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How "Independent" a Source of Health Care Reform Data?

This week, a Washington Post <a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/07/22/AR2009072203696.html">article</a> discussed who provides the data being cited in the ongoing US debate about health care reform. <blockquote> The political battle over health-care reform is waged largely with numbers, and few number-crunchers have shaped the debate as much as the Lewin Group, a consulting firm whose research has been widely cited by opponents of a public insurance option. To Rep. Eric Cantor (Va.), the House Republican whip, it is 'the nonpartisan Lewin Group.' To Republicans on the House Ways and Means Committee, it is an 'independent research firm.' To Sen. Orrin G. Hatch (Utah), the second-ranking Republican on the pivotal Finance Committee, it is 'well known as one of the most nonpartisan groups in the country.' </blockquote> But how independent is the Lewin group? <blockquote> Generally left unsaid amid all the citations is that the Lewin Group is wholly owned by UnitedHealth Group, one of the nation's largest insurers. More specifically, the Lewin Group is part of Ingenix, a UnitedHealth subsidiary that was accused by the New York attorney general and the American Medical Association of helping insurers shift medical expenses to consumers by distributing skewed data. Ingenix supplied UnitedHealth and other insurers with data that allegedly understated the 'reasonable and customary' doctor fees that insurers use to determine how much they will reimburse consumers for out-of-network care. In January, UnitedHealth agreed to a $50 million settlement with the New York attorney general and a $350 million settlement with the AMA, covering conduct going back as far as 1994. Ingenix's chief executive, Andrew Slavitt, said the company's data was never biased, but Ingenix nonetheless agreed to exit that particular line of business. 'The data didn't have the appearance of independence that's necessary for it to be useful,' Slavitt said. Lewin Group Vice President John Sheils said his firm had nothing to do with the Ingenix reimbursement data. Lewin has gone through 'a terribly difficult adjustment' since it was bought by UnitedHealth in 2007, he said, because the corporate ownership 'does create the appearance of a conflict of interest.' 'It hasn't affected . . . the work we do, and I think people who know me know that I am not a good liar,' Sheils said. </blockquote> Is it only an appearance of conflict, and how objective is the Lewin Group's work? <blockquote> Lewin's clients include the government and groups with a variety of perspectives, including the Commonwealth Fund and the Heritage Foundation. A February report by the firm contained information that could be used to argue for a national system known as single-payer, the approach most threatening to insurers, Sheils noted. But not all of Lewin's reports see the light of day. 'Let's just say, sometimes studies come out that don't show exactly what the client wants to see. And in those instances, they have [the] option to bury the study,' Sheils said. </blockquote> So, in summary, a group providing ostensibly "independent" data and opinions about an important health care policy debate is actually a subsidiary of a commercial managed care organization/ health care insurance company which clearly has vested interests in certain policy options. While the consulting group apparently struggles to be objective, its top leader reported that is fashions its reports at the behest of its clients, and that clients can "bury" reports that offend them, possibly because they do not serve their vested interests. It is not surprising that participants in the current, noisy debate about health care reform, like many other health policy debates, have vested interests, and that their positions are likely to promote these interests. However, what should at least be disturbing is how often those with vested interests try to appear to be disinterested and independent. Should we trust "independent" voices that actually are conflicted, or those who cite "independent" views that actually come from interested parties? By the way, we first posted about the Lewin Group's actual status as an Ingenix, and hence UnitedHealth subsidiary <a href="http://hcrenewal.blogspot.com/2009/01/who-is-warning-us-about-shortage-of.html">here</a> in January, 2009, and first posted about how its contribution to the current health care reform debate was being touted as independent <a href="http://hcrenewal.blogspot.com/2009/04/who-is-warning-us-about-perils-of.html">here</a> in April, 2009. That a news organization with the status of the Washington Post is now picking up this story suggests a little optimism that the <a href="http://hcrenewal.blogspot.com/2007/08/bling-bling-poltical-correctness-and.html">anechoic effect </a>might be weakening.

How "Independent" a Source of Health Care Reform Data?

This week, a Washington Post article discussed who provides the data being cited in the ongoing US debate about health care reform. The pol...

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Physicians Down Under Get Direct About Danger of Bad HIT

Too often, physicians acquiese to demands by hospital executives that they adjust to and use health IT, even if that health IT is flawed. This is despite the fact that liability for patient care resides with the physicians, not the HIT vendor or executives. Several physicians Down Under have had enough: <blockquote><a href="http://www.dailyexaminer.com.au/story/2009/07/23/doctors-issue-a-deadly-warning/">Doctors issue deadly warning</a> Daily Examiner, Grafton, Australia David Bancroft | 23rd July 2009 It seems incredible that a patient record system that aims to improve treatment could kill people [not so incredible to the informed - e.g., see "<a href="http://iig.umit.at/efmi/badinformatics.htm">Bad Informatics Can Kill</a>" - ed.], but that is a claim being made about a new system that is almost certainly going to be introduced into the Grafton Base Hospital next week. Earlier this month, leading health officials from the Lismore Base Hospital wrote to the North Coast Area Health Service (NCAHS) claiming a new Surginet electronic medical record system that had been operating in the hospital for several months would 'inevitably' lead to the death of patients. But the health service said changes had been made to the Surginet electronic medical record (EMR) system since the concerns were raised by the four senior clinicians on July 2, and the system had been operating 'satisfactorily' in Sydney without patient concerns being raised. ["Without concerns raised" does not mean they do not exist - ed.] In their letter to NCAHS chief executive officer Chris Crawford, which was copied to the Minister for Health John Della Bosca, the four medical specialists said there had been recurring problems over several months and 'these have not improved'. “This has resulted in unnecessary compromise of patient safety,” they wrote. “There have been repeated well demonstrated cases of near miss disasters due to these problems. [Will patients be as lucky the next time? - ed.] “We believe that negative patient outcomes, including death, will inevitably result from the continuing use of this system. “Surginet is fundamentally flawed. “New technology should: improve the quality of our work; help us to be more efficient, and; make routine tasks easier. “EMR Surginet does none of these; in fact it has had the opposite effect. “We believe that the Surginet EMR system is unsafe and will result in patient morbidity and mortality.” Surginet was to be implemented at the Grafton Base Hospital yesterday, but after concerns were raised with the area health service, implementation was delayed until next Wednesday. A health service spokesman said the implementation had been delayed so the software producers, Cerner [an American company behind the HIT products that caused difficulty in the UK - see the UK House of Commons report <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm" style="font-weight: bold;">here</a>, esp. points 5 and 6 - ed.], could speak with Grafton surgeons and anaesthetists prior to the implementation about any concerns they may have. “NCAHS takes any concerns raised about patient safety seriously and is addressing these,” the spokesman said. “It should be emphasised that Surginet is operating satisfactorily in Sydney hospitals without patient safety concerns being raised. [Again, that does not mean they do not exist; clinicians may be afraid to speak out and working furiously to establish workarounds to problems - ed.] “It is a system used worldwide that can be adapted to accommodate local work practices in NSW hospitals. ["Can be adapted" - anything "can be adapted". But has this application actually been adapted to the culture in NSW hospitals? - ed.] “Arrangements are being made for discussions to be held with the department heads by representatives of the EMR project team and Cerner.” The spokesman said Surginet had recently been introduced at the Maclean Hospital and there had been no complaints and the NCAHS had actually received a letter of thanks from the hospital. [A letter of thanks from whom at the hospital, exactly, and based on what substantive claims? - ed.] </blockquote> Such discrepancies between one hospital and the next regarding HIT require critical evaluation - erring on the side of patient safety, not IT vendor convenience. Considering the aforementioned UK House of Commons report and the "near miss disasters" mentioned by the Australian physicians, such due diligence is mandatory in my opinion. Further, American physicians can probably learn from these Australian counterparts in being vocal about HIT problems. -- SS

Physicians Down Under Get Direct About Danger of Bad HIT

Too often, physicians acquiese to demands by hospital executives that they adjust to and use health IT, even if that health IT is flawed. T...

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Inquiry to Joint Commission on points I raised in my July 22, 2009 JAMA letter on HIT

As I posted <a href="http://hcrenewal.blogspot.com/2009/07/health-care-information-technology.html">here</a>, my letter "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in JAMA on July 22, 2009. 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. This 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/failurecases/?loc=cases&sloc=koppel_kreda">Hold Harmless and Keep Defects Secret Clauses</a>", including the major point that hospital executives signing HIT "Hold Harmless" and "Defects Nondisclosure" 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. I've sent the following inquiry to Paul M. Schyve, M.D., Senior Vice President, The Joint Commission: <blockquote>July 24, 2009 Paul M. Schyve, M.D. Senior Vice President The Joint Commission <a class="Addr" href="javascript:noop()" onclick="BuK('schyve%40jointcommission.org')" title="Create new mail memo with this address">schyve@jointcommission.org</a> Cc: <a class="Addr" href="javascript:noop()" onclick="BuK('MChassin%40jointcommission.org')" title="Create new mail memo with this address">MChassin@jointcommission.org</a>, <a class="Addr" href="javascript:noop()" onclick="BuK('otrippi%40jointcommission.org')" title="Create new mail memo with this address">otrippi@jointcommission.org</a> Dear Dr. Schyve, In testimony to the House Committee on Veterans' Affairs on July 22, 2009 <a href="http://veterans.house.gov/hearings/Testimony.aspx?TID=45015&Newsid=438&Name=%20Paul%20M.%20Schyve,%20M.D." target="blank">at this link </a>, you state: ... The Joint Commission has established standards that require the hospital to: <ul style="margin-left: 40px;" type="disc"><li>Create a culture in which adverse events are reported and evaluated for underlying ("root") causes, and preventative actions are taken. </li><li>Identify high-risk processes and prospectively determine their possible modes of failure, the effects of those failures, and the actions that will prevent the failures or mitigate their effects. </li><li>Establish a culture of safety throughout the hospital. This accreditation standard became effective January 1, 2009, although its purpose and expectations were publicized for over a year in advance. </li></ul> In my JAMA letter to the editor of July 22, 2009 entitled " Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" ( <a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382" target="blank">link </a>), I point out that the Hold Harmless and Defects Nondisclosure clauses signed by hospital executives in contracting for healthcare information technology (such as CPOE and EHR systems) are in violation of Joint Commission safety standards, as well as hospital executive fiduciary responsibilities to patients and clinicians. These clinical IT systems can and do cause medical errors and patient harm. My letter was in response to Koppel and Kreda's March 25, 2009 article " <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276" target="blank">Health Care Information Technology Vendors' "Hold Harmless" Clause: Implications for Patients and Clinicians </a>", JAMA. 2009;301(12):1276-1278. I am interested in the Joint Commission's response to the issues I raise. </blockquote>I await a response. -- SS

Inquiry to Joint Commission on points I raised in my July 22, 2009 JAMA letter on HIT

As I posted here , my letter " Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards " was...

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Announcing the 2009 Google Online Marketing Challenge winners

This year we held the second <a href="http://www.google.com/onlinechallenge">Google Online Marketing Challenge</a> — a global university competition, launched <a href="http://googleblog.blogspot.com/2008/07/students-surf-their-way-to-success.html">last year</a>, that gives undergraduate and post-graduate students hands-on exposure to online marketing. Working with their professors, teams receive the equivalent of US$200 to spend on Google AdWords advertising, then work with a local business to devise an effective online marketing campaign. Teams are given three weeks to mastermind the strategy before submitting a campaign report to an international judging panel of professors. This year's Challenge was bigger and better in every way — more teams, more students, more universities and a significant improvement in the quality of campaigns and reports. We're thrilled to report that 2,187 teams took part from across 57 countries, representing a 36% increase in participation from last year. The Challenge continues to develop as one of the world’s biggest university competitions. We're excited today to announce the results. Our global winners come from Deakin University, Australia and were taught by Chia Yao Lee and Bardo Fraunholz. The team of Andrew Kidd, Richard Blakely, Kevin Fung, Clinton Hinze, Katalin Kish and Howard Lien worked with a local kids play center, www.littletigrrs.com.au, to create a well-crafted campaign that highly impressed our judges. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKu1IHSmDQENRQKS17M1ESmj7-JD_EvIk3PM3L6fNPzzEHl_vTYXQyoOv2b1Tl-YKeQ8jaIUs4-jffwWPL2in83C4V4jV7k_I3w1AOgy0HWk1qdPn49szcplhKBOaBWPg18cZnn-tKuwtn/s1600-h/Deakin-Uni---LittleTigrrs-Montage.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5361742378326156802" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKu1IHSmDQENRQKS17M1ESmj7-JD_EvIk3PM3L6fNPzzEHl_vTYXQyoOv2b1Tl-YKeQ8jaIUs4-jffwWPL2in83C4V4jV7k_I3w1AOgy0HWk1qdPn49szcplhKBOaBWPg18cZnn-tKuwtn/s400/Deakin-Uni---LittleTigrrs-Montage.jpg" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 189px;" /></a> <div style="text-align: center;">Clockwise from top left: Richard Blakely, Chia Yao Lee (professor), Katalin Kish, Kevin Fung, Bardo Fraunholz (professor), Howard Lien, Andrew Kidd, Fiona and Mike (from Little Tigrrs), Clinton Hinze and Mick, The Big Hearted Tiger </div> Team spokesman Andrew Kidd gave us some insight into their winning campaign: <blockquote>"After discussions with the business owners, we decided we needed to conduct three separate campaigns. One would promote the play center to customers outside a 10 kilometre geographic radius, another would attract more mothers' groups to the center, and the third one would attract more party and group event bookings. Visitors to their website more than doubled compared with the same period last year. We knew we had developed a strong campaign — but to win the global competition is outstanding."</blockquote>The team and their professor are off to Mountain View, California for a tour of the Googleplex. To help in their ongoing studies, each team member will also receive an Apple MacBook Pro. There were also three regional winners: for the Americas, the winning team comes from James Madison University in the U.S., while a team from the Warsaw School of Economics in Poland won for Europe, the Middle East and Africa. In the Asia Pacific region, the winners come from the International College of Management in Sydney, Australia. Here are <a href="http://www.google.com/onlinechallenge/2009winners.html">more details about our winners</a>. We developed the Challenge to benefit everyone involved. We're delighted that thousands of small businesses around the world have seen their online presence improved in just three weeks. Professors tell us that the Challenge has allowed them to deliver a unique, practical teaching and learning exercise. For those students that took part, we hope they have developed some useful online marketing skills which they can use when they graduate and enter the workforce. For anyone interested in competing in the 2010 Challenge, formal registrations will open later this year, but in the meantime you can <a href="http://services.google.com/events/marketing_challenge_2009_reg">register your interest</a>. Posted by Lee Hunter, Product Marketing Manager

Announcing the 2009 Google Online Marketing Challenge winners

This year we held the second Google Online Marketing Challenge — a global university competition, launched last year , that gives undergra...

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Google Latitude on your iPhone

Earlier this year we <a href="http://googleblog.blogspot.com/2009/02/see-where-your-friends-are-with-google.html">announced</a> <a href="http://www.google.com/latitude/intro.html">Google Latitude</a>, a service that lets you and your friends share your locations with each other. You control who gets to see your location and where on the map you appear to others. Today, we're releasing Google Latitude for iPhone and iPod touch, available in the Safari browser. Visit google.com/latitude from your device to start using Latitude. Add a bookmark to your home screen to quickly launch Latitude. Just open Latitude in Safari and tap the + icon > Add to Home Screen > Add. For more details, check out the <a href="http://googlemobile.blogspot.com/2009/07/google-latitude-now-for-iphone.html">Google Mobile Blog</a>. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhociaygOlsf0nkKy-dIv9FRN-8vsn-si6yCbbqZUw-lBd4BKnfcrcClSFyxssJ-3CBQeBppcTBQ1571lMCZlB_slAJGCJVPBColar0SpItrsohjjywXTUQS47yT1gwQRHfkpvpeA96MK0e/s1600-h/IMG_0076.PNG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5361745202591056882" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhociaygOlsf0nkKy-dIv9FRN-8vsn-si6yCbbqZUw-lBd4BKnfcrcClSFyxssJ-3CBQeBppcTBQ1571lMCZlB_slAJGCJVPBColar0SpItrsohjjywXTUQS47yT1gwQRHfkpvpeA96MK0e/s400/IMG_0076.PNG" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 267px; height: 400px;" /></a> Posted by Marc Wilson, Software Engineer

Google Latitude on your iPhone

Earlier this year we announced Google Latitude , a service that lets you and your friends share your locations with each other. You control...

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It's a bird...it's a plane...it's iGoogle comics themes!

We have always been excited to introduce design flair and whimsy to our user experience, especially on our homepage. Be it through our special <a href="http://www.google.com/logos">holiday logos</a> or special themes for our iGoogle users, we like to open up our homepage as a canvas for artists to express themselves and reach their fans and Google users around the world. Today, I'm particularly excited to announce the new comics themes for iGoogle, just in time for <a href="http://www.comic-con.org/">Comic-Con's 40th anniversary</a>. The themes showcase the amazingly diverse world of comics. Browse our gallery (<a href="http://www.google.com/comicsthemes">www.google.com/comicsthemes</a>) to choose from nostalgic comic strips like <a href="http://www.google.com/help/ig/comicsthemes/#peanuts">Peanuts</a>, iconic heroes like <a href="http://www.google.com/help/ig/comicsthemes/#batmanreborn">Batman</a> and <a href="http://www.google.com/help/ig/comicsthemes/#ironman">Iron Man</a>, or alternative comics greats like <a href="http://www.google.com/help/ig/comicsthemes/#clowes">Dan Clowes</a>, author of the graphic novel, "Ghost World." The dozens of themes represent talented artists from around the world including <a href="http://www.google.com/help/ig/comicsthemes/#rinne">Rumiko Takahashi</a> from Japan and <a href="http://www.google.com/help/ig/comicsthemes/#trondheim">Lewis Trondheim</a> of France. To offer his unique perspective as one of the world's most accomplished comics artists, I'm pleased to introduce guest author Jim Lee. In addition to being a recognized industry veteran, he also drew today's beautiful <a href="http://www.google.com/">homepage logo</a> incorporating some of <a href="http://www.dccomics.com/">DC Comics</a>' most famous characters. During his 20 year career, Jim has worked with DC and <a href="http://marvel.com/">Marvel Comics</a>, co-founded <a href="http://www.imagecomics.com/">Image Comics</a> and also <a href="http://www.dccomics.com/wildstorm/">WildStorm Comics</a> – one of our iGoogle themes. His Batman, Superman, X-Men, Iron Man, Fantastic Four and WildC.A.T.s issues have sold millions of copies. Jim is a recipient of the <a href="http://www.harveyawards.org/">Harvey Award</a>, Golden Panel Award and is widely respected for his contributions as an artist, a creator and a publisher of comics. An artist's POV by <a href="http://en.wikipedia.org/wiki/Jim_Lee">Jim Lee</a> Even as the world of comics evolves and embraces a new digital era, it doesn't change the universal, international appeal of the unique art form that is created through the simple marriage of word and picture. I'm excited to have been chosen to help launch this wonderful project. But I'm more elated, both as a professional and as a fan, that so many different types of comics have been chosen to be part of the iGoogle comics themes launch. From the mainstream superhero world of DC that I work in to the mainstays of the newspaper funnies from my childhood, to the <a href="http://www.google.com/help/ig/comicsthemes/#kawaii">Tokyopop</a> manga titles I collect with my teenage daughters to the esoteric and more literary works of <a href="http://www.google.com/help/ig/comicsthemes/#clowes">Dan Clowes</a> and <a href="http://www.google.com/help/ig/comicsthemes/#yang">Gene Yang</a>, two of my favorites; I think the breadth of choices available demonstrates the amazing diversity and the fundamental vitality of the stories comics can tell. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQzTwW-01ZaLGFIiyVXauyMbeWeNDsfO9Vq2YUez97HVZMeAei8LzaDWGtP0N05kVbct0PWNBfUe6wGxYm22RboHosPuLPg1K7mL9MZHzUA0eXzsoEaY96Zg6PvGppwJv91OmX3eQ2r1tJ/s1600-h/blogpost.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5361682876346821090" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQzTwW-01ZaLGFIiyVXauyMbeWeNDsfO9Vq2YUez97HVZMeAei8LzaDWGtP0N05kVbct0PWNBfUe6wGxYm22RboHosPuLPg1K7mL9MZHzUA0eXzsoEaY96Zg6PvGppwJv91OmX3eQ2r1tJ/s400/blogpost.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 316px;" /></a> Posted by Marissa Mayer, Vice President of Search Products and User Experience, and Jim Lee, Comics Creator/Publisher

It's a bird...it's a plane...it's iGoogle comics themes!

We have always been excited to introduce design flair and whimsy to our user experience, especially on our homepage. Be it through our speci...

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Pseudo-Evidence Based Medicine Threatens Health Care Reform Based on "What Works"

As I <a href="http://hcrenewal.blogspot.com/2009/07/what-health-care-reformers-dont-discuss.html">posted</a> yesterday, the increasingly noisy debate about health care reform in the US has not dealt much with the issues we often discuss on Health Care Renewal. These include problems in how health care organizations are led which threaten physicians' and other health care professionals' core values using tactics including perverse incentives, deception, and intimidation. Last night, however, President Obama held a news conference mostly devoted to health care issues, in which he stressed the importance of changing not just how health insurance works, but how health care decisions are made. As Newsweek's "The Gaggle" blog <a href="http://blog.newsweek.com/blogs/thegaggle/archive/2009/07/23/obama-presser.aspx">reported</a>, <blockquote> Can I guarantee that there are going to be no changes in the health care delivery system? No. The whole point of this is to try to encourage changes that work for the American people and make them healthier. The government already is making some of these decisions. More importantly, insurance companies right now are making those decisions. And part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works, because that's not how it's working right now. </blockquote> So what the President seems to be advocating is making health care more evidence-based, perhaps in the formal sense of evidence-based medicine. As a card-carrying evidence-based medicine advocate, I certainly agree, but let me reiterate that evidence-based medicine is not just medicine based on some sort of evidence. As Dr David Sackett, and colleagues wrote [Sackett DL, Rosenberg WM, Muir Gray JA, Haynes RB, Richardson WS. Evidence-based medicine; what it is and what it isn't. BMJ 1996; 312: 71-72. Link <a href="http://www.bmj.com/cgi/content/full/312/7023/71">here</a>. ] <blockquote> Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. </blockquote> Furthermore, <blockquote> Evidence based medicine is not 'cookbook' medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. </blockquote> One can find other definitions of EBM, but nearly all emphasize that the approach is designed to appropriately apply results from the best clinical research, critically reviewed, to the individual patient, taking into account that patient's clinical characteristics and personal values. So far, so good. I believe the proper application of "real" (as described above) evidence-based medicine has the potential to improve patient outcomes while moderating health care costs. However, we have pointed out how problems arising from concentration and abuse of power in health care threaten the evidence-based medical ideal. First, there are major problems with the development of the sort of clinical research evidence required by the EBM process. We have discussed how clinical research is frequently <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> by those with vested interests in producing results that favor the products or services that they sell. The critical review process inherent in EBM is meant to cope with less than optimally designed and implemented research. However, the process was designed to cope with honest mistakes and inevitable trade-offs, not deliberate manipulation by vested interests. Worse, we have discussed how vested interests may engineer the <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression of research </a>when manipulation fails to produce the desired results. The EBM process assumes that the research on which decisions should be based is an unbiased sample of research that was done (and done to advance science, not commercial or ideological interests). When research whose results are unwanted by vested interests is suppressed, the resulting distortion of the evidence base may irretrievably bias the EBM process. Finally, we have posted about how vested interests have distorted the discussion, dissemination, and teaching of the results of clinical research. They may develop systematic <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth marketing </a>campaigns, often employing supposed "<a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a>," who are paid on the side by marketers, and using "<a href="http://hcrenewal.blogspot.com/search/label/medical%20education%20and%20communication%20companies">medical education and communication companies</a>"as marketing fronts whose publication strategies include deceptive tactics such as "<a href="http://hcrenewal.blogspot.com/search/label/ghost%20writing">ghost-writing</a>." Thus, a rising tide of "<a href="http://hcrenewal.blogspot.com/search/label/pseudo-evidence%20based%20medicine">pseudo-evidence based medicine</a>" threatens to overwhelm even the most conscientious physicians trying to practice evidence-based medicine. So, while I applaud President Obama's advocacy of reforming health care to emphasize what the best evidence suggests really works, I do not think this effort will get far unless we deal with the rising tide of pseudo-evidence based medicine. As a minimum, we need full and detailed disclosure of all the relationships among vested interests and medical research and education, and a much greater role for research and education that is not subsidized by corporations bent on using research and education to market their products and services.

Pseudo-Evidence Based Medicine Threatens Health Care Reform Based on "What Works"

As I posted yesterday, the increasingly noisy debate about health care reform in the US has not dealt much with the issues we often discuss...

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