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Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rotterdam: <blockquote style="font-family:arial;"> While failures of IT implementation in the UK and more recently the Cerner implementation in Australia has been dissected by [U. Sydney Professor] Jon Patrick, the Dutch initiative for a national health IT infrastructure for exchanging patient data that would start with a medication record and a summary record is about to be voted down in the upper house (Senate) of the Dutch parliament. It means that the trajectory to get this infrastructure and which lasted thirteen years will grind to a halt. Unfortunately this implementation has been poorly documented in scientific journals (to my knowledge only one paper describing the infrastructure was published in Methods of Information in Medicine).</blockquote> I wrote about the exposé by Prof. Jon Patrick of U. Sydney of poor software engineering practices, poor usability, unreliability, and dangers posed by a commercial health IT product slated for the ED's of the Australian state of <a href="http://en.wikipedia.org/wiki/New_South_Wales">New South Wales</a> (NSW) at 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>". Prof. Patrick offers the following additional pithy and highly insightful commentary, reposted here with his permission (emphases mine): <blockquote style="font-family:arial;"><div>Colleagues, Since the publication of my long report on the discontent with and weaknesses of Cerner Firstnet/Millenium in Australia (see <a href="http://www.it.usyd.edu.au/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">http://www.it.usyd.edu.au/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a>) I have been pondering the issue of how we can better define the "EMR" and its functions. I certainly think that the notion of an EMR in terms of current popular discussions in AMIA-WGs [American Medical Informatics Association work groups - ed.] and blogs [such as this one - ed.], government policy and vendor publicity is defined at too high a level of generalisation for analysts to create an adequate specification of it and likewise for the engineers to understand the requirements so that they can build such a system. <div>This position is further justified by the failures to create such systems in the UK, NSW and Victoria (Australia) and the loss of political support in Holland. A counterpoint to this are the successes in New Zealand, Denmark and Scotland with systems of smaller ambition and scale targeted at particular problems. </div> <div>I offer this thesis for deliberation: that large scale enterprise software implementations are an over generalisation of the EMR problem so that their lack of ability to capture local context and their intrinsically weak engineering base demonstrate that the advocates of large scale EMR don't know how to do it, have failed to do it in the past at great cost to various communities, and will continue to fail until they understand and define the task properly and in great detail of what has to be done and how to do it.</div></div></blockquote><div style="font-family:arial;"><div> In other words, the healthcare IT industry itself - starting with its leadership - does not know what it's doing and may itself be ill-suited to purpose, the purpose of facilitating better healthcare. Its overall brute-force, mass-scale, ham-fisted ideologies and approaches cannot succeed except in wasting billions of healthcare dollars. Or, more precisely, transferring that wealth to the IT sector and leaving little to show for it in the health sector. <div>I agree with Prof. Patrick's "thesis." At my own HIT website now at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</a> years ago I wrote similar words: </div> <blockquote style="margin-right: 0px;" dir="ltr"> <div> <div style="margin-top: 0px; margin-bottom: 0px;">Healthcare information technology (HIT) holds great promise towards improving healthcare quality, safety and costs ... however, this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, and underestimations of the expertise essential to achieve the potential benefits of HIT. This often results inclinician-unfriendly HIT design, and HIT leaders and stakeholders operating outside (often far outside) the boundaries of their professional competencies. Until these issues are acknowledged and corrected, HIT efforts will unnecessarily over-utilize precious healthcare resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.</div></div></blockquote> </div></div>Once again, you heard it here first. I also reiterate, our own "National Program for Health IT in the HHS" needs the same treatment that Prof. Patrick recommends for his own state of NSW, as at my Mar. 8, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/future-pathways-for-e-health-in-nsw.html" style="font-family: arial;">The Future Pathways for e-Health in NSW</a>." -- SS

Why The Overambitious, Cavalier Approaches of the Healthcare IT Industry Are Harmful To Health: Guest Post by Dr. Jon Patrick, U. Sydney

Apparently Holland is now veering away from a national project for health information exchange. From a researcher at Erasmus University Rot...

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The Massachusetts Blue Cross Blue Shield CEO's Golden Parachute - "'Have's' Greasing One Another's Pockets"

We have frequently discussed the kind of <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation</a> now frequently given to leaders of health care organizations.  Although often even the most disproportionately outrageous compensation only attracts transient interest, a recent regional story in this genre has really gotten legs. How Big the Golden Parachute? The story was about the severance package given to one Cleve L Killingsworth, the former CEO of not-for-profit health care insurance company <a href="http://hcrenewal.blogspot.com/search/label/Blue%20Cross%20and%20Blue%20Shield%20of%20Massachusetts">Massachusetts Blue Cross Blue Shield</a>.  While first reported as being worth $8.6 million,(1) the estimate of his total severance was soon raised to $11 million.(2) This is a Way to Control Costs? Immediately, that amount was contrasted with the supposed emphasis of the company on controlling costs, and its recent poor performance: <blockquote>Killingsworth’s tenure at Blue Cross, which has nearly 3 million members, was marked by efforts to address skyrocketing medical costs by launching a 'global payment' pilot program, under which health care providers are given an annual budget and incentives to keep patients healthy and out of the hospital. 'Without Cleve’s leadership, we wouldn’t be where we are today in shifting from fee-for-service to global payments,' said senior vice president Jay McQuaide. But the insurer stumbled financially in recent years, recording back-to-back operating losses totaling nearly $215 million in 2009 and 2010 as the economy weakened and state regulators acted to limit premium increases for policies covering small businesses and individuals.(3)</blockquote>Then focus shifted to the company's board of trustees, which lead to recognition of some more striking contrasts. First, some prominent members of the board which approved the huge golden parachute had been vocal supporters of controlling health care costs: <blockquote>Key members of the Blue Cross Blue Shield board that gave the nod to then-CEO Cleve Killingsworth’s controversial $11 million severance have been public advocates for trimming soaring health-care costs — even as they sat on a panel that quietly approved the departing chief’s golden parachute. Greater Boston Chamber of Commerce President Paul Guzzi has crusaded to lower health-care costs in his day job representing the interests of local businesses, many of which struggle under the burden of rising premiums for their employee health plans. 'Advancing payment reform to bring health-care costs under control' is one of the Greater Boston Chamber of Commerce’s top policy agenda items, Guzzi said in a statement in January. Guzzi made $84,463 as the Blue Cross board chairman at the time of the Killingsworth vote. Robert J. Haynes, president of the Massachusetts AFL-CIO who made $72,700 as a Blue Cross board member in 2010, has championed health-care cost reduction for the thousands of union members he represents. 'Unions stand ready to be part of the solution to the health-care cost crisis in which we all find ourselves,' Haynes said in an AFL-CIO statement in January. 'The only way to ensure we are part of the solution is to guarantee that we have a voice and meaningful role in how cost savings are achieved.' Bentley University president Gloria Larson, who earned $76,400 as a Blue Cross board member last year, helped organize a confab of business, labor and political leaders in Ashland in January that addressed rising health-care costs. Those who planned to attend reportedly included two other Blue Cross board members — Haynes and former Suffolk District Attorney Ralph C. Martin II.(4)</blockquote>Why Pay a Non-Profit's Trustees? Also, as the quote above pointed out, it appears that the board members were themselves paid fairly well for a very part-time job, even though in general trustees of not-for-profit organizations serve as unpaid volunteers. However, it was soon revealed the paying board members is common practice for all Massachusetts non-profit health insurance companies.(5) Some Blue Cross board members tried to defuse the issue by minimizing the impact of their pay on the organization's total budget: <blockquote>Robert J. Haynes, president of the Massachusetts AFL-CIO and a critic of excessive corporate pay, was questioned about his role on the board following a State House news conference he held on a union-backed plan aimed at lowering health care costs. He said he would not give up his $72,000 annual payment from Blue Cross until the issue was reviewed by the company, and said the money given to board members does not play a role in rising health care costs. 'The cost of health insurance is not affected very much,' Haynes said. 'It’s about $1 million that board members get paid. On $13 billion in revenue, it’s like pennies a year.' (6)</blockquote>What Should the New CEO Be Paid? However, soon the board felt the need to suddenly stop paying itself.(7) The current Blue Cross CEO noted how little he would be paid: <blockquote>Dreyfus emphasized that he has taken 'rock-bottom-of-the-market' compensation levels -- $800,000 in base pay with the opportunity for $1.6 million in severance – for comparable positions in the insurance industry. 'I will be one of the lowest paid Blue Cross executives in the country,' he said.... (8)</blockquote>Things are tough all over. What is Mr Killingsworth Now Up To? Meanwhile, Mr Killingsworth seems to be weathering the storm. An enterprising reporter attempted to interview him in his house in New York, described as "a sprawling clapboard monstrosity with the charm of an assisted-living facility." However, "Mr Killingsworth was nowhere to be found," and Mrs Killingsworth "slammed the door" on the reporter.  (See picture in cited article.)  (9) Possibly, Mr Killingworth was away tending his other responsibilities, which include serving on the Boards of Directors of <a href="http://investor.travelers.com/phoenix.zhtml?c=177842&p=irol-govBio&ID=165042">The Traveler's Company</a> and <a href="http://www.tiaa-cref.org/public/about/governance/corporate/board-composition/tiaa-overseers/cleve_l_killingsworth.html">TIAA-CREF</a>, and apparently despite their apparently competitive nature, on the boards of the Harvard Medical School and <a href="http://www.bu.edu/trustees/boardoftrustees/members/">Boston University</a>. The Reaction There were plenty of reactions, mostly vigorously unfavorable, to the contrast between the company's non-profit status, supposed commitment to reducing costs, and financial performance, on one hand, and the compensation given to executives, and board members: "undermines the credibility of insurers when they say they're serious about bringing down the cost of care" Deidre Cummings, President of the Massachusetts Public Interest Research Group (3) "If you lose $149 million and then you get paid $11 million for doing it, it is very clear to people where their health-care dollars are going.  And it is not to health care." - Ethan Rome, Health Care for America Now (2) There were also judgments that health care had become the sandbox for wealthy and well-connected insiders, at the expense of everyone else: "What we have here today is yet another enraging story of the 'haves'greasing one another's pockets while the 'have-nots' slip beneath the waves." Margery Egan, columnist for the Boston Herald(10) "Therein lies the problem with boards.  They're supposed to provide oversight, but too often it's the same people tossing money at each other to serve on the boards of each other's companies, the operative word always being 'Yes!'" Brian McGrory, Boston Globe columnist (5) Most pessimistically: "If Massachusetts is the model, then national health care reform is ultimately doomed." Derrick Z Jackson, Boston Globe columnist (11) I am actually now more optimistic.  The coverage of this story really shows that the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> may be fading .  There is starting to be frank discussion of the role of bad leadership of health care organizations as a cause of health care dysfunction.  If we start to admit these problems, maybe we can figure out solutions. I will add just one opinion to those expressed in these articles.  The clear problem here is again perverse incentives.  The issue with how much this CEO was paid, and how his board members were paid was not mainly the diversion from direct health care of the funds involved.  Instead, the concerns ought to be: what sorts of people do these payments attract?  Are they the sorts of people who will uphold the organization's mission?  Once attracted, what sorts of incentives do the prospects of these payments supply for what sorts of decisions?  Do these sorts of incentives lead to decisions that uphold the mission in the long-term? In this case, these concerns are underlined by the Blue Cross trustees' cavalier attitude to their own pay, and the new CEO's belief that $800,000 a year is "rock-bottom."  I hope that the amount of discussion this case provoked might actually lead to some needed regional changes. More globally, as we have <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">said before</a>, far too often the leaders of not-for-profit health care institutions seem more interested in padding their own bottom lines than upholding the institutions' missions. They often seem entirely unaware of their duty to put those missions ahead of their own self-interest. Like the financial services sector in the era of "greed is good," health care too often seems run by <a href="http://hcrenewal.blogspot.com/2009/12/compensation-madness-insiders-hijacking.html">"insiders hijacking established institutions for their personal benefit."</a> True health care reform would encourage leadership of health care who understand health care and care about its mission, rather than those who see a quick way to make a small fortune. References 1.  Gil G. <a href="http://www.boston.com/business/healthcare/articles/2011/03/02/blue_cross_ceo_got_86m_in_exit_deal/">Former Blue Cross CEO got $8.6m last year</a>.  Boston Globe, March 1, 2011.  2. McConville C. <a href="http://www.bostonherald.com/news/regional/view.bg?articleid=1320386&srvc=rss">Ex-Blue Cross CEO walks away with $11M</a>. Boston Herald, March 2, 2011. 3. Weisman R. <a href="http://www.boston.com/business/healthcare/articles/2011/03/02/blue_cross_ceo_got_86m_in_exit_deal">Blue Cross CEO got $8.6m in exit deal</a>. Boston Globe, March 2, 2011. 4. McConville C, Chabot H. <a href="http://www.bostonherald.com/news/regional/view/2011_0303behind_the_hield_trio_publicly_crusaded_against_rising_health_costs/srvc=home&position=0">Trio publicly crusade against rising health costs: behind the shield</a>. Boston Herald, March 3, 2011. 5. McGrory B. <a href="http://www.boston.com/news/local/massachusetts/articles/2011/03/04/such_healthy_pay_its_sick">Such health pay, it's sick</a>. Boston Globe, March 4, 2011. 6. Levenson M, Weisman R. <a href="http://www.boston.com/lifestyle/health/articles/2011/03/08/2_blue_cross_directors_justify_stipends">2 Blue Cross directors justify stipends</a>. March 8, 2011. 7. Crimaldi L, Dwinnell J. <a href="http://news.bostonherald.com/news/regional/view/2011_0308blue_cross_to_suspend_board_member_pay/srvc=home&position=0">Blue Cross board suspends pay, CEO perks cut</a>. Boston Herald, March 8, 2011. 8. Cheney K. <a href="http://www.enterprisenews.com/business/x2011258314/Amid-outrage-Blue-Cross-chief-fights-to-reclaim-company-s-standing#axzz1GKC5WDrB">Amid outrage, Blue Cross chief fights to 'reclaim' company's standing</a>. Enterprise News, March 10, 2011. 9. Gelzinis P. <a href="http://www.bostonherald.com/news/columnists/view/2011_0311cleves_ny_castle_not_shielded_from_bad_taste">Cleve Killingsworth's New York castle not shielded from bad taste</a>. Boston Herald, March 11, 2011. 10. Egan M. <a href="http://www.bostonherald.com/news/columnists/view.bg?articleid=1320681">You call this health care? - it's nauseating</a>.  Boston Herald, March 3, 2011. 11.  Jackson DZ. <a href="http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/03/05/no_wonder_health_costs_are_so_high">No wonder health costs are so high</a>.  Boston Globe, March 5, 2011.

The Massachusetts Blue Cross Blue Shield CEO's Golden Parachute - "'Have's' Greasing One Another's Pockets"

We have frequently discussed the kind of compensation now frequently given to leaders of health care organizations. Although often even th...

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Finally, Some Upcoming Events to Announce: PharmedOut Conference, Transparency International Summer Course

In our side-bar to the right we have a section for "Upcoming Meetings and Events."  Sadly, it is often empty.  Perhaps as a result of the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, there seem to be few talks, workshops, much less symposia, conferences, and courses on the issues we discuss on Health Care Renewal.  However, I am happy to now note two upcoming events of interest. First, and most directly related, is the <a href="http://www.pharmedout.org/2011conference.htm">2011 PharmedOut.org conference</a>, entitled, "Pharma Knows Best? -Managing Medical Knowledge," on 16-17 June, 2011 at Georgetown University in Washington, DC, USA.  PharmedOut.org is dedicated to addressing how pharmaceutical companies seek to influence medical decision making.    My editorial comment is that pharmaceutical companies, and also biotechnology, device, health care information technology, and health insurance companies spend billions on marketing to try to influence health care professionals and patients to use their products just here in the US, and probably hundreds of millions on public relations to try to influence policy-makers in favor of their interests.  The amounts spent to educate health care professionals and the public about these efforts, and particularly about <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> marketing and PR, <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth marketing </a>and <a href="http://hcrenewal.blogspot.com/search/label/stealth%20health%20policy%20advocacy">stealth advocacy</a> campaigns, etc, is minuscule by comparison.  <a href="http://pharmedout.org/">PharmedOut.org</a> is one of the few organizations trying to address the hype and spin.   Second is the <a href="http://tischool.lt/">Transparency International Summer School on Integrity</a>, to be held in Vilnius, Lithuania, on 11-15 July, to provide "intensive anti-corruption training for future leaders."  Unfortunately for the rest of us, enrollment appears to be restricted to "students, graduates, and young professionals" from the post-communist countries.    My editorial comment is that despite the prevalence and importance of health care corruption, as documented by the <a href="http://www.transparency.org./publications/gcr/download_gcr/download_gcr_2006/">2006 Transparency International Global Corruption report</a> which focused on health care, and of the importance of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> as risk factors for corruption, there are very few opportunities to teach and learn about these issues anywhere in the world.  (As I <a href="http://hcrenewal.blogspot.com/2009/12/how-to-give-course-on-corruption-in.html">once noted</a>, I could only find a single course on health care corruption and related issues in any US university.)  <a href="http://www.transparency.org/">Transparency International</a> has a record of efforts made to directly fight corruption, and to teach about related issues.  Would that such courses be available all over the world.

Finally, Some Upcoming Events to Announce: PharmedOut Conference, Transparency International Summer Course

In our side-bar to the right we have a section for "Upcoming Meetings and Events." Sadly, it is often empty. Perhaps as a result...

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Is Microsoft slowly edging towards an "exit stage left" in health IT?

Interesting item seen <a href="http://histalk2.com/2011/03/10/news-31111/">here</a>: <blockquote> From Dabney: “Re: former Sentillion exec departures from Microsoft. Microsoft transferred their 800 Health Solutions Group people into the small-to-medium commercial sector group (Microsoft Business Solutions) last Monday. Peter Neupert and his whole organization have been pushed out of the incubation group in Microsoft Research with the guys who sell Microsoft Axapta ERP and CRM for small commercial customers. That will mark the end of acquisitions and spending of Microsoft on health because they haven’t had any significant sales of Amalga UIS in the past year after already withdrawing Amalga HIS and Amalga RIS/PACS from the market. Microsoft is slowly edging towards an exit stage left in health IT.</blockquote> Why would this not surprise me if true? Because I predicted it. In July 2006, nearly 5 years ago, in my July 2006 post "<a href="http://hcrenewal.blogspot.com/2006/07/bill-have-you-lost-your-mind.html">Bill, Have You Lost Your Mind?</a>" Nobody was listening, just as nobody seems to be listening to my current dire predictions for the National Program for IT in the HHS™ . Wait until 2016... -- SS

Is Microsoft slowly edging towards an "exit stage left" in health IT?

Interesting item seen here : From Dabney : “Re: former Sentillion exec departures from Microsoft. Microsoft transferred their 800 Healt...

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A New Venue From a Surprising Source to Discuss "External Threats to Good Decision-Making"

A <a href="http://blog.abimfoundation.org/">new blog, entitled the Medical Professionalism Blog, </a>signed on last week with <a href="http://blog.abimfoundation.org/welcome-to-the-medical-professionalism-blog/">a post </a>emphasizing some themes that should be familiar to Health Care Renewal readers: <blockquote>There is an increasing focus on the sustainability of the U.S. health care system based on current cost trends. Predictions are for the health care system to consume 19% of the GDP by 2019. How did we get here? Some point to the overuse and misuse of health care services, inefficiencies and lack of care coordination. Others blame the lack of clinical evidence, primary care workforce and the external threats to good decision-making, such as a toxic payment system and the influence of pharmaceutical and device companies. While there are many different ideas about what got us here and what should be done, there is wide consensus that physicians and other stakeholders must begin to develop new more effective and efficient systems of care and make wise choices that preserve our health care system’s sustainability.</blockquote>We have been underlining concerns that health care professionals' values, the mission of academic medicine, and truly evidence-based practice are under a series of threats.  (For a recent, but already out of date list of threats to the academic medical mission, see <a href="http://hcrenewal.blogspot.com/2010/12/lancet-emphasizes-threats-to-academic.html">this post</a>.)  It is nice to see that that others are now alarmed by these threats and looking for ways to counter them. So, our new colleague in the blog-sphere raised the following questions: <blockquote>* What is the appropriate role of physicians and other stakeholders in preserving these resources? * What behaviors foster and which threaten wise choices in medical decision-making? * How can waste be removed from the system without sacrificing quality or safety? * What system changes are needed to achieve better health care outcomes, reduce costs and improve the patient experience? * What effect do the nature and performance of partnerships – clinician-patient, clinician-organization and clinician-society — have on professional behaviors and resource use?</blockquote> Again, the importance of threats was emphasized, and concerns about conflicts of interest affecting physicians' professionals were implied. This blog will apparently have a unique focus which I hope will complement our approach on Health Care Renewal. <blockquote>What we’re hearing from folks is the need to 'show me how' to answer these questions. Through analysis of promising practices, we hope to provide examples of what works – and what doesn’t.</blockquote> So we welcome <a href="http://blog.abimfoundation.org/">The Medical Professionalism Blog</a> to our blog-roll and look forward to some interesting content. For a final twist, I need to note that this blog's authorship appears to be unique. The Health Care Renewal bloggers, and most of our blogging friends mostly seem to include, in no particular order: academic physicians, often tenured or retired (and thus able to speak more freely), other generally senior or retired academics, independent or retired practicing physicians, journalists, independent consultants, some whistle-blowers and others who once worked in the health care establishment, and some very anonymous bloggers in the belly of the beast.  Thus, we are generally an very independent and iconoclastic, if a somewhat rag-tag lot. However, the chief blogger on <a href="http://blog.abimfoundation.org/">The Medical Professionalism Blog</a> is Daniel Wolfson, <a href="http://www.abimfoundation.org/en/About-Us/Staff.aspx">who is</a> Executive Vice President and Chief Operating Officer of the <a href="http://www.abimfoundation.org/">ABIM (American Board of Internal Medicine) Foundation</a>,  and the blog itself is <a href="http://blog.abimfoundation.org/about/">a project</a> of the foundation.  Thus, this is a blog from the heart of the medical establishment, the powers that be, etc, etc.  No other blog on our blog-roll comes from a current leader of such an organization.  (One is written by someone who was a CEO of a major academic medical center/ hospital system, but who lost his job under controversial circumstances.) It is truly refreshing to have a voice coming from the inside, so to speak, <a href="http://blog.abimfoundation.org/about/">proclaim</a>: <blockquote>The Medical Professionalism Blog was created by the ABIM Foundation to stimulate conversation and highlight best practices related to professionalism....</blockquote> Furthermore, <blockquote>Open for considerable debate is my belief that physicians’ engagement in quality, safety and the management of health care resources ultimately improves the care they give their patients and adds to their joy of work. I look forward to hearing your point of view, even if it’s a dissenting one.</blockquote> Lately, we have not heard a lot of calls for vigorous debate and dissent from the medical establishment, the powers that be, etc, etc. In fact, <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">the anechoic effect</a> is how we describe how such debate and dissent has been suppressed. So it appears the <a href="http://blog.abimfoundation.org/">The Medical Professionalism Blog</a> may be a real breath of fresh air. We hope it can truly inspire some discussion, especially open discussion of issues which used to be not what one was supposed to talk about in polite health care company.  This could help advance the transparency which we have long been advocating.

A New Venue From a Surprising Source to Discuss "External Threats to Good Decision-Making"

A new blog, entitled the Medical Professionalism Blog, signed on last week with a post emphasizing some themes that should be familiar to H...

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ONC: "The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results"

The Office of the National Coordinator for Health IT in the US (ONC) has just published an article in "Health Affairs" entitled "<a href="http://content.healthaffairs.org/content/30/3/464.full.html" style="font-weight: bold;">The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results</a>", Buntin, Burke, Hoaglin and Blumenthal, Health Affairs, 30, no.3 (2011):464-471, doi: 10.1377/hlthaff.2011.0178. It is available at the hyperlink above, but may not be publicly accessible. The authors all are, or were, ONC officials: <blockquote> Melinda Beeuwkes Buntin (Melinda.buntin@hhs.gov) is director of the Office of Economic Analysis, Evaluation, and Modeling, Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human Services, in Washington, D.C. Matthew F. Burke is a policy analyst at the ONC. Michael C. Hoaglin is a former policy analyst at the ONC. David Blumenthal is the national coordinator for health information technology.</blockquote> The abstract is as follows: <blockquote>ABSTRACT An unprecedented [indeed- ed.] federal effort is under way to boost [coerce? - ed.] the adoption of electronic health records and spur innovation in health care delivery.We reviewed the recent literature on health information technology to determine its effect on outcomes, including quality, efficiency, and provider satisfaction.We found that 92 percent of the recent articles on health information technology reached conclusions that were positive overall. We also found that the benefits of the technology are beginning to emerge in smaller practices and organizations, as well as in large organizations that were early adopters. However, dissatisfaction with electronic health records among some providers remains a problem and a barrier to achieving the potential of health information technology. [Some? That sounds like an understatement - ed.] These realities highlight the need for studies that document the challenging aspects of implementing health information technology more specifically and how these challenges might be addressed.</blockquote> I have long stated, at least since 1999, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">that</a>: <blockquote>Healthcare information technology (HIT) holds great promise towards improving healthcare quality, safety and costs. </blockquote> The new ONC review article is certainly pointing in this direction. Perhaps Health Affairs will release it to general circulation. However, I also wrote: <blockquote>As we enter the second decade of the 21st century, however, this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, and underestimations of the expertise essential to achieve the potential benefits of HIT. This often results in clinician-unfriendly HIT design, and HIT leaders and stakeholders operating outside (often far outside) the boundaries of their professional competencies. Until these issues are acknowledged and corrected, HIT efforts will unnecessarily over-utilize precious healthcare resources, will be unlikely to achieve claimed benefits for many years to come, and may actually cause harm.</blockquote> Whether the new ONC article demonstrates that these issues are starting to approach resolution, or is just another opinion paper not fully supported by facts, is not certain. Two charts are presented that summarize the findings (click to enlarge): <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpT4pnuIMRS5O0EfqAKR1EYdoGMP-sWmxDx58YmBBgvGXdiAibl3sHbk4l5TMv6fEP2CgrImXYKDZ_hj_3p-NujJNbQh08r-BLxlRP8BoGlNS19YuBonqW7uWYwATUKrIFfhnjNHo1ObS1/s1600/exhibit1.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5582297616857961330" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpT4pnuIMRS5O0EfqAKR1EYdoGMP-sWmxDx58YmBBgvGXdiAibl3sHbk4l5TMv6fEP2CgrImXYKDZ_hj_3p-NujJNbQh08r-BLxlRP8BoGlNS19YuBonqW7uWYwATUKrIFfhnjNHo1ObS1/s320/exhibit1.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 358px; height: 234px;" /></a>(Click to enlarge.) Evaluations Of Outcome Measures Of Health Information Technology, By Type And Rating </div> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpyARa0N5ySQFkIkB-WAOLjomnivQ6d5rbjZoXQbEv9cE4o8vLNBOV2e9hZrb8z019f6pMIHYiJPv_gx128rPq0TNk88VrECAiTVm8YwOiFTHBisj58VbphMhab9sH1NrbDTb60PEqm_am/s1600/exhibit2.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5582297684257203138" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpyARa0N5ySQFkIkB-WAOLjomnivQ6d5rbjZoXQbEv9cE4o8vLNBOV2e9hZrb8z019f6pMIHYiJPv_gx128rPq0TNk88VrECAiTVm8YwOiFTHBisj58VbphMhab9sH1NrbDTb60PEqm_am/s320/exhibit2.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 354px; height: 196px;" /></a>(Click to enlarge.) Health Information Technology: Study Design And Scope Factors Associated With Positive Overall Conclusions </div> There are several caveats. The first has to do with possible selection bias that can be present in any review article. On article selection for the review: <blockquote> ... we decided that to be included in this review, an article had to address a relevant aspect of health IT, as listed in the Appendix [7]; examine the use of health information technology in clinical practice; and measure qualitative or quantitative outcomes. Analyses that forecast the effects of a health IT component were included only if they were based on effects experienced during actual use. ... Using this framework, the review team removed 2,692 articles based on their titles. An additional 1,270 articles were determined to be outside the study’s scope after the team examined the article abstracts. For example, 269 abstracts focused solely on health IT adoption. [What, exactly, does that mean? Were the problems with HIT adoption potentially significant towards causation of lack of benefit, and/or presence of harm, for instance? - ed] By the third review stage, the review team had 231 articles. An additional forty-three were excluded after further review because they did not meet the criteria, and thirty-four review articles were dropped from the analyses because they did not present new work. [What does that mean? Did they drop highly comprehensive articles showing uncertainty in the literature about HIT, such as Greenhalgh's "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" from University College London? That article appeared in the Dec. 2009 <a href="http://www.milbank.org/quarterly.html" style="font-style: italic; font-weight: bold;">Milbank Quarterly</a>. I wrote about it <a href="http://hcrenewal.blogspot.com/2009/12/healthcare-it-as-cybernetic-miracle.html">at this link</a>.] This left 154 studies that met our inclusion criteria, 100 of which were conducted in the United States. This is comparable to the 182 studies found over a slightly longer time period that were evaluated by Goldzweig and colleagues. </blockquote> I should also note that no mention is made of independent reviewers of the article corpus and elimination process. It appears the entire effort was conducted within ONC itself, where a bias towards finding positive results is likely present (and understandable). Another caveat is the the Health Affairs/ONC article appears to bypass a body of literature, both peer-reviewed and non-peer reviewed, that sheds doubt on health IT in its present form from a number of angles such as I recently aggregated at "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist">An updated reading list on HIT</a>" and at "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">2009 a pivotal year in healthcare IT</a>." Bypassing literature such as this is a possible major weakness. Further, in the current political environment, it is not hard to imagine that articles highly critical of health IT, or revealing major mishaps and possibly exposing organizations to litigation, are scarce. I addressed that in a paper "<a href="http://www.scribd.com/doc/28747771/Remediating-an-Unintended-Consequence-of-Healthcare-IT-A-Dearth-of-Data-on-Unintended-Consequences-of-Healthcare-IT">Remediating an Unintended Consequence of Healthcare IT: A Dearth of Data on Unintended Consequences of Healthcare IT</a>." The paper itself was initially found needing revisions, largely in format, by a small group of blinded reviewers in the Medical Informatics community (with the exception of one faux-newshound who commented that "material like this could be read in any major newspaper", a rather perplexing comment considering the topic). Rather than revise, and not being on the tenure treadmill, I chose instead to publish at the Scribd link above. The ONC paper does acknowledge this: <blockquote>A recent study found that for clinical trials, studies with positive results are roughly four times more likely to be published than those without positive findings. Because the articles were limited to health IT adopters, we anticipated that authors more often approached studies looking for benefits rather than adverse effects. </blockquote> They do, however, then issue a value judgment: <blockquote>It is important to note that although publication bias may lead to an underestimation of the trade-offs associated with health IT, the benefits found in the published articles are real.</blockquote> I"m not sure a dear relative of mine would find that value judgment heartening. They suffered a crippling injury that would likely not have occurred if paper had been used in the ED rather than an EHR. I note that if a pharmaceutical company were to issue such a value judgment about a drug as justification for national marketing, they'd likely be nailed to the cross... The ONC paper also ignores accounts of "near misses" and actual patient injury from impeccable sources, such as in "<a href="http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009">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)": <blockquote>Annex A Examples of potential harm presented by health software GP prescribing decision support In 2004 the four most commonly used primary care systems were subjected to eighteen, potentially serious, realistic scenarios including an aspirin prescription for an eight year old, penicillin for a patient with penicillin allergy and a combined oral contraceptive for a patient with a history of deep vein thrombosis. Using dummy records, all eighteen scenarios failed to produce appropriate alerts by all of the systems, most of the time. The best score was a system that flagged up seven appropriate alerts. The health organization clearly has, in such a system deployment, a key responsibility to ensure that knowledge bases used within a design are correctly populated and aligned with clinical practice within their organization. Inadvertent accidental prescribing of dangerous drugs (such as methotrexate) This incident occurred when a user of a primary care system attempted to issue two repeat items. The items were highlighted and instead of the issue selected repeats button, the prescribe acute issues from the formulary button was pressed. This brought up the formulary dialogue which contained the high risk items. Either the issue button was then pressed or the particular items were double clicked. When the warning messages came up, they were all ignored and proceed and issue selected. The user chose the first item presented on the formulary list, which just so happened to be a methotrexate injection. In this particular case, it was determined that patient risk was minimal as the treatment was rarely used in primary care and would, in practice, be rejected by the pharmacist. To preclude any recurrence of the problem, access to the high risk formulary was removed from the formulary part of the acute drug issue dialogue. This example again demonstrates the need to align clinical practice and authority levels with the knowledge and rule bases within the system. Wherever possible, design and implementation of health software systems should be undertaken to improve control and accuracy, note introduce new exposures. Furthermore the hazard and risk assessment of this situation may well not apply in other settings, e.g. prescription issue by nursing staff on a ward versus a pharmacist in a retail store. Incorrect patient details retrieved from radiology information system This incident arose from the fact that medical reference numbers (MRNs) are usually prefixed by an alpha code. Some hospitals however do not use these prefixes and identical MRNs can be generated. This gave rise to the creation of shared MRNs and subsequent confusion of records in the central datastore when retrieval key is the Medical Record Number. Four specific instances were found where a patient number had been entered in the radiology information system and incorrect patient details had been retrieved. The manufacturer could have built in an appropriate format check during development. Alternatively, the problem could have been spotted by the health organization if a structured risk assessment had been undertaken. Drug mapping error Sodium valproate 200 mg slow release was incorrectly mapped to sodium valproate 200 mg in a formulary encoded into a health software system. These are anti-epilepsy drugs and thus the implications for patient safety could be significant. This particular incident is just one of many that have been reported in relation to drug mapping. An initial investigation indicated that 35 prescriptions had been generated using the incorrect map. Corrective action included contacting the relevant primary care practices to check upon patient health and the supplier to correct the mapping process to ensure no further incorrect prescriptions were generated. As before, this was a design/coding error by the manufacturer but was compounded by the health organization not checking the mappings and failing either to build in appropriate prescribing controls, or map the controls to health organization individuals with the appropriate experience and authority. Pre-natal screening The ages of women who had undergone pre-natal screening were wrongly computed by a health software system. As a result 150 women were wrongly notified that they were at no risk. Of these, four gave birth to Down's syndrome babies and two others made belated decisions to have abortions. Patient identification A student died of meningitis because of a misspelling of her name and inadequacy in computer use. The student was admitted and a blood test proved negative for meningitis. The following day another blood test was taken and filed on a new computer entry but the letter ―p was missed in the spelling of the name. When a doctor looked up results they were presented with only the first negative tests result because of the misspelling. If the second result had been seen it would have triggered further investigations and probable diagnosis of meningitis. The investigating panel concluded that problems with the health software system had been greater than first thought and in this case there was a combination of a misspelled name and the doctor not being able to use the computer system property. The health software system could have been designed to use unique numbers either instead of the name or in addition to it.</blockquote> They also missed consideration of serious IT defects reports as in the FDA's Maude database that I wrote about at my Jan. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html">MAUDE and HIT Risks</a>." Another confounding factor is the issue of possible unreliability of the medical literature itself as expressed in a recent post on the <a href="http://hcrenewal.blogspot.com/2011/01/ibms-watson-jeopardy-and-revolutioning.html">IBM Watson supercomputer exuberance</a>: <blockquote>Consider the issue of the medical literature suffering from numerous conflict of interest and dishonesty-related phenomema making it increasingly untrustworthy, as pointed out by Roy Poses in a Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/lancet-emphasizes-threats-to-academic.html">The Lancet Emphasizes the Threats to the Academic Medical Mission</a>", at my Aug. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/08/has-ghostwriting-infected-experts-with.html">Has Ghostwriting Infected The "Experts" With Tainted Knowledge, Creating Vectors for Further Spread and Mutation of the Scientific Knowledge Base?</a>" and <a href="http://hcrenewal.blogspot.com/search/label/pseudo-evidence%20based%20medicine">elsewhere</a> on this blog.</blockquote> They do state what I have been writing about for over a decade now: <blockquote>... In fact, the stronger finding may be that the “human element” is critical to health IT implementation. The association between the assessment of provider satisfaction and negative findings is a strong one. This highlights the importance of strong leadership and staff “buy-in” [which will only occur if the systems are not miserable examples of poor engineering, not due to P.R. or the irrational exuberance of others - ed.] if systems are to successfully manage and see benefit from health information technology. The negative findings also highlight the need for studies that document the challenging aspects of implementing health IT more specifically and how these challenges might be addressed.</blockquote> Dear ONC: see <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">this site</a>, and the many posts since 2004 on this blog. I was surprised to see this: <blockquote> ... Taking a cue from the literature on continuous quality improvement, every negative finding can be a treasure if it yields information on how to improve implementation strategies and design better health information technologies.</blockquote> As in my post <a href="http://hcrenewal.blogspot.com/2011/03/australian-ed-ehr-study-putting-lie-to.html">at this link</a>, does this mean that 'anecdotal' accounts of HIT problems will no longer be summarily dismissed? I wonder. I have also written in the past that in order to truly understand a domain, one must look at both evidence of the upside, and evidence of the downside. My concern is that the latter was not well addressed in this paper. A beneficial technology with a significant downside, especially in medicine, is not ready for national rollout (cf. Vioxx). In summary, the new ONC paper may present a glimmer of hope that health IT is starting to produce real results. On the other hand, its possible deficiencies and biases might also make it more a political statement than anything else. It will certainly be used as such from the high government perch of HHS regardless. This has already started: <blockquote> ... President Obama and Congress envisioned that the HITECH Act would provide benefits in the form of lower costs, better quality of care, and improved patient outcomes. This review of the recent literature on the effects of health information technology is reassuring: It indicates that the expansion of health IT in the health care system is worthwhile. [Note the use of "is worthwhile" as opposed to "may be worthwhile", a continuation of the "it's proven, nothing else to say" style I noted at my July 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html">Science or Politics? The New England Journal and "The 'Meaningful Use' Regulation for Electronic Health Records</a>." Such statements of absolute certainty are of concern; they remind me of the global warming debate - ed.] ...Thus, with HITECH, providers have an unparalleled opportunity to accelerate their adoption of health information technology and realize benefits for their practices, institutions, patients, and the broader system. [Ditto - ed.] </blockquote> Does the article truly show a breakthrough, or is it a flawed review by a governmental agency that will be used for political purposes? I simply do not know which. I am certain, however, that there will be active debate and dissection of this paper and its source articles in the months to come by those with more time, resources, and expertise than I have at my disposal. -- SS March 10, 2011 addendum: <a href="http://www.icms.qmul.ac.uk/chs/staff/trishagreenhalgh.html">Trisha Greenhalgh</a> at Barts and The London School of Medicine and Dentistry and the author of the aforementioned comprehensive review article "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" (<a href="http://hcrenewal.blogspot.com/2009/12/healthcare-it-as-cybernetic-miracle.html">link to my essay</a>), had this observation about the following passage in the ONC paper: <blockquote>“Our findings must be qualified by two important limitations: the question of publication bias, and the fact that we implicitly gave equal weight to all studies regardless of study design or sample size.”</blockquote> Prof. Greenhalgh relates: "Given these very fundamental acknowledged biases, I’m very surprised anyone published this paper in its present form.” -- SS March 14, 2011 addendum: Dr. Roy Poses had this to say: <blockquote> Dr Silverstein commented on a new review of research of health care information technology whose results were mainly optimistic. The authors were from the US government agency that promotes health care IT, so its optimism is not surprising. However, its credibility was unclear, since it did not appear to be systematic. [In general, one at least assesses and takes into account the methodologic quality of studies used in a <a href="http://en.wikipedia.org/wiki/Systematic_review">systematic review</a>, and does not "give equal weight to all studies regardless of study design or sample size" - ed.] Furthermore, the authors had no methodologic standards whatsoever for article inclusion. [They did, sort of, as in my paragraphs "On article selection for the review:", but one might term the standards "loose" - ed.] The review included qualitative studies that were probably not meant to be evaluative, and observational studies subject to severe methodologic bias. The publication of this review demonstrated how the conventional wisdom is continually reinforced based on the strength of the influence of its proponents, rather than the strength of the supporting evidence. Adaptation of new drugs and devices should be based on evidence that their benefits outweigh their harms, rather than the enthusiasm and financial interests of their proponents.</blockquote> -- SS

ONC: "The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results"

The Office of the National Coordinator for Health IT in the US (ONC) has just published an article in "Health Affairs" entitled ...

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"Cogs in the Corporate Machine" - More on the Plight of Corporate Physicians

We discussed last week some of the perils of the latest trend towards the corporatization of medicine, practicing physicians becoming employees of hospital systems, including for-profit corporate systems.  A <a href="http://www.medscape.com/viewarticle/737543">recent article</a> in Medscape Business of Medicine included a striking anecdote about the life of a corporate physician. Controlling Referrals by Contractual Provision It started with the revelation that some employed physicians may sign contracts that obligate them to refer patients within the corporate system, even if that is not in their best interests: <blockquote>Victoria Rentel, a family physician in Columbus, Ohio, joined a hospital-owned group several years ago. At first, nearly everything went fine. There were a few glitches: she'd occasionally order tests or consults at competing facilities, either for patient convenience or because of health plan coverage. When the hospital's administrators found out, they told her it was a violation of her contract; but that didn't stop her because she knew the hospital never enforced this provision.</blockquote>A Non-Compete Clause, Even for a Laid-Off Physician It also included the observation that corporate physicians may be abruptly laid off. Worse, being laid off means having to leave town, because apparently even laid-off physicians are still obligated by non-compete clauses in their contracts: <blockquote>Then, out of the blue, she was informed that the hospital was going to close her practice within 45 days. She knew this wasn't her fault; the recession had hit the hospital hard, and it was laying off nearly half of the primary care doctors in her group. Still, it was a hard pill to swallow. Making matters worse, her contract's noncompete clause prohibited her from going to work for any of the other healthcare systems in town. To avoid legal sanctions, she joined the student health service at Ohio State University.</blockquote>Signing Contracts Without Understanding Them The article's introduction emphasized the problem of physicians signing onerous contracts, perhaps without fully understanding them or without getting adequate legal advice: <blockquote>Many other physicians -- especially those who, like Rentel, were previously in private practice -- complain about their jobs. In some cases, it's because physicians rushed into the arms of a hospital without looking carefully at their contracts or asking the right questions during their job interviews.</blockquote>Cogs in the Corporate Machine The introduction ended ominously: <blockquote>Ultimately, the loss of control over their own professional lives is what irks employed doctors the most if they used to be in private practice. But some doctors also get the sinking feeling that they've become cogs in the corporate machine. 'The reality is that when you work for a hospital system, you're a service line,' says Rentel. 'And because primary care reimbursement is relatively low, you're a service line that feeds more lucrative service lines.'</blockquote> Oddly enough, after that striking beginning, the article peters off into a discussion of some "gripes of employed physicians," which either soft-pedaled or failed to include the issues listed above. The specific issues, and the general response of physicians to their role as corporate wage slaves deserve further consideration. Signing Bad Contracts First, the notion that physicians frequently sign contracts, particularly such important contracts as their own employment agreements, without reading them, without clearly understanding them, and without obtaining competent legal counsel is very disturbing.   A physician who signs a contract without reading it, understanding it, and getting competent legal advice about it is at best naive to the point of foolishness.  My late father, an attorney, done told me to "never sign a contract you haven't read and understood."  Contracts are - surprise - enforceable legal documents that may involve surrendering important rights.  One should never sign a contract without being satisfied that its benefits outweigh its harms. It could be that physicians who so blithely sign contracts are exhibiting <a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">learned helplessness</a>.  Maybe they feel somehow pressured to apparently voluntarily agree to doing something that ultimately will harm them.  I am not sure that simply declaring on a blog that we will have to unlearn our helplessness if we are ever to save medicine and health care will do much to solve what may be a fairly deep problem.  But we must do so. In addition, contracts are valid if entered into voluntarily.  It may be that some physicians truly sign contracts under duress.  Those contracts may not be valid, and could be challenged if they were so signed (again, if physicians are willing to unlearn their helplessness enough to get the counsel of a competent attorney.) Stopping "Leakage" Possibly Unethically, Maybe Illegally? The physician in the example above apparently had a contract provision which was violated simply by referring patients to competing facilities.  This appears to be an extreme way for a hospital to deal with the problem of "leakage," that is, the financial problem to the hospital caused when patients are referred outside the system.  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. Although leakage may pose financial problems for hospitals, fighting leakage may lead to ethical problems.  Physicians are supposed to decide how to manage patients, and specifically to decide where to refer patients in the patients' interests, not just to keep money flowing to the health care system. "Leakage reduction" may possibly threaten physicians' first commandment, to make decisions to maximize benefits and minimize harms to individual patients, before all other considerations. Worse, in the example cited in the Medscape paper, the leakage reduction was apparently implemented not by just trying to persuade doctors to keep patients within the system, but by a contract provision that somehow forbade referrals out of the system.  That may have not only been unethical, but it could have been illegal.   The "<a href="http://quitamguide.org/stark-law-limitation-on-certain-physician-referrals">Stark Law</a>" (Title 42, Chapter 7, Subchapter XVIII, Part E, Section 1395 of the US Code) generally prohibits basing referral decisions on payments.  Full-time employed physicians are exempt from some of its provisions, but only if the physicians' "amount of remuneration under employment" "is not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the referring physician."  Therefore, were the contract referred to above to have forbidden outside referrals on pain of termination or reduction in remuneration, it could potentially violate this law.  There have been rumors that physicians have been pushed to sign contracts that could so violate the Stark Law, but the published example above makes this a real possibility. Physicians ought not to sign contracts that seem to limit referrals under penalty of pay reduction or termination, which may be both unethical and illegal.  Any physician presented with or who has signed such a contract ought to consult a competent attorney. If hospitals and hospital systems are trying to force physicians to make referrals based on the hospitals' financial advantage instead of in the best interests of patients, that is reprehensible.  If these organizations are trying to do so via contractual provisions, this deserves investigation, including investigation by the relevant law enforcement agencies.  Don't Be a Corporate Cog This article underscores my previously expressed <a href="http://hcrenewal.blogspot.com/2011/03/rise-of-corporate-physician-end-of.html">fears</a> about how making physicians into corporate employees may remove the last barriers preventing patients from becoming corporate financial cannon fodder.  Physicians' most central professional value is to put patients' interests first.  Practicing physicians who practice as corporate employees are at risk of being pressured, or even threatened under the cover of contract enforcement to put their corporate employers' revenues ahead of patients' interests.  Physicians should not let their patients, and their own values be so threatened.  Physicians who have inadvertently, foolishly, or under duress signed contracts that could threaten their professionalism and their patients' welfare need to do the right thing and challenge these contracts, or else there will soon be nothing left of the medical profession, and no one left to ethically care for patients.

"Cogs in the Corporate Machine" - More on the Plight of Corporate Physicians

We discussed last week some of the perils of the latest trend towards the corporatization of medicine, practicing physicians becoming employ...

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