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Two Steps Back: International Council on Human Rights Policy Closes, Dutch Healthy Skepticism Ends Domestic Focus

We have <a href="http://hcrenewal.blogspot.com/2011/12/corruption-kills-so-why-is-health-care.html">noted</a> the paucity of organized efforts to combat health care corruption and related phenomena.  What efforts exist tend to focus on corruption elsewhere, as if no one is willing to admit it can occur in their back yard.  Now one organization that has made some efforts in this sphere is closing, and another will explicitly focus its efforts on problems elsewhere. International Council on Human Rights Policy Closes The <a href="http://www.ichrp.org/">ICHRP</a> was located in Geneva.  It had a wide focus, but was willing to consider how corruption could affect human rights.  Its publication, <a href="http://www.ichrp.org/en/projects/131">Corruption and Human Rights: Making the Connection</a>, explicitly noted the threat of corruption to the right to health.  (Note that in international policy, this right is not considered to be to unlimited health care, but to "attainment of the highest available standard of physical and mental health.")  It went on to list a variety of ways in which government corruption, or corruption of health care leaders or organizations outside of government could harm health.  (Full disclosure: I participated in a meeting the IHCRP convened to review a draft of this publication.) Now, as <a href="http://www.ichrpblog.org/2012/02/last-post.html">announced</a> in the IHCRP blog, the IHCRP will close at the end of this month: <blockquote>The decision to close was taken by the Executive Board primarily due to continued financial difficulties, largely a result of the difficult funding climate, especially for human rights and even more so for human rights policy research. It is especially regrettable because for more than a decade the ICHRP stimulated co-operation and exchange across the non-governmental, governmental and inter-governmental sectors, and strove to mediate between competing perspectives.</blockquote> Healthy Skepticism in the Netherland to Only Focus on Problems "Abroad" Today I got a press release (as of 21 February available <a href="http://www.gezondescepsis.nl/component/content/article/1564.html">here</a>) from the Dutch Institute for Rational Use of Medicine (IVM), that stated: <blockquote>The Dutch Institute for Rational Use of Medicine (IVM) is changing the course of its renowned Healthy Skepticism programme, which has critically monitored the pharmaceutical industry’s impact on the use of medication over the past ten years. Healthy Skepticism will be shifting attention away from its activities in the Netherlands, choosing to focus instead on supporting initiatives abroad. </blockquote> The immediate reason seemed to be lack of funding, like the reason advanced for the closing of the ICHRP: <blockquote>The change is prompted by the fact that the Dutch Ministry of Health, Welfare and Sport has eliminated funding for the programme....</blockquote> The announcement first suggested that the change of focus came about because the initiative had attained its original goals: <blockquote>another factor is the radical change that has occurred in the pharmaceutical industry’s attitude and conduct over the past decade. Commenting on the change, IVM director Ruud Coolen van Brakel stated: 'Although there are still some problem areas, overall the industry has become more mature and more responsible’. </blockquote> However, later in the announcement the implication was stronger that this lack of funding may have resulted from how the program challenged the powers that be, perhaps those who were personally profiting the most from the status quo: <blockquote>The impact of Healthy Skepticism’s initiatives has not been unequivocally positive. IVM met with considerable resistance, which at times even became personal, and, because of its critical attitude, often became the target of aggressive attacks that also compromised its funders, the Ministry of Health, Education and Sport and the Healthcare Inspectorate.</blockquote> Summary We noted most recently (<a href="http://hcrenewal.blogspot.com/2011/12/corruption-kills-so-why-is-health-care.html">here</a>, December, 2011) most of the organizations one might have expected would have provided some response to health care corruption instead have largely treated it as at best a nuisance. Specifically, there is almost no teaching or research on corruption in health care academics (including medical and public health schools, and programs in health care research and policy.)  There is almost no mention of corruption by health care professional associations.  There are almost no initiatives to fight corruption on the part of health care charities and donors.  There is almost no interest in corruption among patient advocacy organizations.  (See previous discussion <a href="http://hcrenewal.blogspot.com/2011/02/after-publicity-about-losses-from.html">here</a>.) Furthermore, I also <a href="http://hcrenewal.blogspot.com/2011/11/will-freeze-of-global-fund-finally-put.html">postulated</a> that at least in the US context, this lack of interest in corruption may partially be explained by these organizations' institutional conflicts of interest and the individual conflicts of interest affecting their leaders. It may be further explained by the exposure of some leaders to the irresponsible, if not amoral culture that now currently pervades finance, which may have in turn been one cause of the great recession, or global financial collapse. The ICHRP and the Dutch Healthy Skepticism program seemed to be happy exceptions.  However, both of them depended on outside government or non-profit organizations for funding.  In both cases, these outside funders seem to have lost enthusiasm, maybe for reasons discussed above. At least the <a href="http://www.ichrp.org/">ICHRP archives</a> remain available, and <a href="http://www.gezondescepsis.nl/about-us.html">Dutch Healthy Skepticism</a> may be able to make some useful contribution outside the Netherlands. There is increasing <a href="http://hcrenewal.blogspot.com/2011/12/corruption-kills-so-why-is-health-care.html">evidence</a> that health care corruption may end up killing people.   I still hope that the courage of those who have tried to increase awareness of health care corruption, the conflicts of interest that can increase its likelihood, and surrounding phenomena, will not be in vain.  I still hope that some academic health care institutions, professional societies, health care charities and donors, and patient advocacy groups will gain enough fortitude to stand up for accountability, integrity, transparency, and honesty in health care.

Two Steps Back: International Council on Human Rights Policy Closes, Dutch Healthy Skepticism Ends Domestic Focus

We have noted the paucity of organized efforts to combat health care corruption and related phenomena. What efforts exist tend to focus on...

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The First State's Deadest (Deadliest?) Duck - Is This ED EHR Harming or Killing Anyone in NSW?

Nobody seems to be asking this simple question: Is This ED EHR harming or killing anyone in NSW? It cannot be "<a href="http://hcrenewal.blogspot.com/2012/01/another-our-crappy-computers-screwed-up.html">not compromising patient care</a>" on first principles. This type of practical and ethical question seems to never get asked, while what appears to be a tit-for-tat political kerfuffle goes on. This is due in part to the baffling special accommodations afforded worldwide towards an extremely profitable but potentially extremely dangerous medical device, as well as due to the issues I described in my post about reckless technophilia and the accompanying disregard for rights of others <a href="http://hcrenewal.blogspot.com/2012/02/health-it-ddulites-and-disregard-for.html">here</a>. <h2 style="font-weight: normal;"></h2><blockquote><h2 style="font-weight: bold;">The Register</h2><h2 style="font-weight: bold;"><a href="http://www.theregister.co.uk/2012/02/12/firstnet_flops_again/">NSW government accused of dodgy software cover-up</a></h2> FirstNet: the First State's deadest duck [or "deadliest duck?" - ed.] By <a href="http://forms.theregister.co.uk/mail_author/?story_url=/2012/02/12/firstnet_flops_again/" title="Send email to the author">Richard Chirgwin</a> Posted in <a href="http://www.blogger.com/business/">Business</a>, <a href="http://www.blogger.com/2012/02/12/" title="More stories published on this date">12th February 2012 22:00 GMT</a> <div id="body"> The buggy FirstNet emergency department software has become the subject of a political argument in NSW. [What about a clinical and ethical argument? - ed.] In one of those paradoxes of democracy, an opposition which, in government, was responsible for a now-despised implementation is now using the IT project as a stick to beat a government which was in opposition when the system was chosen. Last week, the Sydney Morning Herald obtained a report into the system by Deloitte, under a freedom of information request. It <a href="http://www.smh.com.au/it-pro/government-it/hospital-computer-system-found-lacking-20120210-1so7j.html">says</a> [1] the Deloitte report criticises FirstNet because it is: - Is chronically under-funded; - Produces inadequate records; - Was unreliable in delivering messages, and did not provide alerts when messages failed to reach their destination; and - Demanded excessive amounts of screen time from clinicians. [But is it harming or killing anyone? Are those statistics being collected robustly and scientifically, or are self-serving statements by hospital executives that "care was never compromised, and nobody was injured" simply being taken at face value? Further, the obvious increased risk of harm due to deficient IT currently in operation is being cavalierly ignored. This is alien to medicine, and could cause career termination or land people in jail in fields such as aviation if planes with known potentially-dangerous avionics software or other defects are kept flying - ed.]In spite of its inadequacies, the Deloitte report seen by the SMH said the $AU100-plus million Cerner FirstNet system is too entrenched to abandon. [I'm quite sure dead or injured patents would not appreciate that explanation - ed.] Over the weekend, opposition health spokesperson Dr Andrew McDonald issued a statement accusing NSW health minister Jillian Skinner of covering up the report since August 2011. However, other published studies into FirstNet, such as a detailed investigation by Sydney University e-health expert Professor Jon Patrick <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">here</a> [2], identify problems similar to those apparently cited by Deloitte. This study was undertaken to investigate issues with FirstNet outlined in November 2008 in a special commission of review, conducted by Peter Garling, While noting that FirstNet represented an improvement on some aspects of its predecessor, Garling said the system attracted complaints that it was unfriendly to users, that the vendor and Health Department did not respond to complaints about the software, and that emergency department patients were being held in triage for excessive times, while clinical staff fought with the software. [What sane patient would want such a system used in their care? - ed.] Deloitte, on the other hand, was far less critical of FirstNet in 2008, when in a <a href="http://www.health.nsw.gov.au/resources/news/pdf/triage-bench-rev.pdf">review</a> [3] of triage benchmarks it managed to turn up a downtime issue, difficulty in uploading triage data to the Health Department, and the identification of the wrong doctor or nurse with a patient’s records. </div> <div id="pf-links"> <h3>Links</h3> <ol><li><a href="http://www.smh.com.au/it-pro/government-it/hospital-computer-system-found-lacking-20120210-1so7j.html">http://www.smh.com.au/it-pro/government-it/hospital-computer-system-found-lacking-20120210-1so7j.html</a></li><li><a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a></li><li><a href="http://www.health.nsw.gov.au/resources/news/pdf/triage-bench-rev.pdf">http://www.health.nsw.gov.au/resources/news/pdf/triage-bench-rev.pdf</a></li></ol></div></blockquote> Stunning. On the argument that "the older system was worse", or the corollary argument that "paper harms and kills too", I suggest anyone who proffers that argument should realize <a href="http://en.wikipedia.org/wiki/Rofecoxib">VIOXX (refoxicib)</a> helped far more people than it harmed in reducing pain while sparing them from GI side effects compared to "older" drugs. <a href="http://www.npr.org/templates/story/story.php?storyId=4054991">Over 84 million people</a> were prescribed rofecoxib at some time and only mere thousands, or tens of thousands, are presumed to have been injured or died. Therefore, following their own illogic and ethical (dis)orientation, they should put all their family members on the drug - especially the elderly with cardiovascular disease - to benefit from pain relief and VIOXX's other miraculous effect, <a href="http://www.sciencedaily.com/releases/2006/08/060830215121.htm">suppression of colonic polyps</a>. Surely those benefits outweigh the risks, and therefore it is ethical to do so, no? Of course not. Health IT, as I've written in many posts on this blog, has a magnitude of harms that is admittedly unknown. Health IT needs significant further study and improvement, certainly before national rollouts, and before decisions are made that particular systems are "too entrenched to abandon." -- SS

The First State's Deadest (Deadliest?) Duck - Is This ED EHR Harming or Killing Anyone in NSW?

Nobody seems to be asking this simple question: Is This ED EHR harming or killing anyone in NSW? It cannot be " not compromising patien...

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Health IT Ddulites and Disregard for the Rights of Others

At my Feb. 8, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/02/health-it-ddulites-and-irrational.html">Health IT: Ddulites and Irrational Exuberance</a> " I defined a "Ddulite" (Luddite with the first four characters reversed) as the opposite of a Luddite, specifically: <blockquote>Hyper-enthusiastic technophiles who either deliberately ignore or are blinded to technology's downsides, ethical issues, and repeated local and mass failures. </blockquote> An astute reader points out that "opposite" may be an incomplete description, as the <a href="http://en.wikipedia.org/wiki/Luddite">Luddites</a>: <blockquote>"were a social movement of 19th-century English textile artisans who protested – often by destroying mechanized looms – against the changes produced by the Industrial Revolution, which they felt were leaving them without work and changing their way of life. The movement was named after General Ned Ludd or King Ludd, a mythical figure who, like Robin Hood, was reputed to live in Sherwood Forest."</blockquote> In other words, they were merely trying to save their jobs, and their actions did not cause life-threatening adverse events, such as death by freezing due to lack of warm garments. Ddulites, on the other hand, ignore the downsides (patient harms) of health IT. This is despite being already aware of, or informed of patient harms, even by reputable sources such as <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">FDA</a> (Internal FDA memo on H-IT risks), <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html">The Joint Commission</a> (Sentinel Events Alert on health IT), the <a href="http://www.isb.nhs.uk/documents/isb-0160/dscn-18-2009/0160182009specification.pdf">NHS</a> (Examples of potential harm presented by health software - Annex A starting at p. 38), and the <a href="http://hcrenewal.blogspot.com/2010/12/ecri-healthcare-it-in-top-ten-health.html">ECRI Institute</a> (Top ten healthcare technology risks), to name just a <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">few</a>. In fact, the hyper-enthusiastic health IT technophiles will go out of their way to incorrectly dismiss risk management-valuable case reports as "anecdotes" not worthy of consideration (see "Anecdotes and medicine" essay <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">at this link</a>). They will also make unsubstantiated, often hysterical-sounding claims that health IT systems are necessary to, or simply will "transform" (into what, exactly, is usually left a mystery) or even "revolutionize" medicine (whatever that means). This is despite the fact that many of this mindset are medical and/or Medical Informatics professionals who know better. They also ignore the draining waste of resources of failed or ineffectual IT ("<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">bad health IT</a>"), potentially depriving patients of the best healthcare possible. Thus, as the reader pointed out, there could be an element of <a href="http://en.wikipedia.org/wiki/Psychopathy">psychopathy</a> or, at best,<a href="http://definitions.uslegal.com/c/conduct-in-reckless-disregard/"></a> reckless disregard for rights of others in their thinking. <blockquote><a href="http://law.yourdictionary.com/reckless-disregard">Reckless disregard</a>: An act of proceeding to do something with a conscious awareness of danger, while ignoring any potential consequences of so doing. Reckless disregard, while not necessarily suggesting an intent to cause harm, is a harsher condition than ordinary negligence.</blockquote> In my opinion, at a time of mass funding and pressure for rapid rollout of health IT in its present state of experimental development, this is not an observation that should be casually dismissed. -- SS

Health IT Ddulites and Disregard for the Rights of Others

At my Feb. 8, 2012 post " Health IT: Ddulites and Irrational Exuberance " I defined a "Ddulite" (Luddite with the first...

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A Camel Through the Eye of a Needle - at Non-Profit Health Insurers

It is time to drag out that well-worn phrase,...  sometimes you just cannot make this stuff up.  Recently, the New York Post <a href="http://www.nypost.com/p/news/local/nonprofit_execs_healthy_wealthy_UhdbNKvMXTqbBIhLjrZ4yO">reported</a> about executive compensation at some non-profit health maintenance organizations/ health insurance companies in New York.  To wit, FidelisCare <blockquote>At one Catholic-run health insurer for the needy, charity starts in the executive suite. Mark Lane, the CEO of the Fidelis Care/New York State Catholic Health Plan, receives a $1.1 million salary plus another $864,000 in retirement pension and other benefits, The Post has learned. His total compensation comes to nearly $2 million. Fidelis is a tax-exempt, not-for-profit HMO serving 750,000 patients throughout the city and state who mostly qualify for Medicaid, the public insurance program for the needy. That means nearly all of Fidelis’ revenues come from taxpayers. Meanwhile Fidelis’ executive vice president and chief operating officer, the Rev. Patrick Frawley, an ordained Catholic priest, is paid $587,249. Frawley received more than $900,000 in other retirement and deferred benefits — raising his total compensation to $1.54 million, according to IRS filings. That’s a lot of pennies from heaven. 'It’s shocking to me,' said a source familiar with Catholic health charities.</blockquote>Amazingly, the justification that was trotted out in this case was just of the "our CEO is brilliant" variety, but in this case, provided by a Bishop: <blockquote>Fidelis defended the salaries of its top officers, who oversee a $3 billion operation. Bishop Joseph Sullivan, a member of Fidelis’ board of trustees who formerly served as chairman, called the compensation 'generous but fair.' He said the goal is for salaries to be at the '75th percentile' of rivals. “Our ability to continue to grow is based on the quality of leadership. You get what you pay for. Lane and Father Frawley are worth every penny,” Sullivan said. Fidelis also issued a statement explaining that Frawley, after serving in pastoral roles for 25 years, was granted release from his priestly assignment to pursue a career in health care.</blockquote> So much for a vow of poverty, even at a non-profit providing health care mainly to the poor. EmblemHealth On the other hand, executives of secular, but still non-profit health insurers do even better, <blockquote>Anthony Watson, CEO of EmblemHealth, gets a compensation package of $8.5 million — about half in salary and bonuses and the rest in retirement and deferred benefits, according to IRS filings. Two other EmblemHealth executives also snagged multimillion-dollar compensation packages.</blockquote>Summary We have <a href="http://hcrenewal.blogspot.com/2011/10/peer-benchmarking-lake-wobegone-effect.html">noted before </a>how the "peer benchmarking process," setting executive (but not necessarily other) compensation based on a comparison with compensation at other, often highly selected organizations, coupled with the "Lake Wobegone Effect," the belief that one's own executives are always above average, will lead to inexorable rises in executive pay, regardless of performance, or whatever else is going on in the world. The Bishop's assertion that Fidelis' executive compensation should be at the seventy-fifth percentile, because of the "quality of leadership," not further described, is a perfect example of these phenomena. It is striking to see these phenomena at a non-profit organization whose <a href="http://www.fideliscare.org/aboutus/index.aspx">mission</a> is: <blockquote>to ensure that every resident, regardless of income, age, religion, gender, or ethnic background, has access to quality health care, provided with dignity and respect.</blockquote> So, ad infinitum, I repeat.... 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.

A Camel Through the Eye of a Needle - at Non-Profit Health Insurers

It is time to drag out that well-worn phrase,... sometimes you just cannot make this stuff up. Recently, the New York Post reported about...

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The Bloat Continues: More Tales of Non-Profit Hospital Executive Compensation

While unemployment remains high, and mortgage foreclosures continue in the US, nothing seems to stop the rise of health care costs, lead by compensation for top health care leaders. So, it is time once again for a round-up of inflated executive compensation at non-profit and government hospital systems.  We will describe the bloat in order of the appearance of the information in public. Cincinnati The December, 2011, the Cincinnati Business Courier <a href="http://www.bizjournals.com/cincinnati/feature/datacenter-hospital-executive.html">tabulated </a>the pay of the best compensated hospital employees, and discussed the results in an <a href="http://www.bizjournals.com/cincinnati/blog/2011/12/in-hospitals-its-not-just-ceos.html">accompanying article</a>.  By my count, 19 local hospital employees made more than $1 million in 2010.  These included 6 system CEO, 4 division CEOs, 5 chief level executives or vice presidents, 1 clinical department chair, and 3 doctors.  The top compensation went to Kenneth Hanover, CEO of Health Alliance/ UC Health, $2,799,338. Three others made more than $2 million. Western New York In January, 2012, Buffalo Business First <a href="http://www.bizjournals.com/buffalo/news/2012/01/23/four-hospital-execs-earn-more-than-1.html">reported</a>: <blockquote>The top hospital administrators in Western New York took home more than $53 million in compensation during 2010, with four executives earning $1 million-plus paydays. Hospital presidents and chief executives at the region’s two largest health systems were among the top earners, with James Kaskie, president and CEO of Kaleida Health , earning $2.36 million; and Joseph McDonald, president and CEO at Catholic Health , earning nearly $1.1 million. Kaskie’s compensation, as well as Kaleida executives Connie Vari, Robert Nolan and Margaret Paroski, included a deferred retirement plan payout. All four were among the top five earners for 2010, the most recent year for which complete data is available.</blockquote> The life of a top hospital executive near Buffalo was not quite as plush as in Cincinnati. Only 4 made more than $1 million, including the CEO, Chief Medical Officer/ Executive Vice President, and Chief Operating Officer of Kaleida Health, and the CEO of Catholic Health System. Eleven more executives got more than $500,000. North Carolina It was a very good year for executives from some of the state's biggest health care systems, per a February, 2012 <a href="http://www.charlotteobserver.com/2012/02/01/2974848/chs-paid-its-ceo-42m.html">article in the Charlotte Observer</a>. <blockquote>Carolinas HealthCare System paid its CEO $4.2 million in 2011, $523,000 more than the year before, as the system celebrated a profitable year and met all of its systemwide goals, according to hospital officials. Chief Executive Officer Michael Tarwater, 58, who has led the $6 billion public hospital system for 10 years, received a base salary of about $1 million, two bonuses totaling $2.5 million, and other compensation, including retirement and health benefits, of about $700,000. That represents a 9 percent increase in base salary and a 14 percent overall increase compared to 2010, when Tarwater's salary was $986,172 and total compensation was $3.7 million.</blockquote> Meanwhile, at Novant Health, <blockquote>The most recent compensation figures for Novant executives are from 2010. In that year, Novant's CEO Paul Wiles, 64, received total compensation of $3.2 million, including his salary of $1 million, a bonus of about $837,000, and $1.37 million in other income, including retirement and health benefits. Wiles retired at the end of 2011 and was succeeded by Carl Armato, who was previously chief operating officer for Novant.</blockquote> A data table within the article showed that there were 10 employees, all executives, at Carolinas Healthcare System in 2011, and 6, again all executives, at Novant Health in 2010, who got more than $1 million in compensation. Why did the Carolinas CEO warrant a multi-million dollar pay package? One of his employees endeavored to explain, <blockquote>'We've had extremely good performance,' said Debra Plousha Moore, the system's chief of human resources. 'All performance goals this year were either met or exceeded.'</blockquote>Why the credit for that performance should not be spread amongst more hospital employees, especially those who actually took care of patients, she did not explain. Northern New York City Suburbs In February, 2012, LoHud.com <a href="http://www.lohud.com/article/20120212/NEWS02/302120060/Business-Medicine-Part-2-Eight-local-hospital-officials-got-1M-2010">reported</a>: <blockquote>Eight executives from 15 Lower Hudson Valley hospitals received more than $1 million in salary, bonuses, benefits and other pay in 2010 at a time when the state struggled to control health-care costs.</blockquote> The details included: <blockquote>Three executives received more in total compensation than Westchester Medical Center CEO Michael Israel, who earned $1.3 million and oversees a hospital that’s more than twice the size of other facilities in the region.</blockquote> Also, <blockquote>The highest-paid hospital employees include White Plains Hospital CEO Jon Schandler with $1.6 million in total compensation, Dr. Edward Lundy at Good Samaritan Hospital in Suffern with $1.48 million and Edward Dinan, CEO of Lawrence Hospital in Bronxville, with $1.41 million. Others in the million-dollar range include John Federspiel, president of Hudson Valley Hospital Center in Cortlandt; Joel Seligman, CEO of Northern Westchester Hospital in Mount Kisco; and Keith Safian, CEO of Phelps Memorial Hospital Center in Sleepy Hollow. A year earlier, Federspiel received a compensation package of nearly $2 million due partly to an $800,000 deferred compensation payout. The average CEO compensation rose 13 percent from 2009, to $939,751. Ten hospitals paid $7.7 million in bonuses to top executives, an increase of 15 percent over 2009. White Plains Hospital alone distributed $2.1 million in bonuses, including $650,000 to Dr. Jesus Jaile-Marti, chief of neonatology, and $575,000 to Schandler.</blockquote> This article highlighted the contrast between compensation for executives and for employees who provide front line care: <blockquote>The high salaries also come as hospitals pressure many employees for wage freezes, rising insurance costs and watered-down pensions, said Deborah Elliott, a nurse and deputy executive officer of the New York State Nurses Association, a statewide union representing nurses at Sound Shore, Mount Vernon, St. John’s Riverside, St. Joseph’s and Nyack hospitals as well as Westchester Medical Center. 'It never ceases to amaze me that we sit at the bargaining table with these executives who are making $1 million and they give us such a hard time about a half-percent increase for a nurse who is making $63,000,' Elliott said. 'It’s galling.'</blockquote>Again, contrast that one half percent with the average chief executive increase of 13%. While it is a rare hospital that would disparage the performance of its dedicated nurses and physicians, somehow executive talent seems to matter more. For example, here is how Hudson Valley Hospital Center president John Federspiel's compensation was justified by his board chair: <blockquote>Edward B. MacDonald Jr., chairman of Hudson Valley Hospital Center’s board of directors, said Federspiel deserves his paycheck. The hospital has earned a profit for 22 of the 25 years that Federspiel has been at the helm and has expanded both its services and payroll in that time, he said. 'He’s the best administrator, planner and motivator I have ever had the privilege to work with,' MacDonald said. 'I wish I could pay him more.'</blockquote>Again, why the CEO, but not the nurses and doctors deserves the credit for the hospital's performance was not stated. Summary It all gets so tedious, doesn't it? CEOs of all but the smallest non-profit hospitals now seem entitled to at least $1 million a year. At larger systems, multiple executives per system seem entitled to that level of compensation, and CEOs may get multiple millions a year. Yet these are ostensibly non-profit organizations dedicated or providing care to their communities, and often to serving the poor. Thus the health care bubble continues to inflate, and executives are ever more distracted by money, and seem less focused on mission. Note that reporting of this ever rising compensation seems to be becoming more perfunctory as the results seem more routine (and tedious). Two of the four articles noted above did not provide any justifications for the high pay, while two only trotted out brief versions of the "our CEO is so brilliant" meme. As I <a href="http://hcrenewal.blogspot.com/2011/12/more-tales-of-hospital-ceo-compensation.html">said in December</a>, in a health care system with ever rising costs, declining access, and stagnant quality, we no longer can tolerate the perverse incentives generated by unaccountably 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 repetitions 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.

The Bloat Continues: More Tales of Non-Profit Hospital Executive Compensation

While unemployment remains high, and mortgage foreclosures continue in the US, nothing seems to stop the rise of health care costs, lead by ...

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Generic Leadership Fine for EHR Implementation in High Acuity, High Risk Areas Such as an Emergency Department?

At my Feb. 16, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html">Hospitals and Doctors Use Health IT at Their Own Risk - Even if 'Certified'</a>" I established that buyers and users of EHR systems do so at their own risk with regard to implementation problems or outright defects resulting in patient harm. As I've also written at my April 2011 post "<a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html">FDA Decides Regulating Implantable Defibrillator Medical Devices a Political Hot Potato; Demurs</a>", FDA has admitted health IT is a medical device that they shy away from regulating because it's politically expedient not to do so. (The area is a "hot potato" per the Director of FDA's <a href="http://www.fda.gov/MedicalDevices/default.htm">CDRH</a>, the Center for Devices and Radiological Health, so FDA stays away.) Yet FDA knows of the stakes. As I observed at my Aug. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">Internal FDA memorandum of Feb. 23, 2010 to Jeffrey Shuren on HIT risks</a>" and elsewhere, patient harm is occurring due to these devices and FDA is aware. Due to admitted impediments to information diffusion, however, even FDA, IOM, The Joint Commission (due to a "dearth of data" as in their 2008 <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html">Sentinel Events Alert On Healthcare IT</a>) and others do not know the true magnitude of the problem. From the FDA internal memo at the preceding FDA memorandum link: <blockquote> Limitations of the MAUDE [<a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.CFM" style="font-weight: bold;">Manufacturer and User Facility Device Experience database</a>] search and final subset of Medical Device Reports (MDRs) include the following: 1. Not all H-IT safety issue MDRs can be captured due to limitations of reporting practices including ... (a) Vast number of H-IT systems that interface with multiple medical devices currently assigned to multiple procodes making it difficult to identify specific procodes for H-IT safety issues; ... (b) Procode assignments are also affected by the ability of the reporter/contractor to correctly identify the event as a H-IT safety issue; ... (c) Correct identification by the reporter of the suspect device brand name is challenged by difficulties discerning the actual H-IT system versus the device it supports. 2. Due to incomplete information in the MDRs, it is difficult to unduplicate similar reports, potentially resulting in a higher number of reports than actual events. 3. Reported death and injury events may only be associated with the reported device but not necessarily attributed to the device. 4 Correct identification by the reporter of the manufacturer name is convoluted by the inability to discern the manufacturer of the actual H-IT system versus the device it supports. 5 The volume of MDR reporting to MAUDE may be impacted by a lack of understanding the reportability of H-IT safety issues and enforcement of such reporting. ... The results of this data review suggest significant clinical implications and public safety issues surrounding Health Information Technology. The most commonly reported H-IT safety issues included wrong patient/wrong data, medication administration issues, clinical data loss/miscalculation, and unforeseen software design issues; all of which have varying impact on the patient’s clinical care and outcome, which included 6 death and 43 injuries. The absence of mandatory reporting enforcement of H-IT safety issues limits the number of relevant MDRs and impedes a more comprehensive understanding of the actual problems and implications. </blockquote> Finally, as I pointed out in my Dec. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/12/onc-defines-taxonomy-of-health-it.html">ONC Defines a Taxonomy of Robust Healthcare IT Leadership</a>", the Office of the National Coordinator for Health IT at HHS (ONC) had published the following with regard to the qualification of those who could "lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States": <blockquote>Clinician/Public Health Leader: By combining formal clinical or public health training with training in health IT, individuals in this role will be able to lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States. In the health care provider settings, this role may be currently expressed through job titles such as Chief Medical Information Officer (CMIO), Chief Nursing Informatics Officer (CNIO). In public health agencies, this role may be currently expressed through job titles such as Chief Information or Chief Informatics Officer. Training appropriate to this role will require at least one year of study leading to a university-issued certificate or master’s degree in health informatics or health IT, as a complement to the individual’s prior clinical or public health academic training. For this role, the entering trainees may be physicians or other clinical professionals (e.g. advanced-practice nurses, physician assistants) or hold a master’s or doctoral degree(s) in public health or related health field. Individuals could also enter this training while enrolled in programs leading directly to degrees qualifying them to practice as physicians or other clinical professionals, or to master’s or doctoral degrees in public health or related fields (such as epidemiology). Thus, individuals could be supported for training if they already hold or if they are currently enrolled in courses of study leading to physician, other clinical professional, or public-health professional degrees.</blockquote> Here, though, is a more typical reality in today's hospitals, the background of an EHR deployment leader in one of the most risk-prone and difficult environments in healthcare, the Emergency Department (ED) in a large hospital of which I am aware: <div dir="ltr"></div><blockquote><div style="font-weight: bold;" dir="ltr">Clinical Systems Analyst </div> <div style="font-weight: bold;" dir="ltr">January 2004 – Present</div> <div dir="ltr">Project manager for implementation of an ED EHR [vendor name redacted] Responsible for all aspects of implementation including build and process design, report build, testing, training, and go-live support. Extensive knowledge ADT processes, HL7, and CPOE. Manage software patches and upgrades. Experience in HTML, SQL and SAP. </div> <div dir="ltr"> </div> <div dir="ltr">Financial Systems Analyst November 2001 – January 2004 </div> <div dir="ltr">Project Team Lead for implementation of Patient Accounting system. Responsible for system development and system build, training, testing, and reporting. </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> Education </div> <div dir="ltr"> [Regional university in the lower 50% of US News rankings in the region, name redacted] B.S., Management Information Systems 2000 – 2003 </div> <div dir="ltr"> </div> <div dir="ltr"> [Name redacted] Community College </div> <div dir="ltr">Associates Degree, Business Administration</div> </blockquote><div dir="ltr"></div> <div dir="ltr"> So, ED physicians (with many years of doctoral and post-doctoral training and experience, boards testing their competence, etc.) may be placing the lives of patients and their careers in the hands of: <ul><li> An experimental medical device, </li><li>unregulated by anyone, </li><li>in a field whose qualifications for leadership are unregulated by anyone, </li><li>devices known to be risky, </li><li>but without anyone knowing the magnitude of that risk, </li><li>whose implementation is led by a generic 'clinical' systems analyst "responsible for all aspects of implementation" with a Bachelor's degree in MIS from a second-tier institution, an Associates degree from a community college, and no medical or Medical Informatics education or experience whatsoever.</li></ul> Further, that project lead jumped from financial systems analyst to 'clinical' analyst/leader of an ED EHR implementation. One should also ask <ul><li>Who was the hiring manager who hired such a person and put them in the role?</li><li>On what credentials and experience was the decision based? </li><li>What were the hiring manager's own credentials? </li></ul> I leave it to the reader to decide if this is an appropriate arrangement, and if they would place their trust in an ED whose activities center around a cybernetic system implemented in this manner. -- SS Feb. 17, 2012 Addendum: At least in this case the person has degrees. Per several prominent healthcare IT recruiters in the past in the article "Who's Growing CIO's" in the journal Healthcare Informatics, as mentioned at my Sept. 2009 post "<a href="http://hcrenewal.blogspot.com/2008/09/correcting-historical-misinformation.html">Correcting historical information from the recruiter component of the Health IT Ecosystem</a>", the School of Hard Knocks was plenty good for health IT leadership roles: <blockquote>I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.</blockquote> -- SS </div>

Generic Leadership Fine for EHR Implementation in High Acuity, High Risk Areas Such as an Emergency Department?

At my Feb. 16, 2012 post " Hospitals and Doctors Use Health IT at Their Own Risk - Even if 'Certified' " I established tha...

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Hospitals and Doctors Use Health IT at Their Own Risk - Even if "Certified"

Due to my observations of confusion about health IT certification [1], and due to vague or incomplete seller language that could be misinterpreted by buyers (perhaps by design), I recently asked several ONC-ATCBs (HHS's Office of the National Coordinator for Health IT-Authorized Testing and Certification Bodies) the following. I sent this question via email to their "questions" email addresses: <blockquote>"Is EHR certification by an ATCB a certification of EHR safety, effectiveness, and a legal indemnification, i.e., certifying freedom from liability for EHR use of clinical users or organizations? Or does it signify less than that?"</blockquote> One ONC-ATCB provided the following in response to my request for information. <div style="margin-left: 40px;">From: Trivedi, Amit V (ICSA Labs) Sent: Thursday, February 16, 2012 11:22 AM To: Scot Silverstein Subject: RE: Form submission from: Contact Us Hello Scot, Thanks for your email. Certification by an ATCB signifies that the product or system tested has the capabilities to meet specific criteria published by NIST and approved by the Office of the National Coordinator. In this case the criteria are designed to support providers and hospitals achieve "Meaningful Use." A subset of the criteria deal with the security and patient privacy capabilities of the system. Here is a list of the specific criteria involved in our testing: <a href="http://healthcare.nist.gov/use_testing/effective_requirements.html" target="_blank">http://healthcare.nist.gov/use_testing/effective_requirements.html</a> In a nutshell, ONC-ATCB Certification deals with testing the capabilities of a system, some of them relate to patient safety, privacy and security functions (audit logging, encryption, emergency access, etc.). What was suggested in the email below (freedom from liability for users of the system, etc.) would be out of scope for ONC-ATCB testing based on the given criteria. [I.e., certification criteria - ed.] I hope that helps to answer your question. Thanks, Amit Amit Trivedi Program Manager - Healthcare ICSA Labs, an Independent Division of Verizon Business</div> Mar. 5, 2012 Addendum:  I also received a response from another ONC-ATCB, the Drummond Group: <blockquote>From: Joani Hughes (Drummond Group) Sent: Monday, March 05, 2012 1:06 PM To: Scot Silverstein Subject: RE: EHR certification question Per our testing team: It is less than that. It does not address indemnification although a certification could be used as a conditional part of some other form of indemnification function, such as a waiver or TOA, but that is ultimately out of the scope of the certification itself. Certification in this sense is an assurance that the EHR functions in way that could enable an eligible provider or eligible hospital to meet the CMS requirements of Meaningful Use Stage 1. Or to restate it more directly, CMS is expecting eligible providers or eligible hospitals to use their EHR in “meaningful way” quantified by various quantitative measure metrics and eligible providers or eligible hospitals can only be assured they can do this if they obtain a certified EHR technology. Please let me know if you have any questions. Thank you, Joani. Joani Hughes Client Services Coordinator Drummond Group Inc.</blockquote> These are direct and clear statements. My question was certainly answered. ONC cerification is not a safety validation, such as in a document from NASA on aerospace software safety certification, "<a href="http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20040014965_2004000657.pdf">Certification Processes for Safety-Critical and Mission-Critical Aerospace Software</a>" (PDF) which specifies at pg. 6-7: <blockquote>In order to meet most regulatory guidelines, developers must build a safety case as a means of documenting the safety justification of a system. The safety case is a record of all safety activities associated with a system throughout its life. Items contained in a safety case include the following: • Description of the system/software • Evidence of competence of personnel involved in development of safety-critical software and any safety activity • Specification of safety requirements • Results of hazard and risk analysis • Details of risk reduction techniques employed • Results of design analysis showing that the system design meets all required safety targets • Verification and validation strategy • Results of all verification and validation activities • Records of safety reviews • Records of any incidents which occur throughout the life of the system • Records of all changes to the system and justification of its continued safety </blockquote> Health IT testing conspicuously lacks attention to most of the aerospace software safety points above. I note that there appears to be no reasonable excuse for such omissions. IOM has recently studied the issue of HIT safety. IOM states in a Nov. 2011 report that HIT safety and safety testing is unsatisfactory, and has recommended HHS study it as well. IOM recommends HHS annually re-evaluate whether regulation is needed to improve safety, although IOM favors industry self-policing [2]. Thus, buyers and users of even "ONC certified" health IT are not indemnified from liability due to medical errors or problems caused by the health IT. Sellers who exaggerate the value of certification or imply its meaning is akin to FDA device approval, likewise, could be faulted for making false representations about their products. It would appear the sellers could potentially be sued for doing so by purchasers/users who themselves get into legal hot water due to EHR defects or other problems. -- SS Note: [1] I believe confusion about EHR "certification" is in part due to the term itself. I raised objections to this term when it was first proposed based on my experience in pharma, suggesting what I felt was the more accurate expression "features qualification" instead. [2] "Health IT and Patient Safety: Building Safer Systems for Better Care", Institute of Medicine of the National Academies, Nov. 2011, <a href="http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx">http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx</a>

Hospitals and Doctors Use Health IT at Their Own Risk - Even if "Certified"

Due to my observations of confusion about health IT certification [1] , and due to vague or incomplete seller language that could be misint...

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