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Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter

An unspoken running assumption of the health IT enthusiast crowd seems to be that any health IT is better than no health IT, because using paper results in mistakes. I offer a different view. At the introduction to <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">my Medical Informatics teaching site</a> I've defined good health IT and bad health IT as follows: <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> There are also good paper systems and bad paper systems. I opine that the elephant in the living room of health IT discussions is that BHIT is infrequently, if ever, made a major issue in healthcare policy discussions. I also opine that BHIT is far worse, in terms of diluting and decreasing the quality and privacy of healthcare, than a very good or even average paper-based record-keeping and ordering system.   This is a simple concept, but I believe it needs to be stated explicitly.  In today's healthcare world, where health IT is dominated by <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">hyper-enthusiasts</a> of one motive or another, such an axiomatic statement will probably be viewed as controversial if not heretical.  This blog has numerous postings about health IT debacles, e.g., query links <a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy" target="_blank">here</a>, that could not occur with paper systems.  The defects of just one company's products, the only one that publicly reports them to FDA (<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">link</a>) are frightening in terms of potential consequences. GHIT needs to be promoted and BHIT needs to be eliminated.  That implies a major transformation of the health IT industry and its oversight. -- SS

Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter

An unspoken running assumption of the health IT enthusiast crowd seems to be that any health IT is better than no health IT, because using p...

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No Skin in the Game - A Private Health System for the Very Rich

We have <a href="http://hcrenewal.blogspot.com/search/label/executive%20health%20plans">noted</a> occasional hints that the very rich may have a separate health care system which may shield them from the vicissitudes of our dysfunctional health care system. A broader hint came in an <a href="http://online.wsj.com/article/SB10000872396390444620104578008182459803120.html">interview</a> in the Wall Street Journal. The Company  The subject of the interview was Leslie Michelson, the CEO of Private Health Management.  The activities of the company were defined somewhat vaguely, <blockquote class="tr_bq">an ultra high-end company that borrows from concierge medicine, managed care, applied-sciences research and information technology while fitting into no neat category. The best analogue might be the investment and tax specialists that the affluent employ to run their finances; Mr. Michelson does the same for their health care. 'Like private wealth management, just far more important,' he quips in his modern Beverly Hills offices, all green glass and steel, white walls, white floors.</blockquote> The Clientele The company manages health care for a select clientele: <blockquote>Private Health caters to 'high net worth individuals' and to businesses that retain its services for their executives as a benefit. Mr. Michelson says he serves between 12,000 and 15,000 clients, 'principally in private equity, hedge funds, professional and financial services firms.' </blockquote>Note that the clientele seem to come mainly from the ranks of top executives of financial firms, probably some of the richest of the rich in the US. Rapid Response Team for Acute Illness Private Health Management's most distinctive service is the rapid response team it can "parachute in" to provide care for an acute illness, <blockquote>whenever one of its patients has a medical emergency or complex condition, say, a traumatic brain injury or newly diagnosed cancer. A personal-care team parachutes in, led by a clinician employed by the company, and compiles a brief on the patient. They centralize and digitize the patient's medical records, usually dog-eared paper piles that can run to thousands of pages. Research scientists immerse themselves in the latest findings and treatment regimens for the particular condition involved. </blockquote><blockquote>Tests are double-checked—biopsy tissues are sent to an outside pathologist, MRIs to another radiologist. For an era of targeted therapies, Private Health runs a full battery of molecular diagnostics 'to sequence the entire three billion base pairs of somebody's DNA in a couple of hours,' Mr. Michelson marvels. </blockquote><blockquote>The goal is to ensure an accurate diagnosis and lay out all the treatment options. Private Health functions as a kind of running, independent second opinion. </blockquote>Physician Network In addition, Private Health Management provides access to a network of ostensibly the very best physicians, <blockquote>Mr. Michelson built a series of proprietary algorithms to distinguish 'the few who are the very best' from 'the many who are very good,' based on 'the factors that predict excellence.' For example, the premier caregivers for metastatic cancer are usually academic researchers on the cutting edge, not general oncologists. The best orthopedic surgeons perform many procedures as they master the clinical learning curve, ideally for a single injury. </blockquote><blockquote>His referral database includes 2,200 specialists across 160 medical fields, 'reified into far finer groupings of disease than is standard practice.' He says that 'the world becomes so much clearer when you are able to identify the physician with the deepest and narrowest expertise in exactly what you need.' </blockquote><blockquote>Mr. Michelson says doctors like to belong to his informal network because they're 'interested in excellence and what we stand for.' </blockquote>However, next, <blockquote class="tr_bq"> He adds, with more than a little euphemism, 'In a world in which 98% of the conversations are about cost containment, it's a joy for them to have somebody who's focused on enhancing quality only.' No doubt true, though it probably doesn't hurt that providers also like to have a relationship with his client base, the sort of people who become university patrons or donate a hospital wing.</blockquote>This raises the question of whether doctors in his network may exhibit some greed along with their putative excellence. Questions Begged About How it Works The article actually devoted more space to Mr Michelson rationalizing his business as part of his overall interest in reforming health care than to discussion of how it works and what its implications are.  The short description of the processes above actually raised more questions about how the Private Health System works than it answered.  Some examples are: how could an optimal rapid response team be quickly mobilized given that the nature of acute illnesses may not be immediately apparent?  How would such a team interact within a hospital setting, or does the company have its own parallel hospital system?  What about the rest of medicine and health care outside of acute and intensive care, particularly primary care and management of chronic disease?  How does the referral data base function, and how would a classification that seems focused on the "narrowest expertise" cope with patients with multiple common illnesses or patients with undefined or undiagnosed problems?  These begged questions suggest there may actually be much more to the Private Health Management system than was discussed in the article. Perhaps instead the care provided by Private Health Management might not actually result in better outcomes for its patients.  Consider some other questions: given how hard it is to assess physician performance and measure quality of care, how can Private Health Management be assured that its physicians are really the best of the best?  Given the apparent financial incentives for participating in the system, would the doctors who most appreciate these incentives be likely to provide the best care?  Would the apparent bias of the system toward high technology and super specialized care, would the system over-treat most of its patients?  Summary and Implications Nonetheless, the article provides more evidence that the US has a secretive parallel health care system for the very rich.  The most important implication is that such a system could protect the very rich from the access problems and bureaucratic annoyances that plague ordinary patients in larger dysfunctional health care system.  By thus having "no skin in the game," those among the very rich who are not themselves directly involved with health care would have little reason to care or want to do anything about the problems besetting the larger health care system.  Since the very rich have become increasingly politically powerful, the absence of such interest or motivation for change among them would make true health care reform much more difficult.  If there is a parallel health care system for the very rich, its real effects on health and health care are unknown.  As best as I can tell, the very concept is almost entirely anechoic except for our very limited <a href="http://hcrenewal.blogspot.com/search/label/executive%20health%20plans">discussions </a>on Health Care Renewal.  The subject cries out for investigative reporting, and consideration by health care policy, research, and ethics experts.

No Skin in the Game - A Private Health System for the Very Rich

We have noted occasional hints that the very rich may have a separate health care system which may shield them from the vicissitudes of our...

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Just the Latest Legal Settlement for HCA

Last month, we<a href="http://hcrenewal.blogspot.com/2012/08/paging-doctor-ebdita-how-private-equity.html"> posted</a> about investigative reports that suggesting that for-profit hospital chain HCAwas pushed by its private equity owners to put short-term revenue ahead of good patient care.  A legal settlement announced this week corroborates these concerns.  As <a href="http://www.wrcbtv.com/story/19584753/hca-to-pay-165-million-to-resolve-health-care-fraud-charges">reported</a> by television station WRCB in Chattanooga, TN, <blockquote>HCA Inc., one of the nation's largest private hospital chains, has agreed to pay $16.5 million to settle alleged violations of the Ethics in Patient Referrals Act (also known as the Stark law), the False Claims Act, and other federal and state laws and regulations in connection with the operation of its subsidiary, Parkridge Medical Center, Inc., in Chattanooga. In addition, Parkridge Medical Center has entered into a comprehensive five-year Corporate Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services (HHS-OIG) to ensure its continued compliance with federal health care benefit program requirements. As alleged in the settlement agreement, during 2007, HCA, through its subsidiaries Parkridge and HCA Physician Services (HCAPS), entered into a series of financial transactions with a physician group, Diagnostic Associates of Chattanooga, through which it provided financial benefits intended to induce the physician members of Diagnostic to refer patients to HCA facilities. The financial benefits included lease of office space from Diagnostic at a rental rate well in excess of fair market value to meet the mortgage obligations of the Diagnostic members and release of Diagnostic members from a separate lease obligation. These financial arrangements violated the Ethics in Patient Referrals Act and the Anti-Kickback Statute – laws designed to protect patients as well as the integrity of government-funded health care benefit programs such as Medicare, Medicaid, TRICARE, and TennCare. </blockquote>The issue here were allegations that HCA and its subsidiaries were paying physicians extra so that they would refer patients to an HCA hospital. Obviously, physicians are supposed to put each patient's interests ahead of extraneous considerations, and hence should make referral decisions based on the patients needs, and the likely benefits and harms of the referral, not the amounts the physicians might make from such payments. Referrals for particular services can be very lucrative for hospitals.  So this settlement seems to provide more evidence that to get profitable referrals, HCA was willing to subvert physicians' values by paying physicians to induce to make what might have been the wrong decisions for individual patients.  Of course, in this situation some physicians were hardly blameless, since they were also willing to set aside their values to receive the payments that generated those referrals. This fits with the thesis we advanced last month.  While hospitals are supposed to have a mission to put care of the sick ahead of all else, it appears that for-profit hospitals, and especially those owned by private equity are more likely to put short-term revenue ahead of patient care. As an aside, while this settlement provides useful information, do not think of it as a solution to the immediate problem.  As we have frequently asserted, it is doubtful that the relatively small payment and the relatively unlikely to be enforced corporate integrity agreement imposed in this settlement will change the company's behavior, in the absence of any negative consequences for the people who authorized, directed or implemented the bad behavior.  HCA once made a $1.7 billion fraud settlement, at the time the biggest such settlement ever made (see <a href="http://hcrenewal.blogspot.com/2010/05/how-did-ceo-who-presided-over-company.html">this post</a>).  However, the company's CEO at the time, Rick Scott, left the firm with a golden parachute and no negative consequences, and is now Governor of Florida.  If that previous huge settlement did not deter the more recent bad behavior in the absence of any penalties for company executives, why should we expect that the current comparatively tiny settlement also in the absence of such penalties will have any effect? As we have now said many, many times, we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich. Furthermore, as I <a href="http://hcrenewal.blogspot.com/2012/08/paging-doctor-ebdita-how-private-equity.html">wrote</a> last month, we need to challenge the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. Before market fundamentalism became so prominent, many stated prohibited the corporate practice of medicine, and the American Medical Association <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">forbade the commercialization of medicine.</a> It is time to heed that wisdom. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.

Just the Latest Legal Settlement for HCA

Last month, we posted about investigative reports that suggesting that for-profit hospital chain HCAwas pushed by its private equity owner...

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Another unsolicited email from a physician describing EHR-caused chaos in the clinic

Another unsolicited email from a physician describing EHR-caused chaos in the clinic

I periodically receive unsolicited stories of EHR difficulties (mayhem, really) as a result of clinicians or others locating my materials on...

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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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