Pfizer's 13th Legal Settlement - Will it be Enough to End the Impunity?

It has been almost two months since we lasted <a href="http://hcrenewal.blogspot.com/2012/10/when-clinical-trials-are-meant-for.html">noted</a> misbehavior by giant global pharmaceutical firm Pfizer Inc. With little fanfare, however, a few small news items noted the corporation's latest legal settlements.<br /><br /><b>Deceptive Marketing of Protonix </b><br /><br />The first settlement merited only a few paragraphs <a href="http://www.reuters.com/article/2012/12/12/us-pfizer-settlement-idUSBRE8BB19O20121212">from Reuters</a>.  The gist was:<br /><br /><blockquote class="tr_bq"><span id="articleText"><span class="focusParagraph"><span class="articleLocatio</span>n"><i>Pfizer Inc will pay $55 million plus interest to settle charges that Wyeth promoted its acid reflux drug Protonix for unapproved uses and made unproven claims</i> about the medicine, the U.S. Department of Justice said on Wednesday.  </span></span></span><br /><br /><span id="articleText">The infractions took place between February 2000 and June 2001, long before the world's largest drugmaker acquired Wyeth in 2009 for $68 billion.</span></blockquote><br /><span id="articleText">A <a href="http://www.examiner.com/article/pfizer-agrees-to-pay-55m-for-illegally-promoting-protonix">report</a> in the examiner explained that Wyeth did not merely go beyond the label in promoting Protonix, it went beyond the evidence.</span><br /><br /><blockquote class="tr_bq">Wyeth allegedly promoted Protonix as the 'best PPI for nighttime heartburn' <i>even though there was never any clinical evidence that Protonix was more effective</i> than any other PPI for nighttime heartburn. </blockquote><br />Furthermore, the charges were that systemic efforts to mislead were sanctioned by top management:<br /><br /><blockquote class="tr_bq"> The allegations in the complaint are that this superiority slogan was formulated <i>at the highest levels of the company</i>. Wyeth retained an outside market research firm, at the cost of tens of thousands of dollars, to ensure that sales representatives delivered that misleading superiority message.</blockquote><br />Finally, the government asserted that Wyeth corrupted physicians' continuing medical education in the process:<br /><br /><br /><blockquote class="tr_bq">Finally, the government alleges that Wyeth<i> used continuing medical education (CME) programs to promote Protonix for unapproved uses. </i>CME programs are sponsored by accredited independent providers, such as universities, nonprofit organizations, or specialty societies. Pharmaceutical companies are permitted to provide financial support for CME programs, but they are not permitted to use CME programs as promotional vehicles for off-label indications.<br /><br />According to the complaint, Wyeth spent millions of dollars providing 'unrestricted educational grants' to CME providers, and <i>these grants invariably included promises that Wyeth would not attempt to influence the content of the program in any way. Nevertheless, the government alleges that one of Wyeth’s core marketing tactics for Protonix was to use CME programs to drive off-label use of the drug. According to the complaint, the Protonix 'brand team' influenced virtually every aspect of these CME programs: program topics, speaker selection, organization, and content.</i> In addition, the government alleges that <i>Wyeth even insisted that the CME program materials use the same color and appearance as Protonix promotional materials</i>–a tactic that Wyeth and the vendor called 'branducation.'</blockquote><br />So it seemed that the company put on quite an effort to promote what we have called elsewhere pseudo-evidence based medicine, yet, like many other legal settlements involving large health care organizations, this one involved no penalties of any type against the people within the organization who authorized, directed, or implemented the bad behavior.  <br /><br /><span id="articleText"> <b>Misleading Marketing of Zyvox, Lyrica</b></span><b><span id="articleText"> </span></b><br /><br /><span id="articleText">Another settlement, for a few dollars less, got even less attention.  Fox Business news did <a href="http://www.foxbusiness.com/news/2012/12/12/pfizer-will-pay-42-million-to-settle-unfair-marketing-charges-related-to-zyvox/">repor</a>t this:</span><br /><br /><blockquote class="tr_bq"><span id="articleText"> </span><i>Pfizer Inc. (PFE) agreed to pay a combined $42.9 million to North Carolina and 32 other states in a settlement of allegations that the drug maker used unfair and deceptive practices in the marketing of antibiotic Zyvox and nerve-pain medicine Lyrica.</i></blockquote><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">I could find no detail about the sorts of deception allegedly involved in the news media.  What little more Fox provided did suggest that this case also involved pitching drugs in instances in which their use was unsupported by good evidence:</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">The states had alleged that Pfizer had marketed Zyvox as superior to another antibiotic in fighting certain types of infections, though there allegedly <i>wasn't substantial evidence to support superior results </i>for some uses that Pfizer claimed.<br /><br />The states also alleged that Pfizer marketed Lyrica for some off-label, or unapproved, uses. </div></blockquote><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">There was no hint that again any individual would suffer any negative consequences for this particular set of deceits either.</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>Avoiding Impunity as a Topic of Polite Discussion</b></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">We have discussed a seemingly endless parade of <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a> by large health care organizations.  In almost none was there any consequence beyond a fine paid by the company, and sometimes a pledge that the company would thereafter behave better.  While these relatively small costs were diffused throughout the organizations, almost never did the people who authorized, directed, or implemented the bad behavior pay any price or suffer any penalty.  Thus we have opined again and again (e.g., most recently <a href="http://hcrenewal.blogspot.com/2012/11/phony-consulting-and-royalty-agreements.html">here</a>) that these settlements have become just another cost of doing business, and have no power to deter future bad behavior.<br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">In addition, we have noted not only have multiple organizations made such settlements, some organizations have settled again and again.  Yet even in the cases of these multiple organizational offenders, the individuals involved maintain their immunity from any negative consequences.  Thus these are examples of impunity.  </div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Transparency International declared 23 November, 2012, as the <a href="http://www.transparency.org/news/feature/international_day_to_end_impunity">International Day to End Impunity</a>, explained as follows:</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><blockquote class="tr_bq"><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">At Transparency International we view <i>impunity as getting away with bending the law, beating the system or escaping punishment. <b>Impunity is anathema</b> to the fight against corruption</i>.</div></blockquote><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />However, impunity is one of those concepts which never seems to be a subject of polite conversation in health care, or, as we say, it has become <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>.  </div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />Therefore, it is fascinating that while these two Pfizer settlements were announced almost simultaneously, each was discussed, such as it was, as if it occurred in a vacuum.  Moreover, it also seems that each settlement was crafted by law enforcers without any attention to the record of the company making the settlement.  Thus, any implications about impunity were avoided.</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>Pfizer's Multiple Ethical Opfenses</b></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">In fact, during the time we have been posting on Health Care Renewal, Pfizer has become one of the great repeat ethical offenders in the health care arena.  Its track record since the beginning of the 21st century, (with yello colored background below, compiled from <a href="http://hcrenewal.blogspot.com/2012/08/pfizers-pforeign-pfiasco.html">this post</a>), is remarkable.</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><span style="background-color: #fff2cc;">In the beginning of the 21st century, <a href="http://articles.philly.com/2009-09-03/business/25267571_1_pfizer-employee-pfizer-sales-representatives-zyvox">according to the Philadelphia Inquirer</a>, Pfizer made three major settlements,</span> <br /><blockquote><span style="background-color: #fff2cc;">October 2002: Pfizer and subsidiaries Warner-Lambert and Parke-Davis agreed to pay $49 million to settle allegations that the company fraudulently avoided paying fully rebates owed to the state and federal governments under the national Medicaid Rebate program for the cholesterol-lowering drug Lipitor.</span></blockquote><blockquote><span style="background-color: #fff2cc;">May 2004: Pfizer agreed to pay $430 million to settle DOJ claims involving the off-label promotion of the epilepsy drug Neurontin by subsidiary Warner-Lambert. The promotions included flying doctors to lavish resorts and paying them hefty speakers' fees to tout the drug. The company said the activity took place years before it bought Warner-Lambert in 2000.</span> </blockquote><blockquote><span style="background-color: #fff2cc;">April 2007: Pfizer agreed to pay $34.7 million in fines to settle Department of Justice allegations that it improperly promoted the human growth hormone product Genotropin. The drugmaker's Pharmacia & Upjohn Co. subsidiary pleaded guilty to offering a kickback to a pharmacy-benefits manager to sell more of the drug.</span></blockquote><span style="background-color: #fff2cc;"><br />Thereafter, Pfizer paid a $2.3 billion settlement in 2009 of civil and criminal allegations and a Pfizer subsidiary entered a guilty plea to charges it violated federal law regarding its marketing of Bextra (see post <a href="http://hcrenewal.blogspot.com/2009/09/pfour-legal-settlements-for-pfizer-why.html">here</a>).  Pfizer was involved in two other major cases from then to early 2010, including one in which a jury found the company guilty of violating the RICO (racketeer-influenced corrupt organization) statute (see post <a href="http://hcrenewal.blogspot.com/2010/03/settlement-and-conviction-round-up.html">here</a>).  The company was listed as one of the pharmaceutical "big four" companies in terms of defrauding the government (see post <a href="http://hcrenewal.blogspot.com/2010/12/drug-companies-are-now-no-1-when-it.html">here</a>).  Pfizer's Pharmacia subsidiary settled allegations that it inflated drugs costs paid by New York in early 2011 (see post <a href="http://hcrenewal.blogspot.com/2011/02/pharmacia-or-maybe-pfizer-settles-only.html">here</a>).   In March, 2011, a settlement was announced in a long-running class action case which involved allegations that another Pfizer subsidiary had exposed many people to asbestos (see <a href="http://www.bloomberg.com/news/2011-03-22/pfizer-reaches-asbestos-settlement-that-may-end-quigley-unit-s-bankruptcy.html">this story</a> in Bloomberg).  In October, 2011, Pfizer settled allegations that it illegally marketed bladder control drug Detrol (see this <a href="http://hcrenewal.blogspot.com/2011/10/what-pfizer-v-few-consequences-for-long.html">post</a>). Finally, in August, 2012, Pfizer settled allegations that its subsidiaries bribed foreign (that is, with respect to the US) government officials, including government-employed doctors (see this <a href="http://hcrenewal.blogspot.com/2012/08/pfizers-pforeign-pfiasco.html">post</a>).  </span></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">By my count, the two current settlements would be numbers twelve and thirteen.  Of course, while I believe this list is accurate, it may be incomplete.</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Since none of these posts involved any negative consequences for any individuals who authorized, directed, or implemented the bad behavior, or who profited from it, and none involved any changed in the leadership or organization of the company, this becomes an amazing record of the impunity of Pfizer leadership over time and space. <br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>Will Impunity Finally Lead to Outrage? </b></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />Impunity, though, is a concept that is beginning to command some attention.</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">The <a href="http://15iacc.org/about/declarations/the-brasilia-declaration/">Brasilia Declaration</a> which was published at the conclusion of the 15th International Anti-Corruption Conference (hosted by <a href="http://www.transparency.org/">Transparency International</a>) included:</div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><blockquote class="tr_bq"><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">it is clear <i>we all face a common challenge in our work: impunity for those who abuse positions of power. </i></div></blockquote><blockquote class="tr_bq"><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">If impunity is not stopped, <i>we risk the dissolution of the very fabric of society and the rule of law, our trust in our politics and our hope for social justice.</i><br /><br />Activists, businesspeople, politicians, public officials, journalists, academics, youth and citizens who gathered in Brasilia to discuss the threat of corruption made it clear that <strong>impunity undermines integrity everywhere. </strong><br /><br />Whether we are investing collective efforts and resources in fighting poverty, human rights violations, climate change or bailing out indebted economies, <i>we need to give the people a reason to believe that impunity will be stopped.</i></div></blockquote><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">While the two latest Pfizer settlements barely got media coverage, maybe a $1.9 billion dollar settlement in the US by international banking giant will get more attention.  The charges in this case were not merely deceiving some doctors and patients about drug efficacy and safety.  The company was accused of aiding money laundering by drug cartels, and facilitating rogue regimes get around international sanctions.  As the New York Times <a href="http://dealbook.nytimes.com/2012/12/10/hsbc-said-to-near-1-9-billion-settlement-over-money-laundering/">reported</a>, </div><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">State and federal authorities decided against indicting HSBC<a class="tickerized" href="http://dealbook.on.nytimes.com/public/overview?symbol=HBC&inline=nyt-org" title="More information about HSBC Holdings PLC"></a> in a money-laundering case over concerns that criminal charges could jeopardize one of the world’s largest banks and ultimately destabilize the global financial system.<br /><br />Instead, HSBC announced on Tuesday that it had <i>agreed to a record $1.92 billion settlement with authorities. The bank, which is based in Britain, faces accusations that it transferred billions of dollars for nations like Iran and enabled Mexican drug cartels to move money illegally through its American subsidiaries.</i></div></blockquote><div style="background-color: white; border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><span id="articleText">Unlike Pfizer's slow-motion impunity, this example got attention.  The Los Angeles Times <a href="http://articles.latimes.com/2012/dec/11/business/la-fi-hsbc-fine-20121212">noted</a>,</span><br /><br /><blockquote class="tr_bq">The massive penalty still was not enough to appease some critics. No bank executives were charged as part of the investigation, leading some analysts to question the government's willingness to hold powerful Wall Street firms accountable.<br /><br />'<i>It's mind-boggling how they think you can have a financial system and allow this kind of impunity</i>,' said William Black, a former banking regulator who aided federal prosecutors during the savings and loan crisis of the 1980s and 1990s. <i>HSBC 'put the world at enormous risk.'</i></blockquote><span id="articleText"><br /></span><span id="articleText">A NY Times <a href="http://www.nytimes.com/2012/12/12/opinion/hsbc-too-big-to-indict.html">editorial</a> opened,</span><br /><br /><blockquote class="tr_bq"><span id="articleText"><i>It is a dark day for the rule of law. </i>  Federal and state authorities have not to indict HSBC, the London-based bank, on charges of vast and prolonged money laundering, for fear that criminal prosecution would topple the bank and, in the process, endanger the financial system.  They have also not charged any top HSBC banker in the case, though it boggles the mind that a bank could launder money as HSBC did without anyone in a position of authority making culpable decisions.</span><br /><br /><span id="articleText">Clearly, the government has bought into the notion that too big to fail is too big to jail.  When prosecutors choose not to prosecute to the full extent of the law in a case as egregious as this, the law itself is diminished.  The deterrence that comes from the threat of criminal prosecution is weakened, if not lost.</span></blockquote><br /><span id="articleText">So maybe this huge financial case will prove to be the straw that breaks impunity's back.  So I will close by quoting the end of the Brasilia Declaration, in the hope that a few people will take it to heart in the context of health care, as well as in finance.</span><br /><br /><br /><blockquote class="tr_bq">To take this important struggle forward the international anti-corruption community should promote greater people engagement and find ways to provide greater security for anti-corruption activists.<br /><br />Reducing impunity also requires independent and well-resourced judiciaries that are accountable to the people they serve.<br /><br />We call on leaders everywhere to embrace not only transparency in public life but a culture of transparency leading to a participatory society in which leaders are accountable.<br /><br />We call on the anti-corruption movement to support and protect the activists, whistleblowers and journalists who speak out against corruption, often at great risk.<br /><br />It is up to all of us in government, business and society to embrace transparency so that it ensures full participation of all people, bringing us together to send a clear message: <i>We are watching those who act with impunity and we will not let them get away with it.</i></blockquote>

Pfizer's 13th Legal Settlement - Will it be Enough to End the Impunity?

It has been almost two months since we lasted noted misbehavior by giant global pharmaceutical firm Pfizer Inc. With little fanfare, howeve...

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

<span style="font-family: Arial,Helvetica,sans-serif;">The <a href="http://patientsafetyauthority.org/Pages/Default.aspx" target="_blank">Pennsylvania Patient Safety Authority</a> has released a report "<b>The Role of the Electronic Health Record in Patient Safety Events</b>."  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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">The report was prepared with the assistance <span class="ms-rteCustom-text-PSABody-P"><span class="ms-rteCustom-text-PSABody-P"><span class="ms-rteCustom-text-PSAByline-P">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 "</span></span></span><span class="UserContent">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.</span></span> <br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Regarding the Patient Safety Authority:</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;">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.<br /><br />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. </span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;">The Authority maintains a database of serious events and incidents:</span><br /><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;">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"). </span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;">Cutting right to the chase, the paper's summary:</span><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><span style="font-family: Arial,Helvetica,sans-serif;"><i><span class="ms-rteCustom-text-PSAAbstract-P">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 <b>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.</b> 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.</span></i></span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;">Results:</span><br /><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;"><span class="ms-rteCustom-text-PSASubhead1-H"><span class="ms-rteCustom-text-PSABody-P">... 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) <span style="color: red;"><i><b>[a risk best avoided to start with, because luck runs out eventually - ed.]</b></i></span>, 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.</span></span> </span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;">A significant "study limitations" section was included that addressed: </span><br /><br /><ul><li><span style="font-family: Arial,Helvetica,sans-serif;">Issues regarding reporting statutes of the PA-PSRS errors database; </span></li></ul><ul><li><span style="font-family: Arial,Helvetica,sans-serif;">lack of awareness of EHRs as a potential contributing factor to an error;</span></li></ul><ul><li><span style="font-family: Arial,Helvetica,sans-serif;">limitations of narrative reporting affecting both the types of reports queried </span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-family: Arial,Helvetica,sans-serif;">and the tags applied </span>(the study used textual data mining methodolgies);</span></li></ul><ul><li><span style="font-family: Arial,Helvetica,sans-serif;">query design of the study; and</span><span style="font-family: Arial,Helvetica,sans-serif;"> </span></li></ul><ul><li><span style="font-family: Arial,Helvetica,sans-serif;">the need for further refinement of the machine learning tool used in creating the working dataset, which may have missed relevant cases.</span></li></ul><br /><span style="font-family: Arial,Helvetica,sans-serif;">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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">(The IOM report specifically observed that t</span><span style="font-family: Arial,Helvetica,sans-serif;">he<span style="font-weight: bold;"> </span>"barriers to generating evidence pose unacceptable risks to safety.") </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">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.  </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">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.  <i>In other words, the data was not "purposed" for this type of study.  </i></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>It is axiomatic that one cannot find data that is simply not present, no matter how fancy the search algorithm.</b>  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. </span><span style="font-family: Arial,Helvetica,sans-serif;"><!--[if !mso]><style>v\:* {behavior:url(#default#VML);} o\:* {behavior:url(#default#VML);} p\:* {behavior:url(#default#VML);} .shape {behavior:url(#default#VML);} v\:textbox {display:none;} </style><![endif]--></span><span style="mso-spacerun: yes;"></span><span style="font-family: Arial,Helvetica,sans-serif;"><!--[if !ppt]--><!--[endif]--> </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Thus, this cautionary statement was made in the new PA Patient Safety Authority report:</span><br /><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;"><b>"<span class="ms-rteCustom-text-PSASubhead1-H"><span class="ms-rteCustom-text-PSABody-P">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."</span></span></b></span> </blockquote><span style="font-family: Arial,Helvetica,sans-serif;"></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">My comments:</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><span style="font-family: Arial,Helvetica,sans-serif;">The report is welcome.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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. </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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:</span><br /><br /><blockquote class="tr_bq"><b><span style="color: black; font-family: Arial;">Good Health IT</span></b><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"> ("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 <span class="SpellE">eHealth</span>information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.<span style="mso-spacerun: yes;">  </span></span></blockquote><br /><blockquote class="tr_bq"><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"><b>Bad Health IT</b> ("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 <span class="SpellE">hypervigilance</span> (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.<span style="mso-spacerun: yes;">  </span></span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;"><b>An additional major factor</b> 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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">But don’t take it from me alone. Here is PA Patient Safety Authority Board Member Cliff Rieders, Esq. on this.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">From “Hospitals Are Not Reporting Errors as Required by Law, Phila. Inquirer”, pg. 4,</span><span style="font-family: Arial,Helvetica,sans-serif;"><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/<wbr></wbr>2008-09-12/news/24991423_1_<wbr></wbr>report-medical-mistakes-new-<wbr></wbr>jersey-hospital-association-<wbr></wbr>medication-safety:</a></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">   </span><br /><span style="font-family: Arial,Helvetica,sans-serif;"> </span><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><i>... 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.</i></span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br /></span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><i>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. <span style="color: red;"><b>[T<span style="font-size: small;">h<span style="font-size: small;">us reducing <span style="font-size: small;">risk of </span>litigation<span style="font-size: small;">, and, incidentally, <span style="font-size: small;">potentially </span>infr<span style="font-size: small;">inging on</span> <span style="font-size: small;">patient<span style="font-size: small;">s'</span> rights</span></span> to legal recourse - ed.]</span></span></b></span></i></span></span><i><br /><br /> 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.<br /><br /> </i><span style="font-size: small;"><i>Fixing this “is not a priority,” he added.</i></span></blockquote><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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 <b>that much more education, stringent reporting requirements,  templates of known causes of error, and enforcement are needed</b>.  (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.) </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><span style="font-family: Arial,Helvetica,sans-serif;">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/<wbr></wbr>faculty/ssilverstein/PA_<wbr></wbr>patient_safety_Jul2012.ppt</a></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">A major concern I have is that the HIT industry will use this new report in a manner that ignores its limitations.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">(Disclosure: I was an invited reviewer of this new PPSA report.)</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">-- SS </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>Addendum Dec. 13:  </b> </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">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.  </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Data here came from FDA's voluntary (i.e., also tip of the iceberg) </span><span style="font-family: Arial,Helvetica,sans-serif;"><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.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">-- SS </span><span class="citation-flpages"></span>

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 <i><a href="http://www.randomhouse.com/book/213722/predator-nation-by-charles-h-ferguson">Predator Nation</a></i>, the book by Charles Ferguson that followed his award winning documentary, <a href="http://www.sonyclassics.com/insidejob/">Inside Job</a>:<br /><br /><blockquote class="tr_bq">Ponder the toxic effects of too much wealth, too much power, the new culture of American investment banking, and a <i>life conducted within the cocoon of America's new oligarchy</i>. [p 112]</blockquote><br />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.<br /><br />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.<br /><br /><b>The Executives of Lancaster General Health </b><br /><br />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.     <br /><br />The system was facing challenges in 2010:<br /><br /><blockquote class="tr_bq">In 2010, times were getting tougher for Lancaster General Health.<br /><br />The mammoth [sic] health care system would notch record revenues of nearly $1 billion that year. But its <i>annual surplus fell</i> for the fourth straight year. Though destitute by no means, <i>galloping expenses and uncertainty in the marketplace</i> were hammering LGH's business model, prompting changes. <i>Two units were closed, some positions were eliminated, and 170 employees were reassigned.</i></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></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;"><br /></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 — <i>earned <b>more than $1 million</b> in total compensation; another six got at least $500,000.</i><br /><br />And those top 21 executives collectively received more than $2 million in bonuses and incentives.</blockquote><br />That lavish total compensation included "perks" that were likely not furnished to lesser employees, for example<br /><br /><br /><blockquote class="tr_bq">The IRS form lists few explicit perks, save one: LGH paid $1,044 in <i>social club dues</i> for Beeman in 2010.<br /><br />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><br />This relatively lavish pay was part of a pattern.  Executive compensation had been increasing out of proportion to any obvious benchmark for a while.<br /><br /><blockquote class="tr_bq"><i> In fiscal year 2005-06, CEO Tom Beeman earned a comparatively modest total compensation of <b>$646,094</b>. By 2010, that had more than doubled, to <b>$1.35 million</b>.</i> 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. <br /><br />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<b><i> $332,823</i></b> in 2005-06 to a total of <b><i>$1.1 million</i></b> 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.<br /><br />The third highest-paid LGH executive in 2010 was McGowan, whose compensation package totaled <b><i>$772,978,</i></b> 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<b><i> $746,830,</i></b> including $405,083 in base pay and $140,377 in bonuses and incentives.<br /><br />Fifth was Chief Financial Officer F. Joseph Byorick Sr., whose total compensation of <b><i>$652,667</i></b> included $397,160 in base pay and $140,500 in bonuses and incentives.</blockquote><br />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.<br /><br />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<br /><br /><blockquote class="tr_bq"> In October 2010, Lancaster General Health had a problem.<br /><br />Its <i>CEO, Tom Beeman, was shipping out for a military tour of duty</i>, to serve as deputy director of the National Intrepid Center of Excellence in Bethesda, Md. <i>Two other administrators —  Executive Vice Presidents Jan Bergen and Marion W. McGowan — would step into Beeman's shoes while he was away.</i><br /><br />Yet Beeman stayed involved. '<i>We had regular Skype [video-conferencing] calls,' </i>said Alex Henderson, chairman of the LGH Board of Trustees.<br /><br /><i>That, LGH officials believed, merited a bonus</i>. 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;"><br />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.<br /><br /></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.<br /><br />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. <br /><br /><b>The Talking Points Reappear as Justifications for Exceptional Compensation of Hired Managers </b></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></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:<br />-  we pay what everyone else pays<br />-  CEOs work hard and are brilliant, and so deserve high pay<br />-  high pay is needed to attract and retain competent, if not brilliant people.<br /><br />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.  .<br /><br /><u>We Pay What Everyone Else Pays</u><br /><br />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,<br /><br /><blockquote class="tr_bq">nonprofits must hire consultants to study how similarly sized nonprofits pay their executives.<br /><br />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.<br /><br /> 'Our role is to be [an] <i>independent source of market norms</i>,' said Scott, determining '<i>levels of compensation available in the market for executive positions</i>, 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><br /><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><br /><u>CEOs Work Hard and Are Brilliant, and So Deserve High Pay</u><br /><br /><u>High Pay is Needed to Attract and Retain Competent, if not Brilliant People</u></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></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;"><br /></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 <i>generous compensation is necessary to attract and retain the top talent.</i> 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.'<br /><br />'<i>We're not looking to be average.'</i></blockquote><br />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.<br /><br />Another version was offered by the chair of the system's board of trustees:<br /><br /><blockquote class="tr_bq"> Trustee Henderson said that as LGH's goal<i> isn't to maximize revenue but save lives</i>, executives can be doing a fantastic job — worthy of six-figure bonus and incentive pay — even when the system's financial performance slips.<br /><br />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;"><br /></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;"><br /></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;"><br /></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;"><br /></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;"><br /></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;"><br /></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 <i>what's considered blue-chip talent</i> ... [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;"><br />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.<br /><br /><b>Summary</b></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></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. <br /><br />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. <br /><br />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.<br /><br />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. <br /><br />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;"><br />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. <br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />I thought his piece would be of interest to HC Renewal readers.  It is at the site of the <b>American Association of Healthcare Journalists</b> 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>."<br /><br />(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>.) <br /><br /><br /><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><br />This work contributed substantially and materially to a reluctant HHS and ONC deciding it was time to actually investigate the issue.<br /><br />(Perhaps sometime soon HHS and ONC may also seriously investigate health IT safety, and take more than Milquetoast action.)<br /><br />-- 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.  <br /><br />Unfortunately for the writer, the IP's of his submissions recorded in the Sitemeter IP audit trail for HC Renewal <b>were of a health IT vendor</b>, 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.<br /><br />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:<br /><br /><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.)<br /><br />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” <span style="color: red;"><i><b>[clinician assessment - ed.]</b></i></span> back in SOAP.</blockquote><br />The post is followed by a largely thoughftul comment thread of dozens of comments.<br /><br />A new comment has appeared as follows, from an anonymous user "EPIC" whose self-submitted URL is "epic.com":<br /><br /><blockquote class="tr_bq"><div class="comment-head"><span class="name"><a class="url url" href="http://epic.com/" rel="external nofollow">Epic</a></span> <span class="date">December 7, 2012 at 9:48 am</span> <span class="perma"><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></span></div><div class="comment-head"><span class="perma"> </span> <span class="edit"></span> </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.<b> It takes common sense to use a computer. Perhaps time spent complaining could be more effectively be used in Epic ClinDoc training. Gotchya…</b></blockquote><br />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!<br /><br />The response I've left requires no additional comment:<br /><br /><blockquote class="tr_bq"><div class="comment-head"><span class="name"><a class="url url" href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" rel="external nofollow">S Silverstein, MD</a></span> <span class="date">December 7, 2012 at 3:18 pm</span> <span class="perma"><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></span></div><div class="comment-head"><span class="perma"> </span> <span class="edit"></span> </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.<br /><br />Your comment might have been at least humorous if it referred to, say, IT issues in a nail parlor or pizza shop.<br /><br />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.<br /><br />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”:<br /><br />——————–<br />… 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.<br /><br />[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 <span style="color: red;"><i><b>[or poorly presented information - ed.]</b></i></span>, etc.<br />——————–<br /><br />Take your perverse attitudes and ignorance elsewhere. Preferably far from your nearest healthcare facility.<br /><br />Scot Silverstein, MD<br />Drexel University, Philadelphia<br /><a href="http://hcrenewal.blogspot.com/" rel="nofollow">http://hcrenewal.blogspot.com</a></blockquote><br /><br />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.<br /><br />-- SS<br /><br />

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<span style="color: windowtext;"> for a possible article</span>:<br /><br /><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.<br /><br />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><br />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.<br /><br />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.  <b>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.</b><br /><br />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.<br /><br />Bear with me for a few moments (and pictures). <br /><br />I showed Mr. Hancock devices I'd built and/or used in teaching such as (click to enlarge):<br /><br /><br /><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;"><i style="mso-bidi-font-style: normal;">An infrared-sensing heart monitor I built in 1980 during a clerkship in biomedical engineering, Boston University Hospital, 1980</i></td></tr></tbody></table><br /><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;"><span class="GramE"><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;">Inside the heart monitor.</span></i></span><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-spacerun: yes;">  </span>I etched and drilled the printed circuit boards myself.</span></i></td><td class="tr-caption" style="text-align: center;"></td><td class="tr-caption" style="text-align: center;"></td></tr></tbody></table><br /><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><br /><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;"><i>A somewhat more sophisticated radio kit.  My <span class="SpellE">Heathkit</span> 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.</i></td></tr></tbody></table><br /><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;"><i style="mso-bidi-font-style: normal;">HW-101 innards, top view.  Not exactly a simple device.</i></td></tr></tbody></table><br /><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;"><i style="mso-bidi-font-style: normal;">HW-101 underside of chassis.<span style="mso-spacerun: yes;">  </span>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.)</i></td></tr></tbody></table><br /><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;"><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;">My <span class="SpellE">Heathkit</span> H8 computer, introduced 1977. <span style="mso-spacerun: yes;"> </span><span class="GramE">Intel 8080 processor.</span> <span class="GramE">One of the first personal computers.</span><span style="mso-spacerun: yes;">  </span>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.</span></i></td></tr></tbody></table><br /><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;"><span class="GramE"><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;">Inside the H8.</span></i></span><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-spacerun: yes;">  </span>I used this to teach computer and CPU architecture to Medical <span class="GramE">Informatics <span style="mso-spacerun: yes;"> </span>postdoctoral</span> fellows at Yale School of Medicine.<span style="mso-spacerun: yes;">  </span>I did not, and do not believe healthcare IT leaders should be mere “appliance operators.”<span style="mso-spacerun: yes;"> </span></span></i></td></tr></tbody></table><br /><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;"><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;">My TRS-80 Model I running VTOS 4.0, a pre-IBM PC precursor to LDOS 5 and TRSDOS 6.<span style="mso-spacerun: yes;">  </span>All were far superior to MS-DOS of any flavor in my opinion.</span></i></td></tr></tbody></table><br /><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;"><span class="GramE"><i style="mso-bidi-font-style: normal;"><span style="color: windowtext;">TRS-80 Model I about to undergo repair by me.</span></i></span></td></tr></tbody></table><br />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.<br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">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 <span style="mso-spacerun: yes;"> </span>in an invasive cardiology <span class="SpellE">cath</span>lab, 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<span class="SpellE"><span style="color: windowtext;"> </span>B.S</span>., 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.<span style="mso-spacerun: yes;">  </span>(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>.)</span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">I was further reminded a<span style="color: windowtext;">bout how I was </span>alarmed by the selfsame hospital IT "experts", lac<span style="color: windowtext;">ki</span>ng healthcar<span style="color: windowtext;">e and medical informatics knowledge and experience,</span> simply ignoring my cou<span style="color: windowtext;">nsel, as if medicine was a harmless parlor game to <span style="color: windowtext;">be <span style="color: windowtext;">played</span></span></span>, winner take all.  And likewise regar<span style="color: windowtext;">din<span style="color: windowtext;">g hospital seni<span style="color: windowtext;">or management who's hired me in the first p<span style="color: windowtext;">lace - at least one of whom expressed to me more conce<span style="color: windowtext;">rn for the career advancement of the IT staff than for patient safety.</span></span></span></span></span></span></span><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><br /></span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">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.</span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">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.</span></span><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><br /></span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">Yet today's health IT domain is rife with leadership by health IT amateurs</span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">**</span></span> [see note below] who patronize, bully and play nasty politics with healthcare informatics-educated clinicians and specialists, and accuse clinicians of being "Luddites" for resist<span style="color: windowtext;">ing <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">bad health IT</a> pushed on them <span style="color: windowtext;">by hyperenthusia<span style="color: windowtext;">sts (<a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">Ddulites</a>) who ignore the downsides</span></span>. </span> </span></span><br /><br /><blockquote class="tr_bq"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="font-size: x-small;"><b><span style="color: black; font-family: Arial;">Good Health IT</span></b><span style="color: black; font-family: Arial;"> ("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 <span class="SpellE">eHealth</span>information secure, protects patient privacy and facilitates better practice of medicine and better outcomes.  <br /><br /><b>Bad Health IT</b> ("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 <span class="SpellE">hypervigilance</span> (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.   </span></span></span></span></blockquote><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">What is lost in these dysfunctional dynamics is that the true "customer" who suffers is the patient.<span style="color: windowtext;">  Patients </span>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 who<span style="color: windowtext;">se political empires were threatened<span style="color: windowtext;"> by internecine and/or industry battles over IT.</span></span></span></span><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><br /></span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">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.  </span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">I will link to it when it if an<span style="color: windowtext;">d when it </span>appears. </span></span><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><br /></span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">-- SS</span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">** </span></span><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">(<span style="color: windowtext;">Amateur, </span>used in the same sense that I am a <a href="http://www.arrl.org/" target="_blank">radio amateur</a> licensed by the government <span style="color: windowtext;">after a series of written exams, </span>but not a professional te<span style="color: windowtext;">lecommunications engineer, </span>knowing I would not want to, nor should be allowed to, lead a mission critical telecommunications project.)</span></span></span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">----------------------- </span></span></span></span><br /><br /><b><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;">Feb. 18, 2013 <span style="color: windowtext;">Addendum:</span></span></span></span></span></b><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="color: windowtext;">The art<span style="color: windowtext;">icle was published as <a href="http://hcrenewal.blogspot.com/2013/02/kaiser-health-newsphiladelphia-inquirer.html" target="_blank">here</a>.</span></span></span></span></span></span><br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="mso-bidi-font-style: normal;"><span style="color: windowtext;"><span style="color: windowtext;"><span style="color: windowtext;">-- SS </span> </span> </span></span></span></span>

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>.)<br /><br /><b>The Basic Ethics Case - A Prescription for the Patient's Spouse? </b><br /><br />Glenn began with a case typically discussed in medical school ethics courses: <br /><br /><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><br />This <br /><br /><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><br /><b>The Politically Correct Way to Teach the Case </b><br /><br />Glenn stated that there is a politically correct way for faculty to teach this case:<br /><br /><blockquote class="tr_bq"> Though we are never expressly instructed to tow [sic] a party line,<i> there is a 'correct' answer to this ethical quandary as far as the institution we work for is concerned</i>. 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><br />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.<br /><br />Note that Glenn did not explain how he inferred what the "correct" answer was, nor its actual source within the institution.<br /><br /><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 <i>obfuscate the much larger ethical issue</i> impossible to tackle in an hour’s time. In essence, 'truth telling' is only a secondary ethical issue at play. <i>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?</i></blockquote><br /><b>Social Justice as Part of Professionalism, and its Avoidance</b> <br /><br />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:<br />-  subordinate their own interests to the interests of others<br />-  respond to social needs and work toward the benefit of the communities in which they live and serve<br />-  adhere to the core humanistic values of honesty and integrity, compassion, altruism, empathy, respect for others, and trustworthiness.<br /><br /><br />Glenn noted that these three competencies, however, have been turned into a more narrow imperative, that<br /><br /><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 <span class="EmphasisTypeItalic">not</span> expressly implicated.</blockquote><br />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<br /><br /><blockquote class="tr_bq"> The professionalism code adopted by the American Board of Internal Medicine in 1999 was bolder and specifically states that doctors <span class="EmphasisTypeItalic">are</span> to advocate for 'the best possible care [for their patients] regardless of the ability to pay'</blockquote><br />Glenn asked<br /><br /><blockquote class="tr_bq"> But where in the medical school curriculum <i>do we teach medical students to be strong patient advocates and take on third party payers and hospital administrators?</i> 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><br />Furthermore, he noted,<br /><br /><blockquote class="tr_bq"> When it comes to justice in medical ethics instruction,<i> 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.</i></blockquote><br />So, now seemingly getting to the key question,<br /><br /><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><br /><b>The Key Question also Avoided </b><br /><br />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?<br /><br />Only at the very end of the article did this appear<br /><br /><blockquote class="tr_bq">the structure of our current medical system has created a<i> network of health care providers, researchers, purveyors and administrators who have strong financial incentives to work against the best interests of patients.</i> 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><br />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<br /><br /><blockquote class="tr_bq"> How can we cultivate within our students an understanding of the threats to medical professionalism <i>posed by the conflicts of interest inherent in the various financial and organizational arrangements in the practice of medicine?</i>  We start by not shying away from the conversation.</blockquote><br /><b>Summary</b><br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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?   <br /><br />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.      <br /><br />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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