New York Times: "In Second Look, Few Savings From Digital Health Records", and AMA Med News on EHR Harms

This post should perhaps be entitled <i>"I told you so."</i><br /><br />A letter I wrote in response to the Wall Street Journal's "<a class="" href="http://online.wsj.com/article/SB123431432273870909.html">A Health-Tech Monopoly</a>", Feb. 11, 2009 was <a href="http://online.wsj.com/article/SB123492035330205101.html">published</a> Feb. 18, 2009 under the header <span style="font-weight: bold;">Digitizing Medical Records May Help, but It's Complex</span>.<br /><br />I wrote:<br /><br /><blockquote class="tr_bq">Dear Wall Street Journal,<br /><br />You observe that the true political goal is socialized medicine facilitated by health care information technology. You note that the public is being deceived, as the rules behind this takeover were stealthily inserted in the stimulus bill.<br /><br />I have a different view on who is deceiving whom. In fact, <b>it is the government that has been deceived by the HIT industry and its pundits.</b> Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. <b>The beneficiaries will largely be the IT industry and IT management consultants.</b><br /><br />For £12.7 billion the U.K., which already has socialized medicine, still does not have a working national HIT system, but instead has a major IT quagmire, some of it caused by U.S. HIT vendors.<br /><br />HIT (with a few exceptions) is largely a disaster. I'm far more concerned about a mega-expensive IT misadventure than an IT-empowered takeover of medicine.<br /><br />The stimulus bill, to its credit, recognizes the need for research on improving HIT. However this is a tool to facilitate clinical care, not a cybernetic miracle to revolutionize medicine. <b>The government has bought the IT magic bullet exuberance hook, line and sinker.</b><br /><br /><b>I can only hope patients get something worthwhile for the $20 billion.</b><br /><br />Scot Silverstein, M.D.<br /><i>Faculty, Biomedical Informatics</i><br /><i>Drexel University Institute for Healthcare Informatics</i><br /><i>Philadelphia</i></blockquote><br />I also had penned essays on the need for a moratorium on HITECH (Nov. 2008, "<a href="http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html" target="_blank">Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?</a>" and Jan. 2009, "<a href="http://hcrenewal.blogspot.com/2009/01/i-ask-again-should-us-call-moratorium.html" target="_blank">I Ask Again: Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?</a>").  My theme was that the issues with implementation of good health IT and elimination of bad health IT, and the issue of how to implement most efficiently, needed to be better understood before a national rollout.  Hold off multi-billion dollar national initiatives "<span style="font-weight: bold;">until we know how to get HIT right</span>", I wrote.<br /><br />Now the New York Times has this, citing a new RAND paper:<br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><b><a href="http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html" target="_blank">In Second Look, Few Savings From Digital Health Records</a></b></span><br />By REED ABELSON and JULIE CRESWELL<br /><br />January 10, 2013<br /><br />The conversion to electronic health records <b>has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care,</b> according to a new analysis by the influential RAND Corporation.<br /><br />Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.<br /><br />“We’ve not achieved the productivity and quality benefits that are unquestionably <span style="color: red;"><i><b>["unquestionably?" why?- ed.] </b></i></span> there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.</blockquote><br />Noted is the provenance of the 2005 report that created the windfall for the electronic records industry:<br /><br /><blockquote class="tr_bq">RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.</blockquote><br />A retraction: <br /><br /><blockquote class="tr_bq">The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure <b>RAND now says was overstated.</b> The study was widely praised within the technology industry and <b>helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems ... </b>But evidence of significant savings is scant, and there is increasing concern that electronic records <b>have actually added to costs</b> by making it easier to bill more for some services.</blockquote><br />In my Feb. 2009 WSJ letter, I'd written that "<i>it is the government that has been deceived by the HIT industry and its pundits. Stated directly, the administration is deluded about the true difficulty of making large-scale health IT work. The beneficiaries will largely be the IT industry and IT management consultants.</i>"  It appears I was correct. <br /><blockquote class="tr_bq"><br />Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.</blockquote><br />Not mentioned are harms that bad health IT is creating.<br /><br /><blockquote class="tr_bq">The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. “<b>We could be getting much more if we could take the time to do a little more planning</b> and to set more standards,” said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system </blockquote><br />A "little more" planning?  How about several years' worth, to ensure the technologies are safe, effective and properly vetted, along with a system for post-market surveillance as exists in other healthcare sectors?<br /><br /><blockquote class="tr_bq">Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.</blockquote><br />Dr. Blumenthal seems to be triangulating from his <a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html" target="_blank">earlier 2010 NEJM statement that</a>:<br /><br /><blockquote class="tr_bq">... <span style="font-size: 100%;">The widespread use of electronic health records (EHRs) in the United States <span style="font-weight: bold;">is inevitable</span>. EHRs <b>will</b> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <b>will demand</b> nothing less from their providers. Hundreds of thousands of physicians have <b>already seen these benefits</b> in their clinical practice.</span></blockquote><br />Meantime, in the real world signs of my expressed concerns about a quagmire are appearing:<br /><br /><blockquote class="tr_bq">... Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.</blockquote><br />A clue as to the candidness of the new report: <br /><br /><blockquote class="tr_bq">... The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND’s health advisory board wanted to revisit the earlier analysis.</blockquote><br />Finally, this from the horse's mouth:<br /><br /><blockquote class="tr_bq">Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. <b>In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.</b></blockquote><br />I repeat my admonition from 2009 that <i>I can only hope patients get something worthwhile for the $20 billion</i>, which by now is probably many times that amount.<br /><br />Finally, I note the American Medical News cites me in a <a href="http://www.ama-assn.org/amednews/2013/01/14/prsa0114.htm" target="_blank">Jan. 14, 2013 article</a> as follows:<br /><br /><blockquote class="tr_bq">... Other experts on health IT said the Pennsylvania [PA Patient Safety Authority] study probably underestimates the extent of health IT safety problems. They say that is because the research is based on voluntary reports and that health professionals are unaware that a patient safety incident was caused by an EHR failure.<br /><br />“These systems are incredibly complex,” said Scot M. Silverstein, MD, a consultant in medical informatics at Drexel University in Philadelphia. “They’re not just huge filing cabinets, they are enterprise resource management systems. There are many ways that things can go wrong that may not be seen as the computer having caused the mess-up in the first place.”<br /><br />For example, he said, it would be difficult for a practicing physician to detect when data are missing from a record or that an alert failed to pop up.</blockquote><br />Yet the title of the article is "<a href="http://www.ama-assn.org/amednews/2013/01/14/prsa0114.htm" target="_blank"><b>EHR-related errors soar, but few harm patients</b></a>" with a table at the bottom labeled "<b>How rarely EHR problems harm patients</b>." More evidence that EHRs always receive special accommodation.  <br /><br />I was an invited reviewer of the PA Patient Safety Authority report, and wrote about the major deficiencies of its dataset at my posts Dec. 13, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/12/pennsylvania-patient-safety-authority.html" target="_blank">Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events</a>" and a follow-up Dec. 19 post "<a href="http://hcrenewal.blogspot.com/2012/12/a-very-signifcant-additonal-observation.html" target="_blank">A Significant Additional Observation on the PA Patient Safety Authority Report -- Risk</a>."<br /><br />My major point was that one simply cannot know what one cannot know, when using a very incomplete dataset gathered in a setting of <b>systematic impediments to accuracy and completeness</b>.  For instance, as I wrote in those earlier posts, through my work I personally know of cases of harms up to and including death that should have been in the PA database, but apparently are not - and I'm just one person.<br /><br />We simply don't know in 2013 how many EHR errors harm patients, and the effects of increasing adoption by organizations and physicians less technology-able than current adopters.  I hope the magnitude of harms is truly small, but hope is not enough; this study and report was just a 'dipping of the toes into the water' towards understanding the realities.<br /><br />Incidentally, we also don't know how severely the known toxic effects of bad health IT might affect care in times of duress, e.g., an epidemic.  However, I am certainly not sanguine about EHRs in their present state as robustly facilitating national emergency preparedness.<br /><br />My dreaded prediction for the future?  A 2016 AMA News story entitled "<b>Known EHR-related harms soar</b>."<br /><br />-- SS

New York Times: "In Second Look, Few Savings From Digital Health Records", and AMA Med News on EHR Harms

This post should perhaps be entitled "I told you so." A letter I wrote in response to the Wall Street Journal's " A Healt...

Đọc thêm »

Pfizer's Pfourteenth Settlement - a Small Reminder of Continuing Impunity

Well, that did not take long.  Less than a month after its last legal settlements were <a href="http://hcrenewal.blogspot.com/2012/12/pfizers-13th-legal-settlement-will-it.html">announced</a>, Pfizer had to settle again.<br /><br /><b>The Details of the Settlement </b><br /><br />This case, involving charges filed by the Texas Attorney General, was only reported locally, e.g., <a href="http://www.bizjournals.com/houston/news/2013/01/04/texas-to-receive-36m-from-pfizer.html">here</a> in the Houston Business Journal:<br /><br /><br /><blockquote class="tr_bq">The state of Texas will receive more than $36 million from two civil Medicaid fraud settlements with Pfizer Inc and Endo Pharmaceuticals,  Attorney General Greg Abbott<a href="http://www.bizjournals.com/houston/search/results?q=Greg%20Abbott"></a> said Friday.<br /><br />Both companies will pay $18.17 million to the state, plus attorney fees and relator shares. The federal government is also entitled to a share of the total settlement, Abbott’s statement said.</blockquote><br />As usual, the settlement was about deceptions:<br /><br /><blockquote class="tr_bq"> State and federal law requires drug companies disclose to the Medicaid program the prices they charge pharmacies, wholesalers and distributors for their products. Texas’ lawsuits claimed the companies misreported the price of various generic drugs and overcharged Medicaid for certain products.</blockquote><br />As usual, Pfizer had excuses:<br />  <br /><blockquote class="tr_bq">In the Pfizer settlement, the state’s investigation originally targeted entities that are now wholly owned subsidiaries of Pfizer.<br /><br />In making the settlements, neither company is admitting to any wrongdoing.<br /><br />New York-based Pfizer released a statement saying the safety of its subsidiaries’ products was not an issue of the investigation and Pfizer was not a target or subject of the case.<br /><br />'Pfizer’s subsidiaries are resolving this investigation to avoid the further time and cost of litigation,' the company said in its statement. 'The majority of the Texas investigation focused on reporting that took place prior to the subsidiaries being acquired by Pfizer. The company remains committed to providing accurate pricing information to the Texas Medicaid program and providing quality pharmaceutical products to the citizens of Texas.'</blockquote><br /> Of course, Pfizer acquired the companies (which were listed in the <a href="http://assets.bizjournals.com/sanantonio/pdf/122712_final_settlement_signed_by_all_parties_press_version.pdf">settlement document </a>as ESI Lederle, Lederle Labs, and Pharmacia) in order to make money from them.  Furthermore, in acquiring the subsidiaries, Pfizer assumed responsibility for them and their actions.<br /><br />As usual, there was no hint in the minimalist coverage of this settlement of any sort of negative consequences for anyone who authorized, directed, or implemented the relevant behavior, which did involve deception upon the government of Texas. <br /><br /><b>Nobody Held Responsible, Even After 14 Settlements </b><br /><br />As is also usual, there was no mention in the media coverage, or the <a href="http://assets.bizjournals.com/sanantonio/pdf/122712_final_settlement_signed_by_all_parties_press_version.pdf">settlement document</a> that Pfizer has made numerous other settlements in the recent past.   By my best count, the total was up to thirteen from the beginning of the 21st century to the present, as most recently tabulated <a href="http://hcrenewal.blogspot.com/2012/12/pfizers-13th-legal-settlement-will-it.html">here</a>, and listed in the Appendix below.  (There may easily have been more that I missed.)<br /><br />At the time of the twelfth and thirteenth settlements, we <a href="http://hcrenewal.blogspot.com/2012/12/pfizers-13th-legal-settlement-will-it.html">wondered</a> whether the sheer volume of documentation of Pfizer's actions, and the sheer number of legal actions against it would finally lead to the end of the impunity of Pfizer's leaders.  After all, one would think that if the town drunk showed up in court for his fourteenth drunk driving charge, the book would be figuratively thrown at him.  Instead, at best, Pfizer had a wet noodle thrown at it.  The costs of this settlement, and even the cumulative costs of all the previous ones over time just added up to costs of doing business.  And these costs were not paid by the people who profited the most from the bad behavior, but were diffused among all stock-holders, employees, patients, and payers.  <br /><br />Of course, leadership and governance of Pfizer is by some very fancy people indeed, and our society has not been good lately at holding such fancy people to any standards whatsoever. <br /><br /> The sorts of practices discussed in Pfizer's multiple settlements have added to the revenue that have helped a lot of people live in the style to which they have become accustomed.  Pfizer has had some very, very well paid executives.  In 2011, according to the <a href="http://services.corporate-ir.net/SEC/Document.Service?id=P3VybD1hSFIwY0RvdkwyRndhUzUwWlc1cmQybDZZWEprTG1OdmJTOWtiM2R1Ykc5aFpDNXdhSEEvWVdOMGFXOXVQVkpVUmlacGNHRm5aVDA0TVRNNU9EVTRKbk4xWW5OcFpEMDFOdz09JnR5cGU9MyZmbj04MTM5ODU4LnJ0Zg==">company's 2012 proxy statement</a>, its CEO, Ian Read, got more than <b><i>$25 million,</i></b> that is to repeat more than twenty-five million dollars, count them, in total compensation.  All the rest of its named executive officers got more than <b><i>$5 million</i></b> in total compensation.  That 2012 report justified this other worldly munificence in part because<br /><br /><blockquote class="tr_bq"> We continued to improve our reputation in society through engagement with our customers, our shareholders, and the investor community.</blockquote><br />Really, after now 14 settlements?  <br /><br />The issue of the impunity of leaders of large organizations has finally made it to the big time.  For example, a New York Times editorial called the latest US government settlement with the large banks whose exploitative mortgage practices helped to usher in the global financial collapse or great recession "<a href="http://www.nytimes.com/2013/01/09/opinion/another-slap-on-the-wrist-for-big-banks.html">another slap on the wrist</a>."  Writ large, continuing impunity is the sort of problem that indicates a degree of societal corruption that can destroy particular civilizations.<br /><br />I am just a simple country doctor and can only do my small part to keep the barbarians outside the gate, but at least those who care about what has gone wrong with health care ought to be calling for vigorous, impartial law enforcement that holds leaders of health care organizations accountable for wrong-doing, and in general, changes that make leaders of health care organizations broadly accountable for their actions.<br /><br />There are some luminaries from health care and academia on the <a href="http://www.pfizer.com/about/leadership_and_structure/meet_board.jsp">current Pfizer board</a>, like  <span class="bluetextstrong">Dennis A. Ausiello, M.D., </span><br />Jackson Professor of Clinical Medicine at Harvard Medical School and Chief of Medicine at Massachusetts General Hospital;  <span class="bluetextstrong">Frances D. Fergusson, Ph.D., President Emeritus of Vassar College; </span><span class="bluetextstrong">Helen H. Hobbs, M.D., </span>Investigator of the Howard Hughes Medical Institute since 2002, is a Professor of Internal Medicine and Molecular Genetics and Director of the McDermott Center for Human Growth and Development at the University of Texas (UT) Southwestern Medical Center; and <span class="bluetextstrong">Marc Tessier-Lavigne, Ph.D., </span>President of The Rockefeller University since March 2011. Maybe some people at their base institutions ought to be asking them about Pfizer's multiple ethical lapses and what they are doing to make its leadership more accountable.  <br /><br /><b>APPENDIX - Pfizer's Settlements</b><br /><br /><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="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="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 December, 2012, Pfizer settled federal charges that its Wyeth subsidiary deceptively marketed the proton pump inhibitor drug Protonix, using systematic efforts to deceive approved by top management, and settled charges by multiple states' Attorneys' General that it deceptively marketed Zyvox and Lyrica (see this <a href="http://hcrenewal.blogspot.com/2012/12/pfizers-13th-legal-settlement-will-it.html">post</a>).   </span></div><br /><br />

Pfizer's Pfourteenth Settlement - a Small Reminder of Continuing Impunity

Well, that did not take long.  Less than a month after its last legal settlements were announced , Pfizer had to settle again. The Details o...

Đọc thêm »

At University of Miami, Faculty Without Confidence in their Hired Managers Afraid to Identify Themselves

The University of Miami has provided some vivid examples of the contrast between the power and privileges of the leaders of large health care organizations and the subservient role of faculty and staff. <br /><br /><b>Background </b><br /><br />Back in 2006, we <a href="http://hcrenewal.blogspot.com/2006/02/tale-of-three-ironies-university-of.html">noted</a> that while the University of Miami was paying its janitorial support staff less than seven dollars an hour, and supplying them with no health insurance, its President, Donna Shalala, was living in a 9000 square foot official mansion, with staff hired to make her bed.  While Ms Shalala did not seem very perturbed about the living conditions of the lowliest University staffers, as a member of the board of directors of UnitedHealth, she approved the munificent compensation given to its then CEO, Dr William McGuire (look <a href="http://hcrenewal.blogspot.com/2006/03/questionable-timing-of-unitedhealth_20.html">here</a>), who was a billionaire until he was forced to give up  some of the backdated stock options she had approved (look <a href="http://hcrenewal.blogspot.com/2009/08/final-settlement-of-unitedhealth.html">here</a>).  More recently, we discussed how Ms Shalala's "visionary" leadership included presiding over the hiring of Dr Charles Nemeroff, who had previously been forced to resign as chairman of psychiatry at Emory University for various unethical activities (look <a href="http://hcrenewal.blogspot.com/2011/06/embedded-networks-of-influence-in.html">here</a>).  Last year, while awaiting the construction of a new presidential mansion, Ms Shalala presided over layoffs of hundreds of faculty and staff, which may have been necessitated by bad spending decisions made by her or those who reported to her (look <a href="http://hcrenewal.blogspot.com/2012/06/university-of-miami-lays-off-800-cuts.html">here</a>).  <br /><br /><b>The Faculty Protest </b><br /><br />All these shenanigans apparently finally succeeded in upsetting the faculty, as described in a <a href="http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html">new article</a> in the Miami Herald.  The article's headline was about the resignation of the University of Miami Miller Medical School's second highest ranking executive in response to faculty anger:<br /><br /><blockquote class="tr_bq">Amid roiling faculty anger over drastic budget cuts, the University of Miami announced that the No. 2 executive at the Miller School of Medicine, Jack Lord, is 'stepping down.' </blockquote><br />Dr Lord was apparently taking the fall for the previous mass layoffs, some affecting faculty in 2012:<br /><br /><blockquote class="tr_bq">[Medical School Dean Pascal]  Goldschmidt defended his administration’s performance: 'Last year we had many challenging issues to fix, as do many medical schools in the U.S. Thanks to Jack Lord’s leadership and hard work by everyone at the Miller School, we have met those challenges and turned things around financially.'  The announcement comes after a tumultuous year<i> in which the medical school suffered a severe financial crisis and its leaders responded with a major overhaul that included the layoffs last spring of over 900 full-time and part-time employees </i>— moves that angered many professors.<br /><br /> In a letter to faculty sent on Wednesday, Goldschmidt insisted the problems have been fixed. Goldschmidt credited Lord for helping improve the medical school’s finances, which showed a surplus of about $9 million for the first six months of this fiscal year — compared to a $24 million loss for the first six months of the previous fiscal year.<br /><br />Lord, a physician who had been an executive at Humana, became chief operating officer last March, as the restructuring plans started. </blockquote><br />However, the faculty's anger was not just directed at Dr Lord, who as noted above seemed to have been hired to take responsibility for the layoffs:<br /><br /><blockquote class="tr_bq">The change, announced by Dean Pascal Goldschmidt, comes as a petition circulates among tenured medical school faculty <i>expressing no confidence in both Goldschmidt and Lord</i>.</blockquote>In particular,<br /><br /><br /><blockquote class="tr_bq">Meanwhile, several sources sent The Herald a copy of a petition being circulated among school faculty members who 'wish to express, in the strongest possible terms, the concern we feel for the future for our school of medicine.' The petition blamed 'the failed leadership of Pascal Goldschmidt and Jack Lord. ... We want to make clear that <i>the faculty has lost confidence in the ability of these men to lead the school.</i>'</blockquote><br /><br />Furthermore,<br /><br /><blockquote class="tr_bq"> Many faculty members, who had spent decades at the medical school without seeing mass layoffs, were angry that the cuts were made without consulting them. A report by a faculty senate committee said medical school professors described the layoffs as 'unprofessional,' 'graceless' and 'heartless.' </blockquote><br />Yet there is no hint that Dr Goldschmidt, or President Shalala to whom he reports are yet affected by this protest.   <br /><br /><b>Tenured Faculty Scared into Anonymity</b><br /><br />In fact, while the faculty are upset, they are also afraid.<br /><br /><blockquote class="tr_bq">The report contended that the internal turmoil had prompted some faculty members to consider leaving and that <b><i>'fear is widespread.</i></b>' It also cited instances of <b><i>employees suffering retribution for criticizing the administration.</i></b><br /></blockquote>There is so much fear that the faculty constructed an elaborate mechanism to register protest while remaining individually anonymous.<br /><br /><br /><br /><blockquote class="tr_bq"> A half-dozen people closely connected to the medical school who requested anonymity told The Herald that they’ve heard that <i>between 400 and 600 of the school’s 1,200 faculty have added their names to individual copies of the petition.</i><br /><br />The petitions are addressed to the chair of the faculty senate, Richard L. Williamson, a law professor. Williamson said last week he would not comment on how many had signed the petition because it was 'an internal matter' and may never become public. He said the number of those who know how many have signed is 'extremely small and none of them will talk.'<br /><br />Three sources told the Herald that faculty are <i>sending individually signed copies of the petition to the senate chair with the understanding that Williamson <b>would not reveal their names to UM administrators</b></i>. </blockquote><br /><b>Summary </b><br /><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198_p2/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><br /> So, up to half of the University of Miami's medical faculty may be so upset with the current administration, apparently in part due to faculty and staff layoffs after questionable decisions by administrators some of whom may have lived large at university expense, that they essentially voted no confidence.  Yet the faculty are afraid to put their own names on their protest.<br /><br />So this is not just a story about allegedly incompetent university executives, and about the contrast between the rewards such executives get and the results of their dubious management.  It is also a story about how the executives' power now threatens a bed-rock value of academia, the ability of faculty (and by extension, staff and students), to speak freely, even if that speech offends the university's management.  In this case, while apparently hundreds of faculty condemned the administration for autocratic, incompetent, self-serving actions, they all feared what that same administration could do to them if their identities were known.<br /><br />In the last few years there has been a lot of prattle about the "flat organization," and there have probably been at least a few small high technology start ups that really were run on a collegial basis.  However, as we have shown again and again, throughout the corporate world, extending to health care corporations, and then to non-profit health care organizations, top management insiders have assumed more power and <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">paid themselves better and better </a>at the expense of all others (look <a href="http://hcrenewal.blogspot.com/2009/12/compensation-madness-insiders-hijacking.html">here</a>).  Even now in universities, which used to be examples of collegiality, and were run in somewhat democratically  by their faculties, faculty are obviously afraid to challenge the hired managers. <br /><br />Clearly, universities in which faculty cannot disagree with management are not going to be able to exercise the free enquiry that is core to their academic role.  In a health care context, why should anyone trust medical schools or academic medical centers run as tin-pot dictatorships by some hired executives?  Clearly, real health care reform would restore free speech and free enquiry to academic medicine.<br /><br />Hat tip to Prof Margaret Soltan <a href="http://www.margaretsoltan.com/?p=38728">on University Diaries</a>.<br /><br /><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div>

At University of Miami, Faculty Without Confidence in their Hired Managers Afraid to Identify Themselves

The University of Miami has provided some vivid examples of the contrast between the power and privileges of the leaders of large health car...

Đọc thêm »

Some Real-World Lessons for the Health IT Hyper-Enthusiasts

An article was published in Health Leaders Media yesterday by Scott Mace, senior technology editor entitled <b>"Scot Silverstein's Good Health IT and Bad Health IT"</b> <a href="http://www.healthleadersmedia.com/content/TEC-288116/Scot-Silversteins-Good-Health-IT-and-Bad-Health-IT" target="_blank">at this link</a>.<br /><br />(Actually, the terms "good health IT" and "bad health IT" themselves came from <a href="http://sydney.edu.au/engineering/it/~jonpat/CV/CV_brief.html" target="_blank">Prof. Jon Patrick</a> as a result of my discussions with him in Australia about my conviction, presented to the Health Informatics Society of Australia in my Aug. 2012 talk "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/HISA2012_Final.ppt" target="_blank">Critical Thinking on Building Trusted, Transformative Medical Information:  Improving Health IT as the First Step</a>", that to be trusted and do no harm, health IT must be “done well".)<br /><br />Scott Mace observes:<br /><br /><blockquote class="tr_bq">Inevitably, when the subject turns to the pitfalls of bad health IT, you will find Scot Silverstein, MD, ready to comment. He has been writing about health IT difficulties since 1998.<br /><br />Silverstein is an adjunct professor at Drexel University who I recently interviewed for an upcoming <i>HealthLeaders</i> magazine story on physician resistance to health IT.<br /><br />A <a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">recent Silverstein blog post</a> caught my eye for the following statement: "It is impossible for people, especially medical professionals, to be 'ready' for a system that 'is not ready for them.'"<br /><br />I wanted to learn about the good doctor's thinking and so I gave him a call. We spoke for two hours and it felt like scratching the surface of issues that healthcare will be facing for a good while to come. </blockquote><br />Indeed, the issues we discussed were just scratching the surface.  The real world is ever so complex.<br /><br />Also noted was my observation that:<br /><br /><blockquote class="tr_bq">... Silverstein says it is wrong to think of the tension in healthcare as being IT modernists versus Luddites ... [he says] "I believe the proper framing of this tension between technologists and physicians is that of technology hyper-enthusiasts, who either are unaware of or deliberately ignore the downsides and ethical issues of healthcare information technology in its present state, versus pragmatist physicians who just want to get a job done."</blockquote><br />The hyper-enthusiasts largely ignore the real world.<b> </b><br /><br /><b>Two recent "real world" posts on other blogs by practicing physicians caught my eye,</b> that help illustrate the concepts of health IT's disruption of clinicians and of clinical care.  These disruptions increase risk of error (even under normal circumstances; in an emergency scenario, I fear the disruptions will become far more destructive).<br /><br />These disruptions need to be thrust in the face of the hyper-enthusiasts as characteristic of a very flawed approach to healthcare improvement. <br /><br />The real-world observations, courtesy <a href="http://www.kevinmd.com/blog/category/tech" target="_blank">KevinMD blog</a> (who reposted them from the source bloggers), with my comments are in <span style="color: red;"><i><b>[red italics]:</b></i></span><br /><br /><blockquote class="tr_bq"><a href="http://www.kevinmd.com/blog/2013/01/information-overload-doctors-increases-malpractice-risk.html" target="_blank">Information overload for doctors increases malpractice risk</a><br />Wes Fisher, MD<br />January 1, 2013<br /><br />I have used the electronic medical record (specifically EPIC) since 2004.  I have grown accustomed to its nuances, benefits and quirks.  There are parts about it I really like.  There are parts of it I’d like to do without but accept that they are necessary evils in our current health care climate.  I know that there will always be parts of any modified computer system that will suffer growing pains.  For any new and adapting technology this is understandable.<br /><br />But there is a little-appreciated issue that I see brewing: doctors (and maybe even patients) are quietly being buried by electronic information overload.  As a result, I believe doctors are being placed at an increased liability risk. <span style="color: red;"><i><b>[Not just doctors, but all clinicians, and the acquirers and implementers of the technology, and those who force the use of it on the clinicians - ed.]</b></i></span><br /><br />Let me explain.<br /><br />In the past era of medicine, nothing happened without a doctor’s order.  Nothing.  If you wanted a medication, lab test, invasive procedure, opportunity to participate in rehab classes – anything – you needed a doctor’s order.   For the years of paper records and independent doctors offices, this work flow assured that doctors (1) knew what was happening with their patients, (2) saw their patients, (3) prescribed the proper therapy, and (4) assumed the risk for the intervention or treatment prescribed.  Information proceeded in a logical linear fashion and the doctor was always at the head of the information line.<br /><br />But we are no longer in the old days in medicine.  We are in the era of near-instantaneous information flow, multi-directional electronic communication, and geographically disparate order entry by “caregivers,” (think nurses, nurse practitioners, advanced practice nurses, clinic operators, registrars, etc.) who help us take messages, continue care, and order things.  In this electronic process, messages are no longer passed from just one individual to another, but rather are passed to two, three, four, or more individuals simultaneously from any one of several different clinical locations – some of which might be many miles apart.  <b>There is an incredible amplifying effect of all of these messages, orders, and notifications — so much so that even the most tech-savvy doctors are struggling to keep up.</b> <span style="color: red;"><i><b>[This observation about an "amplifying effect" gives life to my own observation that the terms "EHR" and "EMR" are anachronistic and suggest to the layperson an innocuous file cabinet, when in reality today's "EHR" is an enterprise healthcare resource and clinician control system, with all that implies in terms of potential adverse unintended consequences - ed.]</b></i></span><br /><br />In fact, it is not uncommon for a doctor these days to work for two hours on a procedure and return to the computer to find twenty or thirty new notifications, e-mails, or orders have been deposited there.  Head back in for the next case and then another thirty items appear.  Pretty soon, it’s an avalanche of items.  Worse: doctors must click on each one of these notifications individually to “verify” he or she has looked at each and every single one.  <span style="color: red;"><i><b>[Looking at the computer has likely become a source of dread to many clinicians; I used to get the same feeling when facing up to a day's emails in Pharma, sometimes more than a hundred - ed.]</b></i></span><br /><br />Doctors understand that the reason we have to click on all these orders is because (a) no one gets paid in our system unless a doctor orders whatever-it-is <span style="color: red;"><i><b>[not the best motivation - ed.]</b></i></span> and (b) someone has to be the fall guy if there’s a problem with a nurse, medical assistant, or lab technician that “orders” something on behalf of the physician.  <span style="color: red;"><i><b>[Ditto; the "social issues" of health IT include factors like these  - ed.] </b></i></span> There is even a trend to auto-order things (like a pneumovax vaccine, for instance) that assure the hospital maintains excellent public reporting metrics whether the doctor ordered them or not with the order later appearing in our inbox to be clicked. <span style="color: red;"><i><b> [This observation gives life to my own that the computer is increasingly becoming the intermediary between doctor and patient - ed.]</b></i></span><br /><br />But worst of all are the <b>silent notifications sent from fellow physician colleagues buried amongst the other notifications.</b> They tell of an important story, one that needs fairly urgent attention, but because people no longer pick up the phone, are not immediately noticed or highlighted. <b>It’s like a landmine sitting in a doctor’s inbox waiting to be stumbled upon.</b><br /><br />* Click* *Click* *Click* * Click* *Click* <b>*Boom* </b> <span style="color: red;"><i><b>[The "silent silo" syndrome, as I called it, also affects lab results reporting.  It should be clear that health IT does not "automagically" improve communications over Alexander Graham Bell's invention - ed.]</b></i></span><br /><br />With all these people and devices ordering and sending, the limited number of doctors out there are<b> being bombarded from multiple directions</b>.   It is getting harder to keep up these days.  Orders and notices come to us on names we don’t recognize or have been long forgotten.  (Computers don’t forget that you saw the patient eight years ago).  <span style="color: red;"><i><b>[These observations should put an end, once and for all, to the oversimplifications of comparing health IT to, say, mercantile or banking IT - ed.] </b></i></span>And once an order is placed and acted upon without our knowledge these days, we click on the order to clear our notices and thereby assume all the legal risk for the care. The legal buck still ultimately stops with us. <br /><br /><b>Doctors need to speak up about this problem.</b> <span style="color: red;"><i><b> [I could not agree more - ed.]</b></i></span> We are not in the old days any longer.  We are in the fast-paced, electronic medical record era where things happen (literally) at the speed of light.  We need the electronic medical record companies, payors, hospitals and legal community to come together to help us find a solution to this current information overload crisis that maintains patient safety and improves efficiencies while limiting legal risks to the doctors who are doing their very best just to keep up.<br /><br /><i>Wes Fisher is a cardiologist who blogs at </i><a href="http://drwes.blogspot.com/" rel="nofollow" target="_blank">Dr. Wes</a><i>.</i></blockquote><br />The above "anecdote" (I use that term somewhat satirically, see <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">here</a>) is likely characteristic of the lives now lived by most clinicians using today's health IT.  Hyperenthusiasts, take note.<br /><br />The second real-world illustration of the naivete of the hyper-enthusiasts is as below.  I'd observed most of the points made in my own writings after my CMIO period in the late 1990's, which I highlight.   It is quite interesting to see these same points come from others without Informatics expertise, directly from the clinic:<br /><br /><blockquote class="tr_bq"><a href="http://www.kevinmd.com/blog/2012/12/explaining-epic-failure-emrs.html" target="_blank">Explaining the epic failure of EMRs</a><br />Kiran Raj Pandey, MD<br />December 19, 2012<br /><br />It is no news a lot of doctors like to stick up a rather snotty nose to EMR. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times.<i><b> <span style="color: red;">[</span></b><b><span style="color: red;">In reality, the tension is </span><a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">between the hyper-enthusiasts or 'Ddulites' vs. pragmatist clinicians</a></b> <b><span style="color: red;">with real-world patient care responsibilities and obligations - ed.]</span></b><span style="color: red;"><b> </b></span></i>But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.<br /><br />On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia <span style="color: red;"><i><b>[the path to Utopia usually has very bad unintended consequences, and Utopia never reached - ed.]</b></i></span>, and let alone being anywhere close to such utopia,<b> it is difficult to ascertain if we are even set in the road leading us there</b>. <span style="color: red;"><i><b>[As I've opined, we're on a speeding bullet train on a quarter-mile track - ed.] </b></i></span><br /><br />Sometime ago, exasperated at the<b> sheer waste of time</b> that the clunky new discharge module was causing <b>because it would not work the way it is supposed to</b> (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS <i><b><span style="color: red;">[and the </span><a href="http://hcrenewal.blogspot.com/2013/01/when-sociologists-uphold-hippocratic.html" target="_blank">Lords of Kobol</a> <span style="color: red;">- ed.]</span></b></i>), I complained to the IT guy that the thing barely works! The guy was sympathetic and said, “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs.” <span style="color: red;"><i><b>[Hospitals and clinics, as I've written, are NOT the proper place for software alpha and beta-testing - ed.]</b></i></span><br /><br />But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with,” he retorted. <b>“Computer records do take a longer time than paper, and there is nothing I can do to change that.” <span style="color: red;"><i>[This reflects healthcare IT culture's of arrogant acceptance of bad health IT, largely ignoring ways to ease human-computer interaction - ed.]</i></span></b><br /><br />Right there, I think is where EMR loses a lot of ground against paper records. At any practice, <b>time is the most valuable resource</b>, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. <span style="color: #cc0000;"><i><b>[The reverse is also true - ed.] </b></i></span>Add to that the inertia people have about their old ways and you have a deal breaker right there.<br /><br />That’s not all. Driven by the constant government whip to adopt EMR, and a<b>n EMR industry that is hell bent upon imposing itself on healthcare</b> <span style="color: red;"><i><b>[long ago I began writing of a territorial invasion of healthcare by the IT industry - ed.]</b></i></span>, a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.<b>The constant juggling not only made the patient encounters time consuming and cumbersome</b> <span style="color: red;"><i><b>[and surely tiring - ed.]</b></i></span>, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. <span style="color: red;"><i><b>[And increase risk of cognitive overload and error substantially - ed.]</b></i></span> Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.<br /><br />What’s wrong with the current adoption of EMR? Why are even the converted like me questioning EMR? <span style="color: red;"><i><b>[Converted to what? - ed.]</b></i></span><br /><br />I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. <b>Second how the EMR tries to impose its will on to us instead of the other way around. <span style="color: red;"><i>[I've written that HIT should work like the clinicians work, not the other way around.  Again, the IT has become the cybernetic 'governor' or 'regulator' of care, and is not just an innocuous records system - ed.] </i></span></b> A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. <br /><br />... On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes 10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better <i><b><span style="color: red;">[when <span style="color: black;"><span style="color: red;">bugs and </span><a href="http://hcrenewal.blogspot.com/search/label/glitch" target="_blank"><span style="color: black;">'</span>glitches'</a> </span>d<span style="color: #b00000;">ue to sloppy </span>industry practices don't cause faulty output such as occurred</span> <a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html" target="_blank">here</a> <span style="color: red;">- ed.] </span></b></i>, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.<i><b> <span style="color: red;">["</span><a href="http://hcrenewal.blogspot.com/2012/09/good-health-it-v-bad-health-it-paper-is.html" target="_blank">not possible with paper</a>" <span style="color: red;">is a theme I've written about as well - ed.]</span></b></i><br /><br />Trying to impose a ready made architecture on to health care will not work. <b>“It works for retail and banking,”</b> some people seem to offer cluelessly<i><b> [<span style="color: red;">Business/mercantile computing and clinical computing </span></b><span style="color: red;"><b>are two different subspecialties of computing, I've long observed - ed.]</b></span></i>. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they <b>force things you to do things you wouldn’t otherwise do.</b> <span style="color: red;"><i><b>[Hyper-enthusiasts don't really seem to care<span style="color: black;">;<span style="color: red;"> if it's a computer, it must be better </span></span>- ed.]</b></i></span><br /><br />Such forced behavior modification may make the administrator, the insurance company, and the government happy <span style="color: red;"><i><b>[it does - ed.]</b></i></span> but I can’t understand how selecting a dozen pesky radio buttons while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamored with the EMR, <b>just because the government said so, or that it made the IT companies a few million dollars richer</b>.<i><b> <span style="color: red;">[Doctors are just supposed to obediently accept this technology by the hyper-enthusiasts and profiteers - ed.]</span></b></i><br /><br /><i>Kiran Raj Pandey is an internal medicine resident who blogs at </i><a href="http://page59.wordpress.com/" rel="nofollow" target="_blank">page59</a><i>.</i></blockquote><br />I feel "<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">anecdote</a>" #2 is also quite common, and the sentiments shared by a large number of clinicians forced into using this technology in its present state.<br /><br />Hyper-enthusiasts and other health IT promoters and grandstanders need to read the above accounts well.  They need to understand that the real-world effects of the technology, recklessly pushed, can be toxic, and not result in the utopia of better care and cost-savings they naively believe will deterministically occur.  <br /><br />-- SS

Some Real-World Lessons for the Health IT Hyper-Enthusiasts

An article was published in Health Leaders Media yesterday by Scott Mace, senior technology editor entitled "Scot Silverstein's Goo...

Đọc thêm »

Why Did the "Dean of Health Care Economics" Urge Reforms that "Appeal to Some Special Interests?"

We have often discussed, some would say belabored, the importance of the "<a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>" in health care.  Particular issues which would make those who benefit the most from our current dysfunctional health care system uncomfortable are often considered not to appropriate for polite conversation.  <br /><br />A prominent recent article in JAMA provided a great example of  how there are certain topics that health care, services, and policy experts avoid discussing.<br /><br /><b>Summary of the Article </b><br /><br />The article was by Victor R Fuchs, who has been <a href="http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html">called</a> the" dean of health care economics."  His topic was why US health care is so expensive compared to those in other countries, but provides little additional value for the extra expense.  [Fuchs VR. How and why US health care differs from that in other OECD countries.  JAMA 2013; 309: 33-34.  Link <a href="http://jama.jamanetwork.com/article.aspx?articleid=1555142">here</a>.]<br /><br />His explained the differences as follows:<br />-  "US individuals appear more distrustful of government...."  Thus presumably they shun government operation of health systems, which can lead to lowering administrative costs, and more effective negotiating "with drug companies and physicians and to control investment in hospitals and equipment."<br />-  "reluctance to achieve more equal outcomes for the population through redistributive public policy."  He attributed this to attitudes stressing personal responsibility for success, and the heterogeneity of the population leading to decreased sympathy to those who are unfortunate but "whose identity may differ greatly from one's own."<br />- "the opposition [to health care reform] of 'special interests,' such as pharmaceutical and device manufacturers, physicians (especially those in high-income specialties), and hospitals."  He noted that other countries have special interests, but attributed the power of US special interests to the country's system of government, especially "checks and balances," which provide "'choke points' for special interests to block or reshape legislation."<br /><br />He ended with three policy prescriptions for more and better health care reform:<br /><br /><br />-  "government's role should be limited to what is necessary, not just desirable."<br />-  "provision of basic coverage for all should not require equality for obtaining additional coverage."<br />-  "reform should have features that would appeal to some special interests, or to some elements within each special interest group (for example, some physicians or some health plans."<br /><br /><br />I believe this essay, because it is in a prominent journal and by the supposed dean of US health care economists, provides a good example of some of the things that ail the discussion of health care policy. First, the author made rather cavalier use of evidence to support his points.  Second, he avoided even mentioning any of the unpleasant issues we discuss on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>.  Third, he not only failed to challenge any of those who benefit the most from the current system, but also suggested further appeasement at least of some of them.<br /><br /><b>Cavalier Use of Evidence</b><br /><br />Prof Fuchs' justification for the role of distrust of government was based on a rather casual review of American history, and a single survey.  In fact, the proportion of people who appear to trust the government appears to depend on who asks the question and how it is asked.<br /><br />For example, <a href="http://www.gallup.com/poll/157700/trust-state-local-governments.aspx">Gallup polling</a> from 1998 to 2012 showed from 65% to 80% of people expressed “a great deal/ fair amount of trust in state and local government.” <a href="http://www.gallup.com/poll/157673/americans-trust-government-handling-problems.aspx"> Gallup polling</a> from 1997 to 2012 showed from 51% to 83% of people had “a great deal” or “fair amount” of “trust in federal government to handle international problems.”  On the other hand, the <a href="http://www.people-press.org/2010/04/18/public-trust-in-government-1958-2010/">Pew Research Center for the People and the Press</a> showed public trust in government peaking at nearly 80% during the administration of President Johnson, then precipitously declining, rarely exceeding 50% over the ensuing years, and now around 20%. Furthermore, although Prof Fuchs argued that distrust of government is uniquely American, he provided no data comparing such poll results from the US with those from elsewhere.<br /><br />Nor did he compare results of polls about trust of the government with those about trust of other organizations involved in health care.  However, while people in the US may be distrustful of government, polling shows even bigger distrust of health care special interests (like pharmaceutical companies and health insurance).    While <a href="http://trust.edelman.com/trust-and-health/">Edelman</a> marketing showed relatively constant trust in the pharmaceutical industry at around 50% from 2009-2012), a <a href="http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/648/ctl/ReadCustom%20Default/Default.aspx">Harris Interactive 2010 poll</a> showed that only about 10% of people thought the pharmaceutical industry was honest and trustworthy from 2003 to 2010, while health insurance companies and managed care companies were trusted by even fewer.<br /><br /><b>Avoiding Unpleasant Issues</b><br /><br />While Prof Fuchs acknowledged the role of "special interests," he avoided mentioning how these special interests might negatively affect health care, and thus how their role could be altered or countered.<br /><br />Some issues we discuss on Health Care Renewal, but which he ignored were:<br /><br /><a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">Concentration of Power</a><br /><br />We have frequently discussed how health care organizations have grown ever larger, increasing their market power, and hence their ability to command revenue.  Although we often hear arguments that larger organizations are more efficient, this historic excuse of monopolists has little evidence in support.  In fact, large organizations seem mainly efficient in extracting money for the benefit of their insiders.  For a recent discussion of the push toward monopolies that has some health care angles, see <a href="http://www.nakedcapitalism.com/2013/01/lazy-corporate-monopolies-are-why-america-cant-have-nice-things.html">this pos</a>t on Naked Capitalism.    <br /><br /><br /><u>Commercialization of Health Care </u><br /><br />The US seems to be unique in that it allows a larger role for private, for-profit corporations in health insurance and the actual provision of health care.  In the US, many health insurance companies, some hospitals and hospital systems, and many other types of health care providers, like hospices and dialysis centers, are now for-profit.  Furthermore, the physicians who provide direct patient care are more frequently employed by corporations (rather than being in solo or small group practice), and these corporations are increasingly for-profit  (look <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">here</a>).<br /><br />This increase in the provision of health insurance and direct health care by for-profit corporations is a historical change.  Through the 1970s, the American Medical Association declared "<i><b>the practice of medicine should not be commercialized, nor treated as a commodity in trade." </b></i>(Look <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>)   In most states, the corporate practice of medicine used to be banned.<br /><br /><br /><u>Commercialization in an Age of</u> <a href="http://hcrenewal.blogspot.com/search/label/financialization">Financialization</a> -<br /><br />This commercialization took place in an era in which economists were advocating that corporate leaders ignore all goals other than increasing "shareholder value" (look <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>).  This de facto meant increasing short-term stock price and/or revenue.  Clearly focusing only on short-term revenue increased the risk of management that ignored or was even <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile</a> to the health care mission.  The focus on short-term revenue lead to strong incentives for employees to "make their numbers," that is, to achieve financial goals, no matter what it took (see examples <a href="http://hcrenewal.blogspot.com/2011/01/making-their-numbers-examples-of.html">here</a>).  This likely lead to many examples of unethical behavior.  Furthermore, physicians were not immune to such requirements (look <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">here</a>). <br /><br /> <u>Abandonment of Government Regulation </u><br /><br />As was noted in the comments on <a href="http://www.nakedcapitalism.com/2013/01/lazy-corporate-monopolies-are-why-america-cant-have-nice-things.html">the post</a> on Naked Capitalism,enforcement of anti-trust law that could prevent concentration of power has generally been abandoned by recent US administrations.  Furthermore, as we have discussed <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here</a>, enforcement of laws against fraud, kickbacks, etc have lead to numerous legal settlements, but almost never any penalties against individuals who authorized, directed or implemented such actions within large health care organizations.  Thus, the leaders of health care organizations, particularly large health care corporations, have experienced<a href="http://hcrenewal.blogspot.com/search/label/impunity"> impunity</a>.  In some cases, there has been outright <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture.</a>  Conflicted regulators have proliferated, often through the mechanism of the <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">"revolving door."</a><br /><br /><a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">Executive Compensation</a>  <br /><br />Thus protected by such impunity, executives of large health care organizations often have become rich, and seem to be able to do so without any accountability for their organizations' actions.  As noted above, their incentives push them to put short-term financial goals ahead of the health care mission.  Furthermore, another currently fashionable business school doctrine is that health care managers may and perhaps should be <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic</a>, and thus need not know anything about health care, have experience caring for patients, or have sympathy for health care values.  All this has lead to health care management that ignores or even is <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile</a> to the health care mission.  <br /><br /><u>Deception Undermining Clinical Research and Education </u> <br /><br />Furthermore, this impunity and lack of accountability has been correlated with a rising tide of unethical behavior.  In particular, corporations that make drugs and devices have taken over clinical research meant to evaluate their own products.  They have often <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> research to favor their products, and <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed</a> research that even when manipulated does not favor these products.  Thus they have corrupted the clinical research base on which physicians and patients rely to make the best possible health care decisions.  Marketers have launched <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth campaigns</a> that have also included corruption of medical education.  In particular, they have paid influential health care professionals, called <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a>, to support marketing under the guise of medical education.  Thus distorting health care and medical research and education decision making has distorted decision making, likely leading to increased costs and decreased quality.   <br /><br />Other examples of poor, that is ill-informed, unaccountable, self-interested, conflicted and corrupt leadership are strewn around Health Care Renewal.  He have also shown how the governance of health care organizations often lacks accountability, integrity, transparency, and honesty.  All these problems can lead to increased costs, and decreased quality and access.  Yet almost never do any of these issues make it into polite discussion within health care research and policy circles.<br /><br /><b>Appeasement of Special Interests</b><br /><br />Over eight years of  effort by a few dedicated academic researchers, health care professionals, investigative reporters, whistle-blowers, and watch dog organizations,  chronicled to some extent on this blog and by other bloggers and commentators, has shown bad leadership and governance of, and resulting unethical behavior by health care "special interests."  Yet, the example essay by Prof Fuchs failed to deal with any of these issues.  Instead of discussing how they might be approached, he suggested continuing appeasement of special interests, which would likely make our problems even worse.  Why he ignored all the privileges the leaders of special interest have, and felt the need to treat them even more nicely, remains unclear.  <br /><br />Thus it appears that the anechoic effect is leading to failure to grapple with the real reasons for health care dysfunction, thus ensuring that health care costs will continue to rise while access and quality fall. <br /><br />Real health care reform will first require honest, unflinching consideration of what has gone wrong.  As long as the conversation seeks to avoid offending those who benefit the most from the current system dysfunction, that dysfunction will only get worse.  <br /><br />US President Theodore Roosevelt had the courage to <a href="http://en.wikiquote.org/wiki/Theodore_Roosevelt">challenge the "malefactors of great wealth" </a>who engineered the first gilded age, at the expense of the public at large.  During this second gilded age, will we have the courage to take on the new malefactors of great wealth, including those who benefit from health care's dysfunction?

Why Did the "Dean of Health Care Economics" Urge Reforms that "Appeal to Some Special Interests?"

We have often discussed, some would say belabored, the importance of the " anechoic effect " in health care.  Particular issues wh...

Đọc thêm »

ONC and "Health IT Patient Safety Action & Surveillance Plan": When Sociologists Uphold the Hippocratic Oath While Physicians Pay Respect to the Lords of Kobol, We Are in a Dark Place, Ethically

<i><span style="font-size: 85%;">[Note: this essay contains many hyperlinks. They can be right-clicked and opened in a separate tab or window.]</span></i><br /><br />I've been meaning to write more on the just-before-Christmas, Friday afternoon, minimal-visibility release of the ONC report I'd written about in my Dec. 23, 2012 post "<a href="http://hcrenewal.blogspot.com/2012/12/oncs-christmas-confessional-on-health.html" target="_blank">ONC's Christmas Confessional on Health IT Safety: HIT Patient Safety Action & Surveillance Plan for Public Comment</a>."   (The ONC report itself is available <a href="http://www.healthit.gov/sites/default/files/safetyplanhhspubliccomment.pdf" target="_blank">at this link</a> in PDF.)<br /><br />The Boston Globe and Globe staff writer Chelsea Conaboy, however, have beaten me to the punch in the Jan. 3, 2013 article "<b>Federal government releases patient safety plan for electronic health records</b>", link below.<br /><br />('<a href="http://en.wikipedia.org/wiki/Lords_of_Kobol" target="_blank">Lords of Kobol</a>', of course, is a pun.  They were fictional gods in a sci-fi series from the 1970's and a remake a few years ago, but in my circles the term is used satirically and derisively to reflect people expressing inappropriate overconfidence in - and perhaps worship of - computers.   <a href="http://en.wikipedia.org/wiki/COBOL" target="_blank">Cobol</a>, the <b>CO</b>mmon <b>B</b>usiness-<b>O</b>riented <b>L</b>anguage, is one of the oldest programming languages and was the major programming language of the merchant computing sector, including business, finance, and administrative systems for companies and governments.)<br /><br />First, I do want to reiterate what I'd mentioned in my earlier post:  the new ONC report is a sign of progress, in terms of a government body explicitly recognizing the social responsibilities incurred by conducting the mass human subjects experiment of national health IT.  However, I also wrote:<br /><br /><blockquote class="tr_bq">... [The ONC report] is still a bit weak in acknowledging the likely magnitude of under-reporting of medical errors, including HIT-related, in the available data, and the issue of <b>risk</b> <b>vs. 'confirmed body counts' </b>as I wrote at my recent post "<a href="http://hcrenewal.blogspot.com/2012/12/a-very-signifcant-additonal-observation.html" target="_blank">A Significant Additional Observation on the PA Patient Safety Authority Report -- Risk</a>". </blockquote><br />The Globe quoted a number of people involved the health IT debate, and I am now commenting on their Jan. 3 article:<br /><br /><blockquote class="tr_bq"><a href="http://www.boston.com/whitecoatnotes/2013/01/03/federal-government-releases-patient-safety-plan-for-electronic-health-records/KBqYjU4Gsup8vnx6ppgfOP/story.html?comments=all#readerComm" target="_blank"><b>Federal government releases patient safety plan for electronic health records</b></a><br />Boston Globe</blockquote><blockquote>01/03/2013 11:16 AM    <br /><br />By Chelsea Conaboy, Globe Staff <br /><br />The federal office in charge of a massive rollout of electronic health records has issued a plan aimed at making those systems safer by encouraging providers to report problems to patient safety organizations.<br /><br />Though some in the field say it doesn’t go far enough, others said the plan is an important step for an office whose primary role has been cheerleader for a technology that has the potential to dramatically improve health care in the United States but that <b>may come with significant risks.</b></blockquote><br />A major issue at the heart of the controversy is the fact that, admittedly, nobody knows the magnitude of the risks - in large part due to systematic impediments to knowing.  This has been admitted by organizations including the Joint Commission (<a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html" target="_blank">link</a>), U.S. FDA (<a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">link</a>; albeit in an "internal memo" never intended for public view, and discovered only through the hard work of Center for Public Integrity investigative reporter Fred Schulte when he was at the Huffington Post Investigative Fund), Institute of Medicine of the U.S. National Academies (<a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html" target="_blank">link</a>, quoted at midsection of post), and others.  <br /><br />I have made the claim that when you don't know the level of harm of an intervention in healthcare, and there are risk management-relevant case reports of dangers, you don't go gung-ho and start a national-scale implementation with penalties for non-adopters, and <i>then</i> decide to study safety, quality, usability etc.  You determine safety first in more controllable and constrained environments.  Anything else is, as I wrote, <i>putting the cart before the horse</i> (<a href="http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html" target="_blank">link</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/AVvXsEh7nInx820f0ENnQAtyZPnEg9adrMvhxLkh-27yVmfwbjwdrm-ybDsdcNvioqVXyXGr_jquEVlg5-HtZ-d5lkfacpkRkVIgVfJbGXHB6iEAHGFAMDFmOy8xsmqHRl_de_qjAh1p2VB0fpoC/s1600/horse-cart.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="131" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7nInx820f0ENnQAtyZPnEg9adrMvhxLkh-27yVmfwbjwdrm-ybDsdcNvioqVXyXGr_jquEVlg5-HtZ-d5lkfacpkRkVIgVfJbGXHB6iEAHGFAMDFmOy8xsmqHRl_de_qjAh1p2VB0fpoC/s200/horse-cart.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Things are a bit out of order here.</td></tr></tbody></table><br /><br />You also certainly don't dismiss risk management-relevant case reports from credible observers as "anecdotal", the common refrain of hyperenthusiasts and (incompetent) scientists who conflate scientific research with risk management - as a researcher from Down Under eloquently observed in the Aug. 2011 guest post "<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html" target="_blank">From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things</a>."<br /><br /> Back to the Globe:<br /><blockquote class="tr_bq"><br />A year ago, the Institute of Medicine issued a report urging the federal government to do more to ensure the safety of electronic health records. It highlighted instances in which the systems were linked to patient injury, deaths, or other unsafe conditions.<br /><br />The report suggested <b>creating an independent body to investigate problems with electronic records and to recommend fixe</b>s, similar to how the National Transportation Safety Board investigates aviation accidents.<br /><br />Instead, the Office of the National Coordinator for Health Information Technology delegated various monitoring and data collection duties to existing federal offices, including the Agency for Healthcare Research and Quality [AHRQ].</blockquote><br />The problem is that <a href="http://www.ahrq.gov/" target="_blank">AHRQ</a> is a research agency (as its name suggests), has no regulatory authority nor any experience in regulation, and most clinicians have never heard of it.  In effect, this ONC recommendation is lacking teeth, even compared to the relatively milquetoast recommendations of IOM itself (as I wrote about in a Nov. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">IOM Report - 'Health IT and Patient Safety: Building Safer Systems for Better Care' - Nix the FDA; Create a New Toothless Agency</a>"). <br /><br /><br /><blockquote class="tr_bq">The [ONC] office has asked patient safety organizations, which work with doctors and hospitals to monitor and analyze medical errors, to add health IT to their agendas. Data from the organizations would be aggregated by the agency, but reporting by doctors and hospitals is <b>completely voluntary.  <span style="color: red;"><i>[A prime example of what I term an extraordinary regulatory accommodation afforded the </i></span></b><b><span style="color: red;"><i><b><span style="color: red;"><i>health IT industry </i></span></b> - ed.] </i></span></b></blockquote><br /><span style="font-family: inherit;">Now we're into septic shock blood pressure-level weakness. Here is PA Patient Safety Authority Board Member Cliff Rieders, Esq. on mandatory, let alone voluntary reporting. From “<b>Hospitals Are Not Reporting Errors as Required by Law"</b>, <i>Philadelphia Inquirer</i>, pg. 4, <a href="http://articles.philly.com/2008-09-12/news/24991423_1_report-medical-mistakes-new-jersey-hospital-association-medication-safety" rel="nofollow" target="_blank">http://articles.philly.com/<wbr></wbr>2008-09-12/news/24991423_1_<wbr></wbr>report-medical-mistakes-new-<wbr></wbr>jersey-hospital-association-<wbr></wbr>medication-safety:</a><br />   </span><span style="font-family: Arial,Helvetica,sans-serif;"></span><br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><span style="font-family: inherit;"><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><br /><br /><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>[Thus reducing risk of litigation, and, incidentally, potentially infringing on patients' rights to legal recourse - ed.]</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><i>Fixing this “is not a priority,” he added.</i></blockquote><br />To expect hospitals to <i>voluntarily</i> report even a relevant fraction of mistakes and near-misses out of pure altruism, or permit their clinicians to do so, with the inherent risks to organizational interests such reporting entails, is risible.<br /><br />The near-lack of reporting by most health IT sellers and hospitals in the already-existing FDA<b> Manufacturer and User Facility Device Experience</b> (MAUDE) database is substantial confirmation of that; the fraction of reports in MAUDE, however, are hair-raising.  See my Jan. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">MAUDE and HIT Risks: What in God's Name is Going on Here</a>?" for more on that issue.<br /><br />Here's an example of what happens to 'whistleblowers', even those responsible for system development and safety: "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=lawsuit" target="_blank">A Lawsuit Over Healthcare IT Whistleblowing and Wrongful Discharge</a>." <br /><br />ONC's recommendations thus in my opinion reflect bureaucratic window dressing, designed to create progress - but progress that can probably be measured in microns.<br /><br /><blockquote class="tr_bq">“There was no evidence that a mandatory program was necessary,” Jodi Daniel, the [ONC] office’s director of policy and planning, said in an interview.</blockquote><br />Really?  See the aforementioned Philadelphia Inquirer article <span style="font-family: inherit;">“<b>Hospitals Are Not Reporting Errors as Required by Law", </b>as well as numerous articles on pharma and medical device industry reporting deficits such as starting at page 5 in my paper "<b>A Medical Informatics Grand Challenge: the EMR and Post-Marketing Drug Surveillance</b>" <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Silverstein_Drug_Surveillance.pdf" target="_blank">at this link</a> in PDF.</span><br /><br /><span style="font-family: inherit;">There is no evidence mandatory reporting is necessary ... to someone who's either </span><span style="font-family: inherit;"><span class="st">naïve</span>, incompetent - or persuaded, e.g. with money, to <i>not</i> find evidence or rationale.</span><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><br /></span>The [ONC] office has been under pressure to roll out the electronic health records systems quickly while protecting patient data and making sure that the systems don’t cause problems in medical care, <b>said Dr. John Halamka, chief information officer at Beth Israel Deaconess Medical Center. </b></blockquote><br />Under pressure by the health IT lobby, perhaps; but nobody else that I can think of.<br /><br /><blockquote class="tr_bq">“It’s this challenging chicken-and-egg problem,” he said. </blockquote><span style="font-family: inherit;"><b><br /></b></span><span style="font-family: inherit;">No, actually, it isn't.  Patient safety must come first. </span>This becomes clear when one considers the late 5th century BC ethical principle <a href="http://en.wikipedia.org/wiki/Primum_non_nocere" target="_blank"><i>Primum non nocere</i></a> ("first, do no harm" or "abstain from doing harm") versus the late 20th and early 21st century IT-hyperenthusiast credo I've expressed as "<a href="http://hcrenewal.blogspot.com/2011/10/cybernetik-uber-alles-computers-have.html" target="_blank">Cybernetik <span class="st">Über</span> Alles</a>"  ("Computers above all"). Under C<span class="st">ÜA</span>, the computer has more rights than the patients, and the IT industry receives <b>extraordinary regulatory accommodation</b> to sloppy practices that no other healthcare or mission-critical non-healthcare sector enjoys.<br /><br />I sent Dr. Halamka a set of arguments such as I make here, and a picture of a health IT 'chicken', my deceased mother in her death robes.<br /><br />I received back a "thank you for the views" message - but no condolences.  (It occurs that I have rarely if ever received condolences from any senior HIT-hyperenthusiast Medical Informatics academic or government official to whom I've mentioned my mother.  Not to play amateur psychologist, but I believe it reflects the level of disdain or even hatred felt by these people towards health IT iconoclasts/patient's rights advocates.)<br /><br /><blockquote class="tr_bq">The plan, which is subject to public comment through Feb. 4, “is a reasonable start,” in part because it puts more pressure on hospitals and doctors to monitor safety, Halamka said. </blockquote><br />As I expressed to Dr. Halamka, we are in agreement on that point.<br /><blockquote class="tr_bq"><br />The government would have risked stifling innovation in the industry if it had opted instead to require the kinds of tests and review by the Food and Drug Administration that new medical devices and drugs must go through, he said.</blockquote><br />To that, I mention here (as I did in my email to him) my response to this industry meme, as I had expressed it at Q&A after my August 2012 <a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html" target="_blank">keynote address to the Health Informatics Society of Australia</a>:<br /><br /><blockquote class="tr_bq">... I had a question from the audience [after my talk], from fellow blogger <a href="http://thehealthcareblog.com/blog/category/matthew-holt/" target="_blank">Matthew Holt of the Health Care Blog</a>.  (I've had some online debate with him before, such as in the comment thread at my April 2012 post <a href="http://hcrenewal.blogspot.com/2012/04/allscripts-shares-plunge-on-weak.html" target="_blank">here</a>.)<br /><br />Matthew asked me a somewhat hostile question (perhaps in retaliation for the thrashing he received at the end of my May 2009 post on the WaPo's HIT Lobby article <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html" target="_blank">here</a>), that I was well prepared for, expecting a question along these lines from the seller community, actually.  The question was preceded by a bit of a soliloquy of the "You're trying to stop innovation through regulation" type, with a tad of Merck/VIOXX ad hominem thrown in (I ran Merck Research Labs' Biomedical libraries and IT group in 2000-2003).<br /><br />His question was along the lines of - you were at Merck; VIOXX was bad; health IT allowed discovery of the VIOXX problem by Kaiser several years before anyone else; you're trying to halt IT innovation via demanding regulation of the technology thus harming such capabilities and other innovations.<br /><br />The audience was visibly unsettled.  Someone even hollered out their disapproval of the question.<br /><br />My response was along the lines that:<br /><br /><ul><li>VIOXX was certainly not Merck at its best, but regulation didn't stop Merck from "revolutionizing" asthma and osteoporosis via Singulair and Fosamax;</li><li>That I'm certainly not against innovation; I'm highly pro-innovation;</li><li>That our definitions of "innovation" in medicine might differ, in that <b>innovation without adherence to medical ethics is not really innovation.  It is <i>exploitation</i>.</b></li></ul></blockquote><br />I stand by that assessment.<br /><br />More from the Globe article:<br /><br /><blockquote class="tr_bq">There is little good research into how the systems improve health care and there are big obstacles to fixing even the known problems, said <b>Ross Koppel, a professor of sociology at the University of Pennsylvania who studies hospital culture and medication error</b>s.<br /><br />Some developers require providers to sign nondisclosure agreements before using their systems, and the safety plan does not prohibit such gag clauses.  <i><b><span style="color: red;">[Note: I wrote on this issue </span><a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=koppel_kreda" target="_blank">here</a>, <span style="color: red;">and in a published July 2009 JAMA letter to the editor "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" </span><a href="http://jama.jamanetwork.com/article.aspx?articleid=184302" target="_blank">here</a> <span style="color: red;">- ed.]</span>  </b></i>While the plan addresses reporting of known problems, Koppel said it <b>will not help researchers and developers understand problems that go unnoticed but that may be causing real patient harm. </b><br /><br />“We only know the tip of the iceberg” about how electronic health records affect patient care, said Koppel, who was an official reviewer for the Institute of Medicine report.<br /><br /></blockquote>As per the title of this blog post, we are in a dark place, ethically, when a PhD sociologist who's never taken the Oath of Hippocrates (to my knowledge) appears to express more concern for patient safety and patient's rights than a Harvard physician-informatics Key Opinion Leader such as Dr. Halamka. <br /><br /><blockquote class="tr_bq">Koppel said the mantra of the Office of the National Coordinator has been that more health IT leads to better health care. “It probably is better than paper,” he said, “but it could be so much better than it is.”</blockquote><br />I agree, but with caveats.  <b>I opine that bad health IT is likely worse for patients than a good, well-staffed paper based system</b>.  For instance, the former can cause systematic dangers that even a bad paper system cannot, such as tens of thousands of prescription errors (see my Nov, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html" target="_blank">Lifespan Rhode Island: Yet another health IT 'glitch' affecting thousands - that, of course, caused no patient harm that they know of - yet</a>") or mass privacy breaches (see the current 30 or so posts on that issue at this blog query link: <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy" target="_blank">http://hcrenewal.blogspot.com/search/label/medical record privacy</a>).<br /><br />On good health IT and bad health IT from my teaching site <i>"Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties"</i> at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">http://www.ischool.drexel.edu/faculty/ssilverstein/cases/</a>:<br /><blockquote class="tr_bq"><br /><span style="font-size: small;"><i><b><span style="color: black; font-family: Arial;">Good Health IT</span></b></i></span><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"><span style="font-size: small;"><i> ("GHIT") is 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 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.</i></span><span style="mso-spacerun: yes;"><span style="font-size: small;"><i> </i></span> </span></span></blockquote><br />The Boston Globe article concludes: <br /><br /><blockquote class="tr_bq">Ashish Jha, associate professor of health policy at Harvard School of Public Health and a member of the panel that drafted the Institute of Medicine report, <b>said he wants doctors to be able to report problems -- errors in medication lists, for example -- in real-time so they can be found and fixed quickly</b>. The safety plan does not require systems to have that capability, but Daniel said her office could soon add such a requirement for products that receive federal certification.<br /><br />The bigger problem is that health care as a whole needs a better way of tracking patient safety, Jha said. Monitoring issues caused by electronic health records “should be a part of it, and<b> then we can actually know if this is a small, medium or large contributor to patient safety issues,” he said. “But we don’t know that.”</b></blockquote><br />I agree with Dr. Jha, but the IT sellers and healthcare organizations will (legitimately) claim that adding real-time error reporting/forwarding to their products will be extremely resource-intensive.<br /><br />I have an alternate approach that will require little effort on the part of the sellers and user organizations.<br /><br /><ul><li>Post a message at the sign-in screen of all health IT along the lines that "This technology is experimental, adopted willingly by [organization] although not rigorously vetted for safety, reliability, usability, nor fitness for purpose, and thus you use it at your own risk.  If problems occur, report them to the following" ...</li></ul><br />"The following" could include a list of alternatives such as I wrote in my Aug. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/08/clinicians-how-to-document-ehr-screens.html" target="_blank">Clinicians: How to Document the EHR Screens You Encounter That Cause Concern</a>."<br /><br /><div class="date-posts"><div class="post-outer"><div class="post hentry" itemprop="blogPost" itemscope="itemscope" itemtype="http://schema.org/BlogPosting"><a href="http://www.blogger.com/blogger.g?blogID=9551150" name="613349029890366576"></a> <br /><div class="post-body entry-content" id="post-body-613349029890366576" itemprop="description articleBody"><blockquote class="tr_bq">... When a physician or other clinician observes health IT problems, defects, malfunctions, <a href="http://www.tinyurl.com/hostileuserexper">mission hostility</a> (e.g., poor user interfaces), significant downtimes, lost data, erroneous data, misidentified data, and so forth ... and most certainly, patient 'close calls' or actual injuries ... they should (anonymously if necessary if in a hostile management setting):<br /><br /><ul><li>Inform their facility's senior management, if deemed safe and not likely to result in retaliation such as being slandered as a "<a href="http://www.jpands.org/vol9no3/huntoon.pdf">disruptive physician</a>" and/or or being subjected to sham peer review (<a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/">link</a>).</li></ul><ul><li>Inform their personal and organizational <span style="font-weight: bold;">insurance carriers</span>, in writing. Insurance carriers do not enjoy paying out for preventable IT-related medical mistakes. They have begun to become aware of HIT risks. See, for example, the essay on Norcal Mutual Insurance Company's newsletter on HIT risks<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=norcal"> at this link</a>. (Note - many medical malpractice insurance policies can be interpreted as <span style="font-style: italic; font-weight: bold;">requiring</span><span style="font-weight: bold;"> </span>this reporting, observed occasional guest blogger <a href="http://hcrenewal.blogspot.com/search/label/Dr.%20Scott%20Monteith">Dr. Scott Monteith</a> in a comment to me about this post.)</li></ul><ul><li>Inform the Joint Commission (or similar national accreditor of hospital safety if not in the U.S.) via their complaint site at <a href="http://www.jointcommission.org/report_a_complaint.aspx">http://www.jointcommission.org/report_a_complaint.aspx</a> . Also consider writing the JC senior officers (<a href="http://www.jointcommission.org/about_us/joint_commission_officers.aspx">link to officer's list</a>), whose awareness of HIT issues I can personally attest to via our correspondences.</li></ul><ul><li>Inform the FDA (or similar healthcare regulator if not in the U.S.) via the FDA Medwatch Form 3500 reporting site at <a href="https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm">https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm</a>. An example of such an adverse event report I filed myself (when the involved hospital refused) is <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/Detail.CFM?MDRFOI__ID=1729552">at this link</a> in the FDA MAUDE (Manufacturer and User Facility Device Experience) database.</li></ul><ul><li>Inform the State Medical Society and local Medical Society of your locale.</li></ul><ul><li>Inform the appropriate Board of Health for your locale.</li></ul><ul><li>If applicable (and it often is), inform the Medicare Quality Improvement Organization (QIO) of your state or region. Example: in Pennsylvania, the QIO is "<a href="http://www.qipa.org/Home.aspx">Quality Insights of PA</a>."</li></ul><ul><li>Inform a personal attorney.</li></ul><ul><li>Inform local, state and national representatives such as congressional representatives. Sen. Grassley of Iowa is aware of these issues, for example.</li></ul><br /><br /></blockquote></div><div class="post-body entry-content" id="post-body-613349029890366576" itemprop="description articleBody">See the actual post for an idea about clinicians seeking indemnification when forced by healthcare organizations to use bad health IT.  I can attest to actually seeing HIT policies that call for "human resources actions" if clinicians refuse to use HIT, or cannot learn to use it at a sufficient pace.<br /><br />(Left out of this reiteration is the demonstration on photographing problematic EHR screens.  See the post for the details - it is easy to do, even with a commodity cellphone.)<br /><br />HHS should be promoting laws on protection from retaliation upon clinicians reporting problems in good faith.<br /><br />Thus, physicians, nurses and other clinicians can create needed health IT transparency and help our society discover the true level of risks of bad health IT.  They simply need the right information on what to do and where to report, bypassing the ONC office and, in the spirit of medicine, taking such matters into their own hands in the interests of patient care and medical ethics.<br /><br /><span style="font-family: inherit;">I also made recommendations to the Pennsylvania Patient Safety Authority on how known taxonomies of health IT-related medical error can be used, and need to be used, to promote error reporting in common formats.  Slides from my presentation to the Authority entitled "<b>Asking the Right Questions:  Using Known HIT Safety Issues to Improve Risk Reporting and Analysis</b>", given 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 />Finally, another sign of progress:  unlike the HITECH Act, this new ONC plan is open to public comment. <br /><br />-- SS<br /><br /><b>Addendum Jan. 8., 2012:</b><br /><br />Dr. Halamka has put more details regarding his views in his blog.  The entry is entitled "<b>Electronic Health Record Safety</b>" at this link:  <a href="http://geekdoctor.blogspot.com/2013/01/electronic-health-record-safety.html">http://geekdoctor.blogspot.com/2013/01/electronic-health-record-safety.html .</a><br /><br />He writes:<br /><br /><blockquote class="tr_bq">... Some have questioned the wisdom of moving forward with EHRs before we are confident that they are 100% safe and secure.   <span style="color: red;"><i><b>[That, of course, is not <u>my</u> argument - nothing is ever 100% safe and secure.  However, we don't yet know just how safe and secure - or unsafe and insecure - HIT is.  That is the issue I am concerned about - ed.]</b></i></span> I believe we need to continue our current implementation efforts.<br /><br />I realize it is a controversial statement for me to make, but let me use an analogy.<br /><br />When cars were first invented, seat belts, air bags, and anti-lock brakes did not exist.    Manufacturers tried to create very functional cars, learned from experience how to make them better, then innovated to create new safety technologies. many of which are now required by regulation. <br /><br />Writing regulation to require seat belts depended on experience with early cars.<br /><br /><b>My grandmother was killed by a medication error caused by lack of an EHR</b>.  My mother was incapacitated by <b>medication issues resulting from lack of health information exchange between professionals and hospitals.</b>   My wife experienced disconnected cancer care because of the lack of incentives to share information.     Meaningful Use Stage 2 requires the functionality in EHRs which could have prevented all three events.</blockquote><br />I express my condolences on those events.<br /><br />I disagree, however, with continuing national implementation efforts at the current rate, with penalties for non-adopters.  I opine from the perspective of believing health IT has not reached a stage where it is ready for national rollout and remains experimental, its magnitude of harms admittedly unknown and information flows systematically impaired.  I recommend and prefer great caution under those circumstances, and remediation of those circumstances before full-bore national implementation.<br /><br />I will leave it to the reader ponder the two views. <br /><br />-- SS</div></div></div></div>

ONC and "Health IT Patient Safety Action & Surveillance Plan": When Sociologists Uphold the Hippocratic Oath While Physicians Pay Respect to the Lords of Kobol, We Are in a Dark Place, Ethically

[Note: this essay contains many hyperlinks. They can be right-clicked and opened in a separate tab or window.] I've been meaning to wr...

Đọc thêm »

BLOGSCAN - When Private Equity Owns Hospitals

<span style="color: #38761d;">On his Not Running a Hospital blog, Paul Levy <a href="http://www.runningahospital.blogspot.co.il/2013/01/beyond-guns-and-gurneys.html">discussed</a> reasons for concern when private equity firms purchase and operate hospitals.  He used the example of<a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care"> Steward Health Care,</a> now a for-profit hospital system (which also employs physicians to provide direct patient care), which in turn is owned by <a href="http://hcrenewal.blogspot.com/search/label/Cerberus">Cerberus Capital Management</a>.   The issue is pertinent due to recent discussion in the media about Cerberus' newly stated intention to sell the large firearms and ammunition business it assembled, Freedom Group.  This intention was only stated after the tragic multiple murders of children and teachers by gunfire from a weapon manufactured by Freedom Group at a Connecticut elementary school.  We have previously posted about questions raised when private equity buys hospitals and employs physicians, specifically about <a href="http://hcrenewal.blogspot.com/search/label/Cerberus">Cerberus</a> and <a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care">Steward Health Care</a>, and have questioned whether a private equity group is a suitable owner and operator of hospitals and physicians' practices when said private equity group also owns a large firearms and ammunition business, and, for that matter, a military contracting company which has been accused or providing "mercenaries" (look <a href="http://hcrenewal.blogspot.com/2012/08/private-equity-obfuscatory-advertising.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/05/continuing-parade-of-legal-settlements.html">here</a>).  </span>  

BLOGSCAN - When Private Equity Owns Hospitals

On his Not Running a Hospital blog, Paul Levy discussed reasons for concern when private equity firms purchase and operate hospitals.  He u...

Đọc thêm »