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At Risk in the Computerized Hospital: The HITECH Act as Social Policy Malpractice, and Passivity of Medical Professionals

I am revisiting the issue of HITECH in light of recent reports on health IT drawbacks and/or failure to achieve long-claimed advantages. The <a href="http://waysandmeans.house.gov/media/pdf/111/hitech.pdf" target="_blank">HITECH Act</a>, a multi-billion dollar EHR incentive/penalty measure inserted into the 2009 American Recovery and Reinvestment Act legislation (<a href="http://en.wikipedia.org/wiki/American_Recovery_and_Reinvestment_Act_of_2009" target="_blank">ARRA</a> or 'economic recovery' act), is proving to be an example of what should be called "Social Policy Malpractice." The HITECH Act was largely a consequence of intense industry lobbying on behalf of the IT industry (as in the Washington Post at "<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>", May 16, 2009). It is in fact not based on science or reliable evidence, and has led to increased patient endangerment and a worsening national debt picture. The recent revelations of reports from diverse sources including but not by any means limited to the following indicate that HITECH and its expenditures of billions of dollars on experimental, unregulated, unproven technology represents social policy malpractice:   <div></div><div><ul><li>ABC News (<a href="http://abcnews.go.com/Health/medical-records-private-abc-news-investigation/story?id=17228986" target="_blank">Your Medical Records May Not Be Private: ABC News Investigation</a>" - privacy of electronic health data is very poor, in ways that paper would and could never have permitted); </li></ul></div><div><ul><li>The Center for Public Integrity "<a href="http://www.publicintegrity.org/2012/09/19/10812/growth-electronic-medical-records-eases-path-inflated-bills" target="_blank">Growth of electronic medical records eases path to inflated bills</a>", on how EHRs lead to increased, not decreased healthcare costs; </li></ul></div><div><ul><li>Experts at Penn and Harvard -"<a href="http://online.wsj.com/article/SB10000872396390443847404577627041964831020.html?mod=googlenews_wsj" target="_blank">A Major Glitch for Digitized Health-Care Records</a>" - savings from EHRs are illusory;</li></ul><ul><li>Budget reports - in view of the deficit spending reported by OMB and others that is causing national debt to spiral out of control, jeopardizing the economic well being of the United States, and with upcoding as a side-effect and no cost savings, HITECH is an unaffordable extravagance.  </li></ul><ul><li>Recent revelations of outright EHR-induced mass chaos largely due to outspoken clinicians who've had enough - "<a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">Contra Costa County health doctors air complaints about county's new $45 million computer system</a>", "<a href="http://hcrenewal.blogspot.com/2012/09/the-extremes-to-which-faith-based.html" target="_blank">Lake County (IL) Health Department - Depression era soup lines at the clinic</a>";</li></ul><ul><li>Abuses of NPRM Public Comment periods on followup health IT incentive regulations via industry ghostwriting (stealth lobbying), reducing EHR effectiveness while further enriching the industry - "<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>;</li></ul> Of course, I'd already cited these reports in past posts but they bear repeating: <ul></ul><ul></ul></div><div><ul><li>The IOM report on HIT safety ("There's risk, but we don't even know the magnitude because there are major systemic impediments to diffusion of that information"), <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html</a>;</li></ul></div><div><ul><li>FDA (known injuries and deaths are likely the "tip of the iceberg" because of the impediments, and EHRs are medical devices that should fall under the FD&C Act, but FDA has largely refrained from enforcing our regulatory requirements with respect to HIT devices because they're a political hot potato - Jeff Shuren MD JD, CDRH), <a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html" target="_blank">http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html</a>;</li></ul></div><div><ul><li>NIST (health IT usability is poor, major remediation is needed) - <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html" target="_blank">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a></li></ul></div><div></div><div> I'd called for a moratorium on ambitious EHR plans for similar reasons as far back as 2008, at posts <a href="http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/2009/01/i-ask-again-should-us-call-moratorium.html" target="_blank">here</a>.</div><div>  </div><div></div><div>The path that ethical medical centers and clinicians should take is to delay computerization in 2012 and push for slowdown or retraction of HITECH and its penalties for non-adopters.  Yet instead, what is usually seen is excuses and cheerleading by healthcare organization leaders, and passive physician and nurse acceptance of deficient information technology.  </div><div></div><div> This stunning passivity and acceptance by physicians and nurses of a deeply flawed technology of unknown risk seems largely due to physician learned helplessness and the Stockholm Syndrome.  See the posts on "physician learned helplessness" at <a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html" target="_blank">http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html</a> (commenting on observations in MedScape written by a lawyer), as well as on the "Stckholm Syndrome"  at <a href="http://en.wikipedia.org/wiki/Stockholm_syndrome" target="_blank">http://en.wikipedia.org/wiki/Stockholm_syndrome</a>.  Per a psychiatrist/informatics specialist Dr. Scott Monteith who has <a href="http://hcrenewal.blogspot.com/search/label/Dr.%20Scott%20Monteith" target="_blank">commented on this blog</a>, the compliance of clinicians may also be a manifestation of the inherent human psychopathology reflected in the <a href="http://en.wikipedia.org/wiki/Milgram_experiment" target="_blank">Milgram Experiment</a> (and elsewhere):</div><div></div> <blockquote class="tr_bq"><div>The Milgram experiment on obedience to authority figures was a series of notable social psychology experiments conducted by Yale University psychologist Stanley Milgram, which measured the willingness of study participants to obey an authority figure who instructed them to perform acts that conflicted with their personal conscience. Milgram first described his research in 1963 in an article published in the Journal of Abnormal and Social Psychology, and later discussed his findings in greater depth in his 1974 book, Obedience to Authority: An Experimental View. </div></blockquote><div> As to the consequences of physician "acceptance" of this technology in 2012 in its present condition, physicians are: <div><ul><li>Acting, in effect, 'in loco parentis' for their patients, not in the latter's best interests, who are not even afforded opportunity for informed consent.  This is in violation of long-accepted norms of human subjects experimentation and research such as the <a href="http://www.hhs.gov/ohrp/archive/index2.html" target="_blank">Belmont Report, Nuremberg Code</a> and <a href="http://www.hhs.gov/ohrp/humansubjects/index.html" target="_blank">HHS human subject protection</a> regulations at <a href="http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html">45 CFR part 46</a> themselves;</li></ul></div><div><ul><li>Giving free provision of their expertise and labor at improvisation and workarounds, in effect providing free alpha and beta testing to an entirely unregulated IT sector;</li></ul></div><div><ul><li>Engaging in passive acceptance of the entire liability and their hospital executives' breach of fiduciary responsibility to protect them from same due to Hold Harmless clauses, and breach of Joint Commission safety standards through signing "gag" clauses on defects and harms (see <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda</a>). </li></ul></div> </div><div>National health IT leaders have proven to be hyperenthusiasts about health IT benefits as well:</div><div></div><div> <blockquote class="tr_bq">... This from Robert Kolodner, former head of the Office of the National Coordinator for Health IT (ONC) at HHS: <blockquote class="tr_bq">Dr. Robert Kolodner, a physician who headed the federal push for electronic medical records in 2007, acknowledged that billing abuse took a backseat to steps likely to entice the medical community to embrace the new technology. Kolodner said officials were certain the savings achieved by computerizing medicine would be so great that billing abuse, “while needing to be monitored, was not something that should be put as the primary issue at that time.”</blockquote> In other words, sideline (ignore) health IT-based billing abuse (and safety risks to the live patients subjected to this experimental technology without informed consent) because "we believe" the savings will be greater based on "our faith in the technology."</blockquote>  </div><div>Such individuals contributed materially to the social policy malpractice represented by the HITECH ACT.</div><div> </div><div>Considering all of the above, I call once again for a moratorium on further economic incentives for EHR adoption, and investment in the very measures recommended by the National Research Council in its Jan. 2009 report "<a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572" target="_blank">Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions</a>" that:</div><div> <blockquote class="tr_bq">In the long term, success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering. </blockquote></div><div></div><div></div><div> This research must be conducted, of course, with full human subjects protections in place.</div><div> </div><div>-- SS</div>

At Risk in the Computerized Hospital: The HITECH Act as Social Policy Malpractice, and Passivity of Medical Professionals

I am revisiting the issue of HITECH in light of recent reports on health IT drawbacks and/or failure to achieve long-claimed advantages. The...

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In addition to nurses, doctors now air their alarm: Contra Costa County health doctors air complaints about county's new $45 million computer system

At my Aug. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html" target="_blank">Contra Costa's $45 million computer health care system endangering lives, nurses say</a>", I described how an experimental EHR being forced on clinicians in Contra Costa county, California, was endangering patients who had not consented to its use, and how nurses were reported to be raising hell about it.  I also noted: <blockquote class="tr_bq">... The[se] scenarios [of EHR-created mayhem] are also usually accompanied by amoral misdirection from these personnel away from patient risks... Herein is the problem:  the attitude that a clinic full of non-consenting patients is an appropriate testbed for alpha and beta clinical software that puts them at risk is medically unethical, based on the guidelines developed from medical abuses of the past.  There is nothing to argue or debate about this.  </blockquote> Now the affected physicians have their say. These physicians are apparently represented by a union; therefore they likely fear retaliation less than non-union physicians, and thus can be candid: <blockquote class="tr_bq"><a href="http://www.mercurynews.com/news/ci_21575727/county-health-doctors-air-complaints-about-countys-new" target="_blank">Contra Costa County health doctors air complaints about county's new $45 million computer system</a> By Matthias Gafni Contra Costa Times Posted:   09/18/2012, Updated:  09/19/2012 MARTINEZ -- One of every 10 emergency room patients at the county's public hospitals in September left without ever being seen by a doctor or nurse because of long waits -- a number rising since implementation of Contra Costa's $45 million computer system July 1. One patient waited 40 hours to get a bed. Dr. Brenda Reilly delivered the troubling news Tuesday afternoon to county supervisors. She was one of three dozen doctors in the supervisors' chamber complaining about EPIC, new computer software aimed at integrating all of the county's health departments to create a federally mandated electronic medical record for patients.</blockquote> The response, as seen later, were characterized by the typical amoral excuses, mistaken beliefs in technological determinism, (a/k/a quasi-religious computer fanaticism) and misdirection I described above. <blockquote class="tr_bq">To allow for the major computer program installation and conversion, administrators cut doctors' patient loads in half, in turn cutting the number of available appointments in half. In a letter to the supervisors, Dr. Ori Tzvieli -- medical staff president whose union has been negotiating a new contract with the county -- along with 14 doctor co-signers pleaded for administrators to continue scaling back physician workloads because doctors are over-stressed. Six doctors have left this year, said Dr. Keith White, a 22-year pediatrician.</blockquote> I point out that such stress from interacting woth a <a href="http://www.tinyurl.com/hostileuserexper" target="_blank">mission hostile</a> EHR (really, a clinician workflow-control system), and the needed state of hypervigilance to avoid IT-related mistakes that harm patients, lead to burnout and ultimately, a lower quality of patient care.  Patient workloads were reduced by 50%, which is bad enough (and indicative of gross project mismanagement, as I wrote about in another example in my Sept. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/09/the-extremes-to-which-faith-based.html" target="_blank">Lake County (IL) Health Department: The extremes to which faith-based informatics beliefs can drive healthcare facilities - Depression era soup lines at the clinic?</a>"). Yet the 50% reduction, according to the principal end users, was still not enough.  Usability and fitness of the software is surely in question. <blockquote class="tr_bq">"We were not ready for EPIC and EPIC was not ready for us," White told supervisors. "As a result, the providers are struggling to provide safe and effective care for 100,000 citizens of the county, many of whom are very ill. We often feel that we are failing. We are very tired ... many doctors have left and all are considering leaving."</blockquote> It is impossible for people, especially medical professionals, to be "ready" for a system that "is not ready for them", i.e., "bad IT" as defined at my teaching site intro <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">at this link</a>: <blockquote class="tr_bq">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. </blockquote> The two phrases "We were not ready for EPIC" and "EPIC was not ready for us" do not belong together in the same sentence. A claim that physicians (and nurses) are "struggling" to provide safe let alone effective care for 100,000 should RAISE ALARM BELLS, not produce a paternalistic, patronizing response from medical and governmental officials as it did, seen below. <blockquote class="tr_bq">Both doctors and administrators agreed Tuesday that creating an integrated electronic health record is important, but a series of white coats stepped to the podium in what they jokingly termed "Doccupy" to share their nightmarish last few months.</blockquote> I disagree with the assessment that "creating an integrated electronic health record is important", in that the technology and know-how to do so without endangering the very patients the technology is supposed to protect does not yet seem to exist in the commercial sector. In that sense, regulating EHR technology and subjecting it to controlled clinical trials and refinement (as with any other medical device or drug, and many other types of healthcare-related IT such as MDDS - <a href="http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/MedicalDeviceDataSystems/default.htm" target="_blank">medical device data systems</a>) with consenting subjects is what's important. On MDDS, from the FDA link above: <blockquote class="tr_bq">Medical Device Data Systems (MDDS) are hardware or software products that transfer, store, convert formats, and display medical device data. An MDDS does not modify the data or modify the display of the data, and it does not by itself control the functions or parameters of any other medical device. MDDS are not intended to be used for active patient monitoring. Examples of MDDS include: <ul><li>software that stores patient data such as blood pressure readings for review at a later time;</li><li>software that converts digital data generated by a pulse oximeter into a format that can be printed; and</li><li>software that displays a previously stored electrocardiogram for a particular patient.</li></ul>The quality and continued reliable performance of MDDS are essential for the safety and effectiveness of health care delivery. Inadequate quality and design, unreliable performance, or incorrect functioning of MDDS can have a critical impact on public health.</blockquote> That health IT used on live patients receives special regulatory accommodation in the form of non-regulation, when clearly the quality and continued reliable performance of EHR systems are essential for the safety and effectiveness of health care delivery, is inexcusable in 2012.   (Of course, stunningly, FDA won't touch the latter, although admitting they are medical devices that should fall under the FD&C Act, because EHRs are a "political hot potato."  See <a href="http://hcrenewal.blogspot.com/2011/04/fda-decides-regulating-implantable.html" target="_blank">this post</a> for the relevant citations.) <blockquote class="tr_bq">... "This has been excruciatingly painful to do what is needed for those people who need it most," said Dr. Rachel Steinhart, an emergency room doctor who worked a graveyard shift ending Tuesday morning, hours before the board meeting. She said she still had to document paperwork for 16 of her patients. "It's going to implode. It can't go on like this."</blockquote> Patients are surely going to be injured or killed in this setting.  There is likely a "hold harmless" clause with the vendor, so, doctors, I'm sorry to say, despite your complaints, you will very likely be held legally liable. <blockquote class="tr_bq">The head of the county's health care system sympathizes, and hopes to work with medical staff to ease the transition for what is a monumental moment in medical history. "We're in an era of massive change right now, not only in our system, but in the system nationwide," said Dr. William Walker, Contra Costa's health services director. "Coming with the rapidity is its throwing people off balance."</blockquote> Dr. Walker has just painted a big red "name me as a defendant for gross negligence and breach of fiduciary responsibilities to patients and clinicians" target on his back for glossing over known health IT risks and what appear to be rather profound complaints coming from his constituents.  Instead, he supplies platitudes, not action to remediate or withdraw the bad IT. <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/AVvXsEinDtXnVAFuOPvRaK5g59iqj2yAbapYdW0lbU6L7m4v_l8DyslOSHCGTuaUi26Zuka7KRKI_XWyHgjZHm4cR_rK7wcnXCy9Ht9Jkl78UnfmwgmfrePkDhIk1fHZ0J0qY76aqXh6PmuYTmJ6/s1600/target.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEinDtXnVAFuOPvRaK5g59iqj2yAbapYdW0lbU6L7m4v_l8DyslOSHCGTuaUi26Zuka7KRKI_XWyHgjZHm4cR_rK7wcnXCy9Ht9Jkl78UnfmwgmfrePkDhIk1fHZ0J0qY76aqXh6PmuYTmJ6/s200/target.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Name me as a defendant for gross negligence and breach of fiduciary responsibilities to patients and clinicians</td></tr></tbody></table> The response is stunning: <blockquote class="tr_bq">To ease the burden, Walker hopes to have teams of medical care providers formed to ease the doctors' paperwork burden, enabling them to return to treating patients.</blockquote> It takes teams of physicians to properly see a patient due to the interference of EHRs?  That is remarkable. <blockquote class="tr_bq">The ccLink program has its benefits, some doctors said. Dr. Chris Farnitano, an ambulatory care medical director, described how he retrieved a patient's biopsy results from a different hospital on the spot, whereas in the past it would have taken weeks. However, other doctors called ccLink clunky and time-consuming, designed more for bureaucrats than physicians. Even with doctors cutting their patient load in half -- meaning half as many appointments are available for patients -- doctors complained that they spend more time on their computers than treating patients.</blockquote> This is misdirection by the Medical Director.  It's unarguable that the risks far outweigh the benefits.  Further, retrieving a biopsy or other result result instantaneously could easily be done from an innocuous, non-disruptive document imaging system (e.g., Documentum).  The latter would also be many millions of dollars less expensive than an EHR. <blockquote class="tr_bq">"It's a truncation of patient care. The individual patient doesn't get the care they used to get," said David MacDonald, a 22-year family medicine doctor.</blockquote> Again, Dr. MacDonald, the liability for adverse outcomes is on you. You are now, in effectm an indentured servant of an IT company, providing free alpha and beta testing at your expense and peril, using the patients as an even lower level of indentured servant/guinea pig. There's also significant patient-endangering collateral damage from this mayhem: <blockquote class="tr_bq">The lack of appointments has overburdened emergency rooms, which already exceeded emergency room wait benchmarks in a facility built to see 80 patients a day, but often sees more than 200 patients a day. Since ccLink started, the average patient spends four hours in the ER, up an hour from before the computer system transition, which was already over national benchmarks, said Reilly.</blockquote> The scenario could not be worse.  The ED's are themselves burdened by EHR's. <blockquote class="tr_bq">The supervisors asked for continued updates, and for patience. "Continuous improvement means you need continuous change," said supervisor Federal Glover. "Eventually, it's going to become second nature as it was with cell phones. We'll wonder how we ever did without it."</blockquote> Supervisor Glover has also painted a "defendant" target on his back.  This is the misdirection I was speaking of earlier, consisting of platitudes, logical fallacy and falsehoods: <ul><li>"Continuous improvement" is not what's going on here; </li><li>Such improvement does not mean creating chaos as a precondition; </li><li>Whether this software will become "second nature" is anyone's guess.  That is a hysterical and logically fallacious statement (e.g., an <a href="http://www.nizkor.org/features/fallacies/appeal-to-belief.html" target="_blank">appeal to belief</a>) of an almost quasi-religious fanaticism regarding computing.  This technology could ultimately be scrapped in favor of, say, simpler document imaging systems due to increasing clinician complaints, inherent usability issues in fast-paced medical settings, litigation, costs, harms etc.;</li><li>What of the patients placed at risk, and/or injured/killed as a result of this experimentation?  What of them, and their medical and human rights?</li></ul> In effect, a response like this is medically unethical.  The correct response would be a halt in the rollout until problems are substantially remediated in a controlled, risk free setting - not the clinic. If that is not possible, the system needs to indeed be scrapped or replaced. Continuation of patient endangerment is inexcusable medically, ethically and legally. -- SS

In addition to nurses, doctors now air their alarm: Contra Costa County health doctors air complaints about county's new $45 million computer system

At my Aug. 2012 post " Contra Costa's $45 million computer health care system endangering lives, nurses say ", I described how...

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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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