Blast from the Anechoic Past: Former UCI Fertility Doctor Arrested in Mexico

Soon after we started Health Care Renewal, we ran a <a href="http://hcrenewal.blogspot.com/search/label/UCI">series of posts</a> about the University of California-Irvine (UCI) medical school and medical center, featuring stories of mismanagement of major programs, especially those involving organ transplantation (liver, kidney, and bone marrow) while the top executives who presided over the mess received generous compensation, sometimes in strikingly irregular ways, and while at least one whistle-blower alleged he lost his job for complaining about safety issues.  Some of the stories went back another 10 years, to 1995.  One particularly striking story involved the UCI infertility program.  Three physicians were accused of stealing ova from some women to implant in others.  One physician was convicted, and two fled the country (see post <a href="http://hcrenewal.blogspot.com/2006/02/more-trouble-but-also-little-hope-in.html">here</a>).<br /><br />One of those physicians just turned up.  As <a href="http://abcnews.go.com/Health/ReproductiveHealth/fugitive-fertility-doctor-ricardo-asch-arrested-mexico/story?id=12492575">reported</a> by ABC News at the end of 2010:<br /><blockquote>U.S. authorities are working to <em>extradite one of the doctors accused of being behind of the biggest fertility scandals in history</em>. Mexican authorities arrested Dr. Ricardo Asch last month. <br /><br />Back in the 1990s, <em>Asch and another fertility doctor, Jose Balmaceda, were charged with stealing embryos and eggs belonging to dozens of women who sought treatment at the University of California-Irvine Center for Reproductive Health and implanting them into other women.</em><br /><br />They are also <em>accused of not reporting more than $1 million in earnings, and fleeing the country to avoid prosecution</em>. <br /><br />Marla McCutcheon is one of the women who says she was victimized by Asch. She was one of his patients until she decided to switch physicians because she said she found him 'uncaring.'<br /><br />McCutcheon, from Irvine, Calif., says she found out years later that after she'd left Asch's care that there were leftover eggs she didn't know about. To this day, she doesn't know what happened to those eggs.<br /><br />'I would have done anything for those eggs at that time. It's still hard for me to grasp that there might be something to my eggs. Someone may have been able to get pregnant from them,' McCutcheon said.<br /><br />At the time of the scandal, ABC News saw documents showing that more than 60 other women who were patients at the fertility center had eggs taken from them without their consent. Asch, however, said he knew nothing about it. During the time the incidents occurred, it was not illegal to transfer human tissue without consent. </blockquote><br />The case had major repercussions for how fertility clinics operate:<br /><blockquote>The scandal allegedly involving Asch, Balmaceda and another doctor, Sergio Stone, <em>rocked the field of reproductive medicine, and doctors say they still feel its effects.</em><br /><br />'Reproductive medicine is very new. It's come a long way and we've made tremendous progress, but because of scientific advances, it's very high-profile,' said Dr. Jani Jensen, a Mayo Clinic reproductive endocrinologist in Rochester, Minn. 'Whenever there are publicized incidents like this that involve ethical issues, it's sometimes difficult to engender the public's trust.'<br /><br />Dr. Howard Zacur, director of the Division of Reproductive Endocrinology and Infertility at the Johns Hopkins Fertility Center in Baltimore, Md., said patients still want reassurance their eggs and embryos will be protected from these types of incidents.<br /><br />It is now against the law in California to take eggs from a woman without her consent. </blockquote><br />Note that the disconnect between problematic quality of care at UCI and the generous compensation afforded its top leaders continued through 2010, as <a href="http://hcrenewal.blogspot.com/2010/01/uci-medical-center-fails-inspection-uci.html">this post </a>discussed. <br /><br />Aside from its colorfulness, there are other reasons to recall the story of the stolen ova and the subsequent troubles at UCI.  First, the list of problems over 15 years discussed in our series of posts suggests an institution whose leadership culture is seriously disturbed.  I cannot view the institution from a distance and figure out what the fundamental problems are with its leadership and governance, but there must be some.  (Note that per a <a href="http://hcrenewal.blogspot.com/2006/02/mismanagement-in-oc-report-on-uci.html">2006 post</a>, an internal report did fault lack of accountability, leadership by people with no medical background, absence of clear reporting lines, and the overlooking of whistleblowers, but these are just descriptions of bad management and governance, not explanations of them.  Furthermore, it is not clear whether there have been any fundamental changes in leadership or governance since then.  If there readers know there is more to this, please let me know in the comments section below.)<br /><br />Second, this case illustrates how the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> has decreased recognition that the problems at UCI may be part of more systemic problems.  Despite the number of problems that occurred, their vividness, and their coverage in local media, the troubles at UCI have not gotten national media attention, nor as far as I can tell, have they ever been discussed in the medical, health care, health services research, or health policy literature.  (I have tried multiple Google scholar searches using the institution's name, and keywords including "scandal," and the names of some of the physicians most prominently named in our series of posts, and have found nothing relevant.)  The 15 year history has produced almost no echoes, and hence now has become as striking a black hole in the annals of bad health care leadership and governance as was the case of the fall of the <a href="http://hcrenewal.blogspot.com/search/label/AHERF">Allegheny Health Education and Research Foundation</a> (AHERF).  <br /><br />Certain issues that we discuss on Health Care Renewal have become less anechoic, in particular, conflicts of interest caused by academic physicians financial ties to the drug, biotechnology and device industries.  However, the larger issues of mismanagement by lavishly compensated, and hence perversely incentivized executives remains relatively anechoic.  I am not sure how big a scandal it will take to remove the taboo from discussing it. 

Blast from the Anechoic Past: Former UCI Fertility Doctor Arrested in Mexico

Soon after we started Health Care Renewal, we ran a series of posts about the University of California-Irvine (UCI) medical school and medical center, featuring stories of mismanagement of major progr…

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Institute of Medicine Committee on Patient Safety and Health Information Technology, and Thoughts on Social Aspects of Health IT Evaluation

<div style="text-align: center;"><span style="font-style: italic;font-size:85%;" >March 2011 addendum: also see my thoughts on Meeting two of the Committee on Patient Safety and Health Information Technology <a href="http://hcrenewal.blogspot.com/2011/03/committee-on-patient-safety-and-health.html">at this link</a>.</span><br /></div><br />The U.S. National Research Council of the <a href="http://www.nationalacademies.org/">National Academy of Sciences</a> issued a report in early 2009 on the state of health IT.<br /><br />That study's report, led in part by pioneers in Medical Informatics G. Octo Barnett and William Stead, was entitled "<span style="font-weight: bold;">Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions</span>" (pre-publication PDF available free at <a href="http://www.nlm.nih.gov/pubs/reports/comptech_prepub.pdf">this link</a>). The report was announced under the following header:<br /><a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572"><br /><span style=";font-family:Arial;font-size:10pt;color:black;" ></span></a><blockquote><span style="font-size:100%;"><a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572"><span style=";font-family:Arial;color:black;" >CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT </span></a></span></blockquote><br />The insufficiencies were largely in the areas of difficulties with data sharing and integration, deployment of new IT capabilities, large-scale data management, and lack of cognitive support by health IT for busy clinicians.<br /><br />One might reasonably conclude such deficits could affect patient safety.<br /><br />Recently the <a href="http://www.iom.edu/About-IOM.aspx">Institute of Medicine</a> (the health arm of the National Academy of Sciences) formed a Committee to study health IT safety. It held its first meeting on Dec. 14, 2010 (quite a few years late in my opinion, and only <span style="font-style: italic;">after</span> tens of billions of dollars have been earmarked for health IT, but better late than never):<br /><blockquote><br />The <a style="font-weight: bold;" href="http://www.iom.edu/Activities/Quality/PatientSafetyHIT.aspx">Institute of Medicine Committee on Patient Safety and Health Information Technology</a> is holding its first meeting on December 14-15, 2010. The first day, December 14, 2010 beginning at 10:30 am, is open to the public to observe the committee proceedings. The committee will hear presentations by the Office of the National Coordinator and other invited guests. There will also be an opportunity for members of the public and representatives of interested organizations to make a brief statement before the committee. Prior registration is requested for attendees and required for those wishing to make a statement.</blockquote><br />Participant lists and materials from that first meeting are available at <a href="http://www.iom.edu/Activities/Quality/PatientSafetyHIT/2010-DEC-14.aspx">this link</a>.<br /><br />This brings to mind some thoughts on the social aspects of health IT evaluation.<br /><br />At a website by Dr. David Healy (<a href="http://www.healyprozac.com/">link</a>) on mass over-promotion and clinical trial data irregularities regarding SSRI's, academic abuses towards critical thinkers, and related affairs, I note an interesting observation in the preface. The author states:<br /><br /><blockquote>"On the face of it, the investigation of possible hazards posed by SSRIs does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of pharmaceutical company influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues."</blockquote><br />This sounds eerily familiar with regard to another domain in biomedicine - health IT.<br /><br />Allow me to substitute a few words:<br /><br /><blockquote>"On the face of it, the investigation of possible hazards posed by <span style="font-weight: bold;">clinical information technology</span> does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of <span style="font-weight: bold;">information technology company</span> influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues."</blockquote><br /><br />Only recently do I note this phenomenon starting to lift. I've aggregated a number of reports and articles of recent years that take a critical-thinking attitude about health IT safety, efficacy, and sociopolitical matters such as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">here</a> and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=other">here</a>. I intend to broaden and deepen this aggregation to make it more comprehensive in the coming months.<br /><br />This is a somewhat personal exercise as my relative was severely injured in 2010 by health IT interference with clinician communications.<br /><br />However, it's also a professional endeavor. I will be presenting at a regional health care attorney's meeting in a few months on health IT risks. In my talk I will undoubtedly recommend aggressive litigation when HIT is implicated in patient injury, and investigations of potential contributions of health IT to medical malpractice when not readily apparent. I am not alone in this stance.<br /><br />Several weeks ago I also asked the IOM Committee on Patient Safety and Health Information Technology to be allowed to present my mother's case at some point, a tragic and ironic example of a family member of a physician and Medical Informatics specialist (not just a layperson) injured as a result of health IT. I have not yet received a reply.<br /><br />Evaluation of health IT will likely become more than an academic endeavor in the next few years. Those engaged in it might find themselves called as expert witnesses - or as defendants.<br /><br />I see a legal storm approaching in health IT. This is a domain I am somewhat familiar with, as pre-informatics I was a medical officer in public transit making safety-related medical decisions on transit authority/DOT-related matters, at a time when nationally-mandated random drug testing in the industry had recently begun. The legal implications of such work can be quite unexpected - and profound, especially when interfered with by outside sources with conflict of interest (e.g., labor unions). Train wrecks - literally, accompanied by litigation through the roof.<br /><br />To those involved in health IT, this is not a scientific opinion, and thus feel free to ignore it.<br /><br />At your own peril IMO.<br /><br />-- SS

Institute of Medicine Committee on Patient Safety and Health Information Technology, and Thoughts on Social Aspects of Health IT Evaluation

March 2011 addendum: also see my thoughts on Meeting two of the Committee on Patient Safety and Health Information Technology at this link.The U.S. National Research Council of the National Academy o…

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Some Call it "Tyranny" - Top Leaders of University of California (Including Leaders of Academic Medicine) Demand Bigger Pensions for Themselves

The state of California, and its flagship university system, the University of California, have been under extreme financial pressure lately.  <br /><br /><strong>The 36 Executives' Demands</strong><br /><br />However, that apparently has not decreased the University's hired managers' and executives' sense of entitlement.  They are threatening to sue if their pensions are not increased.  As reported <a href="http://articles.sfgate.com/2010-12-29/news/26349177_1_uc-employees-uc-system-higher-pensions">by the San Francisco Chronicle</a>,<br /><blockquote><em>Three dozen of the University of California's highest-paid executives are threatening to sue unless UC agrees to spend tens of millions of dollars to dramatically increase retirement benefits for employees earning more than $245,000.</em><br /><br />'We believe it is the University's legal, moral and ethical obligation' to increase the benefits, the executives wrote the Board of Regents in a Dec. 9 letter and position paper obtained by The Chronicle.<br /><br />'Failure to do so will likely result in <em>a costly and unsuccessful legal confrontation</em>,' they wrote, using capital letters to emphasize that they were writing 'URGENTLY.'<br /><br /><em>Their demand comes as UC is trying to eliminate a vast, $21.6 billion unfunded pension obligation by reducing benefits for future employees, raising the retirement age, requiring employees to pay more into UC's pension fund and boosting tuition.</em> <br /><br />The fatter executive retirement benefits the employees are seeking would add $5.5 million a year to the pension liability, UC has estimated, plus $51 million more to make the changes retroactive to 2007, as the executives are demanding.<br /><br />The executives fashioned their demand as a direct challenge to UC President Mark Yudof, who opposes the increase.<br /><br />'Forcing resolution in the courts will put 200 of the University's most senior, most visible current and former executives and faculty leaders in public contention with the President and the Board,' they wrote. </blockquote><br /><strong>Background to the Case</strong><br />Here is the relevant background:<br /><blockquote>The roots of the pension dispute go back to 1999, five years after the IRS limited how much compensation could be included in retirement package calculations. But even after the IRS granted UC's waiver in 2007, nothing changed.<br /><br />University executives were having troubles of their own that year.<br /><br />President Robert Dynes resigned in 2007 after it was discovered that UC was awarding secret bonuses, perks and extra pay to executives. State auditors also found that UC's compensation practices were riddled with errors and policy violations.<br /><br />UC officials also had become aware of another big problem: UC's pension obligations were about to outstrip its ability to pay retirees. Neither UC nor its employees had paid into the fund since 1990.<br /><br />It took until this year for UC to act. In September, a retirement task force offered Yudof several options for closing the $21.6 billion gap - and one to widen it: increasing executive pensions.</blockquote><strong>Health Care Executives Included</strong><br /><br />Note that in addition to a bunch of finance officers and portfolio and asset managers, the demanding executives included quite a few leaders of the medical schools, and academic medical centers, including:<br /><blockquote>UC System's Central Office<br />Dr. Jack Stobo, senior vice president, health services and affairs<br /><br />UCSF<br />Dr. Sam Hawgood, vice chancellor and dean, School of Medicine<br />Ken Jones, chief operating officer, medical center<br />Mark Laret, CEO, medical center<br />Larry Lotenero chief information officer, medical center<br />John Plotts, senior vice chancellor<br /><br />UC Davis<br />William McGowan, CFO, health system<br />Dr. Claire Pomeroy, CEO health system, vice chancellor/dean, School of Medicine<br />Ann Madden Rice, CEO Medical Center<br /><br />UCLA<br />Dr. David Feinberg, CEO of the hospital system; associate vice chancellor<br />Dr. Gerald Levey, dean emeritus<br />Virginia McFerran, chief information officer of the health system<br />Amir Dan Rubin, chief operating officer of the hospital system<br />Dr. J. Thomas Rosenthal, chief medical officer of the hospital system; associate vice chancellor<br />Paul Staton, chief financial officer of the hospital system<br /><br />UC San Diego<br />Dr. David Brenner, vice chancellor for health sciences; dean of the School of Medicine<br />Tom Jackiewicz, CEO, associate vice chancellor of the health system<br />Dr. Thomas McAfee, dean for clinical affairs<br /><br />UC Irvine<br />Terry Belmont, CEO, Medical Center</blockquote><strong>The Outraged Reaction</strong><br />The executives' demands sparked anger on campus.<br /><br /><blockquote>Dissenting members of the task force said it would be<em> <strong>unseemly</strong>' to expand executive pensions</em>. Tuition had just been increased by 32 percent this fall, and the regents were poised to raise it another 8 percent for fall 2011. They also voted to shift more money into the retirement fund from employees' pockets, as low-wage workers worried about retiring into poverty.<br /><br />'I think it's <em><strong>pretty outrageous</strong></em> that this group of highly compensated administrators of a public university are challenging the president and the chair of the Board of Regents, said Daniel Simmons, chairman of UC's Academic Senate and a law professor at UC Davis.<br /><br />'What <strong><em>outrages me</em></strong> the most is that these 36 people are blind to the fact that this is a public entity in dire straits,' said Simmons, who also served on the retirement task force and opposed the higher pensions.</blockquote><br />The demands prompted outrage from politicians and editorialists. A few choice samples:<br /><br />- The executives are "<em><strong>tarnishing the university's name with greed</strong></em>," <a href="http://www.dailybruin.com/index.php/article/2011/01/with_the_uc_in_crisis_senior_executives_should_be_helping_to_fix_the_budget_instead_of_demanding_a_f">editorial (UCLA) Daily Bruin</a>.<br /><br />- "<em><strong>Very out of touch</strong></em>," by Governor Elect Jerry Brown; "<em><strong>truly living in an ivory tower</strong></em>...." while "people are suffering in the rest of the state and losing their homes," by Assemblyman Jerry Hill, D- San Mateo (<a href="http://articles.sfgate.com/2010-12-30/bay-area/26350890_1_uc-system-higher-pensions-uc-execs">per the San Francisco Chronicle</a>)<br /><br />- "<em><strong>Uncaring and divisive</strong></em>," "<em><strong>undercuts public support</strong></em> for one of California's most treasured institutions," "sending out its own special-interest message: <em><strong>what's in it for me</strong></em>," - <a href="http://articles.sfgate.com/2010-12-30/bay-area/26350890_1_uc-system-higher-pensions-uc-execs">editorial, San Francisco Chronicle</a>.<br /><br />- "<em><strong>despicable threat</strong></em>," the California Regents (UC board of trustees) should not "claim that lavish pension may be needed to recruit good people to UC. <em><strong>Good people don't threaten lawsuits against a cash-strapped sate to enrich themselves.</strong></em>" <a href="http://www.sacbee.com/2011/01/02/3290033/editorial-uc-executives-offer.html">editorial, Sacramento Bee</a>.<br /><br />- Governor-Elect B4rown should issue an executive order "to <em><strong>eliminate any position in the University of California system paying $245,000 a year or more</strong></em>," (thus effectively firing all the 36 complaining executives); "free taxpayers and students alike from the <em><strong>tyranny of those whose main objective during any time - tough or otherwise - is to keep milking the state for every penny the can squeeze out</strong></em>," <a href="http://www.mantecabulletin.com/news/article/19725/">editorial, Manteca Bulletin</a>.<br /><br /><strong>Summary</strong><br /><br />We have posted frequently about hired managers and executives of health care organizations receiving <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation</a> and <a href="http://hcrenewal.blogspot.com/search/label/executive%20life%20style">benefits</a> out of all proportion to their apparent performance. The case of the demanding University of California executives is just one of many. However, what is really remarkable about this case is the reaction to it. We are hearing top leaders, including many of the top leaders of the state's medical schools and academic medical centers, called uncaring, greedy, and despicable by well-known politicians and in newspaper editorials, and we are hearing calls that they be fired, en masse.<br /><br />Maybe we are at a tipping point. <br /><br />Of course, hired health care managers and executives are not entitled to line their own pockets while patients and their other constituencies suffer during the great recession. They are not entitled to continually drive health care costs up while they enrich themselves. <br /><br />However, apathy,<a href="http://hcrenewal.blogspot.com/search/label/learned%20helplessness"> learned helplessness</a>, and the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> have let them promote themselves into a de facto new aristocracy (just like the hired managers and executives of some other non-profit organizations, for-profit corporations, and especially financial service corporations have turned themselves into the rest of that aristocracy.)<br /><br />If we do not reclaim health care from these new oligarchs, we will all end up not just with expensive, difficult to access, mediocre health care, but under their tyranny.<br /><br /><strong>Post-Script</strong><br /><br />This is just the latest example of the sense of entitlement displayed by the hired managers and executives of the University of California. Outrageous pay and benefits unjustified by any measure of performance for University of California's hired managers and executives has been grist for the Health Care Renewal mill since 2005.  A few samples:<br />-  The ranks of those paid more than $200 K rose much faster than those paid less, while lower paid employees endured a pay freeze, and the university cut its budget.  Managers got bonuses for extra work, while faculty did not.  Managers got housing allowances, and other perks.  (<a href="http://hcrenewal.blogspot.com/2005/11/leadership-living-large-at-university.html">November, 2005</a>)  <br />- UC-Irvine managers were paid lavishly while presiding over debacles involving transplant services  (liver transplants, <a href="http://hcrenewal.blogspot.com/2005/11/university-of-california-irvine-shuts.html">November, 2005</a>; bone marrow transplants, <a href="http://hcrenewal.blogspot.com/2006/01/even-more-trouble-in-oc-uci-bone.html">January, 2006</a>; kidney transplants, <a href="http://hcrenewal.blogspot.com/2006/01/california-bad-dreamin-more-troubles.html">January, 2006</a>)<br />- UC - San Diego Chancellor was paid $359 K plus a bonus of $248 K for supposed full time work while serving on ten for-profit corporate and non-profit boards, including directorships of for-profit health care corporations that were conflicts of interest with her role overseeing the medical school and medical center.  This was the first case of what we later called the "new species of conflicts of interest" posted on the blog.  (<a href="http://hcrenewal.blogspot.com/2006/01/california-nightmares-more-troubles-at.html">January, 2006</a>)<br />- UC - Irvine managers got bonuses while its medical center failed an inspection (<a href="http://hcrenewal.blogspot.com/2010/01/uci-medical-center-fails-inspection-uci.html">January, 2010</a>), as did managers at other UC campuses (<a href="http://hcrenewal.blogspot.com/2010/01/more-california-medical-centers-plagued.html">January, 2010</a>).<br /><br />Maybe if these older stories produced more outraged, the current situation would not have occurred. <br /><br />You heard it first on Health Care Renewal <br /><br />Hat tip to Prof Margaret Soltan <a href="http://www.margaretsoltan.com/?p=28524">on the University Diaries blog</a>.

Some Call it "Tyranny" - Top Leaders of University of California (Including Leaders of Academic Medicine) Demand Bigger Pensions for Themselves

The state of California, and its flagship university system, the University of California, have been under extreme financial pressure lately.  The 36 Executives' DemandsHowever, that apparently has no…

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BLOGSCAN - Health IT Debacle Down Under?

<span style="color: rgb(102, 102, 0);"><span style="color: rgb(204, 153, 51);">From the blog</span> "</span><a style="color: rgb(102, 102, 0);" href="http://aushealthit.blogspot.com/">Australian Health Information Technology</a><span style="color: rgb(102, 102, 0);">" <span style="color: rgb(204, 153, 51);">by Dr David More MB, PhD, FACHI:</span></span><br /><br /><blockquote><span style="color: rgb(153, 153, 0);">Monday, January 03, 2011</span><br /><br /><a href="http://aushealthit.blogspot.com/2011/01/nsw-health-has-full-blown-health-it.html"><span style="font-weight: bold;">NSW Health Has A Full Blown Health IT Failure on Its Hands. As I Predicted in 2006!</span></a><br /><br /><span style="color: rgb(204, 153, 51);">The Healthelink Project, which was to provide a prototype for a Shared EHR for NSW has essentially imploded. </span><br /><br /><span style="color: rgb(204, 153, 51);">Information provided to this blog confidentially confirms both the number of participants in the project and their information transmission activities have both fallen through the floor over the last 12 months! To protect sources I can’t provide much detail concerning the evidence I have seen, but it is clear and dramatic and confirms what I have been saying for a good while. Sadly HealtheLink is such a badly wounded animal that it really now needs to be helped to pass to a much better place!</span></blockquote><br /><span style="color: rgb(204, 153, 51);">Are the national health IT efforts in the US headed in the same direction?</span><br /><br /><span style="color: rgb(204, 153, 51);">Read the entire post at the link above.</span><br /><br /><span style="color: rgb(204, 153, 51);">-- SS</span>

BLOGSCAN - Health IT Debacle Down Under?

From the blog "Australian Health Information Technology" by Dr David More MB, PhD, FACHI:Monday, January 03, 2011NSW Health Has A Full Blown Health IT Failure on Its Hands. As I Predicted in 2006!The …

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New York Times: The Doctor vs. the Computer Fool

<div style="text-align: center;"><span style="font-size: 85%;"><span style="font-weight: bold;">"Wise men learn more from fools than fools from wise men." </span>- Chinese proverb</span></div><br />A stunning story was published in the New York Times entitled "<span style="font-weight: bold;">The Doctor vs. the Computer</span>."<br /><br />A more appropriate title would have been "The Doctor vs. the Computer <span style="font-style: italic;">Fool</span>."<br /><br />The computer is simply a tool and is not the doctor's opponent; rather, the people under whose auspices the IT was designed and implemented are the physician's foes here:<br /><br /><span class="timestamp published" title="2010-12-30T10:19:32+00:00"> <span class="date"></span></span><br /><blockquote><span class="timestamp published" title="2010-12-30T10:19:32+00:00"><span class="date">New York Times<br />December 30, 2010, <i>10:19 am</i></span></span><span style="font-weight: bold;"><br /></span><a href="http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/" style="font-weight: bold;">The Doctor vs. the Computer</a> <br /><address class="byline author vcard">By DANIELLE OFRI, M.D.<br /><a class="url fn" href="http://well.blogs.nytimes.com/author/danielle-ofri-md/" title="See all posts by DANIELLE OFRI, M.D."></a></address><br />Electronic medical records promise efficiency, safety and productivity in the switch from paper to computer. But there are glitches, as a patient of mine recently brought to light.<br />My patient needs prostate surgery. It is my job, as his internist, to estimate the risks this surgery poses, decide whether he can proceed with the surgery and make recommendations for his medical management before and after the operation. <br />He is an extremely complicated patient. His hypertension requires three concurrent medications. He’s taking pills for diabetes, but he really should be giving himself insulin injections. His kidneys are wending their way toward dialysis. A few years ago he had a reaction to a diabetes medication that caused congestive heart failure. His aortic valve is narrowed — not severely, but enough to keep me on edge.<br /><div style="font-weight: bold;">Estimating my patient’s surgical risk and planning for his operative care is not a straightforward process. </div></blockquote>The complexities are anything but linear and deterministic, and judgment borne of experience is essential. No algorithm will replace this process in my lifetime, I suspect.<br /><blockquote>After our physical exam, I sit down to write a detailed evaluation, because I want the surgeons and anesthesiologists to fully understand the complexity of his situation. </blockquote>In medicine, if you don't know your patient and their history, <span style="font-style: italic;">your patient's dead.</span><br /><blockquote>As I type away, I feel like I’m doing the right thing, explicating my clinical reasoning rather than just plugging numbers into a formula. I’m midway into a sentence about kidney function when the computer abruptly halts.<br />I panic for a moment, fearful that the computer has frozen and that I’ve lost all my work — something that happens all too frequently. But I soon realize that this is not the case. Instead, I’ve come up against a word limit.<span id="more-43619"></span><br /><span style="font-weight: bold;">It turns out that in our electronic medical record system there is a 1,000-character maximum</span> in the “assessment” field. <span style="color: red; font-style: italic; font-weight: bold;"> [Brilliant! - ed.]</span> While I’ve been typing, the character number has been counting backward from 1,000, and now I’ve hit zero. <span style="font-weight: bold;">The computer will not permit me to say anything more about my patient. </span></blockquote>I see no reason for any degree of politeness or sensitivity regarding this <a href="http://www.tinyurl.com/hostileuserexper">mission hostile "feature" of a clinical documentation system</a>. The person(s) who either designed the system this way and/or set constraints such as this were <a href="http://dictionary.reference.com/browse/fool"><span style="font-weight: bold;">fools</span></a> - on first principles - for imposing such a limitation.<br /><blockquote>... In desperation, I call the help desk and voice my concerns. “<span style="font-weight: bold;">Well, we can’t have the doctors rambling on forever</span>,” the tech replies.</blockquote>"We" can't?<br /><br />Yes, I guess "we", a.k.a. the computer Einsteins who've invaded clinical medicine (or more precisely, who've been <span style="font-style: italic;">permitted</span> to invade clinical medicine), a domain in which they are most often manifest laypeople, cannot let the doctors "ramble."<br /><br />Uses up too many electrons - or something.<br /><br />Case closed.<br /><br />In a way this story reminds me of capricious, mission hostile IT limitations I heard about ca. 2002 or '03. I was demonstrating the Saudi Arabia-Yale Genetics Research Database (SAYGR) I'd authored in 1993-5 to world-class AIDS researcher Emilio Emini, in my role as Director of Scientific Information Resources, Research Information Systems division, Merck Research Labs where Dr. Emini was employed at that time.<br /><br />SAYGR by design placed no artificial limitations on the number of descriptors for an entity, nor on the number of user-defined entities (such as lab test results and descriptors of the results) that could be created, even out in the field, by an enduser. Yet I'd developed it with early 1990's relational database technology.<br /><br />Emini remarked that SAYGR was much more advanced than the database tools he was provided by the research IT dept., which fixed the number of descriptors to five or perhaps ten per item (probably thus avoiding the need to set up relational tables to make the programmer's job easier). This limitation was often insufficient for the needs of his advanced AIDS research. Again, brilliant.<br /><br />I will add that there are many good jobs awaiting arrogant computer fools -- if only they'd be thrown out of the medical arena and replaced with IT personnel of a service mentality, who understand the limitations of lack of clinical knowledge and experience, and the asymmetric responsibilities, obligations and liabilities of clinicians compared to their own banal <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">data processing jobs</a>.<br /><br />Deciding on lifeboat capacities for the Titanic, gas tank safety measures for the Ford Pinto, fail-safe systems for the Chernobyl nuclear power plant, and final launch decisions on the Space Shuttle Challenger in cold weather come to mind.<br /><br />-- SS<br /><br /><span style="font-weight: bold;">1/4/11 addendum:</span><br /><br />To those who might think a 1000-character text field limitation of a modern EHR is to save storage space that would have to be "reserved" or set aside to hold longer comments, just consider that your hard disk does not "reserve space" <span style="font-style: italic;">a priori</span> to hold long files. The operating system allocates space dynamically as needed, up to rather massive limits per file set via internal OS and microprocessor addressing characteristics.<br /><br />My aforementioned SAYGR application, initially developed with early 1990's relational technology, limited comment and impression fields as well - but to <span id="search" style="visibility: visible;">appx. 65,535 (64k) characters maximum. The workstations it ran on in the field had precisely 16 megabytes of RAM and 500 megabyte hard drives. (Yes, mega-, not giga-.)<br /><br />I believe health IT vendors in 2011 can do far better than 1000-character impression fields.<br /><br />Others have commented on possible workarounds to this limit. To them, I remind them of this simple wisdom I first posted at my <a href="http://www.tinyurl.com/hostileuserexper">series on mission hostile health IT</a>:</span><br /><blockquote><span id="search" style="visibility: visible;"><br /></span><span id="search" style="visibility: visible;"><span style="font-weight: bold;">"You should not have to work around something that is not in the way." </span></span></blockquote><span id="search" style="visibility: visible;"><br /></span><span id="search" style="visibility: visible;">-- SS</span>

New York Times: The Doctor vs. the Computer Fool

"Wise men learn more from fools than fools from wise men." - Chinese proverbA stunning story was published in the New York Times entitled "The Doctor vs. the Computer."A more appropriate title would h…

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BLOGSCAN - On Device Company's Obfuscation of the Reasons for Payments to Surgeons

<span style="color: #38761d;">On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody </span><a href="http://brodyhooked.blogspot.com/2010/12/in-defense-of-paranoia-suspecting.html"><span style="color: #38761d;">analyzed</span></a><span style="color: #38761d;"> further the case of the huge royalties paid to spine surgeons by Medtronic (see our most recent post </span><a href="http://hcrenewal.blogspot.com/2010/12/spine-surgeons-reticent-about.html"><span style="color: #38761d;">here</span></a><span style="color: #38761d;">).  He wondered why surgeons would get such sizable payments for "intellectual property" related to devices that they neither seemed to use or to research?  I would note that the lack of clarity about the reason for Medtronic's payments to these surgeons is just part of a larger lack of clarity about most of the payments made to physicians and medical and health care academics for "consulting" or serving on advisory boards.  If such professional-industrial collaboration is so important for "innovation," one wonders why the people engaged in it are almost never willing to disclose the topics of these wonderful interchanges?</span>

BLOGSCAN - On Device Company's Obfuscation of the Reasons for Payments to Surgeons

On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody analyzed further the case of the huge royalties paid to spine surgeons by Medtronic (see our most recent post here).  He wondered why s…

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BLOGSCAN - Wandering in the Wilderness

<span style="color: #38761d;">On the 1 Boring Old Man blog, "Mickey," the anonymous blogger, a retired academic psychiatrist, </span><a href="http://1boringoldman.com/index.php/2010/12/31/my-cocoon/"><span style="color: #38761d;">posted</span></a><span style="color: #38761d;"> about how he figured out the extent that health care dysfunction affected psychiatry while wandering the "wildnerness" outside of academic psychiatry.  He proposed that what needs to die is "the shameful mockery many have made of their own rallying cry - 'evidence based medicine'…"  Dr Wally Smith would have called it </span><a href="http://hcrenewal.blogspot.com/search/label/pseudo-evidence%20based%20medicine"><span style="color: #38761d;">pseudo-evidence based medicine</span></a><span style="color: #38761d;">.   (And thanks for the mention of Health Care Renewal.)</span>

BLOGSCAN - Wandering in the Wilderness

On the 1 Boring Old Man blog, "Mickey," the anonymous blogger, a retired academic psychiatrist, posted about how he figured out the extent that health care dysfunction affected psychiatry while wander…

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