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Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events

The <a href="http://patientsafetyauthority.org/Pages/Default.aspx" target="_blank">Pennsylvania Patient Safety Authority</a> has released a report "The Role of the Electronic Health Record in Patient Safety Events."  A press release is <a href="http://www.patientsafetyauthority.org/NewsAndInformation/PressReleases/2012/Pages/pr_December_12_2012.aspx" target="_blank">at this link</a>, and the full report in PDF is <a href="http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Dec;9%284%29/documents/113.pdf" target="_blank">at this link</a>.  In the report, the Pennsylvania Patient Safety Authority analyzed reports of EHR-related events from a state database of reported medical errors and identified several major themes. The report was prepared with the assistance of Erin Sparnon, Senior Patient Safety Analyst the <a href="https://www.ecri.org/Pages/default.aspx" target="_blank">ECRI Institute</a> near Philadelphia.  The ECRI Institute is an independent organization renowned for its safety testing of medical technologies and reporting on same, and that "researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care."  I've mentioned it and its bylaws in this blog in the past as a model for independent, unbiased testing and reporting of healthcare techonlogies. Regarding the Patient Safety Authority: <blockquote class="tr_bq">The Pennsylvania Patient Safety Authority was established under Act 13 of 2002, the Medical Care Availability and Reduction of Error ("Mcare") Act, as an independent state agency. It operates under an 11-member <a href="http://patientsafetyauthority.org/PatientSafetyAuthority/Pages/BoardofDirectors.aspx" title="">Board of Directors</a>, six appointed by the Governor and four appointed by the Senate and House leadership. The eleventh member is a physician appointed by the Governor as Board Chair.  Current membership includes three physicians, three attorneys, three nurses, a pharmacist and a non-healthcare worker. The Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities. Under Act 13 of 2002, these facilities  must report what the Act defines as "Serious Events" and "Incidents" to the Authority. </blockquote> The Authority maintains a database of serious events and incidents: <blockquote class="tr_bq">Consistent with Act 13 of 2002, the Authority developed the Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced "PAY-sirs"), a confidential web-based system that both receives and analyzes reports of what the Act calls Serious Events (actual occurrences) and Incidents (so-called "near-misses"). </blockquote> Cutting right to the chase, the paper's summary: <blockquote class="tr_bq"> As adoption of health information technology solutions like electronic health records (EHRs) has increased across the United States, increasing attention is being paid to the safety and risk profile of these technologies. However, several groups have called out a lack of available safety data as a major challenge to assessing EHR safety, and this study was performed to inform the field about the types of EHR-related errors and problems reported to the Pennsylvania Patient Safety Authority and to serve as a basis for further study. Authority analysts queried the Pennsylvania Patient Safety Reporting System for reports related to EHR technologies and performed an exploratory analysis of 3,099 reports using a previously published classification structure specific to health information technology. The majority of EHR-related reports involved errors in human data entry, such as entry of “wrong” data or the failure to enter data, and a few reports indicated technical failures on the part of the EHR system. This may reflect the clinical mindset of frontline caregivers who report events to the Authority.</blockquote> Results: <blockquote class="tr_bq">... Reported events were categorized by their reporter-selected harm score (see Table 1). Of the 3,099 EHR-related events, 2,763 (89%) were reported as “event, no harm” (e.g., an error did occur but there was no adverse outcome for the patient) [a risk best avoided to start with, because luck runs out eventually - ed.], and 320 (10%) were reported as “unsafe conditions,” which did not result in a harmful event. Fifteen reports involved temporary harm to the patient due to the following: entering wrong medication data (n = 6), administering the wrong medication (n = 3), ignoring a documented allergy (n = 2), failure to enter lab tests (n = 2), and failure to document (n = 2). Only one event report, related to a failure to properly document an allergy, involved significant harm. </blockquote> A significant "study limitations" section was included that addressed:  <ul><li>Issues regarding reporting statutes of the PA-PSRS errors database; </li></ul><ul><li>lack of awareness of EHRs as a potential contributing factor to an error;</li></ul><ul><li>limitations of narrative reporting affecting both the types of reports queried and the tags applied (the study used textual data mining methodolgies);</li></ul><ul><li>query design of the study; and </li></ul><ul><li>the need for further refinement of the machine learning tool used in creating the working dataset, which may have missed relevant cases.</li></ul> Some of these impediments to knowing the magnitude of extant HIT issues are also present in the 2008 <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html" target="_blank">Joint Commission Sentinel Events Alert on HIT</a>, the <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">2010 FDA internal memorandum on HIT Safety</a>, and the <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">2011 IOM report</a> on the same topic. (The IOM report specifically observed that the "barriers to generating evidence pose unacceptable risks to safety.")  The major obstacle to this study in my view, though, was the nature of the dataset.  The database is for general reporting of medical errors, and it contains no specific fields or reminders about EHRs or the known ways in which they can contribute to, or cause, medical mistakes.   The attempt was made, as acknowledged in the study, to glean information about EHR-related events from, in large part, textual analysis of narrative in the hopes that the reporter recognized the role of IT, and reported it using terms that could be detected by the search algorithms.  In other words, the data was not "purposed" for this type of study.   It is axiomatic that one cannot find data that is simply not present, no matter how fancy the search algorithm.  Further, passive analysis of clinical IT risk/harms data in an industry where lack of knowledge of causation and misconceptions abound will produce only partial results that suggest further study is needed, and not give an indicator of just how incomplete the results are.  Thus, this cautionary statement was made in the new PA Patient Safety Authority report: <blockquote class="tr_bq">"Although the vast majority of EHR-related reports did not document actual harm to the patient, analysts believe that further study of EHR-related near misses and close calls is warranted as a proactive measure." </blockquote> My comments: The report is welcome. The most important part of the paper, I point out, is the “Limitations” section. FDA, IOM and others have made similar observations – we don’t know the true magnitude of the problem due to systematic limitations of the available data.  Therefore, at best what is available must be deemed as risk management-relevant case reports, a “red flag” that could represent (using the words of FDA CDRH director Jeffrey Shuren regarding HIT safety), the tip of the iceberg. It is imperative far more work be done in post-market surveillance as this technology is deployed nationally and internationally.  This is to ensure that good health IT (GHIT) prevails and bad health IT (BHIT) is either remediated or removed from the marketplace.  I had defined those in other writings 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 eHealthinformation secure, protects patient privacy and facilitates better practice of medicine and better outcomes.  </blockquote> <blockquote class="tr_bq">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> An additional major factor that also contributes to lack of knowledge of EHR-related adverse events is hospital reporting non-compliance. For instance, I know of cases from my own legal consulting work and personal experience that I would have expected to appear in the database, but apparently do not. But don’t take it from me alone. Here is PA Patient Safety Authority Board Member Cliff Rieders, Esq. on this. From “Hospitals Are Not Reporting Errors as Required by Law, Phila. Inquirer”, pg. 4,<a href="http://articles.philly.com/2008-09-12/news/24991423_1_report-medical-mistakes-new-jersey-hospital-association-medication-safety" rel="nofollow" target="_blank">http://articles.philly.com/2008-09-12/news/24991423_1_report-medical-mistakes-new-jersey-hospital-association-medication-safety:</a>    <blockquote class="tr_bq">... Hospitals don’t report serious events if patients have been warned of the possibility of them in consent forms, said Clifford Rieders, a trial lawyer and member of the Patient Safety Authority’s board. He said he thought one reason many hospitals don’t want to report serious events is that the law also requires that patients be informed in writing within a week of such problems. So, if a hospital doesn’t report a problem, it doesn’t have to send the patient that letter. [Thus reducing risk of litigation, and, incidentally, potentially infringing on patients' rights to legal recourse - ed.] Rieders says the agency has allowed hospitals to determine for themselves what constitutes a serious event and the agency has failed to come up with a solid definition in six years. Fixing this “is not a priority,” he added.</blockquote> This coincides with my own personal experience precisely.  In a case where my relative was permanently injured as a result of EHR-related medication error, and then died of the injuries, I never received the required report in writing from the hospital.  I also do not believe the case was reported to the Safety Authority, at least not as IT-related. I suspect the true rates of EHR-related close calls, reversible injuries, permanent injuries and deaths is significantly higher than the limited data available suggests. That data is merely a red flag that much more education, stringent reporting requirements,  templates of known causes of error, and enforcement are needed.  (An April 2010  "thought experiment" on this issue I wrote about at "<a href="http://hcrenewal.blogspot.com/2010/04/if-benefits-of-hit-can-be-guesstimated.html" target="_blank">If The Benefits Of Healthcare IT Can Be Guesstimated, So Can And Should The Dangers</a>" certainly suggested as much.) Slides where I made those types of recommendations to the Patient Safety Authority, at a presentation I gave in July 2012 at their invitation, are at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/PA_patient_safety_Jul2012.ppt" rel="nofollow" target="_blank">http://www.ischool.drexel.edu/faculty/ssilverstein/PA_patient_safety_Jul2012.ppt</a> A major concern I have is that the HIT industry will use this new report in a manner that ignores its limitations. (Disclosure: I was an invited reviewer of this new PPSA report.) -- SS  Addendum Dec. 13:    Also worth review is "<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243129/" target="_blank">Patient Safety Problems Associated with Heathcare Information Technology: an Analysis of Adverse Events Reported to the US Food and Drug Administration</a>", Magrabi, Ong, Runciman, and Coiera, AMIA Annu Symp Proc. 2011.   Data here came from FDA's voluntary (i.e., also tip of the iceberg) <a class="l" href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm">Manufacturer and User Facility Device Experience</a> (MAUDE) database.  Ironically, the study was done in Australia using Australian grant funds. -- SS

Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events

The Pennsylvania Patient Safety Authority has released a report " The Role of the Electronic Health Record in Patient Safety Events .&...

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Health Care Hired Managers Not Playing by the Same Rules - the Example of Lancaster General Health

That all people in the US do not play by the same rules, and that more specifically the richest people do not play by the same rules as the somewhat or a lot less rich, became a topic of discussion after the 2008 global financial collapse/ great recession.  A powerful discussion of this theme appeared in <a href="http://www.randomhouse.com/book/213722/predator-nation-by-charles-h-ferguson">Predator Nation</a>, the book by Charles Ferguson that followed his award winning documentary, <a href="http://www.sonyclassics.com/insidejob/">Inside Job</a>: <blockquote class="tr_bq">Ponder the toxic effects of too much wealth, too much power, the new culture of American investment banking, and a life conducted within the cocoon of America's new oligarchy. [p 112]</blockquote> He focused on the culture of <a href="http://hcrenewal.blogspot.com/search/label/finance">finance</a>, but as we have seen, this culture has overlapped the culture of health care.  Thus we have shown <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">multiple examples</a> of those who have become rich due to their positions in health care, almost always positions as high-ranking hired managers of health care organizations.  They get paid according to different rules than apply to other hired employees, and <a href="http://hcrenewal.blogspot.com/search/label/executive%20life%20style">live by different rules</a> than their less-favored fellow employees, again by virtue of their positions. Some of these examples were of CEOs of huge, for-profit health care corporations,  However, we have increasingly seen hired managers of moderate size non-profit organizations who also appear to play by different rules than their fellow employees. The Executives of Lancaster General Health The latest example appeared through <a href="http://lancasteronline.com/article/local/790929_Healthy-paychecks-for-LGH-executives.html">reporting</a> found in LancasterOnline, the web presence of several newspapers in Lancaster, Pennsylvania, about a regional community health care system, Lancaster General Health.  The <a href="http://www.lancastergeneralhealth.org/LGH/About-Lancaster-General-Health.aspx">system</a> includes one major hospital, Lancaster General, an obstetrics hospital, and a variety of satellites and out-patient facilities.     The system was facing challenges in 2010: <blockquote class="tr_bq">In 2010, times were getting tougher for Lancaster General Health. The mammoth [sic] health care system would notch record revenues of nearly $1 billion that year. But its annual surplus fell for the fourth straight year. Though destitute by no means, galloping expenses and uncertainty in the marketplace were hammering LGH's business model, prompting changes. Two units were closed, some positions were eliminated, and 170 employees were reassigned.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">However, despite these difficulties, </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">Two executives — CEO Tom Beeman, who was on military leave part of the year, and Executive Vice President Jan Bergen, who helped fill in for Beeman in his absence — earned more than $1 million in total compensation; another six got at least $500,000. And those top 21 executives collectively received more than $2 million in bonuses and incentives.</blockquote> That lavish total compensation included "perks" that were likely not furnished to lesser employees, for example <blockquote class="tr_bq">The IRS form lists few explicit perks, save one: LGH paid $1,044 in social club dues for Beeman in 2010. Said Regina Mingle, LGH's executive vice president of human resources: 'In this community, if you need to do business, you do it at the Hamilton Club or Lancaster Country Club. We decided ... we would pay those fees.'</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">It seems doubtful, however, that any other employees who felt that they did "business" at country clubs or similar establishments were entitled to subsidized dues.</div> This relatively lavish pay was part of a pattern.  Executive compensation had been increasing out of proportion to any obvious benchmark for a while. <blockquote class="tr_bq"> In fiscal year 2005-06, CEO Tom Beeman earned a comparatively modest total compensation of $646,094. By 2010, that had more than doubled, to $1.35 million. That figure included a base compensation of $606,728, along with $345,000 in bonuses and incentives and $279,511 in retirement and other deferred compensation. Bergen, who along with Executive Vice President Marion A. McGowan took on some of Beeman's duties when he left in October 2010 for a nine-month military leave of absence, saw her compensation rise from $332,823 in 2005-06 to a total of $1.1 million in 2010. The latter figure included $425,967 in base pay, $177,752 in bonuses and incentives, $111,383 in retirement and other deferred compensation, and $320,208 in what the IRS calls 'other reportable compensation' such as employee contributions to 401(k) or 403(b) retirement plans. The third highest-paid LGH executive in 2010 was McGowan, whose compensation package totaled $772,978, including $456,789 in base pay and $192,226 in bonuses and incentives. Fourth on the list was  </blockquote><blockquote class="tr_bq">Dr. Lee M. Duke II, senior vice president and chief physician executive, whose compensation totaled $746,830, including $405,083 in base pay and $140,377 in bonuses and incentives. Fifth was Chief Financial Officer F. Joseph Byorick Sr., whose total compensation of $652,667 included $397,160 in base pay and $140,500 in bonuses and incentives.</blockquote> So note that CEO Beeman's compensation was for less than one full year's worth of work.  His annualized rate would have been even more. A <a href="http://lancasteronline.com/article/local/790937_25-execs---2-1-million-in-bonuses-at-LGH.html">companion article</a> noted that part of CEO Beeman's bonus for 2010 was justified by his efforts to keep in touch with the institution while he was physically not present, and was, in fact off-site for an extended period fulfilling a military reserve commitment <blockquote class="tr_bq"> In October 2010, Lancaster General Health had a problem. Its CEO, Tom Beeman, was shipping out for a military tour of duty, to serve as deputy director of the National Intrepid Center of Excellence in Bethesda, Md. Two other administrators —  Executive Vice Presidents Jan Bergen and Marion W. McGowan — would step into Beeman's shoes while he was away. Yet Beeman stayed involved. 'We had regular Skype [video-conferencing] calls,' said Alex Henderson, chairman of the LGH Board of Trustees. That, LGH officials believed, merited a bonus. So Beeman got nearly $90,000 for his efforts in absentia.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> Note that this verified that Beeman got more than $1 million in compensation despite not having worked a whole year, since it was necessary for two other executives to take over his work. </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Furthermore, while US law does mandate employers to re-hire employees who take leaves to fulfill military reserve commitments (look <a href="http://www.dol.gov/vets/programs/userra/userra_fs.htm">here</a>),  I suspect that very few employers pay employees anything while they are away (although reservists are certainly paid by the government for their reserve duty).  However, Beeman got a bonus merely for keeping in touch while he was away doing another job.  I further suspect it is extremely unusual to pay an employee a bonus for trying to keep in touch during his or her military service. So the reporting on compensation given to top hired managers at Lancaster General emphasized that executive pay is set using very different rules than are used to set the pay of other employees. The Talking Points Reappear as Justifications for Exceptional Compensation of Hired Managers </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Furthermore, the justifications made for the Lancaster General top executives' large compensation packages echoed talking points used to support such largess for top hired managers in other health care settings, but did not explain why hired managers merit exceptional treatment.   We first listed the talking points <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a>, and then provided additional examples of their use <a href="http://hcrenewal.blogspot.com/2011/09/more-repeats-of-talking-points.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2012/03/example-of-how-complex-takes-control.html">here</a>.   The talking points are: -  we pay what everyone else pays -  CEOs work hard and are brilliant, and so deserve high pay -  high pay is needed to attract and retain competent, if not brilliant people. None of the examples of these talking points we have seen so far explain why these apply to CEOs and other top hired managers, but not to other kinds of employees.  . We Pay What Everyone Else Pays A <a href="http://lancasteronline.com/article/local/790930_Compensation-for-LGH-executives-has-nowhere-to-go-but-up.html">third article</a> in the LancasterOnline series noted that executive compensation was based on information on what everyone else pays, <blockquote class="tr_bq">nonprofits must hire consultants to study how similarly sized nonprofits pay their executives. LGH's consultant is a firm called Mercer, headquartered in New York City with an office in Philadelphia. Charlie Scott, of Mercer, has in recent years helped LGH determine what to pay its highest-compensated executives.  'Our role is to be [an] independent source of market norms,' said Scott, determining 'levels of compensation available in the market for executive positions, as well as how compensation is paid.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div> <div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><a href="http://lancasteronline.com/article/local/790930_Compensation-for-LGH-executives-has-nowhere-to-go-but-up.html#ixzz2Em2365eC" style="color: #003399;"></a>This is an interesting variant of this talking point, because it essentially blames the reasoning on the Internal Revenue Service.  The article did not explain how Mercer determined the extent of the appropriate market, nor how it obtained a representative sample of data about that market.</div> CEOs Work Hard and Are Brilliant, and So Deserve High Pay High Pay is Needed to Attract and Retain Competent, if not Brilliant People</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">These justifications are often combined.  In the case of Lancaster General, the examples <a href="http://lancasteronline.com/article/local/790929_Healthy-paychecks-for-LGH-executives.html">included</a></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">At LGH, officials say the generous compensation is necessary to attract and retain the top talent. Said Lancaster attorney Alex Henderson III, chairman of the Lancaster General Health board of trustees and its compensation committee, which decides what to pay top execs: 'Demand for top-notch hospital executives has grown, and we have to respond to that.' 'We're not looking to be average.'</blockquote> I seriously doubt that the hospital system is committed to "generous" pay to get "top talent" for all of its job openings.  Again, I doubt the generosity includes full pay for leaves taken for military service, or, for that matter country club dues. Another version was offered by the chair of the system's board of trustees: <blockquote class="tr_bq"> Trustee Henderson said that as LGH's goal isn't to maximize revenue but save lives, executives can be doing a fantastic job — worthy of six-figure bonus and incentive pay — even when the system's financial performance slips. Consider an executive who devises a way to shorten stays for patients, Henderson said: 'That's great for the patients, for insurance companies, for nurses who don't have to take care of people who don't need to be here' — but it's bad for LGH's bottom line.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Left out of the first part of the statement was how one could attribute lives saved to the work of a hired manager, especially, as in the case of CEO Beeman, a manager with no direct experience caring for patients.  Mr Beeman's <a href="http://www.lancastergeneralhealth.org/LGH/About-Lancaster-General-Health/About-LGH/Executive-Leadership.aspx">official hospital bio</a> listed this educational background,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Prior to joining Lancaster General Health, he served at Saint Thomas Health Services as its President and Chief Executive Officer, and the Senior Vice President for Hospital Operations and Executive Director of the Hospital of the University of Pennsylvania. </div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">It did not include any former positions that would have involved direct patient care.  </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Health care actually does not save lives that often, but hopefully does often ameliorate disease and injury, reduce suffering and improve function.  However, the people who actually directly accomplish this are health care professionals, nurses, doctors, therapists, etc, not managers who sit in offices.  </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">I will merely note that Mr Henderson's second example apparently was theoretical.  There was no example given of an executive who actually did shorten length of stay.  </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">In a <a href="http://lancasteronline.com/article/local/790930_Compensation-for-LGH-executives-has-nowhere-to-go-but-up.html">third article</a> in the LancasterOnline series, the compensation consultant employed by Lancaster General Health reiterated the argument that one must pay top dollar for scarce managerial talent:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">[Mercer consultant Charlie] Scott said that the law of supply and demand that applies 'to any type of talent pool applies to health care executives. There's normally a lack of supply of what's considered blue-chip talent ... [and] the increasing complexity of the health care industry requires an increasing level of talent and capability.'</div></blockquote></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> Note that no one who defended the compensation given to CEO Beeman or other top managers provided evidence that they are "top" or "blue chip" talent, or that they, rather than the health care professionals who work at or for the system save lives. Summary</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">In our last US election campaign season, a few candidates pledged to level the playing field so that rich and poor would play by the same rules.  Other candidates scoffed at the importance of the problem, or called its invocation class warfare.  Meanwhile, in health care, we just accumulate more examples that different people play by different rules. So we have yet another particular example of how top hired managers, particularly CEOs, of even modestly sized, non-profit health care organizations get to play by different rules than those affecting other employees, and other people who work in health care.  As in previous cases, the justifications provided for these different rules were basically a repeat of poorly conceived arguments that have been cited often by defenders of executive exceptionalism.  The "we pay what everyone else pays" is basically an<a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html"> appeal to common practice fallacy</a>.  Why we have to do so is never stated.  In any case, the argument did not include why the limited selection of comparator hospitals and executives used is a representative sample of "everyone."  Furthermore, as we noted <a href="http://hcrenewal.blogspot.com/2012/10/more-reasons-to-doubt-how-ceos-are.html">here</a>, what evidence there is suggests that skills required to run one organization do not necessarily transfer to another, suggesting the comparison to "everyone" makes no sense. As is usual, the "CEOs are brilliant" argument is basically an <a href="http://www.nizkor.org/features/fallacies/appeal-to-authority.html">appeal to authority fallacy</a>, and provided no evidence that the particular CEO is brilliant.  In fact, it seems that everyone who has used this talking point before claims his or her CEO is brilliant. (Look <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a> for example.) Obviously, all CEOs cannot be above average.  Finally, as noted <a href="http://hcrenewal.blogspot.com/2012/10/more-reasons-to-doubt-how-ceos-are.html">here</a>, there is no evidence that without high pay worthy leaders could not be hired or retained.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> Unfortunately, the otherwise excellent articles on Lancaster General did not challenge any of the defenders of executive exceptionalism to better justify their assertions.  Nor were they asked to consider its adverse effects.  As we have frequently said, current policies about paying hired health care managers leave the managers unaccountable for the effects of their actions on patients' and the public's health, and worse, fail to deter and may even encourage ignorance of the health care mission, frankly mission-hostile behavior, self-interest, conflicts of interest, and outright corruption.  Meanwhile, paying nearly all top managers as if they were brilliant, while setting much harsher standards for the employees who actually take care of patients, including health professionals, demoralizes those on whom patients actually depend for care. As we have said endlessly,....   Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses. </div></div>

Health Care Hired Managers Not Playing by the Same Rules - the Example of Lancaster General Health

That all people in the US do not play by the same rules, and that more specifically the richest people do not play by the same rules as the ...

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Fred Schulte on Investigative Journalism: "Race to electronic health records may come with a price"

Investigative reporter Fred Schulte of the <a href="http://www.publicintegrity.org/" target="_blank">Center for Public Integrity</a> has written up his experiences on his investigation of upcoding and Medicare billing inflation due to the effects of EHRs. The piece is of interest in regard to, at the very least, the personal recollections of how an investigation comes to be and is conducted. I thought his piece would be of interest to HC Renewal readers.  It is at the site of the American Association of Healthcare Journalists and entitled "<a href="http://healthjournalism.org/resources-articles-details.php?id=249#.UMIeIqyI5eA" target="_blank">Race to electronic health records may come with a price</a>." (The result of the investigation is the series entitled "<a href="http://www.publicintegrity.org/health/medicare/cracking-codes" target="_blank">Cracking the Codes</a>.) <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiAzvhRF-BIaHTtPu5qyez6X2_Yz0E5DLqEO3Rui7IAuwl0B0MtUTgJoT-yKJ-3wp-zkZFbz9VAzT8Ci9g1DS6E6hvNxXnM5h0Xy2M1tkELSOU7Lw9v5aBh9AsfKGsciNOiGYbv4E1xCSa/s1600/fred-schulte.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiAzvhRF-BIaHTtPu5qyez6X2_Yz0E5DLqEO3Rui7IAuwl0B0MtUTgJoT-yKJ-3wp-zkZFbz9VAzT8Ci9g1DS6E6hvNxXnM5h0Xy2M1tkELSOU7Lw9v5aBh9AsfKGsciNOiGYbv4E1xCSa/s1600/fred-schulte.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Fred Schulte</td></tr></tbody></table> This work contributed substantially and materially to a reluctant HHS and ONC deciding it was time to actually investigate the issue. (Perhaps sometime soon HHS and ONC may also seriously investigate health IT safety, and take more than Milquetoast action.) -- SS

Fred Schulte on Investigative Journalism: "Race to electronic health records may come with a price"

Investigative reporter Fred Schulte of the Center for Public Integrity has written up his experiences on his investigation of upcoding and ...

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I Wonder if Dr. Bob Wachter Has An IP Audit Trail For Comment Submissions To His Blog?

In my Jan. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html" target="_blank">More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?</a>" I described how I found that perverse, defamatory and even deranged comments were submitted to comment threads on this blog and elsewhere about my posts.  Unfortunately for the writer, the IP's of his submissions recorded in the Sitemeter IP audit trail for HC Renewal were of a health IT vendor, Meditech, as described in the post.  Even after the post, the abuse continued.  Only after I contacted the General Counsel of that organization did the abuses stop. At <a href="http://community.the-hospitalist.org/bobs-bio/" target="_blank">Bob Wachter's</a> blog "Wachter's World" I have been following a quite serious Sept. 2012 post entitled "<a href="http://community.the-hospitalist.org/2012/09/03/putting-the-a-back-in-soap-notes-time-to-tackle-an-epic-problem/" rel="bookmark" title="Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem">Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem</a>".  The post concerns the effects EHRs have on clinician cognition.  Dr. Wachter thoughfully concludes: <blockquote class="tr_bq">... All in all, I am pleased that UCSF went with the Epic system and I remain a fan of electronic health records. And Larry Weed was right: we must have a structure to record what is happening to our patients, and his problem-oriented approach remains the most appealing one. (Ultimately, one wonders whether <a href="http://en.wikipedia.org/wiki/Natural_language_processing" target="_blank">natural language processing</a> will make such a structure less important, in the same way that I no longer pay much attention to filing documents on my Mac now that its search function is so powerful.) But the time is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive <a href="http://en.wikipedia.org/wiki/Behavior-shaping_constraint" target="_blank">forcing functions</a>, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. Let’s show these computers who’s boss, and put the “A” [clinician assessment - ed.] back in SOAP.</blockquote> The post is followed by a largely thoughftul comment thread of dozens of comments. A new comment has appeared as follows, from an anonymous user "EPIC" whose self-submitted URL is "epic.com": <blockquote class="tr_bq"><div class="comment-head"><a class="url url" href="http://epic.com/" rel="external nofollow">Epic</a> December 7, 2012 at 9:48 am <a href="http://community.the-hospitalist.org/2012/09/03/putting-the-a-back-in-soap-notes-time-to-tackle-an-epic-problem/#comment-223652" title="Direct link to this comment">#</a></div><div class="comment-head">  </div>Physicians – thanks for your thoughts. However, we are not mind-readers and we can only work within the bounds of our archaic code. If you think you have it rough, you should hear what we hear from the nurses, you know, the underpaid ones that actually provide patient care and have to put up with your whining, bossiness, and superiority complexes. Anybody can memorize A&P. It takes common sense to use a computer. Perhaps time spent complaining could be more effectively be used in Epic ClinDoc training. Gotchya…</blockquote> The problems of health IT are all due to whining, complaining, bossy, conceited physicians who just won't learn how to use the EHR properly...who, by the way, lack common sense and should just shut up and read the manual ... gotchya! The response I've left requires no additional comment: <blockquote class="tr_bq"><div class="comment-head"><a class="url url" href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" rel="external nofollow">S Silverstein, MD</a> December 7, 2012 at 3:18 pm <a href="http://community.the-hospitalist.org/2012/09/03/putting-the-a-back-in-soap-notes-time-to-tackle-an-epic-problem/#comment-223858" title="Direct link to this comment">#</a></div><div class="comment-head">  </div>To whomever left the reply “Physicians – thanks for your thoughts” under the pseudonym “EPIC”… Your comment is, quite simply, perverse. It reflects an unfitness for you, if the comment is serious, to be involved in any aspect of healthcare. Your comment might have been at least humorous if it referred to, say, IT issues in a nail parlor or pizza shop. We are discussing, however, IT problems in patient care, that affect everyone, including the most ill of patients who expect the healthcare system to focus on their needs. Further, you show a lack of understanding of what the National Institute of Standards and Technology (NIST) has recently made plain: the concept of “use error”: ——————– … The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized. [3] “Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions - ed.], misuse of color-coding conventions, omission of information [or poorly presented information - ed.], etc. ——————– Take your perverse attitudes and ignorance elsewhere. Preferably far from your nearest healthcare facility. Scot Silverstein, MD Drexel University, Philadelphia <a href="http://hcrenewal.blogspot.com/" rel="nofollow">http://hcrenewal.blogspot.com</a></blockquote> I am curious if the IP audit trail, if any, of Dr. Wachter's blog shows the IP of "Mr. Epic" and whether the IP shows the comment was truly coming from EPIC itself. -- SS

I Wonder if Dr. Bob Wachter Has An IP Audit Trail For Comment Submissions To His Blog?

In my Jan. 2010 post " More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets? " I described how I found...

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How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist in the 10's

I was interviewed in my home yesterday by Jay Hancock, Senior Correspondent, <a href="http://www.kaiserhealthnews.org/About.aspx" target="_blank">Kaiser Health News</a> about my background, how I got to the current point in my Healthcare Informatics career, my opinions on the state of health IT in 2012, and related matters for a possible article: <blockquote class="tr_bq">Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics. KHN’s mission is to provide high-quality coverage of health policy issues and developments at the federal and state levels. In addition, KHN covers trends in the delivery of health care and in the marketplace. KHN is an editorially-independent program of the <a href="http://www.kff.org/" shape="rect" target="_blank">Kaiser Family Foundation</a>, a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible analysis and information on health issues. </blockquote> Mr. Hancock has quoted me regarding health IT in the past in his current role and when he was a reporter for the Baltimore Sun, for instance in the April 2012 article "<a href="http://www.washingtonpost.com/health-insurance-companies-push-to-diversify-raises-concerns/2012/04/27/gIQAWoSkoT_story.html" target="_blank">Health insurers’ push to diversify raises ethical concerns</a>" that appeared in the Washington Post as well, and the Nov. 2011 article "<a href="http://weblogs.baltimoresun.com/business/hancock/blog/2011/11/advice_to_hospitals_be_careful.html" target="_blank">Advice to hospitals: Be careful what you bill for</a>" in the Baltimore Sun. Mr. Hancock wanted to get an understanding of me, the person.  In doing so, I dug out some of my past technology "toys" to show him at the onset of the interview.  Ironically, doing so reminded me of some irritating occurrences in the past that both inform present views, and served as early experiences in why health IT suffers the problems it does. I will illustrate by showing some of the devices I presented to Mr. Hancock in order for him to better know my interests/knowledge of technology, and then presenting the unpleasant recollections that doing so brought on. Bear with me for a few moments (and pictures). I showed Mr. Hancock devices I'd built and/or used in teaching such as (click to enlarge): <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/AVvXsEhNI2bBd1cOfE5MXq_R7FhoDuqo7tsA0MIEZM-DFZRq2L_RF0nbjYKfMTqCbBLXMf05XS_DIX3LXnmrJC14UHPKHVGxIqkzRF_p0dJtjzyaXY4Ku6kswyTxr4uM62C-SoiTDDjY3RX_XHqE/s1600/monitor.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="184" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhNI2bBd1cOfE5MXq_R7FhoDuqo7tsA0MIEZM-DFZRq2L_RF0nbjYKfMTqCbBLXMf05XS_DIX3LXnmrJC14UHPKHVGxIqkzRF_p0dJtjzyaXY4Ku6kswyTxr4uM62C-SoiTDDjY3RX_XHqE/s1600/monitor.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">An infrared-sensing heart monitor I built in 1980 during a clerkship in biomedical engineering, Boston University Hospital, 1980</td></tr></tbody></table> <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/AVvXsEjLRMslJ-L6uo5Up8v3f8gW6Tpn1DsKPohhPgjvkTPgXFzTIiBvxK4QWY04-9OZAPrwntaxdyaXc3FpVl_eBpxroWG5Pbjs1u0pi9D_3uU0e6N2bsn44mmgGA3GlflHNkoBoRJWSjK3E_ET/s1600/monitor_inside.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLRMslJ-L6uo5Up8v3f8gW6Tpn1DsKPohhPgjvkTPgXFzTIiBvxK4QWY04-9OZAPrwntaxdyaXc3FpVl_eBpxroWG5Pbjs1u0pi9D_3uU0e6N2bsn44mmgGA3GlflHNkoBoRJWSjK3E_ET/s1600/monitor_inside.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Inside the heart monitor.  I etched and drilled the printed circuit boards myself.</td><td class="tr-caption" style="text-align: center;"></td><td class="tr-caption" style="text-align: center;"></td></tr></tbody></table> <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/AVvXsEjfaQ4LIqHZqETVHyBYLKV7nBObQVnYUWtTMyFPyCPsLa0TFUf7OPEyf3-MsobysGudPtzn-AikRxWl0IQF8mB_TPCoCWMEmHpu_WNA-6MKmEy2HZhMrPq1Ws_5mAQkjl5Vhi5uM9RwHF3N/s1600/pbox.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfaQ4LIqHZqETVHyBYLKV7nBObQVnYUWtTMyFPyCPsLa0TFUf7OPEyf3-MsobysGudPtzn-AikRxWl0IQF8mB_TPCoCWMEmHpu_WNA-6MKmEy2HZhMrPq1Ws_5mAQkjl5Vhi5uM9RwHF3N/s320/pbox.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">A 3-transistor breadboard shortwave radio I built as a kid.</td></tr></tbody></table> <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/AVvXsEhRBkW3a2lwQrI8Z1iqGOfk9HVmZYLs3atqSj2DqdhEAzgtbr11HcMJQ0UkAQuradR-gr4UeEQk1GcJDAnwyAxgC9PbIwQknRZtk7mnjajZDhoS7AnABcvRkc-EzIfRrIeVxrv0ereDyMJx/s1600/hw101.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="201" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRBkW3a2lwQrI8Z1iqGOfk9HVmZYLs3atqSj2DqdhEAzgtbr11HcMJQ0UkAQuradR-gr4UeEQk1GcJDAnwyAxgC9PbIwQknRZtk7mnjajZDhoS7AnABcvRkc-EzIfRrIeVxrv0ereDyMJx/s1600/hw101.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">A somewhat more sophisticated radio kit.  My Heathkit HW-101 ham radio transceiver, built myself over several months when I was a medical trainee.  Also built its matching power supply box, not shown.</td></tr></tbody></table> <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/AVvXsEioHh-zMYfMv-DtCyWAxE4DsLkBTmP_l0mLMs4LSgcj90n_y6IplsjDBkyE5fFqKU7VaFeMbqzJf9r1R_TLMwZoUbeDVh-5PogmI3F1rJugTWpJcDwqRi_bzsz37ZnkqPL4sp6xJSA9sjxc/s1600/hw101_inside.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="275" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioHh-zMYfMv-DtCyWAxE4DsLkBTmP_l0mLMs4LSgcj90n_y6IplsjDBkyE5fFqKU7VaFeMbqzJf9r1R_TLMwZoUbeDVh-5PogmI3F1rJugTWpJcDwqRi_bzsz37ZnkqPL4sp6xJSA9sjxc/s1600/hw101_inside.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">HW-101 innards, top view.  Not exactly a simple device.</td></tr></tbody></table> <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/AVvXsEjMqX4MYZmY9Ir7PY_5ldAliBxLTsZaW_yERtsdfCgBKjFsTz04ptod_hZCir8n3L_GUh8EohaUfULwL7KGBc-PHpXtCFqlmDQHDvHnupKdFuvctFnTx0_2Ue6kktj9iodAFpu42cdWhvpY/s1600/hw101_under.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="243" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMqX4MYZmY9Ir7PY_5ldAliBxLTsZaW_yERtsdfCgBKjFsTz04ptod_hZCir8n3L_GUh8EohaUfULwL7KGBc-PHpXtCFqlmDQHDvHnupKdFuvctFnTx0_2Ue6kktj9iodAFpu42cdWhvpY/s1600/hw101_under.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">HW-101 underside of chassis.  Each and every one of those solder connections was done by me.  In bulding it, I learned how each circuit worked (and had to debug it when, on initial powerup, smoke rose due to a defective ceramic capacitor and two bad tubes, one of which glowed a delightful cherry-red.)</td></tr></tbody></table> <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/AVvXsEhxcE0GYwocATWczjbtZGBlKniF-7aPALWsis0MBi5u__4pa_VHxmCing_cd6seWbzIamDdbGL2CiAb957sOGYa2nPSKlt1COjY6apzsvGBinI_W8_jq3deMH0X-mlX_LisIeDZlwzOMtBm/s1600/h8.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="194" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxcE0GYwocATWczjbtZGBlKniF-7aPALWsis0MBi5u__4pa_VHxmCing_cd6seWbzIamDdbGL2CiAb957sOGYa2nPSKlt1COjY6apzsvGBinI_W8_jq3deMH0X-mlX_LisIeDZlwzOMtBm/s1600/h8.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">My Heathkit H8 computer, introduced 1977.  Intel 8080 processor. One of the first personal computers.  In true minicomputer style, the 8080 general registers, accumulator/flags register, program counter, stack pointer, and memory addresses were directly accessible via the front panel pushbuttons and the split-octal display.</td></tr></tbody></table> <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/AVvXsEjHGHE5EygfpJBKVtX14fYUUJfIBoAfLSl2qS0MnTelvSda98KbpWW7dgdhroNFhb12xExI1UQssJ9La2gOfpse1R4TrbQSAPkOCfLdcmzZdrMkQgnbzLH5xn0v7R0O1F3ZUqFeDd_KR7yN/s1600/h8_inside.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHGHE5EygfpJBKVtX14fYUUJfIBoAfLSl2qS0MnTelvSda98KbpWW7dgdhroNFhb12xExI1UQssJ9La2gOfpse1R4TrbQSAPkOCfLdcmzZdrMkQgnbzLH5xn0v7R0O1F3ZUqFeDd_KR7yN/s1600/h8_inside.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Inside the H8.  I used this to teach computer and CPU architecture to Medical Informatics  postdoctoral fellows at Yale School of Medicine.  I did not, and do not believe healthcare IT leaders should be mere “appliance operators.” </td></tr></tbody></table> <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/AVvXsEiaQg4SB7pJYQ5Qdi4e4ld8PE41FFf2XnL-l8kA0woZYT5-WCgiS7yayoTWkekfcNI91YlDZDecsp2FTk6sWrQ030m7RDX8CVoNVLS9EOgHCgZO0X3Z6eEOXpm4t93HVe7HUstW4GhetGce/s1600/vtos.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaQg4SB7pJYQ5Qdi4e4ld8PE41FFf2XnL-l8kA0woZYT5-WCgiS7yayoTWkekfcNI91YlDZDecsp2FTk6sWrQ030m7RDX8CVoNVLS9EOgHCgZO0X3Z6eEOXpm4t93HVe7HUstW4GhetGce/s1600/vtos.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">My TRS-80 Model I running VTOS 4.0, a pre-IBM PC precursor to LDOS 5 and TRSDOS 6.  All were far superior to MS-DOS of any flavor in my opinion.</td></tr></tbody></table> <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/AVvXsEhm2GpffAVXmQfo1n78BVq860ijo7GEmRcNpAb9ZX4p80_nuN3399P32r8UOg40-BBBGcwLMZbLsVb79GUGLdApiKm1vSN_zkt8rWuzBN0L7xjmJhLK2hYSnqmsbKu3gbCQL-PI96d60zY1/s1600/trs80_fix.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="244" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhm2GpffAVXmQfo1n78BVq860ijo7GEmRcNpAb9ZX4p80_nuN3399P32r8UOg40-BBBGcwLMZbLsVb79GUGLdApiKm1vSN_zkt8rWuzBN0L7xjmJhLK2hYSnqmsbKu3gbCQL-PI96d60zY1/s1600/trs80_fix.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">TRS-80 Model I about to undergo repair by me.</td></tr></tbody></table> As I mentioned before the pictures, unpacking from their storage boxes and showing this personal technology brought out numerous formative memories, and not always good ones, from my CMIO (Chief Medical Informatics Officer) days. Seeing all this, it may be easier to imagine why, as a CMIO in the mid 1990's I was offended when patronized by hospital IT personnel about how an information system  in an invasive cardiology cathlab, a critical care area, could not be moved from unstable Windows 3.1 to Windows NT to prevent frequent crashes and data loss because “Windows NT needed RAID disk arrays” and other B.S., and also by similar personnel patronizing me on my serious concerns about ICU patients put at risk of infection by improper hardware for a biohazard-prone environment.  (See <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story</a> and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU</a>.) I was further reminded about how I was alarmed by the selfsame hospital IT "experts", lacking healthcare and medical informatics knowledge and experience, simply ignoring my counsel, as if medicine was a harmless parlor game to be played, winner take all.  And likewise regarding hospital senior management who's hired me in the first place - at least one of whom expressed to me more concern for the career advancement of the IT staff than for patient safety. The latter ICU incident, in fact, directly led to my starting to write about health IT issues on the Web in 1998.  Sadly, my colleagues, as well as former students and mentees, tell me little has changed. That type of territorial, political behavior might perhaps be more appropriate (or at least hardly harmful) in a nail salon or pizza parlor, but not in an ICU or cardiac cath lab. Yet today's health IT domain is rife with leadership by health IT amateurs** [see note below] who patronize, bully and play nasty politics with healthcare informatics-educated clinicians and specialists, and accuse clinicians of being "Luddites" for resisting <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">bad health IT</a> pushed on them by hyperenthusiasts (<a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">Ddulites</a>) who ignore the downsides.   <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 eHealthinformation 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> What is lost in these dysfunctional dynamics is that the true "customer" who suffers is the patient.  Patients come to the hospital sick and with expectations that the personnel there will put the patients' interests first.  If they are injured or leave in a pine box, they care little about whose political empires were threatened by internecine and/or industry battles over IT. Mr. Hancock's Kaiser Health News profile of me, if published, should prove interesting.   It will probably mention my own relative's injury and death related to health IT, and may cite the Complaint itself, a public document.   I will link to it when it if and when it appears. -- SS ** (Amateur, used in the same sense that I am a <a href="http://www.arrl.org/" target="_blank">radio amateur</a> licensed by the government after a series of written exams, but not a professional telecommunications engineer, knowing I would not want to, nor should be allowed to, lead a mission critical telecommunications project.) ----------------------- Feb. 18, 2013 Addendum: The article was published as <a href="http://hcrenewal.blogspot.com/2013/02/kaiser-health-newsphiladelphia-inquirer.html" target="_blank">here</a>. -- SS

How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist in the 10's

I was interviewed in my home yesterday by Jay Hancock, Senior Correspondent, Kaiser Health News about my background, how I got to the curre...

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The Parts of Professionalism We Are Not Supposed to Discuss

A recent article in a a relatively obscure medical ethics journal dared to approach some important aspects of medical ethics that medical ethicists fear to discuss, but did not address the reasons for this fear or what to do about it. (Glenn JE. The eroding principle of justice in teaching medical ethics.  HEC Forum 2012; 24: 293-305.  Link <a href="http://link.springer.com/article/10.1007%2Fs10730-012-9199-4">here</a>.) The Basic Ethics Case - A Prescription for the Patient's Spouse? Glenn began with a case typically discussed in medical school ethics courses: <blockquote class="tr_bq">a scenario where a standardized patient asks the student at the end of the examination if his prescription can be written in his spouse’s name as the spouse has health insurance which includes prescription drug coverage while the patient does not.</blockquote> This <blockquote class="tr_bq">poses the question as to whether it is ethical for physicians to deceive third party payers to secure coverage for their patients.</blockquote> The Politically Correct Way to Teach the Case Glenn stated that there is a politically correct way for faculty to teach this case: <blockquote class="tr_bq"> Though we are never expressly instructed to tow [sic] a party line, there is a 'correct' answer to this ethical quandary as far as the institution we work for is concerned. Students who express a willingness to practice deception of third party payers for the good of their patients are to be commended for having their heart in the right place. However, we discuss many reasons why this action would not be a good solution to the problem. One of the issues is that to do so would be committing fraud.</blockquote> Now, of course, writing a prescription for a patient who does not actually need the drug in question, understanding that the patient will give the drug to someone else who does not have insurance coverage to pay for it, is dishonest.  However, the larger point that Glenn made is that it is not politically correct to allow discussion about why the patient made such a request in the first place, and that this ought to be troubling. Note that Glenn did not explain how he inferred what the "correct" answer was, nor its actual source within the institution. <blockquote class="tr_bq">Over the first few years of having this conversation with young medical students, I have always come away feeling empty and flat. Framed as a session on the ethics of 'truth telling,' the conversation and the readings we provide to prepare for it works to obfuscate the much larger ethical issue impossible to tackle in an hour’s time. In essence, 'truth telling' is only a secondary ethical issue at play. The more important ethical issue is a question of social justice: what commitment do doctors have to poor patients and making sure that they get the health care services that they need?</blockquote> Social Justice as Part of Professionalism, and its Avoidance The article by Glenn then emphasized that some of the original conceptions of physicians' professionalism included social justice.  A definition promulgated by Herbert Swick in 2000 expressly included these relevant competencies.  Physicians ought to: -  subordinate their own interests to the interests of others -  respond to social needs and work toward the benefit of the communities in which they live and serve -  adhere to the core humanistic values of honesty and integrity, compassion, altruism, empathy, respect for others, and trustworthiness. Glenn noted that these three competencies, however, have been turned into a more narrow imperative, that <blockquote class="tr_bq">doctors should treat patients with an equally high quality irrespective of their race, ethnicity, gender, religion or cultural background according to what is best for them. In most codes of professionalism, however, class is not expressly implicated.</blockquote> Note that Glenn did not question why the issues of race, ethnicity, gender, religion, or cultural background became important in this context.  He did further question why the issue of class did not.  While <blockquote class="tr_bq"> The professionalism code adopted by the American Board of Internal Medicine in 1999 was bolder and specifically states that doctors are to advocate for 'the best possible care [for their patients] regardless of the ability to pay'</blockquote> Glenn asked <blockquote class="tr_bq"> But where in the medical school curriculum do we teach medical students to be strong patient advocates and take on third party payers and hospital administrators? We now discuss the importance of prescribing generic drugs and we warn against the influence of big pharma, but when do we teach students to rebel against the high cost of medical education that drives students toward boutique medicine and fields of specialty care that offer the most money and most comfortable lifestyles?</blockquote> Furthermore, he noted, <blockquote class="tr_bq"> When it comes to justice in medical ethics instruction, the parameters of the discussion are usually constricted to focus on the conservation of health care resources and rationing care rather than providing more care to more patients.</blockquote> So, now seemingly getting to the key question, <blockquote class="tr_bq">We have created an entire system where all the middlemen that stand between a patient and her health care are expecting to get rich. No oath or professionalism curriculum is structured to teach medical students how to ethically and morally navigate through that. How did the terms of the debate get so co-opted by the health care economists?</blockquote> The Key Question also Avoided However, after this build up, Glenn then had trouble grappling with that question.  He noted that the prices of various parts of US health care are rarely questioned, and wrote about some of the particular issues in pricing new technologies, including the costs of development of new drugs, the tax treatment of drug development, and whether the licenses drug companies obtain from universities to develop drugs are fairly priced.  He also touched on the rising cost of medical school tuition and students' consequent assumption of large levels of debt.  This was interesting, and provided some useful references, but never really directly addressed the key questions above: why was the discussion framed in terms only of current health economics, and more importantly,  why did he and other ethicists feel they could not openly discuss any larger issues? Only at the very end of the article did this appear <blockquote class="tr_bq">the structure of our current medical system has created a network of health care providers, researchers, purveyors and administrators who have strong financial incentives to work against the best interests of patients. This situation makes it difficult to talk with students about the ethical principle of justice in any meaningful way that is not hypocritical, leaving it seldom emphasized relative to the other three core principles of medical ethics.</blockquote> Glenn did not further explain these "financial incentives," detail further who had them, explain how they "work against the best interests of patients," and most importantly, explain how these incentives make "it difficult to talk with students about the ethical principal of justice in any meaningful way that is not hypocritical."  He concluded only <blockquote class="tr_bq"> How can we cultivate within our students an understanding of the threats to medical professionalism posed by the conflicts of interest inherent in the various financial and organizational arrangements in the practice of medicine?  We start by not shying away from the conversation.</blockquote> Summary So Professor Glenn argued that social justice has been considered part of health care ethics, and that ethicists should teach about it by questioning the current economic arrangements within the health care system.  He then suggested that ethicists have been somehow pressured not do raise such questions, and that this pressure has something to do with <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse incentives</a> and <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> prevalent within health care.  However, he never actually addressed who pressured the ethicists, how the pressure was applied, and how that pressure was related to conflicts of interest. Thus, it seems that authors in scholarly health care journals may now hint that there are certain things one must not discuss, that are taboo to discuss in health care, but cannot actually say what exactly is taboo, and why it became that way.  Thus, the article by Glenn seems related to what we sometimes coyly call the "<a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>,"  that the issues we discuss on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> often do not seem to be considered topics of polite conversation.  But in a strange recursive way, the article never could quite manage to discuss what it is it said others cannot discuss, which in a way just further validates the importance of the anechoic effect. The Glenn article is reminiscent of another article we <a href="http://hcrenewal.blogspot.com/2012/01/elephants-we-can-notice-but-cannot-name.html">posted</a> about.  That article, by Souba and colleagues,  found that there are many "elephants," that is,  unmentionable subjects, in academic medicine,  However, that article also never clearly defined what these unmentionable subjects actually are, other than subjects that displease those in power.  Thus this too reinforced just how taboo these topics are.  Even those willing to admit that taboo topics exist are still unable to name them. At least the Glenn article did suggest, however vaguely, a relationship between conflicts of interest and the anechoic effect.  We have documented that <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">individual </a>and<a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest"> institutional</a> conflicts of interest are rampant in health care, including, and probably particularly academic medicine.  For example, pharmaceutical companies (and also all sorts of other health care corporations) may pay medical school faculty members and administrators (as consultants, <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">"key opinion leaders,"</a> speakers, advisers, even board members).  The leaders of academic medicine seem particularly prone to such conflicts. For example, a majority of US medical school department chairs have significant financial relationships with health care corporations (see post <a href="http://hcrenewal.blogspot.com/2007/10/medical-school-leaders-conflicts-of.html">here</a>).  We have shown how top medical school leaders may simultaneously serve on the boards of directors of health care corporations (see post <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">here</a>). Such health care corporations may now also support various aspects of medical academia (through research grants, "unrestricted" and other educational grants, other gifts to hospitals and universities, etc).  Financial conflicts of interest may help to directly enrich many faculty and academic leaders, and indirectly enrich them by enriching their organizations. People who are personally profiting from relationships with health care corporations are unlikely to question such relationships.  The leaders of organizations which depend on funding from such corporations are unlikely to question whether conflicts of interest might lead to corruption.  People whose colleagues, friends, family members, or supervisors are personally benefiting from conflicts of interest may hesitate to challenge such relationships.   Since these relationships permeate the economics of health care, is it any wonder that the entire topic has become taboo?   So the first step in challenging this taboo is to acknowledge it exists, and to not "shy away" from discussing it, as Glenn suggested.  People are beginning to acknowledge there is an elephant in the room.  Now we have to describe the elephant, discuss the elephant, and eventually figure out how to get the elephant out of the room.      Hat tip - to the <a href="http://blog.abimfoundation.org/recommended-reading-november-3-9/">Medical Professionalism Blog</a>.

The Parts of Professionalism We Are Not Supposed to Discuss

A recent article in a a relatively obscure medical ethics journal dared to approach some important aspects of medical ethics that medical et...

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The Life of a Clicker, and Putting the "A" back in "SOAP"

The Life of a Clicker, and Putting the "A" back in "SOAP"

A brief post. I found these two recent links worthy of perusal: The Life of a Clicker - by a Family Physician - describes how EHRs have tur...

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