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Healthcare IT: A 'goldmine' for fraudsters

Health IT is serving another unexpected purpose: it's becoming a landmine for fraud. In "<a href="http://money.cnn.com/2010/01/13/news/economy/health_care_fraud/index.htm">Health care: A 'goldmine' for fraudsters</a>", CNN senior writer Parija Kavilanz observes that: <blockquote>NEW YORK (CNNMoney.com) -- There's a group of people who really love the U.S. health care system -- the fraudsters, scammers and organized criminal gangs who are bilking the system of as much as $100 billion a year. Health care identity theft dominated all other crimes in the sector last year, according to Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association (NHCAA), an advocacy group whose members include insurers, law enforcement and regulatory agencies.The most common method of health care identity fraud occurs when someone with legitimate access, such as a hospital administrator or a doctor's assistant, sells patients' information to organized criminal groups.Increasingly, criminal groups are hacking into digital medical records so that they can steal money from the $450 billion, 44-million-beneficiary Medicare system -- making the government, by far, the "single biggest victim" of health care fraud, according to Rob Montemorra, chief of the FBI's Health Care Fraud Unit. All the stolen information includes medical insurance data and Social Security numbers, explained James Van Dyke, president of Javelin Strategy & Research, a research firm specializing in trends in security and fraud initiatives.Van Dyke said that, with the information, the fraudster falsely bills Medicare and private insurers for drugs, equipment or treatment that were never prescribed. </blockquote> I have somewhat constrained confidence in the health IT prowess of a government that cannot implement proper processes and information systems to prevent $100 billion per year in Medicare fraud. The fraud is not sophisticated; it is performed in the most simplistic manner via simple submission of fraudulent claims via boiler-room billing companies: <blockquote> To collect the money, the criminals set up shell billing companies that disappear as soon as there's any indication of an investigation, according to the FBI.</blockquote> I have less than stellar confidence that the very same government can oversee a national project for health IT to implement technology that is not just a panacea to healthcare's ills as effectively claimed, but goes far beyond that as an alterative that will <a href="http://web.archive.org/web/20080714203445/http://www.hhs.gov/healthit/vision.html">revolutionize healthcare</a>. -- SS

Healthcare IT: A 'goldmine' for fraudsters

Health IT is serving another unexpected purpose: it's becoming a landmine for fraud. In " Health care: A 'goldmine' for fr...

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Non-Profit Health Care Organization Executives: Pay Them Millions or Lose Them?

CareSource is a US not-for-profit managed care organization for Medicaid patients.  This week, the Dayton (Ohio) Daily News ran an investigative series on its leadership and governance which may provide a larger lesson on the disconnect between the high ideals and high costs of the dysfunctional US health care system.  The main issue uncovered by the investigation was CareSource's generosity to its CEO.  As reported in "<a href="http://www.daytondailynews.com/business/caresource-ceos-compensation-grew-faster-than-revenues-at-nonprofit-485261.html">CareSource CEO's compensation grew faster than revenues at nonprofit</a>," <blockquote>From 2005 to 2008, CareSource more than doubled its total revenues — from $770 million to $1.8 billion. It’s now the nation’s third largest nonprofit Medicaid HMO. But CareSource’s phenomenal revenue growth was no match for the increase in total compensation for Chief Executive Pamela Morris, whose pay more than tripled — from $877,000 in 2005 to $2.9 million in 2008, according to IRS filings. </blockquote>Did Pay Buy Performance? Not only did the CEO's pay grow much faster than the organization she lead, it also seemed disproportionate to what ratings of the organization's performance are available. <blockquote>In America’s Best Health Plans for 2009-2010 — a survey conducted by U.S. News & World Report and the National Committee for Quality Assurance (NCQA) — CareSource ranked 72nd in patient satisfaction and quality of care among 82 HMOs participating in the study. It was the lowest ranking among the four participating Ohio Medicaid plans. </blockquote>"We Don't Want to Lose Her" The chair of the organization's Board of Directors claimed that such pay was necessary to secure the CEO's loyalty, per the Daily News, <blockquote>Ellen Leffak, chairwoman of the CareSource board, said a separate committee of the board sets the top executive salaries with the help of a consultant. The committee monitors what is being paid at both for-profit and non-profit competitors. Leffak said Morris is worth her multimillion-dollar compensation. 'We don’t want to lose her' to another HMO, Leffak said. 'She has provided outstanding service to the organization and we think she should be adequately compensated.' </blockquote> The implication, which perhaps Ms Leffak did not mean to openly convey, was that Ms Morris' dedication to the organization and its not-for-profit mission were less important than her desire for a multi-million dollar paycheck.  (Parenthetically, Ms Leffak also failed to specify how Ms Morris' service was determined to be "outstanding,") Furthermore, The Daily News also reported: <blockquote>CareSource officials say Morris’ pay hike, which included a $1.2 million incentive payout in 2008 from her supplemental retirement plan, is in line with salaries paid top executives with similar experience at its for-profit competitors. Morris is 61 and has been with CareSource for 24 years. </blockquote>The newspaper provided a table of CEO compensation at such for-profit competitors. The best-paid CEO in the table was Heath G Schiesser of Wellcare Health Plans, who received $8,077,718. The article did not mention that not onlyh is Wellcare for profit, but it <a href="http://www.wellcare.com/AboutUs/default">claims</a> to be a "nation-wide" operation.  It also did not mention that in August, 2009, Wellcare paid a fine for findings, which it did not contest, that it paid political contributions in Florida that violated state law (see post <a href="http://hcrenewal.blogspot.com/2009/08/wellcare-did-not-contest-that-its.html">here</a>).  Also, in May, 2009 we <a href="http://hcrenewal.blogspot.com/2009/05/wellcare-settles-accepts-deferred.html">posted</a> about WellCare's submission to a deferred prosecution agreemeent based on charges that it defrauded state programs by inflating its expenses. In 2007, we <a href="http://hcrenewal.blogspot.com/2007/11/health-plans-programs-cancelled-for.html">posted</a> about how the state of Connecticut stopped WellCare from running a plan for poor children after the company refused to reveal what it was paying physicians, and why it was failing to pay for particular services. So WellCare has paid three penalties for three different kinds of unethical behavior in the last two years. To be clear, it was the newspaper that stated Wellcare ought to be a standard of comparison, not Ms Leffak, Ms Morrison, or any CareSource official.  However, the choice of comparison further suggests how money may trump mission. Competing Against Stock Options Meanwhile, the Dayton Daily News published another article ("<a href="http://www.daytondailynews.com/business/critics-question-hospitals-ceo-on-caresource-board-485404.html">Critics question hospitals' CEO on CareSource board</a>) which suggested that the governance of CareSource may have resonated with the notion that the leadership of not-for-profit health care organizations may be more motivated by money than mission. <blockquote>Since the HMO’s inception in 1983, Tom Breitenbach, chief executive of Premier Health Partners, has had a hand in shaping CareSource. He continues today on the governing board of its parent, CareSource Management Group Services. But in recent months, health care officials and providers have raised questions about whether the head of the region’s largest hospital system should sit on the board of the parent organization of the region’s largest source of Medicaid payments. 'How can that not be a conflict of interest?' said Dr. Larry Litscher, a Dayton area urologist. 'They (the CareSource board members) have to determine the reimbursement levels' for hospitals and doctors providing service to CareSource patients. 'How can that not be interpreted as a big advantage for the hospitals?' </blockquote> But beyond the issue of conflict of interest, last year, the Dayton Daily News <a href="http://www.daytondailynews.com/n/content/oh/story/news/local/2009/02/22/ddn022209hospitalsinside.html">reported</a> on Mr Breitenbach's own incentives: <blockquote>In 2001, as Premier Health Partners Chief Executive Tom Breitenbach neared age 55, he was given an executive investment plan in addition to his supplemental retirement benefits that paid him nearly $9 million from 2002 to 2007. The requirements were that Breitenbach assume the risk of the investment and stay on as head of Premier until age 60. In 2001, MedAmerica Health Systems Corp., the parent company of Premier Health Partners and six smaller for-profit subsidiaries, found a novel way to help keep Breitenbach at the helm — they invested some of the supplemental retirement benefits he had accrued over 25 years into an executive option plan of mutual funds, in which Breitenbach assumed all risk. Breitenbach cashed out $6.7 million from the plan in 2003, another $660,000 in 2006 and a final payment of $1.5 million in 2007, for a total of $8.9 million, IRS documents show. </blockquote> Also, according to the MedAmerica Health Systems 2007 Form 990 (available <a href="http://www.guidestar.org/FinDocuments/2007/311/040/2007-311040228-048db0b5-9.pdf">through Guidestar</a>), Mr Breitbach's total compensation was $4,044,915. Again, the reason to pay so well seemed to be the fear that in the absence of for-profit levels of compensation, executives of not-for-profit organizations would quit to seek higher recompense in the for-profit world. <blockquote>In setting compensation levels, local hospital officials say they must compete with for-profit enterprises that can offer top executives hefty stock options, country club memberships and other perks that nonprofits can't. 'For-profit or nonprofit, it really has to do with attracting and retaining talent,' said Pete Luongo, who sits on the compensation committee of Kettering Adventist Healthcare, the parent of Kettering Health Network and its six hospitals. </blockquote>The implication is that not-for-profit health care organizations can and should hire people who care more about the level of compensation offered than the not-for-profit organizations' lofty missions. In this case, CareSource Says its <a href="http://www.caresource.com/en/AboutUs/Pages/OurMission.aspx">mission</a> is: <blockquote>to make a difference in the lives of underserved people by improving their health care. At CareSource, our mission is one we take to heart. In fact, we call our mission our 'heartbeat.' It is the essence of our company, and our unwavering dedication to it is a hallmark of our success. Our Vision is to be an innovative leader in the management of quality public-sector health care programs. </blockquote> Premier Health Partners says its <a href="http://www.premierhealthpartners.org/aboutus.aspx?id=760">mission</a> is: <blockquote>We will build healthier communities with others who share our commitment to provide high-quality, cost-competitive health care services. </blockquote> What cognitive dissonance is created by an organization dedicated to serving the "underserved" and another which espouses "cost-competitive" health care lead by CEOs who can only be retained by making them multi-millionaires.  Summary and Conclusions Leaders of not-for-profit organizations, starting with their boards of trustees, are <a href="http://www.boardsource.org/Knowledge.asp?ID=3.364">supposed</a> to subscribe to the duty of  obedience, "to be faithful to the organization's mission,"  and the duty of loyalty, " give undivided allegiance when making decisions affecting the organization." Presumably, that can be extended to the requirement that the top hired executives of not-for-profit put the mission ahead of their own personal gain.  Thus, boards of trustees who feel that they can only retain hired CEOs by pay so high that they will not be tempted by offers from for-profit corporations have failed in their duty by hiring CEOs who put their personal financial interests ahead of the mission.  I believe that the compensation given to CareSource and Premier Health Care CEOs, and the rationale for it, are not anomalies.  There have been many other reports about leaders of not-for-profit health care organizations compensated enough to make them multi-millionaires, justified mainly by the need to provide pay "competitive" with that available from for-profit corporations  (e.g., see posts <a href="http://hcrenewal.blogspot.com/2009/03/more-gravity-defying-compensation-for.html">here</a> and <a href="http://hcrenewal.blogspot.com/2009/03/43-million-dollar-ceo-for-not-for.html">here</a>).  Yet not-for-profit CEOs mercenary enough so that they can only be retained by for-profit levels of pay seem to be exactly the sort of people who should not be running what are supposed to be mission-oriented organizations.  Of course, the problem is only amplified when the same mercenary CEOs sit on each others' boards. When money becomes the only value for health care leaders, the health care system will cost a lot, but provide neither health nor care.  The only way to improve health care is to give it leadership that values health and caring for it more than money.

Non-Profit Health Care Organization Executives: Pay Them Millions or Lose Them?

CareSource is a US not-for-profit managed care organization for Medicaid patients. This week, the Dayton (Ohio) Daily News ran an investiga...

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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 href="http://in3.org/health/" target="blank">http://in3.org/health/</a> that linked to some of the posts here. The site is a blog of the organization <a href="http://www.in3.org/info/" style="font-family: arial;">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 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" style="font-style: italic; font-weight: bold;">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 href="http://lcs.mgh.harvard.edu/projects/dxplain.html" style="font-style: italic; font-weight: bold;">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 href="http://en.wikipedia.org/wiki/Reductio_ad_absurdum" style="font-style: italic;">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 href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0_5l5d5WTr3rCF1OxYjWQCMZ58U02amoTE7trho8x12NYbR6UPP8JmpwY2E19FcZ4oaBUwNh8lYLp8IolYKq_ve9YohOpipWKEuhjtnh02FzauX2HbebCWl6zID8haXMeDLA3WwmxHjyu/s1600-h/STChangeling.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><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 href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html" style="font-weight: bold; font-style: italic;">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 href="http://hcrenewal.blogspot.com/2009/07/health-care-information-technology.html" style="font-style: italic;">JAMA letter: Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards</a>" and "<a href="http://hcrenewal.blogspot.com/2009/07/inquiry-to-joint-commission-on-points-i.html" style="font-style: italic;">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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