healthy4u

Majority of the Public Wants Politicians Who Will Root Out Corporate Corruption

Here is a story that makes me unusually optimistic, at least about the wisdom of the people at large. Reuters <a href="http://in.reuters.com/article/2012/09/19/us-usa-campaign-corporatewrongdoing-poll-idINBRE88I11E20120919">reported </a>on a new poll,   <blockquote>With less than two months to go before the U.S. presidential election, a new survey found 61 percent of Americans say a candidate's commitment to rooting out corporate wrongdoing will be key in deciding who gets their vote. Along with keen interest in knowing each candidate's plans to fix the struggling economy, voters want government to do more to fight corporate misconduct - which they say helped cause the financial crisis. 'In these difficult economic times, Americans are mad as hell about corporate wrongdoing and are going to do something about it in the November elections and beyond,' said Jordan Thomas, a partner at law firm Labaton Sucharow, which commissioned the survey and which represents corporate whistleblowers. A telephone poll of 1,015 people conducted from August 16-19 found that 64 percent of Americans said corporate misconduct helped bring about the current economic crisis. And 81 percent of respondents said the government has not done enough to stop corporate wrongdoing.</blockquote> Furthermore, <blockquote>77 percent of respondents saying they believe politicians favor corporate interests over constituent interests. Some 63 percent of Americans believe government should make more money available to regulators and law enforcement to eliminate corporate wrongdoing.</blockquote> This is really amazing in its contrast to the usual received wisdom in all its cynicism. We on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> have been railing about misbehavior and outright criminal behavior by major health care organizations and their leaders for a long time.  In 2008, the global financial collapse shocked us into awareness that the problems in health care actually parallel perhaps worse problems in <a href="http://hcrenewal.blogspot.com/search/label/finance">finance</a>.  Yet while numerous <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a> documented the continuing epidemic of bad behavior in health care, the relatively small penalties they entailed, generally limited to corporate fines that could be viewed as costs of doing business, and to toothless <a href="http://hcrenewal.blogspot.com/search/label/corporate%20integrity%20agreement">corporate integrity agreements</a> seemed to do little to deter future bad behavior.  Again, since 2008 there were parallels in the world of finance.   As Oscar winning producer of Inside Job Charles Ferguson complained, no one went to jail for financial misbehavior either. In health care, the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> dampened public discussion of bad leadership, including <a href="http://hcrenewal.blogspot.com/search/label/crime">criminally</a> bad leadership as a major cause of health care dysfunction.  While we have been calling for more serious efforts to deter bad behavior at least since 2008 (look <a href="http://hcrenewal.blogspot.com/2008/07/amerigroup-settles.html">here</a>), our position seemed very lonely.  It took until last week for arguably the most prestigious US medical journal to run an article suggesting that leaders of health care corporations that commit fraud ought to go to jail (look <a href="http://hcrenewal.blogspot.com/2012/09/twilight-of-anechoic-effect-new-england.html">here</a>). Yet it may be that the general public has been paying attention to this issue even if policy makers and political leaders have not.  The brief Rueters article did not make it clear whether these poll results only apply to wrongdoing by financial corporations and their leaders, or to all corporations and their leaders. Even if it were the former, the results were certainly striking, suggesting a majority of Americans now identify corporate corruption, and its influence on politics as a major, maybe the major problem for this country. That might lead to some interesting election outcomes, especially since very few US politicians seem to have taken any sort of stand against corporate corruption, at least to my knowledge. If there is so much public awareness of the problem of bad corporate leadership, corporate misdeeds, and corporate corruption of politics, I can only hope that it will translate into awareness of these problems as they affect health care. As I <a href="http://hcrenewal.blogspot.com/2009/09/biovail-settles-and-judge-explains-why.html">wrote</a> in 2009, not long after Pfizer's mere $2.3 billion settlement,...   "Until the people responsible for the bad behavior experience negative consequences from that behavior, they will continue to perform, direct, and condone bad behavior. We will not achieve real health care reform in the US until we effectively deter unethical, self-serving behavior by leaders of health care organizations."  We can start realistically anticipating real health care reform once we get some politicians in office who are committed to "rooting out corporate wrongdoing."

Majority of the Public Wants Politicians Who Will Root Out Corporate Corruption

Here is a story that makes me unusually optimistic, at least about the wisdom of the people at large. Reuters reported on a new poll, With...

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"The Syndrome of Useless Information" Revisited

"The Syndrome of Useless Information" Revisited

At a time when the press seems to be starting to "get it" regarding health IT myths, and expecting significant pushback, I thought...

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BLOGSCAN - Why Not Just Pay Physicians By the Hour?

We have frequently discussed how <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse incentives</a> are spread around health care.  In the US, the physicians are paid according to a system that provides strong incentives for doing procedures, (see <a href="http://hcrenewal.blogspot.com/search/label/RUC">our posts</a> about how the RUC has encouraged this bias towards procedures.)   Since physicians are the most influential "deciders" about the care of individual patients, these incentives encourage overtesting and overtreatment with the highest technology, driving up costs and subjecting patients to increased risks of adverse events.  The recent health care reform law, however, essentially encouraged a version of capitated payment, which might very well provide incentives for undertreatment and undertesting.  For years, Dr Robert Centor has argued logically and forcefully for paying physicians for the time they spend on behalf of payments, very analogous to how lawyers and many other professionals are paid.  This might provide much more neutral, less perverse incentives than would existing or other proposed physician payment schemes.  Dr Centor <a href="http://www.medrants.com/archives/6991">argued again</a> for this seemingly reasonable and logical idea on his DB's Medical Rants blog.  The big question is why this idea has been so <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>?

BLOGSCAN - Why Not Just Pay Physicians By the Hour?

We have frequently discussed how perverse incentives are spread around health care. In the US, the physicians are paid according to a syst...

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WSJ, Koppel and Soumerai: A Major Glitch for Digitized Health-Care Records - Cost Savings Illusory

Two EHR experts from Ivy-league institutions (which are typically hyperenthusiast-oriented) doubt cost savings from EHR technology. <blockquote class="tr_bq">Wall Street Journal Opinion September 17, 2012 <a href="http://online.wsj.com/article/SB10000872396390443847404577627041964831020.html?mod=googlenews_wsj" target="_blank">A Major Glitch for Digitized Health-Care Records</a> Savings promised by the government and vendors of information technology are little more than hype. By <a href="http://www.populationmedicine.org/content/personnelDetail.asp?PID=164&CID=1&Sub=Y" target="_blank">STEPHEN SOUMERAI</a> And <a href="http://sociology.sas.upenn.edu/r_koppel" target="_blank">ROSS KOPPEL</a> In two years, hundreds of thousands of American physicians and thousands of hospitals that fail to buy and install costly health-care information technologies—such as digital records for prescriptions and patient histories—will face penalties through reduced Medicare and Medicaid payments. At the same time, the government expects to pay out tens of billions of dollars in subsidies and incentives to providers who install these technology programs. </blockquote> Which, of course, means printing more money for luxuries we cannot afford in the midst of the worst economic downturn since 1929... <blockquote class="tr_bq">The mandate, part of the 2009 stimulus legislation [I think it would be more accurate to say "sneaked into the 2009 stimulus legislation for IT industry benefit" - ed.], was a major goal of health-care information technology lobbyists and their allies in Congress and the White House. The lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually. </blockquote> By up to $100 billion annually?   (Perhaps these lobbyists need lie detector tests - and/or drug tests to see what they may have been smoking?)  I note the lobbying was covered in the Washington Post in "<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html?hpid=topnews">The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</a>" by Robert O'Harrow Jr., May 16, 2009. <blockquote class="tr_bq">Many doctors and health-care administrators are wary of such claims—a wariness based on their own experience. An extensive new study indicates that the caution is justified: The savings turn out to be chimerical.</blockquote> Some still have empirical observational skills and common sense, fortunately.  In my early days of health IT involvement two decades ago as an NIH-sponsored Medical Informatics post doctoral fellow, I believed there was some cost savings possible, but certainly not in the tens or hundreds of billions per year.  The technology was not solving problems that could lead to such savings (see for instance my Dec. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html" target="_blank">Is Healthcare IT a Solution to the Wrong Problem?</a>").  My experiences since my fellowship have only confirmed my own early opinions. <blockquote class="tr_bq">Since 2009, almost a third of health providers, a group that ranges from small private practices to huge hospitals—have installed at least some "health IT" technology. It wasn't cheap. For a major hospital, a full suite of technology products can cost $150 million to $200 million. Implementation—linking and integrating systems, training, data entry and the like—can raise the total bill to $1 billion.</blockquote> That's countless billions that could have been spent on actual healthcare delivery itself, especially for underserved populations and the poor.  Instead, that money was funnelled to the IT industry for an experimental, unregulated, unvetted technology to be applied on live patients (and without patient consent, I add). <blockquote class="tr_bq">But the software—sold by hundreds of health IT firms—is generally clunky, frustrating, user-unfriendly and inefficient. For instance, a doctor looking for a patient's current medications might have to click and scroll through many different screens to find that essential information. Depending on where and when information on a patient's prescriptions were entered, the complete list of medications may only be found across five different screens.</blockquote> Examples of that from actual systems (sketched to avoid IP problems) is at my ten part series on mission-hostile health IT at this blog, shortened link <a href="http://www.tinyurl.com/hostileuserexper">http://www.tinyurl.com/hostileuserexper</a>. <blockquote class="tr_bq">Now, a comprehensive evaluation of the scientific literature has confirmed what many researchers suspected: The savings claimed by government agencies and vendors of health IT are little more than hype. To conduct the study, faculty at McMaster University in Hamilton, Ontario, and its programs for assessment of technology in health—and other research centers, including in the U.S.—sifted through almost 36,000 studies of health IT. The studies included information about highly valued computerized alerts—when drugs are prescribed, for instance—to prevent drug interactions and dosage errors. From among those studies the researchers identified 31 that specifically examined the outcomes in light of the technology's cost-savings claims. With a few isolated exceptions, the preponderance of evidence shows that the systems had not improved health or saved money. </blockquote> One must understand this in the context of what these systems really are, what they do, and the problems they can actually address as in my post on 'solution to the wrong problem' mentioned supra. <blockquote class="tr_bq">The authors of "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations" found no evidence from four to five decades of studies that health IT reduces overall health costs. Three studies examined in that McMaster review incorporated the gold standard of evidence: large randomized, controlled trials. They provide the best measure of the effects of health IT systems on total medical costs.</blockquote> I point out that randomized controlled trials (RCT's) are notably rare in health IT studies.  Most "confirmatory" studies on health IT benefits are less powerful retrospective/observational studies in specialized settings, with many biases, poor science, etc.  In that sense, such studies can be considered non-generalizable and anecdotal at best (more on the "anecdotes" issue is below). Of course, the pundits and Ddulites ("Luddite" with first four letters reversed; meaning ardent hyperenthusiasts) will likely say "it will all be fixed in version 2.0" despite decades of opportunity to get health IT "right" and demonstrate generalized improved outcomes and cost savings: <blockquote class="tr_bq"> ... At "<a href="http://hcrenewal.blogspot.com/2012/02/health-it-ddulites-and-irrational.html">Health IT: Ddulites and Irrational Exuberance</a>" and related posts (<a href="http://hcrenewal.blogspot.com/search/label/Ddulite">query link</a>) I've described the phenomenon of the: 'Hyper-enthusiastic technophile who either deliberately ignores or is blinded to technology's downsides, ethical issues, and repeated local and mass failures.'</blockquote> From Regenstrief Institute, one of the premier and pioneering centers for Medical Informatics research and teaching: <blockquote class="tr_bq">A study from Regenstrief, a leading health IT research center associated with the Indiana University School of Medicine, found that there were no savings, and another from the same center found a significant increase in costs of $2,200 per doctor per year. The third study measured a small and statistically questionable savings of $22 per patient each year.</blockquote> That's probably not taking into account increased medical malpractice costs as exemplified <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html" target="_blank">here</a> and by other settlements I know of but cannot mention due to my consulting role in those cases. A primer on health IT risks, containing a number of key articles and links, is downloadable at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/HIT_issues_Primer.zip">http://www.ischool.drexel.edu/faculty/ssilverstein/HIT_issues_Primer.zip</a>.  <blockquote class="tr_bq">In short, the most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT—some $1 trillion will be spent, by our estimate—will pay off in reducing medical costs. Those studies that do claim savings rarely include the full cost of installation, training and maintenance—a large chunk of that trillion dollars—for the nation's nearly 6,000 hospitals and more than 600,000 physicians.</blockquote> $1 trillion would pay for a tremendous amount of actual healthcare delivery, I note. These system lifecycle costs, known as "total cost of ownership", are due to upgrades and necessary changes as medicine itself, including the science, business and legal components change over time.   The costs are generally underestimated ahead of time.  A good source on these issues is the article "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Goldfinch_pessimism_PAR.pdf" target="_blank">Pessimism, Computer Failure, and Information Systems Development in the Public Sector</a>"  (Public Administration Review 67;5:917-929, Sept/Oct. 2007).  This is a cautionary article on IT that recommends much more critical attitudes towards major IT initiatives in all sectors.  <blockquote class="tr_bq">But by the time these health-care providers find out that the promised cost savings are an illusion, it will be too late. Having spent hundreds of millions on the technology, they won't be able to afford to throw it out like a defective toaster.</blockquote> There, I disagree.  We may have to "throw it out" as the disruptions to good medical care by bad health IT (BHIT) increase, unless the industry reforms itself very rapidly.  As I state in the introduction to my teaching website "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">Contemporary Issues in Medical Informatics: Good IT, Bad IT, and Common Examples of Healthcare Information Technology Difficulties</a>" (started in late 1998 due, in fact, to my observations of inappropriate leadership and poor quality of health IT): <blockquote class="tr_bq">The site takes a view consistent with medicine’s core values and with patients’ rights that health IT, as a medical apparatus that increasingly forms an enterprise clinical resource management and clinician workflow control mechanism, remains experimental and should be subject to the same ethical considerations, validation processes and regulatory oversight to which almost all other medical technologies and pharmaceuticals are subjected. The site is pro-health IT, but only when the health IT is “good IT” - as opposed to “bad IT." Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. This site challenges medically and ethically controversial views that health IT merits special accommodations in terms of freedom from scientific rigor and evidence-based practices, freedom from regulation, and freedom from accountability.  </blockquote> I  hold little hope of these issues being seriously addressed - let alone solved - any time in the near future due to: 1)  the irrational exuberance about this technology, cf: Twitter feeds on hashtags #EHR, #EMR, #HCIT and similar; 2)  the industry-promoted myths and fabrications over decades; 3)  the FDA-admitted impediments to information diffusion about defects and harms (<a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">link</a>); 4)  IOM-admitted impediments to same (<a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">link</a>);and 5)  the latter's industry-favoring, Milquetoast 2012 recommendations on monitoring, remediation and regulation. These are indicative of an industry that has neatly avoided any meaningful regulation and is, in plain terms, out of control. <blockquote class="tr_bq">Why are we pushing ahead to digitize even more of the health-care system, when the technology record so far is so disappointing? So strong is the belief in health IT that skeptics and their science are not always welcome. Studies published several years ago in the Journal of the American Medical Association and the Annals of Internal Medicine reported that health IT systems evaluated by their own developers were far more likely to be judged "successful" than those assessed by independent evaluators. </blockquote>"Not welcome" is an understatement.  ONC itself is guilty of bad science, as in its grossly deficient March 2011 Health Affairs paper on health IT benefits. (See my Oct. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html" target="_blank">ONC: The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results</a>".  Also see my Aug. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/08/onc-and-irrelevant-comparisons.html" target="_blank">ONC and Misdirection Regarding Mass Healthcare IT Failure</a>".) So bad is the "Health IT critique not welcome" phenomemon that, for example, Medical Informatics leaders such as Bill Hersh of Oregon Health Sciences University (OHSU) openly attack those who are candid on health IT risks (and make fools of themselves via the open attacks), such as the attack I wrote of at my Sept. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html" target="_blank">The Dangers of Critical Thinking in A Politicized, Irrational Culture</a>". Also common in the "Health IT Critique Not Welcome Here" club, and probably deliberately so, is mistaking risk management activities for research observations and calling the former, even when reported by credible witnesses, "anecdotal" while calling at-best weak HIT-positive studies "definitive science."  See "<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things</a>" for the definitive rebuttal of that type of patient-endangering intellectual blindness or dishonesty. <blockquote class="tr_bq">Government agencies like the Office of the National Coordinator of Healthcare Information Technology (an agency of the Department of Health and Human Services) serve as health IT industry boosters. ONC routinely touts stories of the technology's alleged benefits.</blockquote> But almost never the opposite, which is equally if not more important.  Further, they tout "certification" as a means of HIT safety evaluation and assurance, or do not deny that misconception, despite statements by the very certification bodies or ATCB's they appoint to the contrary.  Yet they need to come clean on this. (I've seen the claim of 'certification equals safety' in actual legal briefs in defense of health IT.)  See my Feb. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html" target="_blank">Hospitals and Doctors Use Health IT at Their Own Risk - Even if Certified</a>." ONC also seems to turn a blind eye to industry-ghostwriting abuses in the public comments period of Notices of Proposed Rulemaking for "meaningful use" (itself an Orwellian term) rules.  See for instance my Sept. 2012 posts "<a href="http://hcrenewal.blogspot.com/2012/08/health-it-vendor-epic-uses-clients-as.html">Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?</a>" and "<a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html" target="_blank">Was EPIC successful in watering down the Meaningful Use Stage 2 Final Rule?</a>" <blockquote class="tr_bq">We fully share the hope that health IT will achieve the promised cost and quality benefits. As applied researchers and evaluators, we actively work to realize both goals. But this will require an accurate appraisal of the technology's successes and failures, not a mixture of cheerleading and financial pressure by government agencies based on unsubstantiated promises.</blockquote> I share the same sentiments.  As I've often written, the Achilles heel of the health IT sector is its ignoring the very science and evidence-based approaches of the field - medicine - that health IT is supposed to somehow "revolutionize" and "transform." It is, quite frankly, the utmost in hypocrisy for an industry that demands evidence-based medicine - and touts its expensive products as leading to that change - to itself not practice what I've called "evidence-based computing." <blockquote class="tr_bq"> Mr (sic) Soumerai is professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. Mr. Koppel is a professor of sociology and medicine at the University of Pennsylvania and principal investigator of its Study of Hospital Workplace Culture. </blockquote> <a href="http://www.populationmedicine.org/content/personnelDetail.asp?PID=164&CID=1&Sub=Y" target="_blank">Dr. Soumerai</a> also co-authored "<a href="http://www.huffingtonpost.com/stephen-soumerai/dont-repeat-the-uks-elect_b_790470.html" id="title_permalink" title="Permalink">Don't Repeat the UK's Electronic Health Records Failure"</a> with Anthony Avery, Professor of Primary Care at the University of Nottingham Medical School, UK, Huffington Post, Dec. 5, 2010. I also expect to hear an "Ivy tower academics - what do they know?" refrain from the industry.  However, this will not hold water, as the Ivory tower inhabitants, as I previously stated, are almost uniformly of the Ddulite-hyperenthusist persuasion and touted when they speak or write in uncritical favor of health IT. -- SS Addendum: Penn Wharton professors had a similar opinion on cost-savings in 2009: <blockquote class="tr_bq"><a href="http://knowledge.wharton.upenn.edu/article.cfm?articleid=2260">Information Technology: Not a Cure for the High Cost of Health Care</a>: Knowledge@Wharton, Wharton School of Business, University of Pennsylvania, June 10, 2009. (PDF version available <a href="http://knowledge.wharton.upenn.edu/createpdf.cfm?articleid=2260">at this link</a>) </blockquote> As I observed in my June 20, 2009 post "<a href="http://hcrenewal.blogspot.com/2009/06/improving-patient-safety-in-eu-hit.html" target="_blank">Improving Patient Safety In The EU: HIT Should Be Classified As Medical Devices. And, Can We Drop the "Massive Cost Savings" Fable?</a>", in a WSJ article that same day entitled "<a href="http://online.wsj.com/article/SB10001424052970204005504574235751720822322.html">The Myth of Prevention</a>", Abraham Verghese, Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford echoed the Wharton professors' doubts about the cost savings and ultimate value of electronic medical records: <blockquote>... I have similar problems with the way President Obama hopes to pay for the huge and costly health reform package he has in mind that will cover all Americans; he is counting on the “savings” that will come as a result of investing in preventive care and investing in the electronic medical record among other things. It’s a dangerous and probably an incorrect projection. </blockquote> I also had related observations published in a Letter to the Editor in the WSJ in February of that year: <blockquote class="tr_bq"><a href="http://online.wsj.com/article/SB123492035330205101.html" target="_blank">Digitizing Medical Records May Help, but It's Complex</a>, Feb. 18, 2009 You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill. I have a different view on who is deceiving whom. In fact, it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants. For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors. HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine. The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. The government has bought the IT magic bullet exuberance hook, line and sinker. I can only hope patients get something worthwhile for the $20 billion. Scot Silverstein, M.D. Faculty Biomedical Informatics Drexel University Institute for Healthcare Informatics Philadelphia</blockquote> Next time you hear from some pundit about enormous "cost savings" from clinical IT, remember this post. Let's implement health IT - and do it well, i.e., good health IT (GHIT) instead of bad health IT (BHIT)- to facilitate clinicians, not to work financial miracles or "revolutionize" anything. <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGg0COl5XruSc2M6Tqlbl-KZ69phovYcYzjTceLKGrUR8eAXyQ16-yjmxXJ0OPEbJVRC91slcIJsa4BGJwtZ87D_vM7iBpmTA0awNgSxrNfGGSY42ITYjS6g6SuGfW3SdFDyfur7oq1Ato/s1600/slide1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGg0COl5XruSc2M6Tqlbl-KZ69phovYcYzjTceLKGrUR8eAXyQ16-yjmxXJ0OPEbJVRC91slcIJsa4BGJwtZ87D_vM7iBpmTA0awNgSxrNfGGSY42ITYjS6g6SuGfW3SdFDyfur7oq1Ato/s320/slide1.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">A slide from my Aug. 1, 2012 <a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html" target="_blank">presentation</a> to the Health Informatics Society of Australia at HIC2012.  Click to enlarge.</td></tr></tbody></table> -- SS

WSJ, Koppel and Soumerai: A Major Glitch for Digitized Health-Care Records - Cost Savings Illusory

Two EHR experts from Ivy-league institutions (which are typically hyperenthusiast-oriented) doubt cost savings from EHR technology. Wall Str...

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Cogs in the Money Machine: Money and Trust

Everyone has to make money of course, and there’s not one thing wrong with that.  But, encountering our medical and payment systems, patients now (accurately) perceive that money is the primary object for most of the institutions involved (insurance companies, pharmaceutical companies, hospitals) and for a few of the individuals one encounters (and probably for more than a few of the individuals one does not meet). Although patients seldom articulate this, they sense what Dr. David Belk accurately states at <a href="http://truecostofhealthcare.org/" target="_blank">his interesting website</a>, that prices are deliberately confusing and obscure. It's a scary situation when one cannot know what costs one is incurring.  As Dr. Belk states, this byzantine non-system is designed to benefit someone -- because “[w]hen [it is so difficult to determine costs and prices], you have to ask how much trouble someone has taken to hide it.” (Patients, of course, do not generally understand that prices are as confusing and unknowable to most doctors as to most patients, a point Dr. Belk makes well.) As Dr. Belk notes: “This is a big problem - any cost that is hidden or confusing is easy to inflate.” That the obscurity is deliberate is underlined by recent developments in Texas. Prompted by patients who had had unpleasant billing surprises, the insurance regulator had put out proposed rules for insurance companies that would require them to disclose on their provider directories whether in-network facilities had in-network anesthesiologists, ER doctors, pathologists and so forth. In-network facilities with ample in-network ancillary-service providers would be labelled “approved,” and those with few or no providers “limited.” As well, insurers would be forced to post a web notice if this situation changed markedly – when there was a 75% or greater decrease in in-network providers available at a facility. This would assist patients to minimize their chances of out-of-network billing. But recently, Perry’s Texas Insurance Commissioner appointee <a href="http://www.dallasnews.com/news/state/headlines/20120820-rules-to-help-texans-avoid-surprise-hospital-bills-are-pulled.ece%20" target="_blank">firmly quashed these provisions</a> <a href="http://www.dallasnews.com/opinion/editorials/20120824-editorial-regulator-should-be-protecting-consumers.ece" target="_blank">before they took effect</a>. Eleanor Kitzman disingenuously claimed that these requirements would “not provide substantial benefit to consumers and [might] lead to increased premiums,” saying it would confuse consumers. “I just don’t believe that consumers, the average consumer, is really going to be able to use that information in a meaningful way.” A personal experience of deliberate obscurity makes this particularly interesting to me. Last fall, I had cataract surgery at Bailey Square, a day surgery center in Austin, Texas. Bailey Square got all my insurance details beforehand; then they informed me to the penny of the exact amount to bring in during a detailed phone conversation several days before surgery.  I brought the check with me the day of surgery, and was then surprised to be asked to sign a form stating that anesthesiology charges might be out-of-network and they were my responsibility regardless. That was of course too late for me to do any checking. In the event, the anesthesiologists were on my insurance, so I owed only $25 rather than their full $500 charge – but I am sure than not every patient is so fortunate. However, I thought it was sleazy that, when it concerned my money, they chose to spring the news on me too late for me to do anything, but when it concerned their money, they made sure they provided full details well in advance. I wrote the head of the facility complaining about this. I suggested they disclose this in the advance phone conversation when a patient is told how much money they will owe. Unsurprisingly, he never responded. Another Austin example of charging obscurity is when patients who hoped to avoid ER charges by going to an “urgent care center” found that <a href="http://www.statesman.com/news/local/st-davids-urgent-care-centers-scrutinized-over-er-2432477.html?viewAsSinglePage=true" target="_blank">some urgent care centers are charging as hospital ERs</a>. (Some of  the yelp  reviews indicate that some of the generally good doctors and nurses at these centers are embarrassed and apologetic about this.) But this post is not a plea for financial transparency. I want rather to reflect on how it affects patient trust when people feel like cogs in a money machine (I could write another post but won’t about the effects on physician morale of constantly playing insurance games in this darkness, after all they too are cogs in other people’s money machines). When one needs to be constantly suspicious about the bizarre charge system, this also affects patient attitudes in other ways and creates a general suspicion, which sometimes is warranted and sometimes is not. Either way, it is corrosive to good relationships and good care. To see the impact, read this very harsh post about colonscopy: <a href="http://open.salon.com/blog/john_fracis/2012/06/26/a_tough_love_colonoscopy_dream"></a><a href="http://open.salon.com/blog/john_fracis/2012/06/26/a_tough_love_colonoscopy_dream" target="_blank">A Tough Love Colonoscopy Dream</a>. The author writes: <blockquote class="tr_bq">Q. Who can perform a colonoscopy? A. Watch out. Studies have shown that the experience and quality of the scope user (we now use the term endoscopist more frequently) is essential. You want a GI specialist who has performed hundreds or thousands of these. Of course we used to say that you always wanted a physician for all your medical care, not one of those Nurse Practitioners or Nurse Anesthetists, until we were able to employ Physician Assistants in our practices to increase patient care, and coincidentally, our income. Money is not a factor in our decisions. But make no mistake about it. A Physicians Assistant is no doctor. . . . Q. How come I don’t know any of this? A. Because we do not want you to. It could ruin business, but we do not make decisions based upon financial gain. And of course it would limit the help we can give our beloved patients. And then there are the Porsche payments. . . .</blockquote> He concludes: <blockquote class="tr_bq">It is too bad for you that you are getting into the [medical] system. But you have to get used to it, as you are not getting any younger. And no one can get by without medical care. The healthcare industry controls that at every level. For profit. And you cannot change it, so you had better learn to navigate it if you want to avoid the most horrible outcomes.</blockquote>

Cogs in the Money Machine: Money and Trust

Everyone has to make money of course, and there’s not one thing wrong with that. But, encountering our medical and payment systems, patient...

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Bad health IT and its effects on willingness of patients to share sensitive information

I call your attention to this video from the 2nd International Summit on the Future of Health Privacy where HC Renewal occasional contributor Dr. Scott Monteith, a psychiatrist, presents on how health IT damages the physician-patient relationship, the bedrock of good medicine, in one case via an inexcusable health IT defect. The defect nearly cost a woman her good reputation - and her child - by "transforming" coffee drinking into solvent sniffing. The video is here:  <a href="http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-129-ec40d08a35f947e487f68a5f534a9e82.aspx">http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-129-ec40d08a35f947e487f68a5f534a9e82.aspx</a> <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-129-ec40d08a35f947e487f68a5f534a9e82.aspx" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS2ctf3aR4Od2Bas-tSrdYlO963ONIhluMMnfJ4PqF6gnU2QE8aefxAY08YzO3AgjN8hxWUT18SOKNirUmulqLb1Zbg7mzNbET9VfcD6g8SM1xA5JVVOCFhfXt3iPPs-E4za0PXHd0Vv76/s320/monteith.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Dr. Monteith on how bad health IT damages trust.  See video <a href="http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-129-ec40d08a35f947e487f68a5f534a9e82.aspx" target="_blank">at this link</a> starting at 4:40.</td></tr></tbody></table> Dr. Monteith starts at 4:40 when he is asked <blockquote class="tr_bq">"Do you feel HIT affects the willingness of patients to share sensitive information with providers?"</blockquote> His answer is a definite "yes", and the video should be seen to understand his reasons, the largest one being the trust that is injured by this technology as currently (mal)implemented, failing to maintain privacy, data integrity, affecting doctor-patient interaction (e.g., due to poor usability), etc. His two examples where HIT has injured trust, resulting in decreased willingness of patients to share sensitive information: <ul><li>A patient feared compromised privacy regarding psychiatric information (a fear that was certainly well-justified in view of ABC's recent expose of health IT breaches as I wrote about at my Sep. 14, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/09/a-reason-to-refuse-use-of-ehrs-in-your.html">A Reason to Refuse Use of EHR's in Your Health Care, and Demand Paper</a>.")</li></ul><ul><li>An error in EHR-generated record affecting a child custody battle, with a husband alleging unfitness of the mother due to substance abuse.  The EHR incorrectly showed a damaging diagnosis due to both a data mapping flaw (lumping multiple diagnoses under the same code) and a user interface flaw (permitting all of the diagnoses lumped under that code to not be seen, only the worst one) that transformed caffeine (i.e., coffee) overuse to "inhalant abuse."  </li></ul> Stunningly, Dr. Monteith reported the error was not remediated even after several years. As seen by the voluntary reports submitted by one of many HIT sellers (<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">link</a>), the only one that seems to do so, and some involuntary ones such as at <a href="http://google2.fda.gov/search?q=pulsecheck&client=FDAgov&site=FDAgov&lr=&proxystylesheet=FDAgov&output=xml_no_dtd&getfields=*&ie=UTF-8&ip=98.114.36.41&access=p&sort=date:D:L:d1&entqr=3&entqrm=0&oe=UTF-8&ud=1&filter=0" target="_blank">this link</a>, these issues are just the "tip of the iceberg." That exact phrase was uttered by a senior FDA official himself, reflecting known severe impediments to information diffusion on harms, as I reported <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html" target="_blank">at this link</a>. Yet the government (e.g., HHS's <a href="http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc/1200" target="_blank">Office of the National Coordinator for Health Information Technology</a>, ONC) and IT industry push this technology like candy, emphasizing largely unproven benefits and completely ignoring downsides such as damaged trust, damaged reputations that could have cost a woman custody of her child, and damaged bodies. A video of an attorney personally affected by these issues is at this link:   <a href="http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-137-ec40d08a35f947e487f68a5f534a9e82.aspx">http://www.healthprivacysummit.org/events/2012-health-privacy-summit/custom-137-ec40d08a35f947e487f68a5f534a9e82.aspx</a> -- SS

Bad health IT and its effects on willingness of patients to share sensitive information

I call your attention to this video from the 2nd International Summit on the Future of Health Privacy where HC Renewal occasional contribut...

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Twilight of the Anechoic Effect? - New England Journal of Medicine Article Discusses Previously Taboo Topic of Bad Corporate Health Care Leadership

We have often complained of the<a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect"> anechoic effect</a>, that the issues we discuss on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> often do not seem to be considered topics of polite conversation.  Any discussion that might question the brilliance, integrity, dedication, or selflessness of the leaders of health care organizations seems particularly taboo.  So a major aim of this blog has been to discuss the numerous publicly available examples of leadership that is <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">ill-informed</a>, uncaring about or<a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management"> hostile to</a> the values of health care professionals, incompetent, <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">self-interested</a>, conflicted, or outright corrupt, and of governance that lacks accountability, transparency, integrity, honesty, or ethics.  We have postulated that such problems with leadership and governance are not only causes, but the major causes of the increasing dysfunction of our health care system.  That discussing these issues is simply not done in many contexts, including academic health care, medical and health care journals, and health policy fora has only accelerated health care dysfunction. The New England Journal on Punishing Health Care Fraud Therefore, I note with some surprise that the New England Journal of Medicine just published an article (online first) that implicitly challenged the leadership of some large health care organizations. [Outterson K. Punishing health care fraud - is the GSK settlement sufficient.  N Engl J Med 2012; 367: 1082 - 1085.  Link <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1209249">here</a>.] The article summarized the record settling legal settlement agreed to by GlaxoSmithKline (see <a href="http://hcrenewal.blogspot.com/2012/07/giant-gsk-settlement-provides-reminder.html">this post</a>).  It noted that the company pleaded guilty to three criminal charges.  It then noted that while this was the largest recent legal settlement by a pharmaceutical company, "it would be a mistake to assume that GSK was an outlier in the global pharmaceutical and medical-device industries. Indeed, many of the major companies have settled with the Department of Justice in recent years."  It included a table of the largest pharmaceutical company settlements with the US government from 2009 to now. Based on this background, the article dared to question whether such settlements deter bad behavior: <blockquote>But questions remain about the efficacy of fines and corporate integrity agreements in deterring corporate misbehavior. The 2012 fines against Abbott Laboratories and GSK represent a modest percentage of those companies' revenue. Companies might well view such fines as merely a cost of doing business — a quite small percentage of their global revenue and often a manageable percentage of the revenue received from the particular product under scrutiny. If so, little has been done to change the system; the government merely recoups a portion of the financial fruit of firms' past misdeeds.</blockquote> Even more daring was its challenge to top executives of pharmaceutical corporations, <blockquote>One partial solution would be to impose penalties on corporate executives rather than just the company as a whole. Boston whistleblower attorney Robert M. Thomas, Jr., embraces this approach: 'GSK is a recidivist. How can a company commit a $1 billion crime and no individual is held responsible?'</blockquote>A Taboo Broken Having blogged on Health Care Renewal for nearly eight years, I recall very few, if any instances in which leaders of health care organizations were described as deserving punishment, or perhaps even guilty of crimes within large circulation medical journals, and within the New England Journal of Medicine, the most prominent US journal in particular. While discussion of misbehavior within health care organizations has slowly been seeping into the medical and health care literature, delicate phrasing has often been employed that leaves unclear whether top executives have any accountability for this behavior. (For example, while the Lancet editorial on the GSK settlement condemned "GSK's fraud," accused GSK of "actively encouraging off-label prescription," and asserted that "GSK and other drug companies have come adrift from standards of the societies they seek to serve," it never said anything about GSK's leaders or whether they in paticular had anything to do with the company's bad behavior. [Anon. Moral decaly at GSK reaps record US$# billion fine. Lancet 2010; 380: 2. Link <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961110-6/fulltext">here</a>.]) So it is a big step for the NEJM to publish an article that suggests corporate executives might deserve penalties. I hope that this publication might lead to a bit of discussion of these issues within the larger medical and health care communities, the vast majority of whom have likely never heard of this blog and may have never seen anything other than an occasional news article in local media questioning the leadership of large health care organizations. Things are Even Worse Unfortunately, I need to end with the observation that the problems are even worse than what the NEJM article implies. Legal settlements of allegations of bad behavior by large health care organizations are much more numerous than those mentioned in this article (look <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here </a>for examples). Many of the largest and most prestigious organizations actually have histories of multiple settlements, guilty pleas, and related legal and governmental findings. For example, look <a href="http://hcrenewal.blogspot.com/2012/08/pfizers-pforeign-pfiasco.html">here</a> for Pfizer's record, <a href="http://hcrenewal.blogspot.com/2012/09/how-many-legal-settlements-does-it-take.html">here</a> for Johnson and Johnson's record, <a href="http://hcrenewal.blogspot.com/2012/05/abbott-pleads-guilty-settles-for-16.html">here</a> for Abbott's record, and <a href="http://hcrenewal.blogspot.com/2012/06/huge-insurance-company-wellpoint.html">here</a> for Wellpoint's record. Pfizer was even found by a jury to be a racketeering influenced and corrupt organization (RICO)(see post <a href="http://hcrenewal.blogspot.com/2010/03/settlement-and-conviction-round-up.html">here</a>). Despite these records of recidivism, no leaders of these companies have paid any individual penalties, and none of these organizations have had any restructuring or leadership changes imposed. This is even more disturbing when this kid-glove treatment of misbehavior by big health care organizations is contrasted with the severe penalties imposed on individuals or leaders of small companies found guilty of health care fraud (look <a href="http://hcrenewal.blogspot.com/2012/01/unequal-justice-under-law-comparing.html">here</a>). You Heard It Here First However, in 2003 we first published documentation of individual physicians' concerns that ill-informed, incompetent, self-interested, or even corrupt leadership was threatening their core values [Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link <a href="http://www.sciencedirect.com/science/article/pii/S0953620503000293">here</a>.] Furthermore, <a href="http://hcrenewal.blogspot.com/2008/07/amerigroup-settles.html">since 2008 </a>we have been stating that corporate fines do not deter bad behavior. It is not that law enforcement does not have the power to seek penalties on individuals. As we noted <a href="http://hcrenewal.blogspot.com/2010/06/attempt-to-hold-health-care-leaders.html">here</a>, a Supreme Court case from 1943 empowered the government to seek penalties against responsible corporate officers (the "responsible corporate officer doctrine") who were in a position to stop a fraud that resulted in a guilty plea or conviction, particularly for the selling of misbranded or adulterated drugs into interstate commerce under the US Food and Drug Act.  (This was exactly the situation dealt with by the GSK settlement.)  Despite a threat made in 2010 by the chief counsel of the Inspector General's office of the US Department of Health and Human Services to use such legal authority to "get high level executives out of companies," nothing of the sort has happened. So now that it is no longer taboo to question the pretensions of some leaders of health care organizations to near divine purity, let me state <a href="http://hcrenewal.blogspot.com/2008/09/walgreen-settles.html">as I did in 2008</a>, <blockquote>As long as health care leaders can shrug off the consequences of unethical behavior merely as acceptable costs of doing business, absent any serious attempts to get health care organizations to enforce internal codes of ethical behavior or to avoid hiring ethically challenged leaders, the procession will likely continue. The effects will be continually rising costs, declining quality, shrinking access, and rising numbers of demoralized health professionals. </blockquote>As I <a href="http://hcrenewal.blogspot.com/2009/05/wellcare-settles-accepts-deferred.html">wrote in 2009</a>, <blockquote>Until bad leadership of health care organizations leads to negative consequences for those practicing it, health care leadership can be expected to continuously degrade. </blockquote>

Twilight of the Anechoic Effect? - New England Journal of Medicine Article Discusses Previously Taboo Topic of Bad Corporate Health Care Leadership

We have often complained of the anechoic effect , that the issues we discuss on Health Care Renewal often do not seem to be considered top...

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