healthy4u

Using a "Professionalism" Initiative as a Speech Code to Punish Students' Criticisms of Administrative Authority?

The original impetus to set up <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> was increasing evidence of external threats to physicians' professional values.  So it seemed to me that renewed interest in addressing professionalism in academic medicine might lead to more attention to these threats, and perhaps even real challenges to them.  Instead, most academic professionalism initiatives seem to have steered away from this contentious area.  Worse, at times the academic medical concept of professionalism has been turned on its head.  A Dispute Among Students at University of California - Davis A recent <a href="http://thefire.org/article/14251.html">post</a> in the Torch blog from our friends at FIRE (the Foundation for Individual Rights in Education) provided a graphic example.  The case involved an apparently trivial dispute among two medical students: <blockquote>[University of California - Davis medical student Curtis] Allumbaugh's ordeal began after he emailed the 'med2014' mailing list (or 'listserv') on July 19, 2010, regarding a party he was organizing. The listserv was widely used for a variety of non-academic purposes. Allumbaugh's email provided the address of the party, detailed the available space, and listed the variety of alcohol that would be available at the party. The email noted that others had signed up to bring snacks and mentioned that some things were still lacking for the party, such as music, fruit juice, and beer. Prior to Allumbaugh's message, others had sent similar emails using the same listserv about their own parties, such as a 'kegger' one student called 'CAMP MED.' On July 20, 2010, a second-year student emailed Allumbaugh, notifying him that she had 'been placed on the class of 2014's listserve' and had monitored the class email. She criticized Allumbaugh's email for placing 'a heavy emphasis on alcohol.' In response, Allumbaugh emailed her directly on July 21, calling her a 'busy body' and telling her, 'You should really just mind your own business and let our class be.'</blockquote> Note that the second-year student's email (available <a href="http://thefire.org/article/14238.html">here</a>) carried a suggestion that she had some sort of authority to monitor the extra-curricular actions of first year students as manifested on the list server, and perhaps even punish them for perceived misconduct: <blockquote>I can tell you that as MS2s, we work and play hard, but we do it responsibly and always in the forefront of our minds we remember what image we are portraying in public and through the messages we send. I'd hate to see any one of you 2014ers get into any trouble right before you start an amazing period of your life.</blockquote> Note that the exchange between the two students did not occur in an academic or clinical setting, and it was never clear why the second year student was "placed on" the list server, or why she should have any authority over the Allumbaugh. . The School Administration Invokes "Professionalism" The medical school saw fit to cast Allumbaugh's actions as violations of the school's standards of professionalism: <blockquote>As a result of this email exchange, Associate Dean of Student Affairs and Graduate Medical Education James Nuovo sent Allumbaugh a letter on September 14, 2010, citing him for 'failing to demonstrate the highest standards of civility and decency to all' and 'failing to demonstrate courtesy, sensitivity and respect.' On November 3, 2010, Allumbaugh received a letter from the SOM Committee on Student Progress, punishing him with academic probation for the rest of his time in medical school and requiring him to undergo a psychological assessment to determine whether he was 'fit' to continue in medical school. Finally, on November 19, 2010, SOM changed its rules to force all medical students to abide by the Principles of Community or else face academic probation. </blockquote> The result was a series of interventions by FIRE: <blockquote>In response, FIRE wrote UC Davis Chancellor Linda P.B. Katehi on August 3, 2011, noting that enforcing professional standards in truly professional settings differs greatly from enforcing workplace standards in other settings such as private conversations. FIRE also noted that it is blatantly unconstitutional to police student speech under the UC Davis Principles of Community because such a 'civility' policy violates the First Amendment right to freedom of speech when it is given disciplinary force. </blockquote> When that letter had no effect, it took threats of litigation for the medical school to suspend Allumbaugh's punishment more than one year after it began: <blockquote>SOM Associate Dean of Curriculum and Competency Development Mark Servis replied to FIRE on August 10, 2011, defending the policy. FIRE responded on November 23, 2011, reminding Katehi that 'violating well-established law regarding the First Amendment rights of students at public universities leaves you at risk of losing qualified immunity, thereby opening you and other administrators to personal liability' for the deprivation of students' First Amendment rights. Servis again defended the policy in a reply on December 5, 2011. Finally, on February 16, 2012, the Committee on Student Progress notified Allumbaugh that his probation had been dropped, but persisted in requiring him to adhere to the Principles of Community. </blockquote>Note that Associate Dean <a href="http://thefire.org/public/pdfs/6d24a77115edf335c1cb2b1d1a737622.pdf?direct">Servis' letter</a> stated that the email sent to Allumbaugh by the second year student was "a genuine suggestion of concern and an offer of albeit unsolicited friendly advice."  Thus, Servis seemed unaware that it could have been interpreted as an assertion of authority and a threat of punishment ("I'd hate to see any one of you 2014ers get into any trouble.") Dean Servis also defended the use of probation to punish a student for failing to "work effectively with classmates." Yet the dispute that had nothing to do with (academic or clinical) work, and only involved a single student from another class.  Why that student was not equally to blame was not clear, unless it was because she had been granted special authority by the administration to monitor the actions of less senior students.  The implication appears to be that the punishment was in defense of a student who had been granted special authority by the administration, and hence was ultimately in defense of the administration's power.  Summary In this case, the medical school's professionalism policy seemed to be used by the administration primarily to control students' speech outside of the academic and clinical setting. Furthermore, the student's main offense seemed to be failure to kowtow sufficiently to another student who by implication had been given some sort of authority by the administration.  What the two students' dispute had to with professionalism is not  apparent. On one hand, this seems like a case in which a speech code was mainly used to defend administrators from criticism and challenge. On the other hand, this speech code was cloaked in the mantle of professionalism.  So this case seems to be an example of a professionalism initiative used as an excuse for the leadership to maintain its power. It is beyond ironic that while this was going on, the University of California - Davis, and its Chancellor Linda Katehi were becoming briefly infamous for another effort, a more violent one, by the administration to prevent criticism and challenge. Chancellor Katehi had authorized university police to "clear" student demonstrators from an "occupation" of the campus which was protesting, among other things, rising tuition and economic inequality, and in doing so, the police used pepper spray on unarmed students (see <a href="http://hcrenewal.blogspot.com/2011/11/uc-davis-pepper-spray-case-as.html">this post</a>.) There are a lot bigger threats to physicians' and other health care professionals' professionalism than medical students' sarcasm or even rudeness in disputes about alcohol served at off-hours parties. Since many of these threats also generate personal benefits to academic leadership, it may not be much of a surprise that they have received little attention.  (See the list of threats appended below.  Note that we have discussed two of these threats in the specific context of the University of California - Davis.  <a href="http://hcrenewal.blogspot.com/2009/08/university-leaders-goal-taking-new.html">Here</a> we noted that Chancellor Katehi seemed to be re-imagining her medical school as a biotechnology company.  <a href="http://hcrenewal.blogspot.com/2011/11/john-wiley-and-sons-director-apologizes.html">Here</a> we noted that Chancellor Katehi was also on the board of a company with a medical education and communication company subsidiary.) However, while they remain unaddressed, I submit that using "professionalism" to cloak increased social control of students to prevent them from looking too closely at what academic administrators are doing will eventually backfire.  === ADDENDUM: List of Threats to Professionalism Instead, to really uphold professionalism, we need to defend it from its real threats, as listed in my <a href="http://hcrenewal.blogspot.com/2010/12/lancet-emphasizes-threats-to-academic.html">2010 post</a>: <ul><li>Abandonment of traditional prohibitions of the commercial practice of medicine - In the US, a Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition.  The result was increasing, now rampant commercialization.  See posts  <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">here</a> and <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>.</li><li>Making money takes precedence over education -  A recent survey showing that more than half the faculty at multiple US medical schools felt they were valued more for how much money they brought in than their teaching or patient care abilities (<a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>), confirming previous anecdotal reports (see <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">here</a>).  </li><li>The medical school re-imagined as a biotechnology company -  In 2000, a Vice President of the American Association of Medical Colleges(1) wrote that research universities must respond to "societal demands that they become engines of economic development…."  Many universities now defend lax conflict of interest policies with similar arguments.  For more details, go <a href="http://hcrenewal.blogspot.com/2010/11/who-you-gonna-call-how-should-young.html">here</a>.</li><li>Faculty become employees of industry - For numerous examples of this and other kinds of conflicts of interest, go <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">here</a>.  A survey by Campbell et al suggested that approximately two-thirds of medical academics get significant payments from industry.(2)</li><li>Academics become "key opinion leaders" paid to market drugs and devices - Marketers regard "key opinion leaders" as salespeople who appear more credible because of their professional guise.  See anecdotal evidence <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">here</a>.  </li><li>Control of clinical research given to commercial sponsors - A study by Mello et al showed how universities' grant administrators are willing to sign contracts giving commercial sponsors control over key aspects of human research studies.(3)  See post <a href="http://hcrenewal.blogspot.com/2005/05/troubling-study-of-contracts-between.html">here</a>. </li><li>Conflicts of interest allow manipulation and suppression of clinical research - Commercially sponsored research design, implementation, and dissemination are often <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> to favor the sponsor's interests.  When such manipulation fails to produce favorable results, the results may simply be <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed</a>.</li><li>Academics take credit for articles written by commercially paid ghost-writers - Such <a href="http://hcrenewal.blogspot.com/search/label/ghost%20writing">ghost-writing</a> is often part of organized <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth marketing</a> campaigns.  </li><li>Whistle blowers are discouraged, or worse, and academic freedom is damaged.  Discussion of some examples of what may happen to whistle blowers is <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">here</a>.  The survey mentioned earlier (<a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>) showed that about one-third of faculty fear they may be punished for speaking  out.  </li><li>Leadership of academic medical centers by businesspeople - <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">Ill-informed management</a> may result from leaders who have no background or training in actual health care.  </li><li>Leaders of teaching hospitals and universities become millionaires -  A recent example is <a href="http://hcrenewal.blogspot.com/2010/08/more-hospital-ceos-join-millionaires.html">here</a>, and more may be found <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">here</a>.  Leaders of academic medical centers and the parent universities of medical schools often make more than $1 million a year in the US.  When such amounts are in play, executives may focus more on short-term measures that lead to even more pay than on upholding the mission.  </li><li>Medical school leaders become stewards (as members of boards of directors) of for-profit health care corporations - A recent example is <a href="http://hcrenewal.blogspot.com/2010/12/duke-divinity-students-protest-pay-of.html">here</a>, and a summary of how we discovered this phenomenon in 2006 is <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">here</a>.   The conflict of interest is severe because directors of for-profit corporations are supposed to have unyielding loyalty to the interests of the corporation and its stockholders, although they are frequently accused of acting mainly as cronies of the top hired executives (see <a href="http://hcrenewal.blogspot.com/2010/07/new-york-times-reports-university.html">here</a> and <a href="http://hcrenewal.blogspot.com/2010/01/one-small-step-towards-reducing.html">here</a>).</li><li>Leaders of failed finance firms become stewards of academic medicine - We have found numerous examples, recently <a href="http://hcrenewal.blogspot.com/2010/04/failed-leaders-of-citigroup-as-leaders.html">here</a>, <a href="http://hcrenewal.blogspot.com/2010/04/wamu-worry-more-overlaps-between.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2010/03/members-of-board-of-now-bankrupt-lehman.html">here</a>, of top executives and/or board members of the finance firms who helped bring on the global financial collapse also being trustees of medical schools, academic medical centers, or their parent universities.  Such "stewards" may bring to the academic environment the "greed is good" culture now pervasive in finance.  </li></ul>References 1. Korn D. Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2237. Link <a href="http://jama.ama-assn.org/cgi/content/full/284/17/2234">here</a>. 2. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Llink <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa064508">here</a>. 3. Mello MM, Clarridge BR, Studdert DM. Academic medical centers' standards for clinical-trial agreements with industry. N Engl J Med 2005; 352: 21.  Link <a href="http://content.nejm.org/cgi/content/short/352/21/2202">here</a>.

Using a "Professionalism" Initiative as a Speech Code to Punish Students' Criticisms of Administrative Authority?

The original impetus to set up Health Care Renewal was increasing evidence of external threats to physicians' professional values. So ...

Đọc thêm »

ECRI Institute's Top Health Technology Hazards for 2012

In my Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/ecri-healthcare-it-in-top-ten-health.html">ECRI: Healthcare IT In Top Ten Health Technology Threats to Patient Safety</a>", I wrote that: <blockquote>The <a href="https://www.ecri.org/About/Pages/default.aspx">ECRI Institute</a> is an independent, unbiased, evidence-based healthcare research, information, and advice provider. They have been in operation for more than 40 years and are one of only a handful of organizations designated as both a Collaborating Center of the World Health Organization and an Evidence-Based Practice Center by the U.S. Agency for Healthcare Research and Quality. ... (from WSJ) For the fourth year running, the nonprofit ECRI Institute has put together a list of what it judges to be the top ten health technology hazards on which health-care facilities should focus their efforts. ... #5 Data loss, system incompatibilities and other health IT complications: Problems with electronic-health records and other health IT systems can lead to problems including lost data, the need for repeat testing and even patient injury or death.</blockquote> From <a href="http://www.medscape.com/features/slideshow/tech-dangers?src=mp&spon=38">Medscape</a> (account required), here is ECRI's #6 on the list of top technology threats for 2012: <blockquote>Failing to Pay Sufficient Attention to New Device Connectivity Medical technology and information technology (IT) can create risks. Hazards can arise from software problems, interoperability between systems, and poor network performance. Problems could create a domino effect, in which changes to one component of the system affect the operation of another. Potential problems also include issues about wireless networks, cybersecurity, and software upgrades. "Hospitals must stay on top of routine updates," says Keller. ECRI's recommendations: Make sure that hardware and software changes, security changes, and planned maintenance are approved and implemented in a controlled manner. Because IT help desks are usually the first point of contact for problems with health IT, provide the help desk team with education, training, and clear escalation procedures.</blockquote> I would add "Failing to Pay Sufficient Attention to New Health IT Defects" to the list. -- SS

ECRI Institute's Top Health Technology Hazards for 2012

In my Dec. 2010 post " ECRI: Healthcare IT In Top Ten Health Technology Threats to Patient Safety ", I wrote that: The ECRI Insti...

Đọc thêm »

Drug Discovery and Reductionism for Physicists ... And Others

Having worked both in health IT and in pharma drug discovery, I read numerous pharma-related blogs. From the blog of medicinal chemist Derek Lowe, "<a href="http://pipeline.corante.com/archives/2012/03/06/drug_discovery_for_physicists.php">In the Pipeline</a>" about reductionism in drug discovery. I believe the observations are more widely applicable to health IT, and to medicine itself. Emphases mine: -------------------------------- <h4>March 6, 2012 </h4><h3><a href="http://pipeline.corante.com/archives/2012/03/06/drug_discovery_for_physicists.php">Drug Discovery for Physicists</a></h3><a href="http://pipeline.corante.com/archives/2012/03/06/drug_discovery_for_physicists.php#zemail"></a> Posted by Derek <div class="img"> There's a <a href="http://wavefunction.fieldofscience.com/2012/03/why-its-hard-to-explain-drug-discovery.html">good post</a> over at the Curious Wavefunction on the differences between drug discovery and the more rigorous sciences. I particularly liked this line: <blockquote>The goal of many physicists was, and still is, to find three laws that account for at least 99% of the universe. But the situation in drug discovery is more akin to the situation in finance described by the physicist-turned-financial modeler Emanuel Derman; we drug hunters would consider ourselves lucky to find 99 laws that describe 3% of the drug discovery universe.</blockquote> That's one of the things that you get used to in this field, but when you step back, it's remarkable: so much of what we do remains relentlessly empirical. I don't just mean finding a hit in a screening assay. It goes all the way through the process, and the further you go, the more empirical it gets. Cell assays surprise you compared to enzyme preps, and animals are a totally different thing than cells. Human clinical trials are the ultimate in empirical data-gathering: there's no other way to see if a drug is truly safe (or effective) in humans other than giving it to a whole big group of humans. We do all sorts of assays to avoid getting to that stage, or to feel more confident when we're about to make it there, but there's no substitute for actually doing it. There's a large point about reductionism to be made, too: <blockquote>Part of the reason drug discovery can be challenging to physicists is because they are steeped in a culture of reductionism. Reductionism is the great legacy of twentieth-century physics, but while it worked spectacularly well for particle physics it doesn't quite work for drug design. A physicist may see the human body or even a protein-drug system as a complex machine whose understandings we can completely understand once we break it down into its constituent parts. But the chemical and biological systems that drug discoverers deal with are classic examples of emergent phenomena. A network of proteins displays properties that are not obvious from the behavior of the individual proteins. . .Reductionism certainly doesn't work in drug discovery in practice since the systems are so horrendously complicated, but it may not even work in principle.</blockquote> And there we have one of the big underlying issues that needs to be faced by the hardware engineers, software programmers, and others who come in asking why we can't be as productive as they are. There's not a lot of <a href="http://en.wikipedia.org/wiki/Algorithmic_information_theory">algorithmic compressibility</a> in this business. Whether they know it or not, many other scientists and engineers are living in worlds where they're used to it being there when they need it. But you won't find much here.--------------------------------I personally like the conclusion of Dr. Lowe's source article at Curious Wavefunction:<div></div><blockquote><div> </div><div>... All this can only be a good augury if it means that more physicists are going to join the working ranks of drug discoverers. And it will all work out splendidly as long as they are willing to occasionally hang their reductionist hats at the door, supply pragmatic solutions and not insist on getting answers right to twelve decimal places.</div></blockquote><div></div> </div> The reductionistic ideas prevalent in medicine today, where EHRs and Watson-like computers are <a href="http://hcrenewal.blogspot.com/2011/01/ibms-watson-jeopardy-and-revolutioning.html">supposed to be able to work miracles</a> real soon now, is likely worse than reductionism in drug discovery, as they lead to the current mess with EHR's (see for instance <a href="http://ctlab.org/documents/Hiding%20in%20plain%20sight.pdf">this article</a>) and threats to patients. -- SS

Drug Discovery and Reductionism for Physicists ... And Others

Having worked both in health IT and in pharma drug discovery, I read numerous pharma-related blogs. From the blog of medicinal chemist Derek...

Đọc thêm »

AMA News Article Offers Incomplete (and Thus Misleading) Advice on the Legal Risks of EHRs and other Clinical IT

An article was published in the AMA News by Alicia Gallegos, AMA Medical News staff, entitled "Legal risks of Going Paperless." While it is not clear if these are the official views of the AMA leadership, the article is interesting nonetheless. It should perhaps have been entitled "Some of the Legal Risks of Going Paperless, excluding the ones that make the health IT industry look bad:" <a href="http://www.ama-assn.org/amednews/2012/03/05/prsa0305.htm" style="font-weight: bold;"> </a><blockquote><a href="http://www.ama-assn.org/amednews/2012/03/05/prsa0305.htm" style="font-weight: bold;">Legal Risks of Going Paperless</a> AMA News March 5, 2012 Electronic medical records are meant to save time and money, but they also can create liability issues for doctors. By Alicia Gallegos, amednews staff. Defense attorney Catherine J. Flynn knows how electronic medical records can overwhelm — and often change — the course of a medical liability lawsuit. In one of her cases, a New Jersey doctor being sued for medical negligence has been accused by a plaintiff’s attorney of modifying a patient’s electronic history. A printing glitch caused the problem, Flynn said, but the accusation has meant extra time and defense costs. Computer screen shots were reviewed, more evidence was gathered and additional arguments were made. “This has taken a life of its own, and we’ve done virtually no discovery on the medical aspects of the case,” she said. “The cost of the e-discovery alone is in excess of $50,000.”</blockquote> This is a variation on the theme of plaintiff's lawyers being the cause of EHR problems as I wrote at "<a href="http://hcrenewal.blogspot.com/2012/02/those-goddamn-trial-lawyers-are-to.html">Plaintiff's Trial Lawyers Are to Blame for EHRs That 'Tattle' on Doctors - And Harm Patients</a>." <blockquote>System breaches. Modification allegations. E-discovery demands. These issues are becoming common courtroom themes as physicians transition from paper to EMRs, legal experts say. Not only are EMRs becoming part of medical negligence lawsuits, they are creating additional liability.</blockquote> Missing is the problem that is most important of all: health IT system defects, poor user interfaces, unreliability, data loss, etc. causing or contributing to medical malpractice that results in patient harm or death. (An example that I personally observed and reported to the FDA MAUDE database is <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/Detail.CFM?MDRFOI__ID=1729552">here</a>; there are numerous others in this blog.) <blockquote>Data breaches are among the most common reasons that electronically stored information lands doctors in court, said Lisa Gallagher, senior director for privacy and security at the Health Information and Management Systems Society, which advocates health information technology</blockquote> Most common perhaps (a big problem unto itself), but not the most clinically significant problem. Yet the AMA article goes on about this issue for many paragraphs; it's the prime focus of the article. <blockquote>A 2011 ruling in New York highlights how e-discovery creates a burden for doctors. During a lawsuit against St. Luke’s Hospital Roosevelt Center, a debate arose about whether the plaintiff should be allowed access to screen shots from a doctor’s computer. Joan Bowman, who sued the hospital for wrongful death on behalf of her husband, wanted to see a computer template used to aid physicians in diagnoses. The hospital said the request was overly broad and oppressive. But the Supreme Court of the State of New York ordered the release of the screen shots. “Defendant doctors testified that they utilized these materials in coming to their diagnosis,” Judge Alice Schlesinger wrote. “It is not a stretch to allow counsel to see and understand these materials.” At this article’s deadline, the hospital’s attorney had not returned messages seeking comment. The case sets a precedent, said Susan Dennehy, Bowman’s attorney. “If others want to see screen shots from records, I think they’ll rely on this case,” she said. “It was important to see where the template led you if you put in an inaccurate chief complaint.”</blockquote> Note the "spin" about the "burden for doctors" of eDiscovery. To the pundits and voluntary adopters: you have gotten what you asked for. To the non-pundit clinicians forced to use health IT: I hate to say this, but you've gotten screwed. The article then offers a laundry list of how to avoid EHR-related liability: <blockquote>... As the number of electronic medical records increases, so do certain legal risks, medical liability experts say. Common mistakes doctors make with EMRs and how attorneys recommend that physicians reduce their liability risks: Mistake: EMRs allow users to move quickly through patient records, but cutting and pasting information makes it easy to paste incorrect information. Recommendation: Refrain from copying and pasting EMR data, and be cautious when moving from one patient’s record to the next. Mistake: Computer programs can help doctors make a differential diagnosis, but the templates don’t often include every possible symptom and corresponding medical condition. Recommendation: Doctors should not become overly dependent on electronic diagnosis aids. Electronic systems are no substitute for hands-on diagnosis. Mistake: Because EMRs allow physicians to move through patient charts much more quickly than paper charts, attorneys are noticing that some doctors are not being thorough when writing notes electronically. Recommendation: Physicians should keep meticulous electronic notes on each patient and take time to document each chart. Mistake: Some practices can fail to safeguard electronic patient data. Recommendation: Practices should encrypt all information on computer devices and have policy that discourages employees from taking portable devices out of the office. Mistake: A system may not clearly indicate changes to records. Recommendation: Physicians should install systems that show transparency when modifications are made and/or have a program lockout period where no more modifications can be made to a record. Mistake: Doctors may fail to follow notification requirements in the event of a data breach. Recommendation: Be clear on what your state law requires when a data breach occurs, and make sure employees follow the rules immediately. Mistake: Doctors may destroy or delete electronic records when a lawsuit is possible. Recommendation: If doctors suspect they are being sued, they must preserve all electronic data related to the patient in question, including emails, phone messages and computer records.</blockquote> Missing is this, as is well-covered by almost 8 years of posts on this blog, and elsewhere: <blockquote> Big mistake: Doctors and hospitals buy and implement experimental technology approved by nobody, of uncertain quality to the point of <a href="http://sydney.edu.au/engineering/it/%7Ehitru/index.php?option=com_content&task=view&id=91&Itemid=146">losing or corrupting data</a>, often with glass-tube black-and-white TV user interface modernity. Such technology is "errorgenic", i.e., it promotes "use error", can mislead, and can promote medical errors. Recommendation: Hold off until the industry has gotten its act together.</blockquote> Also missing from the AMA News article is the fact that physicians and hospitals use health IT at their <a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html">own risk</a>, even if the IT is "certified." This article is clearly pregnant with omissions and spin that reveal a pro-health IT bias. -- SS

AMA News Article Offers Incomplete (and Thus Misleading) Advice on the Legal Risks of EHRs and other Clinical IT

An article was published in the AMA News by Alicia Gallegos, AMA Medical News staff, entitled "Legal risks of Going Paperless." W...

Đọc thêm »

Another Health IT Mythbuster: Doctors order more X-rays, not fewer, with computer access

This piece is in the Washington Post about a just-released piece in Health Affairs (<a href="http://content.healthaffairs.org/content/31/3/488.abstract">at this link</a>) by Danny McCormick, David H. Bor, Stephanie Woolhandler and David U. Himmelstein of Harvard Medical School. (Woolhandler and Himmelstein have written on such topics before, such as in the Nov. 2009 article “<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf">Hospital Computing and the Costs and Quality of Care: A National Study</a>”, Amer J Med 123:1; 40-46.) In the abstract of the new article, the researchers note: <blockquote>Giving Office-Based Physicians Electronic Access To Patients’ Prior Imaging And Lab Results Did Not Deter Ordering Of Tests Health Aff March 2012 vol. 31 no. 3 488-496 Abstract <div id="p-1">Policy-based incentives for health care providers to adopt health information technology are predicated on the assumption that, among other things, electronic access to patient test results and medical records will reduce diagnostic testing and save money.</div>To test the generalizability of findings that support this assumption, we analyzed the records of 28,741 patient visits to a nationally representative sample of 1,187 office-based physicians in 2008. Physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered. The electronic availability of lab test results was also associated with ordering of additional blood tests. The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key. These findings raise the possibility that, as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering. We conclude that use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests. </blockquote><div id="p-1"></div> The WaPo offered these observations in their article: <a href="http://www.washingtonpost.com/national/health-science/doctors-order-more-x-rays-not-fewer-with-computer-access/2012/03/05/gIQATghCtR_story.html"> </a><blockquote><a href="http://www.washingtonpost.com/national/health-science/doctors-order-more-x-rays-not-fewer-with-computer-access/2012/03/05/gIQATghCtR_story.html" style="font-weight: bold;">Doctors order more X-rays, not fewer, with computer access</a> By <a href="http://www.washingtonpost.com/lena-h-sun/2011/03/03/ABUvPGP_page.html" rel="author">Lena H. Sun</a>, Published: March 5 <div class="module byline"><h3> </h3></div><div class="article_body"> <article> In the debate over the high cost of health care, federal policymakers have always claimed that one way to cut costs is for doctors to use <a href="http://www.washingtonpost.com/national/despite-incentives-doctors-are-wary-about-switching-to-electronic-health-records-/2011/02/24/ABvRCuV_story.html" xslt="_http">electronic medical records </a>and other information technology. <a href="http://www.washingtonpost.com/national/one-doctors-digital-journey/2011/02/18/ABZrMSW_story.html" xslt="_http">Doing so</a>, they say, avoids duplication and saves money. But new research suggests that may not be the case.</article> </div>Doctors who have easy computer access to results of X-rays, CT scans and MRIs are 40 to 70 percent more likely to order those kinds of tests than doctors without electronic access, according to a study to be published in the March issue of the journal Health Affairs.</blockquote> This is not surprising to me. Click a button, order an test, click a button, get the results. What could be easier? What the pundits failed (and continually fail) to take into account is the social context of health IT. It is not used on a robotic assembly line. There are incentives, both proper and perverse (e.g., "defensive medicine", profits, patient demands) that figure into how any IT will "play out" in healthcare. Making the blanket statement that "IT in healthcare will save money" without solid, sustained evidence (as opposed to the anecdotal evidence that now exists), while simultaneously ignoring contrary evidence is simply promoting an industry-created meme, a.k.a. wishful thinking. <blockquote>“On average, this is comparing doctors who had electronic medical records and those who didn’t,” said lead author Danny McCormick, a physician and assistant professor of medicine at Harvard Medical School. Researchers say the findings challenge a key premise of the nation’s multibillion-dollar effort to promote the widespread adoption of health information technology. “This should give pause to those making the argument,” McCormick said. Instead of saving money, that effort could drive costs higher, he said. For the study, researchers at the Cambridge Health Alliance, a health system in Cambridge, Mass., and the City University of New York analyzed data from a 2008 federal government survey. The data included information collected from 28,741 patient visits to 1,187 office-based doctors. The information included the type of doctor, their office computerization and the tests ordered at each visit. About half of the doctors’ offices surveyed had computerized access to results of X-rays and other imaging tests. Researchers found that doctors who did not have computerized access ordered imaging tests in 12.9 percent of visits, while doctors with electronic access ordered imaging in 18 percent of visits, a 40 percent greater likelihood. Doctors with computerized access were even more likely — about 70 percent more likely — to order advanced imaging tests, such as PET scans, which experts said are most commonly used to detect cancer, heart problems, brain disorders and other central nervous system disorders. The study found the results hold true even after taking into account other factors, such as patient demographics, doctor specialty and physician self-referral. </blockquote> Unfortunately, nothing up to and including HIT-related patient deaths will give pause to health IT pundits pushing national rollout. They have too much skin in the game in the health IT bubble, psychologically (<a href="http://hcrenewal.blogspot.com/2012/02/health-it-ddulites-and-irrational.html">link</a>) and financially. The pundits need to be opposed by medical and legal professionals in an organized, systematic fashion until such time as this industry follows the National Academies' <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">direct recommendations on getting health IT "right."</a> <blockquote>... Researchers were not able to determine why physicians ordered the imaging tests, or whether in those cases, physicians had looked at patients’ prior chest X-rays. Nor were they able to assess whether the increased imaging helped or harmed patients.</blockquote> That needs to be followed up upon, obviously. Will it? Probably not. <blockquote>At some flagship hospitals with customized health information technology systems, for example, doctors get specific feedback about diagnostic tests that can result in ordering fewer tests.</blockquote> Note the word "can." (After decades there is no rigorous, unopposed proof, yet we are embarking on a national rollout with penalties for non-adopters?) This rationalization is both the "it will be better in version 2.0" and wishful thinking combined. <blockquote>Michael Furukawa, a health economist in the Office of the National Coordinator for Health Information Technology, the administration’s health IT czar, said the researchers’ focus was not deep enough to support the study’s conclusions. “The data are sound, the methods are appropriate, but the focus is limited,” he said. “They only looked at one piece of health IT.”</blockquote> "But the focus is limited?" So what? That was all they intended to look at, and the result was concerning. Moving the goalposts is not a valid refutation of research. On the other hand, coming from a political office that clearly does not understand how to conduct qualitative research and creates political promotion pieces masquerading as "research", such a statement is not surprising. See "ONC: "The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results" <a href="http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html">at this link</a>, where essential research methodologies were thrown under the bus for publication in Health Affairs. At least the deviations from rigorous research methodologies were admitted: <blockquote>“... Our findings must be qualified by two important limitations: the question of publication bias [e.g., bias in evidence selection - ed.], and the fact that we implicitly gave equal weight to all studies regardless of study design or sample size.”</blockquote> Unfortunately, the media, politicians, financial decisionmakers and others are likely not to really comprehend, in-depth, the full significance of that sentence. I can only imagine the reaction to such an excuse made by pharma for the mainstreaming of a risk-prone drug. I personally take with the greatest of skepticism anything coming from ONC, an increasingly politicized government office in my observation. You should, too, in my opinion. -- SS

Another Health IT Mythbuster: Doctors order more X-rays, not fewer, with computer access

This piece is in the Washington Post about a just-released piece in Health Affairs ( at this link ) by Danny McCormick, David H. Bor, Stepha...

Đọc thêm »

Gentiva's Odyssey Healthcare Settles Again, Signs Yet Another Corporate Integrity Agreement

The Milwaukee Journal-Sentinel <a href="http://www.jsonline.com/news/milwaukee/whistleblower-case-on-hospice-fraud-settled-for-25-million-e54d9un-141143483.html">reported</a> a legal settlement worth noting.  Here are the basics: <blockquote>One of the nation's largest providers of hospice care has agreed to pay $25 million to settle a Medicare fraud case initiated after a former company nurse in Milwaukee filed a whistle-blower suit. It was the second such settlement in six years for Odyssey Healthcare Inc., which paid the federal government $12.5 million in 2006 after another Wisconsin-based employee sued.</blockquote> Also, <blockquote>Medicare provides a benefit meant to cover hospice care for the terminally ill. It covers 24-hour in-home nursing service only during limited crisis periods. But from 2006 to 2009, Odyssey practiced a pattern of enrolling and recertifying non-terminal patients, and billing for continuous care that wasn't necessary or reasonable, according to the False Claims Act suit filed in 2008 but just unsealed Thursday.</blockquote> As is usual in such cases, Odyssey's parent company denied that it did anything wrong: <blockquote>Odyssey, which operates in 26 states, is now part of Atlanta-based Gentiva Health Services, which runs hospice offices in West Allis and Burlington. Gentiva officials declined to comment, but referred to an announcement it posted on its investor relations website last month. 'Gentiva cooperated fully with this investigation, which covered a period prior to our acquisition of Odyssey, and the settlement is consistent with our efforts to instill Gentiva's culture of compliance throughout the company,' said John Camperlengo, general counsel and chief compliance officer. The statement said the firm is proud of the care its thousands of hospice clinicians provide, and of Gentiva's efforts to ensure strict compliance with all regulatory requirements.</blockquote> The Implications of the Need for a New Corporate Integrity Agreement However, there are some disturbing aspects of this case that require a bit more explanation. First, as noted by the Associated Press (in a story available <a href="http://www.thonline.com/news/iowa-illinois-wisconsin/article_d2a4d2d0-8f73-53c2-86dc-e6ff3c7e2ab5.html">here</a> from the Dubuque [Iowa] Telegraph-Herald), <blockquote>Besides agreeing to pay the $25 million settlement, Odyssey entered a five-year corporate integrity agreement with the federal government.</blockquote> Now corporate integrity agreements are not known for their effectiveness. In fact, as we noted in <a href="http://hcrenewal.blogspot.com/2011/07/executives-get-rich-despite-ethical-and.html">this blog post</a>, according to <a href="http://files.shareholder.com/downloads/GTIV/1338648526x0x456437/CEA1782E-FB2C-4850-A530-9CF06AA6C55B/Gentiva_AR_2010.pdf">Gentiva's 2010 annual report</a>, its Odyssey subsidiary had been subject to a corporate integrity agreement arising from its 2006 settlement, one which was apparently not effective in preventing its misbehavior from 2006 to 2009. However, corporate integrity agreements do serve as markers for the need to improve the integrity of the corporations who need to make them. In this case, why would Gentiva be asked to sign such an agreement if its integrity were already beyond reproach? So Gentiva's current "culture of compliance" is open to question. The Implications of "Enrolling and Recertifying Non-Terminal Patients" A quick read of the Journal-Sentinel and Associate Press stories above might give the impression that what Odyssey did wrong involved a billing technicality, admittedly, one that allowed it to collect more money that that to which it would otherwise be entitled. This story actually goes beyond the issue of fraud, and raises important concerns about patient care. The enrollment  by a hospice of patients who are actually not terminally ill could have serious adverse effects on such patients. As we noted in <a href="http://hcrenewal.blogspot.com/2011/07/prepare-them-to-die-for-profit-hospices.html">this post</a>, hospices are meant for patients with very limited life expectancies. The goal of hospice is to provide comfort and palliation, not active treatment of illnesses. So if patients who actually do not have such severely limited life expectancies are admitted to a hospice, they might be denied therapy that could actually make them feel better, or even cure acute illnesses or prolong their lives. For example, a hospice patient who developed an open wound might not get maximal wound therapy, as in an example (allegedly involving a different commercial hospice provider) in the post above. So it is possible that Odyssey's enrolling and re-certifying of non-terminally ill patients could have lead to failure to provide some of these patients with the care they should have had. Whether this did or did not occur in individual cases, and what adverse effects may have been produced is not clear from the coverage of this case.   Summary As I wrote in 2011, .... There has been a lot of blather from politicians in the US about "death panels" in debates about health care reform. Many such politicians seem worried that the US government has or will have death panels under the new health care reform legislation. We have criticized that legislation for not addressing many important health care problems. No one, however, has convincingly demonstrated how its provisions would convene "death panels." Wendell Potter argued in his book, <a href="http://wendellpotter.com/deadlyspin">Deadly Spin</a>, (see <a href="http://hcrenewal.blogspot.com/2011/02/wendell-potters-deadly-spin.html">this post</a>) that for-profit insurance companies had their own "death panels." The Bloomberg article strongly suggests that for-profit hospices may also act like death panels. In search of more revenue, for-profit hospices may enroll patients who are not at the end of life, but then provide them only "comfort care," so that if they develop new conditions that are treatable, they are likely to die in the absence of treatment. I am waiting for the politicians who so enthusiastically condemned the supposed "death panels" to be found in health care reform legislation to condemn for-profit hospices for behaving like death panels. In my humble opinion, the case discussed above are the strongest argument yet that we need to reconsider our headlong rush to turn health care, particularly the direct care of patients, over to relatively unregulated, for-profit corporations. The cases above suggest that the pursuit of revenue ahead of patients' welfare by such organizations may lead to sick and dead patients. I cannot see how for-profit direct patient care can be made safe for patients without intense government regulation. If any of those vocal advocates of "free market" health care (in the absence of any good explanation of how health care can ever be an ideal free market, see <a href="http://hcrenewal.blogspot.com/2010/08/how-fallacy-of-perfect-health-care.html">this post</a>) can explain to me how for-profit hospices can be made safe for patients without such regulation, I would welcome their attempts. Meanwhile, this just calls out for legislative and legal investigation, and urgent policy changes.   By the way, the case above also shows how the current approach used by the government to address misbehavior in health care does not work.  We have noted previously how these <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a> often only lead to financial penalties imposed on companies, not individuals, which diffuses their impact, and provides no disincentives to future bad behavior by individuals.  Sometimes <a href="http://hcrenewal.blogspot.com/search/label/corporate%20integrity%20agreement">corporate integrity agreements</a> are added, but as in the current case, they also seem not to deter future bad behavior.   So, I further conclude, de rigueur, to really deter bad behavior, those who authorized, directed or implemented bad behavior must be held accountable. As long as they are not, expect the bad behavior to continue. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

Gentiva's Odyssey Healthcare Settles Again, Signs Yet Another Corporate Integrity Agreement

The Milwaukee Journal-Sentinel reported a legal settlement worth noting. Here are the basics: One of the nation's largest providers of...

Đọc thêm »

Courses and Conferences on Health Care Ethics, Corruption, Marketing

Two courses and two conferences of interest to Health Care Renewal readers are coming soon. Short Course: Why Do Physicians Not Make Rational, Evidence Based Decisions? A full-day course at the <a href="http://smdm2012.com/">14th Biennial European Meeting of the Society for Medical Decision Making</a> on Sunday, 10 June, 2012 in Oslo, Norway. Taught by bloggers Dr Roy Poses and Dr Wally Smith, the course will address both the effects of cognitive psychological limitations and of external influences by vested interests leading to less than optimal decisions. A full description of the course is <a href="http://smdm2012.com/course_proposals">here</a>.   Online Course: Corruption in the Health Sector A 30 hour online course given by the <a href="http://www.u4.no/">U4 Anti-Corruption Resource Center</a>, offered in collaboration with the Boston University School of Public Health.  The course is "on causes and consequences of corruption in the health sector; vulnerabilities in drug supply systems, informal payments, and strategies to minimise the problems."  A full description is <a href="http://www.u4.no/training/online-training/corruption-in-the-health-sector">here</a>.  Conference: Deception, Incentives and Behavior A two-day conference given by the Rady School of Management, University of California - San Diego, on 20-21 April, 2012 in San Diego, California, USA.  This will be a multidisciplinary meeting to facilitate "research of deception and related unethical behavior in the fields of economics and psychology/judgment and decision making (JDM)." The conference web-site is <a href="http://rady.ucsd.edu/dib-symposium">here</a>.  Conference: Third Annual PharmedOut Conference on How Patient Harms May Result from Industry Promotion A two-day conference given by <a href="http://www.pharmedout.org/">PharmedOut</a> at Georgetown University in Washington, DC on 14-15 June, 2012.  The conference will focus on the how industry promotion may lead to under-use, over-use, or mis-use of drugs and devices. The conference web-site is <a href="http://pharmedout.org/2012Conference.htm">here</a>.

Courses and Conferences on Health Care Ethics, Corruption, Marketing

Two courses and two conferences of interest to Health Care Renewal readers are coming soon. Short Course: Why Do Physicians Not Make Rationa...

Đọc thêm »