healthy4u

Just Say "No" to the Term "Anecdotes"; and HIT as a Medical Metadevice

A New Year's thought: there needs to be a push in healthcare for dropping of the word "anecdote" to describe case reports of health IT-related errors. This word even appears in the late 2011 <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf">IOM report on HIT safety</a> (PDF), e.g., the preface: <blockquote style="margin-right: 0px; font-style: italic; font-family: arial;font-family:arial;" dir="ltr"> ... We found that specific types of health IT can improve patient safety under the right conditions, but those conditions cannot be replicated easily and require continual effort to achieve. We tried to balance the findings in the literature with anecdotes from the field but came to the realization that the information needed for an objective analysis and assessment of the safety of health IT and its use was not available.</blockquote> The "A" word needs to be dropped from the healthcare IT lexicon, since such reports from reliable sources are in fact incident reports purposed for risk management activities.Incident reports do not need peer review for consideration for that purpose.Of note, I do not believe the incident reports filed in hospitals when something awry occurs are labelled "anecdotes", either. See the Aug. 2011 post "<a style="font-weight: bold;" href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things</a>" for more on this topic. And on another vein, the issue of HIT being a medical device: As the good State Rep. Marino of my home state of Pennsylvania and <a href="http://hcrenewal.blogspot.com/2011/11/emr-defects-that-injure-and-kill-and.html">others</a> oddly proffer - that 'certification' of health IT, having nothing to do with safety or usability, relieves HIT from being a device [1] - and as the IOM itself debates exactly what to call HIT and under what guidelines to regulate it, another term/category for HIT devices is needed. In the spirit of the naming of the <a href="http://www.nlm.nih.gov/pubs/factsheets/umlsmeta.html">UMLS Metathesaurus</a>, and in consideration of HIT's informational governance/orchestration of other medical devices and personnel (including the 'carbon units' known as clinicians and patients) -- I suggest the term "metadevice" for HIT. Healthcare metadevices need their own specific regulation, apart from traditional medical devices.-- SSNote: [1] As in line 21- 24 on page 6 of the "<a href="http://www.gpo.gov/fdsys/pkg/BILLS-112hr3239ih/pdf/BILLS-112hr3239ih.pdf">Safeguarding Access For Every Medicare Patient Act</a>" Bill (PDF) that I wrote about <a href="http://hcrenewal.blogspot.com/2011/10/cybernetik-uber-alles-computers-have.html">here</a>. The Bill states: "CLARIFICATION OF AUTHORITY. Certified EHR’s shall not be considered a device for purposes of the Federal Food, Drug, and Cosmetic Act." (This proposal, of course, raises the question of whether Rep. Marino believes non-certified HIT shall be considered a medical device, a topic for another time.)

Just Say "No" to the Term "Anecdotes"; and HIT as a Medical Metadevice

A New Year's thought: there needs to be a push in healthcare for dropping of the word "anecdote" to describe case reports of ...

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SELF INFLICTED DAMAGE

SELF INFLICTED DAMAGE The American Psychiatric Association (APA) is in the news again for bad public relations: worse than bad, actually – appalling. Locked in a bunker mentality, they have moved to stifle advance criticism of their flagship initiative, DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), which is a work in progress. Lawyers for the APA have threatened the owner of a UK blog that served as a discussion forum for issues affected by DSM-5 and other, international psychiatric classifications. The blog, named <a href="http://dsm5watch.wordpress.com/">dsm5watch</a> was considered authoritative and accurate. If you go to this site now you will find that it has been deleted. As <a href="http://www.psychologytoday.com/blog/dsm5-in-distress/201201/is-dsm-5-public-trust-or-apa-cash-cow">recounted</a> this week by Allen Frances, MD, the editor of the last published DSM edition, the blog’s owner, Suzy Chapman, told him, ”On December 22, I was stunned to receive two emails from the Licensing and Permissions department of American Psychiatric Publishing, claiming that the domain name my site operates under was infringing upon the DSM 5 trademark in violation of United States Trademark Law and that my unauthorized actions may subject me to contributory infringement liability including increased damages for willful infringement. I was told to cease and desist immediately all use of the DSM 5 mark and to provide documentation within ten days confirming I had done so." "Given my limited resources compared with APA's deep pockets, I had no choice but to comply and was forced to change my site's domain name to <a href="http://dxrevisionwatch.wordpress.com/">dxrevisionwatch</a>. Hits to the new site have plummeted dramatically and it will take months for traffic to recover - just at the time when crucial DSM 5 decisions are being made." In effect, the APA, acting not through its medical or scientific officers but through its wholly owned publishing house, has attempted a SLAPP maneuver. SLAPP is the acronym for strategic lawsuit against public participation. What kind of leadership does this signal in a major professional organization? The normal remit of professional medical societies is stewardship of professional values and ethics. That is why these societies are accorded deference and respect on matters of clinical guidelines, health policy and public education. Even when, like the Institute of Medicine of the National Academy of Sciences, they <a href="http://hcrenewal.blogspot.com/2009/04/institute-of-medicine-report-on.html">tolerate compromised members</a>, they can generally hope to retain the public trust. One reason for this assurance is that they are expected as a matter of professional duty to avoid conflicts of interest – personal and financial. The APA, however, has an enormous conflict in this case: it counts on millions of dollars in revenue from sales of the DSM volumes and it is under siege currently for perceived scientific and clinical weaknesses of the DSM-5 that is due to be released next year. Professional criticism is running so high that over 10,000 interested parties have signed a petition for the APA to reconsider planned changes. There is even talk of abandoning DSM-5 in favor of the ICD system (International Classification of Diseases), which is a WHO initiative. The APA doesn’t own psychiatric classification and diagnostic criteria. When the field allows the APA to take the initiative for revisions of the DSM, it is with the understanding that the work will be conducted in the public interest rather than in the commercial interest of the APA itself, which is said to derive over $5 million annually in profits from DSM sales. The public interest and the public trust are served by transparency and open discussion, not by contrived SLAPP threats. It is bad enough that the APA resorts to this legal artifice to stifle public discussion. When they do it through their lawyers and business entities rather than through their medical and scientific officers, they sink to a lower level yet. The parallels with corporate sleaze that we have discussed so often on this blog are obvious. For shame.

SELF INFLICTED DAMAGE

SELF INFLICTED DAMAGE The American Psychiatric Association (APA) is in the news again for bad public relations: worse than bad, actually – a...

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New York - Presbyterian Hospital Trustee Advocated Novel Cardiac Procedure - "Reach In, Rip Out Their Heart, and Eat It Before They Die"

The dominant theme of <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> has been how problems with the leadership of health care organizations have lead to our current state of health care dysfunction.  We have discussed examples of <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">ill-informed,</a> <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">mission-hostile</a> leadership rewarded with <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">excess compensation</a>, exhibiting <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity</a> in the face of alleged misbehavior, and at times descending into <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">corruption</a>.  The cause of these problems is doubtless multi factorial.  However, one possible cause is that rather than exercise stewardship and hold leadership accountable, those in charge of <a href="http://hcrenewal.blogspot.com/search/label/governance">governance</a> of health care organizations, that is, boards of directors or <a href="http://hcrenewal.blogspot.com/search/label/boards%20of%20trustees">trustees</a>, have instead infected the organizations with the amoral culture now dominant in much of the business world, especially <a href="http://hcrenewal.blogspot.com/search/label/finance">finance</a>.  We have discussed, most recently <a href="http://hcrenewal.blogspot.com/2011/12/they-think-we-are-imbeciles-and-they.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/10/health-cares-99-percenters.html">here</a>, how the <a href="http://hcrenewal.blogspot.com/search/label/boards%20of%20trustees">boards</a> of health care corporations often include heavy representation of leaders of finance, including many of those who seemed responsible for the global financial collapse, great recession, or whatever we will end up calling it.  I recently stumbled upon a particularly graphic example of the sort of predatory culture that now exists on the boards of health care organizations.  (More on how I did so later.)  Below is an embedded YouTube video of a speech made by a current <a href="http://nyp.org/about/board-trustees.html">Trustee of New York - Presbyterian Hospital</a> (who has been on the board since 2007).  He is Richard Fuld, the former CEO of Lehman Brothers, whose continuing role on the hospital board, despite his failed leadership of one of the financial firms whose bankruptcy ushered in the global financial collapse, we discussed first <a href="http://hcrenewal.blogspot.com/2008/09/failed-masters-of-universe-running.html">here</a>. <iframe allowfullscreen="" frameborder="0" height="315" src="http://www.youtube.com/embed/x93EHs627GI" width="560"></iframe> Just to underline it once more, Mr Fuld, referring to short sellers of his company's stock, said he "what I really want to do is I want to reach in, rip out their heart, and eat it before they die."  Can there be a more stark reminder of what has gone wrong with the governance of health care?  Can anyone watch this video and argue that Mr Fuld ought to be on the board of a hospital system?  Why is he still on the board in January, 2012, when this video was released in October, 2011? While I suspect not many other hospital system board members have been videographed displaying equally brutal sentiments, there are likely others with similarly barbaric tendencies. So, on a more positive note.... The boards of hospitals, hospital systems, medical schools, and their parent universities ought to be populated with people who take their stewardship roles seriously.  They ought to be people who understand, agree with, and support the organizations' mission, and their dedication to patient care and teaching.  They ought to understand what good leadership of health care organizations entail.  Needless to say, they ought to be of good character and above any ethical reproach.  In short, they ought to be the opposite of the sort of person displayed in the video above. It should now be obvious that grievous problems with the leadership and governance of health care organizations are principle causes of the dysfunction in our health care system.  True health care reform will require wholesale changes in health care leadership and governance. PS - In case the video above seems too short on context, see the one below: <iframe allowfullscreen="" frameborder="0" height="315" src="http://www.youtube.com/embed/GZCmWkQuyPc" width="420"></iframe>

New York - Presbyterian Hospital Trustee Advocated Novel Cardiac Procedure - "Reach In, Rip Out Their Heart, and Eat It Before They Die"

The dominant theme of Health Care Renewal has been how problems with the leadership of health care organizations have lead to our current s...

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They Think We are "Imbeciles," and They Run Health Care Organizations

Arrogance seems to fuel many of the problems with health care leadership that we discuss, particularly <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostility to the mission</a>, often driven by self-interest; a sense of entitlement to <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">lavish compensation</a> out of proportion to any measure of performance; and a lack of <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountability</a> shading into <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity</a>.  Some recent stories hint at some of the origins of such arrogance.  The Occupy Wall Street movement drew attention to the plight of the poor and middle class, who had lost income, retirement benefits, jobs, houses, and access to health care while the richest, especially corporate executives, got richer.  The less fortunate's anger was not directed indiscriminately at the successful or the rich, but those who got wealthy by gaming the system, or flaunting the rules that lesser mortals had to obey.  Perhaps not surprisingly, some of those most vulnerable to such criticism have responded with contempt.  Anonymous or Indirect Defenses of the One Percent The initial defense of the plutocrats came from some of their political supporters, who denounced their "demonization" (see this <a href="http://www.washingtonpost.com/opinions/rich-people-demonized-for-flaunting-their-wealth-are-under-attack/2011/09/28/gIQAcJn4AL_story.html">opinion piece</a> by Barbara Ehrenreich in September, 2011) or decried the rise of "mob rule" (see <a href="http://www.nytimes.com/2011/10/10/opinion/panic-of-the-plutocrats.html">this</a> by Paul Krugman in October).  Then several articles documented the anonymous complaints of finance insiders about: <blockquote>a bunch of whiny people who are lazy and incompetent and have nothing to do with their time</blockquote>from a Reuters <a href="http://www.reuters.com/article/2011/10/11/us-usa-wallstreet-bankers-idUSTRE79A4LF20111011">article</a> in October. <blockquote>a ragtag group looking for sex, drugs and rock 'n' roll</blockquote>from a NY Times <a href="http://www.nytimes.com/2011/10/15/business/in-private-conversation-wall-street-is-more-critical-of-protesters.html">article</a> in October. The Plutocrats Strike Back However, increasingly those in the one percent are willing to be open. In late December a Bloomberg <a href="http://www.businessweek.com/news/2011-12-28/bankers-join-billionaires-to-debunk-imbecile-attack-on-top-1-.html">article</a> documented the sentiments of a number of finance and other corporate leaders. - Jamie Dimon, CEO of JP Morgan Chase, complained: <blockquote>Acting like everyone who's been successful is bad and because you're rich you're bad, I don't understand it.</blockquote> - Bernard Marcus, founder of Home Depot: <blockquote>Who gives a crap about some imbecile? Are you kidding me?</blockquote> - John A Allison IV, Chairman of BB&T: <blockquote>'Instead of an attack on the 1 percent, let’s call it an attack on the very productive,' Allison said. 'This attack is destructive.'</blockquote> - Stephen Schwarzman, CEO of the Blackstone Group: <blockquote>'You have to have skin in the game,' said Schwarzman, 64. 'I’m not saying how much people should do. But we should all be part of the system.'</blockquote> - John Paulson, President of hedge fund Paulson & Co: <blockquote>has also said the rich benefit society. 'The top 1 percent of New Yorkers pay over 40 percent of all income taxes,...'</blockquote> - Tom Galisano, founder of Paychex Inc: <blockquote>If I hear a politician use the term ‘paying your fair share’ one more time, I’m going to vomit</blockquote> - Ken Langone, founder of Home Depot: <blockquote>I am a fat cat, I’m not ashamed</blockquote> Considering how <a href="http://www.nytimes.com/2011/10/10/opinion/panic-of-the-plutocrats.html">Paul Krugman explained </a>the generation of the global financial collapse by <blockquote>people who got rich by peddling complex financial schemes that, far from delivering clear benefits to the American people, helped push us into a crisis whose aftereffects continue to blight the lives of tens of millions of their fellow citizens. Yet they have paid no price. Their institutions were bailed out by taxpayers, with few strings attached. They continue to benefit from explicit and implicit federal guarantees — basically, they’re still in a game of heads they win, tails taxpayers lose. And they benefit from tax loopholes that in many cases have people with multimillion-dollar incomes paying lower rates than middle-class families. </blockquote>Thus the responses by the very rich above only represent some or more arrogance. The Plutocrats as Health Care Leaders One wonders how much this arrogance carried over into health care. We have <a href="http://hcrenewal.blogspot.com/2011/10/health-cares-99-percenters.html">noted previously</a> how the leadership of finance has increasingly overlapped the leadership of health care, and how top executives increasingly seem to identify more with each other than with their employees, customers, or other stakeholders. Therefore, it should be no surprise that all but one of the group above also had or have leadership roles in health care organizations. - Jamie Dimon is on the <a href="http://www.med.nyu.edu/about-us/who-we-are/medical-center-leadership/trustees">board of trustees of the New York University Langone Medical Center</a>.  - Bernard Marcus formerly served as the chair of the <a href="http://www.cdcfoundation.org/who/board">board of the CDC Foundation</a>. - John A Allison IV is a member of the board of visitors of Wake Forest University Baptist Medical Center, per <a href="http://bbt.mediaroom.com/index.php?s=18&item=94">his BB&T Corp official biography</a>. - Stephen Schwarzman's Blackstone Group includes the Blackstone Healthcare Group, which invests in various health care corporations (as of 2010, Nycomed, Gerresheimer, Stiefel Laboratories, and Catalant per <a href="http://www.blackstone.com/cps/rde/xchg/bxcom/hs/news_pressrelease_6354.htm">this press release</a>), and all of whose members serve on one or more boards of directors of health care corporations (per the <a href="http://www.blackstone.com/cps/rde/xchg/bxcom/hs/news_pressrelease_6354.htm">press  release</a>, Arthur Higgins serves on the boards of Zimmer, Eco Labs, and Resverlogix Corp; Lodewijk J R de Vink serves on the <a href="http://www.roche.com/about_roche/management/board_of_directors/board_of_directors-devink.htm">board of Roche</a>; Doug Rogers serves on the <a href="http://www.codevax.com/n/who.html">boards of Codevax</a>, Charles River Laboratories, and Computerized Medical Systems.) - John Paulson is on the <a href="http://www.nyu.edu/about/leadership-university-administration/board-of-trustees.html">board of trustees of New York University</a>, - Kenneth G Langone, is vice chair again of the board of trustees of New York University, and chair of the board of trustees of the NYU Langone Medical Center. I submit that linking their sentiments above to their leadership roles in health care should be highly disconcerting.  Do we want people running medical centers who are proud to be "fat cats?"  Do we want people running medical centers who do not understand why people who have lost income, retirement funds, jobs or their homes might be upset?  Do we want people running health care corporations who do not think the poor and middle-class have any skin in the economic game?   Do we want people running health care foundations who think that those who complain about the current economic situation are "imbeciles?" Summary The problems of health care increasingly seem to be a part of the larger problems with the global political economy.  The problems we have been discussing that affect health care leadership seem to have come out of the culture of what now many are calling the larger plutocracy.  So it now seems that true health care reform will require a larger reform of the political economy.  However, we still need leaders who understand the health care context, uphold health care professionals' values, and put patients first.  We do not need leaders who are ill-informed, incompetent, self-interested, conflicted, or corrupt.  We need governance that is accountable, honest, transparent, ethical, and again puts patients first.

They Think We are "Imbeciles," and They Run Health Care Organizations

Arrogance seems to fuel many of the problems with health care leadership that we discuss, particularly hostility to the mission , often driv...

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IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised."

At my Nov. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">Lifespan (Rhode Island): Yet another health IT glitch affecting thousands - that, of course, caused no patient harm that they know of - yet</a>" I wrote: <blockquote>There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" <a href="http://hcrenewal.blogspot.com/2011/05/twelve-hour-health-it-glitch-at.html" style="font-weight: bold;">here</a>, <a href="http://hcrenewal.blogspot.com/2011/01/orderless-in-seattle-software-glitch.html" style="font-weight: bold;">here</a>, <a href="http://hcrenewal.blogspot.com/2010/03/will-it-take-luminosity-of-dozen.html" style="font-weight: bold;">here</a> and at other posts which can be found by searching this blog on the banal term 'glitch'.</blockquote><span class=" down" id="formatbar_CreateLink" onmousedown="CheckFormatting(event);FormatbarButton('richeditorframe', this, 8);ButtonMouseDown(this);" onmouseout="ButtonHoverOff(this);" onmouseover="ButtonHoverOn(this);" onmouseup="" style="display: block;" title="Link"> Add another case to the health IT glitch file, under the "do we feel lucky today?" patient risk category.<span class=" down" id="formatbar_CreateLink" onmousedown="CheckFormatting(event);FormatbarButton('richeditorframe', this, 8);ButtonMouseDown(this);" onmouseout="ButtonHoverOff(this);" onmouseover="ButtonHoverOn(this);" onmouseup="" style="display: block;" title="Link"> From the Pittsburgh Post-Gazette (I am quoted): <blockquote><a href="http://www.post-gazette.com/pg/11358/1199140-53-0.stm?cmpid=news.xml" style="font-weight: bold;">Computer outage at UPMC called 'rare'</a> Systemwide disruption potentially dangerous, expert warns Saturday, December 24, 2011 By Jonathan D. Silver, Pittsburgh Post-Gazette UPMC's electronic medical records system for inpatients went offline for more than 14 hours at nearly all its hospitals in the region, marking what the health system called a "rare" outage, but one that it claims did not harm patients.</blockquote> First, as my aforementioned Nov. 2011 post and its contained links point out, these events are not as "rare" as they should be. (The asteroid colliding with Earth that caused the extinction of the dinosaurs - now that's a "rare" event.) Second, as multiple posts on this blog have pointed out, the claims that "no patients were harmed" is both misleading and irrelevant: Such claims of 'massive EHR outage benevolence' are misleading, in that medical errors due to electronic outages might not appear for days or weeks after the outage, depending on what information was corrupted/lost/misindentified/or otherwise mishandled after it is 'backloaded' once the system is up. All it takes is one med lost to cause misery and death. (I can speak about that from unfortunate personal experience. Claims of 'massive EHR outage benevolence' are also irrelevant in that, even if there was no catastrophe directly coincident with the outage, their was greatly elevated risk. Sooner or later, such outages will maim and kill. <blockquote>The outage affected a system designed by Cerner Corp., a global electronic records company, and customized by UPMC that doctors and nurses rely on for communication about patient records, medical orders and prescriptions. It was unavailable from about 8:45 p.m. Thursday to 11 a.m. Friday at almost all of UPMC's hospitals except for Children's and UPMC Hamot in Erie, spokeswoman Wendy Zellner said. "This is rare. This kind of widespread, extensive downtime would be rare," Ms. Zellner said. Doctors and nurses continued to have access to patients' electronic records through backup systems, she said. They also had to resort to using old-fashioned paper records for documentation and orders. "These things happen. They have really well spelled-out procedures for what to do when something goes down," Ms. Zellner said. She acknowledged that doctors and nurses faced some challenges.</blockquote> Faced 'some challenges?' In other words, care was compromised by the outage and the 'challenges' were to avoid medical error (and, of course, to make sure billing was unaffected): <a href="http://www.thefreedictionary.com/compromised" style="font-style: italic;">Compromised</a> - <div class="sds-list" style="font-style: italic;">a. To expose or make liable to danger, suspicion, or disrepute</div><div class="sds-list" style="font-style: italic;">b. To reduce in quality, value, or degree; weaken or lower. </div>Thousands of patients were affected, again reinforcing my point about how IT can and does greatly amplify the risks of paper -- as in my Rhode Island post -- such as errors and confidentiality breaches. I cannot, for example, think of a single instance where thousands of paper records went unavailable simultaneously (unless, that is, someone lost the key to the Medical Records department), were made available to identity thieves en masse, or where thousands of medical orders were scrambled or truncated in a relatively short period of time as in Rhode Island. These amplified risks could wipe out any advantages of EHR's over paper in a microsecond. A partial list of facilities apparently affected in this latest episode of EHR mayhem, from <a href="http://www.upmc.com/HOSPITALSFACILITIES/HOSPITALS/Pages/default.aspx">this list</a>: <blockquote><ul><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/Magee/Pages/Home.aspx" target="_blank" title="Visit the Magee-Womens Hospital of UPMC website in a new window.">Magee-Womens Hospital of UPMC</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/upmcbedfordmemorial/Pages/default.aspx" title="Use this link to visit the UPMC Bedford Memorial website.">UPMC Bedford Memorial</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/east/Pages/east.aspx" title="Visit the UPMC East website. ">UPMC East</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/horizon/Pages/default.aspx" title="Use this link to visit the UPMC Horizon website.">UPMC Horizon </a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/mckeesport/Pages/default.aspx" title="Use this link to visit the UPMC McKeesport website.">UPMC McKeesport</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/Mercy/Pages/default.aspx" title="Use this link to visit the UPMC Mercy website.">UPMC Mercy</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/upmc-montefiore/Pages/default.aspx" title="Use this link to visit the UPMC Montefiore website.">UPMC Montefiore</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/Northwest" title="Use this link to visit the UPMC Northwest website.">UPMC Northwest</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/UPMCPassavant/Pages/passavant.aspx" title="Use this link to visit the UPMC Passavant website.">UPMC Passavant </a> </li><li><a href="http://www.upmc.com/HOSPITALSFACILITIES/HOSPITALS/PRESBYTERIAN/Pages/default.aspx" title="Use this link to visit the UPMC Presbyterian website.">UPMC Presbyterian</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/Shadyside/Pages/default.aspx" title="Use this link to visit the UPMC Shadyside website.">UPMC Shadyside</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/stmargaret/Pages/default.aspx" title="Use this link to visit the UPMC St. Margaret website.">UPMC St. Margaret</a> </li><li><a href="http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx" title="Use this link to visit the Western Psychiatric Institute and Clinic website.">Western Psychiatric Institute and Clinic of UPMC</a></li></ul></blockquote> That accounts for several thousand active patients, I am sure. (12/28 Addendum: Bed counts of PA hospitals are <a href="http://www.ahd.com/states/hospital_PA.html">here</a>. Searching on "University of Pittsburgh Medical Center", it can be seen that thousands of beds were indeed involved.) <blockquote>"Whenever people aren't working in their native system and workflow I have to believe that is more cumbersome for the clinicians, but these folks are well-trained in what to do when these things happen."</blockquote> This seems at best an insensitive and perhaps even inhumane bit of P.R. More "cumbersome" for the clinicians? What about the poor patients? How would Ms. Zellner feel, I wonder, if it were her mother, child or significant other on the Operating Room table or having an acute MI when the EHR/CPOE systems went down? <blockquote>Ms. Zellner said UPMC's public relations staff was unaware of the outage until contacted by a reporter.</blockquote> It appears P.R. is not very high on the list for receiving information when a crisis arises. I may have known of the outage before they did. <blockquote>The outage was caused by a "bug" or glitch in software designed by a vendor affiliated with Cerner, Ms. Zellner said. She refused to identify the company. "We're not trying to point fingers at different vendors. It's a database bug, that's all I can tell you."</blockquote> (That is, it's not our fault, it's the fault of the database vendor. Hospitals, I regret to inform you - you are responsible for unapproved medical devices used in your facilities, no matter what the source.) And there's that word "glitch" again, accompanied by the equally banal "bug." <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_I5WmFxtz7xMx_bhF3SbRrbCCxpaC8XWJz9sXOCfM8T3XN2iIIW7-qLzHhpbK7TTB5cgMeauukXNEObD-6khVlq4EYm098U-ifHnCkwDhmT8DmCkdz0r9NrBbItcIjfxY8fcFvlMspf_p/s1600/happybug.bmp"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5691264547995216018" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_I5WmFxtz7xMx_bhF3SbRrbCCxpaC8XWJz9sXOCfM8T3XN2iIIW7-qLzHhpbK7TTB5cgMeauukXNEObD-6khVlq4EYm098U-ifHnCkwDhmT8DmCkdz0r9NrBbItcIjfxY8fcFvlMspf_p/s320/happybug.bmp" style="cursor: pointer; display: block; height: 94px; margin: 0px auto 10px; text-align: center; width: 76px;" /></a></div><div style="text-align: center;">It's just a "bug." Cute little critter!</div> Me again in the Post-Gazette: <blockquote>Scot M. Silverstein, a doctor and assistant professor Healthcare Informatics at Drexel University in Philadelphia, disagreed with the use of the terms "bug" and "glitch." "What occurred here was a disruptive, potentially dangerous major malfunction of a life-critical enterprise medical device," he said.</blockquote> Somehow, when a clinician makes a mistake, the terms "bug" and "glitch" are never used. In fact, when clinicians fail to meet accepted professional standards of healthcare practice, it is called "malpractice." I think we can all agree that a major near-full-day outage of an enterprise EHR affecting multiple hospitals and thousands of patients does not meet accepted professionals standard of life-critical computing practice. Yet, all this merits is the word "glitch." It seems to me that if patients are harmed by, in reality, what is (on its face) IT malpractice during such events, not only the clinicians affected should be held liable. <blockquote> Ms. Zellner said the problem was not a "crash" of the system because there were alternate methods used to cope that prevented patient care from being compromised.</blockquote> The usual refrain. Let me repeat my definition of "compromised:" <a href="http://www.thefreedictionary.com/compromised" style="font-style: italic;">Compromised</a> - <div class="sds-list" style="font-style: italic;">a. To expose or make liable to danger, suspicion, or disrepute</div><div class="sds-list" style="font-style: italic;">b. To reduce in quality, value, or degree; weaken or lower.</div> A simple question - if extended EHR outages like this never seem to "compromise" care, then why not eliminate health IT entirely and spend the hundreds of millions saved on patient care? <blockquote>"This is not a crash of Cerner either," Ms. Zellner said. "I think a crash is, 'Oh my God, the sky is falling,' nobody can get anything."</blockquote> I leave it to the readers to ascertain the computer expertise levels and reasonableness of what Ms. Zellner thinks a "crash" is. <blockquote>Technicians from UPMC, Cerner and the third company [the 'mystery' database company? - ed.] worked together on-site to identify and fix the problem. Ms. Zellner said she did not know why it took 14 hours to fix and the underlying cause was still unclear. "They know what the problem is and I believe it's been fixed, but we really don't know what triggered it," Ms. Zellner said. "I think the next step would be some actual software upgrades."</blockquote> They "don't know what triggered the 'problem'" - is a proper translation that they have no idea what went wrong? In fact, regarding another Cerner EHR system which was extensively studied (see "A Study of an Enterprise Information System" <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">at this link</a>), Dr. Jon Patrick came to the conclusion that one of the sources of catastrophic failures is poor software engineering that has made the behavior of the studied system "non-deterministic." Further, software upgrades are not protected from incremental changes made by maintenance and customization staff, and may introduce even more instability. A software upgrade without clearly understanding "what triggered the problem" is simply asking for more trouble. (My bet, however, is that they attempt it anyway.) <blockquote>A Cerner representative could not be reached for comment.</blockquote> What's to say? How about this: <blockquote>Dr. Silverstein said based on what he was told about the computer outage, it means that hospital medical staff would have been unable to update patient charts and probably would not have been able to issue any orders through the system during the time it was off line. He also questioned how up-to-date the hospital's redundant records were.</blockquote> Repeating UMPC's statement from the article that appeared after I gave my quotes to the reporters: "Doctors and nurses continued to have access to patients' electronic records through backup systems, [the UPMC spokesperson] said. They also had to resort to using old-fashioned paper records for documentation and orders." My stated fears of disruption and increased risk due to compromised care seem well-grounded. <blockquote> In May, Allegheny General Hospital had to shut its electronic medical records computer system down because of problems with the vendor's hardware. The hospital used backup procedures to continue care for patients, including using paper orders and record-keeping.</blockquote> Wait ... I thought I'd heard these events were "rare." Two in the same city within six months? --------------------------- Truth be told: The primary rule in computing is: <blockquote> Either you are in control of your information systems, or they are in control of you. </blockquote> Clearly the latter was the case here. The following questions arise: <ul><li>Was the software containing the "bug" properly vetted before being used on live patients? This is not just the vendor's obligation.</li><li>If it was not vetted properly, why not? </li><li>Was it an "upgrade" or patch? (If so, the same vetting rules apply.)</li></ul> Further, the soft-selling of these incidents must end. The use of terms such as "bug" and "glitch" must also end. What occurred here, echoing my newspaper quote, was a disruptive, potentially catastrophic major malfunction of a life-critical enterprise medical device. System-wide EHR crashes are not merely ‘glitches’ or ‘bugs.’ They need to be considered, as in medicine itself, as 'never events.' From <a href="http://psnet.ahrq.gov/primer.aspx?primerID=3">AHRQ</a>: <blockquote> The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.</blockquote> Further, re: "patient care was never compromised." How do they know that? In fact, this is 'spin' and word games on its face. By definition, if CPOE and chart updating was unavailable, patient care was compromised, where "compromised" means "increased levels of risk for error were created, requiring workarounds." Further, as mentioned earlier, harms might not show up for some time. Lost orders, corrupted data, errors of omission or commission transcribing backup paper records into the computer ("backloading"), etc. can take their toll later. Post-outage vigilance is essential, putting even more stress on clinicians that increases likelihood of further error and that they certainly do not need. Clinicians are stressed enough already. Finally: IT personnel have not only deliberately inserted themselves into clinical affairs (e.g, via the HITECH Act of 2009), they have also done so with a stunning arrogance and unproven braggadocio about their systems "<a href="http://hcrenewal.blogspot.com/2010/01/yet-another-service-profession-to-be.html">revolutionizing</a>" medicine (whatever that means). Indeed, they need to accept the medical responsibility and obligations this territorial intrusion entails. On its face, this massive outage was the result of issues that did not meet accepted professional standards of IT practice for life-critical environments. <a href="http://en.wikipedia.org/wiki/Res_ipsa_loquitur">Res ipsa loquitur</a>. Something was not vetted properly, there was a lack of redundancy, the IT personnel were NOT in control of their systems. Just as when physicians don't provide care that meets accepted professional standards of healthcare, this incident and others like it are, by definition, a result of IT malpractice. If patients are harmed, IT personnel and their management (often non-IT C-level officers) involved in this system need to be held accountable. If they can't take the clinical heat (as clinicians do daily since the time they enter medical or nursing school), then they need to get out of the clinical kitchen. -- SS Note: see <a href="http://histalk2.com/2011/12/27/news-122811/">this take</a> on these matters at the HIStalk blog: <blockquote>UPMC’s Cerner systems <a href="http://www.post-gazette.com/pg/11358/1199140-53-0.stm" target="_blank">go down</a> for 14 hours at most campuses last Thursday and Friday, forcing them to go back to paper. The PR person blamed “a database bug,” which makes the <a href="http://www.oracle.com/us/corporate/press/422644">above Oracle press release</a> from this past summer a particularly fun read. Cerner and UPMC have an atypical vendor-customer relationship since they’ve invested big money together in innovation projects and UPMC runs a Cerner implementation business overseas. </blockquote> Now we know who the unnamed "mystery database vendor" is... -- SS Dec. 29, 2011 Addendum: Was UPMC acting as a "proving ground" for some Oracle-Cerner-UPMC experimental health IT technology that resulted in the crash? The claim of being an IT "proving ground" has been made in the past: <blockquote> Pittsburgh Tribune May 2, 2006<a href="http://www.pittsburghlive.com/x/pittsburghtrib/news/s_449506.html" style="font-weight: bold;">UPMC partners with technology provider</a> The University of Pittsburgh Medical Center is taking another step in a quest to commercialize new medical technology. UPMC on Monday signed a three-year deal with health care information technology provider Cerner Corp. to develop and market medicine-related technological advances. Both parties will contribute $10 million in cash, services and intellectual property to the effort. The deal is a smaller version of an April 2005 deal between UPMC and information technology behemoth IBM. As is the case in the IBM deal, UPMC will serve as a built-in proving ground for jointly developed technologies and products, with Cerner marketing the products and UPMC awarded a share of profits.</blockquote> As I wrote at <a href="http://hcrenewal.blogspot.com/2009/04/upmc-pioneers-in-health-it-or-pioneers.html">"Proving Ground for IT Tests On Children: Pioneers in Health IT, or Pioneers in Ignoring the Past?"</a>: "A hospital and patients are not a learning lab for HIT vendors. The appropriate "proving ground" for new medical technology is the controlled clinical trial where participants (in this case, patients and healthcare professionals alike) have freedom of choice whether or not to participate, and a chance to give (or deny) consent after being fully informed of potential risk."This is a fundamental human rights issue. -- SS

IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised."

At my Nov. 2011 post " Lifespan (Rhode Island): Yet another health IT glitch affecting thousands - that, of course, caused no patie...

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Legal Settlements Have Become So Common that They are Barely News

<a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">Legal settlements</a> by big health care organizations have become so common that those of less than blockbuster size barely seem to qualify as news.  They have become "dog bites man" stories.  For example, the following stories barely got noticed in the media (presented chronologically). Novartis Settles Price Misrepresentation Suit for $150 Million This story was mentioned as an aside in a a <a href="http://www.businessweek.com/news/2011-09-15/watson-sandoz-pay-145-million-to-settle-drug-price-case.html">news story</a> covering a settlement by Watson Pharmaceuticals in September.  In slightly more detail, it has only appeared <a href="http://www.pharmalot.com/2011/11/novartis-pays-150m-to-settle-pricing-fraud">in PharmaLot</a> in November.  In a very small nutshell, <blockquote>the Sandoz unit of Novartis earlier this week agreed to pay $150 million to settle lawsuits filed by the states of Florida and California, as well as a whistleblower, to settle charges that it deliberately misreported pricing information in order to hike reimbursements from Medicaid.</blockquote> By the way, per <a href="http://freepdfhosting.com/0885cf397f.pdf">the settlement document</a>, the allegations were that Novartis' subsidiary knowingly maintained, set or reported "false, fraudulent, and/or inflated Reported Prices," yet, as is typical of nearly all settlements, the settlement "shall not constitute or be construed as an admission of fault, liability, or unlawful conduct." Roche Settles Off-Label Promotion, Physician Kickback Suit for $20 Million This story was reported briefly in some blogs, including again PharmaLot, and in the most detail <a href="http://www.bizjournals.com/sanfrancisco/blog/biotech/2011/12/genentech-roche-rituxan-whistleblower.html">in the San Francisco Business Times</a>. The basics of it were: <blockquote>Genentech Inc. will pay $20 million to settle a whistleblower lawsuit around off-label marketing of the cancer-fighting drug Rituxan.</blockquote> It only took eight years since a whistle-blower raised the issue: <blockquote>John Underwood, ... was a senior manager of sales development from the start of Genentech’s oncology franchise in 1997. When Underwood filed the suit in July 2003 in U.S. District Court for the Eastern District of Pennsylvania, he was a senior hospital systems specialist for Genentech.</blockquote> This suit is actually of particular interest because it was not just about off-label promotion, <blockquote>Genentech, the suit claimed, retained doctors to act as independent speakers on behalf of Rituxan and its off-label uses, paid kickbacks to doctors that were disguised as consulting payments, 'exerted significant pressure' on sales reps to increase off-label uses of Rituxan, and devised and conducted 'selling skills workshops' for sales reps devoted to non-label uses, What’s more, the suit claimed, Genentech invited doctors to attend “medical education seminars” at 'luxurious locations' and gave financial incentives to sales reps to get doctors who sold the most Rituxan to attend the events.</blockquote> These were serious allegations, involving allegedly direct efforts by the company to subvert physicians' ethics by tying their decisions for individual patients to payments for prescribing specific products whatever the benefits and risks of those products for those patients.  The allegations suggested that "consulting payments" to physicians may be nothing more than disguised bribes, and that the companies making these payments may be quite conscious of this.  Nonetheless, as usual, <blockquote>Genentech, the South San Francisco-based U.S. subsidiary of Swiss drug giant Roche, did not admit wrongdoing....</blockquote> So, as in the famous recent Citigroup case (see <a href="http://hcrenewal.blogspot.com/2011/11/will-citigroup-ruling-challenge-health.html">this post</a>), the settlement obfuscates the crucial question, did the corporation involved commit illegal acts? It seems likely that what they did was in some sense unethical, since they were willing to pay millions not make the matter go away. By the way, one member of the Executive Committee of Genentech at the time these events were allegedly occurring is now the <a href="http://ucsfchancellor.ucsf.edu/leadership/susan-desmond-hellmann-md-mph">Chancellor of the University of California - San Francisco</a> (See our post <a href="http://hcrenewal.blogspot.com/2009/05/bio-tech-u.html">here</a>). Maybe concerned students or faculty might ask her what really went on. CVS Caremark Settles Fraud Suit for about $20 Million As <a href="http://latimesblogs.latimes.com/money_co/2011/12/cvs-caremark-to-pay-20m-to-three-states-over-fraud-allegations.html">reported</a> briefly in the Los Angeles Times, <blockquote>Pharmacy and prescription drug management company CVS Caremark Corp. has agreed to pay nearly $20 million to settle three lawsuits involving allegations that the company defrauded pension systems in three states, including California’s giant pension fund, attorneys said. The whistleblower lawsuits, filed by two former CVS Caremark pharmacists, accused the company of reselling returned drugs, changing prescription orders to make them more expensive and submitting false reports about how long it took to fill prescriptions.</blockquote> Not the least bit surprisingly, the company did not admit liability in the settlement, and had no comment for the Times. Ho, hum, another big company paying millions to make allegations of fraud go away... nothing to see here, so we will just move on. Merck Settles Fraud Suit for $24 Million This story was picked up by AP, so a very brief version of it did appear in a variety of locations. A longer version was <a href="http://bostonglobe.com/business/2011/12/21/merck-pay-overcharging-case/05zJqmztpJGuD3elBs0HkM/story.html">published</a> by the Boston Globe, At this point, it should be no surprise that it took a long time to get to this settlement, eight years in fact, just as in the case above, <blockquote>Merck & Co. has agreed to pay $24 million to the state Medicaid program to settle long-running civil charges that it charged too much for some drugs, in the largest single-case Medicaid fraud settlement in Massachusetts history. The agreement, unveiled yesterday by Attorney General Martha Coakley’s office, closes out a 2003 lawsuit....</blockquote> Again, the allegations were of fraud, <blockquote>Coakley said her office’s Medicaid fraud division wanted to hold accountable drug companies that defraud taxpayers. </blockquote> Again, "hold accountable" did not translate into establish the allegations as true, <blockquote>Ron Rogers, a spokesman at Merck corporate headquarters, said the drug company did not admit liability or wrongdoing in the settlement. He said Merck agreed to resolve the claims to put the matter behind it.</blockquote>Nothing more to see here, so we will move on again. Summary Every month, it seems that<a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements"> more settlements</a> are announced of cases alleging all sorts of wrongdoing by major health care organizations. Very often, the allegations are of wrongdoing that appears serious to the uninitiated. For example, most of the above cases involved allegations of fraud, and one involved allegations of kickbacks, that is, bribes to doctors. Yet, in every one of these cases - - The monetary penalties were barely more than pocket change for the corporations involved. - The payments were made by the organization as a whole, and hence would disadvantage many people who were not involved in and did not benefit from the specific actions alleged. Such de facto victims of the settlement included company shareholders, employees, and probably patients (who may have paid prices raised to pay for settlements), and the public (who may have indirectly paid these higher prices through insurance premiums or taxes.) - The organization did not have to admit any facts, leaving the record foggy, and clouding the chances for any people who might have been hurt by the actions to take legal action. - No people who actually authorized, directed, or implemented the apparent bad behavior suffered any negative consequences. Thus, these settlements, like many others we have discussed, did not appear to be any major deterrent of future bad behavior. These settlements do provide a public, if largely ignored, record that suggests how a miasma of sleazy behavior, if not outright corruption has settled over health care. These settlements do provide the context for many pithy questions that could be asked of health care organizational leaders, if anyone dared to do so. The settlements do suggest a need for wholesale, real health care reform that would make health care leaders accountable for what their organizations do, particularly when these organizations misbehave.

Legal Settlements Have Become So Common that They are Barely News

Legal settlements by big health care organizations have become so common that those of less than blockbuster size barely seem to qualify as...

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More Tales of the Hospital CEO Compensation Bubble

The hospital <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">CEO compensation</a> bubble continues to grow. As the year draws to a close, I have found another set of stories about outsized payments to health care executives.  While their repetitive features suggest the magnitude of the issue, they featured some twists on the usual justifications given for large compensation packages. Presented in order of the size of the compensation package..... Maxis Health System, Pennsylvania The Scanton Times-Tribune <a href="http://thetimes-tribune.com/news/marian-community-hospital-to-leave-behind-more-than-19-million-in-liabilities-1.1240913">reported</a>: <blockquote>Mary Theresa Vautrinot, president and CEO of parent company Maxis Health System, earned a little more than $464,000 in salary and other compensation, according to 2010 tax forms filed by the hospital.</blockquote> These days, compensation under a half a million dollars may not seem like all that much, but it should be viewed in context. Maxis Health Systems actually actually owns only one hospital, Marian Community Hospital. In 2010, that hospital, already small, shrunk further, <blockquote>In January 2010, the 70-bed hospital scaled back operations to just 35 beds. For the past six months, Marian Community Hospital has had about 20 inpatients each day.</blockquote> Now it will close: <blockquote>Last Monday, parent company Maxis Health System announced the Carbondale hospital's impending closure, citing ongoing financial pressures and a dwindling patient population</blockquote> $464,000 seems like a lot of money to run a tiny hospital under "ongoing financial pressure" into bankruptcy. This seems like another example of pay for poor performance. Summa Health System, Akron Children's Hospital, Akron General Health System, Ohio In a survey of local hospital CEO compensation, the Akron Beacon-Journal <a href="http://www.ohio.com/news/top-stories/hospitals-disclose-executive-pay-charity-care-1.248669">noted</a>, <blockquote>Children’s President and Chief Executive William Considine received compensation and other benefits totaling $1,560,659 in 2010. Thomas J. Strauss, president and chief executive of Summa Health System, received a total compensation and bonus package worth $1,408,062 last year. For Akron General, 2010 was a year of leadership transition, with a former, interim and current leader all receiving executive pay. Alan J. Bleyer, who retired as the hospital’s leader in 2009, received $677,267 in compensation. Michael Rindler, a national health-care consultant who was interim chief executive and continued in a consulting role through the year, made $983,744. Vincent J. McCorkle, who took over as president and chief executive on July 1, 2010, received $568,605 in total compensation last year.</blockquote>Lest anyone think that these hospitals were paying their CEOs a lot of money, <blockquote>Nonprofit hospital executives could make substantially more if they worked in for-profit industries, [Ohio Hospitals Association spokesperson Mary] Yost said. 'A million dollars certainly is a decent package, but it’s not the highest thing that these people could command,' she said. 'We’re blessed that there are people who want to work for a nonprofit that has the mission of serving its community and they’re not just in it for the money.'</blockquote> Only within the protected world of top executives would $1 million a year seem only a "decent package."  The stock defense of lavish executive pay is <a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">an appeal to common practice</a>, i.e., the pay is justified because so many organizations pay their executives similar amounts.  This version of the defense lacked even the common accompanying assertions that the particular executives are so brilliant and hard-working that they would be assured of a high market price. Furthermore, let us consider another comparison.  Consider the following data, <blockquote>Summa’s revenue exceeded expenses by $31.7 million, for an operating margin of about 3 percent. Akron General Medical Center’s revenue exceeded expenses by about $8 million, resulting in an operating margin of 1.7 percent. Parent company Akron General Health System posted a loss of about $1 million on revenue of $854,207, according to IRS filings. The health system's filings reflect investment income and the costs of providing health screenings to the public, not hospital operations, Akron General spokesman Jim Gosky said. Revenue at Children’s exceeded expenses by about $35.3 million for a 7.4 percent operating margin.</blockquote>These data implied that the CEOs of Summa and Childrens' each received compensation equal to about 5% of their organization's total operating margins. The two people who acted as CEO at Akron General received together an amount that was larger than their system's operating loss, so had they been paid $1 million less, their system would have broken even. In this case, the newspaper found no one to quote who would assert that the former CEOs' performance was so good as to command that much of the hospital's excees, or the latter CEO's performance was so good as to be worth putting the hospital system into a deficit.   Mercy Health Systems, Wisconsin The Janesville, Wisconsin Gazette published a story about one CEOs response to previous reporting of his compensation, <blockquote>Javon Bea saw the August article in a Madison newspaper that questioned the salaries of area health care leaders. Bea, the president and chief executive officer of Janesville-based Mercy Health System, was singled out for receiving considerably more than hospital executives in Madison. The article was based on 2009 tax filings, which show that Mercy paid Bea $3.6 million in total compensation. That included compensation of nearly $2 million and deferred pension payments of just more than $1.6 million. The newspaper reported that the national average was $630,000 and included base salaries, bonuses, pensions and other benefits.</blockquote> Many stories of executive pay have shown leaders who make many times other employees' compensation.  In this case, however, a CEO tried to assert that he did many times other employees' work.  Bea defended his salary by arguing he did the work of at least three, perhaps six people: <blockquote>Bea said the Madison newspaper story compared executives at individual operations to him, an executive of a system that has three hospitals and 61 other facilities in 24 communities in southern Wisconsin and northern Illinois. 'To equal the job description of the CEO of Mercy Health System, you'd have to (add together) the salary of the CEO of DeanCare insurance, the salary of the CEO of Dean Clinic and the salary of the CEO of St. Mary's Hospital,' Bea said. 'And then you'd better throw in the chief operating officers at all three.' Bea said Mercy doesn't have COOs and that he does that work.</blockquote>Mr Bea did not explain how he found enough time in a 24 hour day to do the work of three to six people.  This seems to be a particularly hyperbolic version of argument that the executive is so brilliant and hard-working as to command such a high market price. Perhaps Mercy does not have CEOs or COOs of individual hospitals, but its 2010 Form 990 (from Guidestar <a href="http://www.guidestar.org/FinDocuments/2010/390/816/2010-390816848-0734ca49-9.pdf">here</a>) documents that it has ten vice-presidents who each make approximately $200,000 to over $375,000 a year. Why Mr Bea would need to do the work of three or six people when he has so many other well-executives around to help was not clear. Furthermore, Mr Bea came up with an apparently unique justification for his high pay, that its source was some sort of magic money that did not add to health care costs, <blockquote>Bea said his salary has no effect on health care costs or the premiums MercyCare subscribers pay each year. He likened his salary to capital costs, which he also said don't affect what patients are charged. John Cook, Mercy's chief financial officer, said Medicare, Medicaid and private insurance companies don't pay providers based on the costs of capital improvements or salaries, which in Bea's case is determined by a board of directors that works with national consultants and attorneys. 'My salary isn't going to affect your health care cost,' Bea said.</blockquote> Maybe Mr Bea needs a second opinion from another CFO. His compensation appears to come from the hospital system's budget, per its 990 form, so it affects hospital costs as much as any other expense of the same amount. Furthermore, it is well known that hospital systems negotiate payment rates with private insurers, and that larger systems with more market power may negotiate higher rates.  Finally, it is also well known that different hospitals collect different amounts from government insurance programs for patients with apparently similar problems.  Thus, the notion that executive pay has no effect on health care costs, and the implication that it somehow comes from a magical place outside of the budget, seems to be an entirely new rationale for huge executive compensation.  From a psychological standpoint, it appears to be based on wishful or magical thinking.  Another way to look at it is as a logical fallacy, a <a href="http://www.nizkor.org/features/fallacies/special-pleading.html">special pleading</a>, an assertion without a clear basis that the usual rules or principles do not apply. Montefiore Medical Center, New York-Presbyterian Medical Center, and Others, New York, New York A brief <a href="http://www.nypost.com/p/news/local/rich_ceos_performing_cashectomy_neFNAu2KnwUlm3Wi3rWVSK">article</a> in the New York Post focused on the bonuses given to some local CEOs, <blockquote>Dr. Kenneth Davis, the head of Mount Sinai hospital and medical school, raked in a $1.2 million bonus in 2010, and Michael Dowling, the CEO of the North Shore-LIJ Health System, got $1 million. Louis Shapiro, president of the Hospital for Special Surgery, got a $1.5 million bonus and $992,215 salary. Some CEOs also got a housing allowance, car and driver, and first- or business-class air travel. Montefiore Medical Center in The Bronx paid CEO Steven Safyer $1.4 million plus a $359,845 bonus. The hospital also put $2.2 million into Safyer’s retirement fund, which he can take only when he leaves.</blockquote> In addition, <blockquote>The highest total compensation — $4.3 million — went to Dr. Herbert Pardes, the retiring head of New York-Presbyterian Hospital, who got $1.7 million in salary, a $1.9 million bonus and $648,686 as “other” compensation.</blockquote> The Post found someone to provide the usual rationale, <blockquote>Brian Conway, a spokesman for the Greater New York Hospital Association, defended the packages. 'Hospital CEO compensation reflects their myriad responsibilities, the complexity of running a medical center, and the national market for their talents,' he said.</blockquote> That was a quick one-sentence summation of the "market" and "brilliant, hard-working" arguments.  Note that, as usual, no justification of why the particular people involved should be considered particularly brilliant or hard-working, and no comparison of their dedication or brilliance to that of lesser paid hospital employees was supplied.  Note also that CEO compensation is usually determined not by the market, but by a biased <a href="http://hcrenewal.blogspot.com/2011/10/peer-benchmarking-lake-wobegone-effect.html">benchmarking process,</a> see post here. Note further that this process almost never includes comparisons with employees who are not CEOs, nor includes explicit comparison of particular CEOs dedication, brilliance, etc with either that of other CEOs or other employees. Premier Health Partners, and Others, Cincinnati, Ohio The Middletown (Ohio) Journal <a href="http://www.middletownjournal.com/news/middletown-news/some-health-ceos-earned-millions-1297729.html">reported</a>, <blockquote>Jim Pancoast, president and CEO of Premier Health Partners, the parent organization of Atrium Medical Center in Middletown, had the highest pay in 2010 of information available to date from that year. Pancoast collected about $4.6 million in 2010, most of which is a lump sum paid out through a supplemental executive retirement program.</blockquote> The year before saw someone get even richer compensation, <blockquote>Kettering Health Network’s former Chief Executive Officer Frank Perez and UC Health’s former CEO Kenneth Hanover topped the list in 2009, with each receiving more than $2.6 million. Frank Perez’ total reportable pay in 2009 of more than $5.5 million included a more than $4.5 million lump-sum, taxable retirement payment. </blockquote> Ron Seifert, executive compensation practice leader for the health care practice at Hay Group, supplied the usual rationale, <blockquote>'No one, including the boards of these organizations, denies this is a lot of money. But what they’ll tell you is this takes a special leader,' he said. 'They come with a price tag.'</blockquote> As is also usual, why the particular leader should be considered so special, particularly in comparison to other lesser paid hospital employees,  was not specified.. Northwestern Memorial Healthcare System, Chicago, Illinois Last but not least, we address the compensation given Dean M Harrison, the CEO of Northwestern Memorial Healthcare System, as discussed in an editorial in FierceHealthFinance, entitled, "<a href="http://www.fiercehealthfinance.com/story/evaluating-eight-figure-paychecks-and-near-poor-patients/2011-11-28">The problem of 8-figure hospital paychecks and near-poor patients</a>." In summary, <blockquote>Harrison was paid an astonishing $10.2 million in 2010, the result of a $7.5 supplemental retirement fund payout.</blockquote> The ire this generated, so unlike the tone in the typical news article about executive compensation,  is worth quoting: <blockquote>There are hundreds of nonprofit hospital CEOs like Harrison, compensated with millions of dollars while their institutions throw a few bread crumbs to the poor living in their service areas. Many these institutions spend more on CEO pay than charity care. Alan Sager, a professor of health policy and management at Boston University, recently told Crain's Chicago Business what a lot of healthcare pay and governance experts dare not say: 'There's an enormous sense of self-entitlement among CEOs. It started in the for-profit corporate sector, but it has sloshed over into the non-profit hospital world.' I worked up some talking points for Northwestern Chief Financial Officer Peter J. McCanna that he can bring to the next board meeting, although I'm guessing he won't do so. For those CFOs actually willing to rock the boat, these bullet points work for practically any large urban hospital in the country: • Dean Harrison's 2010 compensation was approximately 170 times that of a charge nurse on their feet 12 hours a day. Does Dean Harrison work 170 times harder? • Dean Harrison's compensation was approximately 20 times that of a cardiac surgeon performing 300 to 400 high-revenue procedures a year. Does Dean Harrison provide 20 times the benefit? • Dean Harrison's compensation could be used to cover the first 10,000 uninsured patients who come through the emergency room each year. Which would provide a greater benefit to the hospital and community? • The purpose of a supplemental retirement plan is to ensure its recipient maintains a reasonable standard of living past their working years. Given the tens of millions of dollars Dean Harrison has already received during his career and the six-figure pension and high five-figure Social Security income he is guaranteed upon retirement, will the $7.5 million payout actually accomplish its goal? Or will it merely be gravy for his heirs?</blockquote> He concluded, <blockquote>Meanwhile, if your hospital has a single patient who works hard, will be bankrupted by the bill they receive, and no one on your staff has walked them through every step of a charity care claim, that is where some imagination and original thought is sorely needed. Too much money in some places, and not enough in others. Someone needs to announce that the buck stops here. And start moving around all the other bucks.</blockquote> Summary In a health care system with ever rising costs, declining access, and stagnant quality, we no longer can tolerate the perverse incentives generated by unaccoutanably high compensation to top executives. As long as top executives continue their sense of "self-entitlement," and can continue their current management practices reinforced by ever rising pay checks, expect poor leadership to undermine any attempts to improve health care.  Tired repititions of the usual rationales, that the CEOs are brilliant and hard-working, and that their compensation is mandated by the market do not make these rationales true. We need health care leadership that has compassion for the increasing hardships that their patients have to endure, and that puts doing the right thing for patients' and the public's health ahead of self-interest.

More Tales of the Hospital CEO Compensation Bubble

The hospital CEO compensation bubble continues to grow. As the year draws to a close, I have found another set of stories about outsized pa...

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