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What Health Care Reformers Don't Discuss

Health care reform is now the big health care story in the US. Discussion of various health care reform proposals regularly lead in print and electronic media. Yet we have been very quiet here on Health Care Renewal about health care reform. I personally have written little, because it seems to me that hardly any of the discussion swirling around relates to the concerns we discuss on this blog. We write about the bad effects of continuing concentration and abuse of power in health care on physicians' and other health care professionals' core values. We note instances of ill-informed, incompetent, self-interested, conflicted, or even corrupt leaders of health care organizations. We discuss how problems with the governance of health care organizations allow such leadership. We comment on instances in which bad leaders use tactics such as deception, creation of perverse incentives, and intimidation. And we address how all this can lead to higher costs, decreasing access, poor patient outcomes, and demoralized professionals. For example, just in this month, July, 2009, we posted about: How Trusted Health Care Institutions are Lead by the Conflicted <ul><li>One of the largest and most respected medical societies gets three times as much income from the pharmaceutical, biotechnology and device industries as from membership dues, and its current generously salaried president just asks the public to "trust us, we're doctors" (link <a href="http://hcrenewal.blogspot.com/2009/07/again-logical-fallacies-in-defense-of.html">here</a>); </li><li>The White House health care reform czar just stepped off the board of directors of a health care corporation accused of "ruthless" behavior and making patients feel they are only equivalent to "dollars" (link <a href="http://hcrenewal.blogspot.com/2009/07/turning-patients-into-dialysis-dollars.html">here</a>); </li><li>An award-winning show on public television featured remarks favoring drug treatment of psychiatric illness by an academic "key opinion leader" without disclosing his multiple financial ties to the pharmaceutical industry (link <a href="http://hcrenewal.blogspot.com/2009/07/peabody-award-for-show-featuring.html">here</a>); </li><li>A state legislator pleaded guilty to selling his services to an academic medical center (link <a href="http://hcrenewal.blogspot.com/2009/07/ny-state-legislator-pleads-guilty-to.html">here</a>); </li></ul>Health Care Leaders Do Not Share Physicians' Traditional Values <ul><li>Leaders of the university that employs the academic "key opinion leader" mentioned above intimidated another of its professors because he wrote a blog critical of the pharmaceutical industry (link <a href="http://hcrenewal.blogspot.com/2009/07/blogger-that-dares-not-speak-his.html">here</a>); </li><li>A study showed that primary care doctors burn out not just because they think their pay is low, but because they work in "chaotic" environments, lead by people who do not inspire trust and whose values are not aligned with those of the physicians (link <a href="http://hcrenewal.blogspot.com/2009/07/window-on-unworkable-settings-in-which.html">here</a>); </li></ul>And our archives, going back now to the end of 2004, include much more.For the most part, however, these are not the issues discussed in the great health care reform debate. There does seem to be, at the margins, some discussion of a few productive approaches, which deserve credit. These include the Sunshine bill, which would improve disclosure of conflicts of interest generated by health care corporations' payments to health care professionals and academics; the push to support some comparative effectiveness research; and some attempts to address the perverse incentives built into the system used by Medicare to pay physicians. It is not clear, however, whether these efforts are going to get very far, and in any case, they remain peripheral to fervent discussions of health care financing, which seems to be the only topic of interest to most would-be health care reformers. I believe that the US health care reform will not produce good results if it fails to address the issues we discuss on Health Care Renewal. But discussion of them, of course, may threaten many with vested interests, and lots of people who have been made rich and powerful by the current system.So look forward to endless debates about whether the "public option" for health insurance is a good or bad idea, but nothing about how the insurance industry is lead, much less how pharmaceutical, biotechnology, device companies, hospitals and academic medical centers, medical not-for-profit organizations, health care information technology companies, and government agencies are lead, and how bad leadership facilitated by bad governance will continue to make things worse.

What Health Care Reformers Don't Discuss

Health care reform is now the big health care story in the US. Discussion of various health care reform proposals regularly lead in print an...

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JAMA letter: "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards"

My letter "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in JAMA yesterday. A preview of the letter can be seen <a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382">here</a>, or a full version <a href="http://jama.ama-assn.org/cgi/content/full/302/4/382">here</a> if you subscribe to JAMA. <div> </div><div>The letter was in response to Koppel and Kreda's groundbreaking March 2009 JAMA article "<a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">Health Care Information Technology Vendors' Hold Harmless Clause: Implications for Patients and Clinicians</a>." </div><div><div> </div><div>The JAMA letter covered some of the same points I addressed extensively at my Drexel HIT website essay "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda">Hold Harmless and Keep Defects Secret Clauses</a>", including the major point that hospital executives signing such contracts are in violation of Joint Commission standards for conduct related to safety, and in violation of their fiduciary responsibilities towards patient and employee safety and freedom from undue liability. In the Drexel website essay I also noted that:</div><div> </div><div><blockquote>... these stipulations [hold harmless and gag clauses in contracts] further instantiate my observation that health IT lacks the rigor of medical science itself, its major Achilles heel.</blockquote></div><div> </div><div>Koppel and Kreda note <a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382-a">in their JAMA reply</a> to my JAMA letter that:</div> <blockquote>Dr Silverstein's letter adds context to our Commentary on HIT vendors' self-protective "hold harmless" clauses while introducing an important discussion about hospitals' and vendors' possible violations of Joint Commission standards. We agree with Silverstein about the misapplication of the standard business software contracting model.</blockquote><div> <div>Of interest, the American Medical Informatics Association (AMIA) had authored a reply to Koppel and Kreda quite different than mine, which for a time appeared on their national website (www.jamia.org) but was later withdrawn apparently due to concerns that such a letter might be viewed as an official organizational position. It was entitled "Response to Commentary in JAMA -- Ross Koppel, David Kreda" and can be read in its entirety <a href="http://evernote.com/pub/poikonen/PublicPharmacoinformatics#Note/582cbf46-d342-46bc-a39e-3d57e3a31388">here</a>. </div> The AMIA response piece concluded:</div><div> </div><div><blockquote>"While we support increased transparency around error disclosure, the belief that the best approach to increase the safety and effectiveness of EHR systems is by legal regulation of system vendors is misplaced. Such an approach would stifle innovation and not achieve the desired goals. At a minimum equal attention needs to be given to the role that provider organizations bring to configuration, management and oversight of the software and related processes."</blockquote><blockquote> </blockquote></div></div><div>In fact, Koppel and Kreda addressed the provider side issues extensively in their article.</div><div> </div>Of interest, JAMA did not publish the AMIA response but instead published mine. Perhaps it's because JAMA felt I had something important to say, as opposed to simply making excuses for HIT vendors and valuing prevention of "stifling of innovation" over hospital leadership's safety and fiduciary obligations to patients and staff.<div> </div><div>"The belief that the best approach to improving HIT safety is via regulation is misplaced?" (Misplaced how, exactly?) Tell that to the airline or public transit or pharma or the medical device industries. Or to the public whose care is increasingly dependent upon these HIT systems.</div><div> </div><div>It is my firm opinion that "innovation" done recklessly, in secrecy, without accountability, and via exploitation is not innovation at all. <div> </div><div>-- SS July 23 addendum: Dr. Koppel has forwarded to me a letter he and Mr. Kreda submitted to AMIA in response to AMIA's aforementioned critique of his March 2009 JAMA "Hold Harmless Clause" article. Koppel and Kreda's letter, "On the AMIA Response to Commentary in JAMA by Ross Koppel and David Kreda" can be read <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/koppel_holdharmless_amia_reply.doc">here</a> (MS Word .doc format). Highlights: <blockquote> ... Where the AMIA authors disagree with us is the emphasis placed on errors produced in the coupling. [The coupling of healthcare organization and software, i.e., alterations and customizations beyond the control of the software vendor - ed.] We say a vast number or errors are generated in the marriage. But they say we have essentially ignored how many errors are created by doctors and hospitals seeking to consummate their relationship with HIT systems in situ ... ... A brief recap of our JAMA commentary seems in order. We wrote about: (1) the HIT vendor “non-disclosure” clauses that prevent clinicians from sharing information about errors generated from faulty software; (2) the clauses that remove all vendor responsibility for errors in their systems – and place all responsibility on clinicians and hospitals (the “hold harmless/learned intermediary” clauses); (3) the need to protect vendors from responsibilities for errors introduced when hospitals implement HIT or when untrained or incompetent clinicians use the HIT; and (4) the need for more balanced contracts that are fair to clinicians and hospitals ... ... Given that we addressed the non-software issues we are said to have ignored, we are not sure why our JAMA commentary earned the response it received on official AMIA letterhead. We hope, therefore that this letter can further a longer conversation about the many ways to make clinical IT software and its implementation better. Nonetheless, we stand by our statement that the imbalance in incentives we described in our JAMA Commentary is a structural obstacle that on balance hurts improving the clinical part of clinical IT. </blockquote>Read the whole thing at the link above. (I placed Koppel and Kreda's response to AMIA on my faculty server. The response, to the best of my knowledge, was not published by AMIA itself.) -- SS </div></div>

JAMA letter: "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards"

My letter " Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards " was published in JAMA ...

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Explore the moon in Google Earth

Posted by Anousheh Ansari, Trustee, X PRIZE Foundation, and first female private space explorer [From time to time we invite guests to blog about initiatives of interest, and are very pleased to have Anousheh Ansari join us here. – Ed.] Ever since I was a young girl, it has been a dream of mine to travel into space. In September of 2006, I was fortunate enough to make that dream a reality — I took off from the launch pad in <a href="http://www.russianspaceweb.com/baikonur.html">Baikonur</a> bound for the International Space Station and became the world's first private female space tourist. Since then, it's been my mission to help as many people as possible think ambitiously about ways to push the boundaries of exploration, both here on Earth and beyond. As a trustee of the <a href="http://www.xprize.org/">X PRIZE Foundation</a>, and the sponsor of the Ansari X PRIZE, I support Google's goal of opening up space through projects like the Google Lunar X PRIZE, which serve to educate the public about the global benefits of space exploration. That's why I'm so excited about the release of <a href="http://earth.google.com/moon">Moon in Google Earth,</a> which is launching today at the <a href="http://www.newseum.org/">Newseum</a> in Washington D.C. This tool will make it easier for millions of people to learn about space, our moon and some of the most significant and dazzling discoveries humanity has accomplished together. Moon in Google Earth enables you to explore lunar imagery as well as informational content about the <a href="http://en.wikipedia.org/wiki/Apollo_program">Apollo landing</a> sites, panoramic images shot by the Apollo astronauts, narrated tours and much more. I believe that this educational tool is a critical step into the future, a way to both develop the dreams of young people globally, and inspire new audacious goals. With Google Earth, young explorers around the world can bounce around the galaxy in <a href="http://earth.google.com/sky">Sky</a>, fly to <a href="http://earth.google.com/mars">Mars</a> and now visit the <a href="http://earth.google.com/moon">moon</a> from wherever they may be. To learn more watch the video below or visit the <a href="http://google-latlong.blogspot.com/2009/07/fly-yourself-to-moon.html">Lat Long Blog</a>. Finally, outer space doesn't seem so far away anymore. <object height="295" width="480"><param name="movie" value="http://www.youtube.com/v/zHJ77RsnFXI&hl=en&fs=1&rel=0"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/zHJ77RsnFXI&hl=en&fs=1&rel=0" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="295"></embed></object>

Explore the moon in Google Earth

Posted by Anousheh Ansari, Trustee, X PRIZE Foundation, and first female private space explorer [From time to time we invite guests to blog ...

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Philadelphia VA Hospital Brachytherapy Debacle: For The Want of One Competent and Industrious IT Person

This post should perhaps be subtitled "The Theatre of the Absurd." At Healthcare Renewal and other sites I've often commented on the remarkable accommodation given to IT personnel in hospitals, even when these personnel make capricious decisions that are contrary to the support of the mission of healthcare organizations, or contrary to the mission itself. I <a href="http://hcrenewal.blogspot.com/2009/03/health-it-project-success-and-failure.html">wrote that</a> many HIT problems observationally appeared due to ill-informed, capricious edicts of overempowered (relative to clinical leadership) MIS leaders, sanctioned by equally ill-informed executive leadership, for which the IT personnel were rarely held accountable. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">Endangerment of ICU patients</a> via PC's entirely inappropriate for a biohazards environment, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">chaos in a critical procedure area</a> from IT complacency and incompetence, payment of millions of dollars for <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf">HIT with gross defects rendering it unusable</a> by clinicians without consultation of in-house medical informatics expertise, and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=pharma">denial of access for hundreds of drug discovery scientists</a> to the informatics tools their own leaders said were essential to new drug discovery are just a few of the situations I've personally observed due to IT department whimsy. Remarkably, none of these situations nor others reported from numerous sources resulted in repercussions against the teflon-coated IT deities (other than, in some cases, generous promotions), thereby obstructing remediation of the attitudinal and competency problems that created the scenarios. If physicians had it this good, they'd be chopping off wrong limbs, removing the wrong organs, and failing to diagnose and treat with impunity. At my June 2009 posting regarding an unfolding clinical debacle of national import at the Philadelphia VA hospital entitled "<a href="http://hcrenewal.blogspot.com/2009/06/computer-and-other-mysteries-at.html">Bungled Brachytherapy, Computer Interfaces and Other Mysteries At The Philadelphia Veterans Administration Hospital</a>" I wrote: <blockquote>... I am uncertain how "computer interface problems" (in the <a href="http://www.philly.com/philly/news/homepage/20090621_Feds_see_wider_woes_in_VA_s_cancer_errors.html">Philadelphia Inquirer</a>, they were referred to as "glitches") prevented medical personnel from determining treatment success over several years. I would be most interested in hearing more about these "interface problems."</blockquote> That question has now been answered, and I am disappointed (but not surprised) at the results. Having rewritten a poor interface between a gamma scintillation camera and a PDP-11 computer in medical school during a nuclear medicine rotation at Boston City Hospital, allowing endusers to identify ROI's (regions of interest) with a light pen for automated calculation of intensities, I thought perhaps some arcane coding or driver configuration was the culprit at the VAMC Philadelphia. That was not the case: <a href="http://www.philly.com/inquirer/front_page/20090719_VA_radiation_errors_laid_to_offline_computer.html?viewAll=y">VA radiation errors laid to offline computer</a>By Marie McCullough and Josh Goldstein Philadelphia Inquirer July 19, 2009... It is not surprising, then, that NRC and VA investigators spent considerable time delving into why the calculations weren't done for more than a year at the Philadelphia VA. Their investigative reports blamed a "computer interface problem" - the same terminology Kao used during his testimony last month at a congressional hearing. The implication was that some intractable technology breakdown was behind the lapse in care [i.e., some cryptic problem requiring magical incantations and byzantine scripts that mere mortals could not understand nor remedy - ed.] In fact, technology had little to do with the breakdown, as James Bagian discovered when he led an inquiry at the Philadelphia VA and the veterans' health system's 12 other brachytherapy programs. Bagian, a Philadelphia-born physician and former astronaut who is now the national VA's patient-safety director, discovered that the "interface problem" was nothing more than the disconnected computer. Here's what else his inquiry found: The computer was initially unplugged so that another medical device could use the network port. Then, various departments dithered and ducked a request for an additional network port, which was finally installed - after a year. ["Various departments dithered and ducked?" Which departments, exactly? See below - ed.] Some doctors, physicists, and other professionals at the VA acknowledged it was "clinically inappropriate" to omit the post-implant calculations. Some said they had informed their "chain of command." When asked why they didn't tell the hospital's patient-safety officer, they said "it had not occurred to them to do so." ["Had not occurred to them to do so?" I've seen situations where physicians and scientists were afraid of IT leaders, due to the latter's often overinflated political influence and proficiency in playing games of political intrigue. Did this occur here, I wonder? - ed.] So, it appears that for the want of one network connection, installed by one competent, industrious, non-complacent IT person, a national scandal has erupted that has injured many patients. First, I ask the following questions regarding the "various departments" that "dithered and ducked" the responsibility to install an additional network connection in the brachytherapy suite: <ul><li>Was the job the responsibility of the Department of Medicine? The doctors and nurses? Could they have done so? </li><li>Perhaps it was the responsibility of the Public Relations Department (who now have to pick up the pieces?)</li><li>Was it the reponsibility of the Facilities Department? </li><li>Was it the responsibility of the Housekeeping Department?</li><li>Or, was it the responsibility of the IT Department and CIO? </li></ul> (If you need help answering these questions, stop reading now.) I also ask: <ul><li>Why was the IT department's failing to perform this task kept low profile through use of cryptic "interface problem" language that implied complex IT problems, as opposed to simple people problems? </li><li>Who originated this language?</li><li>Did they believe the truth could remain hidden? </li><li>Why do we use the term "medical malpractice" to describe negligence in medical care, not "provider glitch?" Why the different standards? </li></ul> I can visualize what went on behind the scenes in the IT department, refrains I have heard before - "we don't have the resources ... we need to hold more meetings to consider the issues ... it's the vendor's responsibility ... it's the network group's job, not the hardware group ... putting a new network outlet in there will cause packet storms and interfere with system XYZ ... we need to get consensus .... you [doctors] can't understand the complexities of the problem, but don't worry, we'll make it better ... hey, the docs don't need it anyway ..." What would happen to, say, the Facilities Department if a plumbing problem led to failure of a piece of vital equipment in the OR's, and they failed to repair it for a year? This is not to excuse the multiple layers of complacency among clinicians, safety staff, and others for toleration of this network denial situation and the lack of QC on the procedures themselves, but at the heart of this debacle is this attitude, which seems common in hospital IT departments: <blockquote style="font-style: italic;">"Doctors and nurses toil in hospitals so IT personnel can have comfy jobs and nifty computers."</blockquote> Perhaps on this occasion, IT leaders and personnel may end up on the witness stand and be held accountable, and perhaps lose their jobs instead of being promoted. However, even this is doubtful, and it has taken a congressional investigation led by Sen. Arlen Specter to get even this far, to simply find out that the mysterious "interface glitches" were a lack of a network jack due to laziness and complacency. Finally, I point out that it is hospital IT personnel upon whom clinicians will depend for acquisition and implementation of the HIT tools the President of the United States said are essential to changing the culture of healthcare. As I have written, before the IT profession can change the culture of healthcare (in a positive manner, that is), its own culture must change. IT personnel in hospitals must become part of the clinical team and support the mission of clinicians, not the other way around. July 22 addendum:<div> </div><div>I note again that multiple people failed here, including executives, physicians, safety officers, etc. I believe responsibility needs to be fairly assigned. However, IT needs to be included. I've witnessed or heard about too many HIT incidents where IT personnel and leadership remained scot-free when their behavior and attitudes were contributors or root causes.<div>As per my letter to the editor published in JAMA on July 22, "<a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382">Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards</a>", IT privilege and accommodation must stop. HIT is not business IT used for widget inventory or payroll. As the VA incident shows, patient lives and well being are at stake.July 24 addendum:More on this from a blog on medical physics, "The Sharp End of the Photon", <a href="http://www.drflounder.com/archives/406">here</a>:<blockquote>... the errors in the placement of the radioactive seeds went undiscovered for so long because post-implant dosimetry was not performed. This involves CT scanning the patient, finding the positions of the seeds and calculating the ultimate dose the patient received. In the NRC report, the explanation was that a problem with the interface between the CT scanner and the treatment planning computer prevented transferring the CT images.</blockquote>A "problem with the interface", indeed.Also provided is a link to testimonies from witnesses at the house.gov website, which are <a href="http://veterans.house.gov/hearings/hearing.aspx?newsid=438">here</a>.Notable is the absence of any testimony from IT leadership. The only allusion to IT is in testimony by the doctor who performed the procedures who stated:<blockquote>"There should be a method of categorizing systematic problems by level of urgency so that serious problems, such as those involving failures of medical equipment or transfer of patient-related data, will receive immediate attention from the proper personnel and be quickly resolved."</blockquote>Perhaps, but not in this case. A simple phone call to IT should have been adequate to resolve this particular simple problem. -- SS </div></div>

Philadelphia VA Hospital Brachytherapy Debacle: For The Want of One Competent and Industrious IT Person

This post should perhaps be subtitled "The Theatre of the Absurd." At Healthcare Renewal and other sites I've often commented ...

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STOSSEL and ACRE: WHERE'S the BEEF?

STOSSEL and ACRE – WHERE’S the BEEF? Thomas Stossel from Harvard is at it again. As Daniel Carlat has humorously <a href="http://carlatpsychiatry.blogspot.com/2009/07/acre-academics-craving-reimbursement.html">described</a>, Stossel is planning the inaugural meeting next week of a group to counter those he calls pharmascolds. The group is named ACRE – Association of Clinical Researchers and Educators. Here is its website: <a href="http://www.acreonline.org/">http://www.acreonline.org/</a> For months, Stossel has been warning of the dire negative consequences that will result from tightened conflict of interest policies, but he has not presented any persuasive examples of damage to “productive relationships between industry and physicians involved in clinical research and educational outreach.” At the same time, Dr. Stossel has conveniently overlooked the shenanigans of the bad actors whom Senator Grassley exposed. Dr. Stossel is a blowhard, as I have described here <a href="http://hcrenewal.blogspot.com/2008/02/dr-stossel-sounds-off.html">before</a>. But wait! ACRE has found something! A News item in the July 2009 issue of Nature Medicine (“Conflict of interest rules seen by some as too stringent”) quoted one of the participants in the upcoming ACRE conference. Avi Markowitz, chief of oncology at UT Medical Branch, Galveston, came up with this example: Patients taking a Sanofi Aventis chemotherapy product may experience peripheral neuropathy, which can cause unpleasant sensations in the hands and feet. ‘Sanofi Aventis had been providing Markowitz and his UTMB colleagues with free blankets and gloves for those patients. Last fall, however, the university adopted stricter rules banning industry freebies. Now, Markowitz can’t even accept the unbranded blankets and gloves that Sanofi Aventis has offered to provide.’ Reading between the lines, it is a good bet that these items originally were branded. Whatever. And never mind that the patients receiving chemotherapy at UTMB are doubtless billed a hefty facility fee that must include comfort items like blankets and gloves. Since when does a chief of oncology need to beg for these basic patient care provisions from drug companies? Is this all that ACRE can come up with? The ACRE homepage warned sternly of “restrictive conflict of interest policies that often sever productive relationships between industry and physicians involved in clinical research and educational outreach.” Does Thomas Stossel’s whining and catastrophizing through ACRE come down to piffling items like blankets and gloves for chemotherapy patients? That’s it? Where’s the beef? At least ACRE has the good sense not to include on its program the smooth operators whom Senator Grassley outed – like Nemeroff at Emory, Schatzberg at Stanford, Kuklo at Walter Reed, Keller at Brown, Biederman at Harvard. Not even Stossel has been brazen enough to try to defend them. The Nature Medicine News item does close on a helpful note: 'Stossel would like to see abuses involving financial conflicts of interest treated more like cases of scientific misconduct. Rather than forcing everyone to abide by prohibitive rules, he says administrators should focus on weeding out those who misbehave.' I say Amen to that, even if it is a day late and a dollar short. We have arrived at our present state of discomfiture because the leaders of academic institutions and professional societies looked the other way for too long. They failed to do their job of reining in the ethical outliers. Grassley had to do it for them. As a result, the rest of us will be burdened with new regulations for years to come. Those who did speak up years ago were ignored or demonized. As the saying goes, every group gets the leadership it deserves. Those in academic medicine had better not count on Stossel and ACRE to lead them out of the wilderness. Bernard Carroll.

STOSSEL and ACRE: WHERE'S the BEEF?

STOSSEL and ACRE – WHERE’S the BEEF? Thomas Stossel from Harvard is at it again. As Daniel Carlat has humorously described , Stossel is plan...

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Irish Physicians Opt Out of Vital Patient Maintenance Care, Refuse to Release Records; Court Agrees

Well, no, actually. Irish physicians did not opt out of "maintaining" the healthcare of patients and refuse to release their medical records. Even imagining such an event is absurd. IT providers in Ireland did, however, opt out of caring for the HIT of 180+ hospitals and releasing the source code so others could do it: <blockquote><a href="http://www.herald.ie/national-news/courts/hse-fails-in-bid-to-secure-it-servicing-for-180-hospitals-1825034.html">HSE fails in bid to secure IT servicing for 180 hospitals</a> By Tim Healy Thursday July 16 2009 The HSE [<a style="font-style: italic;" href="http://www.hse.ie/eng/">Health Service Executive</a> - ed.] has failed to get a High Court order compelling a company to continue providing vital computer maintenance services for 180 hospital and other sites around the country. Ms Justice Mary Laffoy also refused to grant an injunction requiring the company, Eamon Keogh, trading as Keogh Software, Harold's Cross, Dublin, to temporarily release source codes necessary for someone else to maintain and fix the computer system's software. [In other words, traditional business computing customs of source code secrecy even in face of software orphancy shall apply - quite inappropriately - to healthcare, and providers and patients be damned. - ed.] The system is used by A&Es, radiology departments, HSE billing services as well as in environmental health areas and "parliamentary affairs" of the HSE. Keogh Software, which laid off all its staff providing the service on May 29, undertook to maintain the service until yesterday's judgment. The HSE had sought an injunction requiring it to continue to provide the service pending full court proceedings. Ms Justice Laffoy ruled that the issue of the release of the software source codes should be dealt with under an independent resolution procedure set up to deal with this eventuality. [By that time, the hospitals will have been forced to return to manual methods and then replace the systems, or run the risk of chaos and patient harm from defective software, assuming it functions at all - ed.] The judge also turned down a cross-application from Mr Keogh for an injunction requiring the HSE to pay for work done under a new fee agreement entered into by the parties on April 3 last. She also dismissed his application for an injunction waiving a HSE requirement that he produce a tax clearance certificate prior to payments being made. When the High Court heard applications from both sides last month for their respective injunctions, the judge was told the dispute was precipitated when operational problems were experienced in Naas Hospital's radiology information system [not an unimportant system - ed.] The HSE claimed Mr Keogh failed to respond properly to these while he (Keogh) claimed they were denied access to the system by the HSE [vendor denied access to malfunctioning RIS software needing remediation? I simply find that hard to believe - ed.] hnews@herald.ie - Tim Healy</blockquote> One wonders who will be held accountable if this unremediated, defective software results in patient harm or death. (I, however, doubt it will be the IT vendor.) Thus are the dangers of hospitals becoming dependent on an IT industry privileged and accomodated to the point of having no accountability (as in the U.S. as detailed by Koppel and Kreda in JAMA <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">here</a>). Thus are also the dangers of hospitals becoming dependent on proprietary HIT, and/or not having the expertise nor the source code required to fix bugs and perform maintenance themselves. I add that nearly our entire country is about to go that route. But at least the software will be "<a href="http://hcrenewal.blogspot.com/2009/06/mark-leavitt-head-of-cchit-behind-times.html">certified</a>" by the fierce watchdog group and safety advocate, the CCHIT. <a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html">Fierce to its critics</a> and to its own organizational safety, that is (HIMSS, CCHIT's parent organization, is currently seeking to have CCHIT <a href="http://www.healthdatamanagement.com/news/stimulus-38650-1.html">declared the monolithic force for HIT 'certification'</a> in the United States). -- SS

Irish Physicians Opt Out of Vital Patient Maintenance Care, Refuse to Release Records; Court Agrees

Well, no, actually. Irish physicians did not opt out of "maintaining" the healthcare of patients and refuse to release their medic...

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Turning Patients into "Dialysis Dollars"

As we have discussed in previous posts (<a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">here</a> and <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>), prior to a US Supreme Court decision in 1975, physicians (and other professionals) were left free to set up and enforce their own codes of ethics. Until about 1980, the US American Medical Association (AMA) stated, <ul><li>"in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients"</li><li>"the practice of medicine should not be commercialized, nor treated as a commodity in trade"</li></ul> The Supreme Court decision was widely construed as meaning that any promulgation by US professional organizations of ethical regulations that constrained any economic practices of their members was a violation of anti-trust laws. Thus, in 1980, the AMA dropped their prohibitions against the commercialization of medicine, and nobody, it appeared, tried to change the anti-trust law whose provisions the court interpreted. A vivid example of how physicians and patients may be caught in the cross-fires among health care corporations in this brave new era of commercialized health care was provided by a <a href="http://www.denverpost.com/commented/ci_12830453">recent report </a>in the Denver Post: <blockquote>News that Fortune 500 company DaVita Dialysis is moving its headquarters to Denver socked its competitors like a punch in the gut. To its rivals, the kidney-care giant is a bully armed with high-powered attorneys who use lawsuits as tools to intimidate. DaVita executives counter that they are simply strong competitors — they act as aggressors only when doctors or nurses or other dialysis companies break promises and double-cross them. Either way, a string of DaVita-filed lawsuits around the country — with two major battles boiling in Denver and Colorado Springs — shed light on the ruthless competition over dialysis patients in an industry that costs Medicare alone more than $8 billion per year. For years, DaVita's competition in Colorado's two largest cities was almost nonexistent. The mud began to fly last year when the second-largest group of Denver kidney doctors, called nephrologists, ended their exclusive affiliation with DaVita and partnered with a Massachusetts dialysis company entering the Denver market. Near the same time, the largest nephrology group in Colorado Springs dumped DaVita in favor of Liberty Dialysis, which recently opened two dialysis centers in the city. DaVita quickly sued doctors in both cities, plus a nurse battling breast cancer who quit her job at a DaVita dialysis center and took one with Liberty. The hostility between the companies is so intense, it's seeping down to the patients. 'With everything that is going on, you feel like you are becoming sort of a dialysis dollar,' said Julie Estes, a 53-year- old Colorado Springs woman who spends three days a week, four hours at a time, hooked to a dialysis machine in order to stay alive. DaVita says it 'paid millions' in 1998 to the doctors of Western Nephrology in Denver to retain them as medical directors of six dialysis centers in the metro area for 10 years. The doctors signed non-compete agreements, promising not to join forces with DaVita rivals or steal any of the California-based company's nurses. Patients are free by law to choose any dialysis center they want. But dialysis companies bank on the fact that snagging the most popular kidney doctors in town to serve as medical directors of their centers will bring in the most patients — and the most dollars. Every dialysis center is required by federal law to have a medical director to oversee the care of patients and the water purification system used to flush toxins from the blood of people with failing kidneys. It's a side job, separate from a nephrologist's practice, that some estimate takes only a couple of hours each week. Companies and doctors declined to say what salary comes with the job, but estimates range from $20,000 to $200,000 per year depending on the competitiveness of the market. After 10 years with DaVita, when they believed the non-compete agreement was about to expire, Western Nephrology doctors began making plans to become medical directors of shiny-new American Renal Associates dialysis centers opening in Denver with a flat-panel TV and heated, massage chair at every dialysis station. Four of the new centers are within 3 1/2 miles of existing Da Vita centers. The non-compete agreement that Western Nephrology doctors had signed for DaVita prohibited them from having relationships with competitors within a 35-mile radius. DaVita contends in its lawsuit that it found out about Western Nephrology's 'secret campaign' because the dialysis company they were working with applied for Medicare billing numbers for five new centers in the Denver area. In its counterclaim, American Renal Associates accused DaVita of violating federal antitrust law — the company had controlled at least 80 percent of the Denver market. DaVita lagged in updating its dialysis centers until competition was imminent, according to court records. And the claim accused DaVita of 'filing legal actions that are objectively baseless' merely as an 'anticompetitive weapon.' </blockquote> "Ruthless competition," "lawsuits as a tool to intimidate," "double crosses," flying mud, patients who feel like "dialyis dollars," non-compete agreements, medical directors paid according to "the competitiveness of the market," "secret campaigns?" - is this any way to run a health care system? As Dr Arnold Relman pointed out (see our previous posts linked above), through the 1960s there was some consensus that health care does not function like a pure market, partially because patients cannot function like steely-eyed consumers. They do not have enough information about the benefits, harms and costs of their possible choices. They have trouble understanding the ambiguity and uncertainty of the medical context. And most important, they may not be capable of the cold cognition the free market model requires, since they may be dealing with choices whose potential outcomes prompt extreme emotions, and in many cases, they may be too frightened, sick, or cognitively impaired to make fully rational choices. In particular, patients with end-stage kidney disease, requiring dialysis to maintain life, seem very different from some ideal, coldly cognitive consumers. So what in the world are they doing caught up in these sorts of disputes? I submit that real health care reform ought to help physicians and other health care professionals renew their professionalism, and put the provision of health care (and health education and clinical research) back in the hands of people who view these activities as callings, not purely as ways to get rich. Meanwhile, when you are a patient, be prepared to be treated merely like a source of revenue. PS - Please note that, as we have <a href="http://hcrenewal.blogspot.com/2009/03/meet-new-boss-same-as-old-boss-health.html">posted</a> before, the new US "czar" for health care reform is a former member of the board of directors of DaVita.

Turning Patients into "Dialysis Dollars"

As we have discussed in previous posts ( here and here ), prior to a US Supreme Court decision in 1975, physicians (and other professionals...

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