healthy4u

A Few Additional Comments on the GE Radiation Debacle

Roy Poses beat me to posting about the General Electric CT over-irradiation debacle (<a href="http://hcrenewal.blogspot.com/2010/08/ge-dont-know-much-about-radiation.html">GE: Don't Know Much About Radiation Safety, Don't Know Much About Physics</a>). I am going to add two points: Point 1: The National Research Council in its <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">2009 report on health IT</a> warned that "current approaches to healthcare IT are insufficient", and one of the major caveats was that: <blockquote> ... greater emphasis should be placed on information technology that provides health care workers and patients with cognitive support, such as assistance in decision-making and problem-solving.</blockquote> In fact the lack of cognitive support for clinicians was one of the report's major themes. "Cognitive support" by definition means producing devices (whether physical or virtual) that are intended for busy clinical settings where situations often resemble a madhouse - not calm, solitary office environments (borrowing from Joan Ash's <a href="http://www.eurekalert.org/pub_releases/2003-11/ohs-mhd112403.php">findings on CPOE flaws</a>): <blockquote>"Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors …Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician." </blockquote> It does not mean, as reported on July 31, 2010 in the <a href="http://www.nytimes.com/2010/08/01/health/01radiation.html?pagewanted=3&_r=1">New York Times</a>, that designers and vendors of these medical devices should take the stance of blaming the user: <blockquote>A GE spokesman, Arvind Gopalratnam, said the way scanners were programmed was “determined by the user and not the manufacturer.” GE, he added, has no record of Glendale seeking its help setting up the new procedure in 2009. ... GE says the hospitals should have known how to safely use the automatic feature. Besides, GE said, the feature had “limited utility” for a perfusion scan because the test targets one specific area of the brain, rather than body parts of varying thickness. In addition, experts say high-clarity images are not needed to track blood flow in the brain. GE further faulted hospital technologists for failing to notice dosing levels on their treatment screens. But representatives of both hospitals said GE trainers never fully explained the automatic feature. </blockquote> Imagine the reaction if Boeing blamed pilots for collisions if those pilots, busy with other matters, were only alerted to an impending collision via a range reading on their cluttered instrument panel - rather than a LOUD AUDIBLE ALARM - such as WARNING, WARNING, COLLISION IMMINENT. Point 2: What's really missing here was attention to cognitive support for busy clinicians. This, of course, requires proper senior management - senior management with the appropriate expertise. Proper senior management then controls talent management down the chain of an organization. If the leaders "don't know nothing 'bout trigonometry", they will be less likely to put mathematicians in appropriate leadership roles. If management doesn't understand Medical Informatics, they will be less likely to put informaticists into leadership roles as well. One major focus of Medical Informatics is cognitive support of busy clinicians in their all too real-world environments. Why might the latter point be relevant at GE? In 1999 after working for a competitor of GE, Comdisco Healthcare Group, who among other business aspects reconditioned and resold capital equipment such as CT scanners, I wrote this in an essay on "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/infordef1.htm#isnot">what medical informatics is not</a>": <blockquote>... I've noted a number of large vendors and even national medical organizations whose so-called "Medical Informatics Directors" had neither clinical backgrounds nor training in medical informatics (nor in information science of any kind). MIS managers, social workers, and clinicians with no more experience than some tinkering with a home Macintosh can be found as "Directors of Medical Informatics" in the (unfortunately) unregulated healthcare IT industry. Sometimes the term is used as a sales slogan. General Electric displayed a huge banner over their booth proclaiming themselves "the world leader in Radiology Informatics" at the 1999 <a href="http://www.rsna.org/">Radiological Society of North America</a> (RSNA) conference in Chicago. Unfortunately, nobody present, including sales, management, and engineering representatives, could explain to me what that term meant. They actually said they did not know. I had only identified myself as a physician at that point, not as a medical informatics professional, and expressed incredulity on nobody being able to explain the banner to me. Under pressure, one GE engineer offered the statement "I think it has something to do with computers attached to our x-ray machines." </blockquote> It's now 2010. It seems GE still may not know what Medical Informatics is. Handing busy clinical end users a revolver with a single bullet in the chamber, and asking them to play Russian Roulette under busy circumstances with a warning to "check the chamber carefully each time before you pull the trigger", is simply unacceptable for computerized medical device design. -- SS

A Few Additional Comments on the GE Radiation Debacle

Roy Poses beat me to posting about the General Electric CT over-irradiation debacle ( GE: Don't Know Much About Radiation Safety, Don...

Đọc thêm »

GE: Don't Know Much About Radiation Safety, Don't Know Much About Physics

Don't know much about history Don't know much biology Don't know much about a science book Don't know much about the french I took. (<a href="http://artists.letssingit.com/sam-cooke-lyrics-wonderful-world-wzxlmlw">Wonderful World</a>, sung by Sam Cook) This is becoming the theme song for executives of health care corporations.  We have posted about a series of cases in which major health care corporations suddenly seemed unable to carry out their core business functions, a phenomenon I am going to start calling "core business incompetence."  Some recent examples: -  Baxter International apparently failed to check the purity of heparin it bought from a foreign supplier; the contaminated heparin resulted in approximately 81 deaths. (See post <a href="http://hcrenewal.blogspot.com/2010/07/more-about-what-we-dont-know-about.html">here</a>.) -  A major Genzyme manufacturing facility had multiple quality problems, resulting in the production of a very expensive, but contaminated biologic medication. (See post <a href="http://hcrenewal.blogspot.com/2010/05/genzyme-settles.html">here</a>.) -  Three Johnson and Johnson manufacturing facilities had multiple quality problems, resulting in the production of contaminated batches of over-the-counter medications for children. (See post <a href="http://hcrenewal.blogspot.com/2010/07/are-ill-informed-leaders-cause-of-drug.html">here</a>.) -  Aetna made mathematical errors in computing the rates it proposed charging; WellPoint made computer errors that exposed sensitive policy-holder information.  (See blog post <a href="http://hcrenewal.blogspot.com/2010/06/wellpoint-dont-know-much-about-computer.html">here</a>.) Manufacturing pure, unadulterated medicines is a core function of a drug company.  Correctly calculating policy-costs and correctly handling patient data are core functions of health insurance companies.  But in the above cases, three large pharmaceutical companies and two large insurance companies could not perform these core functions competently. Radiation Sickness from CT Scans In the last few days, more details of what appears to be another example of core incompetency afflicting a major health care organization has surfaced.  The details were <a href="http://www.nytimes.com/2010/08/01/health/01radiation.html">reported</a> by Walt Bogdanich in the New York Times. Here is the summary: <blockquote>When Alain Reyes’s hair suddenly fell out in a freakish band circling his head, he was not the only one worried about his health. His co-workers at a shipping company avoided him, and his boss sent him home, fearing he had a contagious disease. Only later would Mr. Reyes learn what had caused him so much physical and emotional grief: he had received a radiation overdose during a test for a stroke at a hospital in Glendale, Calif. Other patients getting the procedure, called a CT brain perfusion scan, were being overdosed, too — 37 of them just up the freeway at Providence Saint Joseph Medical Center in Burbank, 269 more at the renowned Cedars-Sinai Medical Center in Los Angeles and dozens more at a hospital in Huntsville, Ala. The overdoses, which began to emerge late last summer, set off an investigation by the Food and Drug Administration into why patients tested with this complex yet lightly regulated technology were bombarded with excessive radiation. After 10 months, the agency has yet to provide a final report on what it found. But an examination by The New York Times has found that radiation overdoses were larger and more widespread than previously known, that patients have reported symptoms considerably more serious than losing their hair, and that experts say they may face long-term risks of cancer and brain damage. </blockquote> So not to mince words, in this sad case, many patients seem to have been subject to radiation poisoning from a diagnostic x-ray procedure (not from radiation therapy for cancer.)  Most people (and physicians) may have not previously thought that radiation poisoning was a possible harm from a single diagnostic CT scan. A Design Failure? Moreover, it appears that the radiation poisoning did not result from some freak accidents or malfunction: <blockquote>The review also offers insight into the way many of the overdoses occurred. While in some cases technicians did not know how to properly administer the test, interviews with hospital officials and a review of public records raise new questions about the role of manufacturers, including how well they design their software and equipment and train those who use them. </blockquote> Also, <blockquote>None of the overdoses can be attributed to malfunctions of the CT scanners, government officials say. At Glendale Adventist Medical Center, where Mr. Reyes and nine others were overdosed, employees told state investigators that they consulted with GE last year when instituting a new procedure to get quicker images of blood flow, state records show. But employees still made mistakes. As a result, hospital officials said, a feature that technicians thought would lower radiation levels actually raised them. Cedars-Sinai gave a similar explanation. 'There was a lot of trust in the manufacturers and trust in the technology that this type of equipment in this day and age would not allow you to get more radiation than was absolutely necessary,' said Robert Marchuck, the Glendale hospital’s vice president of ancillary services. A GE spokesman, Arvind Gopalratnam, said the way scanners were programmed was 'determined by the user and not the manufacturer.' GE, he added, has no record of Glendale seeking its help setting up the new procedure in 2009. Most of the known overdoses, including the biggest, occurred on scanners made by GE Healthcare. At two hospitals that use Toshiba scanners — Los Angeles County-U.S.C. and South Lake in Florida — officials said the manufacturer suggested machine settings that ultimately produced too much radiation. Representatives of Toshiba agreed to be interviewed in their California office but abruptly canceled. </blockquote> In particular, <blockquote>To this day, no one at Cedars-Sinai knows who programmed the scanners that delivered the overdoses, officials there say. But in written statements to The Times, hospital officials said they had figured out how they might have occurred. Normally, the more radiation a CT scan uses, the better the image. But amid concerns that patients are getting more radiation than necessary, the medical community has embraced the idea of using only enough to obtain an image sufficient for diagnosis. To do that, GE offers a feature on its CT scanner that can automatically adjust the dose according to a patient’s size and body part. It is, a GE manual says, 'a technical innovation that significantly reduces radiation dose.' At Cedars-Sinai and Glendale Adventist, technicians used the automatic feature — rather than a fixed, predetermined radiation level — for their brain perfusion scans. But a surprise awaited them: when used with certain machine settings that govern image clarity, the automatic feature did not reduce the dose — it raised it. As a result, patients at Cedars-Sinai received up to eight times as much radiation as necessary, while the 10 overradiated at Glendale received four times as much, state records show. GE says the hospitals should have known how to safely use the automatic feature. Besides, GE said, the feature had 'limited utility' for a perfusion scan because the test targets one specific area of the brain, rather than body parts of varying thickness. In addition, experts say high-clarity images are not needed to track blood flow in the brain. GE further faulted hospital technologists for failing to notice dosing levels on their treatment screens. But representatives of both hospitals said GE trainers never fully explained the automatic feature. In a statement, Cedars-Sinai said that during multiple training visits, GE never mentioned the 'counterintuitive' nature of a feature that promises to lower radiation but ends up raising it. The hospital also said user manuals never pointed out that the automatic feature was of limited value for perfusion scans. A better-designed CT scanner, safety experts say, might have prevented the overdoses by alerting operators, or simply shutting down, when doses reached dangerous levels. </blockquote> Summary: Core Incompetence To summarize, GE diagnostic CT scan machines apparently were designed so that they could deliver so much radiation that their use could cause radiation sickness. The machines had no built in safeguards to limit the dose of radiation. Users, that is, X-ray technicians, could program the machine so as to deliver dangerous radiation doses, but GE did not warn them that this was the case, nor provide a machine feature that would give a real-time warning of incipient overdose. Thus it appears that GE, which has been <a href="http://www.boston.com/business/technology/articles/2010/08/03/ge_intel_form_chronic_care_venture/">described</a> as "the world’s biggest maker of health care imaging and information technology systems," failed in its core function of designing and manufacturing safe diagnostic x-ray machines. (Presumably the same might be said of Toshiba, but the NY Times report does not include so much detail about problems with its machines.) A straightforward explanation of the magnitude of the core incompetence was provided by one of the patients who got radiation sickness: <blockquote>To Mr. Heuser, it is unconscionable that equipment able to deliver such high radiation doses lacks stronger safety features. 'When you are in a car and it backs up, it goes beep, beep, beep,' he said. 'If you fill the washing machine up too much, it won’t work. There is no red light that says you are overradiating.' </blockquote> It really seems like we are seeing an epidemic of core incompetence by major US health care corporations. I can only speculate about why this occurring. One explanation is that the organizations may be lead by people who do not understand the health care context, and do not understand the scientific, engineering, and technical issues involved with core competence. Many health care corporations have come to be lead by people with no experience or background in relevant areas. For example, the current, and often acclaimed CEO of GE is <a href="http://www.ge.com/company/leadership/ceo.html">Jeffrey Immelt</a>, who "earned a B.A. degree in applied mathematics from Dartmouth College in 1978 and an M.B.A. from Harvard University in 1982." The leader of GE Healthcare is <a href="http://www.ge.com/company/leadership/bios_exec/john_dineen.html">John Dineen</a>, who "is a graduate of the University of Vermont where he earned Bachelor's degrees in biology/genetics and computer science," and "joined GE in 1986 as a telecommunications engineer." Another, even more speculative explanation is that many major US and global health care organizations seem to have been infected with the virus of putting short-term financial results ahead of everything else, leading to cutting of costs and particularly human expertise in the areas most core to the organizations' functions, and pushing for hurried results even at the expense of clear thinking, carefully engineering, and consideration of the effects on patients and other humans of the resulting mistakes. Hopefully, further investigation will reveal more about what went wrong in this case. Meanwhile, I say again, again, again,... As long as "imperial CEOs" can continue to get extremely rich while presiding over incompetence and stupidity, if not worse), we can expect the foolishness to continue. Meanwhile, the foolishness drives up costs and drives down quality of health care for the poor suffering patients, let alone the physicians and other health care professionals who must deal with it. To really reform health care, we need to provide incentives for competent, honest leadership, and make that leadership accountable for its shortcomings. Postscript - Why the Rush to Aggressive Treatment? The NY Times article described the rush to get one of the afflicted patients to the CT scan: <blockquote>on the morning of July 4, when a 52-year-old executive producer of films, H. Michael Heuser, arrived in the emergency department with stroke symptoms. A 'code brain' was immediately called, signaling a life-or-death situation. A blood clot in the brain can be dissolved with medicine, but doctors must do it within several hours, before brain cells die from a lack of oxygen. So Mr. Heuser was rushed into a room with several CT scanners, where he underwent one brain perfusion study and at least one more later. A CT perfusion scan, which lasts about 45 seconds, can identify a stroke through a series of blood flow images. Mr. Heuser did have a stroke, from which he would recover. But other parts of his body inexplicably began to break down. </blockquote> However, there is no clear evidence that such a rapid and drastic approach is really that good for patients. A recently updated <a href="http://www.ncbi.nlm.nih.gov/pubmed/18843603">Cochrane review </a>concluded: "In patients with acute ischaemic stroke, immediate anticoagulant therapy is not associated with net short or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any the currently available anticoagulants in acute ischaemic stroke." However, many physicians seem to advocate the drastic approach based on some controlled trials that showed at best small improvements in average neurological function for patients receiving rapid anti-coagulation (and which were done before anyone thought about radiation sickness as a possible harm of the approach.) Once again, an aggressive, technological, expensive approach, possibly advocated by people who stood to gain financially from it, may not be as advantageous as it appears.

GE: Don't Know Much About Radiation Safety, Don't Know Much About Physics

Don't know much about history Don't know much biology Don't know much about a science book Don't know much about the french ...

Đọc thêm »

Huffington Post Investigative Fund: FDA, Obama Digital Medical Records Team at Odds over Safety Oversight

<div style="text-align: center;">(Note: also see my followup post "<a href="http://hcrenewal.blogspot.com/2010/08/more-on-huffington-post-investigative.html">More on Huffington Post Investigative Fund: "FDA, Obama Digital Medical Records Team at Odds over Safety Oversight"</a>) </div> The Huffington Post Investigative Fund has published a remarkable expose of health IT difficulties and the Big Politics that surround them regarding safety and efficacy: <a href="http://huffpostfund.org/stories/2010/08/fda-obama-digital-medical-records-team-odds-over-safety-oversight"></a><blockquote><a href="http://huffpostfund.org/stories/2010/08/fda-obama-digital-medical-records-team-odds-over-safety-oversight">FDA, Obama Digital Medical Records Team at Odds over Safety Oversight</a> Aug. 3, 2010 By <a title="View user profile." href="http://huffpostfund.org/users/fredschulte" jquery1280932414984="124">Fred Schulte</a> and <a title="View user profile." href="http://huffpostfund.org/users/eschwartz" jquery1280932414984="125">Emma Schwartz</a> Computers at a major Midwest hospital chain went awry on June 29 [after an 'upgrade' - ed.], posting some doctors’ orders to the wrong medical charts in a few cases and possibly putting patients in harm’s way. The digital records system “would switch to another patient record without the user directing it to do so,” said Stephen Shivinsky, vice-president for corporate communications at Trinity Health System. Trinity operates 46 hospitals, most in Michigan, Iowa and Ohio. [In other words, data entered by clinicians was going into the wrong charts. How many charts were involved? Does the hospital system even know, I wonder? - ed.] Less than two weeks later, an unrelated glitch caused Trinity to shut down its $400 million system for four hours at 10 hospitals in the network because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, he said. ... Even absent any harm to patients, such incidents underscore possible risks faced by even large health organizations that have eagerly embraced new medical software to track patient records and treatment. As the Obama administration ramps up plans to create a digital medical file for every American by 2014 – at an anticipated tab to taxpayers of up to $27 billion – technology’s boosters tend to tout its potential benefits to patients and ability to slow runaway medical costs. Yet despite the high [actually, potentially catastrophic - ed.] political and financial [and clinical -ed.] stakes, the administration has established no national mandatory monitoring procedure for the new devices and software. That no process exists to report and track errors, pinpoint their causes and prevent them from recurring is largely the result of two decades of resistance by the technology industry, a review of government records and interviews by the Huffington Post Investigative Fund shows. The industry argues that even with flaws, digital systems are an improvement over current paper records.</blockquote> I began to document some of the problems and the resistance of what Washington Post reporter Robert O'Harrow Jr. in May 2009 called the "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">Healthcare IT lobby</a>" a decade ago in a website. That website, now hosted at Drexel University, is entitled "<a style="font-weight: bold;" href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties</a>." Few in government and industry were apparently listening, despite <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/content/documents/FINAL_Healthcare%20IT%20Failure_Oct_19_2006.ppt">ongoing worldwide interest in the topic</a> (PPT). Read the Huffington Post report in its entirety. It includes a slide-show timeline of the health IT industry's sidestepping of government oversight and safety concerns. As I am currently busy helping out my ill mother, I will offer more commentary later. However, one quote really stuck out. Is the Chairman of the Office of the National Coordinator for Health IT (ONC) <a href="http://healthit.hhs.gov/portal/server.pt?open=514&objID=15930&&PageID=15653&mode=2&in_hi_userid=10731&cached=true&utm_source=National+eHealth+Collaborative&utm_campaign=e1871fd68c-CONNECT_09_announcement_061209&utm_medium=email">Dr. David Blumentha</a>l lying, or simply misinformed? Judging by the quality of academic discourse these days, I'd hope the latter (an alarming situation in and of itself), but the former is also possible. He is quoted as stating: <blockquote> “We know that every study and every professional consensus process has concluded that electronic health systems strongly and materially improve patient safety. And we believe that in spreading electronic health records we are going to avoid many types of errors that currently plague the healthcare system,” Blumenthal said when unveiling new regulations in Washington on July 13.</blockquote> As at my July 14, 2010 post <a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html">Science or Politics? The New England Journal and "The 'Meaningful Use' Regulation for Electronic Health Records"</a> , however, I pointed out some examples that contradict this meme. This list is just for starters: (Hyperlinks to these and others can be found at my Medical Informatics teaching site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=other">here</a> and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">here</a>:) <div class="PlainText" style="font-family:arial;"></div> <blockquote style="margin-right: 0px;font-family:arial;" dir="ltr"><div class="PlainText" style="font-family:arial;"></div><div class="PlainText" style="font-family:arial;">1. Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop by Bonnie Kaplan and Kimberly D. Harris-Salamone. From the May/June 2009 issue of JAMIA. 2. "E-Health Hazards: Provider Liability and Electronic Health Record Systems.” Hoffman and Podgurski’s followup paper on EHR medical and legal risks 3. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203 4. Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405. The authors examined electronic health records (EHR) use throughout the U.S. and the association of EHR use with 17 basic quality indicators. They concluded that “as implemented, EHRs were not associated with better quality ambulatory care.” 5. Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand) 6. <a href="http://www.blogger.com/redir.aspx?C=cd79bb9ef239435c91597828510ff401&URL=http%3a%2f%2fiig.umit.at%2fefmi%2fbadinformatics.htm" target="_blank"></a>Bad Health Informatics Can Kill. his site contains summaries of a number of reported incidents in healthcare where IT was the cause or a significant factor. It comes from the Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI). </div><div class="PlainText" style="font-family:arial;"></div><div class="PlainText">7. The U.S. National Research Council’s "Current Approaches to U.S. Health Care Information Technology are Insufficient." 8. The UK Public Accounts Committee report on disastrous problems in their £12.7 billion national EMR program. 9. Gateway reviews of the UK National Programme for IT from the Office of Government Commerce (OGC) (released under the UK’s Freedom of Information Act). 10. A report on the serious problems with the Department of Defense’s AHLTA system, Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress. (This system, as I <a href="http://hcrenewal.blogspot.com/2010/07/4-billion-military-emr-ahlta-to-be-put.html">wrote here</a>, is slated for abandonment. I cannot imagine it was greatly improving outcomes). 11. A New York Times report “Little Benefit Seen, So Far, in Electronic Patient Records” on Jha’s research at the Harvard School of Public Health, that compared 3,000 hospitals at various stages in the adoption of computerized health records and found little difference in the cost and quality of care. 12. An American Journal of Medicine paper “Hospital Computing and the Costs and Quality of Care: A National Study” by Himmelstein and Woolhandler at Harvard Medical School, that also concluded “as currently implemented, hospital computing might [very] modestly improve process measures of quality but not administrative or overall costs." 13. A Milbank Quarterly article “Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London. 14. Health Affairs, 29, no. 4 (2010): 639-646 Electronic Health Records’ Limited Successes Suggest More Targeted Uses, Catherine M. DesRoches et al. 15. NORCAL Mutual Insurance Company: "Electronic Health Records: Recognizing and Managing the Risks" (PDF <a href="http://www.norcalmutual.com/publications/claimsrx/oct_09.pdf">here</a>) </div></blockquote> My healthcare informatics graduate students are well aware of studies such as these. [Feb. 2011 addendum: see a much longer list at this link - <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">An Updated Reading List on Health IT</a> - ed.] Why isn't ONC Chairman Dr. Blumenthal? Perhaps equally as remarkable is this from <a href="http://www.trinity-health.org/index.htm">Trinity Health</a>, the healthcare system whose health IT crashed: <blockquote>We are not aware of any patient safety or quality of care issues caused by this event,” he said. </blockquote> Many of the "safety and quality" issues due to erroneous data in charts can come out weeks, months or even years later. The issue that the health IT cheerleaders seem to ignore is risk. Has the erroneous data been identified and corrected, I wonder? Probably not. According to the Huffington Post Investigative Fund article, they don't even know what caused the problem: <blockquote>... While doctors were concerned about the problems, ... [well, yes, I'd be quite frightened myself, especially considering who <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda">holds the liabilities</a> for health IT defects - ed.] ... Shivinsky said that most are happy with the system and would “never go back to paper.” [That sounds very nice. Is it true? - ed.] Meanwhile technicians are still trying to figure out the root cause. “We’ll get to the bottom of it and fix it,” he said.</blockquote> Eventually, I would hope, since the kludged "correction" I heard about is that clinicians can now only open one electronic patient chart at a time, potentially slowing and impairing their work. I've emailed Mr. Shrivinsky asking if they'd truly identified and remediated the problem yet. -- SS

Huffington Post Investigative Fund: FDA, Obama Digital Medical Records Team at Odds over Safety Oversight

(Note: also see my followup post " More on Huffington Post Investigative Fund: "FDA, Obama Digital Medical Records Team at Odds o...

Đọc thêm »

ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR

ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR What a difference a month makes. When I went on vacation in June the Director of NIMH, Thomas Insel, was stonewalling about his relationship with Charles Nemeroff. Insel wanted to put distance between himself and the poster boy for conflict of interest in academic medicine. The heat was on Insel because of revelations that he helped Nemeroff get a new position at Miami after his fall from grace at Emory. Insel also gave a green light for Nemeroff to reapply for NIMH grant funding, and he appointed Nemeroff to new research review committees. These actions were widely seen as efforts to help Nemeroff get back into circulation. It didn’t help that people called attention to past favors and lobbying by Nemeroff on behalf of Insel. Things continued to unravel, and on about June 29 Insel placed a <a href="http://www.nimh.nih.gov/about/director/2010/more-on-public-trust-and-conflict-of-interest.shtml">disclaimer</a> on his official blog. Insel here allowed that his earlier official statements “may be viewed as misleading.” This softening of Insel’s position was picked up June 29 by the <a href="http://chronicle.com/blogPost/NIH-Official-Softens-Denial-of/25174">Chronicle of Higher Education</a>. Not only was Insel’s disclaimer on his official weblog undated, it is mealy mouthed and it was widely criticized – <a href="http://hcrenewal.blogspot.com/2010/06/insel-admits-his-statements-may-be.html">here</a> and <a href="http://1boringoldman.com/index.php/2010/06/29/plausible-deniability-is-neither-a-medical-nor-scientific-standard/">here</a>, for instance – as further evidence of Insel’s disingenuousness. By July 7 we learned of further revisions to Insel’s position. In response to pressure from Senator Charles Grassley (R-Iowa), Insel <a href="http://freepdfhosting.com/2e0f575924.pdf">issued</a> a mea culpa in which he agreed that Nemeroff’s actions constituted “an egregious violation of NIH policy and University rules.” Insel also acknowledged that his willingness to help Nemeroff “may have created the appearance of favoritism. In retrospect, I regret that my actions… appear inappropriate for a Federal research official given my past association with Dr. Nemeroff.” This new statement also was raked over as further evidence of Insel’s dissembling – see <a href="http://www.pharmalot.com/2010/07/nimhs-insel-on-nemeroff-i-regret-my-actions/">here</a> and <a href="http://1boringoldman.com/index.php/2010/07/08/a-start/">here</a> and <a href="http://www.margaretsoltan.com/?p=24272">here</a>. Nowhere in Insel’s new self serving statements is there any apology for his ill advised appointment of Nemeroff to new Federal research review panels. This signals once again that Insel just doesn’t get it when it comes to his crony Nemeroff. It is not in the job description of an NIH Institute Director to taint research review panels with compromised and sanctioned scientists. Keep in mind that the appearance of malfeasance and impropriety most often occurs in the presence of malfeasance and impropriety. That is a standard Bayesian proposition that Insel seems not to grasp. In light of these developments, who can take seriously the work Dr. Insel says he has done to develop a new NIH initiative on ethics? The leadership of NIH tacitly acknowledged this problem when they recently <a href="http://blogs.nature.com/news/thegreatbeyond/2010/07/nih_extends_public_comment_per.html">extended</a> the period of comment on the new ethics proposals. This was done specifically to mend the regulatory hole that Insel and his crony Nemeroff walked through when Insel assured Pascal Goldschmidt at Miami that Nemeroff could go right ahead to apply for new NIMH funding. Left to his own initiative, Insel kept the hole wide open. His July 7 statement to Senator Grassley that "I do not condone the gap in our policy that allowed (Nemeroff) to avoid the penalty implemented by Emory by moving to another university…” rings hollow: actions speak louder than words, and Insel had many months in which he could have closed the gap before the present scandal surfaced. How much longer can NIH tolerate an ethical prevaricator as an Institute Director? Bernard Carroll

ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR

ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR What a difference a month makes. When I went on vacation in June the Director of NIMH,...

Đọc thêm »

Primary Care and the HC Renewal RUC-kus

Dr. Richard Baron, a Philadelphia internist who's unusual in that he's both a private-practice clinician and a well-published and -respected academic (he was recently ABIM <a href="http://www.abim.org/news/news/07_01_08-baron.aspx">Chair</a>), has been mixing it up in the pages of the New England Journal. To readers of this blog, it'll be useful armchair review: not just because the theme of generalist clinicians' decline should concern us, but because the blog itself comes into play! The topic of the day: why primary care doctors are in trouble. Why they're (my words, perhaps, not his) so prone to burnout. And why they're not replacing themselves. In his original April 26, 2010 <a href="http://www.nejm.org/doi/full/10.1056/NEJMon0910793">article</a>, Baron provided a "snapshot" from his own group practice to address the question, "What's keeping us so busy in primary care?" The piece repays reading if one wants the gory detail on just how tedious and time-consuming the "long tail" of primary care has become. Largely because of demands of third parties, primary care providers are mired in the briar patch of making money for other people instead of themselves, through myriad pre-authorizations, forms, renewals, and all the other parts of the glue that keeps health care going. We already knew a lot of this, at least tacitly. But what's wonderfully useful about Baron's above piece was that (a) he spelled it out crisply, (b) he did so with lots of numbers people could cite, and (c) did so in such a highly visible and prestigious venue. Now, in the latest number of the NEJM, Baron <a href="http://www.nejm.org/doi/full/10.1056/NEJMc1006151">mixes it up </a>with a couple of critics. First I have to wonder aloud, just how did the journal pick these particular two letters? (Or maybe the author did? Hard to believe they were the only two.) Typical--and this is something else it would be easy to measure in the Journal's correspondence pages--in that they both come from the ivory tower, not the trenches where Baron himself labors. The first letter, from a non-clinician at the Palo Alto Medical Foundation Research Institute, lamely posits the value of the electronic health record in identifying staffing needs for primary care. We happen to know not only that Baron's practice was a very early EHR adopter, but Dr. Baron himself has published eloquently on the sundry limitations of the EHR. In response, Baron gently reminds the Palo Alto ivory tower-dweller that very few practices can afford a registered nurse--even if the EHR could somehow magically discern the need for such a presence. A second writer chimes in from the equally rarefied reaches of the AMA's Relative Value Update Committee, or RUC, "appointed by the American Academy of Neurology." This writer avers that "the value assigned for evaluation and management is the same for all specialties," which clearly is the RUC's take on things but is fairly jaw-dropping to the rest of us. In response, Baron cites R. M. Poses, MD, moderator of the present blog, and a June 1, 2010 HCRenewal <a href="http://hcrenewal.blogspot.com/2010/06/ruc-off-new-england-journal-once-again.html">offering</a>--Poses has in fact given us many such offerings on the RUC--regarding the "significant structural and political issues" surrounding that body's untransparent deliberations. Usefully, Baron finally joins others stepping outside the visit-oriented physician payment schema, urging a paradigm shift in which he urges "systems that encourage and support services of high value ... rather than anchoring payment to visits." This exchange is telling in a number of ways. It shows up the lack of sync between the basic understandings on the part of health policy's chattering classes--those prone to publish and write letters to premiere journals--and of those actually doing the work of primary care. It also, I'll venture to say, shows up something more elusive about why this predicament is so difficult to fix. That is, we have, almost uniquely in this country, an imbalance--the imbalance in numbers, slowly evolving over the past century, between generalists and specialists--that's been around so long it's become part of the warp and woof. Something like ubiquitous guns or illicit cannabis, something very difficult to even think of getting beyond. We've written in this blog about the anechoic effect, how so much of what happens in health care (corrupt executives, nontransparent RUCs, etc. etc.) barely stirs a ripple in the public consciousness. Why that is we'll leave for another day, but it's been lately of interest to more and more folks. (For starters, just plug the term "anechoic" into the HCRenewal search box.) Add to this, now, what one might call the reverse Robin Hood effect. The result of such an effect is how the RUC and others--many others, in government as well as in industry--have managed to set in motion a specious reasoning process, a process that allows decision makers to justify robbing from the poor to give to the rich. Understandably, Baron does not go beyond the bland statement that such a process has "militated against appropriate updates for primary care services." But imagine what would happen if the RUC were suddenly, in what really boils down to a matter of power, dominated by people from primary care. Imagine what would then happen not only to reimbursements for cognitive services, but also to practitioners' morale, and to recruitment of medical students into primary care. History, both recent and not-so-recent, bears out such an assertion. When the UK increased the value of primary care a few years ago, in terms of pounds sterling, it had a salutary effect on non-fiduciary metrics such as recruitment. To quote Gomer Pyle, "surprise surprise surprise." Indeed, as the Economist <a href="http://www.economist.com/node/3966234">reported </a>five years ago (the preceding <a href="http://www.economist.com/node/3966234">link</a> may require subscription or library access), price signals worked wonders in making the primary care role more attractive. Further back, ironically, when procedural specialties had lower status than cognitive specialties--we're talking a couple hundred years ago, now--this controversy would have been simply incomprehensible to patients and clinicians alike. For those who'd respond, "but back in the wayback, we didn't have all the fabulous benefits of modern procedures," the simple response is, well, stuff and nonsense. The rising tide of science has raised all boats. Not a week goes by that the evidence base doesn't provide new reasons to assay minimally- or non-invasive technologies that are devolved to primary care physicians. No, underlying Baron's plea is the reverse Robin Hood effect and a simple matter of power. In fact, it's a phenomenon exceedingly well known to sociologists ever since <a href="http://www.garfield.library.upenn.edu/merton/matthew1.pdf">Robert Merton</a> in the 1960s. They call it the "<a href="http://en.wiktionary.org/wiki/Matthew_principle">Matthew Principle</a>," after the Gospel of St. Matthew. "To him who has, it shall be given." But in the US such a system, like that of sub-prime mortgages earlier in the present decade, has finally become so over-evolved it's threatening to topple over of its own weight. Thus, lobbyists are just now fighting the recess <a href="http://www.businessweek.com/news/2010-07-19/obama-sends-senate-berwick-nomination-for-medicare.html">appointment </a>of Dr. Don Berwick not because they think he doesn't understand how these processes work, but because they know that he does. Wish him, and Dr. Baron, luck.

Primary Care and the HC Renewal RUC-kus

Dr. Richard Baron, a Philadelphia internist who's unusual in that he's both a private-practice clinician and a well-published and -r...

Đọc thêm »

Where No Hospital CEOs are Below Average

In Lake Woebegon, all children are above average.  Now it seems that hospital CEOs have moved there.  Ventura County, Where No CEO is Below Average The Ventura County (California) Star <a href="http://www.vcstar.com/news/2010/jul/24/lofty-pay-for-hospital-ceos-area-administrators/">reported</a> on the uniformly high remuneration of the CEOs of local, mostly small, not-for-profit hospitals and hospital systems. <blockquote>T. Michael Murray reaped $330,545 in 2008 as chief executive officer of St. John’s hospitals in Oxnard and Camarillo. He drew an additional $187,071 in bonuses with $73,113 more in benefits and other compensation. His total package, according to IRS records, reached $590,729. And he may have been underpaid, according to a statewide survey of 118 nonprofit hospitals. The report by the Payers & Providers healthcare business publication suggests the base salary for CEOs averaged $514,237. Kick in bonuses, retirement money, reimbursement for education costs, expense accounts and the average total compensation hit $732,004. Public records show similarly lofty numbers at Ventura County’s three nonprofit, tax-exempt hospital groups. Gary Wilde of Community Memorial Health System, which runs hospitals in Ventura and Ojai, was the highest paid CEO in 2008. He earned a base salary of $508,682 and his total compensation was $853,528, with much of the additional money placed into a retirement fund that won’t be paid out until Wilde serves six more years as CEO. Simi Valley Hospital changed its leadership in 2008, with a total compensation of $1.25 million recorded in 990 tax forms for two different CEOs. That’s slightly more than the hospital provided in treatment for poor uninsured patients where there was no attempt to collect payment, though hospital leaders say charity care definitions encompass only a fraction of the total care they provide without pay. Outside the county, tax records from the Cottage Health System in Santa Barbara showed a base salary of $848,826 for CEO Ronald Werft and other compensation of $546,846. His total topped $1.3 million. Ken Anderson of the John Muir Health System, which operates hospitals in Walnut Creek and Concord, was the highest compensated CEO in the Payers & Providers study. He made $745,000 in base salary and nearly $7 million in other compensation, much of it deferred over his career for retirement.</blockquote>Recall that these people are leading relatively small, not-for-profit community hospitals whose missions are to provide health care to the community.  Total compensation ranging from three-quarters of a million dollars to multi-millions seems vastly disproportionate to the jobs and their settings. Explanations and Excuses As expected, those supporting the CEOs have all sorts of explanations and excuses: <blockquote>Hospital leaders in Ventura County and throughout California say the numbers are inflated by retirement plan accumulations that must be included on tax records even before executives qualify to receive the money. They defend the half-million-dollar salaries, with bonuses on top, as the only way to compete with for-profit hospitals for executives who can lead a facility that may employ more than 1,000 workers, drive a community’s economy, provide access to the uninsured and deliver care that saves lives. 'Given the context, it’s not out of line,' said Murray, a CEO with 28 years of experience who is now semiretired after resigning from St. John’s at the end of March. 'I think you need to retain and also attract sufficient talent. I’m not saying there aren’t inappropriate salaries out there. I don’t think mine was one of them.'</blockquote> Also, <blockquote>But [economist Sung Won] Sohn said that paying below average is risky. 'When you try to get somebody at $400,000 rather than $700,000 you will get plenty of takers but they’re not competent,' he said. 'Hospitals are so important in the community that you want to make sure it’s run properly.' Nor does he see any problem with paying more than average if a hospital board wants to reward an executive.</blockquote> Furthermore, <blockquote>John Romley, an economist at the Schaeffer Center for Health Policy and Economics at USC, said the amount hospitals spend on executive pay is a sliver of their total expenses and can’t legitimately be blamed for driving the rising cost of healthcare. 'I guess I’m not shocked even though I’m jealous,' he said of the compensation.</blockquote> Some people were not pleased about this use of health care dollars: <blockquote>Others worry the compensation may push hospitals into spending more on executives than their nonprofit mission of providing care for the poor. Federal regulations already limit compensation for CEOs of corporations bailed out by the government to $500,000. Similar caps placed on nonprofit hospitals could create dramatic differences, said Ron Shinkman, author of the Payers & Providers statewide survey on CEO salaries. 'You’re looking at close to $39 million that could be used on uncompensated patient care,' he said. 'It’s a lot of money.' Consumer advocates aim much of their concern at nonprofit hospitals that not only reward CEOs with lucrative paydays but also provide little charity care to poor, uninsured patients. The Payers & Providers research identifies 17 hospitals — all outside of Ventura County — where the total compensation to CEOs exceeded the cost of charity care. 'It would be outrageous if hospitals are paying more to their (entire) executive teams than in indigent care in their community,' said Anthony Wright of Health Access California. 'For some hospitals to provide more to one individual just seems wrong.'</blockquote>The Mechanism: Ego Bias The mechanism making CEO compensation constantly increase appears to be simple: <blockquote>Typically, hospital boards hire consultants to conduct studies showing market averages for comparable hospitals in their regions. They often try to pay somewhere around the 50th percentile. That’s a reasonable way to do it, but such studies tend to push up the salaries, said economist Sung Won Sohn, who was involved in setting compensation at two Minneapolis hospitals. 'People at the low end try to increase the CEO closer to the average,' said the professor at CSU Channel Islands. 'If everyone does that, the average CEO salary will go up.'</blockquote> So there you have it. At no hospital is the CEO deemed by a sympathetic (and sometimes crony filled board) below average. If the CEO's compensation has somehow dropped below average one year, it is immediately raised to at least average the next. Apparently almost never is the CEO's pay deemed to be too high. That notion is corroborated by the assumption by the CEO documented above that all CEOs have "sufficient talent," and the assertion above that anyone who would accept a lower salary would be "not competent." So every year all the CEOs who had below average compensation the previous year get compensation increased at least to last year's average.  Almost no CEO gets a reduction.  So the average moves up relentlessly year after year.  Of course, unless all CEOs are exactly alike, some CEOs must be below average.  So this becomes a great example of the ego bias at work. Ego bias is a common cognitive bias usually discussed in the context of making probabilistic judgments. A simple definition is that people tend to believe that outcomes of what they do, or what a group with whom they identify does will be above average. A long time ago, colleagues and I showed that interns in an intensive care unit judged the survival of their patients on average to be better than their judgments of the mean survival of all patients in the ICU. On the other hand, ICU attending physicians displayed a slightly more sophisticated version of the bias. They judged their patients' survival accurately, but judged the mean survival of their ICU's patients to be higher than it really was. [Poses RM, McClish DK, Bekes C, Scott WE, Morley JN.  Ego bias, reverse ego bias, and physicians' prognostic judgments.  Crit Care Med. 1991 Dec;19(12):1533-9.  Link <a href="http://www.ncbi.nlm.nih.gov/pubmed/1959374">here</a>.] So we have the ego bias writ large in judgments made about the performance and compensation of hospital CEOs, at least in Ventura County, California. The Implications I agree that paying a CEO more than a hospital's entire expenditures for the care of the poor is unseemly. However, in my humble opinion, the issue is even bigger than that. It is not so much how much of the hospital's budget goes to executive compensation, but what lessons this teaches CEOs.  I propose they are: -  I am a wonderful person.   I can do no wrong. -  If I do wrong, I cannot be punished. -  I can get rich and powerful doing this. Of course, as we have written many times, being the CEO of a small community hospital is supposed to be a calling, whose goal is to uphold the institution's mission.  Instead, CEOs are learning to be tin-pot dictators.  Some are probably sensible enough to resist learning this message.  I am afraid many are not. Furthermore, there is no reason to think that this phenomenon is confined to Ventura County, California, or to small community hospitals.  We have discussed how the management of health care organizations have become unsympathetic to, or even <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile to the mission</a>.  We have discussed their organizations' <a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest">institutional conflicts of interests</a>.   We have discussed how they have wound up with <a href="http://hcrenewal.blogspot.com/search/label/imperial%20CEO">imperial CEOs</a>.  The resulting ill-informed, mission-ignorant or mission-hostile, self-interested, conflicted, or even corrupt leadership is a major, but still largely anechoic cause of our health care dysfunction. As I have said endlessly, true health care reform will require finding well-informed leaders who understand and support the mission, put the mission before their own self-enrichment, and are unconflicted and honest.

Where No Hospital CEOs are Below Average

In Lake Woebegon, all children are above average. Now it seems that hospital CEOs have moved there. Ventura County, Where No CEO is Below ...

Đọc thêm »

The Hospital CEO as Debt Collector

Last year we <a href="http://hcrenewal.blogspot.com/2009/05/irs-changes-form-990-to-make-not-for.html">noted</a> that the US Internal Revenue Service (IRS) required more detailed reporting starting in 2009 by US not-for-profit organizations. Many US health insurance companies/ managed care organizations, most hospitals, nearly all medical associations, nearly all disease advocacy organizations, all health care charities, and nearly all medical schools are not-for-profit organizations. We suggested then that this reporting might lead to more transparency about the leadership and governance of these organizations.  The 2009 990 forms seem to be trickling into public view, sometimes leading to some striking disclosures about how US not-for-profit health care organizations are lead. The California Watch blog just <a href="http://californiawatch.org/watchblog/4-laguna-beach-hospital-ceo-was-also-debt-collector-34">reported</a> about the interesting part-time job of a hospital CEO: <blockquote>The former president of a Laguna Beach hospital has been operating a debt-collection company that recovered medical payments from his own facility, raising conflict-of-interest questions as the CEO moves to a new hospital in Riverside County. Bruce Christian ran South Coast Medical Center from 2005 until it was sold in 2009. At the same time, Christian was owner of Metro Republic Commercial Services, a consulting and medical debt-collection firm that provided at least $110,000 in services to South Coast while Christian was a top manager, records show. South Coast Medical Center disclosed the arrangement as 'self-dealing' in federal tax filings. State law allows self-dealing by board members of nonprofits, typically as long as the body explores other options and determines they are not unduly enriching one of their own.</blockquote> Of course, I also get to write, but wait, there is more: <blockquote>Christian was also at the helm of the hospital in 2006 when Adventist hired one of his Metro Republic consultants as interim chief financial officer, tax records show. Adventist said it appointed the interim CFO when it believed the hospital would be sold quickly. Additionally, a version of the Metro Republic <a href="http://web.archive.org/web/20040712223946/www.mrcsinc.com/set_repclients.htm">website</a> in 2006 said the firm supplied South Coast Medical Center with health care financial consulting, managed care-revenue recovery and accounts-receivable services. The website, which appears to have been offline since 2006, describes Christian as a health industry leader for 30 years who built the Corona-based Metro Republic from a three-person office to one with 150 employees.</blockquote> Predictably, the response from the hospital and its parent health system was that it was all no big deal. <blockquote>Adventist Health West, the Roseville-based company that owned South Coast, acknowledged that the arrangement was 'unusual' and 'not the norm' for the firm. In a statement, Adventist said Christian's firm collected hospital debts for years before Adventist bought the hospital and prior to Christian’s tenure as president and CEO. Board members were aware of the arrangement. It remained in place while the chain sought to sell the medical facility throughout Christian’s tenure, the statement said. 'Unfortunately, it took much longer than originally envisioned to sell the hospital,' Adventist Health said in a statement. 'Adventist Health continues its deep commitment to providing mission-driven, quality health care to the communities we serve.'</blockquote> Some thought otherwise: <blockquote>But allowing a hospital administrator – who can have considerable power over setting prices on medical procedures – to operate as the hospital’s own bill collector presents a thorny conflict of interest, said Ken Berger, executive director of Charity Navigator, a New Jersey-based charity evaluation group. 'Just because the (hospital) board may sanction it doesn’t make it right, appropriate or ethical,' he said. 'The mission of hospitals and the mission to squeeze money out of those that are slow to pay can be quite contradictory. It’s just wrong.'</blockquote> Another expert thought something ought to be done: <blockquote>Kathryn Peisert, managing editor for publications at the San Diego-based Governance Institute, said a hospital CEO’s duty is to further the interests of the hospital. As such, she said, Christian should have eliminated all appearances of impropriety and cut ties between the medical center and his consulting firm. 'That’s really a big no-no,' said Peisert, whose organization advises hospital boards. 'I’m surprised some regulatory agencies haven’t been after this.'</blockquote> We will see if anything will be done, but this conflict of interest seems not to have gotten in the way of Mr Christian's career advancement. <blockquote>Christian is now chief executive of a Loma Linda University Medical Center campus expected to open in 2011 in Riverside County. A Loma Linda University Medical Center spokesman said the Murrieta campus will not contract with Metro Republic.</blockquote> As I have said before, I expect that as more 990s dribble out, seemingly as slowly as many organizations can manage, we will see many more examples of these sorts of conflicts of interest, in which top organizational leaders also turn out to be vendors, consultants, etc. In theory, and perhaps in a golden era in the past, leaders of not-for-profit health care organizations were supposed to regard their work as a calling, and to be primarily concerned with upholding the mission of the organization. Instead, we now see more leaders who seem to regard their organizations as their own personal sand boxes, providing opportunities for play, and sometimes personal enrichment. (Note that Mr Christian's total compensation from the hospital was "$360,000 and $400,000 in salary, benefits and deferred compensation in 2006 and 2007 at South Coast Medical Center.") Unfortunately, Mr Christian's case demonstrates that leaders who get used to their organizations as personal sand boxes, rather than face punishment,  may be given the opportunity to play in larger venues. One wonders how much he will make at the helm of a new academic medical center, what other side deals he will manage, and how much he will be concerned with the academic and clinical missions. Once again, I say that true health care reform will only be achieved when health care organizations are lead by people who put the mission ahead of their personal enrichment, and are held accountable for their ability to do so.

The Hospital CEO as Debt Collector

Last year we noted that the US Internal Revenue Service (IRS) required more detailed reporting starting in 2009 by US not-for-profit organi...

Đọc thêm »