Kaiser Health News/Philadelphia Inquirer on InformaticsMD: "The flaws of electronic records"

At my Dec. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/12/upcoming-profile-of-informaticsmd-in.html" target="_blank">How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist in the 10's</a>" I mentioned an interview by a reporter from the Kaiser Health Foundation regarding health IT flaws.<br /><br />His article appeared in both the <a href="http://www.philly.com/philly/entertainment/20130218_The_flaws_of_electronic_records.html" target="_blank">Philadelphia Inquirer</a> and <a href="http://www.kaiserhealthnews.org/Stories/2013/February/18/Scot-Silverstein-health-information-technology.aspx" target="_blank">Kaiser Health News</a> today under the title "The flaws of electronic records":<br /><br /><blockquote class="tr_bq"><b>Philadelphia Inquirer / Kaiser Health News</b><br /><span style="font-family: inherit;">Feb. 18, 2013</span><br /><h5 class="byline"><span style="font-family: inherit;">Jay Hancock, <i>KAISER HEALTH NEWS</i></span></h5><b><span style="font-size: large;"><span style="font-family: inherit;"><a href="http://www.philly.com/philly/entertainment/20130218_The_flaws_of_electronic_records.html" target="_blank">The flaws of electronic records</a></span></span><br /><br />Drexel University's Scot Silverstein is a leading critic of the rapid switch to computerized medical charts, saying the notion that they prevent more mistakes than they cause is not proven.</b><br /><b><br /> </b><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_8NHZXfqJrMOagNsDryhPIBfqkCL6Fpg0AV_7cXGpvSysrGf5LNS4vuXZ7bHr0FvlxiN9_8QDMVh7JtYnhDxeQ9XkUACF_VE4yC5XetVqe3I7aWif1W7wxpor32l3xF1SPfZxrg-mSG9S/s1600/silverstein_fixing_computer.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="205" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_8NHZXfqJrMOagNsDryhPIBfqkCL6Fpg0AV_7cXGpvSysrGf5LNS4vuXZ7bHr0FvlxiN9_8QDMVh7JtYnhDxeQ9XkUACF_VE4yC5XetVqe3I7aWif1W7wxpor32l3xF1SPfZxrg-mSG9S/s1600/silverstein_fixing_computer.JPG" width="320" /></a></div><br /><br />Scot Silverstein of Lansdale, one of the most ardent critics of electronic medical records, works on an antique computer. A growing collection of evidence suggests poorly designed medical software can obscure clinical data, generate incorrect treatment orders, and cause other problems. <br /><div class="photo_area" style="width: 600px;"><div class="photocaption"><br />RON TARVER /Staff Photogapher </div></div><br />Jay Hancock, KAISER HEALTH NEWS<br />Posted: Monday, February 18, 2013, 3:01 AM<br /><br />Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than proponents of electronic medical records believe, says Drexel University's Scot Silverstein.<br /><br />Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed.<br /><br />But Silverstein, a physician and adjunct professor of health-care informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem.<br /><br />"We're in the midst of a mania right now" as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. "We know it causes harm, and we don't even know the level of magnitude. <b>That statement alone should be the basis for the greatest of caution and slowing down."</b></blockquote><br />In an ethical world, it would be.  Medicine, though, is in the throes of a loss of ethics, as many stories at this site and many others attest to.<br /><br /><blockquote class="tr_bq">Use of electronic medical records is speeding up, thanks to $10 billion and counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So 4,000 hospitals have installed or are installing digital records, the Department of Health and Human Services said last month. Seventy percent of doctors surveyed in September by research firm CapSite said they had switched to digital data.<br /><br />But the notion that electronic charts prevent more mistakes than they cause just isn't proven, Silverstein says. Government doesn't require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.</blockquote><br />The recent ECRI "deep dive" study of "EHR events" (<a href="http://hcrenewal.blogspot.com/2013/02/ecri-institute-pso-uncovers-health.html" target="_blank">link</a>) is just the latest to raise red flags on that point.<br /><br />Even Dr. David Blumenthal, former chair of the Office of the National Health IT Coordinator (ONC) in HHS seems to have <a href="http://hcrenewal.blogspot.com/2010/05/david-blumenthal-on-health-it-safety.html" target="_blank">changed his message</a> about reporting of medical problems.<br /><br />From a Feb. 16, 2013 New York Times article "<a href="http://www.nytimes.com/2013/02/17/sunday-review/the-hip-replacement-case-shows-why-doctors-often-remain-silent.html?_r=0" target="_blank">Doctors Who Don’t Speak Out</a>":<br /><br /><blockquote class="tr_bq"><span style="font-size: small;">....  TRADITIONALLY, doctors have brought problems to the attention of colleagues by conducting research and publishing their findings in a medical journal. The advantage of that system helps ensure the credibility of study data and protects a researcher from random attack, said Dr. David Blumenthal, the president of the Commonwealth Fund, a group that studies health policy issues.<br /><br />But getting a study published can take a year or two; some Johnson & Johnson consultants did publish studies about the hip’s flaws, but they largely appeared after it had been recalled.<br /><br /><b>Dr. Blumenthal said there was probably a need for more immediate ways for doctors to share their concerns</b>, like forums supported by professional medical organizations. </span></blockquote><br />Back to the Inquirer article: <br /><br /><blockquote class="tr_bq">He doesn't discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers.<br /><br />But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being used in life-and-death situations, much like medical hardware or airplanes.</blockquote><br />In fact, arguments otherwise are specious.  "Harm to innovation" is the one I've heard most often.  Yet, those proffering such claims cannot point out what aspect of regulation - adherence to GMP's (good manufacturing processes), pre-market safety and quality testing, post-market surveillance, etc. - will "harm innovation."  Indeed, they opine as if innovation in medicine without objective safety and quality checks is a virtue, rather than a potential vice.<br /><br /><blockquote class="tr_bq">Silverstein "is an essential critic of the field," said physician <b>George Lundberg</b>, editor at large for MedPage Today and former editor of the Journal of the American Medical Association. "It's too easy for those of us in medicine to get excessively enthusiastic about things that look like they're going to work out really well. Sometimes we go too far and don't see the downside of things."</blockquote><br />(Dr. Lundberg mentioned me in Nov. 2011 at MedPage today in a piece entitled "<span style="color: black; font-size: 100%;"><span style="font-weight: bold;">Health IT: Garbage In, Garbage Out"</span></span> as <a href="http://hcrenewal.blogspot.com/2011/11/george-lundberg-promise-of-health-it.html" target="_blank">here</a>.)<br /><br />The patients - including ourselves and our own family members, I might add - are the ones who pay the price of our hyper-enthusiasm.<br /><br /><blockquote class="tr_bq">... The FDA's Jeffrey Shuren, a neurologist, has said such cases "likely reflect a small percentage of the actual events that do occur."</blockquote><br />"Tip of the iceberg" were his exact words (<a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html" target="_blank">link</a>).<br /><br /><blockquote class="tr_bq">... At conferences and working from home on the "Health Care Renewal" blog, Silverstein chronicles digital failures and criticizes hospitals in the same dogged way he applied himself to building the 1970s-era Heathkit computers <i>[and amateur radio equipment - ed.]</i> he still keeps in his home, say people who know him.<br /><br />"His message has been consistent": Health IT "provides far less benefit than is claimed by its proponents and opens new, sometimes potent, routes to failure," said <b>Richard I. Cook</b>, a medical error expert at the University of Chicago who sat on a panel examining electronic record safety at the authoritative Institute of Medicine. "No one wants him to be visible. But his message and tone have not wavered."</blockquote><br />Dr. Cook wrote the lone dissent to milquetoast IOM recommendations on health IT risk - the magnitude of which IOM itself admitted is unknown - in their 2012 report <b>"Health IT and Patient Safety: Building Safer Systems for Better Care"</b> available <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf" target="_blank">here</a>.  See Appendix E.<br /><br />The last scientific conference at which I chronicled these failures was at the Health Informatics Society of Australia's HIC2012, as a keynote speaker on health IT trust (<a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html" target="_blank">link</a>).  I would have been at HIC2011, to which I had been originally invited, but was helping care for a relative injured by bad health IT at that time.  Her death freed me to travel Down Under in 2012.<br /><br />I have presented at a number of plaintiff attorney's meetings since then, however, such as the <b>American Association for Justice Winter Convention</b> (AAJ, formerly the Trial Lawyer's Association) just last week (<a href="http://www.justicewinterconvention.org/" target="_blank">link</a>).  Trial lawyers don't seem to mind a very direct approach to the issues, unlike many so-called scientists who, as author Michael Crichton once warned (<a href="http://www.goodreads.com/quotes/344539-i-want-to-pause-here-and-talk-about-this-notion" target="_blank">link</a>), seem to believe in "consensus" rather than science.<br /><blockquote class="tr_bq"><br />The HIMSS Electronic Health Record Association, an industry group, declined to comment on Silverstein. A spokesman for the Office of the National Coordinator for Health Information Technology, the administration's proponent of digital records, said: "It's important to listen to all the voices" in the discussion of the subject.  </blockquote><br />Some voices, unfortunately, are louder than others and backed by lobbyists and big money.  See, for instance, the May 2009 Washington Post article by Robert O'Harrow Jr. "<b>The Machinery Behind Health-Care Reform: How an Industry Lobby Scored a Swift, Unexpected Victory by Channeling Billions to Electronic Records</b>" (link to the article and my essay about it is <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html" target="_blank">here</a>). <br /><br />I do point out, however, for the benefit of those at HIMSS and ONC, that knowing of risks, while doing nothing substantive while "listening to all voices in the discussion" can be seen as gross negligence.<br /><br /><blockquote class="tr_bq">Trained as an internist and in medical information technology <i><b>[Medical Informatics- ed.]</b></i> as a Yale University postdoc, Silverstein, 55, served as Merck & Co.'s director of scientific information in the early 2000s and then as a full-time Drexel professor, shifting in recent years to part-time teaching and working on medical liability cases for plaintiff attorneys. His insistent warnings about digital health risks over more than a decade <b>have effectively barred him from a lucrative career at a hospital or software vendor.</b></blockquote><br />Perverse as that reality may be, it's also the reverse:  <i><b>I would not want to work for a hospital or software vendor in 2013</b></i>, where effecting change to protect patients from bad health IT is hard if not impossible, e.g., as at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=lawsuit" target="_blank">link</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU" target="_blank">link</a>, and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story" target="_blank">link</a>, and at the other case examples at that site.  I find it a far more effective use of my time to help enact change from the outside - and avoiding the pathological individuals who make such scenarios possible.<br /><br /><blockquote class="tr_bq">"I'm sure Scot would be better off by keeping his mouth shut and getting a job with a hospital that's just put in a big . . . system," said Matthew Holt, a Silverstein critic and cochairman of Health 2.0, which organizes health technology conferences.</blockquote><br />I note that the <i>raison d'être</i> for this blog is the impact of many people doing just that sort of thing - "keeping their mouth shut" and making money, no matter what the ethical implications.  (The patients killed by such behaviors are, unfortunately, unavailable for comment.)<br /><blockquote class="tr_bq"><br />Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn't comment on a pending suit.) <b>Personalizing his campaign, some thought, made him seem less objective.</b></blockquote><br />I'm at a loss here.  "Too strong" - on matters of life and death that affect everyone?  A proficient writer, who had been writing about health IT problems <i>since 1998</i>, should have kept silent about a first hand story of HIT harm <i>in 2010</i> of potential great relevance towards public safety?  Writing about the incident 'lessens objectivity'?  That makes little sense, and is perverse.  Those who opined as such have their priorities in serious disarray.<br /><br />Such personalized accounts are common and have caused great change.  <a href="http://en.wikipedia.org/wiki/Libby_Zion_law" target="_blank">Libby Zion's death</a> due to hospital neglect, and her father's making the issues quite public, comes to mind, as do the many laws enacted that are named after people who've gone public after personal tragedy:<br /><br /><blockquote class="tr_bq">... Grieving the loss of their child, Zion's parents became convinced that their daughter's death was due to inadequate staffing at the teaching hospital.  Sidney Zion questioned the staff's competence for two reasons. The first was the administration of meperidine, known to cause fatal interactions with phenelzine, the antidepressant that Libby Zion was taking. The second issue was the use of restraints and emergency psychiatric medication. Sidney's aggrieved words were: "They gave her a drug that was destined to kill her, then ignored her except to tie her down like a dog." To the distress of the doctors, Zion began to refer to his daughter's death as a "murder." Sidney also questioned the long hours that residents worked at the time. In a New York Times op-ed piece he wrote: "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call—forget about life-and-death." The case eventually became a protracted high-profile legal battle, with multiple abrupt reversals; case reports about it appeared in major medical journals.</blockquote><br />An alternate explanation is that, lacking other credible means, this is an ad hominem reaction (of those "some") seeking an angle to attack the message ... and the messenger ... or is simply a reaction of, to put it bluntly, castrati who are more at home in a country club than in the world of ideas.<br /><br /><span style="font-family: inherit;"><span style="font-size: small;">For a bona fide example of "coming on too strong", there's this:</span></span><br /><br /><div class="PlainText"><span style="font-family: inherit;"><span style="font-size: small;">In the NEJM article "<span style="font-weight: bold;">The 'Meaningful Use' Regulation for Electronic Health Records</span>", David Blumenthal, M.D., M.P.P. (ONC Chair) and Marilyn Tavenner, R.N., M.H.A. (10.1056/NEJMp1006114, July 13, 2010) available <a href="http://healthcarereform.nejm.org/?p=3732&query=home">at this link</a>, the opening statement is (emphases mine):</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span></div><blockquote dir="ltr" style="margin-right: 0px;"><div class="PlainText"><span style="font-family: inherit;"><span style="font-size: small;">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></span></div></blockquote><div class="PlainText"><span style="font-family: inherit;"><span style="font-size: small;"><br />I think it fair to say those are grandiose statements and predictions presented with a tone of utmost certainty in one of the world's most respected scientific medical journals. </span></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">Even though it is a "perspectives" article, I once long ago learned that in writing in esteemed scientific journals of worldwide impact, statements of certainty were at best avoided, or if made should be exceptionally well referenced.</span></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">I note the lack of footnotes showing the source(s) of these statements.</span></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">Another bona fide exa<span style="font-size: small;">mple of "coming on too strong":</span></span></span><br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: 100%;">“We have the capacity to <b><i>transform health</i></b><span style="color: black;"> </span><span style="color: red;"><span style="color: black;">with</span></span><span style="color: black;"> <b><i>one thunderous click of a mouse after another</i></b>,” </span><span style="color: red;"><span style="color: black;">said (former) HHS Secretary Michael Leavitt</span> -</span> <a href="http://www.himss.org/ASP/ContentRedirector.asp?ContentId=65039&type=HIMSSNewsItem">2005 HIMSS Summit</a></span> </span></span></span></blockquote><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/AVvXsEi81rMzS-WFiPrb91_Guccc9_kcbOUplIvRl6eAqyOYRwvsQoibE1PA5rhERJ-q54ZC1TCcdeuJH1o7Ecm_5F5wI4yqIzw4j7xvllLz7pS9-fYIc6we-mJokTLmpLZsggAjGOMJS-veYpb3/s1600/lightning.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi81rMzS-WFiPrb91_Guccc9_kcbOUplIvRl6eAqyOYRwvsQoibE1PA5rhERJ-q54ZC1TCcdeuJH1o7Ecm_5F5wI4yqIzw4j7xvllLz7pS9-fYIc6we-mJokTLmpLZsggAjGOMJS-veYpb3/s1600/lightning.jpg" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">We shall transform health (into what, exactly, is not specified) one thunderous mouse click after another!</td></tr></tbody></table></div><br />It doesn't get any stronger than that, unless, perhaps, the thunderous wrath of God is invoked.<br /><br /><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;">Back to the Inquirer on<span style="font-size: small;">ce</span> again:</span> </span></span><br /><br /><blockquote class="tr_bq">"His refusal to temper his message makes it sometimes difficult to hear," said Ross Koppel, a University of Pennsylvania sociologist and digital health record skeptic.</blockquote><br />As per a recent article by Joe Conn in Modern Healthcare entitled <b>"Health IT Iconoclasts"</b> (<a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">link</a>), which wrote of Dr. Koppel, Deborah Peel, Lawrence Weed and me, Dr. Koppel has firsthand experience at his message being found "difficult to hear" by the hyper-enthusiasts:<br /><br /><blockquote class="tr_bq">... Researcher Ross Koppel started an uproar in 2005 when he and a colleague coauthored an article in the Journal of the American Medical Association that found a first-generation computerized physician order entry system (CPOE) at the Hospital of the University of Pennsylvania was simultaneously creating new errors even as it reduced others.<br /><br />Koppel’s bombshell—he’s now an adjunct professor of sociology at the University of Pennsylvania— <b>brought down the wrath of information technology boosters.</b> The Healthcare Information and Management Systems Society, a health IT trade group, challenged the study’s “methodology and its subsequent outcomes,” and criticized its authors for their “limited view” and not “looking at the big picture.”  <span style="color: red;"><i>[Others wrote that his work was 'disingenuous', although it had similar findings to my own observation of the very same CPOE system at Yale-New Haven Hospital ... in 1992 - ed.]</i></span><br /><br />... In 2009, he revealed in another JAMA article that health IT vendors’ contracts included “hold harmless” clauses that shielded software developers from legal liability for medical errors their systems caused, even if the developers had been warned about the defects. <b>“That got me major upheaval,” the worst of his career, Koppel recalls.</b></blockquote><br />Koppel, a sociologist, has probably done more for health IT transparency and safety than the physicians of the entire academic medical and medical informatics community combined.<br /><br /><blockquote class="tr_bq">... But Silverstein says his position today is the same as it has always been. He believes in the potential power of electronic records for good, he says. But any doctor who feels bound by the Hippocratic oath's injunction to "first, do no harm," he adds, should balk at what's going on.<br /><br />"Patients are being harmed and killed as a result of disruptions to care caused by bad health IT," he said. "I'm skeptical of the manner and pace" of implementation, "not of the technology itself. . . . My only bias is against bad medicine. And my bias is against people with complacent attitudes about bad medicine."</blockquote><br />The issues are actually relatively simple, using terminology coined by <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGiHKiF08nosKVU7uTAYFAuZg0tzy09D_tVjFrfb2sJmv6LrJlm_Pv-vazJeH5joFN8HbBEAGFJRgS9EIIr5grSxultREvX8Uycje6Tgf0cYzN6BfLqgbHbKFxor9o14guSy_qimQdUwou/s1600/jon_IMG_1038a.jpg" target="_blank">Dr. Jon Patrick of U. Sydney</a> at the aforementioned HIC2012 meeting in Australia during our discussions.  Bad health IT must be removed from the market, and good health IT must replace it.<br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="font-size: small;"><b>Good Health IT </b>("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. <br /><b><br />Bad Health IT </b>("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </span></span></blockquote> <span style="font-size: small;"> </span><br /><span style="font-size: small;">It is this auth<span style="font-size: small;">or's </span></span>opinion that this change will not happen by "going along to get along" or "listening to all the voices in the discussion of the subject" (especially those with Big Money and Big Lobbyists behind them) while doing nothing.<br /><br />I also note that "complacent attitudes about bad medicine" are not the sole province of IT personnel or healthcare management.  Physicians and nurses who acquiesce to bad health IT are part of the problem.<br /><br />-- SS

Kaiser Health News/Philadelphia Inquirer on InformaticsMD: "The flaws of electronic records"

At my Dec. 2012 post " How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist...

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A Right Royal Mess: EHRs and Royal Berkshire NHS Foundation Trust

Almost every theme I've written about for the past 15 years, at this blog and at my teaching site (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">link</a>) regarding health IT mismanagement is present here:<br /><br /><blockquote class="tr_bq"><b><span style="font-size: large;"><a href="http://www.ehi.co.uk/insight/analysis/1033/a-right-royal-mess" target="_blank">A Right Royal Mess</a></span><br />     <br />ehealth INSIDER<br />12 February 2013 </b><br /><br />Newly released reports on Royal Berkshire NHS Foundation Trust’s implementation of Cerner Millennium show that many crucial issues were not addressed prior to go-live; and that the trust is continuing to face considerable operational and financial issues because of the system. Rebecca Todd reports.</blockquote><br />Read it at the link above.<br /><br />I feel this scenario is being repeated in many countries, including the U.S., with many different vendor products.  The industry's pathologies and self-serving memes are difficult to overcome.<br /><br />As Orwell said:  "To see what is in front of one's nose needs a constant struggle."<br /><br />But don't worry...you're perfectly safe.  Computers, after all, improve healthcare and are entirely beneficent, according to the pundits.  Every untoward event is a mere "anecdote."<br /><br />-- SS<br /><br /><b>Addendum 2/15/13:</b>  just to illustrate my point, there's also this:<br /><br /><blockquote class="tr_bq"><span style="font-size: large;"><b><a href="http://www.ehi.co.uk/news/EHI/8392/monitor-blasts-rotherham%27s-epr-programme" target="_blank">Monitor blasts Rotherham's EPR programme</a></b></span><br />ehealth INSIDER<br />15 February 2013<br />Lis Evenstad  <br /><br />The Rotherham NHS Foundation Trust has been found in significant breach of its terms of authorisation by Monitor, with its electronic patient record implementation identified as a key issue.<br /><br />The trust this month admitted it was facing "persistant serious issues" with the deployment of its <b>Meditech EPR</b> including "clinician and staff acceptance and usability" ... “The trust <b>has not managed EPR implementation in an effective way</b> and significant operational and financial risks will remain until the trust has a robust and operationally effective EPR system." ... “It is unclear whether the trust has sufficient visibility over <b>operational performance and quality issues, including incidents of patient harm</b>,” it adds.</blockquote><br />-- SS

A Right Royal Mess: EHRs and Royal Berkshire NHS Foundation Trust

Almost every theme I've written about for the past 15 years, at this blog and at my teaching site ( link ) regarding health IT mismanage...

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A Sewage-Laden Cruise Ship, Burning Aircraft Batteries, Neo-Nazi Factory Security - Will Jaw Dropping Cases Prompt the Public to Demand Better Leadership?

The dysfunction of modern health care likely arises from larger trends within the economy and the society.  We frequently discuss how poor leadership and governance within health care and other organizations exist in a context of <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">focus on short-term revenue</a> above all else (<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>); <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse incentives,</a> particularly leading to <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">excess executive compensation</a> unrelated to leaders' actions or performance; <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a>, especially in <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> and <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> coupled to suppression of internal <a href="http://hcrenewal.blogspot.com/search/label/free%20speech">dissent </a>and <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">whistle blowing</a>;  <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">lax regulation and law enforcement</a>, in a climate of <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture </a>and by governments afflicted with the <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving door</a> allowing <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> and <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">corruption</a>, etc, etc.<br /><br />I was thinking of this last weekend while like many Rhode Islanders we were shivering in an unheated house.  A big but not unprecedented snow storm had apparently caused the failure of multiple high-voltage electrical transmission lines and substations, which should be designed to resist such conditions.  <b>(<a href="http://news.providencejournal.com/breaking-news/2013/02/national-grid-says-cause-still-unknown-for-failure-of-high-voltage-lines-se.html">National Grid says cause still unknown for failure of high-voltage lines serving East Bay, Aquidneck Island.</a></b>)<br /><br />Poor leadership and governance under these circumstances likely lead to threats to public health and safety.  Focus on cost-cutting and current revenue to drive executive compensation may lead to bad design, manufacture, and maintenance of critical systems.  So maybe we should not be surprised at a recent barrage of cases involving threats to health and safety by well-known corporations:<br /><br /><b><a href="http://www.telegraph.co.uk/finance/newsbysector/retailandconsumer/9821366/Walmart-in-supply-chain-crackdown-after-Bangladesh-factory-fire.html">Walmart in Supply Chain Crackdown after Bangladesh Factory Fire </a></b><br /><br /><b><a href="http://www.dailymail.co.uk/news/article-2268210/Apple-vows-eradicate-child-labour-workforce-increased-audits-following-suicide-report-reveal-problem-persists.html">Apple Vows to Eradicate Child Labour from Workforce</a> </b><br /><b><br /></b><b><a href="http://www.salon.com/2013/02/14/taibbi_hsbc_got_away_with_murder/singleton/">HSBC Got Away with Murder: the Bank Laundered Money for Drug Traffickers and Terrorist Groups... </a></b><br /><b><br /></b><b><a href="http://online.wsj.com/article/SB10001424127887324624404578253010041254492.html">Probe of Boeing 787 Battery Fire Expands</a></b><br /><b><br /></b><b><a href="http://www.nydailynews.com/news/world/passengers-crippled-cruise-ship-face-long-bus-rides-article-1.1264072">Sewage-laden Carnival Cruise Ship Docks in Mobile, Alabama: Passengers Finally Disembark from Vacation Vehicle Turned Smelly Nightmare</a></b><br /><b><br /></b><b><a href="http://www.belfasttelegraph.co.uk/news/world-news/amazon-used-neonazi-guards-to-keep-immigrant-workforce-under-control-in-germany-29070825.html">Amazon 'used neo-Nazi guards to keep immigrant workforce under control' in Germany</a></b><br /><br /><br />Those were just the cases I could easily recall.  Readers are invited to add more to the comments section.<br /><br /><br />At least, I don't think I can blame poor leadership and governance for a huge exploding meteor:<br /><br /><br /><iframe allowfullscreen="" frameborder="0" height="315" src="http://www.youtube.com/embed/90Omh7_I8vI" width="560"></iframe> <br /><br />But maybe a society less dominated by top insiders skimming off more and more money would be better prepared for the next meteor strike.<br /><br />One can only hope that this onslaught of increasingly jaw-dropping cases that threaten health and safety that would have been unimaginable a short time ago might lead the public to demand accountable, transparent, mission-focused, honest leadership of the big organizations, for-profit, non-profit and governmental, that now control our lives.

A Sewage-Laden Cruise Ship, Burning Aircraft Batteries, Neo-Nazi Factory Security - Will Jaw Dropping Cases Prompt the Public to Demand Better Leadership?

The dysfunction of modern health care likely arises from larger trends within the economy and the society.  We frequently discuss how poor l...

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Carolinas Healthcare System Pays Executives Even More

In May, 2012, we <a href="http://hcrenewal.blogspot.com/2012/05/from-serving-poor-to-pay-executives.html">discussed</a> the contrast between the outsize compensation given to top executives of Carolinas Healthcare System, a large tax-exempt public hospital authority, and the apparent failure of the system to fulfill it promise to provide community care.  Now we can update that story.<br /><br /><b>2012 Executive Compensation</b><br /><br />The Charlotte Observer <a href="http://www.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.html">reported </a>on the compensation given to top executives at the Carolinas Health Care System in 2012:<br /><br /><blockquote class="tr_bq">The<i> top executive at Carolinas HealthCare System received <b>$4.76 million</b> in 2012</i> compensation, <i>a 12 percent increase over 2011</i>, as the system celebrated a profitable year and met all of its systemwide performance goals, the system announced.<br /><br />CEO Michael Tarwater, 59, who has led the $7.5 billion nonprofit system for more than 10 years, received a salary of $1.1 million, two bonuses totaling $2.8 million, and other compensation, including retirement and health benefits, of $795,724.<br /><br /><i>The top 10 executives at Carolinas HealthCare each received more than $1 million in total compensation. Most received increases of more than 8 percent.</i></blockquote><br />A more detailed list, which included the rate of increase since 2011::<br /><br /><blockquote class="tr_bq"><i>Michael Tarwater, CEO: <b>$4,760,026</b></i><b> </b>– 12.36 percent increase <br /><i>Joseph Piemont, president and chief operating officer:<b> $2,880,926</b></i> – 13.57 percent increase <br /><i>Greg Gombar, chief financial officer: <b>$1,898,027</b></i> – 8.35 percent increase <br /><i>Laurence Hinsdale, executive vice president: <b>$1,844,413</b> </i>– 8.92 percent increase <br /><i>Paul Franz, executive vice president: <b>$1,704,671</b></i> – 8.17 percent increase <br /><i>Dennis Phillips, executive vice president: <b>$1,420,521</b></i> – 5.14 percent increase <br /><i>Dr. Roger Ray, chief medical officer: <b>$1,315,148</b></i><b> </b>– 21.76 percent increase <br /><i>John Knox, chief administrative officer: <b>$1,296,185</b></i> – 8.24 percent increase <br /><i>Debra Plousha Moore, executive vice president: <b>$1.145,357</b> </i>– increase not available <br /><i>Russell Guerin, executive vice president: <b>$1,141,171 million</b></i> – 7.56 percent increase </blockquote><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.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.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.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.html#storylink=cpy</div><br />Also here were the compensation figures for some leaders of individual hospitals within the system:<br /><br /><blockquote class="tr_bq"><span class="factbox_subhead">Others in Carolinas HealthCare System - 2012</span> <br />• <i>Spencer Lilly, president, Carolinas Medical Center: <b>$633,326 </b></i><br /><i>• Robert Larrison, president, Carolinas Rehabilitation: <b>$348,976 </b></i><br /><i>• Douglas Roush, president, CMC-Mercy: <b>$262,745 </b></i><br /><i>• Christopher Hummer, president, CMC-Pineville: <b>$549,616 </b></i><br /><i>• William Leonard, president, CMC-University: <b>$378,369 </b></i><br /><i>• Phyllis Wingate-Jones, president, CMC-NorthEast: <b>$761,160 </b></i><br /><i>• Peter Acker, president, CMC-Lincoln: <b>$385,847 </b></i><br /><i>• Michael Lutes, president, CMC-Union: <b>$488,427 </b></i></blockquote><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.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.html#storylink=cpy</div><br /><b>The Context</b><br /><br />The context is that Carolinas Healthcare is a large tax-exempt public hospital system that claims that it "works to improve and enhance the overall health and wellbeing of its communities" according to <a href="http://www.carolinashealthcare.org/about-chs">its web-site</a>.  However, there have been accusations, for example here by "Jessica Curtis, director of the Hospital Accountability Project for Community Catalyst in Boston," that is has been<br /><br /><blockquote class="tr_bq">'...sending very low income patients to collections and suing them as well.'<br /><br />The Observer and The News & Observer reported last year that during the five years ending in 2010, North Carolina hospitals filed more than 40,000 lawsuits. Most of the suits were filed by Carolinas HealthCare.</blockquote><br />Note that we discussed the contrast between this hospital system's public nature and aspirational statements about serving the community on one had, and its oversize executive compensation on the other hand <a href="http://hcrenewal.blogspot.com/2012/05/from-serving-poor-to-pay-executives.html">here</a>.  Since then, executive compensation has only gone up.<br /><br /><b>The Usual Talking Points for Justification </b><br /><br />Of course, when asked, defenders of the hospital system gave the stock justifications.  For example,<br /><br /><blockquote class="tr_bq">Carolinas HealthCare officials said executive compensation is <i>'performance based'</i> and reflects the system’s growth. </blockquote><br />The Observer found a health care executive compensation consultant to make the usual arguments about the need to pay market rates to prevent supposedly talented executives from being recruited elsewhere:<br /><br /><blockquote class="tr_bq"> Consultants who assist hospitals in setting executive compensation say they <i>compare peers at hospital systems of comparable size, complexity and performance.</i><br /><br />'If , he’s going to get paid higher in the range. <i>That individual is very vulnerable to being recruited away</i>' said Bob Erra, president of Integrated Healthcare Strategies.<br /><br />'<i>The last thing a compensation committee wants to do is to lose a leader over pay,'</i> said Erra, whose Minneapolis-based firm works with Novant Health but not Carolinas HealthCare.</blockquote><br /> Just as we mentioned in our <a href="http://hcrenewal.blogspot.com/2013/02/non-profit-hospital-executive-salaries.html">most recent post</a>, whenever anyone bothers to try to justify extravagant executive compensation at hospitals, and for that matter, most other health care organizations throughout the US, they seem to repeat the same set of talking points.    We first listed the talking points <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a>, and then provided additional examples of their use <a href="http://hcrenewal.blogspot.com/2011/09/more-repeats-of-talking-points.html">here</a>, <a href="http://hcrenewal.blogspot.com/2012/03/example-of-how-complex-takes-control.html">here</a> and <a href="http://hcrenewal.blogspot.com/2012/12/health-care-hired-managers-not-playing.html">here</a>.   The talking points are:<br />-  we pay what everyone else pays<br />-  CEOs work hard and are brilliant, and so deserve high pay<br />-  high pay is needed to attract and retain competent, if not brilliant people.<br /><br /><br /><br />Note that without specific evidence to back them up, the first two talking points at least are logical fallacies.  The first is an <a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">appeal to common practice</a>.  The second is an <a href="http://www.nizkor.org/features/fallacies/appeal-to-authority.html">appeal to authority</a>.<br /><br />None of the examples of these talking points we have seen so far explain why these apply to CEOs and other top hired managers, but not to other kinds of employees.<br /><br />So it should be no surprise that the justifications for the largess to hospital executives at Carolinas follow the talking points yet again.<br /><br />-  We Pay What Everyone Else Pays => "they compare peers at hospital systems of comparable size, complexity and performance."  Note further that it is hard to believe the comparisons were only to other public hospital systems, that is, hospital systems run by local government<br /><br />- CEOs Work Hard and Are Brilliant => "(the CEO) is a high performer...."  Note further that as usual no evidence of the CEO's specific performance was offered.<br /><br />- High Pay Needed for Retention => "That individual is very vulnerable to being recruited away."  Note that as we wrote recently, most CEOs are recruited from within the organization, and no specific evidence that this specific CEO was particularly likely to be recruited away was offered.  <br /><br />So as is usual, underlying these talking points there was no evidence, nor arguments that would make them more logical.<br /><br /><br /><b>Summary: the More Things Change</b><br /><br />The more they stay the same.  Thus this seems to be yet another example of how top managers almost always now seem able to personally profit from their positions of trust.  In this particular example, however, these were managers of a public organization, so it may be possible that public pressure could make them more accountable and hold them to more reasonable pay.   <br /><br />So to repeat my conclusions from 2012....  The governance of this organization, like that of many others we have discussed, needs to regain accountability, transparency, integrity, and ethics. It must insist that the leaders it hires uphold the mission ahead of other concerns, particularly personal enrichment. It must provide these leaders with realistic incentives based on how well they uphold this mission, not on revenue or operating margin. <br /><br />Until such changes are accomplished, expect this hospital system, like many other health care organizations, to contribute only to our ever rising prices, declining access, and stagnating health care quality.

Carolinas Healthcare System Pays Executives Even More

In May, 2012, we discussed the contrast between the outsize compensation given to top executives of Carolinas Healthcare System, a large ta...

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Bipartisan Policy Center's Health Innovation Initiative: Health IT Industry Officials Lying to Regulators With Impunity?

On Wednesday, February 13, 2013, The <a href="https://bipartisanpolicy.org/" target="_blank">Bipartisan Policy Center's</a> Health Innovation Initiative held a discussion on its new report: <i>An Oversight Framework for Assuring Patient Safety in Health Information Technology</i>.  The announcement is here:  <a href="https://bipartisanpolicy.org/news/press-releases/2013/02/bipartisan-policy-center-releases-recommendations-oversight-framework-pa">https://bipartisanpolicy.org/news/press-releases/2013/02/bipartisan-policy-center-releases-recommendations-oversight-framework-pa</a><br /><br />The report is here (PDF):  "<a href="http://bipartisanpolicy.org/sites/default/files/Patient%20Safety%20Health%20IT_0.pdf" target="_blank">An Oversight Framework for Assuring Patient Safety in Health Information Technology.</a>"<br /><br />The "who's" of the<a href="https://bipartisanpolicy.org/" target="_blank"> Bipartisan Policy Center's</a> Health Innovation Initiative included these people:<br /><br /><ul><li><b>Senator Tom Daschle</b>, Former U.S. Senate Majority Leader; Co-founder, Bipartisan Policy Center (BPC); and Co-leader BPC Health Project Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality, Department of Health and Human Services</li><li><b>Farzad Mostashari, M.D., ScM</b>, National Coordinator for Health Information Technology, Department of Health and Human Services </li><li><b>Peter Angood, M.D.</b>, Chief Executive Officer, American College of Physician Executives</li><li><b>Russ Branzell</b>, Chief Executive Officer, Colorado Health Medical Group, University of Colorado Health</li><li><b>John Glaser, Ph.D.</b>, Chief Executive Officer, Siemens Health Services </li><li><b>Douglas E. Henley, M.D., FAAFP</b>, Executive Vice President and Chief Executive Officer, American Academy of Family Physicians</li><li><b>Jeffrey C. Lerner, Ph.D.</b>, President and Chief Executive Officer, ECRI Institute</li><li><b>Ed Park</b>, Executive Vice President and Chief Operating Officer, athenahealth</li><li><b>Emad Rizk, M.D.</b>, President, McKesson Health Solutions</li><li><b>Janet Marchibroda, Moderator</b>; Director, BPC Health Innovation Initiative </li></ul><br />Unfortunately, I was unable to attend.  I was at the <a href="http://www.justicewinterconvention.org/" target="_blank">2013 Annual Winter Convention of the American Association for Justice</a> (Trial Lawyer's Association) in Florida, as an invited speaker on health IT risk, its use in evidence tampering, and other legal issues.<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/AVvXsEh1kTtcFaa9AlR4ehFZ2saSVQIFGGXDXX0oj-i8Ak1HQVCSfth5AWUu_Z2XZr0dLHOklLh0MpDCA_dcNT35QiGkJfroeHJDohpj7zLVKul8fjan3Ob9p4DSsotj8f0vdTceuobxQiizwqFv/s1600/aaj.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1kTtcFaa9AlR4ehFZ2saSVQIFGGXDXX0oj-i8Ak1HQVCSfth5AWUu_Z2XZr0dLHOklLh0MpDCA_dcNT35QiGkJfroeHJDohpj7zLVKul8fjan3Ob9p4DSsotj8f0vdTceuobxQiizwqFv/s400/aaj.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">"United for Justice" - click to enlarge</td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td></tr></tbody></table><div class="separator" style="clear: both; text-align: center;"></div><br />I found the following statement from the Bipartisan Policy Center's Health Innovation Initiative <a href="http://bipartisanpolicy.org/sites/default/files/Patient%20Safety%20Health%20IT_0.pdf" target="_blank">report</a> remarkable as a "framework for health IT safety":<br /><br /><blockquote class="tr_bq">The Bipartisan Policy Center today proposed an oversight framework for assuring patient safety in health information technology. Among other guiding principles, the framework should be risk-based, flexible and assure patient safety is a <b>shared responsibility</b>, the authors said. “Assuring safety in clinical software in particular is a shared responsibility among developers, implementers, <b>and users</b> across the various stages of the health IT life cycle, which include design and development; implementation and customization; upgrades, maintenance and operations; and risk identification, mitigation and remediation,” the report states. <b>Among other recommendations, the center said clinical software such as electronic health records and software used to inform clinical decision making should be subject to a new oversight framework, rather than traditional regulatory approaches </b><span style="color: red;"><i>[e.g.,  FDA - ed.] </i></span><b>applied to medical devices <u>given its lower risk profile</u>.</b></blockquote><br />I find it remarkable that the health IT industry and its supporters now feel they can lie to our government and regulatory agencies with impunity.  Stating that health IT has a <b>"lower risk profile"</b> is an example.<br /><br /><i>One cannot know what is acknowledged to be unknown.</i><br /><br />From the Institute of Medicine in its 2012 report on health IT safety:<br /><br /><blockquote class="tr_bq"><span style="font-style: italic;">Institute of Medicine. 2012. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf" target="_blank">Health IT and Patient Safety: Building Safer Systems for Better Care</a> .  Washington, DC: The National Academies Press</span>.<br /><br />... While some studies suggest improvements in patient safety can be made, others have found no effect. Instances of health IT–associated harm have been reported. However, <b><u>little published evidence could be found </u></b><span style="font-weight: bold;"><u>quantifying the magnitude of the risk</u>. </span><br /><br />Several reasons health IT–related safety data are lacking include the <span style="font-weight: bold;">absence of measures and a central repository</span> (or<span style="font-weight: bold;"> linkages</span> among decentralized repositories) to collect, analyze, and act on information related to safety of this technology. Another impediment to gathering safety data is <span style="font-weight: bold;">contractual barriers (e.g., nondisclosure, confidentiality clauses)</span> that can prevent users from sharing information about health IT–related adverse events. These barriers limit users’ abilities to share knowledge of risk-prone user interfaces, for instance through screenshots and descriptions of potentially unsafe processes. In addition, some vendors include language in their sales contracts and escape responsibility for errors or defects in their software (i.e., “<span style="font-weight: bold;">hold harmless clauses</span>”). The committee believes these types of contractual restrictions <span style="font-weight: bold;">limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety.</span><span style="font-style: italic;"></span><br /><br /><b>... More worrisome, some case reports suggest that poorly designed health IT can create new hazards</b> in the already complex delivery of care. <u><b>Although the magnitude of the risk associated with health IT is not known</b></u>, some examples illustrate the concerns. Dosing errors, failure to detect life-threatening illnesses, and delaying treatment due to poor human–computer interactions or loss of data have led to serious injury and death.”  </blockquote><br />Even to those with particularly thick skulls, this statement seems easy to comprehend:<br /><br /><span style="color: red;">"<b>The magnitude of the risk associated with health IT is not known."</b></span><br /><br /><span style="color: red;"><span style="color: black;">I repeat once again:</span><b> </b></span><br /><br /><span style="color: red;"><b><i>One cannot know what is acknowledged to be unknown.</i> </b></span><br /><br />A statement that health IT has a <b>"lower risk profile"</b> compared to other regulated healthcare sectors such as devices or drugs, in order to seek continued and extraordinary regulatory accommodations, is remarkable.  It is either reckless regarding something that the statement's makers should know, or should have made it their business to know - or a deliberate prevarication with forethought.<br /><br />The report did attempt to shroud the declarative "lower risk profile" in a sugar coating through misdirection, citing the need to take into account "several factors" including<i>:</i><br /><br /><blockquote class="tr_bq"><i>"the level of risk of potential patient harm, the degree of direct clinical action on patients, the opportunity for clinician involvement, the nature and pace of its development, and the number of factors beyond the development stage that impact its level of safety in implementation and use."</i> </blockquote><br />These "factors" speak to a <b>higher level</b> of potential risk, not lower, and are a justification for stronger regulatory oversight, not weaker.  I would opine that there is a possibility that health IT. through which almost all transactions of care need to pass (e.g., orders, results reporting, recording and review of observations, finding, diagnoses, prognoses, treatment plans, etc.), <b>could have a higher risk profile</b> than one-off devices or drugs<b>.  Health IT affects every patient, </b>not just those under a specific therapy or using a specific device or drug.<br /><br />Partial taxonomies developed from limited data themselves speak to the issue of a potentially huge risk profile of health IT, e.g., the <b>FDA Internal Memo on HIT Risks</b> (<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-IT.pdf" target="_blank">link</a>), the <b>AHRQ Hazards Manager taxonomy</b> (<a href="http://healthit.ahrq.gov/HealthITHazardManagerFinalReport" target="_blank">link</a>), and the sometimes hair-raising <i>voluntary </i>defects reports (largely from one vendor) in the <b>FDA MAUDE database </b>(<a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html" target="_blank">link</a>).  Further, health IT can and does affect thousands or tens of thousands of patients <i>en masse </i>even due to one simple defect, such as happened in <b>Rhode Island </b>at Lifespan (<a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html" target="_blank">link</a>), or due to overall design and implementation problems such as at <b>Contra Costa County, CA</b> (<a href="http://hcrenewal.blogspot.com/2012/09/in-addition-to-nurses-doctors-now-air.html" target="_blank">link</a>) and <b>San Francisco's Dept. of Public Health</b> (<a href="http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html" target="_blank">link</a>).<br /><br />We don't know the true levels of risk and harm - but we need to, and rapidly.  Industry self-policing is not the answer; it didn't work in drugs and devices, and even with regulation there are still significant problems in those sectors.  (Imagine how it would be if those sectors received the special accommodations that health IT receives, and wishes to continue to receive.)<br /><br />My other issue is with the "shared responsibility" including "users."<br /><br />The user's responsibility is <b>patient care</b>, not being a beta tester for bug-laden or grossly defective health IT products.  Their responsibility ends at reporting problems <b><i>without retaliation</i></b>, and ensuring patient safety.<br /><br />Their responsibility is to avoid carelessness - as it is when they drive their cars.<br /><br />In other words, the inclusion of "users" in the statement is superfluous. <br /><br />It is not a responsibility to be omniscient and be held accountable when <b>bad health IT</b> promotes <b>"use error" </b>(the NIST definition of "use error" I will not repeat again here; search the blog) -- as opposed to <b>and as distinct from "user error"</b> - note the final <b>"r"</b> - i.e., carelessness.<br /><br />Bad health IT (see <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/" target="_blank">here</a>):<br /><br /><blockquote class="tr_bq"><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"><span style="font-family: inherit;"><span style="font-size: small;"><b>Bad Health IT</b> ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for <span class="SpellE">hypervigilance</span> (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.</span></span><span style="mso-spacerun: yes;"><span style="font-family: inherit;"><span style="font-size: small;"> </span></span> </span></span></blockquote><br />One special accommodation that the health IT industry has been afforded for far too long is to be able to <b>"blame the user."</b><br /><br />"Blaming the victim" of bad health IT is a more appropriate description.<br /><br />-- SS

Bipartisan Policy Center's Health Innovation Initiative: Health IT Industry Officials Lying to Regulators With Impunity?

On Wednesday, February 13, 2013, The Bipartisan Policy Center's Health Innovation Initiative held a discussion on its new report: An Ov...

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Non-Profit Hospital Executive Salaries Continue to Defy Gravity and Logic

The old saying is that nothing is certain except death and taxes.  In health care, the other near certainty seems to be that compensation for health care leaders is big and always getting bigger.  <br /><br />Over the past few weeks several reports about the compensation of top executives of US non-profit hospitals and hospital systems have appeared.  So it is time to do our latest round-up of incessantly buoyant hospital executive compensation, and argumentative hot air that seems to fuel it.  I will first summarize the latest cases in alphabetical order by state, and then examine some common justifications for the seemingly anti gravitational nature of executive compensation in this part of health care.<br /><br /><b>Arizona</b><br /><br />On AZCentral.com was an <a href="http://www.azcentral.com/news/politics/articles/20130208maricopa-county-health-care-chief-big-raise.html">article</a> about the CEO of a single relatively small public hospital system:<br /><br /><blockquote class="tr_bq">The leaders of Maricopa County’s public health-care system agreed to raise chief executive Betsey Bayless’ pay by 33 percent, bringing her salary to <i><b>$500,000.</b></i></blockquote><br />That may not seem like a lot of money as executive compensation goes, but consider the context:<br /><br /><blockquote class="tr_bq">The Maricopa Integrated Health System is a <i>public hospital system that provides care for the Valley’s poor and uninsured. It is funded by federal and state health-care dollars and a special county levy paid by all county property-tax payers.</i><br /><br /><i>MIHS budgeted $3.5 million for market adjustments and merit raises for its employees in fiscal 2013. Bayless’ salary increase alone will consume one-quarter of the $500,000 the board had allocated this fiscal year to bring all employees’ pay in line with similar positions elsewhere.</i><br /><br />The health-care system’s rank-and-file employees have received annual merit-based salary<i> increases of no more than 2.9 percent since fiscal 2008.</i></blockquote><br />Nonetheless, the CEO did not exactly feel rich:<br /><br /><blockquote class="tr_bq">Bayless said she did not request the raise and was not expecting it. She said she believes MIHS employees will understand that her salary has been comparatively low and that her replacement likely will be brought in at an even higher salary.</blockquote><br /><br />She justified her pay by comparing it to what she thought the market would bear.<br /><br /><blockquote class="tr_bq">'Any salary information will show you that my salary is always the <i>lowest of any (hospital) CEO currently in the entire state</i>, even the little-bitty hospitals,' Bayless said. 'On any measure, <i>375 (thousand dollars) is below market</i>. So, do I feel undercompensated? I don’t know. But on any measure,<i> it always comes in below market</i>.'</blockquote><br />Members of the hospital system's board also justified the pay on the grounds that it was at the market rate:<br /><br /><blockquote class="tr_bq">[Board Members Mary] Harden and [Terence] McMahon said they voted for the pay raise because a national search firm hired to find Bayless’ replacement set $500,000 as a minimum competitive salary for qualified candidates.</blockquote><br />Another board member also noted how hard CEO Bayless works:<br /><br /><blockquote class="tr_bq">'The lady works 70-plus hours a week. She’s on call 24/7. So, I think the job warrants it. She works very, very hard,'  Dewane said.</blockquote>I am sure health care professionals who also work long hours, and are frequently on call, but unlike managers, have to make decisions with real life and death consequences would understand, or not. <br /><br /><br /><b>California</b><br /><br />In California a report focused in contrast on the bigger hospitals and hospital systems.  California Healthcare News <a href="http://www.payersandproviders.com/news-article.php?news_id=138&region=3">reported</a> on the best compensated hospital executives in the state.  In general,<br /><br /><blockquote class="tr_bq">More than <i>one in five non-profit hospital chief executive officers in California received compensation totaling $1 million or more in 2010,</i> according to a new pay survey by Payers & Providers.<br /><br />Altogether, <i>32 CEOs of the 154 surveyed received pay packages that ventured into the seven figures</i>. That compares to 19 CEOs who received seven-figure pay packages in the only prior survey Payers & Providers conducted. That survey was published in June 2010, and relied primarily on data from 2007 and 2008.  </blockquote><br />Some specifics about the best paid executives:<br /><br /><blockquote class="tr_bq"><i>Kaiser Permanente's George Halvorson is the most highly-compensated hospital system executive in California, receiving <b>$7.74 million </b>in 2010.</i> That included more than $6 million in additional compensation. Halvorson is retiring as Kaiser's CEO in June.<br /><br /><i>Thomas Priselac, the chief executive officer of Cedars-Sinai Medical Center in Los Angeles, was the highest-paid standalone hospital CEO, earning <b>$2.77 million</b> in 2010.</i> That included additional compensation of $1.6 million.</blockquote><br />The article provided the justification for Priselac's seven-figure compensation:<br /><br /><blockquote class="tr_bq">According to an email response from Cedars-Sinai spokesperson Duke Helfand, Priselac's compensation '<i>reflects the top-tier clinical, research and educational performance</i> the medical center consistently has delivered in his 19 years of leadership.'</blockquote><br />He did not offer how this performance was measured, how it compared to that of any other hospital, or whether anyone other than the CEO might have been responsible for that performance. <br /><br />The survey results included the best compensated CEO of a health-district<br /><br /><blockquote class="tr_bq"><i>Michael Covert,  the CEO of the two hospital Palomar-Pomerado Health system in San Diego County, was the highest-paid district hospital CEO, earning<b> $1.09 million </b>in 2010. </i>He was among two district hospital CEOs to earn seven-figure compensation. </blockquote><br />The survey results also included the best compensated CEO for academic medical centers run by the (state supported) University of California:<br /><br /><blockquote class="tr_bq"><i>David T. Feinberg, M.D., is by far the highest-paid CEO among those who oversee the five research hospitals operated by the University of California. Feinberg, who runs Ronald Reagan UCLA Medical Center, earned <b>$1.33 million</b> in 2010 </i>– the only seven-figure pay package among that cohort of CEOs, and nearly $450,000 more than the second-highest earner in that group, Mark Laret of UC San Francisco Medical Center.</blockquote><b>Connecticut</b><br /><br />Becker's Hospital Review <a href="http://www.beckershospitalreview.com/compensation-issues/9-connecticut-hospital-ceos-pay-tops-1m-in-fy-2011.html">provided information</a> on the highest paid Connecticut hospital CEOs:<br /><br /><blockquote class="tr_bq">Here are the nine CEOs who earned at least $1 million in 2011. <br /><br />•    <i>Clarence Silvia, The Hospital of Central Connecticut: <b>$2.76 million</b><br />•    Marna Borgstrom, Yale-New Haven Hospital: <b>$2.59 million</b><br />•    Brian Grissler, Stamford Hospital: <b>$2.24 million</b><br />•    Elliot Joseph, Hartford Hospital: <b>$1.74 million </b><br />(*CEO is now Jeff Flaks)<br />•    Frank Corvino, Greenwich Hospital: <b>$1.71 million</b><br />•    Susan Davis, RN, Saint Vincent's Medical Center: <b>$1.48 million</b><br />•    Chris Dadlez, Saint Francis Hospital and Medical Center: <b>$1.42 million</b><br />•    John Murphy, MD, Danbury Hospital: <b>$1.08 million</b><br />•    Christopher O'Connor, Hospital of Saint Raphael: <b>$1.04 million</b></i></blockquote><br /> The report did not provide any justification for the pay levels, and I could find no further news coverage that was relevant.<br /><br /><b>Massachusetts</b><br /><br />The Fitchburg (MA) Sentinel and Enterprise seemed to be the only media outlet which  <a href="http://www.sentinelandenterprise.com/local/ci_22266835/questions-raised-pay-mass-hospital-execs">noted</a> the compensation of hospital executives reported to the state attorney general.  It listed compensation of some regional hospital leaders,<br /><br /><blockquote class="tr_bq"><i>Patrick Muldoon, president and CEO of HealthAlliance Hospital, a member of the UMass Memorial Health Care system, received a compensation package of<b> $653,868</b> in 2010</i>, the most recent year for which compensation data is publicly available.<br /><br />The HealthAlliance system includes a 135-bed community hospital with services on two campuses in Leominster and Fitchburg. <br /><br />Over that same period, <i>Daniel P. Moen, former president and CEO of the 153-bed Heywood Hospital in Gardner, received a compensation package of <b>$386,126. </b> </i><br /><br /><i>Christine Schuster, CEO of Emerson Hospital in Concord, earned a total compensation package of <b>$669,844</b>. Emerson has 179 beds. </i><br /><br /><i>Lahey Clinic chief executive Howard Grant, who oversees a facility with 317 beds, was paid a total compensation package of <b>$768,568</b> in 2010. </i> </blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />The article did not note the justification for the pay of any of these CEOs.  I was unable to find any other recent reporting that took advantage of the data supplied to the state Attorney General.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>New York</b></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><u>SUNY - Downstate Medical Center </u><br /><br />The New York Daily News <a href="http://www.nydailynews.com/new-york/brooklyn/suny-downstate-bigs-earn-200k-lich-closing-moves-article-1.1257273">reported</a> on compensation given to executives at one state supported university medical center:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">15 SUNY Downstate Medical Center bigs are raking in $200,000-plus salaries even as plans move forward to shut down its Long Island College Hospital campus.<br /><br />Downstate president Dr. John Williams who’s leading the drive to close the Cobble Hill hospital gets the fattest pay of all.<br /><br />He’s paid <i><b>$650,000</b> a year salary and gets an annual housing allowance of up to $80,000 and the use of a car.</i></div></blockquote>It listed the following compensation information for other executives:<br /><br /><blockquote class="tr_bq">Other big hospital administrators’ salaries, 2011<br /><i></i><i> * <b>$552,556.33</b> — Debra Carey, vice president</i><br /><i></i><i> *<b> $357,379.26</b> - Grace Wong, vice president</i><br /><i></i><i> * <b>$334,072.19</b> — Ivan Lisnitzer, vice president</i><br /><i></i><i> *<b> $312,182.24 </b>— Paul Davis, assistant vice president</i><br /><i></i><i> * <b>$286,954.51</b> Renee Poncet, vice president</i></blockquote><br /><br />This should be viewed in the context of the medical center's current dire straits:<br /><br /><blockquote class="tr_bq">SUNY Downstate — which has a hospital and medical school in East Flatbush — <i>is in such bad financial shape it could go broke by March, </i>SUNY chairman Carl McCall has said.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Of course, despite these financial threats, a "spokesman" defended these payments again as market-based:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">[Robert] Bellafioire defended the brigade of big salaries — though the controller’s audit suggested Downstate should consider cutting the number of high-paid administrators. </blockquote><blockquote class="tr_bq">'We<i> have to offer competitive compensation, particularly when we’re up against any number of the country’s best hospitals and medical schools</i> just across the bridge and in the metropolitan area,' Bellafiore said.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><u>Rural Hospitals in Upstate New York </u><br /><br />On the other hand, the Plattsburgh (NY) Press-Republican <a href="http://pressrepublican.com/0100_news/x1303545809/Salaries-of-hospital-CEOs-detailed">reported</a> on the compensation given to hospital executives in rural northern New York state.  These included Alice Hyde Medical Center:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><i>John Johnson, president and chief executive officer, was paid <b>$339,539 </b>in 2010.</i> He retired in the fall of 2012.<br /><br />He was replaced by Douglas DiVello, who is paid $246,682 in salary and benefits.</div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br />Then there was CVPH Medical Center in Plattsburgh </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><i>Hospital President Stephens Mundy has been at CVPH for 10 years and was paid <b>$749,563 </b>in salary, bonuses and other compensation in 2010.</i><br /><br />His base salary for 2013 is $478,421,...</div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">In addition, there was Elizabethtown Community:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><i>Rodney Boula, president and chief executive officer at ECH, was paid <b>$229,902 </b>in 2010.</i></div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Note that later the article explained that this hospital has no more than 25 beds.<br /><br />However, the reporter was unable to find out the compensation of the CEO of the Adirondack Medical Center in Saranac Lake:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><i>Chandler Ralph, president and chief executive officer for 16 years, is not employed by the hospital or its umbrella organization, Adirondack Health.</i><br /><br />She is paid through a contract with a management company, Health Tech Management Services, said Joe Riccio, AMC communications director.<br /><br /><i>Her salary is a confidential employment contract</i>, 'just like any other vendor that does business' with the hospital, he said.<br /><br />Because of that, her salary was not available through IRS records. The Press-Republican pressed Ralph to release her salary, noting that it was publishing the pay of all other area hospital CEOs, but she refused, citing confidentiality.</div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Parenthetically, this seems to be an unusual case of the actual outsourcing of top leadership. <br /><br />This compensation information again should be considered in the context.  These are all relatively small hospitals in a rural area with low costs of living.  In addition, these hospitals were facing substantial financial challenges:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><i>Numerous jobs were cut in 2012 at the area’s five hospitals, some the first substantial layoffs in decades. One hospital recorded an operating deficit, and at some, programs and services were reduced.</i><br /><br />Adirondack Health, parent company of Adirondack Medical Center in Saranac Lake, and CVPH Medical Center in Plattsburgh, each laid off 17 employees last fall and eliminated vacant positions.<br /><br />Alice Hyde Medical Center in Malone let 12 people go in September and had closed down more than a dozen vacancies.</div></blockquote><br /><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Nonetheless, the justifications for these compensation levels included the usual suspects.In an introductory discussion not specific to any hospital, we find:</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /><blockquote class="tr_bq">'The <i>responsibilities of a CEO have exploded</i> in the last four years,' said William Van Slyke of the Healthcare Association of New York State, an organization that represents hospitals and health-care systems across the state.</blockquote>Similarly,<br /><br /><blockquote class="tr_bq">'Being a hospital CEO, <i>you are ‘all in,’ all the time, every hour</i>. It’s a tremendous responsibility.'</blockquote>  <br />This is the familiar argument about how hard seemingly all hospital CEOs work.  As noted above, it is particularly incongruous in a health care setting in which numerous health professionals are also "all in," and these professionals bear the responsibility of making decisions and taking actions that can directly affect patients' health, safety, and even survival.<br /><br /> Following this were the equally familiar arguments that the compensation of CEOs is determined by the market, and so to retain CEOs one must pay at this market rate:<br /><br /><blockquote class="tr_bq">'Being a hospital CEO, especially in the state of New York, is <i>complex and demanding job</i>. There is an <i>extraordinarily limited pool of candidates</i>, and that increases their value.'<br /><br />'I can’t speak for the hospitals in your area,' he told the Press-Republican, 'but <i>a qualified and successful CEO can go anywhere</i> in the country and make equal or higher salaries.'</blockquote><br />The Press Republican also elicited very similar articles justifying pay for individual hospital CEOs, for example, regarding the CEO of the Alice Hyde Medical Center, here is the "compensation is determined by the market" argument from "Dean Johnston, president of the Board of Trustees, and member of the hospital's Compensation Committee"<br /><br /><blockquote class="tr_bq">'It’s important that <i>the salary is competitive</i> with other institutions because <i>it’s difficult to attract </i>professional leaders who will improve the quality of care.'</blockquote><br />And from the same person, here is the "CEOs work very hard" argument<br /><br /><blockquote class="tr_bq"> '<i>It’s difficult being CEO</i>,' Johnston continued, 'because you’re the head of a complex and multi-faceted institution.'</blockquote><br />Very similar arguments were made to justify the compensation of the CEO of CVPH Medical Center.  <br /><br /><b>The Usual Talking Points and Logical Fallacies</b><br /><br />So, to summarize, hospital executive compensation, at least such compensation that gets noted in the media, seemingly never has been better.  CEOs at even the smallest, most rural, non-profit community hospitals can make well into the six figures.  CEOs at public hospitals can make over half a million dollars.  CEOs at larger hospitals, even those that are state supported, can make even more, up to millions a year for CEOs of moderate to large non-profit hospital systems.  Even hospitals that are facing financial challenges, or that are laying off employees still pay substantial amounts. <br /><br />In previous posts, we noted that whenever anyone bothers to try to justify extravagant executive compensation at hospitals, and for that matter, other health care organizations throughout the US, they seem to repeat the same set of talking points.    We first listed the talking points <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a>, and then provided additional examples of their use <a href="http://hcrenewal.blogspot.com/2011/09/more-repeats-of-talking-points.html">here</a>, <a href="http://hcrenewal.blogspot.com/2012/03/example-of-how-complex-takes-control.html">here</a> and <a href="http://hcrenewal.blogspot.com/2012/12/health-care-hired-managers-not-playing.html">here</a>.   The talking points are:<br />-  we pay what everyone else pays<br />-  CEOs work hard and are brilliant, and so deserve high pay<br />-  high pay is needed to attract and retain competent, if not brilliant people.<br /><br />None of the examples of these talking points we have seen so far explain why these apply to CEOs and other top hired managers, but not to other kinds of employees. <br /><br />So it should be no surprise that the justifications for the largesse to hospital executives found in the cases above follow the talking points yet again.<br /><br /><u>We Pay What Everyone Else Pays</u><br /><br /> Another way to put this is that some market determines CEO pay.  We saw versions of this to support the compensation of the CEOs of Maricopa Integrated Health System in Arizona, and SUNY - Downstate Medical Center and Alice Hyde Medical Center in New York. <br /><br />Note that almost never is this argument supported by data about whether comparisons were actually made to a representative peer group.  In any case, as we <a href="http://hcrenewal.blogspot.com/2012/12/health-care-hired-managers-not-playing.html">asserted before</a>, this justification may be a logical fallacy, an <a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">appeal to common practice</a>.<br /><br /><u>CEOs Work Hard and Are Brilliant</u><br /><br /> This is an especially frequently used talking point.  I have yet to see an instance in which any hospital official would omit a CEO was anything other than supremely diligent and totally brilliant.  We saw versions of this to support the compensation of the CEOs of Maricopa (AZ), Cedars-Sinai Medical Center in California, the Alice Hyde Medical Center and CVPH Medical Center in New York, and generically to support all New York State hospital CEOs. <br /><br />As we noted above, this justification is almost never accompanied by any evidence that CEOs work harder or are more brilliant than the numerous health care professionals who actually make it possible for the hospital to operate.  I would guess it would be very hard to show that CEOs work longer hours, are under more stress, make more consequential decisions, are smarter or better trained than typical doctors, nurses and other health care professionals.  This justification thus appears to be another kind of logical fallacy, an <a href="http://www.nizkor.org/features/fallacies/appeal-to-authority.html">appeal to authority</a>.<br /><br /><u>High Pay is Needed for Retention</u><br /><br /> We saw versions of this to support the CEOs of Maricopa, SUNY - Downstate, Alice Hyde, CVPH, and generically again to support all NY hospital CEOs.  </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Note that this justification is also almost never supported by any evidence.  As we noted <a href="http://hcrenewal.blogspot.com/2012/10/more-reasons-to-doubt-how-ceos-are.html">here</a>, while this argument, probably like the others, comes from the generic business management literature, there is little data in the larger business world to show that CEOs are very mobile, or likely to succeed when transplanted to a new environment.  In fact, a recent report looking at the mobility of CEOs worldwide called this a "self-serving myth."  (See <a href="http://www.huffingtonpost.com/2013/02/11/ceo-pay_n_2661438.html">this summary</a> for a link to it.) </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">It is too bad that no one ever seems to get the opportunity to challenge these talking points when they are offered as justifications for outlandish executive compensation.  <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.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.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.charlotteobserver.com/2013/02/06/3835851/charlotte-hospital-pay.html#storylink=cpy</div><br /></div></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>Summary</b></div><br />As we have <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">shown again and again</a>, the pay of top health care leaders seems to endlessly increase, without clear justification, regardless of the vicissitudes affecting the organizations they lead, their employees, their patients and society.  This suggests that health care organizations, like many other organizations, seem to be run primarily for the benefit of their executives and their cronies, regardless of what happens to anyone else.   <br /><br />As we have frequently said, current policies about paying hired health care managers leave the managers unaccountable for the effects of their actions on patients' and the public's health, and worse, fail to deter and may even encourage ignorance of the health care mission, frankly mission-hostile behavior, self-interest, conflicts of interest, and outright corruption.  Meanwhile, paying nearly all top managers as if they were brilliant, while setting much harsher standards for the employees who actually take care of patients, including health professionals, demoralizes those on whom patients actually depend for care.<br /><br />As we have said endlessly,....   Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.<br /><br />If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses. <br /><br /><br />

Non-Profit Hospital Executive Salaries Continue to Defy Gravity and Logic

The old saying is that nothing is certain except death and taxes.  In health care, the other near certainty seems to be that compensation fo...

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Texas Medical Association slams ONC Healthcare IT safety plan

<span class="Apple-style-span" style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><span style="color: #333333; font-family: Verdana, Arial;">The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality and patient care risks:</span></span><br /><blockquote class="tr_bq">FierceHealth IT today</blockquote><div style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><div class="gmail_quote"><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;"></span></span><br /><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;"><blockquote><a href="http://links.mkt1985.com/ctt?kn=167&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__S4c8UaRxIHMoxpErecFsKw" target="_blank"><span class="Apple-style-span" style="color: black;">Texas Medical Association slams ONC safety plan</span></a></blockquote><blockquote><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" width="31"></td><td style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" valign="bottom" width="150"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">By Dan Bowman</span></span></td><td style="color: #888888; font-family: Verdana, Arial; font-size: 9px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;" valign="bottom"><span style="color: black; font-family: Arial, Helvetica, sans-serif;"><span style="font-size: small;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /><span class="Apple-style-span" style="font-family: Verdana, Arial; font-size: xx-small;"><span class="Apple-style-span" style="border-collapse: separate; font-size: 9px;"><br /></span></span></span></span></span></span></td></tr></tbody></table></blockquote><blockquote><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td style="font-family: arial, sans-serif; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">The </span></span><a href="http://links.mkt1985.com/ctt?kn=57&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__kdmrdIyd6sIcVcFLYphXQ" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">health IT safety action plan proposed by the Office of the National Coordinator for Health IT</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> in December is not specific enough to succeed, according to recent comments made by the Texas Medical Association. In its </span></span><a href="http://links.mkt1985.com/ctt?kn=92&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_assets_fiercemarkets_com__roPjbL4h6p1at3aX94znog" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">letter</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> to National Coordinator for Health IT Farzad Mostashari, TMA said that responsibility for the plan "lacks focus," and should be overseen by a "highly visible HIT Safety Czar.</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">TMA also called setting mandatory deadlines and developing a "robust" reporting and learning system imperative to the success of the plan, saying that the plan's current reliance on voluntary reporting and funding represents a "fundamental weakness."</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">"TMA believes that significant patient safety risks exist now, and new ones will emerge in the next one to two years as many [electronic health record] and other HIT vendors merge or go out of business," the letter said.</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">Additionally, the group expressed doubts about a code of conduct proposed to keep vendors in line as far as ensuring cooperation with safety organizations for adverse event reporting. "TMA is concerned that this will not materially affect industry accountability and generate the changes that are needed," the letter said. "For example, what if a developer does not comply with said code of conduct? There is no penalty or impetus for change."</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">The American Medical Association was a bit less harsh in its </span></span><a href="http://links.mkt1985.com/ctt?kn=190&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_ama_assn_org_resources_do_kLlOCnendmgZnkafWC36A" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">assessment</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> of ONC's plan. It supports most of the ideas outlined in the plan, although it called for more research to be done on the impact of electronic health record use regarding patient safety in the ambulatory setting.</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">"Physicians are concerned about potential liabilities from EHR system design and software flaws, as well as lack of interoperability among EHR systems that could result in incomplete or missing information, which may lead to errors in patient diagnosis and treatment," the AMA letter said. "In addition, the impact that EHRs have on physician practice workflows can lead to unintended consequences. Those impacts are the result of how the software is developed."</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><a href="http://links.mkt1985.com/ctt?kn=5&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__fdelaLMvtjHW1QKrOUvegg" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">HIMSS said in its letter to Mostashari</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> that it wants to see more provider-vendor cooperation when it comes to investigation of patient safety events, as well as usability, while the AHA said in its letter that its stakeholders would like to see more of a focus on a single, national approach to matching patients with their records with a goal of patient safety.</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">The </span></span><a href="http://links.mkt1985.com/ctt?kn=146&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__Uy2fglIMzJM3HSXPTivQVg" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">College of Healthcare Information Management Executives, meanwhile, said that the plan needs to be facilitated</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> by stakeholders not directly under government control.</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">To learn more:<br />- here's the TMA </span></span><a href="http://links.mkt1985.com/ctt?kn=92&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_assets_fiercemarkets_com__roPjbL4h6p1at3aX94znog" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">letter</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> (.pdf)<br />- read the AMA </span></span><a href="http://links.mkt1985.com/ctt?kn=190&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_ama_assn_org_resources_do_kLlOCnendmgZnkafWC36A" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">letter</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"> (.pdf)</span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">Related Articles:</span></span><a href="http://links.mkt1985.com/ctt?kn=5&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__fdelaLMvtjHW1QKrOUvegg" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">HIMSS, AHA support ONC's patient safety plan</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span><a href="http://links.mkt1985.com/ctt?kn=146&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__Uy2fglIMzJM3HSXPTivQVg" target="_blank"><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;">CHIME: ONC's role in health IT safety plan 'overstated'</span></span></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><br /></span></span><span class="Apple-style-span" style="color: black; font-family: Arial, Helvetica, sans-serif; font-size: small;"><span class="Apple-style-span" style="border-collapse: collapse; font-size: 13px;"><a href="http://links.mkt1985.com/ctt?kn=57&ms=NDcyNDQxMAS2&r=MTg5MDYxNTI0MDQS1&b=0&j=MTQyMjg5MTEzS0&mt=1&rt=0" name="13cd3c696d1da2b0_13cd3c13f19db484_13cd3bf97a5f8ea4_13cd0586c68a10a9_fiercehealthit_com_story__kdmrdIyd6sIcVcFLYphXQ" target="_blank">HHS issues health IT safety action plan</a></span></span></div></div></td></tr></tbody></table></blockquote></span></span></div></div><div style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><div class="gmail_quote"><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;"><br />The TMA and AMA letters linked above are worth reading in their entirety. <br /><br />I note, with little surprise, the "softer" stances (e.g., self-policing vs. government oversight) taken by industry-dominated bodies such as HIMSS and CHIME.<br /><br />On the other hand, I find the AMA's "less harsh" views somewhat disappointing.  Their letter is welcome, and more research needs to be done as to risks in ambulatory settings (and inpatient settings as well).  However, the delays in <b>action</b> during the research are of concern.</span></span><br /><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;"><br /></span></span><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;">Where patient safety is concerned, fast action is a top priority.  Patients, needless to say, have more rights than computers and their sellers.</span></span><br /><span style="color: black; font-family: arial;"><span style="background-color: transparent; font-family: Arial, Helvetica, sans-serif;"><br />-- SS<br /><br /></span></span></div></div>

Texas Medical Association slams ONC Healthcare IT safety plan

The Texas Medical Association offers views similar to the views I have been writing about for a decade and a half on healthcare IT quality a...

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