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Once Again, on IBM Watson, Cybernetic Miracles and Reductionist Views of Medicine

The cybernetic miracle shamans are at it again: <blockquote><a href="http://www.engadget.com/2011/09/12/ibms-watson-set-to-tackle-health-insurance-takes-diagnosis-fo/">IBM's Watson set to tackle health insurance, takes 'Diagnosis for $1,000'</a> via Engadget by Billy Steele on 9/12/11 After tackling your tech support woes, the famed Watson is moving on to mop up the health insurance industry. That's right, the IBM showstopper we all know and love for trouncing trivia kings on Jeopardy has been hired by one of the largest health insurance company's in the US. WellPoint Inc. [yes - <a href="http://hcrenewal.blogspot.com/search/label/WellPoint">this</a> WellPoint, a company that HC Renewal has referenced not just a few times - ed.] will make use of the system's breakneck speed and healthcare database alongside patient records -- allowing the supercomputer to guide treatment options and prescribe medicines. [Med Mal plaintiff's attorneys: take note - ed.] Once implemented, data will be combined from three sources in a matter of seconds: a patient's chart / records from a doctor, the insurance company's patient history and the medical knowledge that Watson already possesses. A pilot program will roll out next year to a number of cancer facilities, academic medical centers and oncology practices. No word yet on when The Watson School of Medicine will start accepting applications.</blockquote> I wrote on these issues quite seriously back in January 2011 at this post: "<a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/01/ibms-watson-jeopardy-and-revolutioning.html">IBM's Watson, Jeopardy, and Revolutionizing Medicine</a>." I wrote on a somewhat sarcastic note at this March 2011 post: "<a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/03/quick-thought-on-cybernetic-medicine.html">Here Comes the Judge! A Quick Thought on Cybernetic Medicine: Why Can't Computers Also Do Law?</a>" My views are unchanged since then. Roy Poses adds a good point: <ul><li>Where are the clinical trials? There is nothing here about actually doing clinical trials to test if Watson is accurate enough to do more good than harm before rolling this out. [As Scot has said a zillion times] This is an experimental technology akin to a new medical device that should be tested as rigorously as any new device or drug should be tested before it is used on patients. </li></ul>To which I further add: <ul><li>Where is the patient informed consent? </li></ul>-- SS Addendum: Perhaps Watson should better replace our "they're all the best and brightest" hospital CEO's and managers.

Once Again, on IBM Watson, Cybernetic Miracles and Reductionist Views of Medicine

The cybernetic miracle shamans are at it again: IBM's Watson set to tackle health insurance, takes 'Diagnosis for $1,000' via En...

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Director of Bristol-Myers-Squibb to Run Weill Cornell Medical School

How the New York Times reported on a change in leadership at one New York medical school has made one issue of interest to Health Care Renewal a bit less <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>. Here is the beginning of the <a href="http://www.nytimes.com/2011/09/08/nyregion/laurie-h-glimcher-named-dean-of-weill-cornell-medical-college.html">story</a>: <blockquote>A Harvard University researcher and professor with strong ties to the pharmaceutical industry has been selected as the new dean of Weill Cornell Medical College in Manhattan, as Cornell University seeks to greatly expand its research programs and obtain more federal and private financing, college officials said Wednesday. The new dean, Dr. Laurie H. Glimcher, 60, who has ties to the pharmaceutical giants Merck and Bristol-Myers Squibb as well as to scientific and biotechnology companies, said she wanted to use her experience to forge partnerships with both the public and private sectors. </blockquote> Dr Glimcher's "ties" to Bristol-Myers-Squibb are particularly striking: <blockquote>Bristol-Myers Squibb, where she has been on the board since 1997, paid her $244,500 in compensation in 2010, including fees and stock awards, according to its 2011 proxy statement. She received $1.4 million in deferred share units, by far the most of any director. </blockquote>A "New Species" of Conflicts of Interest A long time ago, in 2006, we first blogged about a "<a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">new species of conflict of interest</a>" which we thought might prove to be even more important than other conflicts of interest afflicting health care that were then starting to be discussed.  This new species  involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive.  It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. <a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986">Corporate Governance</a>, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]   Thus, for example, the conflict posed by the president of a university, to whom a medical school and academic medical center report, who also is the director of a pharmaceutical company, would be extreme. In 2006, these apparently major conflicts of interest were highly anechoic, and generally otherwise not considered to be newsworthy or fit for discussion in the medical and health care literature.  This, however, is starting to change.  By 2010, the New York Times published a report, albeit in one of their blogs, on a controversy at the Unviersity of Michigan about whether its president's position on the Johnson and Johnson board had influenced her backing of anti-smoking measures, given that Johnson and Johnson makes smoking cessation products (see post <a href="http://hcrenewal.blogspot.com/2010/07/new-york-times-reports-university.html">here</a>). Now, mention of this sort of particularly intense conflict of interest went into the lead paragraph of a story in one of the world's most respected newspapers. A Conflict Cutting Both Ways: The Bristol-Myers-Squibb Settlement In addition, the Times story connected another dot: <blockquote>While she has been on the board, the company has paid hundreds of millions of dollars to settle federal and shareholder complaints that it had inflated sales figures, although Dr. Glimcher herself was not found liable. </blockquote> That underlines the point that people who simultaneously are leaders of both non-profit health care institutions (like medical schools and hospitals) and for-profit health care corporations ought to simultaneously be held accountable for the actions of both, which may put them in uncomfortable positions. Actually, the Times article seemed to soft-pedal what the 2007 Bristol-Myers-Squibb settlement was actually about. As we discussed in <a href="http://hcrenewal.blogspot.com/2007/10/bristol-myers-squibb-settles-enters.html">this post</a>, the settlement was actually in the amount of $515 million, and the government allegations that lead to the settlement were actually about more than inflated sales figures. From the 2007 Department of Justice <a href="http://www.justice.gov/opa/pr/2007/September/07_civ_782.html">news release</a>: <blockquote>First, the Government alleged that, from approximately 2000 through mid-2003, BMS knowingly and willfully paid illegal remuneration to physicians and other health care providers to induce them to purchase BMS drugs.</blockquote><blockquote>Second, the Government alleged that, from 2002 through the end of 2005, BMS knowingly promoted the sale and use of Abilify, an atypical antipsychotic drug, for pediatric use and to treat dementia-related psychosis, both 'off-label' uses. The Food and Drug Administration has approved Abilify to treat adult schizophrenia and bi-polar disorder, but has not approved the use of Abilify for children and adolescents or for geriatric patients suffering from dementia-related psychosis. Indeed, the FDA has mandated that the package for Abilify carry a 'black box' warning concerning its use in the treatment of dementia-related psychosis.</blockquote><blockquote>Third, the Government alleged that both BMS and Apothecon set and maintained fraudulent and inflated prices for a wide assortment of oncology and generic drug products with the knowledge that federal health care programs established reimbursement rates based on those prices. By reporting false and fraudulent prices that were substantially higher than commonly and widely available prices in the marketplace, BMS and Apothecon created a 'spread' between the reimbursement rates for federal health care providers and the actual prices for the drugs charged to its customers. The larger the spread on a drug, the larger the profit or return on investment for the provider. Because reimbursement from federal programs was based on the fraudulent, inflated prices, the United States alleged that BMS and Apothecon caused false and fraudulent claims to be submitted to federal health care programs.</blockquote><blockquote>Finally, the Government alleged that BMS knowingly misreported its best price for the anti-depression drug, Serzone.  </blockquote> Dr Glimcher has been on the BMS board since 1997, so the actions that lead to these allegations and then the settlement clearly occurred on her watch. Nonetheless, the Times noted: <blockquote>Dr. Glimcher, an immunologist with a strong interest in osteoporosis, defended her outside interests, saying they presented no conflict as long as they were transparent. She said she wanted to 'leverage the strengths of everyone,' whether scientists, pharmaceutical companies or biotechnology companies. 'There should be no silos between all of these different strengths,' she said. </blockquote> How simple transparency would remove a conflict created by a fiduciary duty to the Bristol-Myers-Squibb stockholders, and reinforced by a yearly pay-check of $244,500, she did not say.  Neither did she say how transparency about her service on the board would eliminate her responsibility for actions taken by the BMS management that occurred on her watch. Dubious Enthusiasm from the Former Chairman of Bailed-Out Citigroup The conflict did not seemingly dim the enthusiasm of the Weill Cornell board for her candidacy. As the Times reported: <blockquote>Sanford I. Weill, the former chairman of Citigroup who with his wife was the benefactor for whom the college was named in 1998, said Wednesday that Dr. Glimcher had come to his attention through a good friend, Jim Robinson, a co-founder of the technology venture-capital firm RRE Ventures and a former chairman of Bristol-Myers Squibb and chairman and chief executive of American Express. 'He recommended that I meet Laurie Glimcher when he heard we were going to look for a new dean,' Mr. Weill said.</blockquote> That would be the Sanford Weill who built up Citigroup into a bank that was too large to fail, and which was prevented from failing by a huge government bailout (see this post). In his epic, <a href="http://www.harpercollins.com/books/9780061892486/The_Sellout/index.aspx">The Sellout</a>, about the global financial collapse, this is how Charles Gasparino described Weill (p. 144): <blockquote>But in reality, Will never really ran anything. He was a visionary, to be sure, but one whose vision was so myopically focused on building the empire had lusted for for so long and on its share price that he ignored just about everything else.</blockquote>Weill's record would suggest that his judgment about Dr Glimcher may be open to question. Even More Conflicts of Interest To add a bit more icing to the conflict of interest cake, Dr Glimcher has other financial relationships to which the Times vaguely alluded. The latest (2011) Bristol-Myers-Squibb <a href="http://services.corporate-ir.net/SEC/Document.Service?id=P3VybD1odHRwOi8vaXIuaW50Lndlc3RsYXdidXNpbmVzcy5jb20vZG9jdW1lbnQvdjEvMDAwMTE5MzEyNS0xMS0wNzI0NTcvZG9jL0JyaXN0b2xNeWVyc1NxdWliYl9ERUYxNEFfMjAxMTAzMjEucGRmJnR5cGU9MiZmbj1CcmlzdG9sTXllcnNTcXVpYmJfREVGMTRBXzIwMTEwMzIxLnBkZg==">proxy statement</a> listed the following: - scientific advisory board memberships: <a href="http://www.hcven.com/">Health Care Ventures</a>, Inc, (which invests in new pharmaceutical and biotechnology companies) <a href="http://www.nodality.com/">Nodality Inc</a>, (which develops diagnostics and pharmaceuticals), <a href="http://www.abpro-labs.com/">Abpro Inc</a> (which makes antibodies and proteins), and <a href="http://theraclone-sciences.com/home.php">Theraclone Sciences Inc</a>, (which also is developing antibodies for therapeutic purposes) - board of directors membership: <a href="http://www.waters.com/waters/home.htm?locale=en_US">Waters Corporation </a>(maker of laboratory equipment used in life sciences and pharmaceutical discovery, research and development, and commercialization.) One hardly knows how she would find the time to do anything besides fulfill these responsibilities. No wonder that the Times article said: <blockquote>Cornell University’s president, Dr. David J. Skorton, said he believed Dr. Glimcher had the skills to carry out the medical school’s plan to double its research capacity and to help the university compete to develop a new high-tech campus proposed by the Bloomberg administration. </blockquote> Dr Glimcher certainly seems as tied into the world of commercial pharmaceuticals and biotechnology as much as any ostensible academic might be. Indeed, as posted <a href="http://hcrenewal.blogspot.com/2009/03/harvard-medical-students-against.html">here</a>, Dr Glimcher was quoted in a defense of the then current policy and conflicts of interest at Harvard: <blockquote>Dr. Glimcher says industry money is not only appropriate but necessary. 'Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,' she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year.</blockquote>So at that time Dr Glimcher thought it was perfectly proper and appropriate for her to be paid by Merck to develop new drugs for that company while she was ostensibly a full-time faculty member at the Harvard Medical School (not to mention a full-time board member of one of Merck's competitors.) Summary and Some Questions So to summarize, Cornell Weill Medical School just named a new dean who has been a leader (as member of the board of directors) of Bristol-Myers-Squib for 14 years, on whose watch there the company paid a huge settlement and entered a corporate integrity agreement for allegations of kickbacks and fraud, and who has also been a leader of a biotechnology company, and advisor to a biotechnology and pharmaceutical venture capital fund and to three other biotechnology companies.  She declared she has no conflicts because she has revealed these relationships, and seemingly has been hired mainly to raise money from the pharmaceutical and biotechnology industry. So maybe some intrepid journalist and/or student will ask her: - Given that they now will be reporting to a member of the board of Bristol-Myers-Squibb, should Cornell students and faculty favor its products or policies that it supports?  Should they worry if they do not?  Should they worry about saying or writing anything that might not be seen as supportive of it?  Should they consider themselves to be now in the Bristol-Myers-Squibb medical school? On the other hand, - Does Dr Glimcher feel responsible for the actions of BMS management that lead to its settlement and corporate integrity agreement?  If not, how can she have a fiduciary responsibility to its stockholders? But I will not hold my breath waiting for answers. At least one hopes that putting these issues in the New York Times will provoke some discussion about whether academic institutions should knowingly seek leaders who must serve so many masters.  Maybe they would do better if they sought leaders who would be notable for their whole-hearted devotion to patient's interests and to the integrity of teaching and research rather than for their cozy ties to other top health care leaders.

Director of Bristol-Myers-Squibb to Run Weill Cornell Medical School

How the New York Times reported on a change in leadership at one New York medical school has made one issue of interest to Health Care Renew...

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Talking Points, Sans Original Thought, to Justify Million Dollar Hospital CEO Compensation

Generous pay given to health care leaders has become an area of interest in the media.  Some recent regional stories had a certain dreary sameness, however.  It seems that nearly everywhere in the US, million dollar CEOs have become commonplace at non-profit hospitals and health care systems.  Atlanta, Georgia Region In July, the Atlanta Journal Constitution <a href="http://www.ajc.com/news/atlanta/hospital-ceo-pay-has-997155.html">reported</a> on the compensation given to some regional hospital leaders.  It included the usual gaggle of million dollar CEOs: <blockquote>Edward Bonn of Southern Regional Health System, which operates Southern Regional Medical Center and two affiliated facilities, made $2,610,175 in fiscal 2009. Bonn left the system that year and received his pay of $421,822 plus $2.2 million from a retirement plan. Hospital CEOs commonly receive extra pay from retirement plans when they leave.</blockquote>and <blockquote>In fiscal 2009, John Fox of Emory Healthcare made $1,671,999 to manage Emory University Hospital and five associated institutions. Tim Stack of Piedmont Healthcare, who manages Piedmont Hospital and three others, made $1,340,974 the same year</blockquote> There were two other million dollar CEOs that the article did not name. The State of Georgia Last month, Georgia Health News published a <a href="http://www.georgiahealthnews.com/2011/08/high-ceo-pay-common-hospitals-statewide">story</a> on other highly paid hospital leaders. In general, <blockquote>Georgia Health News has found that executives at nine other Georgia nonprofit hospitals or health systems outside metro Atlanta received at least $1 million in total compensation during their organizations’ most recent fiscal year</blockquote> Some specifics: <blockquote>Ken Beverly, former CEO and president of Archbold Medical Center, a four-hospital system based in Thomasville, who received $6.2 million in fiscal 2009. The health system told Atlanta Unfiltered that most of that compensation related to Beverly’s retirement benefits, accumulated over many years of service.</blockquote>Also, <blockquote>The Gainesville [Northeast Georgia Health] system, which has 5,000 employees, paid CEO James Gardner $1.4 million in total compensation in fiscal 2009.</blockquote>Furthermore, <blockquote>** The Medical Center of Central Georgia paid Donald Faulk, its CEO, $1,003,412 in fiscal 2009. Faulk has been CEO of the Macon hospital since 1995, and has been employed there for 37 years.</blockquote><blockquote>** Larry Sanders, CEO of Columbus Regional Healthcare System, received compensation of $2.2 million in fiscal 2010, with $1 million of it a payout of a supplemental retirement benefit called a split-dollar life insurance policy. Sanders has worked in that system, which includes the Medical Center in Columbus, for 30 years. ** Jack Drew, with 29 years of service at Athens Regional Medical Center, received $1,185,902 in fiscal 2009.</blockquote><blockquote>** University Health in Augusta paid CEO Larry Read $3.5 million in fiscal 2009, with the majority coming as payment of his retirement benefit. Read retired last year. ** Joel Wernick, longtime CEO at Phoebe Putney in Albany, received $1.3 million, with part of it a one-time deferred compensation payment, in fiscal 2010. ** Kurt Stuenkel, CEO of Floyd Medical Center in Rome, received $1.35 million in compensation in fiscal 2010. ** At St. Joseph’s/Candler in Savannah, Paul Hinchey received $1,053,390 in total compensation in fiscal 2010.</blockquote> Madison, Wisconsin Region Madison.com <a href="http://host.madison.com/wsj/news/local/health_med_fit/article_c9e10fae-d174-11e0-93ad-001cc4c002e0.html">discussed</a> the area's highest paid hospital CEOs. They included: <blockquote>Javon Bea, CEO of Janesville-based Mercy Health System, made $3.6 million in total compensation in 2009 and $4.5 million the year before. The system has hospitals in Janesville, Lake Geneva and Harvard, Ill.</blockquote> Columbus, Ohio Region Columbus Business First <a href="http://www.bizjournals.com/columbus/blog/2011/08/hospital-ceo-pay-shows-wide-disparity.html">noted</a> compensation of regional hospital systems, including: <blockquote>By far the highest paid was Dave Blom, CEO of Columbus-based OhioHealth Corp ., at $1.8 million. About $675,000 of that total is deferred compensation. Among chiefs, he’s followed by Dr. Steve Allen of Nationwide Children’s Hospital at $1.2 million,...</blockquote> Furthermore, the justifications for these pay packages uncovered by reporters in different parts of the country also had a certain sameness.  They were actually so similar as to suggest they came from a common set of talking points generated by a common public relations effort.  We Pay What Everyone Else Pays In Atlanta, in general: <blockquote>Atlanta hospital boards have compensation committees of community leaders to ensure executive salaries meet Internal Revenue Service guidelines and are competitive with salaries offered by other medical facilities.</blockquote> Also, <blockquote>All of the tax exempt hospitals in the area issued statements asserting their CEO’s compensation is vetted by their boards and in line with industry standards....</blockquote> In Georgia <blockquote>Hospital boards 'have to pay market rates in order to attract talent,' said Glenn Pearson, Georgia Hospital Association executive vice president. CEO salaries in Georgia 'appear to be very much in line with national trends,' he said.</blockquote> In Columbus, Ohio <blockquote>Hospital trustees set compensation after studying comparable positions in both the nonprofit and for-profit sectors.</blockquote> CEOs Work Hard and are Brilliant, so They Deserve High Pay In Atlanta, in general: <blockquote>Industry representatives say these pay packages ensure communities get the best possible care by attracting the few people capable of administering these complex organizations.</blockquote> Also, <blockquote>Pay in excess of $1 million a year may seem high for an organization subsidized by taxpayers, but hospital executives and industry representatives said the public should think of these hospitals not as charities, but as complex, billion-dollar organizations. Georgia hospitals report to 27 state and federal agencies and engage in multimillion-dollar building projects. The larger hospital systems have billions in revenue and are among the largest employers in their communities. Many also operate for-profit subsidiaries. 'You can’t lose sight of the fact that it’s not an ice cream shop on the side of the street,' said Joseph Parker, president of the Georgia Hospital Association.</blockquote> In Georgia as a whole, <blockquote>GHA added that hospitals are accountable to 27 state and federal agencies, while dealing with tight Medicaid reimbursement and an increasing number of uninsured people.</blockquote> In Madison, Wisconsin, <blockquote>health care has become much more complicated than when Catholic nuns ran many nonprofit hospitals while taking vows of poverty, said [Integrated Healthcare Strategies vice president David] Bjork, the health care consultant. He said today's hospital executives struggle to keep their complex enterprises afloat, dealing with independent doctors who make many of the key financial decisions while being largely unable to predict when patients need services.</blockquote> High Pay is Needed to Attract and Retain Competent, If Not Brilliant People In Atlanta, <blockquote>The number of people who can manage these facilities is limited and recruitment is competitive, Parker said. Qualified leaders will gravitate to other fields over time if compensation for nonprofit CEOs is decreased, [Mercer Inc pay consultant Jose] Pagoaga said. The 'substandard leadership' that replaces them will degrade the quality of medical care for the community.</blockquote> In Georgia, <blockquote>The pay decision is made by community leaders who serve on hospital boards, Pearson said. Those board leaders want to make sure they 'have the person of the highest quality,' given the challenging financial times that hospitals face, he said.</blockquote>Furthermore, <blockquote>It’s a competitive market nationally for the top people, said Kevin Talbot, a vice president of the [Integrated Healthcare Strategies consulting] firm.</blockquote>Also, <blockquote>Boards of Georgia nonprofit health systems responded to GHN that the compensation is needed to attract and retain talented executives. </blockquote>In particular, <blockquote>'Establishing and maintaining competitive executive compensation is critical to our ability to ensure that we have a highly competent and effective leader at the helm, and it is a responsibility that our board does not take lightly,' said Mary Lynn Coyle, chairman of the board of Northeast Georgia Health System.</blockquote>Finally, <blockquote>'This is a field where there's a great demand for talent,' said Nancy Anderson, chairman of the board of the Medical Center of Central Georgia.</blockquote> In Madison, Wisconsin, <blockquote>But large hospitals such as those in Madison have to pay top dollar to attract people with the skills to manage them, said David Bjork, senior vice president of the Minneapolis-based consulting firm Integrated Healthcare Strategies. 'Running a hospital is probably the toughest management job that exists,' Bjork said.</blockquote> In Columbus, Ohio, <blockquote>'People who are running hospitals and hospital systems are running businesses that are literally saving people’s lives, so it’s really important to have a quality leader,' said Tiffany Himmelreich, spokeswoman for the Ohio Hospital Association</blockquote>And, <blockquote>'People with these types of leadership abilities could easily be snatched up by for-profit businesses,' she said.</blockquote>There was also a certain sameness in what the the reports did not say. Things Unsaid, and Questions Begged None of the news reports contained a response from a million dollar CEO.  Justifications of CEO pay came from hospital trustees, hospital spokespeople, or compensation consultants. None of the news reports explained why a particular CEO should be considered above average, much less brilliant.  None explained why a particular group of comparator hospitals were appropriate for a particular hospital and its CEO.  As we have discussed before, all CEOs cannot be above average, some CEOs must be below average.  Yet while the reports mentioned CEOs who made less than $1 million, none would dare characterize them as below average.  Some news reports noted reasons that particular hospitals or CEOs or CEOs ought not to be compared so favorably to their peers.  For example, Edward Bonn's Southern Regional Health System in the Atlanta area lost $12 million in 2009, Tim Stack's Piedmont Health "will cut 464 jobs," and Ken Beverly, of Archbold Medical Center, "was found guilty on six counts in a health care fraud case." (See <a href="http://hcrenewal.blogspot.com/2011/01/executive-compensation-at-non-profit.html">this post</a> on the latter.)However, nobody in the news reports dared to suggest that these CEOs might be below average in some sense, and hence might not be entitled to such high pay.    The report from Atlanta noted, "hospital executives and industry experts consider the examination of salaries a titillating issue for the public, but a subject lacking in substance."   However, they failed to explain why the incentives created by large salaries may not generate concerns of substance, or address the concern that "the 'rarified existence' of some nonprofit hospital CEOs may warp their financial decisions and blunt the charitable mission." Finally, if CEOs, most of whom are not health care professionals, are credited with "literally saving people's lives," why are the health care professionals who actually do save people's live not credited even more? Summary The extreme consistency of justifications for generous compensation given to hospital and health system CEOs, (and as <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">we have seen</a>, for such compensation given to other health care leaders) suggests that these justifications are talking points being generated by the leaders public relations flacks.  They may be using talking points because they know the real reason for the high pay is that the CEOs have become unaccountable, and able to set their own pay.  If the CEOs and their friendly boards cannot refute this contention, the latter do not deserve their pay, and the former do not deserve their positions of stewardship. Over and over, I say... Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Talking Points, Sans Original Thought, to Justify Million Dollar Hospital CEO Compensation

Generous pay given to health care leaders has become an area of interest in the media. Some recent regional stories had a certain dreary sa...

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New way to get kids interested in medicine: post confidential medical records on a homework site?

Was this a new way to get kids interested in medical careers? Or was it an accident due to the highest levels of negligence associated with lowest/cheapest standards in hiring for mission critical roles? <blockquote><a href="http://www.nytimes.com/2011/09/09/us/09breach.html?_r=1&hp">Patient Data Posted Online in Major Breach of Privacy </a> New York Times Sept. 8, 2011 Kevin Sack A medical privacy breach at <a href="http://topics.nytimes.com/top/reference/timestopics/organizations/s/stanford_university/index.html?inline=nyt-org" title="More articles about Stanford University" class="meta-org">Stanford University</a>’s hospital in Palo Alto, Calif., led to the public posting of medical records for 20,000 emergency room patients, including names and diagnosis codes, on a commercial Web site for nearly a year, the hospital has confirmed. Since discovering the breach last month, the hospital has been investigating how a detailed spreadsheet made its way from one of its vendors, a billing contractor identified as Multi-Specialty Collection Services, to a Web site called “Student of Fortune,” which allows students to solicit paid assistance with their school work. Gary Migdol, a spokesman for Stanford Hospital and Clinics, said the spreadsheet first appeared on the site on Sept. 9, 2010, as an attachment to a question about how to convert the data into a bar graph.<div id="articleBody"> </div></blockquote><div id="articleBody"> To teach the kids to be medical bean counters at an early age, perhaps? <blockquote>Even as government regulators strengthen oversight by requiring public reporting of breaches and imposing heavy fines, experts on medical security said the Stanford incident spotlights the persistent vulnerability posed by legions of outside contractors who gain access to private data. </blockquote> In the Oct. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/10/private-medical-records-offered-for.html">Private medical records offered for sale</a>" I wrote about how such data was for sale by onion-like layers contractors - cheap. <blockquote>The spreadsheet contained names, diagnosis codes, account numbers, admission and discharge dates, and billing charges for patients seen at Stanford Hospital’s emergency room during a six-month period in 2009, Mr. Migdol said. It did not include Social Security numbers, birthdates, credit-card accounts or other information used to perpetrate identity theft, he said, but the hospital is offering free identity protection services to affected patients. </blockquote> (Partial) luck prevailed - this time. <blockquote>The breach was discovered by a patient and reported to the hospital on Aug. 22, according to a letter written four days later to affected patients by Diane Meyer, Stanford Hospital’s chief privacy officer. The hospital took “aggressive steps,” [i.e., its CIO made a quick, panicky phone call - ed.] and the Web site removed the post the next day, Ms. Meyer wrote. It also notified state and federal agencies, Mr. Migdol said. </blockquote> Perhaps "aggressive steps" should have been taken before private medical data was published on a kid's homework site? <blockquote>“It is clearly disturbing when this information gets public,” he said. “It is our intent 100 percent of the time to keep this information confidential and private, and we work hard every day to ensure that.” </blockquote> Would "Master of the Obvious" (a favorite line of my early medical mentor, cardiothoracic surgeon/polymath <a href="http://www.facebook.com/pages/Dr-Victor-P-Satinsky/147849525268828">Dr. Victor P. Satinsky</a>, be too kind a response to this statement? <blockquote>Diane Dobson, of Santa Clara, Calif., said her “jaw dropped” on Saturday when she intercepted the letter from Ms. Meyer addressed to her 21-year-old son, who she said received emergency psychiatric treatment at Stanford in 2009. Ms. Dobson said it could have been disastrous if her son, who lives at home, had learned that his name was linked online to a diagnosis for psychosis. “My son, I can tell you, is fragile and confused enough that this would have sent him over the edge,” Ms. Dobson said. “Everyone with an electronic medical record is at risk, and that means everyone.” </blockquote> My sympathies go out to this mother and her son. Her concerns show that cavalier attitudes towards EMR's can lead to catastrophe beyond identity theft or career damage. <blockquote>The incident at Stanford, while egregious in its details, is far from rare. Records compiled by the Department of Health and Human Services reveal that personal medical data for more than 11 million people has been improperly exposed during the last two years alone ... The major breaches — a disconcerting log of stolen laptops, hacked networks, unencrypted records, misdirected mailings, missing files and wayward e-mails — took place in 44 states. </blockquote> I'm certain there is an increasing amount of critical medical data being withheld by patients as publicity about these breaches become more well-known. <blockquote>The breaches at Stanford reinforce that even the most prestigious medical centers are not immune to risk. <a title="Web site" href="http://www.massgeneral.org/"> Massachusetts General Hospital</a> in Boston, which trains Harvard medical students, agreed this year to pay a $1 million federal fine after an employee left paper medical records on a subway train while commuting to work. The pages contained the names of 192 patients, and diagnoses for about a third of them, including for H.I.V./AIDS. They were never recovered. </blockquote> I note these are both pioneers in electronic health records. Imagine what might be happening at Podunk Hollow General Hospital... <blockquote>Mr. Migdol said the hospital had concluded that “there is no employee from Stanford Hospital who has done anything impermissible.” He said he expected the federal Department of Health and Human Services to conduct its own investigation. Susan McAndrew, deputy director of <a href="http://topics.nytimes.com/top/reference/timestopics/subjects/h/health_information_privacy/index.html?inline=nyt-classifier" title="Recent and archival health news about health information privacy." class="meta-classifier">health information privacy</a> for the department’s Office of Civil Rights, said she could not discuss whether an investigation was in progress ... Bryan Cline, a vice president with the Health Information Trust Alliance, a nonprofit company that establishes privacy guidelines for health care providers, said that nearly 20 percent of breaches were perpetrated by outside contractors, accounting for more than half of all the records exposed. </blockquote> When you start to outsource mission critical data, you should probably be prepared to take responsibility for whomever you outsource it to. <blockquote>The vendor, identified by Mr. Migdol as Multi-Specialty Collection Services LLC, based in Los Angeles, could not be reached for comment. Mr. Migdol said the company created the spreadsheet as part of a billing-and-payment analysis for the hospital. He said the hospital immediately suspended its relationship with the contractor and received written certification that previous files would be destroyed or returned securely. </blockquote> Apparently someone there with access to the spreadsheet was less than careful about keeping it away from children. One wonders if they would have been more careful with pornography... <blockquote>“We’re still kind of caught in the pre-high-tech trust model instead of the insurance model,” Mr. Cline said. “Health care providers say, ‘I’m going to have some contract language and then just trust that you’ll protect my data because if you don’t I’m going to sue you.’ That just doesn’t work, as we can see. You have to do due diligence, something to assure yourself that the people you’re giving your data to can be trusted.”</blockquote> <div class="articleCorrection"> </div> </div> I'd say we're still in the stone age with respect to our irrational exuberance about health IT. See my series of articles on these issues at these query links: <a href="http://hcrenewal.blogspot.com/search/label/computer%20security">computer security</a>, <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">medical record privacy</a>, <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality">medical record confidentiality</a>. A fundamental set of rules in today's hire-on-the-cheap, keep-staffing-minimal environment is this: <blockquote>1. If you want information to be kept secure, don't place it on a computer. 2. If you place the information on a computer, don't place the computer on a network. 3. If you place the computer on a network, the information is no longer secure. </blockquote>In our current culture I do not believe these issues to be easily remediable, but hiring the truly best and brightest (after satisfactory scores in a very hard test in critical thinking skills) into IT roles - including design, implementation, and management - might be a start. -- SS

New way to get kids interested in medicine: post confidential medical records on a homework site?

Was this a new way to get kids interested in medical careers? Or was it an accident due to the highest levels of negligence associated with ...

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Another Hospital Putting on the Ritz

The usual definition of a hospital is an institution which treats the sick and injured,.  That is a messy business, so some hospital executives seem to yearn to be doing something a little more - shall we say - upscale.  For example, the Chattanoogan <a href="http://www.chattanoogan.com/articles/article_207569.asp">reported</a>: <blockquote>Erlanger Health System will launch in October one of the most ambitious employee training initiatives in its 120-year history. All 4,500 employees will participate in a new service excellence program based on the legendary Ritz-Carlton service model. 'This is not a program. This is the beginning of long-term cultural transformation,' says Erlanger CEO James Brexler. 'Our board and leadership team believe this initiative is one of the most significant developments in the continued evolution of Erlanger.' The Erlanger Health System strategic plan, adopted by the board of trustees last year, identified service excellence as a priority. Funding for the initiative was approved in this year’s operating budget. The corporate university of Ritz-Carlton was selected to help take Erlanger’s patient experiences to the next level.</blockquote> A hospital, of course, provides services to patients. However, it seems glaringly obvious that the sort of services required by the sick and injured, especially the critically ill, are very different than those people who go to four-star hotels. Providing care to a patient on a ventilator (breathing machine), for example, hardly resembles providing spa services to a wealthy hotel guest. Furthermore, Erlanger Health System is a public, non-profit health system with a <a href="http://www.erlanger.org/body.cfm?id=38">mission</a> that involves service to the poor: <blockquote>To deliver excellence in medical care to improve the health status of our region, while providing vital services to those in need, and training to health professionals through affiliation with academic partners</blockquote> The Boston hotel in the Ritz-Carlton chain, its flagship property, <a href="http://www.ritzcarlton.com/en/Properties/BostonCommon/Rooms/Default.htm">boasts</a> that it: <blockquote>features hotel rooms and suites in Boston designed as sanctuaries of urban luxury. </blockquote> Where is the parallel to providing health care services to "those in need" who are acutely ill and injured? By the way, a few days after the Erlanger, Ritz-Carlton connection was announced, the Time Free Press <a href="http://timesfreepress.com/news/2011/aug/30/830-a1-erlanger-defends-ritz-bid-process">noted</a> questions about how the contract was awarded: <blockquote>Erlanger officials defended the no-bid procedure Monday, saying the hospital was correct in bypassing a competitive bid process and awarding a 'professional services' contract to Ritz-Carlton. 'Tennessee law says government entities do not have to bid professional services,' hospital spokeswoman Susan Sawyer said. Even early in the process, Whisman said, 'it was so clearly the Ritz going forward.' 'There was a lot of board support, executive-level support and steering committee support,' she said. 'Ritz had it all.'</blockquote> Furthermore, how well the money will be spent may be difficult to find out: <blockquote>In October, a Ritz-Carlton speaker is expected to lead several four-hour sessions, each of which will hold 400 employees, hospital officials said. The bill for those sessions is $288,000. On Thursday, Sawyer said Ritz-Carlton prohibited the media from attending the sessions because of proprietary information the hotel chain prefers to keep secret.</blockquote> It is not that the hospital system has money to burn, as the Chattanoogan just <a href="http://www.chattanoogan.com/articles/article_207569.asp">revealed</a>: <blockquote>Erlanger Health System officials reported a $1.3 million loss for July,...</blockquote> In addition, <blockquote>Admissions were under budget by 1.6 percent for the month and ahead of the previous year by 3.8 percent.</blockquote> So, in summary so far, a public hospital system that is currently experiencing budgetary challenges is spending hundreds of thousands of dollars for the Ritz-Carlton luxury hotel chain to train its employees in secret sessions about "service excellence," and the hospital system's management thinks this is a top priority. In my humble opinion, this illustrates a larger problem with the leadership of health care. Health care organizations are often lead by ultra <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic managers</a>, that is, managers trained in such fields as marketing, public relations, and finance, but without any experience or training in actually taking care of patients. (The supremacy of generic management is strange given that patient care itself has become so specialized.) The utter lack of gut feeling for what health care is really about seems to lead to managers thinking that hospitals are <a href="http://hcrenewal.blogspot.com/2005/09/reasoning-by-misanalogy-revisited-how.html">like automobile assembly plants</a>, or in this case, like luxury hotels. I cannot but help believe that such ultra generic managers, who do not appreciate the values of health care professionals, and do not understand the health care context, are going to make some very bad decisions, and are an important cause of health care dysfunction. I cannot help believe that the <a href="http://www.erlanger.org/body.cfm?id=191">Erlanger CEO</a>, Mr James Brexler, (whose most advanced degree was a "Masters of Public Affairs from North Carolina State University") was entirely off base when he was <a href="http://www.chattanoogan.com/articles/article_207720.asp">quoted</a>: <blockquote>'This is not a flavor-of-the-month thing,' continues CEO Brexler. 'This is a strategic priority and business imperative. We are committed to this. We are excited about it. Our staff is excited. Our physicians are excited. The results, we believe, will be evident to our patients and their families.'</blockquote> True health care reform would make sure health care leaders actually understand health care and uphold its values. PS - Long ago, we <a href="http://hcrenewal.blogspot.com/2006/03/putting-on-ritz.html">noted</a> the trustees of another hospital system who seemed to think that Ritz-Carlton experience was perfect background for hospital executives.

Another Hospital Putting on the Ritz

The usual definition of a hospital is an institution which treats the sick and injured,. That is a messy business, so some hospital executi...

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Yet more health IT articles based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y"

The article "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London appeared in the Dec. 2009 <a href="http://www.milbank.org/quarterly.html">Milbank Quarterly</a>. I wrote about it extensively and quoted it at <a href="http://hcrenewal.blogspot.com/2009/12/healthcare-it-as-cybernetic-miracle.html">this post</a>. A key statement: <blockquote>... This review has also identified some areas where more research does not appear to be needed ... [including] simplified experimental studies based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y?” or variations thereof ... the circumstances in which they add value are more limited than is often assumed. We [also] believe that surveys of attitudes of patients or staff towards ‘the EPR’ or ‘computerization’ which are not adequately contextualized have almost no enduring value.</blockquote> So guess what was just published in the NEJM? An article based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y." In a special article entitled "Electronic Health Records and Quality of Diabetes Care", NEJM August 31, 2011 (<a href="http://healthpolicyandreform.nejm.org/?p=15235&query=TOC">link</a>), a study was performed in which the researchers: <blockquote>... compared EHRs with paper-based records in a long-term regional collaborative that seeks to improve care and outcomes for patients with chronic conditions. </blockquote> They found that: <blockquote> ... EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes. Our findings focus on composite standards, although the results were similar for virtually all component standards. </blockquote> This is not really news. I had the same results in a more limited EHR data-based study of diabetics ... in 1997. As I've often written, health IT can be of great benefit...but only if done well. (I have to frequently repeat that there is massive, perhaps <a href="http://en.wikipedia.org/wiki/Wicked_problem">wicked</a> complexity behind those simple two words "done well.") When not done well, disaster can strike. There are no statistics in in the NEJM article regarding complications, "close calls", patient injuries, or patient deaths due to the implementation of health IT. I sincerely doubt the incidence was zero. Their dismissal or lack of mention is common in the medical and health IT literature and seems to reflect an amoral, pervasive paternalism in medicine. The amoral paternalism in turn seems to be a repeat of the attitudes towards experimentation that led to the many human subjects protections that apply everywhere else in biomedicine (<a href="http://ohsr.od.nih.gov/guidelines/index.html">link</a>) - except computing - e.g.: <a href="http://ohsr.od.nih.gov/guidelines/45cfr46.html"></a><blockquote><a href="http://ohsr.od.nih.gov/guidelines/45cfr46.html">45 CFR 46</a> Protection Of Human Subjects <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> <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 <a href="http://ohsr.od.nih.gov/guidelines/nuremberg.html">Nuremberg Code</a> Directives for Human Experimentation <a href="http://ohsr.od.nih.gov/guidelines/helsinki.html">World Medical Association Declaration Of Helsinki</a> </blockquote> To their credit, the NEJM authors did issue several caveats: <blockquote>... we compared sites that had sophisticated EHR systems with paper-based organizations that, as safety-net practices, care for a vulnerable patient population and may have fewer quality-related resources than other paper-based practices ... Our results, showing accelerated improvement in care and outcomes, should encourage those concerned that the quality of ambulatory care may fail to improve with increased adoption of EHRs [per numerous past studies - ed.] ... our study did not determine changes in achievement after the conversion from paper to electronic records, which would provide more compelling evidence of the benefits of EHRs.</blockquote> One might wonder how the tens or hundreds of millions of dollars spent on EMR's might compare, with regard to disease management, with the results achieved by hundreds of dedicated people who could be hired for that purpose for far less money. In other words, the ROI issues of the health IT investment vs. alternatives are not addressed (they rarely are), and truly robust RCT's were not performed comparing the two alternatives. Greenhalgh et al. also wrote in the aforementioned Milbank article: <blockquote>... as a cross-cutting theme in all the above areas, the realpolitik of EPR projects within and between organizations and interest groups should be more explicitly explored ... Orlikowski and Yates have called for more research on the “messy, dynamic, contested, contingent, negotiated, improvised, heterogeneous, and multi-level character of ICTs [information & communications technologies - ed.] in organizations” (page 132) (Orlikowski and Yates 2006). We suggest that sponsors and publishers eschew sanitized accounts of successful projects and instead invite studies of the EPR in organizations that “tell it like it is” – perhaps using the critical fiction technique to ensure anonymity (Winter 1986).</blockquote> There's no trace of that in the new NEJM article. Where health IT is concerned, that's where the money is (no pun intended) in learning how to "do health IT well." -- SS

Yet more health IT articles based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y"

The article " Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Met...

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Millions for tribute, but not one cent for defense: If hospitals cannot afford to legally defend EMR mishaps, should they be investing in them?

<div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;">Imagine an airline going out and buying new multimillion-dollar jets with increased fuel efficiency and that produce less pollution. However, they knowingly buy them under conditions of not being able to afford to perform complete diagnostics/forensics for the FAA when something goes awry and a plane malfunctions or crashes. Absurd? Apparently not in the domain of healthcare IT. The hospital where my mother was injured (now of blessed memory as a result) has still refused to substantively answer EMR-related questions, after a motion by my mother's attorney to compel discovery. As part of their legally sworn-truthful response they write:</div> <div dir="ltr" style="font-family:arial;"> </div> <blockquote style="margin-right: 0px; font-weight: bold;font-family:arial;" dir="ltr"> <div dir="ltr"> "The burden and expense of more detailed responses would put a substantial drain on the hospital's limited resources."</div></blockquote> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> If this is true, perhaps hospitals (which generally do have limited resources) should not be spending tens or hundreds of millions of dollars on electronic medical records, a still-experimental technology (<a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">link</a>). It also causes concern about the maintenance state of the current technology. The general point of which this is a specific example is this: If hospitals cannot afford to defend/produce forensics for the technology when mishaps inevitably occur (such as in the Feb. 2010 FDA internal memorandum on health IT related mishaps, <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">link</a>, which the director of CDRH states are likely the "tip of the iceberg, <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">link</a>), then perhaps hospitals need to rethink the initial investment and ongoing maintenance/upgrading costs until the technology is more mature. Should the motto of hospitals be "Millions for IT tribute, but not one cent for defense?" Finally, in the same brief claiming poverty, I, now representing my deceased mother was referred to as a "self-described expert in computerized medical records" and "critic of use of computerized medical records in hospitals" (as opposed to the reality of my being a critic of misuse of computerized medical records, especially deficient ones, in hospitals). </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;">Just to further nail that point down as to my being a health IT amateur and Luddite, they also included as an attachment to their brief my entire CV and publications history -- 17 pages long - as retrieved from <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about</a>, picture included. (Perhaps I should send the hospital a thank-you note for introducing me to the judge, without my having to lift a finger.) Also issued were subpoenas for another fifteen or so doctors and practices that saw my mother, in addition to many others in past subpoenas. These records, mostly paper, will need to be reviewed. This will likely be a very profitable piece of work with many billable hours for the retained defense firm's lawyers. All this was more than one month after the state's Medicare Quality Improvement Organization found my mother's care "did not meet applicable professionally accepted standards of healthcare", and the deficiencies led to the catastrophic "subsequent medical complications" that she filed a complaint about while still lucid. Medicare also set up a monitoring program at the facility "for several quarters" as a result. (This was not mentioned in the defendant's brief to the court.) In effect, for probably $300+ per hour for legal services in the attempt to defend a case Medicare itself found not to have met applicable professionally accepted standards of healthcare, the hospital seems to have plenty of money. Again, the general point here is this: I believe this type of behavior is not atypical for hospitals today, and is likely another unfortunate manifestation of the medical leadership deficiencies and ethical gaps (e.g., at <a href="http://hcrenewal.blogspot.com/search/label/leadership">link</a>, <a href="http://hcrenewal.blogspot.com/search/label/Mismanagement">link</a>) commonly noted on this blog. -- SS </div>

Millions for tribute, but not one cent for defense: If hospitals cannot afford to legally defend EMR mishaps, should they be investing in them?

Imagine an airline going out and buying new multimillion-dollar jets with increased fuel efficiency and that produce less pollution. How...

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