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Making Health Care More Representative and Accountable - the Example of the Thai National Health Assembly

On Health Care Renewal, we have often shown how the governance of health care organizations may be unaccountable, unrepresentative of relevant constituencies, opaque, and not subject to ethical standards. Conversely, we have repeated the need to make the governance of health care organizations accountable, representative, transparent, and ethical. Meanwhile, our US debate about health care reform seems to be driven by leaders of powerful health care organizations, while common citizens need to scream to be heard. Maybe we could benefit from a lesson from another country. As reported in the <a href="http://www.who.int/bulletin/volumes/87/2/09-030209/en/index.html">Bulletin of the WHO</a>, Thailand seems to have found a way to get ordinary citizens and members of civil society involved in a civil, organized health care discussion. <blockquote> For Dr Suwit Wibulpolprasert, chairman of the committee organizing Thailand’s first National Health Assembly (NHA), which took place from 11 to13 December 2008 in Bangkok, opening up the debate on public health is an essential part of developing effective national policy. 'In the past, health policy has tended to be drawn up by politicians and officials,' Wibulpolprasert says. 'But the National Health Assembly is a forum for the public to pool views and initiate health agendas that truly address people’s needs.' More than 1500 people attended the conference, the first of its kind to take place since the passing into law of the National Health Act of 2007, which also brought the NHA into existence. A broad cross-section of Thai society was represented, including 178 delegations from government agencies and provincial authorities, the private sector and civil society. In addition, groups including stateless people living near the Myanmar border gave presentations at technical briefings for participants. Dr Kumanan Rasanathan, from WHO’s Department of Ethics, Equity, Trade and Human Rights, described the meeting as 'a very interesting exercise in participatory governance'. The 12 topics that were up for discussion were distilled from more than 68, including such familiar ones as universal access to medicines and equal access to basic public health services. Also addressed were matters as diverse as agriculture and food prices in the current economic crisis and safe media access for youth and family – an agenda that included a proposal for addressing problems of children addicted to online games and television. 'The broad slate of topics reflects the intention to encourage input from everyone,' says Rasanathan, 'and improve public participation as well as intersectoral collaboration.' In other words, the assembly’s organizers actively encouraged the participation of stakeholders from outside the field of public health – from education, agriculture and industry, to name but a few. 'The Thais have adapted much of the machinery of the World Health Assembly [WHO’s supreme decision-making body] for their own context,' says Rasanathan, who noted that each of the 178 constituent groups had equal speaking rights. Briefing papers were produced and resolutions were passed on each of the agendas. As with WHA resolutions, these resolutions are not binding. According to Dr Amphon Jindawatthana, secretary-general of the National Health Commission Office, once the resolutions have been adopted they are considered by the National Health Commission, which reworks them for ministerial review and possible inclusion in national policy. Given the hurdles that still need to be cleared once a resolution is passed at the Assembly, one might be forgiven for dismissing the body as something of a talking shop. This is a charge that Wibulpolprasert firmly denies. He is convinced that NHA-formulated resolutions will certainly lead to policy, and policy that is closer to the needs of Thailand’s 63 million people. </blockquote> The 2009 Assembly will be held in December. Details can be found <a href="http://www.nhcthailand.com/aboutus_detail.php?id=00000000025">here</a>. I wonder if we would be having a more productive health care debate in the US if the way had been prepared by a US National Health Assembly? Maybe if the multi-million dollar a year leaders of health care organizations had to listen to the concerns of ordinary people, and some practicing health care professionals, a little common sense might penetrate into the bubble created by their <a href="http://hcrenewal.blogspot.com/search/label/superclass">superclass</a> membership.

Making Health Care More Representative and Accountable - the Example of the Thai National Health Assembly

On Health Care Renewal, we have often shown how the governance of health care organizations may be unaccountable, unrepresentative of releva...

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"A cadre of people who understand the science"

Here is a fascinating, spot-on exchange regarding biomedical information science between Bill Moyers on PBS and the new President of Dartmouth College Dr. Jim Yong Kim (<a href="http://www.pbs.org/moyers/journal/09112009/transcript3.html?print">link</a>). My comments in [red italics]: <blockquote>DR. JIM YONG KIM: My own particular take on it is that I think for many, many years, we've been working under the fantasy that if we come up with new drugs and new treatments, we're done.   The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences.   In other words, what we've learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal. In the business world, if you don't do it well, the market gets rid of you. You go out of business. But many hospitals executing very poorly persist for a very, very long time. So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they'll think about the complexity of delivery as a topic that we can take on and study and learn about as a science. [And possess a broad and deep enough background to understand these issues at very fine-grained levels, which in my opinion includes a rigorous scientific background to start with - ed.] BILL MOYERS: What do you mean, complexity of delivery? DR. JIM YONG KIM: Well, just think about a single patient. So a patient comes into the hospital. There's a judgment made the minute that patient walks into the emergency room about how sick that person is. And then there are relays of information from the triage nurse to the physician, from the physician to the other physician, who comes on the shift.   From them to the ward team, that takes over that patient. There's so many just transfers of information. You know, we haven't looked at that transfer of information the way that, for example, Southwest Airlines has. Apparently they do it better than any other company in the world. [I would add that the nature of such transfers and the complexity of the information itself is far simpler in the Airline business than in medicine, so this is not the best analogy - ed.] BILL MOYERS: Computers? DR. JIM YONG KIM: No, they have taken seriously the human science of how you transfer simple information from one person to the next. [Note how Dr. Yong Kim wisely dismisses computers as the solution, in favor of people. He does not suffer the syndrome of inappropriate overconfidence in computers - ed.] And in medical school, and in the hospitals that I've worked in, we've done it ad hoc. Sometimes we do it well. Sometimes we don't do it well. But what we know is that transfer of information is critical. Now to me, again, that's the rocket science. That's the human rocket science of how you make health care systems work well   What we need now is a whole new cadre of people who understand the science, who really are committed to patient care. But then also think about how to make those human systems work effectively. We've been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth.   30 years ago, one of our great faculty members, Jack Wennberg, started asking a pretty simple question. Why is there variation, for example, in the number of children who get their tonsils taken out, between one county in Vermont versus another? 'Cause one of his children was in school at one place. Another of his children were in the school in another place.   And in one place, almost everyone had their tonsils out. And in another place, almost no one did. And of course, he found that there happened to be a doctor there who liked to take tonsils out and benefited from it. And he kept asking this question, you know, outcome variation. He called it the evaluative clinical sciences. And I think that's really the forerunner to what we're talking about in terms of the science of-- BILL MOYERS: Fancy-- DR. JIM YONG KIM: --health care delivery. </blockquote> I can add that part of that "cadre of people who understand the [information transfer] science" exists, in the form of Medical Informatics specialists (e.g., as produced by <a href="http://www.nlm.nih.gov/ep/GrantTrainInstitute.html">these organizations</a> and many others in the U.S. and <a href="http://www.amia.org/informatics/acad&training/international.asp">worldwide</a>). Understanding the complexities of information transfer also calls for understanding the clinical environment and, in my view, the biomedical science as well. However, you might never know this via reading statements from some of the <a href="http://histalk2.com/2009/08/31/being-john-glaser-83109/">non-clinical HIT </a><a href="http://histalk2.com/2009/08/31/being-john-glaser-83109/">leaders</a> such as "computers enable complexity" [as opposed to well-trained and experienced medical experts - ed.] It is indeed unfortunate that most hospital ads seeking Medical Informatics expertise are for "Director level" positions with little control of resources, i.e., they are "Director of Nothing" roles, diluting the contributions of such experts in the highly politicized and territorial environment of a hospital IT department. Unfortunately, most in hospital IT today are just repackaged business computing personnel of a management information systems (MIS) background whose lack of knowledge of these topics or cavalier attitudes about them has actually harmed the progression of health IT as a practical tool, as I've profusely documented on this blog (e.g., <a href="http://hcrenewal.blogspot.com/2009/03/reader-on-why-we-have-busywork.html">here</a>) and at my educational HIT site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">here</a>. An example of just how difficult the "rocket science" of information transfer can be is this, from a psychiatrist: <blockquote>I work on an acute psychiatric inpatient unit. We see each patient on rounds each day, write a note in the chart each day and bill each day. However, the nature of psychiatric units are that patients wander freely around the unit. Consequently, whenever I walk onto the unit, I often have interactions with one or more patients, just in the short distance between the door and the nursing station. Some of those are brief but still give me a sense of how they are doing at that point, other interactions involve brief questions from the patients, still others involve walking to the patients' room and sitting down to discuss a particular issue in greater depth with the patient and/or family. Each of these involves a direct patient to clinician interaction and require that I exercise judgment (often a judgment that they're doing OK). Yet none of these are billable interactions and most are not documented. </blockquote> I was aware of this from my own medical school clerkship in psych. The fact that these valuable interactions are largely undocumented (except in the physician's gray matter) merely shows that modeling the real world of healthcare into neat, tidy little containers of information is harder than modeling the inventory and sale of widgets, due to the complexities of healthcare. One more of those "EHR as panacea" exceptions ... (And even the modeling of widgets isn't always done well. I went to my local MicroCenter last week seeking an EIDE-to-USB hard drive enclosure, to use the orphaned 80Gb hard drive I upgraded in my Mac Mini to serve as a Time Machine backup drive. Their inventory system showed they had a dozen on hand; nobody could find them, anywhere. A week later - yesterday - the same situation prevailed.) Finally, a quibble. Later in the exchange Dr. Yong Kim makes the statement that "Right now, the physicians who are running these hospitals have never been trained. Most of them have never been trained in system thinking, in strategy, in management." As most hospitals are not run by physicians, I'd have to disagree with that statement. It perhaps should be redirected to the non-medical businesspeople in the C-suite and on the hospital Boards who do run hospitals, to which I'd add "who have never been trained in biomedicine." -- SS

"A cadre of people who understand the science"

Here is a fascinating, spot-on exchange regarding biomedical information science between Bill Moyers on PBS and the new President of Dartmo...

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More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?

Both Roy Poses and I have written on a plague of healthcare mismanagement and perhaps malfeasance in part due to leadership by domain amateurs, i.e., healthcare leadership profoundly lacking in biomedical education and experience. Examples of recent posts about the risks posed by domain neutral biomedical leadership are: <blockquote> "<a href="http://hcrenewal.blogspot.com/2009/08/ny-times-proclaims-anyone-can-run.html">NY Times Proclaims Anyone Can Run a Health Care Organization with a Little Studying Up</a>" (Poses) "<a href="http://hcrenewal.blogspot.com/2009/08/health-care-leaders-dont-know-much.html">Health Care Leaders: Don't Know Much About Health Care</a>" (Poses) "<a href="http://hcrenewal.blogspot.com/2009/08/on-optimal-expertise-for-leadership-in.html">On Optimal Expertise for Leadership in Biomedicine</a>" (me) "<a href="http://hcrenewal.blogspot.com/2009/02/informatics-or-infomagic-health-it.html">Informatics, or Infomagic? Health IT Cannot Flourish When Everybody is an Expert</a>" (me) and "<a href="http://hcrenewal.blogspot.com/2009/01/pfizerwyeth-merger-and-sacrificing.html">Pfizer/Wyeth Merger And Sacrificing The Future: Laying Off Scientific Staff All Over The Place</a>" (me).</blockquote> I have also written of a <a href="http://hcrenewal.blogspot.com/2009/04/business-week-on-health-it-dubious.html">cross-occupational invasion</a> of healthcare by the IT profession, in the form of power and territorial grabs over clinicians with regard to the tools clinicians increasingly need in order to provide patient care. These leadership inversions, where domain neutral personnel are viewed as best able to lead any endeavor as if the world consists of interchangeable, faceless resources following equally interchangeable processes, are due to attitudinal laxity and permissiveness on the part of medical leadership, a takeover of healthcare by those with primary pecuniary interests, and perhaps a lack of appreciation for the value of domain expertise as sign of a waning western culture. In a <a href="http://histalk2.com/2009/09/10/histalk-interviews-avery-cloud/">recent hospital CIO interview</a>, in this case of CIO Avery Cloud at New Hanover Regional Medical Center in Wilmington, NC, we see both of these elements - supportive views towards healthcare leadership by domain amateurs, and towards a cross-occupational invasion of healthcare by IT personnel - combined: <blockquote> Q: Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts? A: That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT. I’d like to think that I could run any of the departments in this hospital [wow - ed.] A good example is that nobody is surprised when the CFO runs the pharmacy department [i.e., nobody in this CIO's limited circles - ed.], or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same [In fact, it likely would be a big surprise to many -ed.] A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division [this is, in fact, stunning and should be a cause of great concern to healthcare regulators if true - ed.] </blockquote>I'm sure CIO's would like to think that they could "run any of the departments in a hospital." (How about: Legal? Risk management? Health Information Management a.k.a. Medical Records? Biomedical engineering? Nursing? Trauma? Diagnostic Imaging? Neurosurgery?) The question is this: is this a realistic view? Or, is it an extreme form of hubris and the <a href="http://gagne.homedns.org/%7Etgagne/contrib/unskilled.html">Dunning Kruger effect</a>? Can they run complex departments far outside their core competencies optimally? Or will they more likely be running an area they know little about by the seat of their pants? Further, do leadership roles in organizations such as NIH or the Centers for Disease Control call merely for an MBA and domain neutral backgrounds? If not, why not? Why are hospitals exempt from a requirement for domain specific expertise in their leadership? As to CIO's (and, for that matter, CFO's) running hospital pharmacies, let's show the knowledge gaps graphically by first exploring the prerequisite <a href="http://www.hsc.wvu.edu/sop/students/Curriculum/Curriculum2011_2012_2013_fall2009.htm">training of a typical Pharm.D. pharmacist:</a> <blockquote> Professional Degree (Pharm.D. Degree) Curriculum Class of 2011, 2012, & 2013 (Admitted Fall 2007, 2008 & 2009) First Year, Fall Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">NBAN 301</td> <td width="400">Principles of Human Anatomy</td> <td width="135">3 credit hours</td> </tr> <tr> <td>PSIO 743</td> <td>Fundamentals of Physiology</td> <td>5 credit hours</td> </tr> <tr> <td>PHAR 700</td> <td>Pharmacy as a Profession</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 701</td> <td>Pharmaceutical Care Lab 1</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 702</td> <td>Physical Pharmacy</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 703</td> <td>Intro Pharmacy Practice Experiences 1</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 720</td> <td>Patient Health Education</td> <td>2 credit hours</td> </tr> <tr> <td> </td> <td class="bld">Total hours</td> <td class="bld">17 hours</td> </tr> </tbody></table> First Year, Spring Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">BIOC 531</td> <td width="400">General Biochemistry</td> <td width="135">4 credit hours</td> </tr> <tr> <td>PHAR 708</td> <td>Pharmaceutics</td> <td>3 credit hours </td> </tr> <tr> <td>PHAR 709</td> <td>Immunology and Biotechnology</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 710</td> <td>Intro Pharmacy Practice Experiences 2</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 711</td> <td>Chemical Properties of Drugs</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 712</td> <td>Pharmaceutical Care Lab 2</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 737</td> <td>Disease Prevention and Health Promotion</td> <td>2 credit hours</td> </tr> <tr> <td> </td> <td>Elective</td> <td>2-3 credit hours</td> </tr> <tr class="bld"> <td> </td> <td>Total hours</td> <td>18-19 hours</td> </tr> </tbody></table> First Year, Late Spring – after spring term concludes <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PHAR 714</td> <td width="400">Introductory Community Rotation (2 weeks)</td> <td class="bld" width="135">2 credit hours</td> </tr> </tbody></table> Second Year, Fall Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PCOL 743</td> <td width="400">Pharmacology 1</td> <td width="135">3 credit hours</td> </tr> <tr> <td>PHAR 715</td> <td>Pathophysiology & Therapeutics 1</td> <td>4 credit hours</td> </tr> <tr> <td>PHAR 716</td> <td>Chemistry of Drug Action 1</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 717</td> <td>Intro Pharmacy Practice Experiences 3</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 723</td> <td>Pharmaceutical Care Lab 3</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 727</td> <td>Medical Literature Evaluation</td> <td>2 credit hours</td> </tr> <tr> <td> </td> <td>Elective</td> <td>2-3 credit hours</td> </tr> <tr class="bld"> <td> </td> <td>Total hours</td> <td>16-17 hours</td> </tr> </tbody></table> Second Year, Spring Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PCOL 744</td> <td width="400">Pharmacology 2</td> <td width="135">3 credit hours</td> </tr> <tr> <td>PHAR 719</td> <td>Intro Pharmacy Practice Experience 4</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 724</td> <td>Pharmaceutical Care Lab 4</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 725</td> <td>Pathophysiology & Therapeutics</td> <td>4 credit hours</td> </tr> <tr> <td>PHAR 726</td> <td>Chemistry of Drug Action 2</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 728</td> <td>Pharmacy Management</td> <td>2 credit hours</td> </tr> <tr> <td> </td> <td>Elective</td> <td>2-3 credit hours</td> </tr> <tr class="bld"> <td> </td> <td>Total hours</td> <td>16-17 hours</td> </tr> </tbody></table> Second Year, Late Spring – after spring term concludes <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PHAR 729</td> <td width="400">Introductory Institutional Rotation (2 weeks)</td> <td class="bld" width="135">2 credit hours</td> </tr> </tbody></table> Third Year, Fall Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PHAR 730</td> <td width="400">Pathophysiology & Therapeutics 3</td> <td width="135">4 credit hours</td> </tr> <tr> <td>PHAR 731</td> <td>Biopharmaceutics & Pharmacokinetics</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 732</td> <td>Non-Prescription Drugs</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 733</td> <td>Pharmacy Systems</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 735</td> <td>Pharmaceutical Care Lab 5</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 742</td> <td>Intro Pharmacy Practice Experiences 5</td> <td>1 credit hour</td> </tr> <tr> <td> </td> <td>Elective</td> <td>2-3 hours</td> </tr> <tr class="bld"> <td> </td> <td>Total hours</td> <td>16-17 hours</td> </tr> </tbody></table> Third Year, Spring Semester <table class="alltrBodytext" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="103">PHAR 734</td> <td width="400">Pharmacy Law and Ethics</td> <td width="135">3 credit hours</td> </tr> <tr> <td>PHAR 736</td> <td>Pharmaceutical Care Lab 6</td> <td>1 credit hour</td> </tr> <tr> <td>PHAR 738</td> <td>Outcomes Assessment/Quality Improvement</td> <td>2 credit hours</td> </tr> <tr> <td>PHAR 739</td> <td>Therapeutic Patient Monitoring</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 740</td> <td>Pathophysiology & Therapeutics 4</td> <td>4 credit hours</td> </tr> <tr> <td>PHAR 741</td> <td>Clinical Pharmacokinetics</td> <td>3 credit hours</td> </tr> <tr> <td>PHAR 746</td> <td>Intro Pharmacy Practice Experiences 6</td> <td>1 credit hour</td> </tr> <tr> <td> </td> <td>Elective</td> <td>0-2 credit hours</td> </tr> <tr class="bld"> <td> </td> <td>Total hours</td> <td>17-19 hours</td> </tr> </tbody></table> Fourth Year Students complete eight five-week experiences beginning in the summer preceding their fourth year. Students will have required experiences, such as ambulatory care and acute care, and elective experiences. Students are required to complete at least 10 professional elective hours selected from an approved course list during their first, second, or third professional year and prior to fourth year experiential rotations. With the exception of Fall semester in the first professional year, one elective can be taken each semester of the didactic program. Electives are intended to complement the required curriculum and allow students to select courses based on professional interests. Students wishing to take electives during summer terms may do so after their first professional year on any of the campuses in the WVU system (Morgantown, Parkersburg, Potomac State, West Virginia Tech) provided the courses are selected from the list of professional electives or are deemed equivalent by the University. Students wishing to receive course credit for courses taken outside of the WVU system must have pre-approval by the Curriculum Committee.</blockquote> Of course, even assuming no requirement for a Dissertation defense (which is a typical Ph.D. requirement), the candidate needs to take state and/or federal exams for <a href="http://www.bls.gov/oco/ocos079.htm">licensure</a>: <blockquote>Licensure. A license to practice pharmacy is required in all States, the District of Columbia, and all U.S. territories. To obtain a license, a prospective pharmacist must graduate from a college of pharmacy that is accredited by the ACPE and pass a series of examinations. All States, U.S. territories, and the District of Columbia require the North American Pharmacist Licensure Exam (NAPLEX), which tests pharmacy skills and knowledge. Forty-four States and the District of Columbia also require the Multistate Pharmacy Jurisprudence Exam (MPJE), which tests pharmacy law. Both exams are administered by the National Association of Boards of Pharmacy (NABP). Each of the eight States and territories that do not require the MJPE has its own pharmacy law exam. In addition to the NAPLEX and MPJE, some States and territories require additional exams that are unique to their jurisdiction.</blockquote> (I can add that the typical M.D. curriculum, such as at the medical school I attended, is even <a href="http://www.bumc.bu.edu/admissions/curriculum/">more rigorous</a>. That is prior to the medical internship, residency, and postdoctoral fellowship(s) most physicians also must perform, where they become intimately familiar with the services of many hospital departments). Now, let's explore the comparable pharmacy science/biomedical training of the typical hospital CIO or CFO (or CEO for that matter): <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBqfEJsMhbThujn4qjQ-ZGDRwKAIs5mBKCFMQEyuL6A1O00AQGi4ASPA6hYitEmS9RhxTgGvWR3kc7hAhaKVUZLKepJ9HMSizizlkkfN_pD3RniLanguQEBx5h6kWaRv-oZSeStyz-egao/s1600-h/FC_NullSet_41726_lg.gif" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5380374871468209650" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBqfEJsMhbThujn4qjQ-ZGDRwKAIs5mBKCFMQEyuL6A1O00AQGi4ASPA6hYitEmS9RhxTgGvWR3kc7hAhaKVUZLKepJ9HMSizizlkkfN_pD3RniLanguQEBx5h6kWaRv-oZSeStyz-egao/s320/FC_NullSet_41726_lg.gif" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 85px; height: 112px;" /></a> (This, of course, is the mathematical symbol for the <a href="http://en.wikipedia.org/wiki/Null_set">null set</a>.)<div> </div><div>For comparison and contrast, see Roy Poses' post "<a href="http://hcrenewal.blogspot.com/2008/11/what-is-not-taught-about-leadership-in.html">What is Not Taught About Leadership in Healthcare</a>" for the healthcare MBA curriculum at a prominent School of Management, namely Yale's. Dr. Poses observed:</div><div> </div><div></div><blockquote><div>... So what is missing? There seem to be two obvious areas that are not taught. </div><div> </div><div>The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." ... The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.</div></blockquote><div></div><div> In the first of my posts linked above I wrote: <blockquote>... Those in charge [and who lack domain credentials -ed.] cannot see that which the domain specialist sees. They cannot see because they lack the training, experience, and what is described as 'meta-competence' (in <a href="http://gagne.homedns.org/%7Etgagne/contrib/unskilled.html">this brilliant article</a> on competence [the Dunning-Kruger effect - ed.]) essential to seeing that which is obvious. Obvious, that is, to those who do not lack these characteristics. In addition, I've also observed that some lack the fundamental analytical abilities essential to understanding and managing the complexities of biomedical R&D. Why those without domain expertise are in charge of organizations whose long term viability depends entirely on the most advanced and creative pursuit of biomedical 'miracles' [i.e., pharma - ed.] is another matter. I won't address this here, other than saying it reflects the adverse consequences of a bias that has evolved in management "science." That bias is the belief that all the world consists of faceless labor resources performing easily definable processes upon interchangeable widgets, and that management can therefore be done by generic managers, exclusively. Some of the world is like that [i.e., fast food chains - ed.], but some isn't, such as biomedical R&D. [And clinical medicine as well - ed.] <div style="text-align: left;">Management in the absence of domain expertise in this industry is, in fact, mismanagement. </div> There is nothing here to spin, there is nothing to debate. There is nothing to discuss. This is a first principle. Failure to accept this reality results in corporate failure.</blockquote> These views apply to hospitals perhaps even more critically than to biomedical R&D. In hospitals, mistakes in judgment can result in great patient harm, and far more rapidly than in an R&D organization. Finally, in the same CIO interview there's this: <blockquote> Q: If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start? A: I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one ... So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides. </blockquote> The fact that this "customer is king" advice seems to merit constant repetition among healthcare IT leadership circles, especially when the “customers” are clinicians with patient care obligations and responsibilities, should be a cause of deep reflection and introspection among those in HIT. At the very least, they need to ask themselves - and healthcare professionals need to ask them - "who are you, and what are your motives for stepping foot in our hospital?" It is also such a fundamental first principal that its frequent repetition suggests typical hospital CIO's are not truly fit in 2009 to lead anything in healthcare where domain expertise and viewpoints are essential, healthcare IT included. Its need for frequent repitition - dating to many HIT publication I've seen since I entered the Medical Informatics field professionally in the early 1990's - suggests they don't truly recognize that the business of hospitals is taking care of patients, the clinicians being the enablers of that business, everyone else being facilitators. The <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/">known problems and failure rates of heath IT in hospitals</a> is corroborative of that view. Healthcare reform will certainly require healthcare leadership reform, and the first task of that reform should be a re-evaluation of expertise required to tamper with people's lives and well being in a hospital setting. -- SS</div>

More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?

Both Roy Poses and I have written on a plague of healthcare mismanagement and perhaps malfeasance in part due to leadership by domain amateu...

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Make History with the National September 11th Memorial & Museum

The anniversary of September 11th evokes difficult memories here in New York and all over the world. The events of the day left an indelible mark on many New Yorkers, including me. The offices of my startup were at <a href="http://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=30+west+broadway+nyc&sll=40.713753,-74.011135&sspn=0.135841,0.350189&ie=UTF8&z=16">30 West Broadway</a>, right next door to 7 World Trade Center, so I was downtown that morning. I saw the planes hit and then watched, shocked, from the West Side Highway as the towers fell. It was a terrible day for all who were there, an impossible day for those who lost friends and loved ones and a shared experience of loss and grief for New York and the world. Today I'm proud that Google is part of the launch of <a href="http://www.911history.org/">Make History</a>, a website created by the <a href="http://www.national911memorial.org/">National September 11th Memorial & Museum</a> in partnership with design firm <a href="http://www.localprojects.net/">Local Projects</a>. Make History is a participatory archive that invites people to share their experiences of 9/11 and its aftermath in an effort to preserve the memories of that time. The Museum has created a collaborative storytelling tool that makes innovative use of Street View through the <a href="http://code.google.com/apis/maps/">Google Maps API</a>. The Make History site allows people to place and then share their photos and videos in geographical context, collectively piecing together the history that was witnessed, one photo and video at a time. To participate, simply go to the <a href="http://www.911history.org/">site</a> and click "Add Your Story." You'll be asked to write about your experience of 9/11 and share your photos and videos, and then to place them at the spot where they were captured. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1OrEbIiKWwim1Lad5dOluoscbp7S3I0prcSEOWqazQB2jJ_MF7OhJGvO4jHsTj72TdKKrJ_pfrXAf-9pllM1tnNvJHL154YNLvIfaJoOAeji7KDZe5wm7llKjPZ7Dv2Y0AqOAhAWUsGtM/s1600-h/NS11_MH_Press_11_WBroadway_Ron_Agam.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379620598838655250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1OrEbIiKWwim1Lad5dOluoscbp7S3I0prcSEOWqazQB2jJ_MF7OhJGvO4jHsTj72TdKKrJ_pfrXAf-9pllM1tnNvJHL154YNLvIfaJoOAeji7KDZe5wm7llKjPZ7Dv2Y0AqOAhAWUsGtM/s400/NS11_MH_Press_11_WBroadway_Ron_Agam.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 304px;" /></a> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhirQ65py2O1bWEkbcDVxdbNY6b00W2HjVbD6iYJlFtZDPNLndaRc5QQXIC84Z5VFcR25yj-uXKDKr_RibhyphenhyphenqaSPFe23lhK0vPXvf6jENjuFt2W0EDpcsE8MYET3l60xL2ASBAK_zBhg4i6/s1600-h/NS11_MH_Press_03_homepage.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379620585023930594" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhirQ65py2O1bWEkbcDVxdbNY6b00W2HjVbD6iYJlFtZDPNLndaRc5QQXIC84Z5VFcR25yj-uXKDKr_RibhyphenhyphenqaSPFe23lhK0vPXvf6jENjuFt2W0EDpcsE8MYET3l60xL2ASBAK_zBhg4i6/s400/NS11_MH_Press_03_homepage.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 304px;" /></a> To power the Make History website, the Museum is using <a href="http://code.google.com/appengine/">App Engine</a> and leveraging the power of cloud computing. By taking advantage of the scalability of Google's infrastructure, the Museum can focus on building great applications and telling important stories — not on how many servers they will need. The developer community that uses our tools and APIs is a source of inspiration for all of us at Google who work on platforms, partnerships and developer outreach — and <a href="http://www.911history.org/">Make History</a> is a powerful example of why we all do what we do. This September 11th, as we sit with our memories of the day, we're honored to have been able to help enable the creation of such a significant and deeply moving archive. Posted by Jill Szuchmacher, New Business Development

Make History with the National September 11th Memorial & Museum

The anniversary of September 11th evokes difficult memories here in New York and all over the world. The events of the day left an indelible...

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Now S-U-P-E-R-sized!

<a href="http://www.google.com/">Search</a>, that is. For us, search has always been our focus. And, starting today, you'll notice on our homepage and on our search results pages, our search box is growing in size. Although this is a very simple idea and an even simpler change, we're excited about it — because it symbolizes our focus on search and because it makes our clean, minimalist homepage even easier and more fun to use. The new, larger Google search box features larger text when you type so you can see your query more clearly. It also uses a larger text size for the suggestions below the search box, making it easier to select one of the possible refinements. Over the past 11 years, we've made a number of <a href="http://www.google.com/corporate/timeline/#homepage-original-prototype">changes to our homepage</a>. Some are small and some are large. In this case, it's a small change that makes search more prominent. Google has always been first and foremost about search, and we're committed to building and powering the best search on the web — now available through a supersized search box. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlaOghn_RZAuYlgs3jwy9j740_UYNCEDAZ1hT5vw7VAljQsJsSinm1SthGwF4SXznKUgaRvI8To3jWcvTJ7vu7dGIf5aoeafEL6mFblD8eVjmKYpVH9wigDSrcuSn88YUn_Am4OhDU63vJ/s1600-h/new-old-search-next.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379583174096973298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlaOghn_RZAuYlgs3jwy9j740_UYNCEDAZ1hT5vw7VAljQsJsSinm1SthGwF4SXznKUgaRvI8To3jWcvTJ7vu7dGIf5aoeafEL6mFblD8eVjmKYpVH9wigDSrcuSn88YUn_Am4OhDU63vJ/s400/new-old-search-next.png" style="margin: 0px auto 10px; display: block; text-align: center; width: 500px;" /></a> <div style="text-align: center;">Before and after on Windows XP, running Google Chrome. Click on the image for a larger view. </div> Posted by Marissa Mayer, Vice President, Search Products & User Experience

Now S-U-P-E-R-sized!

Search , that is. For us, search has always been our focus. And, starting today, you'll notice on our homepage and on our search results...

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The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris <a href="http://www.nytimes.com/2009/09/02/business/02drug.html">writing</a> for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Laboratories' Fiscal Year 2004 Marketing Plan for the drug Lexapro (escitalopram oxalate), an anti-depressant. The document is available <a href="http://www.nytimes.com/packages/pdf/politics/20090831MEDICARE/20090831_MEDICARE.pdf">here</a>. Review of this plan revealed the marketing department's various activities, including activities that others might have believed were educational, scientific, or had some other high minded purpose. Continuing Medical Education Overall, one "promotional objective" was to "Maintain SRI category leadership in total number of medical education events (including CME symposia, speaker promotion, teleconferences, and peer selling programs)" One "critical issue" was to "increase Med Ed efforts: more sponsorships of CME, increased level of speaker programs, maintain level of teleconferences and peer selling." Under "Marketing Tactics" was a long section on "Continuing Medical Education." It covered various venues for CME such as internet/electronic CME, "sponsoring symposia at major meetings," "regional CME symposia" which would "serve a number of medical specialties," "sponsorhips of scientific sessions," etc Production of Scholarly Articles The "Publications" section of "Marketing Tactics" noted "publications will be geared toward psychiatrists, PCPs, .... Articles will appear in several formats, including original reports, review articles, and journal supplements." Thought Leaders and Consultants Under the "Continuing Medical Education" section of "Marketing Tactics," and then in the "Advisor Relations" section, there were numerous references to what "thought leaders" would do, including - "present new data" at "symposia at major meetings" - act "as advisors to Lexapro in order to obtain critical feedback and recommendations on educational and promotional strategies and tactics." - sit on the "Lexapro Exectuive Advisory Board" to "keep our advisors apprised of the commercial development ... of escitalpram." - sit on the "Primary Care Advisory Board" to "obtain critical feedback and recommendations on educational and promotional strategies and tactics...." Role of Medical Centers Under the CME section of "Marketing Tactics," we see that "academic health centers" would help develop "regional CME symposia." Under the "Sponsorship" section are plans to fund the "Professional Relations Group in their mission of establishing mutually beneficial long-term relationships with appropriate professionals and associations." Specific plans included funding the Department of Psychiatry and Behavioral Sciences at Emory Medical Societies The "Sponsorship section" also noted that these relationships "will also provide the basis for advocacy development and issues management, and will establish an appropriate environment for commercial and policy activities." Under the CME section of "Marketing Tactics, we see that "medical associations and professional societies" would help develop "regional CME symposia" Also in this section is the note that "smaller, more prestigious societis do not accept industry-sponsored symposia." So instead, "sponsorship of a study groups or plenary sessions is recommended. Marketing will work with the professional relations group regarding potential opportunities." Appendix VII, "Professional Associations of Priority" noted funding provided for guideline development by a "collaboration between APA, AAFP and ACP" for "chronic depression in primary care practice;" by AAGP for guidelines for late-life depression; multiple guidelines developed by AMDA; The appendix also noted that Forest supports ACNP "annual programming, and is a founding sponsor of it's newly created International College of Geriatric Pscyhopharmacology (ICGP)," is a "Corporate President's Circle Sponsor of AAFP," became a "corporate sponsor of ACP in FY03," became "a Corporate Sponsor of AMDA for the last few years," Also, it noted that Forest has "expanded its involvement" with APA for "lobbying of State Health Departments...." Disease Advocacy Organizations Also in Appendix VII, Forest was identified as a "Corporate Sponsor of NAMI," a "major Corporate Sponsor of NMHA," and a "major Corporate Sponsor of DBSA." Summary We have often heard from pharmaceutical, biotechnology, device and other health care corporations that they are only involved in education to disseminate accurate information for the good of society. We have often heard from physicians and academics who consult for such corporations that their advice is sought about clinical, scientific, and technical issues. We often hear from academic medical institutions, medical associations and disease advocacy groups that the money they get from such corporations does not influence the content of their educational and scientific work. Yet here we see, in considerable detail, that in the case of one drug company's promotional efforts for one drug, - The marketing plan from the marketing department paid for medical education as a "promotional objective," that is, to market, not to educate. - Thought leaders and consultants were again paid by marketing to market, and sometimes to provide opinions about "promotional strategies" and "commercial development." - Medical associations are funded by marketing "for commercial and policy activities." This suggests that health care corporations develop financial relationships with physicians, academics, academic institutions, medical and professional associations, and disease advocacy groups to support marketing first. This allows the corporations to advance marketing disguised as education, research, and other high-minded and apparently selfless activities by professionals, not-for-profit organizations, and dedicated inviduals. Such marketing, of course, is DECEPTIVE and DISHONEST. It also is in conflict with the professionals' ideals, and the missions of the medical and professional assocations and disease advocacy groups. The physicians, other health care professionals, and not-for-profit organizational leaders involved may rationalize these activities as consistent with their mission and professionalism, but such rationalizations are at best self-delusion. No one knows how representative the Lexapro marketing plans are of the marketing of other drugs, devices and health care services. The only way to find out would be to force many other corporations' marketing plans into public view. The Lexapro documents suggest that society would benefit if many more marketing plans were made public, but that such publication might generate a wave of revulsion about how deceptive marketing of health care goods and services has become, and the extent that health care professionals have betrayed their professional ideals, and academic medical institutions, professional and medical societies, and patient advocacy groups have betrayed their missions. I submit that we will not truly reform health care without making the marketing of health care goods and services honest, getting health care professionals to give up their financial relationships with health care corporations to reclaim their professionalism, and getting academic medical institutions, professional and medical societies, and patient advocacy groups to give up their financial relationships with health care corporations to reclaim their missions. See additional comments on how the marketing plan was meant to promote CME <a href="http://carlatpsychiatry.blogspot.com/2009/09/forests-promotional-objective-use-cme.html">by Dr Daniel Carlat</a> on the Carlat Psychiatry Blog.

The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris writing for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Labo...

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A Solution To Pharma's Repeated Drug Offenses: Incarceration

Some straightforward common sense follows. No spin, no indirection, no excuses: Pfizer has recently paid a $2.3 billion dollar settlement on civil and criminal charges that potent drugs were being improperly promoted (i.e., pushed onto unsuspecting physicians and patients) for uses not approved by the regulatory agencies responsible for such matters. What is the real world meaning of these charges? The meaning is that patients - the final consumers - were ingesting drugs that were not only not indicated, but held possibilities of harming the drug taker. We have seen negative outcomes from these practices before in the form of, for example, children in whom improperly pushed antidepressants caused suicidal thoughts and actual suicide (the teenage daughter of a friend of my mother hanged herself after starting such drugs, resulting in a lawsuit that the parents ultimately won). It demonstrates reckless and malicious disregard for others to tamper with people's lives in this fashion. Perhaps sociopathy is an apt description of such behavior. One wonders about the adverse consequences to patients of this latest round of pharma fraud. Ultimately, those engaging in these practices (usually at the group director or VP level) are doing the following: They are gambling with the lives and well-being of countless patients. In some of these cases, patients will have been harmed; in others, patients will have died. In the former case, the perpetrators of the fraud are facilitators of the injury. In the latter case, the perpetrators are accessories to murder. Fining a corporation is a nearly useless exercise, as ultimately the conversation in the executive offices and Wall Street will be about the <a href="http://www.investors.com/NewsAndAnalysis/Article.aspx?id=505405">cost of doing business</a>, not about crimes or morals. Terminating perpetrating individuals is also not extremely effective in motivating reform, even if terminated with prejudice, if those terminated have already made their fortune. <div>(The $2.3 billion could have been used, in fact, as a war chest to reduce the need for layoffs during economic downturns, like our current one, were it not wasted in paying fines due to the behaviors of unscrupulous executives.)</div><div> The solution to this problem is straightforward. Deal with the individuals involved in the following manner: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMJeiV3peuzXP_OVWQdui0uhnqmvF77W2w9YkrOlwTAFpOgZ9L16lt8mnOwhfGPydqmuM4YnvnbxQu5Yr5KMQng-WL4EobGpr1BDf2w693deGnPiADvBmVLukn2dkZ2F6BM6pF2G1vqnhL/s1600-h/Jail_doors.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379191722950654450" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMJeiV3peuzXP_OVWQdui0uhnqmvF77W2w9YkrOlwTAFpOgZ9L16lt8mnOwhfGPydqmuM4YnvnbxQu5Yr5KMQng-WL4EobGpr1BDf2w693deGnPiADvBmVLukn2dkZ2F6BM6pF2G1vqnhL/s320/Jail_doors.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 320px; height: 214px;" /></a>Where the executives behind these abuses belong: jail </div> Time in jail for these executives is a needed remedy. The following, however, is the situation we have: <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlM3HQADphppCKx0jG-iHRaW9hyphenhyphenga4rcXPGJOIBqUhJdISSbTmVZX_L6SYtMVzzzS2tMoVwQcy-TlEt1YXNlQSfsEhoXOkVvhs399U-u3LghBgleIELg-MTreXqqLXLhIkQrYYKovW7TGM/s1600-h/get_out_of_jail_free.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5379192350058766658" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlM3HQADphppCKx0jG-iHRaW9hyphenhyphenga4rcXPGJOIBqUhJdISSbTmVZX_L6SYtMVzzzS2tMoVwQcy-TlEt1YXNlQSfsEhoXOkVvhs399U-u3LghBgleIELg-MTreXqqLXLhIkQrYYKovW7TGM/s320/get_out_of_jail_free.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 246px; height: 144px;" /></a> This is inexcusable. Healthcare advocacy groups and relatives of those injured need to lobby for the solution proposed in the first picture: long, stiff sentences for those committing medical fraud and quackery by proxy in the form of these industry abuses. Finally, the Pfizer scenario causes me to ask: Is the leadership of this company competent to manage its operations? Or, is that leadership - for instance a CEO lacking science and biomedical education and experience - an "enabler" of the creative marketing for drugs -- creative advertising campaigns being seen as a virtue in his <a href="http://hcrenewal.blogspot.com/2006/07/pfizer-brings-life-to-my-if-youve-run.html">prior industry</a>? -- SS</div>

A Solution To Pharma's Repeated Drug Offenses: Incarceration

Some straightforward common sense follows. No spin, no indirection, no excuses: Pfizer has recently paid a $2.3 billion dollar settlement o...

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