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HealthMemes: A "Healthcare Disruptive Innovation" custom Google search site

In my March 2009 post "<a href="http://hcrenewal.blogspot.com/2009/03/disruptive-innovators-at-healthcare.html">Disruptive Innovators at Healthcare Renewal: Disruptive to whom, exactly?</a>" I wrote about a fascinating site "HealthMemes: Tracking Conversations About the Future of Health" at <a target="blank" href="http://in3.org/health/">http://in3.org/health/</a> that linked to some of the posts here. The site is a blog of the organization <a style="font-family: arial;" href="http://www.in3.org/info/">International Informatics Institute (IN3.ORG)</a> and identifies latest trends in health care disruptive innovations (innovations that go "outside the box"). In that post I opined that: <blockquote>... If there are disruptive innovators, then there must be a whole taxonomy of people who are not disruptive innovators. The taxonomy might go something like this: <ul style="font-family: arial;"><li>disruptive innovator</li><li>soothing, tradition-bound innovator</li><li>disruptive imitator (the antonym of innovator)</li><li>tradition-bound imitator</li><li>disruptive non-contributor</li><li>tradition-bound non-contributor</li><li>disruptive demolisher</li><li>tradition-bound demolisher (perhaps an oxymoron)</li></ul> Disruptive innovators, thus, are disruptive to the interests of a wide variety of others. </blockquote> Now, the site has created a custom Google search that searches over 80 healthcare blogs, news sites and research sources considered "disruptively innovative" and used in the daily Health Memes postings. Healthcare Renewal is one of those sites as are some of our favorite others. The "Healthcare Disruptive Innovation" custom Google search is at <a href="http://in3.org/health/sources.php">http://in3.org/health/sources.php</a> and includes quite an impressive collection of sites. Take a look. -- SS

HealthMemes: A "Healthcare Disruptive Innovation" custom Google search site

In my March 2009 post " Disruptive Innovators at Healthcare Renewal: Disruptive to whom, exactly? " I wrote about a fascinating si...

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Does the CEO of Google Use Google? - And: Platform, Platform, Who's Got The Platform?

<div style="text-align: left;">Over at the WSJ health blog, reporter Jacob Goldstein's Jan. 8, 2010 post "<a href="http://blogs.wsj.com/health/2010/01/08/google-ceo-harvard-surgeon-talk-health-it/">Google CEO & Harvard Surgeon Talk Health IT</a>" quotes Google's CEO:</div><blockquote> "Google’s CEO Eric Schmidt doesn’t know why docs haven’t embraced databases to help them sort through medical information." [Schmidt said] ... So when you show up at the doctor with some set of symptoms, in my ideal world what would happen is that the doctor would type in the symptoms he or she also observes, and it would be matched against the data in this repository [such as <a style="font-style: italic; font-weight: bold;" href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=dxplain&btnG=Google+Search">DXplain</a>? -- which we learn from a - er, um, Google search - was developed starting in the mid 1980's by medical informatics researchers who actually know this domain, and which offers this explanation and warning: "DXplain uses an interactive format to collect clinical information and makes use of a modified form of Bayesian logic to derive clinical interpretations ... DXplain does not offer definitive medical consultation and should <a style="font-style: italic; font-weight: bold;" href="http://lcs.mgh.harvard.edu/projects/dxplain.html">not be used</a> as a substitute for physician diagnostic decision making"? - ed.] ... Then this knowledge engine would use best practices, and all the knowledge in the world to give physicians some sort of standardized guidance. This is a generalized form of the checklists that you’re talking about … As computer scientists, this is a platform database problem, and we do these very, very well, as a general rule. And it befuddles me why medicine hasn’t organized itself around these platform opportunities. [No - the successful practice of medicine is not a 'platform database' or any other reductionistic information retrieval problem - ed.]</blockquote> I note that IT personnel like to refer to "<a href="http://en.wikipedia.org/wiki/Computing_platform">platforms</a>", "solutions" - a rather presumptuous term, "paradigms", and other buzzwords to mask the fact that what they're referring to are more commonly known as "hardware" and "software" and arrangements thereof. Does this "platform opportunity" view reflect naïveté about the complexities of medicine and medical decision making, or does it reflect something else? Could this "befuddlement" be construed as calling physicians obtuse? Is this yet another example of what I referred to in my post "<a href="http://hcrenewal.blogspot.com/2009/12/utter-arrogance-of-it-industry.html">Healthcare IT Failure and The Arrogance of the IT Industry</a>" and other writings as a cross-occupational invasion of medicine by IT? IT personnel seem to have a propensity to offer healthcare-related opinions far outside their own areas of expertise -- or if in healthcare organizations, edicts - based upon the narrow view of their own relatively linear and deterministic fields. The risk is, especially when coming from high perches, that such opinions and edicts can result in deleterious actions (e.g., government initiatives). In an absurdist <a style="font-style: italic;" href="http://en.wikipedia.org/wiki/Reductio_ad_absurdum">reductio ad absurdum</a>, deliberately made absurdist due to many years of exposure to equally absurd (to those with actual domain experience) "who needs medical school/residency/patient care experience to profess on medical matters?" attitudes: Why don't physicians offer the advice that Google could improve its search algorithms, or Intel and AMD their microprocessors, by utilizing intelligent psittacine platforms <a href="http://www.youtube.com/watch?v=O_Fpad20Zbk">as in this British Broadcasting Company (BBC) video</a> narrated by a true technology expert, Captain James T. Kirk? <div style="text-align: center;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0_5l5d5WTr3rCF1OxYjWQCMZ58U02amoTE7trho8x12NYbR6UPP8JmpwY2E19FcZ4oaBUwNh8lYLp8IolYKq_ve9YohOpipWKEuhjtnh02FzauX2HbebCWl6zID8haXMeDLA3WwmxHjyu/s1600-h/STChangeling.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5424782084411649186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0_5l5d5WTr3rCF1OxYjWQCMZ58U02amoTE7trho8x12NYbR6UPP8JmpwY2E19FcZ4oaBUwNh8lYLp8IolYKq_ve9YohOpipWKEuhjtnh02FzauX2HbebCWl6zID8haXMeDLA3WwmxHjyu/s320/STChangeling.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 157px; height: 112px;" /></a>Kirk did have a (computerized) physician son: <a href="http://en.wikipedia.org/wiki/Nomad_%28Star_Trek%29">Nomad</a>! </div> ---------------- Quite seriously, physician reluctance to "embracing databases" and health IT in general is not about database platforms. I only wish it were so simple. The WSJ seems to understand this. In a Jan. 12, 2009 article by reporter Bret Stephens entitled "<a href="http://online.wsj.com/article/SB10001424052748703652104574652002740167932.html">Can Intelligence be Intelligent?</a>", the observation is made that technology is a mere facilitator, and intelligent, well trained, experienced, critical-thinking people are the enablers of any complex field that requires human judgment. They must be unfettered by machine and bureaucrat: <blockquote> ... Terrifying as the thought may be to many of its current practitioners, the true art of intelligence requires, well, intelligence. That is a function neither of technology nor of "systems" [a.k.a. "platforms" - ed.], which begin as efforts to supplement and enhance the work of intelligence and typically wind up as substitutes for it. It is, instead, a matter of experience, intellect, initiative and judgment, nurtured within institutions that welcome gadflies in their midst.</blockquote> I've left the following comment at the WSJ health blog: <blockquote>Mr Schmidt, If you’d like to learn more about why many physicians are reluctant to embrace clinical IT, you might also do a Google search on “<a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=healthcare+IT+failure">healthcare IT failure</a>” and similar terms.</blockquote> Need I say anything more about the irony of that advice? I'd also noted a fixation on "platforms" as solutions to biomedical problems (best when they come in shrinkwrapped, off the shelf, "on the IT roadmap" packages!) in my June 2008 post "<a href="http://www.bio-itworld.com/issues/2008/may/cover-story-merck-informatics.html">An Open Letter to Merck CEO Richard Clark on Merck's Mission to Rediscover the Wheel.</a>" A nonmedical research IT leader, who'd found a move from basic research to clinical IT "quite an eye opening experience" (i.e., a domain in which she had little or no experience but was paradoxically appointed to lead) talked all about "platforms" in <a href="http://www.bio-itworld.com/issues/2008/may/cover-story-merck-informatics.html">Bio-IT World</a>: <blockquote>... We've invested a lot in some core platforms; we need to start translating that into results in the clinic at some point. And so having people who have an understanding of what does that really take to help inform the earlier research directions, the platform directions [i.e., research direction = platform direction - ed.], is a key theme...We already have siloed platforms to show that data, we need to integrate it more than it is... combining the results data from clinical samples with the associated patient data, what's that platform?</blockquote> Platform, platform, platform. Who's got the platform? My comments to that CEO in my Open Letter were that this was the wrong mindset and question, based upon an IT person's focus on information technology. This is as opposed to a focus on information science and on facilitating people in interacting with data and information in order to gain actionable knowledge, i.e., an information science and human-computer interaction-based approach that those in medical informatics thought about long ago. In line with the conclusions of <a href="http://hcrenewal.blogspot.com/2009/12/healthcare-it-as-cybernetic-miracle.html">Greenhalgh et al</a>. [1] who called for "eschewing sanitized accounts of successful projects" and instead recommending studies of clinical IT in organizations that “tell it like it is” using the de-identified critical fiction technique, I'd written on how conflation of information technology and information science impaired R&D in pharma at my essay "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=pharma">Sure path to R&D failure: Conflation of IT with information science in the pharmaceutical industry</a>." That piece and the aforementioned Open Letter were written before Merck sold itself to Schering-Plough in a "<a href="http://www.biojobblog.com/2009/03/articles/ideas-and-indulgences/the-merckschering-plough-deal-under-the-microscope-why-a-reverse-merger/">reverse merger</a>" due to the <a href="http://www.forbes.com/2009/04/21/merck-schering-earnings-business-healthcare-merck.html">unsustainability of doing business from an empty wagon</a> of new products, a sign of just how well this IT-centric "platformania" has been working out for R&D. In the information science-centered view and approach, the "platform," a.k.a. computer technology, is merely a canvas and facilitator, the artist (clinician or scientist) and the brush wielded by them being the primary enabler of and contributor to the masterpiece. Unfortunately, I don't think anyone is "home" in pharma or in the HIT sector anymore to parse these ideas; in fact I've only recently learned that the people I did work with who could parse these ideas into creative reality were laid off by the very IT people making such statements and asking such questions. IT personnel perhaps need to move away from their reductionist platformania. (Perhaps they are confusing "platforms" with "pixie dust.") Rather, they need to start thinking in terms of facilitating clinicians and scientists through domain specific and individualized-to-need information science and HCI innovation that arises of true cross-disciplinary expertise. They need to leave creation of cybernetic miracles to people such as <a href="http://en.wikipedia.org/wiki/Irwin_Allen">Irwin Allen</a> and <a href="http://en.wikipedia.org/wiki/George_Lucas">George Lucas</a>. And platforms to carpenters. -- SS [1] Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method. Greenhalgh, Potts, Wong, Bark, Swinglehurst, University College London. Milbank Quarterly, Dec. 2009. Available at: <a href="http://eprints.ucl.ac.uk/18821/">http://eprints.ucl.ac.uk/18821/</a>

Does the CEO of Google Use Google? - And: Platform, Platform, Who's Got The Platform?

Over at the WSJ health blog, reporter Jacob Goldstein's Jan. 8, 2010 post " Google CEO & Harvard Surgeon Talk Health IT " ...

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Ode to the Paperless Society

I thought <a href="http://www.aapsonline.org/newsoftheday/00767/comment-page-1#comment-3887">this comment</a> to a piece on "Healthcare IT myths" was worthy of wider distribution. (The <a href="http://www.aapsonline.org/newsoftheday/00767/">full piec</a><a href="http://www.aapsonline.org/newsoftheday/00767/">e</a> is also a worthwhile read by itself; disclosure - my work is cited.) Here is the comment: <blockquote>bill waters iii md says: January 8, 2010 at 3:57 amJames Fallows, in a recent Atlantic Monthly, writes that, unlike paper in any of its forms–which retains images –computer software, disks, and drives contain only magnetic impulses that can dissipate. Furthermore, anything over 5 years old runs the risk of there being no software or hardware which can read it. In the coding cubicle of a famously “wired” hospital, I recently noted scores of pigeonholes containing packs of forms.With the advent of electronic methods to manipulate and store data, business has between 1980 and 2000 quadrupled its production and utilization of paperwork.Hence: ODE TO THE PAPERLESS SOCIETY By Bill Waters, MD Write on the beach, the tide will erase; Write on the dune, the wind will deface; Write on the disk, time will show its hand; Remember now—they’re all just sand.* But papyrus and parchment are so well made The Dead Sea Scrolls will never fade. The vaunted electron will soon turn to vapor And its principal product is still just—paper. ____ *For those in Washington, we’re talking about silicon, get it?</blockquote> There is wisdom in this short piece, as well as a certain charm. -- SS

Ode to the Paperless Society

I thought this comment to a piece on "Healthcare IT myths" was worthy of wider distribution. (The full piec e is also a worthwh...

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Abbott Laboratories Settles

Another day, another settlement, this time,as reported <a href="http://www.reuters.com/article/idUSN0720003720100107">by Reuters</a>: <blockquote>New York Attorney General Andrew Cuomo said Abbott Laboratories (ABT.N) and French drugmaker Fournier have agreed to pay $22.5 million to settle a multistate lawsuit that accused them of conspiring to block generic forms of their TriCor treatment for triglycerides. The drugmakers will pay the money to New York, 22 other states and the District of Columbia, Cuomo said in a news release on Thursday. About $4.5 million goes to New York. The lawsuit, filed in Delaware federal court in March 2008, alleged Abbott and Fournier schemed to block generics when competitors started to develop versions of TriCor, used to treat a type of blood fat that increases the risk of heart disease. Cuomo said Abbott and Fournier made minor changes to TriCor that provided no clinical benefit, but were meant to prevent pharmacists from dispensing less-expensive generic versions of TriCor. The states alleged the drugmakers also thwarted generic competition by filing baseless patent-infringement suits against generic drugmakers, thereby securing a monopoly for blockbuster TriCor. </blockquote>The ongoing march of legal settlements of charges of various kinds of wrongdoing by diverse health care organizations is a reminder of the pervasiveness of bad conduct by such organizations. We have commented repeatedly (see some posts<a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements"> here</a>) such settlements, including the "corporate integrity agreements" now frequently attached to them, seem to have done little to deter bad behavior. Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior. While each new entry in the ongoing march of settlements merits a few lines in the business media,separately, or in the aggregate these settlements rarely get noticed by health services or health policy research, or receive attention in health policy circles.  Nor do the contrasts between the conduct revealed by such settlements and the rosy public relations of the settling companies attract much attention.  For example, Abbott Laboratories proclaims <a href="http://www.abbott.com/global/url/content/en_US/10.10:10/general_content/General_Content_00003.htm">its "promise</a>," <blockquote>We are here for the people we serve in their pursuit of healthy lives. This has been the way of Abbott for more than a century - passionately and thoughtfully translating science into lasting contributions to health. Our products encircle life, from newborns to aging adults, from nutrition and diagnostics through medical care and pharmaceutical therapy. Caring is central to the work we do and defines our responsibility to those we serve: We advance leading-edge science and technologies that hold the potential for significant improvements to health and to the practice of health care. We value our diversity - that of our products, technologies, markets and people - and believe that diverse perspectives combined with shared goals inspire new ideas and better ways of addressing changing health needs. We focus on exceptional performance, a hallmark of Abbott people - worldwide - demanding of ourselves and each other because our work impacts people's lives. We strive to earn the trust of those we serve by committing to the highest standards of quality, excellence in personal relationships, and behavior characterized by honesty, fairness and integrity. We sustain success - for our business and the people we serve - by staying true to key tenets upon which our company was founded over a century ago: innovative care and a desire to make a meaningful difference in all that we do. The promise of our company is in the promise that our work holds for health and life. </blockquote>The settlement of allegations about a scheme to maintain a monopoly on a profitable drug raise doubts about the company's committment to "earn the trust of those we serve" through "behavior characterized by honesty, fairness and integrity."  Whether the disconnect between this settlement and the "Abbott Promise" will affect the stratospheric earnings of Abbott executives (for example, in 2008, the total compensation of Abbott CEO Miles D White was $28,335,494 per the company's <a href="http://www.abbottinvestor.com/phoenix.zhtml?c=94004&p=IROL-secToc&TOC=aHR0cDovL2NjYm4uMTBrd2l6YXJkLmNvbS94bWwvY29udGVudHMueG1sP2lwYWdlPTYyMDg3NjQmcmVwbz10ZW5r&ListAll=1">2009 proxy statement</a>) is a question that could be put to the company's Board of Directors.  Perhaps our readers at Yale University might want to ask Dr Robert J Alpern, Dean of the Yale  School of Medicine, who just joined the Abbott <a href="http://www.abbott.com/global/url/content/en_US/70.45.10:10/general_content/General_Content_00083.htm">Board of Directors</a> in 2008 about that.

Abbott Laboratories Settles

Another day, another settlement, this time,as reported by Reuters : New York Attorney General Andrew Cuomo said Abbott Laboratories (ABT.N) ...

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Two New Challenges to a Healthcare Cybernetic Utopia: Yet More Hurdles Exposed

At "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=2009">2009: a Pivotal Year in Healthcare IT</a>" I concluded that 2009 had proven to be a critical year in HIT, due to authoritative publications on HIT difficulties and related issues that appeared that year. It was good to see the critical thought processes and the scientific methods inherent in modern medicine applied to the irrational exuberance and marketing-dominated field of healthcare IT. It seems in 2010 the trend may continue. Two new very interesting publications have recently come to my attention regarding the complications that can, and are, introduced by HIT. These complications are worsened by the "boatload of cash," as one author expressed it, that is helping fuel what I term an irrational exuberance, or purchased exuberance, in this technology and its use in social re-engineering in medicine. ----------------------- The first publication of note is a newsletter "Medical Risk Management Advisor" from <a href="http://www.proassurance.com/">ProAssurance Indemnity Company</a>, Inc. and affiliates, a provider of medical insurance for clinicians. It can be downloaded <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Proassurance_newsletter.pdf">here</a> (PDF). It advises: On choosing an EHR system: <blockquote>Be sure to obtain physician input and review of the software prior to purchase to ensure it meets the needs of your practice. Consider talking to other medical practices already using the software, not only to assist in your decision, but to anticipate flaws or errors existing users may have encountered. Lastly, establish a process to address problems discovered after implementation.</blockquote> "Anticipating flaws or errors existing users may have encountered" seems to be at odds with nondisclosure clauses in heathcare IT contracts, but this insurer seems to have gotten the message that HIT is not a perfected technology by a long shot. On Alert fatigue: <blockquote>Physicians may ignore e-prescribing alerts for a variety of reasons (e.g., excessive alerts or alerts that are not clinically useful). Again, input from physicians prior to implementation can help prioritize and choose alerts appropriate to the practice.</blockquote> That the advice has to be given by an insurance company to healthcare organizations that "input from physicians prior to implementation" is crucial reflects a pathology, whose root is within the paternalistic and patronizing IT culture. This culture and occupation has <a href="http://histalk2.com/2010/01/06/readers-write-1710/">invaded medicine</a> and supplied endless predictions of utopia for at least the past thirty years, in a domain it generally understands at the level of a layperson. On "additional features" creating risk: [HIT incurs risk? How can the tool touted to revolutionize medicine incur risk? - ed.] <blockquote> For example, some software programs require a diagnosis listed with each prescription. Consider the following: a patient is on Depakote for bipolar and seizure disorders, but the e-prescribing system only notes bipolar disorder because of its one-diagnosis limitation by design. Subsequently, the patient becomes manic and the on-call psychiatrist starts the patient on lithium for the bipolar disorder. Checking the e-prescribing system, he notes Depakote was prescribed for bipolar disorder so he titrates the Depakote to discontinuation. The patient has a seizure during the titration which leads to death. The on-call psychiatrist assumed the patient was on Depakote solely for bipolar disorder and not seizures. If the diagnosis feature had been more extensive or had not been used with the software, the on-call psychiatrist might have explored further before discontinuing the Depakote. Again, input from physicians prior to implementation may help prevent potential risks. </blockquote> (According to <a href="http://hcrenewal.blogspot.com/2010/01/socky-meditech-sockpuppet-on-vacation.html">Socky the Meditech Sockpuppet</a>, such events are impossible.) On Interoperability: <blockquote>Another issue is whether your e-prescribing system fully integrates with pharmacy systems. Using the previous example, what if the diagnosis was changed in the psychiatrists’ system, but the pharmacy system did not automatically update this information? Be sure to investigate the compatibility of your system with others in your area. Not all pharmacies have e-prescribing capabilities. Many rural areas do not have the broadband internet access required.</blockquote> It is unfortunate that the HIT vendor community is based on a business-computing model. That culture is extremely territorial. Seamless interoperability will be a long time in coming in HIT. On Medication Reconciliation: <blockquote>Physicians and pharmacies may find it difficult to trust the completeness and currency of the medication history and reconciliation, since medication histories often derive from multiple sources. Continue to verify medication histories with patients, and update records accordingly.</blockquote> What? Actually not rely on the computer? What kind of extremist anti-health IT Luddite advice is this insurer proffering? On Indemnity or "Hold Harmless" agreements: <blockquote>Finally, be cautious about entering into hold harmless agreements with software vendors. Your ProAssurance policy excludes from coverage liability assumed under any contract or agreement, unless the liability would be imposed by law in the absence of the contract or agreement. It covers only the insured’s professional liability and not the liability of another party that the insured may assume through an indemnity agreement. If you are asked to sign such an agreement, you should have your attorney carefully review the agreement and your insurance policy.</blockquote> I did not think of this issue when I wrote my <a href="http://jama.ama-assn.org/cgi/content/extract/302/4/382">July 2009 JAMA letter to the editor</a> and a fuller posting on this issue at my Drexel HIT difficulties <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=koppel_kreda">website here</a>. In addition to violating their fiduciary responsibilities and Joint Commission Safety Standard obligations, hospital executives signing nondisclosure and hold harmless agreements may be putting their organizations under undue financial risk if a HIT-related catastrophe occurs. ----------------------- The second publication of note is an article from the IEEE (Institute of Electrical and Electronics Engineers). A Jan. 6, 2010 IEEE Spectrum article entitled "<a href="http://spectrum.ieee.org/riskfactor/computing/it/more-hurdles-appear-in-us-electronic-health-record-adoption">More Hurdles Appear in U.S. Electronic Health Record Adoption</a>" has been published. I would actually have entitled it "More Hurdles Exposed in U.S. EHR Adoption", but that's not important now. What is important, once again, is the Management Information Systems (business computing) approach to healthcare IT. The typical convoluted licensing arrangements for this software (really a virtual clinical tool that happens to reside on a computer) has created this fine mess: <blockquote>The first was a <a href="http://www.allbusiness.com/legal/legal-services-litigation/13153613-1.html">story</a> from a few months back that [the IEEE author] ran across recently from the Washington State <a href="http://www.spokesman.com/">Spokesman-Review </a>about <a href="http://www.inhs.info/">Inland Northwest Health Services</a> suing the owner of <a href="http://www.deaconessmc.com/Pages/home.aspx">Deaconess Medical Center</a>, which the paper said alleged breach of "contracts and bad faith dealings that imperil the region's acclaimed electronic medical records network. It is a bit complicated, but in essence, in 1994, Spokane's <a href="http://www.deaconessmc.com/Pages/home.aspx">Deaconess Medical Center</a>, <a href="http://www.holy-family.org/">Providence Holy Family Hospital</a>, <a href="http://www.shmc.org/">Providence Sacred Heart Medical Center & Children's Hospital</a> and <a href="http://www.spokanevalleyhospital.com/Pages/home.aspx">Valley Hospital & Medical Center</a> established the non-profit Inland Northwest Health Services (INHS) as a way to merge competing lines of business and to oversee them. One of the things INHS did was to invest in electronic medical records using <a href="http://www.meditech.com/">MEDITECH's</a> technology. [You mean <a style="font-weight: bold; font-style: italic;" href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">this</a> Meditech? - ed.] Apparently, <a href="http://www.chs.net/">Community Health Systems</a>, a Tennessee company that <a href="http://nashville.bizjournals.com/nashville/stories/2008/09/29/daily29.html">bought</a> Spokane's Deaconess Medical Center and Valley Hospital & Medical Center in 2007 decided that it was going to start charging INHS $150,000 a month to use the MEDITECH license, claiming that Deaconess Medical Center was owner of the license. INHS says that Deaconess transferred ownership to it years ago. The Spokesman says some 38 hospitals along with many private practices and clinics are affected by the dispute. The upshot of all this is that license ownership of the underlying EHR technology will likely be a big issue in the future as more <a href="http://en.wikipedia.org/wiki/Regional_Health_Information_Organization">regional health information networks</a> are started, as will be technology lock-in (INHS has been using MEDITECH technology for 13-years, and it moving to another EHR is unlikely to be an easy or inexpensive proposition). Neither issue has appeared much in the EHR literature.</blockquote> Yes, indeed, except once again I would have written: <blockquote> The upshot of all this is that license ownership of the underlying EHR technology will likely be a big disaster in the future...</blockquote> ... as the HIT vendors will likely only allow their profitable licensing practices to be pried from their cold, dead fingers (metaphorically speaking, of course). Then, this on EHR patient data trafficking: <blockquote>... there was also a <a href="http://www.ama-assn.org/amednews/2009/11/30/bisc1130.htm">story </a>in the <a href="http://www.ama-assn.org/amednews/">American Medical News</a> in late November about the <a href="http://my.clevelandclinic.org/default.aspx">Cleveland Clinic </a>giving $1 million to a start-up company called Explorys to "commercializing the patient database search system Cleveland Clinic developed." The Cleveland Clinic <a href="http://my.clevelandclinic.org/patients/records/electronic.aspx">has</a> a very extensive EHR system and data base of patient information that it now wishes to exploit. As I <a href="http://spectrum.ieee.org/riskfactor/computing/it/electronic-health-records-are-worth-it-or-not">mentioned</a> last month, there was a <a href="http://www.pwc.com/us/en/healthcare/publications/secondary-health-data.jhtml">report</a> by <a href="http://www.pwc.com/">PricewaterhouseCoopers LLP</a> that found 76% of healthcare executives surveyed felt that all the data being collected in their EHR systems was going to be their organization's greatest asset over the next five years. It also found that the executives only felt they could recoup their investments if they could exploit that information in some way.</blockquote> The IEEE author largely addresses health IT failure as an impediment to such EHR patient data trafficking. In my Oct. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html">Health IT Vendors Trafficking in Patient Data?</a>" I came at the issue from an ethical and legal angle. I wrote: <blockquote>This practice [trafficking in EHR patient data] raises numerous questions: <ul><li>Meaningful informed consent issues: as an example, of 1000 patients at one of the facilities using this vendor's HIT products, what percentage would be able to tell me they know their data is being trafficked to pharmaceutical companies and other organizations for profit?</li></ul><ul><li>Healthcare data ownership and stewardship issues: who, exactly, extracts the data for aggregation and sale? Hospital employees properly trained and bonded (i.e., Healthcare Information Management professionals) regarding privacy of patient data? IT personnel lacking such credentials and experience? HIT vendor employees?</li></ul><ul><li>De-identification issues: what processes are being used to de-identify data? Who is performing it? At some point before the data is de-identified, it is protected information in identifiable form. Is access to the data during de-identification audited in any way, and if so, by whom? If not, why not? (Also see article on re-identification below.) </li></ul><ul><li>Legal issues: who is, by contract, liable for data breaches that occur in the transfer process?</li></ul><ul><li>Fiduciary issues: as I expressed in my July 22, 2009 JAMA letter to the editor regarding "vendor hold harmless" and IT defects gag clauses, are hospital executives further violating their fiduciary responsibilities by signing HIT contracts that surrender ownership of patient data to third parties? (see my posts "<a style="font-style: italic;" href="http://hcrenewal.blogspot.com/2009/07/health-care-information-technology.html">JAMA letter: Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards</a>" and "<a style="font-style: italic;" href="http://hcrenewal.blogspot.com/2009/07/inquiry-to-joint-commission-on-points-i.html">Inquiry to Joint Commission on points I raised in my JAMA letter on HIT</a>" for more on those issues.</li></ul><ul><li>Pharma integrity issues: with the many stories on this blog and others about ethically questionable pharma practices such as <a href="http://hcrenewal.blogspot.com/search/label/ghost%20writing">ghostwriting</a>, <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation of clinical research</a>, <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression of research</a>, pushing drugs on physicians and patients for unapproved <a href="http://hcrenewal.blogspot.com/search?q=unapproved">off-label </a>uses, etc., what are these organizations going to do with the data? Who will have access to it, and will their access be audited? Are they going to resell it? Might they try to re-identify data to locate individuals of interest? And so forth. </li></ul> Serious consideration of these issues in vendor-led healthcare data trafficking becomes more imperative in the face of just how easy it is to "re-identify" data: Ohm, Paul: "Broken Promises of Privacy: Responding to the Surprising Failure of Anonymization" (August 13, 2009). University of Colorado Law Legal Studies Research Paper No. 09-12. Available at SSRN: <a href="http://ssrn.com/abstract=1450006">http://ssrn.com/abstract=1450006</a></blockquote> In Dec. 2007 I'd also presented to the IEEE Medical Technology Policy Committee on some of these issues in "<a href="http://www.scribd.com/doc/12392282/To-The-Moon-In-A-Hot-Air-Balloon-Why-Is-Clinical-IT-Difficult">To the Moon in a Hot Air Balloon: Why is Clinical IT Difficult?</a>". In response, they introduced me to the term "resilience engineering" in the sense that healthcare IT was lacking in that particular characteristic: <blockquote>The term <a href="http://www.resilience-engineering.org/">Resilience Engineering</a> represents a new way of thinking about safety. Whereas conventional risk management approaches are based on hindsight and emphasise error tabulation and calculation of failure probabilities, Resilience Engineering looks for ways to enhance the ability of organisations to create processes that are robust yet flexible, to monitor and revise risk models, and to use resources proactively in the face of disruptions or ongoing production and economic pressures.</blockquote> Health IT as a cybernetic miracle? As I've stated before, healthcare is a harsh environment for cybernetics, talent to accomplish the needed IT and medical culture changes essential to successful computerization in medicine is grossly mismanaged by the HIT and hospital industries, and reality is a harsh mistress. -- SS

Two New Challenges to a Healthcare Cybernetic Utopia: Yet More Hurdles Exposed

At " 2009: a Pivotal Year in Healthcare IT " I concluded that 2009 had proven to be a critical year in HIT, due to authoritative p...

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Socky the Meditech Sockpuppet on Vacation?

[Note: this post is written semi-satirically, but the issues it addresses are dead serious.] It seems Socky the HIT Sockpuppet, a.k.a. anonymous heckler and physician-ridiculer “IT Guy” here as well as "Programmer" at the <a href="http://www.histalk.com/">HIStalk</a> blog, whose <a href="http://www.military.com/ContentFiles/techtv_update_PSYOPS.htm">psyops</a> appeared to emanate from Massachusetts HIT company <a href="http://www.meditech.com/">Meditech</a> ("over 2,200 customers worldwide"), has disappeared. I imagine that my post "<a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?</a>" had something to do with the sudden silence. <div class="commenttxt">I'd conducted a forensic exercise in that post using the publicly accessible <a href="http://www.sitemeter.com/stats.asp?site=s20hcrenewal">Sitemeter</a> access logs for this blog. The analysis pointed straight to that company. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLWs8g5NYl1iJ1O6ieGfPklg_kmkSgU0wb4_O47ZWRn_RtrWSFr4QcVkct3xGW1bZBUzcS1Bd54rdBY9q8DEHjfSThYKySROxkD9ex3sfJbbccd2MfbBPEltrD47_l6SnEMibUXhcUOSBj/s1600-h/sockpuppet2.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5424054698608473634" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLWs8g5NYl1iJ1O6ieGfPklg_kmkSgU0wb4_O47ZWRn_RtrWSFr4QcVkct3xGW1bZBUzcS1Bd54rdBY9q8DEHjfSThYKySROxkD9ex3sfJbbccd2MfbBPEltrD47_l6SnEMibUXhcUOSBj/s320/sockpuppet2.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 153px; height: 176px;" /></a>Health IT Expert Socky the Sockpuppet! That HIT company-based trolls would resort to psyops to support diffusion of tools that are eliciting widespread complaints from physicians — about the tool’s interferences with patient care, in fact — and ridicule those physicians is perverse, whether company-sanctioned or not.It is not uncommon for company competitive intelligence and corporate communications personnel to monitor blogs. Aggregators actually sell information about what's being said in blogs and other new media back to the companies themselves, for enhancing market awareness among other purposes. It would not at all surprise me if companies were resorting to anonymous online harassment of those whose views they do not like. In the case of HIT, however, everyone reading this could one day be a victim, or have loved ones who could be a victim, of defective health IT. Imagine, say, <a href="http://www.freep.com/article/20100107/NEWS06/1070452/1319/Abdulmutallab-faces-life-in-prison-for-Flight-253-plot">Northwest Airlines</a> conducting online psyops to discourage and discredit those fighting for better security screening of passengers. Would that be perverse enough to attract attention?By the way, it was rather unthoughtful for the perpetrator to have carried out these activities considering that I had conducted <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/content/documents/FINAL_Healthcare%20IT%20Failure_Oct_19_2006.ppt">this research</a> (PPT) a few years ago, a fact they might have been aware of if they had bothered to follow the HIT literature.Anyone listening in the U.S. Senate or House of Representatives? (The visitation logs of this blog also show "hits" from those IP's.) Perhaps you should perform some health IT vendor forensics of your own. -- SS 1:00 PM Addendum: Socky, ya still out there? We'd love to hear from you! <blockquote> Domain Name (Unknown) IP Address 12.11.157.# (Medical Information Technology) [Meditech - ed.] ISP AT&T WorldNet Services Location Continent : North America Country : United States (Facts) State : Massachusetts City : Milford Lat/Long : 42.1544, -71.521 (Map) Language English (U.S.) en-us Operating System Microsoft WinXP Browser Internet Explorer 6.0 Mozilla/4.0 (compatible; MSIE 6.0; Windows NT 5.1; SV1; GTB6.3; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.04506.30; .NET CLR 3.0.04506.648; MS-RTC LM 8) Javascript version 1.3 Monitor Resolution : 1024 x 768 Color Depth : 16 bits [Who uses 1024x768 @ 16 bit color depth anymore? Can't this rich HIT company afford better? - ed.] Time of Visit Jan 7 2010 11:28:16 am Last Page View Jan 7 2010 11:36:41 am Visit Length 8 minutes 25 seconds Page Views 2 Referring URL Visit Entry Page <a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=01329f424a1b4b5e92323f9b80e72025&URL=http%3a%2f%2fhcrenewal.blogspot.com%2f2010%2f01%2fsocky-meditech-sockpuppet-on-vacation.html" target="_blank">http://hcrenewal.blogspot.com/2010/01/socky-meditech-sockpuppet-on-vacation.html</a> Visit Exit Page <a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=01329f424a1b4b5e92323f9b80e72025&URL=http%3a%2f%2fhcrenewal.blogspot.com%2f2010%2f01%2fmore-on-perversity-in-hit-world.html" target="_blank">http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html</a> Out Click News 1/6/10 | HIStalk <a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=01329f424a1b4b5e92323f9b80e72025&URL=http%3a%2f%2fhistalk2.com%2f2010%2f01%2f05%2fnews-1610%2f" target="_blank">http://histalk2.com/2010/01/05/news-1610/</a> Time Zone UTC-5:00 Visitor's Time Jan 7 2010 11:28:16 am Visit Number 645,750</blockquote> /sarc -- SS </div>

Socky the Meditech Sockpuppet on Vacation?

[Note: this post is written semi-satirically, but the issues it addresses are dead serious.] It seems Socky the HIT Sockpuppet, a.k.a. anon...

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To Whom Does a Leading "Off-Shore" Medical School Owe its Allegiance?

We have noted how existing US medical schools seem unwilling to invest or reward teaching (see post <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">here</a>.)   It is no secret in academic medicine that for years, US medical schools have been unable to train enough students to meet the country's current demand for doctors. Brain Drain Hence, a significant proportion of physicians practicing in the US were trained by medical schools in other countries.  One well-known adverse consequence of our disinclination to put sufficient resources into medical education is "brain drain," the migration of physicians from countries with severe physician shortages and major unmet health care needs to the US.  (For more discussion of this issue, see our 2005 post <a href="http://hcrenewal.blogspot.com/2005/10/physician-brain-drain.html">here</a>, and also Mullan F. The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810-1818. Link <a href="http://content.nejm.org/cgi/content/full/353/17/1810">here</a>.) At the end of 2009, the St Petersburg (Florida) Times published an <a href="http://www.tampabay.com/news/health/medicine/article1061189.ece">investigative report</a> which showed some further adverse effects of the US disinclination to support medical education sufficient to meet the country's needs.  Ross University and Its Problems The report profiled the problems at one important "off-shore" medical school. <blockquote>Ross University School of Medicine may be the biggest medical school you've never heard of. For decades, the school on the Caribbean island of Dominica has been accepting U.S. students whose poor test scores make it impossible for them to get into medical schools in the States. And though Ross is 1,500 miles from the mainland, U.S. residents who attend the school, and about two dozen other offshore medical schools, qualify for federal student loans. That has meant more than $150 million a year in government-guaranteed aid for Ross, which has about 3,500 students, double the biggest U.S. medical school. Ross and other foreign medical schools say they're responding to U.S. demand for new doctors as the population ages. And there's no question that these schools have produced thousands of practicing physicians. There are more than 80 Ross graduates in the Tampa Bay area alone. But federal regulators are taking a closer look at evidence suggesting taxpayers and students may be getting shortchanged by foreign medical schools. • At Ross, fewer than one-third of the students finish in four years, compared to nearly 100 percent at U.S. medical schools. [And as reported later in the article, the six-year graduation rate is only 66% - editor] • Since Ross, like other Caribbean medical schools, doesn't have a teaching hospital, it pays hospitals stateside for students' clinical training, with wide variations in quality. • Students of foreign medical schools like Ross graduate with higher average debt, $235,000 compared to the average $158,000 owed by graduates of U.S. medical schools, according to an August report to Congress by regulators. • About 20 percent of Ross graduates fail to land a residency, the key to a license to practice in the United States. If they cannot pay their student debts, taxpayers are left holding the bag. </blockquote> The article concludes with: <blockquote>In a report to Congress in August, the group that accredits offshore medical colleges recommended that the schools raise standards and improve reporting on everything from test scores to graduation rates to total cost. [Michael] Rendon, the former Ross registrar, said he agrees with the need to stiffen entrance requirements. 'We want doctors but we can't give that kind of money to everyone who's chasing a dream of being an M.D.,' he said. 'We need to be a little bit more discriminating about who those tax dollars go to.' </blockquote> Based on what I wrote above, these criticisms do seem very "US centric." It seems obvious that a school based in the tiny Commonwealth of Dominica, with a population of little more than 72,000, and an estimated gross domestic product of $726 million in 2008, (according to the <a href="https://www.cia.gov/library/publications/the-world-factbook/geos/do.html">CIA factbook</a>), might have trouble meeting US standards.  But instead of trying to do so, wouldn't it be better if the school could concentrate on training physicians to practice in the Caribbean region? But wait, it is not so simple...  Who  Really Owns Ross University? It is true that the missions of most of the medical schools outside of the US which make substantial contributions to the US physician workforce are mainly to train physicians to practice within their countries.  But that description hardly applies to Ross University.  Per the St Petersburg Times, <blockquote>Robert Ross, a commodities trader in New York, opened his medical school in 1978 in a motel in Dominica's capital at the suggestion of an employee whose son couldn't get into medical training in the States. By 2000, Ross had sold majority interest in both the medical school and an affiliated veterinary school in St. Kitts to a group of New York investors. Three years later, both schools were acquired by <a href="http://www.devryinc.com/index.jsp">DeVry, [Inc]</a> for $310 million. Ross is the only offshore medical school owned by a publicly traded corporation, which must disclose more financial data than privately owned schools. Last year, DeVry, better known for its tech training schools, reported $165.7 million in net income after taxes. But the company also reported an additional $140 million in tax-free income from the Ross operations. </blockquote> "<a href="http://www.rossu.edu/">Ross University</a>" <a href="http://www.rossu.edu/about/">describes itself</a> as: <blockquote>Ross University is one of the largest and most successful medical educators in the world – and remains one of the great secrets in medical education. Since opening in 1978, Ross has been committed to our students with a rigorous curricula that mirrors the education of its U.S. peers. </blockquote>I see nothing obvious on the "<a href="http://www.rossu.edu/">Ross University</a>" web-site that mentions DeVry Inc.  But "Ross University" and "<a href="http://www.rossu.edu/medical-school/">Ross University School of Medicine</a>" are really just operating subsidiaries of DeVry Inc, which does <a href="http://www.devryinc.com/index.jsp">describe itself</a> as: <blockquote>one of the largest publicly held, international, higher educational organizations in North America, is the parent organization for DeVry University, Ross University,.... </blockquote>This raises questions whether the US students who apply to the medical school know they will be taught by a for-profit US corporation? Who Leads Ross University?   Note that the CEO of DeVry Inc, and his lieutenants most responsible for medical education at Ross University do not seem to have the sort of qualifications you would expect from those in charge of a "unviversity" and a medical school.  Per the DeVry Inc., web-site: <a href="http://www.devryinc.com/corporate_information/about/srmgmt_daniel_hamburger.jsp">Daniel Hamburger</a>: <blockquote>Daniel Hamburger is President and Chief Executive Officer of DeVry Inc. Hamburger joined DeVry in 2002 as Executive Vice President, responsible for DeVry’s online operations and Becker Professional Review. He was named President and Chief Operating Officer in 2004, and Chief Executive Officer in 2006. Prior to DeVry, Hamburger served as Chairman and Chief Executive Officer of Indeliq (pronounced 'in-DELL-ik'), now owned by Accenture Learning. In addition, his previous experience includes serving as Division President of WW Grainger's Internet Commerce group, growing revenues from $10 million to over $100 million in one year. Previously, Hamburger started the Internet Services Group for RR Donnelley’s Metromail division, and was responsible for its venture capital investments. He also served as a consultant with Bain & Company in London, Warsaw and Boston. Hamburger graduated in 1986 from the University of Michigan with bachelor's and master's degrees in Industrial Engineering. In 1990, he earned an MBA from Harvard Business School. </blockquote><a href="http://www.devryinc.com/corporate_information/about/thomas_shepherd.jsp">Dr Thomas C Shepherd</a>: <blockquote>Dr. Thomas C. Shepherd has been the president of Ross University since 2004. In this position, Dr. Shepherd is responsible for the operations of the School of Medicine, located in Dominica,.... Prior to joining Ross University, Dr. Shepherd was the president of Bastyr University, a Washington-based university with multiple offerings in healthcare education. Prior to Bastyr he co-founded Royale Healthcare, Inc., a hospital management company in North Carolina, to provide hospitals and health systems throughout the United States with management and consulting services. He has served in senior management roles for a variety of [for-profit] hospitals and healthcare systems, including Hallmark Healthcare (now Community Health Systems), American Healthcorp, Inc., and HCA. Dr. Shepherd received a bachelor of science degree in business administration cum laude from Fairleigh Dickinson University in 1972, a master’s degree in hospital administration from George Washington University in 1975, and a doctor of health administration from the Medical University of South Carolina in 1999. </blockquote><a href="http://www.devryinc.com/corporate_information/about/wiliam_hughson.jsp">William Hughson</a>: <blockquote>William Hughson is President of the Medical and Healthcare group at DeVry Inc. Hughson joined DeVry from DaVita Inc., a leading provider of dialysis services in the United States. At DaVita, he managed a wide number of business units including co-founding DaVita at Home, and founding DaVita Rx. Prior to that, he headed Ultra Lucca from 1997-1999, which under his guidance, rebranded itself A.G. Ferrari Foods and more than doubled in size. Previously, Hughson was president and chief financial officer of Noah’s New York Bagels, which he helped to grow from one to 39 stores. Hughson began his career in the Capital Markets Division of Morgan Stanley in 1986 and subsequently worked at Bain & Company in 1990. He received his bachelor’s degree in English from Williams College and graduated from the Stanford Graduate School of Business with a master’s in business administration. </blockquote>For their pains, Mr Hamburger had amassed 548,666 shares of DeVry stock, worth $30,966,709, at today's price of $56.44/share, and received $3,454,711 in total compensation in fiscal 2009, while Mr Shepherd had amassed 74,950 shares, worth $4,230,179,  and received $714,688, according to the <a href="http://ccbn.10kwizard.com/xml/download.php?repo=tenk&ipage=6551795&format=PDF">2009 DeVry Inc proxy statement</a>. Yet none of the three top leaders of DeVry Inc with responsibilities for the Ross University medical school subsidiary are physicians, have any obvious direct clinical or biomedical scientific experience, or have any educational expertise or experience. Conclusions So here we have a new kind of example of what laissez faire unregulated capitalism has wrought for US health care.  The medical school in tiny, impoverished Dominica exists only to train physicians for the US not for Dominica, or the Caribbean area.  Nonetheless, the school does not do a great job: one-third of its students do not graduate even in six years, and one-fifth of those graduates never even start a residency.  Yet the students pay more than $30,000 a year in tuition, and graduate with an average debt much higher than US trained medical students.   In fact, the school is actually a subsidiary of a large, US for-profit corporation, although it is not clear if this is made obvious, or even revealed to prospective students.  The leaders to whom the school report to seem to have no expertise or background in clinical medicine, biomedical science.   Yet they are handsomely rewarded for their lack of relevant expertise and experience, and apparently for the poor performance of their graduates. There is something really <a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">perverse</a> about a nation that spends $2.3 trillion a year on health care, yet does not spend enough on medical education to educate the physicians it needs, while drawing physicians from unregulated, for-profit schools located in less developed countries, but owned by US corporations.

To Whom Does a Leading "Off-Shore" Medical School Owe its Allegiance?

We have noted how existing US medical schools seem unwilling to invest or reward teaching (see post here .) It is no secret in academic me...

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