is also considerable evidence and opinion suggesting that the RUC has singular responsbility for the dysfunctionality of the payment system and how it is skewed in favor of procedures as opposed to cognitive services and primary care.<br /><br /><strong>Summarizing: the Opacity of the RUC, and its Negative Effects on Primary Care and Cognitive Services</strong><br /><br />So, I stand by my statement that the RUC process is opaque. Instead of saying "the identities of RUC members are secret, as are the proceedings of the group," I would be willing to now say, "the identities of the RUC members are obscure and difficult to ascertain, and the proceedings of the group are secret." That is not much of an improvement.<br /><br />If the RUC leadership wants to make its membership transparent, all it needs to do is post it on the web. If it wishes to make its proceedings transparent, all it needs to do is publish them as well. If it makes such changes, I would happily and publicly applaud them.<br /><br />If the RUC leadership wants to show that their members are not influenced by individual conflicts of interest, transparency about the committee's membership would inspire more trust than making the information as obscure as possible.<br /><br />Furthermore, there may be more reason to be concerned about the effects of institutional rather than individual conflicts of interest on the RUC. Most RUC members appear to represent specialty societies. Rothman et al claimed that industry funding of professional medical societies is "pervasive."(5) If the RUC leadership wants to show that their committee as a whole is not affected by institutional conflicts of interest of its specialty societies, it ought at least to disclose the relationships of those societies and their leaders with companies that stand to profit from increasing utilization of the specific services whose use is influenced by the incentives which the RUC largely determines.<br /><br />Finally, if there is a "wedge between cognitive and procedural specialties" it was driven a long time ago, particularly by a payment system that progressively favored the latter over the former, and by a bureaucratic burden that fell disproportionately on the former. But blaming the messenger is a time-honored, if not necessarily honorable tactic.<br /><br /><span style="font-size:85%;"><strong>References</strong><br /><br />1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link </span><a href="http://www.annals.org/cgi/content/full/146/4/301"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.<br />2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link </span><a href="http://jama.ama-assn.org/cgi/content/short/298/19/2308"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.<br />3. Ginsburg PB, Berenson RA. Revising Medicare's physician fee schedule - much activity, little change. N Engl J Med 2007; 356: 1201-1203.<br />4. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884.<br />5. Rothman DJ, McDonald WJ, Berkowitz CD et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA 2009; 301: 1367-1372. Link </span><a href="http://jama.ama-assn.org/cgi/content/full/301/13/1367"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">. </span>

A Letter from the RUC, and My Reply

The vast amounts spent in the US on health care have not translated into access for many patients, consistently excellent quality of care, a...

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Experience our largest developer gathering online

<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoToJESLTB0NMkouQuQyT2iQBSu1X-Fj5tOUQ2sKNtg2fKEjB5-OubNPnK58xtJDdVaefyjvVU16fuEKnwAhhgxPRZEHs2pQkDEwGmgM-7a8FJL9WVspwrkw6LitNH1THMGpNORx8ac1zu/s1600-h/io.JPG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5345743922032044642" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoToJESLTB0NMkouQuQyT2iQBSu1X-Fj5tOUQ2sKNtg2fKEjB5-OubNPnK58xtJDdVaefyjvVU16fuEKnwAhhgxPRZEHs2pQkDEwGmgM-7a8FJL9WVspwrkw6LitNH1THMGpNORx8ac1zu/s400/io.JPG" style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 300px; height: 156px;" /></a><a href="http://code.google.com/events/io/">Google I/O</a> has come and gone, and we've been working to get all of the content online so those of you who couldn't be there could experience some of the excitement. At the conference, we shared <a href="http://www.youtube.com/watch?v=S5aJAaGZIvk">our thoughts</a> on the future of the web along with some exciting announcements including a <a href="http://code.google.com/apis/wave/">developer preview</a> of <a href="http://wave.google.com/">Google Wave</a>, our new collaboration and communication tool, and <a href="http://www.google.com/webelements/">Google Web Elements</a>, which makes adding a bit of Google to your website or blog as simple as copy and paste. In addition, I/O featured <a href="http://code.google.com/events/io/sessions.html">80+ sessions</a> of technical insight, and over 140 companies joined our <a href="http://code.google.com/events/io/sandbox.html">developer sandbox</a> at the conference to showcase the web applications they've been building using Google developer products. <div><br /></div><div>All of these sessions, along with interviews and screencasts from many of the sandbox developers, are now available for you to <a href="http://code.google.com/events/io/">watch online</a>. Also, to get a real feel for the happenings on the conference floor at Moscone Center in San Francisco, check out our <a href="http://code.google.com/events/io/map/#level2">interactive map</a> to watch session videos embedded in their actual conference rooms, or browse our <a href="http://code.google.com/events/io/photos.html">photo gallery</a>.<br /><br />You can stay tuned for further updates on all of our developer products at the <a href="http://google-code-updates.blogspot.com/">Google Code Blog</a> and <a href="http://code.google.com/">code.google.com</a>. We had a great time getting to meet all of developers building amazing apps using Google technology and want to thank the 140 other companies that participated. See you next year!<br /><br /><span class="byline-author">Posted by Azhar Hashem, Google Developer Products and Mike Marchak, Google Code Team </span></div>

Experience our largest developer gathering online

Google I/O has come and gone, and we've been working to get all of the content online so those of you who couldn't be there could e...

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Mr. HISTalk has a pair

I've been somewhat concerned about the <a href="http://histalk2.com/">HISTalk</a> blog site becoming HIT ad revenue-beholden in recent years, perhaps diluting its critique of HIT industry dysfunction.<br /><br />However, after seeing <a href="http://histalk2.com/2009/06/09/news-061009/">these posts</a> today, I am reconsidering that impression (comments in red are mine).<br /><br />On why physicians are ignored in HIT decisions:<br /><br /><blockquote>... Because that’s what IT executives do (no offense to those CIOs who really do give physicians a strong voice in decision-making). I’ve been on that IT side and the working assumptions where I’ve been were that doctors and nurses (a) don’t understand organizational strategy; (b) are too easily swayed by demo eye candy and insincere vendor promises; (c) understand only products themselves and not the big picture IT world of vendor stability, product positioning, and integration; and (d) don’t appreciate IT’s technology, support, and organizational challenges. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[In other words, are basically stupid; s</span><span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">ee my 1999-ish piece on doctor stereotypes</span> <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/tactics.htm" style="font-style: italic; font-weight: bold;">here</a><span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);"> - ed.]</span> I’ve worked in three places where users were invited to review and recommend clinical systems. In every one, the first choice of doctors and nurses wasn’t the one that was purchased because we IT folks (some of whom were held in very high regard, mostly by themselves and their easily influenced peers) were so much more knowledgeable that we had the right … no, the <em>obligation</em> … to override them to buy what <em>we </em>thought was the best system. Their resulting adoption was about what you would expect. CIOs are often fixated on buying whatever will cause them the fewest headaches or that carries the lowest organization risk. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[I would not dismiss the potential influence of conflict of interest as well - ed.]</span><br /><br /></blockquote>on CCHIT:<br /><br /><blockquote>Some anonymous blog commenters (not here) are demanding that Mark Leavitt step down from his role as CCHIT chairman, claiming his history with HIMSS will always taint CCHIT. My thoughts: I agree. HIMSS wisely used its clout to create CCHIT in its image and nurture it through general acceptance to advance its own agenda, but the strings need to be cut now (including replacing Steve Lieber as CCHIT board chair). I predicted when CCHIT was created that it wouldn’t really change the industry because the interoperability changes CCHIT was supposed to certify (and nothing more) weren’t capabilities customers cared about anyway. That’s what has happened, at least from my cheap seat. Now that CCHIT indirectly affects billions in stimulus dollars, I’d rather see it run by people with no trade group or vendor connections. If it isn’t willing to do that, I’d say choose or form another group to run the certification program. Some of what CCHIT wants to measure, report, or certify (functionality, security, specialty capabilities) is going way beyond what the government should be mandating anyway, although this particular government seems to enjoy telling carmakers and banks how to run their affairs (kind of like letting the Mafia buy into your business). It’s funny that the industry has fought tooth and nail to avoid FDA oversight that it couldn’t control, but seems to like CCHIT because it removes some competitors and sends innovation to the back of the line. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[I largely agree with the caveat that the #1 issue for me is clinical IT safety -- primum non nocerum -- and also recently found part of CCHIT leader Mark Leavitt's </span><a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html" style="font-style: italic; font-weight: bold;">response to my pointed questions</a> <span style="font-weight: bold; color: rgb(255, 0, 0); font-style: italic;">patronizing and a bit hysterical. Sign of a leader who can't handle the pressure of public scrutiny and controversy without blowing up? My early mentor, cardiovascular surgeon Dr. Victor P. Satinsky, had a rule in medicine - "If you don't like it, don't come" - i.e., if you can't take the heat, get out of the kitchen - ed.]</span><br /></blockquote><br />Regarding Mr. HisTalk's comments: wow.<br /><br />-- SS

Mr. HISTalk has a pair

I've been somewhat concerned about the HISTalk blog site becoming HIT ad revenue-beholden in recent years, perhaps diluting its critiqu...

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Wind Cripples Hospital's EHR Systems - But These Things "Just Happen"

I would like to pretend these incidents don't occur, but alas, they do. Of course, we only know about the ones that are reported.<br /><br />At "<a href="http://hcrenewal.blogspot.com/2009/06/hospital-computing-backwater-and-need.html">Indiana Power Surge</a>" I wrote about the dangers of EHR "glitches" that do, but should not, cause catastrophic failure of clinical IT systems that clinicians are increasingly dependent upon to deliver healthcare.<br /><br />At "<a href="http://hcrenewal.blogspot.com/2009/06/another-episode-in-series-hit-failure.html">Another Episode in the Series: HIT Failure</a>" I wrote about yet another hospital whose clinical IT suffered a "glitch" that caused the hospital to struggle for a week with computer failures.<br /><br />Here we go again, this seems almost daily now. Wait until hospitals and offices really try to push the envelope to get onboard the ARRA EHR gravy train by 2014:<br /><br /><blockquote><a href="http://www.kswo.com/Global/story.asp?S=10498210">Strong winds damage Indian Hospital systems</a><br /><br />Posted: June 8, 2009 05:48 PM<br /><br />LAWTON Okla. - The Lawton Indian Hospital is trying to recover from damaging winds that came with a severe storm Sunday night, leaving the hospital without air-conditioning and <span style="font-weight: bold;">severely crippled in their computer systems</span>.<br /><br />The storm damaged a coil to a $200,000 cooler that provides air conditioning for the hospital. The power went off for a short time around 8:30.<br /><br /><span style="font-weight: bold;">The power outage affected all their medical records, charts, everything that held patients' information. </span>The only way to overcome the glitch was to resort to an old filing system. A system that used colors to match up what kind of care a patient needed.<br /><br />And with 55,000 files to pour through, the hospital has<span style="font-weight: bold;"> severely slowed down</span>. Rows and rows of thousands of files. Each one containing a patient's history.<br /><span style="font-weight: bold;"><span class="Apple-style-span" style="font-weight: normal;"><span style="color: red; font-style: italic; font-weight: bold;"><span class="Apple-style-span" style="color: black; font-style: normal; font-weight: normal;"></span></span></span></span><br /></blockquote>Of course, there is the traditional disclaimer about how such outages NEVER, EVER jeopardize patient safety (<span style="font-weight: bold;"><span class="Apple-style-span" style="font-weight: normal;"><span style="color: red; font-style: italic; font-weight: bold;"><span class="Apple-style-span" style="color: black; font-style: normal; font-weight: normal;">see "</span></span><span style="color: red; font-weight: bold;"><span class="Apple-style-span" style="color: black; font-style: normal; font-weight: normal;"><a href="http://hcrenewal.blogspot.com/2009/05/health-it-failure-never-puts-patients.html">Health IT Failure Never Puts Patients at Risk</a></span></span><span style="color: red; font-style: italic; font-weight: bold;"><span class="Apple-style-span" style="color: black; font-style: normal; font-weight: normal;"><i>")</i>:<br /></span></span></span></span><br /><blockquote>Despite this setback hospital officials remain optimistic.<br /><br />"The staff <span style="font-weight: bold;">knows a lot of the folks</span>, they know what's going on with them," said hospital Chief Executive Officer Hickory Starr.</blockquote><br />I can attest to memory not being an optimal way to practice medicine ...<br /><br />The outage has repercussions beyond inpatients:<br /><br /><blockquote>Even if the hospital could call all of the existing patients to let them know the hospital's system is down, he says that would not solve everything.<br /><br />"We have a lot of folks that show up here. Some that have appointments and a lot that do not."<br /><br />Then there are those who need refills on their prescriptions.<br /><br />"And we <span style="font-weight: bold;">can not do refills</span> because we can not pull up that electronic chart."</blockquote><br />Finally, the prevailing attitude that safety is an Act of Providence (in reality, safety is not an accident):<br /><br /><blockquote>Despite it all, most people remain pretty cheery.<br /><br />"Generally they are. There is always some frustration but<span style="font-weight: bold;"> this is one of those situations that just happens."</span></blockquote><br />One of those situations that "just happens" is <span style="font-style: italic;">days of EHR failure due to a power outage? </span><br /><br />It'll all be fixed soon:<br /><br /><blockquote>Hospital officials expect the computer systems back online late Monday or early Tuesday morning.</blockquote><br />Real soon.<br /><br />I repeat my oft-stated observation that IT culture will need to be reformed before IT will be able to "reform medicine."<br /><br />-- SS

Wind Cripples Hospital's EHR Systems - But These Things "Just Happen"

I would like to pretend these incidents don't occur, but alas, they do. Of course, we only know about the ones that are reported. At ...

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The state of cloud computing

Earlier today at the Clift Hotel in San Francisco, we convened a group of journalists, partners and customers for a discussion on <a href="http://www.google.com/apps/intl/en/business/index.html#utm_medium=et&utm_source=us-en-ogb&utm_campaign=en">Google Apps</a> in the enterprise. We're pleased to report that the "state of <a href="http://googleenterprise.blogspot.com/2009/04/what-we-talk-about-when-we-talk-about.html">the cloud</a>" is strong, and we've taken a number of steps to make it stronger.<br /><br />At the event we discussed the growth of our business, introduced some new customers, and announced a feature that makes switching to Apps even easier. The Clift was a particularly appropriate venue because it's a member of the <a href="http://www.morganshotelgroup.com/">Morgans Hotel Group</a>, which is deploying Google Apps to its 1,750 employees. <a href="http://www.johnsondiversey.com/cultures/en/default.htm">JohnsonDiversey</a>, a global provider of commercial cleaning and hygiene products and solutions, has also gone Google. Choosing Apps helped JohnsonDiversey migrate its 12,000 employees to one communications platform while lowering its IT costs and furthering its commitment to sustainability through the elimination of a number of energy-intensive email servers.<br /><br />Of course, when big companies like Morgans move all their employees from Microsoft Exchange to Google Apps, there are often a few folks who aren't ready to give up Microsoft Outlook right away. To help them make the transition, today we also introduced <a href="http://www.google.com/apps/intl/en/business/outlook_sync.html#utm_medium=et&utm_source=us-en-ogb&utm_campaign=en">Google Apps Sync for Microsoft Outlook</a> to our Premier and Education edition customers. It lets Outlook work easily with Apps and — like <a href="http://googleenterprise.blogspot.com/2009/01/announcing-offline-access-in-gmail-labs.html">offline Gmail</a> and the <a href="http://www.google.com/apps/intl/en/business/mobile.html#utm_source=en_US-blog-gbes&utm_medium=blog&utm_campaign=gbes">Google Apps Connector for BlackBerry® Enterprise Server</a> — is another example of how we're making it dead simple to switch to Google Apps.<br /><br />To read more about Google Apps Sync for Microsoft Outlook and hear why 1.75 million companies are now running their business on Google Apps, check out the <a href="http://googleenterprise.blogspot.com/2009/06/use-microsoft-outlook-with-google-apps.html">Google Enterprise Blog</a>.<br /><br /><span class="byline-author">Posted by Matthew Glotzbach, Product Management Director, Enterprise team</span>

The state of cloud computing

Earlier today at the Clift Hotel in San Francisco, we convened a group of journalists, partners and customers for a discussion on Google App...

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Translating the world's information with Google Translator Toolkit

At Google, we consider translation a key part of making information universally accessible to everyone around the world. While we think <a href="http://translate.google.com/">Google Translate</a>, our automatic translation system, is pretty neat, sometimes machine translation could use a human touch. Yesterday, we launched <a href="http://translate.google.com/toolkit">Google Translator Toolkit</a>, a powerful but easy-to-use editor that enables translators to bring that human touch to machine translation.<br /><br />For example, if an Arabic-speaking reader wants to translate a <a href="http://www.wikipedia.org/">Wikipedia</a>™ article into Arabic, she loads the article into Translator Toolkit, corrects the automatic translation, and clicks publish. By using Translator Toolkit's <a href="http://translate.google.com/support/toolkit/bin/answer.py?hl=en&answer=147838">bag of tools</a> — translation search, bilingual dictionaries, and ratings, she translates and publishes the article faster and better into Arabic. The Translator Toolkit is integrated with Wikipedia, making it easy to publish translated articles. Best of all, our automatic translation system "learns" from her corrections, creating a virtuous cycle that can help translate content into 47 languages, or over 98% of the world's Internet population.<br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVUgirudPjlpNWYbq5lZ265a7ohJE_I6llq2XIEARWDLz2dAKUhH9vQyWwmLRuxEuELnZStTRs9urr58sjAO02x20p5tWZb8lLY_-l2BYm9_-8CiwkBJvsCGpZrQ1aqgWLTGVOOKXVP7KK/s1600-h/cycle.PNG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5345332671139597682" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVUgirudPjlpNWYbq5lZ265a7ohJE_I6llq2XIEARWDLz2dAKUhH9vQyWwmLRuxEuELnZStTRs9urr58sjAO02x20p5tWZb8lLY_-l2BYm9_-8CiwkBJvsCGpZrQ1aqgWLTGVOOKXVP7KK/s400/cycle.PNG" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 201px;" /></a><br />Besides Wikipedia, we've also integrated with <a href="http://knol.google.com/">Knol</a>, and we support common document types including Word and HTML. For translation professionals, we provide advanced features such as <a href="http://translate.google.com/support/toolkit/bin/answer.py?hl=en&answer=147859">terminology</a> and <a href="http://translate.google.com/support/toolkit/bin/answer.py?hl=en&answer=147863">translation memory</a> management.<br /><br />For more information, check out our introductory video below. And if you're a professional translator or just a linguaphile, try <a href="http://translate.google.com/toolkit">Google Translator Toolkit</a> for easier and faster translations. Be sure and <a href="http://translate.google.com/support/toolkit/bin/request.py?hl=en&contact_type=contact_us">let us know what you think</a>.<br /><br /><object height="340" width="560"><param name="movie" value="http://www.youtube.com/v/C7W2NJFdoIg&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/C7W2NJFdoIg&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="340" width="560"></embed></object><br /><br /><span class="byline-author">Posted by Michael Galvez and Sanjay Bhansali, Google Translator Toolkit team</span>

Translating the world's information with Google Translator Toolkit

At Google, we consider translation a key part of making information universally accessible to everyone around the world. While we think Goog...

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Another Episode in the Series: HIT Failure

At "<a href="http://hcrenewal.blogspot.com/2009/06/hospital-computing-backwater-and-need.html">Indiana Power Surge</a>" I wrote about the dangers of EHR "glitches" that do, but should not, cause catastrophic failure of clinical IT systems that clinicians are increasingly dependent upon to deliver healthcare. <div><br /></div><div>Heart-lung machines, for example, do not generally have "unscheduled downtime" during surgery. It would not be tolerated.<br /><br />With EHR's, though, here we go again:<br /><br /><blockquote>June 6, 2009<br /><br /><a href="http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20090606/NEWS01/906060351/1043">Hospital stricken by computer glitch</a><br />Staff forced to keep records by hand<br /><br /><span class="Byline">By CHELSEA CONABOY Monitor staff</span><br /><br />Concord Hospital CEO Mike Green said the hospital has been struggling for a week with computer system failures but, as of yesterday, everything was working again.<br /><br />Green said the hospital was adding memory to its storage area network on May 28 and something went wrong - possibly because of faulty hardware or a bad installation. <span style="font-weight: bold;"><span style="font-style: italic; color: rgb(255, 0, 0);">[It is remarkable that the cause seems unknown - ed.]</span> In the days that followed, the systems that access that network began to fail.<span class="Apple-style-span" style="font-weight: normal;"><br /><br />Those used by nurses and pharmacists in the hospital and by providers to make orders for lab work <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[i.e., CPOE - ed.] </span>and other tests crashed.<br /><br />"People had to revert to paper processes," Green said. "It was a lot of work, particularly for pharmacists who had to do things manually that are ordinarily done by the electronic system." <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[The increased risk of error in the mayhem is not insignificant - ed.]<span class="Apple-style-span" style="color: rgb(0, 0, 0); font-style: normal; font-weight: normal;"><br /><br />The systems that handle electronic medical records and financial information in physicians' offices weren't affected.<br /><br />The hospital financial system, which processes about $1.5 million in charges each day, was briefly offline but quickly repaired, Green said.<br /><br />He said staff members were working around the clock to correct the problems and to ensure that <span style="font-weight: bold;">the quick shift to manual processes posed no safety concerns for patients</span> <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[as I've written before, HIT crashes NEVER, EVER seem to present safety concerns - </span> <i><b><span class="Apple-style-span" style="color: rgb(255, 0, 0);">see</span></b></i> "<a href="http://hcrenewal.blogspot.com/2009/05/health-it-failure-never-puts-patients.html"><i>He</i><i>alth IT Failure Never Puts Patients at Risk</i></a><i>"</i> <b><i><span class="Apple-style-span" style="color: rgb(255, 0, 0);">- ed.]<span class="Apple-style-span" style="color: rgb(0, 0, 0); font-style: normal; font-weight: normal;"><br /><br />The systems are new, some installed within six months, and are state of the art for the industry.<br /><br />"It's remarkable how quickly you become reliant on that technology," he said. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[I'm not so sure what's remarkable about it when you get rid of paper. Clinicians have to record their orders, findings and observations, etc. somewhere - ed.]<span class="Apple-style-span" style="color: rgb(0, 0, 0); font-style: normal; font-weight: normal;"><br /><br />Green said the issues highlighted the fact that some nurses at the hospital have only ever used electronic processes for keeping patient charts and <span style="font-weight: bold;">don't have the experience of using manual systems to fall back on when the systems crash</span>. The hospital plans to create training and procedural standards for what to do in case that this happens again. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[Why in god's name wasn't it done before?- ed.]<span class="Apple-style-span" style="color: rgb(0, 0, 0); font-style: normal; font-weight: normal;"><br /><br />Green did not have an estimate for how much the computer crash would cost the hospital, though he said it was something that would be accounted for through minor adjustments in the organization. He said patients were not likely aware of the problems.<br /><br />"This was a painful learning experience," he said. "Between dealing with H1N1 and dealing with this, I am very confident in saying we are the best prepared hospital in the state to deal with any disaster." <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[This seems a bit of a non-sequitur. They apparently don't really know what went wrong with the IT, and they claim they're prepared to deal with any disaster? - ed.]</span></span></span></span></span></span></span></i></b></span></span></span></span></blockquote><br />This organization recently won an award for IT excellence:<br /><span style="font-weight: bold;"></span><br /><blockquote><a href="http://www.concordhospital.org/news/news.php?shownews=true&id=842&artid=842&arttype=1">Concord Hospital’s Michael Green nationally awarded for leadership and commitment to utilize information technology to enhance patient care</a><br /><br />January 22nd, 2009<span style="font-weight: bold;"><br /><br /></span>Michael B. Green, president and CEO of Concord Hospital, has been selected as one of three winners of the CEO IT (Information Technology) Achievement Award by Modern Healthcare magazine and Healthcare Information and Management Systems Society. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[HIMSS - ed.] </span><br /><br />A panel of judges consisting of two CEOs and three chief information officers or IT experts chose three winners from a pool of 48 nominees. This year’s winners will be spotlighted in the February 16th issue of Modern Healthcare. Green is one of 18 winners of the award since its creation in 2003.<br /><br />Concord Hospital’s Michael Green nationally awarded for leadership and commitment to utilize information technology to enhance patient care</blockquote><br />This hospital is an IT award winner. I fear what's going to happen at hospitals with far less IT savvy deal when they deal with this increasingly complex and critical technology in coming years.<br /><br />-- SS<br /><br />6/19 Addendum:<br /><br />I've had an exchange with Concord Hospital's CIO, Deane Morrison RPh, which I am posting here with permission. He wrote me a polite letter expressing concern that my post was downplaying Concord's HIT accomplishments. We had this exchange:<br /><blockquote><br />Deane,<br /><br />I believe you misconstrue my post. I am an HIT supporter - but in recent years have concerns the field has moved too fast.<br /><br />I am pointing out that your hospital won an award for IT excellence, reproducing a paragraph about that, yet still has problems with the technology. I do this in the context of my concerns about what will happen at hospitals <span style="font-weight: bold;">without</span> the IT savvy yours has in future years. In that sense, I am complimenting your organization, with a few nitpicks that, believe me, are relatively minor compared to your competitors.<br /><br />I am an HIT expert going back many years (see my bio page in the link below), was a CMIO in both hospital and pharma serttings, and know that there are universal problems in both clinical IT and research IT. I also spent time at Comdisco working on disaster recovery and business continuity solutions for hospitals and know the complexities of that.<br /><br />As to risk/benefit, I have written volumes at the 10-year-old website now hosted at Drexel, again at the link below <span style="font-style: italic;">[<a href="http://www.tinyurl.com/hit-misadventure">link</a> -ed.]</span> My concerns are that HIT can finally produce the benefits long claimed (decades!) for it, and in fact have achieved those benefits in projects I led - with a caveat - only if done well. There is a lot of meaning as I'm sure you well know behind those two words, from vendor origins to implementation to lifecycle management.<br /><br />It sounds like you've done HIT very well (I hear really terrible stories from my colleagues and grad students in operational HIT positions almost daily these days), but yet you are still faced with the unexpected events predicted by those in the field of social informatics with any ICT (information & communication technology) - the unthinkable and chaotic things that find a way to happen despite good planning.<br /><br />Again, my concern is about the hospitals who are not award winners and yet who are being rushed into HIT by the provisions in the ARRA.<br /><br />If you would like me to add a comment or address some specific concern, please let me know.</blockquote><br />CIO Morrison then wrote me back:<br /><br /><blockquote>Scot,<br /><br />Thank you for your reply. I clearly misconstrued the intent of your blog. I very much agree with you that our society as a whole and the leadership of our country do not understand how hard it is to successfully implement clinical IT technology.<br /><br />At Concord I've never contended that what success we've had has been related to the systems we have choosen. Rather I've tried to emphasize for our leadership that its the people (It & clinicians) who work on the projects that make the difference. We have invested in a CMIO (Dr. Joel C. Berman). He has three other MD's working part time. We have a 4 person nursing informatics team. And we have a very large IT department. And even with that we are still vulnerable to the hiccups that come with increasong reliance on technology. So all in all I believe that well installed IT technology will result in a better healthcare system but I aslo very much agree with you that we can not underestimate the amount of hard work its going to take to get us there.<br /><br />Deane Morrison, RPh<br />CIO<br />Concord Hospital<br />Concord, NH </blockquote><br />It is a pleasure to communicate with CIO's who understand what's strategic and what's tactical in healthcare and HIT. I replied:<br /><br /><blockquote>Deane,<br /><br />Thanks. You've made an interesting comment:<br /><br /><span style="font-style: italic; font-weight: bold;">"... Rather I've tried to emphasize for our leadership that its the people (IT & clinicians) who work on the projects that make the difference."</span><br /><br />Indeed. I expressed this years ago by observing that "healthcare IT projects are complex medical/social projects that happen to involve computers, as opposed to complex IT projects that happen to involve clinicians."<br /><br />You are way ahead of many of your competitors in pointing out to your leadership what's strategic in IT (the right people with the right skills) vs. what's transient and tactical (the right package, platform etc.). Technologic determinism prevails (i.e., computers solve problems, automatically, and people are interchangeable cogs in an IT project).</blockquote><br /><br />In my opinion we as a nation need more CIO's in hospitals who share these insights about people.<br /><br />-- SS<br /></div>

Another Episode in the Series: HIT Failure

At " Indiana Power Surge " I wrote about the dangers of EHR "glitches" that do, but should not, cause catastrophic failu...

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