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The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes")

<div style="text-align: center;">"Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic doctor. Dr. Data will be that doctor; <s style="font-style: italic;">better</s> worse than he was before. <s style="font-style: italic;">Better, stronger, faster</s> Worse, weaker, slower." -- parody of Oscar Goldman from the 1970's scifi series <a href="http://www.youtube.com/watch?v=HofoK_QQxGc">The Six Million Dollar Man</a>. </div><div style="text-align: center;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqzasoTiRKrqW917SPMiqTdjbdN5HIlHCXgUfbNIfBWTD4XeQkZfy9lf5N9Xco8sPERtjLya5T8uhctdg9j4zFlVjiuCkMzFzon9ihChnpVyKp66kif_i3xYmzW8DByUScF3aAEaJy6w61/s1600/sixmillion.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5513937992318855618" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqzasoTiRKrqW917SPMiqTdjbdN5HIlHCXgUfbNIfBWTD4XeQkZfy9lf5N9Xco8sPERtjLya5T8uhctdg9j4zFlVjiuCkMzFzon9ihChnpVyKp66kif_i3xYmzW8DByUScF3aAEaJy6w61/s320/sixmillion.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 187px; height: 121px;" /></a>"Gentlemen, we can rebuild him." </div><div style="text-align: center;"> <div style="text-align: left;">The EMR is a technology that was supposed to improve clinical medicine (revolutionize it, some say). It was supposed to facilitate clinical medicine. It was not supposed to slow physicians and others down to the point of impairing their ability to practice medicine. However, the rosy predictions are not proving to be the case. Instead, we have the ultimate workaround to the health IT <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a>: <blockquote>Los Angeles Times September 6, 2010 <div class="byline"> Harris Meyer <a href="http://www.latimes.com/health/la-he-medical-scribes-20100906,0,2694959.story" style="font-weight: bold;">Scribes are doctors' tech support</a> Melissa Genove has dreamed of becoming a physician since childhood. To help her prepare, she spends as many as 35 hours each week shadowing emergency room doctors at Loma Linda University Medical Center. The 23-year-old listens intently as they examine patients, records their treatment plans in a laptop computer, and follows up on prescriptions, lab tests, consultations with specialists and anything else the doctors order. Genove is not an intern, or even a medical student. She is the chief medical scribe in the hospital's emergency department — and one of several thousand young people pioneering a new healthcare field. Scribes are filling a necessary niche as doctors make the wrenching transition from old-fashioned paper charts to 21st century electronic medical records. The computerized system is supposed to make doctors more efficient and ensure better care for patients. Congress has such faith in the value of electronic medical records that it provided as much as $27 billion over 10 years to encourage doctors to use them, and the Centers for <a class="taxInlineTagLink" href="http://www.latimes.com/topic/health/government-health-care/medicare-HEPRG00002.topic" id="HEPRG00002" title="Medicare">Medicare</a> and Medicaid Services will penalize those who don't by cutting their reimbursement rates as much as 5%. But while the conversion is underway, doctors estimate that their productivity plummets by about 30% as they learn to cope with a complicated new system. [And what clinical IT in 2010 isn't complicated, I ask? - ed.] That's where scribes come in.</div></blockquote><div class="byline"> </div> This brings real meaning to the observation that "you should not have to work around something that is not in the way." <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuU_k88RnHpQsZuxQqubBBxqzCSNIcPnx0vkTOwPc2fQZxA4JcqMshHV21HrzV-cTje_k_iXnqkA02yE6mz7d2M8_kEremGFdfSsMI17KQ5JIGnJMd6FrVyDWXlLDdUHRzVI-DTq72Aeen/s1600/labyrinth.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5514150356466381106" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuU_k88RnHpQsZuxQqubBBxqzCSNIcPnx0vkTOwPc2fQZxA4JcqMshHV21HrzV-cTje_k_iXnqkA02yE6mz7d2M8_kEremGFdfSsMI17KQ5JIGnJMd6FrVyDWXlLDdUHRzVI-DTq72Aeen/s320/labyrinth.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 237px;" /></a>Just one screen from a Cerner product (from a presentation touting recent addition of a simple database "<a href="http://www.screencast.com/users/kkoche1/folders/Jing/media/5d3aa28f-2312-4a40-8e0d-47c15dcaee90">search</a>" feature that should/could have been present eons ago). Each menu item leads to even more screens, subscreens, menus and pick lists, in labyrinthine fashion. Click to enlarge. </div> In a domain as complex as medicine, ever-increasing demands for fine grained data on clinical encounters now outstrip the 2010-style human-computer interface's abilities to allow capture of the data without massive interference in the process of medicine itself. This mismatch is due largely to the limitations of the GUI as the primary user interface (UI) metaphor, especially the widget-centric UI currently in vogue, characterized by massive numbers of screens and <a href="http://en.wikipedia.org/wiki/GUI_widget">GUI widgets</a>, labyrinthine navigation, and forced data entry of artificially and needlessly "atomized" data through interaction with multiple widgets. CPOE as an example has become a <a href="http://en.wikipedia.org/wiki/Rube_Goldberg_machine">Rube Goldberg</a> contraption (def: "deliberately over-engineered machine that performs a very simple task in a very complex fashion"), the furthest thing from a straightforward "typewriter for orders" as can be. For instance, a simple order requires interaction with search boxes, multiple drop down lists, scroll bars, check boxes, and other widgets to capture each micro-component of the order, wasting much time compared to writing "Sotalol hydrochloride 120 mg PO BID, first dose now." There are alternatives to "data atomization" and "widget-centricity" in the health IT user interface, apart from simply cleaning up the current interaction disorganization and other weaknesses, but the health IT industry seems largely oblivious to alternatives. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh21K_FklxQqTMcml0C6D5UHN3L7VF4tMXNK6_X6XNKFF0BSXZG3ClJ_iM5IDHpuWCnJgFW_rnArDAlIoBui_M_utv0-WOQXQM7rNzuKpRkbNAj3mmSoIMRhE2jd0SpRFXvkgB15CQOyl1N/s1600/Rubenvent.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5514195533630289058" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh21K_FklxQqTMcml0C6D5UHN3L7VF4tMXNK6_X6XNKFF0BSXZG3ClJ_iM5IDHpuWCnJgFW_rnArDAlIoBui_M_utv0-WOQXQM7rNzuKpRkbNAj3mmSoIMRhE2jd0SpRFXvkgB15CQOyl1N/s320/Rubenvent.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 129px;" /></a>Professor Butts and the Self-Operating Napkin: EMR's have become machines that perform simple tasks in a very complex fashion </div> Unfortunately, it's difficult to show this complexity using actual EMR images, as most health IT vendors avoid posting screen images and user manuals online, and forbid customers from doing so. They are excessively secretive about their products. Try a Google image search on 'Cerner Millenium' as an example (click <a href="http://www.google.com/images?hl=en&client=firefox-a&hs=FKy&rls=org.mozilla:en-US:official&channel=s&q=cerner%20millenium&um=1&ie=UTF-8&source=og&sa=N&tab=wi&biw=1680&bih=861">here</a>), then compare to an image search on, say, Microsoft Word (click <a href="http://www.google.com/images?um=1&hl=en&client=firefox-a&hs=q3I&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&biw=1680&bih=861&tbs=isch%3A1&sa=1&q=microsoft+word&aq=f&aqi=g10&aql=&oq=&gs_rfai=">here</a>). The inappropriate-for-medicine, management information systems (MIS)-derived business model of the healthcare IT vendors and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem">HIT ecosystem</a> also contributes to the, at best, stuck-in-the-1980's health IT user interface. (As an example of these issues, the industry wouldn't even listen to aforementioned UI alternatives even if I served them up on a silver platter, because using the advice would require significant investments on their part to incorporate alternative UI approaches into their products, meaning lower short and medium term profits. Unlike pharma and tangible medical devices, interest in advanced R&D in the health IT industry seems nil. Instead, complacency rules.) An important question to ponder is whether the dream of the health IT pioneers back in the 1950's and 1960's was too idealistic and indeed unrealistic to begin with. Was it based on "2001, A Space Odyssey"-style overoptimism, and the lack of foreknowledge of how little true progress would be made in the commercial IT market in human computer interaction, artificial intelligence, natural language processing, voice recognition, and other innovations by the 21st century? <blockquote>Doctors have embraced the scribes as well. "The physicians were spending too much time documenting and not enough time with the patient," said Dr. Robert Steele, chief of Loma Linda's emergency department, which began using scribes in November. "The solution was to take the doctors off the computer, put them at the bedside, and let the scribe do the transcription. It's been a huge success. The physicians love it.</blockquote> It is not hard to understand why physicians, with their years of training and expertise, would welcome relief from extremely tedious clerical tasks. <blockquote>Leaders of the three biggest companies providing scribes estimate that about 200 emergency departments in community hospitals and academic medical centers currently use them. More scribes are on the way. Ronald Reagan UCLA Medical Center, Emory University Hospital in Atlanta and Beth Israel Medical Center in New York City said they are exploring the idea. Physicians in other specialties, including urology and family practice, also are starting to adopt scribes. Still, some physicians question whether college students are equipped to handle the complicated task of charting patients after only two to four months of training. Others wonder why it's necessary to hire additional staff to fill out computerized records that were supposed to be simpler and more efficient than paper.</blockquote> The key phrase is "were supposed to be simpler and more efficient" than paper. I'd likely be hard-pressed to find robust research supporting that assertion in the scientific literature. I'd be more likely find the origins of this meme in vendor marketing materials. <blockquote> "It will be interesting to watch whether the need for scribes goes away as the next generation of physicians who grew up with computers and electronic medical records comes in," said Dr. Ann O'Malley, a senior researcher at the Center for Studying Health System Change in Washington, D.C.</blockquote> This passage implies the bottleneck is those physicians who need to "get used to the IT", whereas a major component of the problem is the health IT user interface itself. Scribes might "go away" if the health IT user experience was vastly improved. The IT needs to become more physician and medicine-friendly. <blockquote> At Loma Linda [Hospital], Steele said doctors used to spend two minutes with a patient, then take four minutes typing the information into a computer. Now the doctor talks to the patient with the scribe present and summarizes the encounter to the scribe in 30 seconds. While the scribe spends three minutes entering the information into an ever-present laptop, the doctor can spend extra time with the patient. Afterward, the doctor checks the accuracy of the scribe's chart, makes any necessary additions or corrections, and signs off. Although novice scribes sometimes need the doctor's help in understanding terminology, those with several months' experience usually are spot-on, Steele said. </blockquote> Again, clerical work is a very poor use of a physician's time. Scribes are a good idea considering 2010's EMR technology, at least from the time/skills perspective. <blockquote>... [Dr. Michael] Murphy of ScribeAmerica estimates that doctors can see eight additional patients over a 10-hour shift, hiking Medicare revenues alone by $91 an hour. The companies that develop and sell electronic medical records systems are "in total denial" about how complicated they are for doctors to use, [Dr. David] Strumpf said. "They know these systems need scribes," he said. "They work with us to train our scribes on their systems, but they don't want to be public about it."</blockquote> (One wonders how much in "denial" the companies are and just who is truly in denial; after all, purchase of these systems just became a governmental priority.) Here, of course, is the major drawback to scribes: money. Scribes "typically cost $20 to $26 an hour" today, and that number is likely to rise. While the article's contributors maintain that physicians can boost their revenues by "$50 to $60 an hour" using scribes, I wonder if the overall economic impact of the generalized use of tens or hundreds of thousands of EMR scribes would be in the "wrong" direction (i.e., from the payor and government perspective). The billions spent on EMR's were supposed to reduce the costs of healthcare, not increase the expenses associated with it. I also wonder what could happen when a scribe is not available. <blockquote>At the University of Virginia Medical Center in Charlottesville, Va., emergency room physicians can complete electronic charts just as fast as scribes, most of whom are pre-med students at UVA. But doctors would rebel if the scribes disappeared, said Dr. Robert Reiser, medical director of the scribe program, which the university runs itself. </blockquote> Sept. 10 Addendum: See an interesting financial analysis by Doug Perednia <a href="http://www.kevinmd.com/blog/2010/11/scribes-lead-unintended-consequences-electronic-medical-records.html">here</a>. -- SS </div></div>

The Ultimate Workaround To Mission Hostile Health IT: Humans (a.k.a. "Scribes")

"Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic doctor. Dr. Data w...

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At the End of Summer, Everybody, Well, Nearly Everybody (Allergan, CVS Caremark, Stryker, WellStar) Settles

Many US health care organizations announced legal settlements as the dog days of summer drew to a close.  The hit parade included, in order of dollar amount: Stryker Corp As reported <a href="http://www.bloomberg.com/news/2010-08-26/stryker-to-pay-1-35-million-to-settle-massachusetts-marketing-claims.html">by Bloomberg News</a>: <blockquote>Sryker Corp., a maker of artificial hips and knees, will pay $1.35 million to settle claims it marketed items without regulatory approval and misled health care providers about the use of its products, the Massachusetts attorney general said. Stryker’s biotech unit engaged in unfair and deceptive trade practices that boosted sales of products used to strengthen and promote growth of bones, Massachusetts said in a filing in state court in Boston. 'Stryker Biotech subverted review procedures designed to safeguard patients and promoted uses of its products that were not shown to be safe or effective,' Martha Coakley, the attorney general, said today in a statement. </blockquote> Note that this appeared to be one of those rare cases in which allegations were made against individuals, as well as the company as a whole: <blockquote>In October 2009, the biotech unit and former president Mark Philip were indicted by a federal grand jury for misleading the U.S. Food and Drug Administration about the use of the products. Philip, who was president from 2004 to 2008, was accused along with three sales managers of promoting therapeutics in a manner contrary to their FDA-approved use. They pleaded not guilty, according to the case docket. </blockquote>However, the case has not yet gone to trial. As usual, the company denied anybody did anything wrong: <blockquote>As part of the Massachusetts settlement, Kalamazoo, Michigan-based Stryker didn’t admit any liability, the company said in an e-mailed statement. </blockquote> As usual, the penalties were trivial compared to the company's revenues: <blockquote>Under the agreement, Stryker will pay $325,000 in civil penalties, $875,000 to fund efforts to combat unlawful marketing and other programs to benefit health-care consumers, and $150,000 to cover attorney fees and investigative costs. The company reported 2009 revenue of $6.72 billion. </blockquote> CVS Caremark As reported very briefly by the Associated Press <a href="http://www.boston.com/business/articles/2010/08/31/cvs_settles_pricing_case_for_265m">via the Boston Globe</a>, <blockquote>CVS Caremark Corp. has agreed to pay $2.65 million under a settlement with the Massachusetts attorney general’s office, which accused the pharmacy chain of overcharging public entities for prescription drugs. CVS will pay Massachusetts and about 200 cities and towns in the state that were allegedly overcharged under the workers compensation insurance system, Attorney General Martha Coakley said yesterday in a prepared statement.</blockquote> WellStar This story was published <a href="http://www.ajc.com/health/wellstar-agrees-to-2-602802.html">in the Atlanta Journal-Constitution</a>: <blockquote>WellStar Health System has agreed to pay $2.7 million to settle allegations that it improperly billed the state Medicaid system, Attorney General Thurbert Baker announced Monday. The agreement came after a six-month state investigation which found that WellStar mishandled claims involving patients covered by both Medicare and Medicaid. WellStar filed claims that did not properly reflect payments it received from Medicare, allowing it to receive excessive payments from Medicaid.</blockquote> As expected, the hospital system denied it was anything more than a soft-ware glitch: <blockquote>The allegations related to patients served at WellStar’s five hospitals: Cobb, Douglas, Kennestone, Windy Hill and Paulding. 'Upon learning from the state of this potential billing issue, WellStar immediately conducted an internal investigation and fully cooperated with the state,' WellStar said in a statement. The hospital system said a flaw in claims processing software caused the problem. 'The State specifically found no intent to defraud,' WellStar said. WellStar admitted no wrongdoing as part of the settlement , according to the attorney general’s office. </blockquote>It is not entirely clear whether any individuals suffered any negative consequences because of this soft-ware "flaw" which went undiscovered until the state investigated. In <a href="http://www.ajc.com/news/cobb/wellstar-ceo-fired-by-606194.html">another AJC story</a>, which did not directly refer to the one above, published four days later: <blockquote>WellStar Health System’s president and CEO Gregory Simone was fired by the system’s board on Thursday. Board chairman and Marietta attorney Randall Bentley said the decision was a personnel matter and provided no information on the reason for Simone’s termination, which is effective immediately. Earlier this week Bonnie Wilson, WellStar’s executive vice president and general counsel, received notice that her contract would not be renewed. Bentley did not say if the terminations were related.</blockquote> Then, in <a href="http://www.ajc.com/news/cobb/questions-surround-wellstar-dismissals-606572.html">a third story</a>, the hospital denied any relationship among the firings and the legal settlement: <blockquote>WellStar Health System's board this week fired the Gregory Simone, president and chief executive of the non-profit operator of five north metro hospitals and dozens of other facilities. Board chairman Randall Bentley, a Marietta attorney, gave no explanation other than to say Simone's termination was a personnel matter. It was announced Thursday and was effective immediately. His firing follows the Aug. 31 departure of Bonnie Wilson, WellStar’s executive vice president and general counsel. She was told her contract would not be renewed, according to WellStar. Bentley did not say if the Simone's firing and Wilson's departure were related. WellStar and Bentley said Simone's firing was not related to a six-month Medicare and Medicaid investigation. In August, the hospital system agreed to pay $2.7 million to settle allegations that it improperly billed the state Medicaid system, resulting in excessive payments from Medicaid.</blockquote> [sarcasm on] Of course, it was just a soft-ware "flaw," so no one was responsible, just the soft-ware. [sarcasm off] Allergan As reported again <a href="http://www.bloomberg.com/news/2010-09-01/allergan-will-pay-600-million-plead-guilty-to-misdemeanor-in-botox-probe.html">by Bloomberg</a>: <blockquote>Allergan Inc., maker of the wrinkle smoother Botox, agreed to pay $600 million and plead guilty to a misdemeanor in settling a U.S. investigation of its marketing practices. Allergan will pay $375 million to the government as part of a 'misbranding' charge that the marketing of Botox from 2000 to 2005 led to use in treating headache, pain, muscle stiffness and juvenile cerebral palsy, purposes for which the Food and Drug Administration during that time hadn’t approved marketing. Allergan will also pay $225 million to resolve civil claims from the Justice Department, the company said today in a statement. </blockquote> Once again, although the amount this time appears large, it is small compared to the revenues produced by the product in question. The total fines amount to about $100 million per year of sales, but: <blockquote>Botox, [is] Allergan’s top product with $1.3 billion in annual sales,.... </blockquote> Once again, the company denied it did anything all that bad, (even though it did plead guilty to a crime), reported <a href="http://online.wsj.com/article/SB10001424052748703882304575465371767239834.html">by the Wall Street Journal</a>, <blockquote>The company, meanwhile, said the settlement resolves the investigation while avoiding substantial litigation costs and other risks associated with a government enforcement action. Allergan said its plea to the single misdemeanor 'misbranding' charge didn't involve 'false or deceptive conduct.' Specifically, the Botox marketing from 2000 to 2005 resulted in intended Botox use for four unapproved conditions, Allergan said. The drug didn't have directions for these uses, which means it was misbranded, the company said. </blockquote> Got that? On the other hand, <blockquote>Prosecutors alleged Allergan engaged in tactics to promote the drug for unapproved uses, including paying kickbacks to doctors. For example, the government charged that in 2005, Allergan hosted about 100 doctors at an invitation-only program at its corporate headquarters and a Newport Beach, Calif., resort while paying them $1,500 'to listen to off-label marketing presentations.' </blockquote> I did not see anything in any news article that suggested any individual at Allergan would suffer any negative consequences as part of this settlement. Summary So, the parade of<a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements"> legal settlements</a> marches on.  We have now documented a very large number of heretofore respectable health care organizations who have made legal settlements of all sorts of charges of wrong-doing.  As we have repeatedly noted, these settlements have certain characteristics.  The amount of money involved, although it may seem big to those paid less than CEOs, is usually much smaller than the amount of money that could be made by the bad behavior.  The settlement is usually paid by the organization as a whole, and so its effect may be diffused among the employees, the patients or clients, and the stock-holders, if any.  The settlement rarely involves any negative consequences for those who might have authorized, directed, or implemented the bad behavior.  Rarely is the settlement widely reported, and rarely does the organization involved seem to suffer any stain on its reputation. So is it any wonder that the bad behavior that leads to such settlements continues?  Is it any wonder that health care organizational leaders now just seem to think of such settlements as a (relatively negligible) cost of doing business? Inquiring minds may want to know how this state of affairs came to be.  Why are leaders of health care organizations (and other large organizations) able to behave with such relative impunity?  The answer may have to wait for more historical inquiry (although I recently saw what might be a clue, so stay tuned.)  My refrain has been: we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

At the End of Summer, Everybody, Well, Nearly Everybody (Allergan, CVS Caremark, Stryker, WellStar) Settles

Many US health care organizations announced legal settlements as the dog days of summer drew to a close. The hit parade included, in order ...

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American Board of Medical Specialties to "incorporate tools to promote meaningful use of health IT into its maintenance-of-certification program"

From an Aug. 16 article "<a href="http://www.modernhealthcare.com/article/20100816/MAGAZINE/100819962">Industry pushes meaningful use through incentives</a>" in Modern Healthcare (signup unfortunately required): <blockquote>... Physicians will also be feeling the pressure to be IT savvy in order to maintain their professional certification. The American Board of Medical Specialties said that it would incorporate tools to promote meaningful use of health IT into its maintenance-of-certification program. More than 750,000 U.S. physicians are certified by an American Board of Medical Specialties (<a href="http://www.abms.org/">ABMS</a>) member board, “so it’s readily apparent” [really? - ed.] that building meaningful use of health IT into [Board] certification maintenance will benefit patients, ABMS President and CEO Kevin Weiss, said in a written statement. Additionally, the merging of these two tools “will help to facilitate physicians’ knowledge, skill and use of health IT, and in turn can improve physician performance and patient outcomes,” he said.</blockquote> The bolded statements of certitude from ABMS CEO Kevin Weiss follow the familiar pattern I observed such at my July 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>". These are statements of certitude supported at best by scanty evidence, "estimations" and "projections", while refuted by a growing body of significant research on health IT as it exists now (such as the recent materials <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">here</a>). It is unfortunate that the ABMS has now fallen away from evidence-based medicine and fallen prey to mysticism-based IT practices in medicine. I did, however, see moves like this coming. I believe the ABMS move augurs future, more forceful demands from the <a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">healthcare IT "Trade Federation"</a> that physicians and hospitals buy and use this technology, a form of totalitarian caprice considering the evidence base. With respect to seeing this coming, here's what I wrote in my post<a href="http://hcrenewal.blogspot.com/2009/04/masochism-medicine-and-clinical-it-how.html"> </a><a href="http://hcrenewal.blogspot.com/2009/04/masochism-medicine-and-clinical-it-how.html">Masochism, Medicine and Clinical IT: How Physicians Can Be Beaten Over and Over, and Still Come Back For More</a> back in April 2009: <blockquote>... Here is a tale about the companies that medicine will be dependent upon for EHR's and other clinical IT - now by force of government (financial at first, but I would not at all rule out punitive licensure and other measures as a possibility in the future for "EHR noncompliers")... </blockquote><style title="owaParaStyle">P { MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px } BODY { SCROLLBAR-ARROW-COLOR: #3f52b8; SCROLLBAR-DARKSHADOW-COLOR: #fafafa; SCROLLBAR-BASE-COLOR: #f7f7f7; SCROLLBAR-HIGHLIGHT-COLOR: #cecfce; SCROLLBAR-TRACK-COLOR: #fff</style>We're not there yet, but I would not be surprised to see moves in that direction in the future. I also consider the ABMS succumbing to IT mysticism as another sign of the degradation of efforts towards true evidence-based medicine in favor of corporate interests. Fortunately, some research organizations have not entirely bought into the irrational exuberance, although whether they can exert enough influence to reform the healthcare IT industry before billions of precious dollars are wasted on today's ill conceived systems is debatable. For example, (and in <a href="http://hcrenewal.blogspot.com/2010/08/health-it-via-observation-and-research.html">another example</a> of research done today affirming conclusions I'd reached years ago using observational skills, knowledge of Medical Informatics, internal medicine thought processes and common sense), McKinsey offers the following. Per the recent McKinsey study "<a href="http://www.mckinseyquarterly.com/Health_Care/Strategy_Analysis/Reforming_hospitals_with_IT_investment_2653">Reforming hospitals with IT Investment</a>": <blockquote>... The realization of the benefits from health care IT investments will require a radically new approach to IT on the part of the CIOs of health care providers, as well as the business leaders and clinicians those CIOs serve. Health care providers will need to use new approaches to achieve an inclusive governance process with streamlined decision-making authority, a radically simplified IT architecture, and a megaproject-management capability.</blockquote> Based on observation alone, I'd <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/scotsilv/invascard.htm">written this in 2002</a> (and probably before as well, somewhere): <blockquote>... From a dual perspective as both a clinician and computer professional, it is evident that critical clinical computing projects benefit greatly from an alternate approach to project preparation, development, implementation, customization and evaluation, as compared to management information systems (business computing) projects. Clinical and business computing appear to be different subspecialties of computing. </blockquote> Instead of naïve, unquestioning IT exuberance, the ABMS and other medical professional organizations should long ago have put their efforts behind moving the health IT vendors and their hospital customers to adopt the 'radical changes' required as in the McKinsey report (and elsewhere, such as in the 2009 <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">National Research Council's report on health IT</a>). They should have done so before insisting use of the technology be a metric for qualifications to practice medicine. They should be pushing for the approval of health IT as medical devices under the <a href="http://www.fda.gov/regulatoryinformation/legislation/federalfooddrugandcosmeticactfdcact/default.htm">Federal Food, Drug, and Cosmetic Act</a> (FD&C Act), such as the EU is now moving towards; see for example the Swedish Medical Products Agency 2009 report <a href="http://www.lakemedelsverket.se/upload/foretag/medicinteknik/en/Medical-Information-Systems-Report_2009-06-18.pdf">here</a> (PDF). From that report entitled "Proposal for guidelines regarding classification of software based information systems used in health care": <blockquote> A general opinion of the health care providers represented in this Working group is that from a patient safety point of view, it is desirable that stand alone software and systems intended to, directly or indirectly, affect diagnosis, health care and treatment of an individual patient shall be regulated under a Product Safety Regulation. The Working group has not been able to define any other appropriate regulation than the Medical Device directives when it comes to the definition of such systems. ... The Working group believes that software intended for a medical purpose must be regarded as a "device" and expressions such as "project", "service" and similar must be avoided describing a Medical Information System.</blockquote> Further, ABMS should also be pushing for robust post-marketing studies of health IT. If truly representative of ensuring medical practitioners' competence in the interest of patient safety, ABMS should be discouraging specialty societies from blindly buying in to this experimental technology, and instead encouraging them to evaluate health IT critically - as critically as any new medical device or technology - including a complete examination of the literature. The ABMS should hold off on linking clerical capabilities of clinicians to board certification, per Brown University ophthalmologist <a href="http://bms.brown.edu/surgery/ophthalmology/faculty/profiles/migliori.html">Michael Migliori</a> in the above-linked Modern Healthcare story: <blockquote> “I don’t believe achieving meaningful use equates to maintenance of certification,” said Michael Migliori, an ophthalmologist in Providence, R.I. Maintenance of certification is a measurement of clinical knowledge, whereas meaningful use is a clerical designation, he said. “I understand the clinical importance of electronic medical records both in terms of patient safety and quality [although not in today's form IMO - ed.], but we are not at the point where EMR and health information exchange are ready for universal implementation,” Migliori said. “They should not be linked at this time.”</blockquote> In other words, today's health IT is not ready for national roll out, especially with any form of coercion in effect. Here's a major problem in slowing this train. The following chart appeared in the aforementioned McKinsey report on "startup costs" of EMR systems. The figures are presented in the form of dollars per bed: <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhivTP3gNOa-siHY7pXij5OOG-H0-4xs27PnRv26Rctf2LDMG1zAtCgVlo1VCILmcQONUpIyiNCpfDiwDMaPHu6NtyGr6WFpqn_WQBEeJigKPLKPAYTylip4vD0nauv4VJgAFUQHANEaTOH/s1600/mckinsey.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5511958181866088706" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhivTP3gNOa-siHY7pXij5OOG-H0-4xs27PnRv26Rctf2LDMG1zAtCgVlo1VCILmcQONUpIyiNCpfDiwDMaPHu6NtyGr6WFpqn_WQBEeJigKPLKPAYTylip4vD0nauv4VJgAFUQHANEaTOH/s320/mckinsey.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 396px; height: 227px;" /></a> <div style="text-align: center;">McKinsey on EMR startup costs, estimated at $80,000-$100,000 per bed - click to enlarge. </div><style title="owaParaStyle">P { MARGIN-TOP: 0px; MARGIN-BOTTOM: 0px } BODY { SCROLLBAR-ARROW-COLOR: #3f52b8; SCROLLBAR-DARKSHADOW-COLOR: #fafafa; SCROLLBAR-BASE-COLOR: #f7f7f7; SCROLLBAR-HIGHLIGHT-COLOR: #cecfce; SCROLLBAR-TRACK-COLOR: #ff</style> With these levels of money moving like an overflowing fountain of champagne to the IT industry, with likely tributaries into medicine's regulatory, representation and accreditation organizations, no research seems likely to bring the radical changes needed to ensure this technology is safe and effective. (The McKinsey report also opines that well-done EMR's can recoup the gap between costs and government financial incentives shown in the chart within a few years; that is also highly debatable, even if the HIT is "done well" via radical reform.) I have no answers to these problems other than the many suggestions I've written on these blog pages since 2004, and on my <a href="http://www.tinyurl.com/hitfailurecases">academic site</a> on HIT since 1999. Without those in power willing to consider that health IT today is yet another bubble or mania, then like some diseases, it may only be tincture of time that corrects these problems. That is, when the current Jurassic <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem">health IT ecosystem</a> collapses of its own dead weight. What's sad are the expensive IT fossils -- and bodies -- that will be left behind for some future archeologist to discover. -- SS Addendum Sept. 5: EMR use as condition of licensure appears to be heading for reality in at least one state: Massachusetts. See <a href="http://healthblawg.typepad.com/healthblawg/2010/05/hit-incentives-in-massachusetts-less-carrot-more-stick.html">http://healthblawg.typepad.com/healthblawg/2010/05/hit-incentives-in-massachusetts-less-carrot-more-stick.html</a> Hat tip to Al Borges, MD. See his comment in the comments section.

American Board of Medical Specialties to "incorporate tools to promote meaningful use of health IT into its maintenance-of-certification program"

From an Aug. 16 article " Industry pushes meaningful use through incentives " in Modern Healthcare (signup unfortunately required)...

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More Hospital CEOs Join the Millionaire's Club, This Time in Baltimore

As we predicted, more stringent requirements by the US Internal Revenue Service for financial reporting by not-for-profit organizations, including hospitals and hospital systems, have produced an enlarging parade of revelations of obese pay packages for hospital leaders.  The latest report came out <a href="http://www.baltimoresun.com/health/bs-bz-hospital-ceo-salary-20100826,0,7954079.story?page=1">courtesy the Baltimore Sun</a>: <blockquote>Baltimore-area hospital CEOs and presidents boast seven-figure salaries, club and gym memberships, and paid financial planning and tax services as part of compensation packages from their nonprofit employers. According to a survey of Baltimore-area hospitals, the highest-ranking executives were often the recipients of financial payouts and perquisites that many private-sector companies have abandoned in the face of intense public debate about excessive CEO pay. The heads of hospital systems, which oversee many facilities, tended to make the biggest salaries and incentives. Eight top executives made more than $1 million, and the largest CEO pay package totaled $7.8 million.</blockquote> The article described some of the more corpulent compensation packages. St Joseph Medical Center One was from St Joseph Medical Center, already under fire for for the lavish use of cardiac procedures by one of its staff doctors: <blockquote>St. Joseph Medical Center, a member of Catholic Health Initiatives, said in a statement that it offers a level of compensation that allows it to compete for talent. The hospital paid former CEO John K. Tolmie $846,128 in salary, bonus and other pay, the latest IRS filing shows. 'Hospital CEOs have one of the most demanding, high-pressure jobs in the nation, dealing on a daily basis with everything from ever-changing regulations to workforce shortages and lower reimbursement for services,' the hospital statement said. Tolmie resigned in May 2009 after being on administrative leave to avoid a conflict of interest during a federal investigation. Since then, one of the hospital's cardiologists, Dr. Mark G. Midei, has been accused of performing hundreds of unnecessary heart procedures. </blockquote> Mercy Medical Center: <blockquote>Mercy Medical Center head Thomas Mullen made $1.08 million in compensation during fiscal 2009. The hospital said in a statement that it 'believes this compensation to be appropriate given the responsibilities of serving as a president and CEO of a $520 million health system.'</blockquote> Johns Hopkins One might expect the CEO of the Johns Hopkins hospital system to be paid well, but he was paid particularly well since he also seemed to have the full-time, separately paid position of dean of the medical school: <blockquote>Edward Miller, CEO of Johns Hopkins Medicine, made $729,297. He also gets paid separately for his position as dean of the School of Medicine at Johns Hopkins University. The fiscal 2009 filing for the medical school was not yet available. But Miller collected $1.4 million for that job the year before.</blockquote>Summary A chart of the compensation of all CEOs is <a href="http://www.baltimoresun.com/health/bal-hospital-ceo-pay-data,0,373861.htmlpage">here</a>. As noted in the article, eight CEOs got more than $1 million, and another three got over $900,000. A Baltimore Sun commentator <a href="http://www.baltimoresun.com/health/bs-bz-hancock-hospital-pay-20100829,0,3121681.column">noted</a> that not only did the CEOs get large salaries, but: <blockquote>Close to a dozen had personal dues for 'social clubs' financed by your charitable donations, tax dollars and health insurance premiums. Many enjoy lavish and opaque executive retirement plans that also put upward pressure on the medical costs that threaten government budgets and the economy.</blockquote> As we have noted before, he pointed out that it is unseemly for not-for-profit hospitals, which are supposed to be devoted to the mission of caring for patients, usually explicitly including poor patients, and which are funded to a great extent by government programs and the income from donations, to make millionaires out of their top hired executives: <blockquote>Hospitals aren't Goldman Sachs. They're not Stanley Black & Decker or Microsoft, either. They're nonprofits, getting charitable donations and huge government subsidies beyond all the loot they rake in from Medicare and Medicaid. If the newly required disclosures on the IRS 'Form 990' put pressure on hospital boards and CEOs to tone it down, it's about time.</blockquote> People who donate to hospitals, thinking they are doing so to provide better health care, or to help out the less fortunate, may be surprised to hear about the hospital CEO as millionaire: <blockquote>For some hospital donors, the revelations are transparently shocking. 'Donors are completely outraged,' says Ken Berger, president of Charity Navigator, an organization that helps people make smart giving choices. 'Donors tell us more than anything that they're just blown away by the fact that an organization that is a charity basically is creating millionaires in its leadership.' 'The most common remark we get is this: 'I've been giving to this organization for years, and I can't believe what the CEO is making, and I will never support this organization again.' '</blockquote> I am glad that newspaper commentators are getting even more wound up on this issue than I have: <blockquote>Why any hospital executive should need a company-paid club membership is a deep mystery. It can't be to woo potential donors. No donor with half a brain wants to endow an institution so employees can play golf with her money. It shouldn't be to wine and dine business prospects. A hospital's business is collecting revenue for medical care. To be frank, there's too much of that going on already for the good of the country's wallet. Hospitals are far too focused on sales and marketing and not enough on delivering quality, efficient care. Hospital trustees on any compensation committee can deliver a windy treatise about how pay for senior executives is ethical, carefully considered and worth every penny. It's all a crock. The 'independent' compensation consultants that boards rely on are often referred by the CEO himself. The consultants know they can't make waves, or they won't get hired to rubber-stamp executive pay at other hospitals. To justify high pay, boards and consultants often use unrealistic comparisons from much bigger institutions or from the for-profit sector. It doesn't take $1 million to get a great boss.</blockquote> But it gets worse. People who love to play golf on company money, and feel entitled to make a million or more are not the right people to lead organizations that are supposed to focus first on health care, including health care for the less fortunate. Moreover, people who get used to the pay and perks are likely to focus on keeping them coming, rather than the mission, even if they started out with some devotion to the mission.  Furthermore, the excessive pay and perks are perverse incentives, telling the CEOs that they are wonderful people, they can do no wrong, and should stand for no criticism, all further diverting them from what they really are supposed to be doing: upholding the mission. As we have said many times before, true health care reform would encourage leadership of health care who understand health care and care about its mission, rather than those who see a quick way to make a small fortune.

More Hospital CEOs Join the Millionaire's Club, This Time in Baltimore

As we predicted, more stringent requirements by the US Internal Revenue Service for financial reporting by not-for-profit organizations, inc...

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"Trouble Coming Every Day" as Discussed by our Fellow Health Care Skeptics

With apologies to the late Frank Zappa... even though we are going through the dog days of summer, the parade of health care troubles in the news is never ending, so I thought I would recap some of the more interesting issues discussed by some of my fellow health care skeptic bloggers. We have discussed the ongoing decline of <a href="http://hcrenewal.blogspot.com/search/label/primary%20care">primary care</a>. On DB's Medical Rants, Dr Robert Centor <a href="http://www.medrants.com/archives/5776">takes on </a>the topic: "The system has, without consciously meaning to, held primary care in contempt." The result is a "quiet rebellion: of primary doctors. We have <a href="http://hcrenewal.blogspot.com/2010/08/how-oligopolists-rationalize-their.html">discussed</a> whether the currently fashionable idea of "accountable care organizations" (ACOs) might turn out to be a cover for health care oligopolies. See what Paul Levy, CEO of the Beth Israel/ Deaconess Medical Center <a href="http://runningahospital.blogspot.com/2010/08/aco-global-payments-market-dominance.html">said</a> about them in his blog, Running a Hospital. We frequently talk about the <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> or <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression </a>of clinical research studies by those with vested interests in the results pointing in a particular direction. On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody <a href="http://brodyhooked.blogspot.com/2010/08/spinal-fusion-devices-whats-fda-hiding.html">wondered</a> why the FDA will not even reveal the identities of the clinical researchers who did the studies on which it based its decision to approve the Infuse bone growth enhancement device. Prof Carl Elliott has done an outstanding job investigating commercially funded and implemented clinical research. Dr Brody <a href="http://brodyhooked.blogspot.com/2010/08/more-tidbits-from-white-coat-black-hat.html">reviewed</a> his new book, White Coat, Black Hat.  In the Carlat Psychiatry Blog, Dr Daniel Carlat <a href="http://carlatpsychiatry.blogspot.com/2010/08/making-killing-new-carl-elliott-article.html">reviewed</a> Prof Elliott's new article in Mother Jones on how a pharmaceutical company sponsored drug trial went badly awry. We <a href="http://hcrenewal.blogspot.com/2010/05/how-did-ceo-who-presided-over-company.html">asked </a>whether the former CEO of a for-profit hospital chain who resigned after the company paid a > $1.7 billion penalty to settle charges of fraud would be a proper candidate to be governor of Florida. After Rick Scott won the Florida Republican primary, Maggie Maher, writing in the Health Beat blog, <a href="http://www.healthbeatblog.com/2010/08/i-remember-rick-scott-a-great-makeover-but-still-the-same-guy-part1.html">took on </a>Scott's dubious past as prologue to a worrisome future. Well I'm about to get sick From watchin' my TV Been checkin' out the news Until my eyeballs fail to see I mean to say that every day Is just another rotten mess And when it's gonna change, my friend Is anybody's guess So I'm watchin' and I'm waitin' Hopin' for the best Even think I'll go to prayin' Every time I hear 'em sayin' That there's no way to delay That trouble comin' every day No way to delay That trouble comin' every day - Frank Zappa

"Trouble Coming Every Day" as Discussed by our Fellow Health Care Skeptics

With apologies to the late Frank Zappa... even though we are going through the dog days of summer, the parade of health care troubles in the...

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Health IT Personnel - Aliens in Healthcare?

-------------------------------- Sept. 1 Important note - it appears the survey results referenced below were contaminated by activists who could not allow this survey to occur unmolested. From <a href="http://histalk2.com/2010/08/31/news-9110/">HIStalk</a>, the source of the survey, a site ordinarily read by a relatively narrow health IT-involved audience: <blockquote style="font-style: italic;">If you’ve been following the current poll and comments on Ed Marx’s <a href="http://histalk2.com/2010/08/25/cio-unplugged-82510/" target="_blank">Blessing of the Hands</a> post, you may wonder why the comments suddenly turned ugly. An <a href="http://en.wikipedia.org/wiki/PZ_Myers" target="_blank">atheist blogger</a> linked to it and his followers dropped by to vote and opine. Since the point was to find out what industry people think, here’s the stat that counts: the poll was running 50-50 when it was just real readers voting. </blockquote> The Aug. 30 post below may reflect sabotage of the poll. -- SS -------------------------------- It is commonly accepted that respect for patient's cultural, ethical and religious views must be taken into account in their care. In fact, that understanding and respect for those values are critical. I think it also fair to say that many if not most practitioners of medicine also believe in a force higher than themselves, even if not formally involved in organized religion. I, in fact, minored in the history of religion in college. One of the most valuable pre-med courses I participated in concerned religious beliefs about illness, death and dying. In a remarkable survey at the anonymous <a href="http://www.histalk.com/">HIStalk</a> health IT industry/rumor blog site, however, these views seem alien to many of the HIT personnel who frequent that site. As of this time (8/3/2010, 10:15 AM EST) the tally of responses to this<a href="http://histalk2.com/2010/08/28/monday-morning-update-83010/"> sidebar question at that site</a> in part created after reactions to a CIO essay on religious values <a href="http://histalk2.com/2010/08/25/cio-unplugged-82510/">here</a>: <blockquote style="font-weight: bold; color: rgb(255, 0, 0);">Should hospital IT employees be expected to have a higher level of compassion and spiritual beliefs than their counterparts in other industries?</blockquote> are as follows: <blockquote style="font-weight: bold;">No - 90% (519 votes) Yes - 10% (59 votes)</blockquote> While informal, I'd say a red flag is raised. These results go against mainstream values in medicine, and the values of our American culture and heritage at large. Some of the <a href="http://polldaddy.com/poll/3686153">comments</a> in particular were revealing of contempt for these values and arrogant certitude typical of the IT field in general: Example 1: <blockquote>Higher level of compassion and sense of responsibility yes, spiritual beliefs - no. Relying on belief in many cases may cause more harm than good. Of course, some types of spiritual beliefs lead to heightened sense of responsibility (like the one Ed Marx has demonstrated), but not all, and heightened sense of responsibility is not dependent on one's spiritual beliefs.</blockquote> Example 2: <blockquote>I understand the meaning of the word COMPASSION, as the expression of sympathy for a separate person in different circucmstances. I expect that understanding is the common on. I have some ideas on how it works conceptually, and I expect I could find common ground with a great many people on that subject. I understand the meaning of the term SPIRITUAL BELIEFS, as the holding of a baseless conviction as to the existence of disembodied consciousness. I am confident that those who have them would express them as convictions or the equivalent of convictions, that they are unable to point to evidence supporting their convictions, would agree their beliefs entail disembodied consciousness, but would prefer to put it some other way. I have no understanding at all of how a disembodied consciousness would be able to exert influence on embodied third parties, or how a person who believes in the existence of disembodied consciousness might explain it. Perhaps I am missing something obvious. If so, I would appreciate someone explaining it here.</blockquote> Example 3: <blockquote>I agree ... I'm very tired of this idea that only religious people can be moral or compassionate or sensitive. It's simply not true. And competence, the most important quality in an IT person, has absolutely no connection to religiosity.</blockquote> Example 4: <blockquote>Good grief, I hope I don't get sick and then have to go to a hospital full of staff that think that their religious bend can help heal people. Annointing oil? What a bunch of mumbo-jumbo.</blockquote> Example 5: <blockquote><div class="img"> <a href="http://polldaddy.com/poll/3686153#"> </a> </div> <div class="text">Lol, this ceremony probably makes the chaplains maintain a sense of importance. Sorry to puncture the bubble, but your magic oil and mumbo jumbo belong to the first century desert tribes, not a 21rst century hospital.</div></blockquote><div class="text"></div> While people in healthcare and anywhere else in this country are free to believe in God or not, people in healthcare should be sympathetic to those who do, no matter what their own personal feelings. These comments and the survey results in general, I fear, show contempt for religious values and for those who hold them. There's a comment about these folks actually having a cybernetic religion of sorts: <div class="text"></div><blockquote><div class="text">You folks *do* have a religion. You worship machines.</div></blockquote> I agree with that assessment. Others in a <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformatic1/saudi.htm">Middle Eastern oil-producing country I once visite</a><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinformatic1/saudi.htm">d</a> to implement IT for care improvement of children with birth defects, in part out of interest in personally living by example and promoting cultural and religious reconciliation, have a different term for that particular religion: idolatry. I can't say I disagree with that, either. "Compassion" and "contempt" may both begin with the letter "c", but are essentially incompatible. Those with contempt for common patient values such as religious beliefs should not be working on tools critical for safe care delivery, in my opinion. In fact, I'd rather have this type of arrogant, contemptuous healthcare facilitator not working in healthcare at all. -- SS

Health IT Personnel - Aliens in Healthcare?

-------------------------------- Sept. 1 Important note - it appears the survey results referenced below were contaminated by activists who ...

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Similar Conclusions on Health IT Via Observation and Via Research: Is HIT 'Mission Impossible'?

The Wall Street Journal reported on a study in Health Affairs entitled "<a href="http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0502">A Progress Report On Electronic Health Records In U.S. Hospitals</a>" by Harvard researcher Ashish Jha and colleagues. An Aug. 27 WSJ Health Blog post was entitled "<a href="http://blogs.wsj.com/health/2010/08/27/only-2-of-hospitals-could-have-met-meaningful-use-in-2009/">Only 2% of Hospitals Could Have Met ‘Meaningful Use’ in 2009.</a>" While the topic of this Healthcare Renewal post is not about Jha's new article per se, I will provide the article's summary: <blockquote>Despite all the talk about digitizing the health-care world, only 11.9% of U.S. hospitals had adopted at least basic electronic medical records by last year, and only about 2% had done enough to qualify for future government financial incentives, a study finds. The study, <a href="http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0502" modo="false" target="_blank">published online in Health Affairs</a>, covers responses from 3,101 hospitals surveyed by the American Hospital Association ... It’s actually not surprising that hospitals were slow to adopt new systems in 2009, given the horrible economic conditions, difficulty of raising money for capital investments and uncertainty over what the final government requirements would be. “I’d be shocked if we didn’t see an uptick in 2010 and an even bigger one in 2011,” Jha tells the Health Blog. “But are we going from 2% to 40%? No. We might go from 2% to 5% [in 2010] to 15% or 20% in 2011.”</blockquote> No surprises there. Jha has previously published research articles I've mentioned on Healthcare renewal such as at<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> and <a href="http://hcrenewal.blogspot.com/2010/03/hospitals-under-knife-sacrificing.html">"Hospitals Under the Knife: Sacrificing Hospital Jobs for the Extravagance of Healthcare IT?</a>": <blockquote>... Ashish 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. A New York Times story "Little Benefit Seen, So Far, in Electronic Patient Records" on those findings is <a href="http://www.nytimes.com/2009/11/16/business/16records.html?_r=1">here</a>. </blockquote>What is of interest to me are statements made by Jha in response to questions asked by the WSJ reporter Katherine Hobson. Hobson: "We hear from a lot of physicians and others who are doubtful about the benefits of electronic records, and we asked Jha about the evidence supporting quality and safety improvements." Jha's response was quite interesting. There are a number of issues he raises: <blockquote>[Jha] "There are really two sides of the coin. I can point to about 400 studies done really well that show electronic health records can have a substantial impact on improving quality and safety. [But] we had a <a href="http://content.healthaffairs.org/cgi/content/abstract/29/4/639" modo="false" target="_blank">paper published earlier this year</a> [Electronic Health Records’ Limited Successes Suggest More Targeted Uses - ed.] showing that when hospitals adopted EHRs, there was no impact on quality. So how to reconcile that?" [Hobson] Jha says we have evidence that “when high-performance hospitals develop their own systems, implement them and tweak them, they can work wonders.” But the benefits gained from purchasing an off-the-shelf product and failing to implement or tweak it to meet an institution’s particular needs are likely to be “far less pronounced,” he says. “If you adopt a new technology, and do it badly, you can end up making productivity worse” or causing harm, he says. [There must be a lot of organizations meeting that description for such low impacts on quality to be the norm - ed.] “This is not a plug and play.” </blockquote> I find this interesting for several reasons. First point of interest: On doing health IT badly, and on health IT not being "plug and play": I came to the same industry-challenging conclusions a decade ago observationally that Jha came to through empirical research and review of the literature. On "doing health IT badly", in the late 1990's I'd written the following (now at my academic health IT site <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">here</a>): <blockquote>... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources. Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity. This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.</blockquote> I'd also made the observation, to the consternation of health IT marketing departments I'm sure, that health IT was not plug-and-play in an essay entitled "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cultures%20of%20mismanagement%20toxic%20to%20healthcare%20quality">Cultures of mismanagement: toxic to healthcare quality</a>" about my experiences as a CMIO: <blockquote>... To make matters worse [in an ongoing EPR project], the executive team then gave a key EPR staff member, a Senior Resident who'd done an excellent job writing and programming custom templates for the EPR system, a difficult time on promised payment for his services. They believed such a customization function was trivial and wasteful, and essentially reneged on their agreements with the Resident. When challenged by the informaticist and others that this person's services were essential, the views were met with indifference, if not disdain, for facts and logic. In fact, the executive team clung persistently to a mind-numbing leap of logic: they seemed to believe that just as home computers were "plug and play", so was [or should be - ed.] clinical IT. Their attitudes seemed to reflect a belief that the EPR team and resident were basically deceiving them. ... Unfortunately, healthcare IT is never plug-and-play, and in IT a person is either part of the solution or part of the problem.</blockquote> Second point of interest: Jha did mention two systematic reviews as describing hundreds of articles in the literature supporting potential benefits of health IT, one in May 2006 by Chaudhry et. al in the Annals of Internal Medicine (<a href="http://www.annals.org/content/144/10/742.abstract">link</a>), and one by Goldzweig et. al in Jan. 2009 in Health Affairs (<a href="http://content.healthaffairs.org/cgi/content/abstract/28/2/w282">link</a>). These reviews were rather weak on substance, though, in terms of robustness that could support spending hundreds of billions of dollars on health IT as national policy. The former article concluded: <blockquote>Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear. </blockquote> The articles' conclusions matched my own writings from observation and critical thought about what I was seeing personally and hearing from Medical Informaticists in the field. Third point of interest: In the WSJ blog post comment section, several commenters including Dr. Jha opined on the issue of lack of regulation of health IT as a factor in its limited diffusion and benefit to date. In a comment of 8:06 am August 29, 2010 Jha wrote: <blockquote>... On the issue of FDA approval [of HIT devices - ed.] — this is a tricky issue on which reasonable people can disagree. FDA regulates devices that are used on patients (not on doctors and nurses) traditionally so you could make a very reasonable argument that this is out of their scope.</blockquote> This argument goes back to the customary notion of the clinician as "learned intermediary" thus providing a shield from liability for the vendors of commercial HIT systems. Here I disagree with Jha. I would argue, again from observation, that this notion is obsolete. For example, in an item from the HIStalk blog site news of 8/30/10 (<a href="http://histalk2.com/2010/08/28/monday-morning-update-83010/">lin</a><a href="http://histalk2.com/2010/08/28/monday-morning-update-83010/">k</a>): <blockquote>... [a reader] sent a UPMC internal document describing a quality improvement project at Shadyside [Shadyside Hospital, Pittsburgh - ed.]. Before Cerner was implemented, the ED stocked 95% of the meds they used in their automated dispensing cabinet and the other 5% were requested by tubing the paper order to pharmacy, resulting in a pretty good turnaround time of 28 minutes. With CPOE, the ED had no good way to alert pharmacy about those 5% of meds, so turnaround time shot up to over two hours. An ED nurse came up with a solution: tubing a yellow “Stat ED Med” card to pharmacy along with an index card listing the patient and med needed, dropping TAT back to six minutes. </blockquote>From the medical informatics perspective, the lesson here is that the physician is effectively no longer a “learned intermediary” between computer and patient when a complete system of EMR, CPOE, decision support etc. linked to Pyxis medication dispensing and other machines is constructed. This model from the earlier days of simple advice-giving and-records keeping health IT no longer holds (arrows represent interaction): <blockquote>[Computer] <---> [Clinician] <---> [Patient] </blockquote>Rather, the computer has become a cybernetic governor of care, as in a programmatic intermediary between clinician and patient regulating care operations: <blockquote>[Clinician] <---> [Computer] ---> [Patient] (note one way arrow). </blockquote>The fact that a “workaround” a.k.a. an “override around the cybernetic regulator of care” had to be created in order for appropriate care to be delivered in a critical care environment supports the latter conceptual and legal model. You should not have to work around something that is not in the way. In other words, the computer is now the intermediary. There only way around it are workarounds. Articles by Koppel on CPOE and barcoding workarounds are other examples of how the health IT system is now the intermediary between clinician and patient, not the clinician as learned intermediary between IT and patient. One might also ask - what is the cognitive impact of continually devoting intellectual power to create work arounds, which add to the already complex multi-tasking of clinicians? It likely is not a positive contributor to the best care. These and many other issue contribute to the low diffusion of health IT in 2010. It is interesting that much of this was known to people in Medical Informatics (at least those without industry conflicts of interest) through in situ observation of health IT projects, going back many years, in fact decades with regards to the pioneers (as mentioned in my post "<a href="http://hcrenewal.blogspot.com/2009/03/health-it-industry-out-of-control.html">Healthcare IT: How Much More Out of Control Can An Industry Be?</a>"). Finally: The question should be asked: will health IT ever achieve the benefits claimed for it? Will it ever "revolutionize", or even make substantial contributions to medicine in a cost effective, non negatively-disruptive fashion? Will we ever stop "doing it badly" (per Jha) and start consistently "doing it well" (per me?) I am beginning to believe that health IT will never be successful without a major revolution in the IT field itself. Currently, its culture is one of cavalier practices regarding talent management, and it lacks a culture of safety. In 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, made the observation that <blockquote>"... computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21).</blockquote> I believe the problem was -- and is -- not "computer engineering experts" but "business computing personnel." First, there's the issue of the customs and traditions of business IT. As I've written before, these rigid traditions are antithetical to the poorly bounded, rapidly changing, improvisation-rich world of clinical medicine. Second, the current status quo is highly profitable to the vendors, resulting in reactionary mindsets and conduct. Third, there is a lack of appropriate intellectual capital in leadership roles in health IT. Medicine is a largely scientific field. Automation in the field is a highly scientific endeavor. Yet the field is dominated by business computing personnel (usually of a management information systems background), instead of true computer scientists and engineers, human factors scientists, safety and risk management experts, information scientists, and the like. If my observations of who went into science/medicine/perhaps law vs. who went into business-related fields when I graduated high school and college are indicators, the very best scientific minds are poorly represented in healthcare IT leadership circles. In summary, both observations of health IT and research on health IT show many stumbling blocks towards achieving major, unequivocal, reproducible benefit with a robustness that could support spending tens or hundreds of billions of dollars on the technology in ambitious national-scale implementations. I fear that under the current culture of IT, achieving effective national health IT is Mission Impossible. <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-imfifVmqF1bRrF7kLtg-nUaCmMISSg7h-uXxtwDLeOFDAty9YXeqUBv6wGjrfq1giGtBJB-vO-d7OUYt1LvVDOMu3AveeQCt1uu1A1xXm3vyPdIEM13ZVg7sVWXpCHD5m5JrD0X89g8k/s1600/mission-impossible-66-tv-02-g.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5511040463156536722" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-imfifVmqF1bRrF7kLtg-nUaCmMISSg7h-uXxtwDLeOFDAty9YXeqUBv6wGjrfq1giGtBJB-vO-d7OUYt1LvVDOMu3AveeQCt1uu1A1xXm3vyPdIEM13ZVg7sVWXpCHD5m5JrD0X89g8k/s320/mission-impossible-66-tv-02-g.jpg" style="text-align: center; margin: 0px auto 10px; width: 203px; display: block; height: 258px; cursor: pointer;" /></a>Your mission, Mr. Phelps, should you choose to accept it... A vast body of new, critical thinking about the technology and its industry is needed. Aug. 30 note: As a result of a rather underhanded complaint to the blog owner (not to me, curiously) that I am not providing answers to the problems I write about, that the blog owner informed me of without naming names ... <blockquote style="font-style: italic;">... his long screed ends with "national Health IT is mission impossible"... and while he says "new, critical thinking is needed", he doesn't say what that is. His next post is even more out there. </blockquote> ... I will add this: I do not have all the answers (if I did, I'd sell them). This is a serious social problem. The best I can do, and have done, is point out <a href="http://www.tinyurl.com/hitfailurecases">what not to do</a> - and even that has not had much of an effect despite ten years of public writing in numerous venues. I do know that believing there's a major problem is the first and most important step to solving these vexing issues. We as a country and culture have not yet reached that point; irrational exuberance prevails. Thinking about health IT requires a reboot, but denial of the problems must stop before that can occur. I exert my efforts largely in an attempt to bring the health IT patient out of denial. Final addendum 8/31: On reconsideration, it's not as if I haven't offered advice on "what to do" as well; see for example my 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>." -- SS

Similar Conclusions on Health IT Via Observation and Via Research: Is HIT 'Mission Impossible'?

The Wall Street Journal reported on a study in Health Affairs entitled " A Progress Report On Electronic Health Records In U.S. Hospita...

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