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Are Those Sockpuppers From Down Under?

We at Healthcare Renewal have had experience with the healthcare sock puppets. They are shills, a person or group working on behalf of a company or other special interest. They attempt to use distraction, ad hominem, misdirection and other psyops tactics to attack points of view they don't like. They also plant memes they or their sponsor deem desirable. They are universally anonymous in their postings. One got careless and got nailed via IP forensics, as at my Jan. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?</a>" and my semi-satirical followup post a few days later, "<a href="http://hcrenewal.blogspot.com/2010/01/socky-meditech-sockpuppet-on-vacation.html">Socky the Meditech Sockpuppet on Vacation?</a>" after he/she disappeared after exposure. A Healthcare Renewal reader with an MBA at that time non-anonymously related the following (emphases mine): <blockquote>In reading this thread of comments I have to believe IT Guy [the Sock puppet - ed.] is a salesperson. My only question is: Were you assigned this blog or did you choose it? We had this problem a number of years ago where a salesperson was assigned a number of blogs with the intent of using up valuable time in trying to discredit the postings. In my very first sales class we learned to focus on irrelevant points, constantly shift the discussion, and generally try to distract criticism. I would say that HCR is creating heat for IT Guy’s employer and the industry in general. I find it sad that a company would allow an employee to attack anyone in an open forum. IT Guy needs to check with his superiors to find out if they approve of this use of his time, and I hope he is not using a company computer, unless once again this attack is company sanctioned. Steve Lucas</blockquote> It seems this foul type of creature is starting to crawl out of the woodwork regarding Prof. Jon Patricks' analysis of an ED EHR system mandated by the state's government of NSW for public hospitals, as I wrote about in my posts such as on Mar. 5, 2011 at "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.</a>". They may be corporate, they may be government. They likely have a financial stake in the ED EHR project as well. For instance, the sockpuppet/shill comments are starting to appear at the Australian Health Information Technology blog of Dr David More MB, PhD, FACHI at <a href="http://aushealthit.blogspot.com/">http://aushealthit.blogspot.com</a>: <blockquote>This blog has only three major objectives. The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide. The second is to provide commentary on what seems to have become the lamentable state of e-Health in Australia and to foster improvement. The third, sadly, is now to try and force accountability for the actions of, and the funds spent, by NEHTA. [National E-Health Transition Authority <a href="http://www.nehta.gov.au/about-us/contact-us">as at this link</a> - ed.] </blockquote> (Sounds like a kindred mission relative to HC Renewal.) For instance at Dr. More's post "<a href="http://aushealthit.blogspot.com/2011/03/prof-patrick-has-really-hit-bullseye-it.html">Prof Patrick Has Really Hit the Bullseye It Would Seem. Lots of Supportive Comments From All Over!</a>" we see the following sock puppet-like comments rearing their holey (not holy) woven head: <blockquote>... It seems that the heuristic axiom of Ockham’s Razor (as presented by Jon) is the design criteria by which Jon thinks NSW Health should have selected their CIS ... unbelievable! Unfortunately Jon has not proposed any practical alternatives in his papers. His papers are full of opinions, unfounded claims and incorrect facts (not to mention the countless flaws in his research methodologies). </blockquote>and <blockquote>Dr Patrick - you are so misinformed. There are so many untruths in what you report. Why is this? Because you interviewed 7 people. Being Directors, what is the likelihood they are hands on with the system? Minimal I would say from experience in the EDs. Call yourself a researcher - huh! It is a totally biased report which reflects the opinions of those with an axe to grind. Why don't you talk to some nurses,clerical staff and junior doctors? There are hundreds of them working in EDs across the state. Their opinion should matter as they are the ones caring for our patients. You should be ashamed of yourself! I certainly would not hire you to do a research project if this is the biased and blatantly incorrect rubbish that you come up with. Shame on you!! </blockquote> and the ever-so-common refrain of: <blockquote> Has Dr Patrick ever completed (or even been involved in) an implementation of an EMR (at all or of any scale)? Can someone tell us what makes him an authority the subject? [I, OTOH, have done so, authoring, implementing, managing for hospitals and major pharma - ed.] ... His view is unbalanced and his paper is clearly bias. How Sydney University tolerates papers of such poor quality and biasness (being published by their professors) is beyond me. [Paper is 'clearly bias'? Biasness? This person needs a grammar lesson - ed.] </blockquote> Ink is never put to specifics of the supposed transgressions in these largely <a href="http://www.nizkor.org/features/fallacies/ad-hominem.html">ad hominem</a>, anonymous attacks. If those who wrote them had the fortitude to identify themselves, perhaps they might be somewhat credible. However that rarely if ever is the case. In my humble opinion, such comments are risible, not even worth the electrons they're written with. Except for amusement: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3DtCGREf4I9i7ZUFKWW3kCq2yWxsrw3okOy0YckEIFo4dqu0qNZkdqiOwcKXBoV3ptTR9LjEJ3yg5dBmYoDv9qBXxNd8hFXNWAKUsUb8xEG4keQovVddB6Oj0ZWsvlFynC5Keh5eqlxJG/s1600/sockpuppet2.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5581573263825574290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3DtCGREf4I9i7ZUFKWW3kCq2yWxsrw3okOy0YckEIFo4dqu0qNZkdqiOwcKXBoV3ptTR9LjEJ3yg5dBmYoDv9qBXxNd8hFXNWAKUsUb8xEG4keQovVddB6Oj0ZWsvlFynC5Keh5eqlxJG/s320/sockpuppet2.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 129px; height: 148px;" /></a>Socky the Health IT Sockpuppet. Click to enlarge. </div> p.s. an ED EHR-injured relative of mine has a message to the sockpuppets of the world. It's not fit for a public site, but it has to do with travel to a very hot, deep, sulfurous place in the earth. -- SS

Are Those Sockpuppers From Down Under?

We at Healthcare Renewal have had experience with the healthcare sock puppets. They are shills, a person or group working on behalf of a co...

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EHR ED's in New South Wales. Will the Problems Magically "Disappear?"

It occurs that one could look at Prof. Jon Patrick's recent <a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">health IT forensic analysis</a> as a kind of "indictment" of the industry. He can be seen as suggesting the industry needs to be "put on trial" (figuratively) regarding "crimes" (again, figuratively speaking) they've committed with regard to IT robustness and reliability. The latter translate directly to patient safety. In a lawsuit such as a medical malpractice trial, obvious as well as potential evidence is put under "legal hold." For instance, if an EHR defect is suspected, metadata, audit trails, and patient data are asked (or should be asked) to be frozen or archived in the state they were in at the time of the alleged accident. It can take a page or three (or more) of specifications simply to define what information, exactly, needs to be put on legal hold. My former staff were frequently required to place myriad materials on legal hold at Merck Research Labs, for example, baed on the lawsuit du jour. Once frozen, discovery and forensic analysis of these now-static data can then proceed. In fact, cases can be lost on the basis of evidence of an archiving omissions, destruction or tampering when information holds are requested. It occurs to me that Prof. Patrick has given the industry a detailed look into factors they could start to remediate, without publicity and without telling anyone. While this would be a net plus for patients, it might result in less of a learning experience to the industy than that industry needs, to motivate the industry to avoid future product engineering and quality issues and put quality (not simply margin) as priority #1. I therefore would believe a "hold" put on the present state of these ED EMR systems, or a "snapshot" of their current state (i.e., an evaluation environment mirrored from the present operational one) would allow a careful evaluation of the impact of the issues noted in the study. Such an evaluation would be far more difficult with a cybernetic moving target. The "snapshot" idea would allow evaluation of system risk levels, intermittent "glitches", interference with workflows, etc. in a controlled testing environment, using mock data or data drawn from actual cases. The "snapshot" approach would also allow incremental remediation of the "live" system that comes out of safe, controlled testing, rather than sticking with what exists now until the studies could be completed on the as-is system, and then applying all the fixes as one or more large "upgrades." I, for one, would be interested in studying this "built by software professionals" system and comparing it to health IT systems we "academic nerds" <a href="http://ycmi.med.yale.edu/trialdb/">were authoring</a>, say, 10-15 years ago. -- SS

EHR ED's in New South Wales. Will the Problems Magically "Disappear?"

It occurs that one could look at Prof. Jon Patrick's recent health IT forensic analysis as a kind of "indictment" of the indu...

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Getting Out of Our RUC - "An Open Letter To Primary Care Physicians"

Since 2007, we have been <a href="http://hcrenewal.blogspot.com/search/label/RUC">writing</a> about the secretive RUC (RBRVS Update Committee), the private AMA committee that somehow has managed to get effective control over how Medicare pays physicians.  The RUC has been accused of setting up incentives that strongly favor invasive, high technology procedures while disfavoring primary care and other "cognitive medicine."  Despite the central role of (perverse) incentives in raising health care costs while limiting access and degrading quality, there has been surprisingly little discussion about the pivotal role played by the RUC.  Now there is a movement afoot to <a href="http://replacetheruc.org/">replace the RUC</a>.  In a new post <a href="http://careandcost.com/2011/03/05/an-open-letter-to-primary-care-physicians/">on the Care and Cost blog</a>, and <a href="http://replacetheruc.org/2011/03/05/an-open-letter-to-primary-care-physicians/">the Replace the RUC site</a>, Paul M. Fischer and Brian Klepper urged four approaches: 1. Make the public aware of the RUC’s role and urge the primary care societies to stop “enabling” the RUC through their participation. 2. Recruit experts who can credibly calculate the economic impacts of the RUC’s actions, and who can devise alternative payment methodologies. 3. Demonstrate the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on the RUC. 4. Develop a collaboration between primary care and non-health care business. They are also urging three specific actions: <blockquote>1. Contact your primary care society to demand that they withdraw from the RUC. 2. Broaden awareness of what we’re doing and why by rebroadcasting to your primary care colleagues. 3. Get in touch to help us with resources, relationships or approaches that can strengthen this project.</blockquote> They have set up an <a href="http://www.ipetitions.com/petition/quittheruc/">electronic petition</a> that people can use to urge the three major medical societies that represent primary care physicians to quit the RUC. On Health Care Renewal, we have been trying to make the systemic problems with with the leadership of health care organizations less <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a> in the hopes that greater realization that these problems exist would lead to actions to solve them. The regulatory capture by the RUC of Medicare's payment setting mechanism is one problem that really cries out for a solution. In 2007, I <a href="http://hcrenewal.blogspot.com/2007/05/more-on-disparities-between.html">called for</a> "an unbiased re-evaluation of the components of the RBRVS by people who are dedicated to doing it fairly, not benefiting one group of physicians, or the organizations that benefit from the increased use of procedures"; and "an unbiased investigation of what went awry with the process used by Medicare to determine physician payments."  Your heard it here first on Health Care Renewal.  It is nice to now have such distinguished company.  I urge our readers to consider the actions urged above.  True health care reform will require a transparent, honest, fair process for governments to decide on how they will pay for physicians' care and other health care services and goods.

Getting Out of Our RUC - "An Open Letter To Primary Care Physicians"

Since 2007, we have been writing about the secretive RUC (RBRVS Update Committee), the private AMA committee that somehow has managed to ge...

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Dr. Scott Monteith on "The Best Compromise" on Physicians and Use of Troublesome Health IT

I have posted two guest posts by Dr. Scott Monteith, a psychiatrist/informaticist, at the Jan. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/01/dr-monteith-hit-testimony-to-hhs.html">Interesting HIT Testimony to HHS Standards Committee, Jan. 11, 2011, by Dr. Monteith</a>" and the Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/meaningful-use-and-devil-in-details.html">Meaningful Use and the Devil in the Details: A Reader's View</a>". Here is another, with his permission. He is responding to a talking point from a health IT commentary website that was distributed among the AMIA evaluations special interest group readership. Dr. Monteith asks some very probing questions. He writes: <blockquote>I would like to respond to what I see as being one of the most important and challenging “real-life” issues confronting clinicians, and is captured in this excerpt [below, from the multi-vendor sponsored site HISTalk - ed.]: <blockquote> HisTALK: ... Somewhere between “we vendors are doing the best we can given a fiercely competitive market, economic realities, and slow and often illogical provide procurement processes that don’t reflect what those providers claim they really want” and “we armchair quarterbacks critics think vendors are evil and the answer is free, open source applications written by non-experts willing to work for free under the direct supervision of the FDA” is the best compromise.</blockquote> That is, this excerpt performs the helpful task of framing “the best compromise” somewhere between two extreme viewpoints. It would be helpful (at least for me) if this group could discuss what “the best compromise” actually ‘looks like’ in practice. How does one actually understand and live within “the best compromise”? Let’s start with a relatively simple scenario: What should clinicians do when they are working with EHRs that have known “problems” that are putting patients at risk, and the problems are not being immediately addressed, either directly or indirectly through, for example, an acceptable “work around,” or other adjustments to the EHR or local business processes? Should the clinician continue to use the EHR and… <ul><li> assume that others (e.g., vendor, IT department, administration, etc.) will fix the problem(s)?</li></ul><ul><li> report the problem(s)? Once? Twice? Three or more times? (How many?) To whom?</li></ul><ul><li> inform the patient of the known problem(s) (if the problem(s) apply to the patient)?</li></ul><ul><li>inform the patient that we do not have a good understanding of how to balance or even understand the risks posed by the EHR, given the dearth of peer-reviewed literature and algorithms? (What is “acceptable risk” for a given EHR problem? Does the EHR-related problem’s risk/benefit analysis change if the patient is in the hospital for a simple, nonlife-threatening problem vs. a complex, life-threatening problem)?</li></ul><ul><li> give the patient the option to NOT use the EHR? (Note that we almost always give patients the choice to refuse other “risky ventures” such as diagnostic procedures and treatments.)</li></ul><ul><li> inform their medical malpractice insurance company of the EHR-related problems?</li></ul><ul><li> submit the problem(s) to the organization’s ethics committee, if there is one?</li></ul><ul><li> report the problem(s) to the organization’s risk management staff?</li></ul><ul><li> report the problem(s) in writing or verbally?</li></ul><ul><li> stop using the EHR?</li></ul> Etc. (including some combination of things). Can providers (especially physicians) legitimately rationalize, given our ethical (to patients and our colleagues) and legal obligations (to patients and the state where we are licensed), the use of tools that are posing risks to patients and providers, when those risks are not spelled-out, not well understood, not peer-reviewed, etc.? (Obviously everything we do has risks, but we are obligated to revel and discuss those risks as noted above. Further, the risks/benefits of a given diagnostic or treatment intervention are the product of peer-reviewed algorithms. Are patient’s aware of the risks associated with their doctor’s or hospital’s EHR?) Again, the above excerpt suggests that there is a “ best compromise.” But what is/are “the best compromise(s)”? I joke with friends that I am a “radical moderate” – that is, I usually find myself committed to the “middle ground” in most complex and thoughtful discussions. But when it comes to EHRs, I am finding it difficult to define or understand what a “moderate” or an acceptable “best compromise” looks like. Given the current EHR exuberance driven by ONC’s incentive dollars and vendor profits (or hoped-for profits), we all know that the “politically correct” approach is to “go along” and be an “early adopter” (without too many protests). But is the politically correct approach really the “best compromise,” especially in light of our ethical and legal obligations? I am anxious to hear what other people think about this matter. I am sincerely seeking help in better understanding a sensible, real-life “best compromise” for those of us in the trenches. Note that if we cannot define “the best compromise,” then what does that say about us? How can we justify “getting on board” with patient care tools (e.g., EHRs, eRx’ing, etc.) that are posing risks (known and unknown), with no clear processes for informing patients, not giving patients their choice to use these e-tools, no clear evidence-based risk/benefit analyses, etc.?</blockquote> My own pithy, initial responses are as follows: <blockquote>Re: Given the current EHR exuberance driven by ONC’s incentive dollars and vendor profits (or hoped-for profits), we all know that the “politically correct” approach is to “go along” and be an “early adopter” (without too many protests). But is the politically correct approach [i.e, "go along to get along" - ed.] really the “best compromise,” especially in light of our ethical and legal obligations?</blockquote> No, for the reasons after your comma. [i.e., in light of our ethical & legal obligation - ed.] One should look to the past for lessons in what the "compromises" might be. How about the <a href="http://en.wikipedia.org/wiki/Flexner_Report">Flexner Report of 1910</a> as a start? The treatises on human research protections penned largely after the <a href="http://en.wikipedia.org/wiki/Tuskegee_syphilis_experiment">Tuskegee experiments</a> and the horrors of WW2, such as these as listed on an NIH web page "<a href="http://ohsr.od.nih.gov/guidelines/index.html">Office of Human Subjects Research, Regulations and Ethical Guidelines</a>" might also shed some light: <ul><li><a href="http://ohsr.od.nih.gov/guidelines/45cfr46.html">45 CFR 46</a> Protection Of Human Subjects</li></ul> <ul><li><a href="http://ohsr.od.nih.gov/guidelines/GrayBooklet82404.pdf">Guidelines for Conduct of Research Involving Human Subjects at NIH (Gray Booklet) (pdf file)</a></li></ul> <ul><li><a href="http://ohsr.od.nih.gov/guidelines/belmont.html">The Belmont Report</a> Ethical Principles and Guidelines for the Protection of Human Subjects of Research</li></ul> <ul><li><a href="http://ohsr.od.nih.gov/guidelines/nuremberg.html">Nuremberg Code</a> Directives for Human Experimentation</li></ul> <ul><li><a href="http://ohsr.od.nih.gov/guidelines/helsinki.html">World Medical Association Declaration Of Helsinki</a></li></ul>I further opine:<blockquote>Re: How can we justify “getting on board” with patient care tools (e.g., EHRs, eRx’ing, etc.) that are posing risks (known and unknown), with no clear processes for informing patients, not giving patients their choice to use these e-tools, no clear evidence-based risk/benefit analyses, etc.?</blockquote> Perhaps with the line that "I never make mistakes ... everything I do is an experiment." The technology is experimental. Perhaps the best way forward is to treat it as such. In medicine I think there's a rich history of how to conduct proper (and improper) experimental research. Again, Dr. Monteith raises some critical questions that need to be answered. Or, more correctly, needed to be answered a long time ago, and long before planned national rollouts of healthcare information technology. -- SS

Dr. Scott Monteith on "The Best Compromise" on Physicians and Use of Troublesome Health IT

I have posted two guest posts by Dr. Scott Monteith, a psychiatrist/informaticist, at the Jan. 2011 post " Interesting HIT Testimony to...

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Australian ED EHR Study: An End to the Line "Your Evidence Is Anecdotal, Thus Worthless?"

At my Sept. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html">The Dangers of Critical Thinking in A Politicized, Irrational Culture</a>" I lamented that while my early mentor in biomedicine Victor P. Satinsky MD taught the wise credo "critical thinking always, or your patient's dead" in the 1970's, our culture had become so perverse that this credo had been largely supplanted with: <blockquote>"Critical thinking anytime, and your career's dead." </blockquote>That post was in reaction to continued heckling on a professional mailing list, the American Medical Informatics Association (AMIA) Clinical Information Systems Working Group (cis-wg). On this list, Oregon Health Sciences University professor <a href="http://www.billhersh.info/">William Hersh</a> expounded on how the evidence of health IT dangers was largely "anecdotal" therefore to be discounted, and how I, specifically, "didn't know the literature on health IT." In that post I put the lie to the latter figment. On the former prevarication Dr. Jon Patrick, author of the recent thorough dissection of problems with the ED EHR system being rolled out in public hospitals in New South Wales, Australia (see my Mar. 5, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>"), hit the ball out of the park: <blockquote>Prof. Patrick to AMIA cis-wg: I think such defences are particularly unuseful especially with respect to the dismissal of personal stories and experiences as "anecdotes", hence committing them to the realm of folklore. I offer these notions as a counterpoint. Discounting Anecdotes: 1. Is a perfidious and specious act. 2. It denies early warning signs of problems. 3. It denies a voice and disempowers the working clinical community who have to operationalise decisions made by others. 4. It denies a route to process improvement within an institution - which is most important for EBM and incremental review of local processes. 5. It defends software manufacturers from fault rectification - cuts off even a need to deliberate on it. Critics of the value of anecdotes are squarely on the side of the faulty and deficient manufacturer. 6. A rule of project management is that projects consist of 3 components, cost, quality and time and if their needs to be a compromise it has to be on quality. Anecdotes are early warning signs of such a compromise. </blockquote><blockquote> </blockquote>Prof. Patrick had to once again put the lie to this refrain at a comment on the HISTalk blog yesterday, where the anonymous proprietor <a href="http://histalk2.com/2011/03/06/monday-morning-update-3711/">had written in a review of Patrick's EHR study</a>: <blockquote>... On the other hand, I wouldn’t say it’s [Prof. Patrick's Cerner FirstNet study] necessarily unbiased, it focuses on implementation of a single department application that didn’t go well for a variety of reasons (despite many successful FirstNet implementations elsewhere), it uses the unchallenged anecdotal comments of unhappy users who make it clear they liked their previous EDIS better, and it nitpicks (I wasn’t moved to find a pitchfork when I learned that the primary keys in the Millennium database aren’t named consistently). [Considering the complexity and changeability of healthcare and the corresponding software lifecycle, I duly note that that latter attitude about 'failing to find pitchforks' regarding breaches of sound software engineering practices seems to be a symptom of the larger health IT disease that Prof. Patrick writes about - ed.] </blockquote> Dr. Patrick then knocked the ball out of the Southern Hemisphere with a <a href="http://histalk2.com/2011/03/06/monday-morning-update-3711/#comment-14097">comment of his own</a> about anecdotalism and a link to an expansion of the aforementioned ideas he'd shared on "discounting anecdotes": <blockquote>Prof. Patrick to HISTalk owner: Your Comment “it uses the unchallenged anecdotal comments of unhappy users ” is not only unfair but unreasonably inaccurate. The comments made by the users are the Directors of 7 EDs and so they have a right to carry authority by virtue of the experience but also the number of 6 out 7 presenting a view of Firstnet as unfit for purpose has numeric validity, which they justify with about 20+ pages of their comments – see Part 2 Appendix 2. I would also point readers to my editorial about the role of personal experiences being the most useful information to understand the nature of socio-technical failures. <a href="http://aci.schattauer.de/en/contents/archive/issue/1124/manuscript/15463/show.html" rel="nofollow">http://aci.schattauer.de/en/contents/archive/issue/1124/manuscript/15463/show.html</a></blockquote> The essay at that link, "The Validity of Personal Experiences in Evaluating HIT", is an editorial in Johns Hopkins informaticist Chris Lehmann's brilliant new journal "<a href="http://aci.schattauer.de/en/contents/archive.html">Applied Clinical Informatics</a>." The editorial is available free, and is a must-read for anyone in a decision-making or managerial role in mission critical domains, including our elected representatives. In the editorial Dr. Patrick concludes. similarly to his earlier AMIA mailing list opinion: <blockquote> ... the denial of recounted personal experiences in discussion and analysis of HIT is biased and specious and has the effect of: 1. Denying early warning signs of problems. 2. Denying a voice for the working clinical community who have to operationalise decisions made by others and thus disempowers them. 3. Denying process improvement within an institution – which is most important for Evidence Based Medicine and incremental review of local processes. 4. Discourages staff from engaging in any form of process improvement hence worsening the sense of disenchantment. Every legitimate personal experience of a HIT deserves to be considered on its merits lest we wish to retreat from process and product improvement. Mechanisms of censorship both implicit due to contrived processes of disinformation and disempowerment or explicit due to contractual specifications will lead to more waste, lost productivity, contempt for the providers, and distress among frontline staff rather than increased productivity and improved patient health and safety as we all desire. </blockquote> In my view, the drivers or motivators for the "anecdotalist" accusation are these, singly or in combination: <ul><li>Too much "education" to see the nose on one's face, as in, to think zebras and unicorns instead of horses when hearing hoofbeats outside one's midwest U.S. abode (eggheads); </li><li>Too little common sense (fools), as in <a href="http://www.morgantownbrights.com/2009/09/10/you-are-wrong-because/">Scott Adams' example</a>: "IGNORING ALL ANECDOTAL EVIDENCE - Example: I always get hives immediately after eating strawberries. But without a scientifically controlled experiment, it’s not reliable data. So I continue to eat strawberries every day, since I can’t tell if they cause hives"; </li><li>Too much concern for the possible interruption of flow of money or power in one's direction (<a style="font-weight: bold;" href="http://www.thefreedictionary.com/gonif">gonifs</a>). </li></ul> In conclusion, the anecdotalist refrain of "your evidence is anecdotal" [therefore of little or no value] when used repetitively against competent observers is the refrain of eggheads, fools and gonifs. In healthcare, the end result is "your patient's dead." My "anecdotal relative" injured in a mid-2010 HIT mishap is sadly an example. [June 2011 addendum: <a href="http://hcrenewal.blogspot.com/2011/06/my-mother-passed-away.html">my relative</a>, after much suffering, has now died of complications of the "anecdotal HIT mishap" - ed.] As for myself, I am a Markopolist (see my Sept. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html">Health IT: On Anecdotalism and Totalitarianism</a>"). -- SS

Australian ED EHR Study: An End to the Line "Your Evidence Is Anecdotal, Thus Worthless?"

At my Sept. 2010 post " The Dangers of Critical Thinking in A Politicized, Irrational Culture " I lamented that while my early men...

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What to do about the state of the ED EHR's in NSW?

<div dir="ltr" style="font-family:arial;">At my post yesterday "<a href="http://hcrenewal.blogspot.com/2011/03/on-emr-forensic-evaluation-from-down.html">On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts</a>", I've come down pretty hard on internal and external (i.e., human interface) sloppiness in mission critical IT systems. In my view, the flaws that create randomly-occurring errors, combined with a <a href="http://www.tinyurl.com/hostileuserexper">mission hostile user experience</a> highly and especially inappropriate in the hectic and unpredictable ED environment, turn these systems into slot machines. The jackpot, however, is not wealth. It's injury or death. I've been asked, "So - what to do about the state of the ED EHR in NSW?" Here are some simple initial suggestions: A. For the time being: securing and implementing a paper backup (pen & paper) with scanning and document imaging retrieval system (integrated or standalone) as an 'EHR supplement", in order that really critical info can be steered in that direction. Clinicians are already avoiding the EHR system and not entering or minimizing data, or using other "workarounds." Therefore, informationally and safety-wise, a document imaging/retrieval system for paper would probably be a net plus. ED charts are not Tolstoy novel-length, as a matter of fact. There would not be many pages per patient, but even small morsels of key information collected easily and quickly, then retrieved easily, and presented clearly, cleanly and rapidly, as on a sheet or three of physical, then virtual parchment, can have enormous value. </div> <div style="font-family: arial;" dir="ltr" face="arial"> </div> <div dir="ltr" style="font-family:arial;">B. Clinicians and responsible executives and officials should start demanding that the ED EHR vendor release its full conceptual and logical data models so that others can, competitively (including the original vendor if they wish), cleanse it and redo a user interface that meets the needs of NSW ED's. The latter should be determined collaboratively with the key stakeholders, and developed using agile, iterative and incremental methodologies, not the usual stale Management Information Systems approach. (I.e., the mercantile, manufacturing and management computing paradigms that are ill-fitting to healthcare informatics as further explained at my post <a href="http://hcrenewal.blogspot.com/2008/05/seedie-society-for-exorbitantly.html">here</a>.) That way moving data over to the "redone" new system would not be a nightmare. Or perhaps less of a nightmare than an entirely new extant system from another vendor (which would likely have similar flaws anyway and need similar rework). </div> <div dir="ltr" face="arial"> </div> <div dir="ltr" style="font-family: arial;">The closed-system, locked-in-to-one-vendor paradigm that's apparently holding the ED's of an entire state of the fine country of Australia hostage must end. Let the best organization win. As I also observed in the aforementioned post, the UK, having their own HIT issues (see my Aug. 2010 "Battle of Britain" post <a href="http://hcrenewal.blogspot.com/2010/08/cerners-blitzkrieg-on-london-wheres-raf.html">at this link</a>), apparently learned something, as evidenced in: <blockquote style="font-family:arial;"><a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn14.pdf">Health Informatics — Application of clinical risk management to the manufacture of health software</a>. UK National Health Service, DSCN14 (2009), formerly ISO/TS 29321:2008(E). and <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn18.pdf">Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software</a>. UK National Health Service, DSCN18 (2009), formerly ISO/TR 29322:2008(E). <a href="http://www.connectingforhealth.nhs.uk/engagement/clinical/occo/safety/dscn14.pdf"> </a></blockquote>Perhaps those in the U.S. and in VK-land (<a href="http://www.wia.org.au/">amateur-radio speak</a> for Australia; I am <a href="http://www.arrl.org/">KU3E</a> here in the U.S.) can also heed these documents and their recommendations. -- SS Mar. 8, 2011 addendum: Prof. Patrick has added a new section to his report, entitled "The Future Pathways for e-Health in NSW." It is available <a href="http://sydney.edu.au/engineering/it/%7Ehitru/essays/Things%20we%20should%20change%20in%20NSW-v4.pdf">at this link</a> (PDF). It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, magical thinking about the technology, and lack of accountability): More on the Pathways at my post <a href="http://hcrenewal.blogspot.com/2011/03/future-pathways-for-e-health-in-nsw.html">here</a>. The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation. --SS </div>

What to do about the state of the ED EHR's in NSW?

At my post yesterday " On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts ", I've come down...

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The Rise of the Corporate Physician - the End of the (Health Care) World As We Know It?

In discussing how concentration and abuse of power threatens health care professionals' values and professionalism, we have <a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">discussed</a> how ostensibly academic institutions value faculty more for their earning power than their academic abilities.  We have <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">discussed</a> how financial relationships between physicians and drug, biotechnology, device and other companies risk abuse of entrusted power.  But up to now, I have been comforted by the hope that physicians in small independent practices who do not have such conflicts of interest are trying to uphold their professional values, even as they were buffeted by the <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse incentives</a> imposed by managed care organizations/ health insurance companies and government insurance (e.g., US Medicare whose payments are controlled by the <a href="http://hcrenewal.blogspot.com/search/label/RUC">RUC</a>). However, a<a href="http://www.smartmoney.com/personal-finance/health-care/farewell-to-the-family-doctor-1298917784955/"> recent article</a> in SmartMoney suggests that the end of the independent physician is nigh: <blockquote> Remember the solo family doctor? In places like Springfield, it has become increasingly likely that she's collecting a paycheck from a large regional hospital—and practicing medicine according to the hospital's strict playbook. The experience in Springfield is just a needle prick compared with what's going on nationwide. At least one in six doctors—more than 150,000 nationwide—now works as an employee of a hospital system. And with about half of recent medical school graduates deciding to work for hospitals and many established doctors looking to unload their practices amid the tough economic climate, what was a trickle of change has turned into a torrent. Jim Pizzo, a Chicago-area hospital consultant, says the blistering pace of these mergers is leading some colleagues to joke that there are two types of physicians today: 'Those employed by hospitals and those about to be.'</blockquote> So we are seeing physicians who practiced solo or in physician-lead, physician-run group practices becoming employees of large health care organizations. And here on Health Care Renewal, we know how most large health care organizations are run. This appears to be an unintended consequence of our recent US health care "reform" law: <blockquote> But hospital executives also believe that buying doctors' practices could yield a big payday, thanks to a different provision in the health care law. The law will encourage doctors and hospitals to share some payments when treating each patient; as collaborative teams, they could earn bonuses for holding down costs and meeting quality markers. 'The real question for everyone is how that pie—that money—is going to get split up,' Goertz says; hospitals think they'll have the upper hand if they employ the doctors that they're sharing their banana crème with. And that's touched off a flurry of mergers everywhere—from Seattle to Roanoke, Va.</blockquote> The name of these supposedly collaborative organizations, which are turning out to simply be hospital systems which have purchased physicians' practices and now employ physicians, is "accountable care organizations," which now appears ironic at least. The article detailed some of the adverse effects to be expected when accountable care organizations become hospital systems with employed physicians providing patient care. Increased Costs with Decreased Care <blockquote> Ruth Taylor, a 44-year-old woman in Bozeman, Mont., started seeing Robert Hathaway as her doctor during college, and she stuck with him through everything from routine blood tests to a kidney transplant. Taylor, a professional nurse with warm blue eyes, describes Hathaway as a 'classic small-town doctor' who knew all his patients by name and socialized with them at local basketball games; he was accessible and thorough—even catching a health problem of hers that other doctors had missed. But after Hathaway sold his practice to the local hospital, Taylor says, things began to sour. She was more likely to be assigned to see the physician assistant rather than Hathaway himself. And when she went in for a comprehensive physical (also run by the assistant) in late 2008, she was charged $360, more than double what she'd paid for a workup in previous years.</blockquote> Imposition of Dysfunctional Health Care Information Technology On this blog, Dr Scot Silverstein frequently posts about how poorly designed and implemented commercial health care information technology may have harms that outweigh any benefits, and how these systems are rarely objectively evaluated. Employed physicians are likely to be required by their new executive overlords to use commercial health care IT that benefits the managers and their strategies, but may not benefit patient care: <blockquote> Last spring Hospital Sisters tried to shift all of its Springfield medical offices to electronic medical records simultaneously. But there wasn't enough tech support to deal with all the problems physicians ran into on day one, and wait times spiked at the system's walk-in locations. Nenaber, a soft-spoken 64-year-old with wire-rim glasses, sounds acquiescent about the situation. 'We're getting the hang of these things,' he says slowly, sitting at his desk overlooking a gas station and a strip-mall parking lot. But his practice is still waiting for its electronic payoff</blockquote> Increasing Prices by Providing Care in the Hospital <blockquote> Now that the acquisition spree is in full swing, some experts worry that price increases could become the dominant narrative for patients. When hospitals run medical practices, federal law allows them to add substantial 'facility fees' to patients' bills to cover overhead expenses. The new bosses also often rip equipment like X-ray machines and MRIs out of the physician's office, preferring to have patients get those tests from radiologists at the hospital. That, too, can cost patients. A consumer with a high-deductible Aetna plan, for instance, would pay up to $1,400 for an MRI of her back at the University Medical Center at Princeton, N.J., according to data that the insurer makes available to its members. The same scan would cost about a third as much at nearby Radiology Affiliates of New Jersey, a nonhospital facility. Based on a review of insurance databases and state regulatory records, that's a fairly typical price gap</blockquote> Increasing Prices by Market Domination <blockquote>Price increases also have the potential to bleed outward—affecting not only the patients of the absorbed doctor, but also the cost of health care citywide. That's because when hospitals sit down at the bargaining table with insurers, they're almost always able to negotiate higher payment rates for their big groups of doctors than a lone physician with little bargaining power</blockquote> Despite the usual spin provided by the would-be monopolists: <blockquote>Fast-growing hospital systems, including Hospital Sisters and Bozeman Deaconess, say that their growth will eventually make care more efficient and bring costs back down, since they'll be able to cut back on unnecessary care and duplicate tests</blockquote> I am sure that the 19th century robber barons made the same pitch about increasing efficiency. Of course, the efficiency mainly benefits the insider managers. By the way, of course, the hospital systems own public relations machines and lobbyists are now busy attacking any restrictions on such concentrations of power, while the hospital managers figure out how to game the system to increase their market domination before the regulators notice: <blockquote> As more patients face such disruptions, regulators are taking notice. In October, the Federal Trade Commission and the Department of Health and Human Services met with doctors, insurers and other health officials to discuss the referral and pricing problems that could arise from 'accountable-care organizations'— those new groups of hospitals and doctors that will share financial incentives. The Federal Trade Commission will offer guidelines on what's permissible by midyear. But hospitals are already lobbying for accountable-care groups to be exempt from antitrust and antifraud rules, even as they scoop up more and more medical practices. Under current regulations, officials in Washington must green-light all mergers involving companies valued at more than $63 million. But by buying up tiny medical practices one at a time, critics say, hospitals stay below the threshold and avoid getting much attention. And by the time regulators settle on more-formal legal guidelines, those mergers may be hard to undo, says Cory Capps, a Washington economist specializing in health care antitrust issues.</blockquote> Excess and Unnecessary Utilization via "Leakage Control" With big hospital systems now owning physician practices, and practicing physicians directly answering to executives, the push will be on to maximize use of the most lucrative services. Once the hospital systems have made employees out of the physicians, it is easy to pressure their own employed physicians to refer patients to the hospital units that can bill most lucratively: <blockquote>By their own admission, most hospitals are eager to keep patient referrals under the same corporate umbrella, to save on costs and share medical records but also to boost revenue. The hospitals say they wouldn't force an internist, for example, to refer a patient with heart problems to their own cardiologists, but critics say there's certainly financial pressure. Under a little-noticed regulation that took effect in 2007, hospitals are allowed to pay doctors less if they don't do enough internal referrals. Doctors in Bozeman and Springfield who granted interviews said they didn't feel pressure to be 'team players' with referrals. But some of those who've left large health systems tell a different story, including Mark Callenberger, an orthopedist in Merritt Island, Fla. Callenberger says that the hospital group where he used to work urged him to direct more patients to the MRI machine owned by the hospital. The doctor preferred a more advanced machine at a private practice that he says offered clearer pictures. But after he ignored the recommendations, Callenberger says, the hospital told his office manager to schedule patients at the hospital's MRI anyway, leaving him to perform surgery using 'crummy images.' (The hospital declined to comment on Callenberger's case but says its doctors can use whatever facilities they choose.) Patients may never know about these power struggles, because doctors aren't required to disclose how they choose specialists. And while patients who ask can always see a specialist outside the network, in practice few are likely to challenge their doctors' judgment, says Bruce A. Johnson, a Denver health care lawyer. 'Face it, when we're really sick,' says Johnson, 'if the doctor tells us to jump off a roof, we'll probably consider doing it.'</blockquote> Note that we discussed (<a href="http://hcrenewal.blogspot.com/2011/02/new-steward-health-care-will-superbowl.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/02/send-mercenaries-guns-and-money.html">here</a>) the example of a for-profit hospital system with a large number of physician employees pushed to choke off "leakage" of patient referrals outside the system. Summary The overarching problem is that employed physicians now must answer to managers and executives who may put financial goals, and their own enrichment, ahead of physicians' values, and specifically will choose increased revenue over providing the best possible care to individual patients: <blockquote> . Executives here are also hoping to push the needle further—standardizing everything from how long patients wait on hold to the ease of parking at the doctor's office (valets, luxury-restaurant style, are one solution under consideration). Still, Mikell acknowledges, 'doctors don't want follow-the-directions, cookbook medicine.' And for many physicians, the idea of following new rules triggers a much larger unease at giving up their independence—a feeling of loss, both for the businesses they built and for their patients. Back in Bozeman, Blair Erb, the sole cardiologist in town, is a picture of resignation as he prepares to sign a contract with Deaconess. 'I feel defeated,' Erb says, looking around at the office furniture he and his wife, Liz, chose from a catalog years ago. The weathered ranchers and bundled-up women that come through his door mostly express disbelief when they hear that this frank-talking Tennessee native will sell his practice. His staffers say they're not looking forward to the questions the hospital's medical records system will soon prompt them to ask patients. (Do you wear a bike helmet regularly? Do you have a smoke detector?) 'We'll try to retain as much professional independence as possible,' Erb says, gazing at the hospital building, whose bulk he can see through his window. 'But the fact of the matter is, we'll have a new master.'</blockquote> So I for one do not welcome our new executive overlords. We have <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">posted</a> about numerous examples of health care organizational leaders who put their own enrichment ahead of the mission. Now even ostensibly non-profit hospital systems are increasingly competing against for-profit systems. We have seen, as noted above, an example of a for-profit system that seems to betting everything on a business strategy to reduce "leakage" of patient referrals.  We can expect that non-profit hospital systems will have to act more like for-profit systems, and the perverse financial incentives given the managers of all hospital systems will lead to pressure on physicians to forgo their responsibilities to provide the best care to individual patients in favor of actions that will bring in the most money in the shortest time. We seem to be witnessing the rise of the corporate physician, the rise of a physician who must first answer to managers who never committed to putting patient care first, who may have no sympathy for physicians' core values, who may receive huge incentives to maximize short-term revenue no matter what. Such a rise of corporate physicians would be unprecedented in the US, and I believe in any developed country. The rise of the corporate physician would require patients to put their trust in corporations, rather than individual doctors, in the era of the global financial collapse, in the new gilded age. We may be seeing the end of health care world as we know it. The upcoming brave new world of health care may be worse that we can imagine. What is to be done? - I rarely have ventured into specific policy suggestions, but I think that the consequences of the well-intended "accountable care organization" blunder may be so severe that I must so venture now. We must derail the movement towards "accountable care organizations." Any movement to make organizations more accountable cannot do so by making most professionals into employees answering to the sorts of ill-informed, incompetent, self-interested, conflicted or even corrupt leaders that we have been writing about for more than six years on Health Care Renewal.  We need to make it impossible for for-profit companies to employ physicians to take care of patients.  Maybe we need to think about making it impossible for for-profit companies to provide patient care at all, and for for-profit companies to sell health insurance.  Meanwhile, we need to ensure the accountability, integrity, transparency, and honesty of leaders of health care organizations. If we do not reverse the current trends, anyone who wants good health care may have to look for it somewhere other than in the US.

The Rise of the Corporate Physician - the End of the (Health Care) World As We Know It?

In discussing how concentration and abuse of power threatens health care professionals' values and professionalism, we have discussed h...

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