healthy4u

BLOGSCAN - An Ex-Pharmaceutical Company CEO to Run the American College of Cardiology?

Marilyn Mann's blog <a href="http://marilynmann.wordpress.com/2013/04/28/should-a-former-drug-company-executive-be-ceo-of-the-american-college-of-cardiology/">discussed</a> the appointment of a former pharmaceutical company executive, most recently at Actelion, and previously at Hoffman La Roche, Abbott Canada, Nordic Labs and Marion Merrill Dow (now known as Aventis), as president of the American College of Cardiology.  Although Mr Jacobovitz, who boasts a bachelor's degree in biology but no obvious experience in direct health care or biomedical science, was <a href="http://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine/2013/04/CEO-Announcement.aspx">touted </a>by the ACC as having "developed a strong patient- and customer-centered corporate strategy," Ms Mann provided documentation that his trajectory at Actelion seemed more money- than patient-centered.   During his watch, Actelion was cited for not reporting 3500 deaths of patients taking two of its drugs to the US Food an Drug Administration (FDA).  Actelion blocked availability of samples of one of its drugs to generic drug companies, an action that the US Federal Trade Commission (FTC) alleged violated anti-trust laws.  Actelion purchased a company that was working on a drug that could have become a competitor to Actelion's most remunerative product, and then shut down development, possibly preventing a drug that might help patients from reaching them.  Finally, Acetelion's marketing practices seem to be currently under investigation by a US Attorney.    One wonders why cardiologists would want such an individual representing them as leader of their premier organization?  (Dr Wes<a href="http://drwes.blogspot.com/2013/04/the-american-college-of-cardiology-gets.html"> wondered</a> as well.)

BLOGSCAN - An Ex-Pharmaceutical Company CEO to Run the American College of Cardiology?

Marilyn Mann's blog discussed the appointment of a former pharmaceutical company executive, most recently at Actelion, and previously at Hoffman La Roche, Abbott Canada, Nordic Labs and Marion Merrill…

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07 May 2013

AMA says EHRs create 'appalling Catch-22' for docs - And just how many experts does it take to screw in a light bulb, anyway?

(NOTE:  this post, being about minor matters like death and financial mayhem, is particularly and unusually [even for me] biting and lacking in euphemisms and political correctness.  If you are easily offended and want the latter, and/or believe we all need to be 'nice' about banal issues like patient injury and death, fraud, and other minor matters, click here:  <a href="http://www.disney.com/">http://www.disney.com</a> and skip the post below.) You were warned. --------------------------------------- At some point, so-called EHR "experts" and pundits need to stop being accommodated for their having ignored years of warnings, complaints, "anecdotes" -a particularly egregious term that comes from those who don't understand risk management, especially academics of the echo chamber-egghead subspecies (<a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">link</a>) - and other signs that health IT is not a beneficent, omniscient gift from the <a href="http://en.wikipedia.org/wiki/Lords_of_Kobol">Lords of Kobol.</a> (The latter is a pun on the business-IT programming language Cobol, of course.) Instead, they simply need to be ridiculed for being stupid. I will do so:  folks, you have been, and remain, stupid: <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/AVvXsEhZE95zecrMVRB1bq9q2g01AUsab2c67jIhlE-ARIcXChO_6KSU5IP-c2sQpFyO-MiKOXWOOrpyAZAeWR-1L3VIpsiYWG_2dldo8bUN1af4BuG8p24xo2u2V_pTviw9_w3ZMLvXbAvwG9Zo/s1600/cow3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZE95zecrMVRB1bq9q2g01AUsab2c67jIhlE-ARIcXChO_6KSU5IP-c2sQpFyO-MiKOXWOOrpyAZAeWR-1L3VIpsiYWG_2dldo8bUN1af4BuG8p24xo2u2V_pTviw9_w3ZMLvXbAvwG9Zo/s200/cow3.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">The Bovine Stare of Incomprehension (click to enlarge)</td></tr></tbody></table> The Bovine Stare of Incomprehension describes the reactions I've gotten over the years to many warnings about health IT.  It was like talking to a cow. So now there's this: <blockquote class="tr_bq"><a href="http://www.govhealthit.com/news/ama-says-ehrs-create-appalling-catch-22-docs">AMA says EHRs create 'appalling Catch-22' for docs</a> May 03, 2013 | Tom Sullivan, Editor As the healthcare industry moves to EHRs, the medical record has essentially been reduced to a tool for billing, compliance, and litigation that also has a sustained negative impact on doctors' productivity, according to Steven J. Stack, MD, chair of the American Medical Association’s board of trustees. </blockquote> Gee, they're only realizing and complaining about that - now?  In 2013? <blockquote class="tr_bq">“Documenting a full clinical encounter in an EHR is pure torment,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records on Friday. </blockquote> (What, the "pure torment" in such a mission-critical function only started with the most recent patches installed last month on the nation's EHRs?  EHRs were just dandy until then?) It's nice to know in May 2013 that “documenting a full clinical encounter [essential to avoid injurious and even lethal mistakes, I anecdotally note - ed.] in an EHR is "pure torment”, several years into an accelerated "National Program for HIT in the HHS" costing hundreds of billions of dollars. I guess sites like this blog, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">this site</a> extant since 1998, and <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=readinglist">other materials</a> written over the years by backwards stubborn health IT iconoclast fear-mongering Luddites were beyond the comprehension level of - those now proffering the exact same pronouncements. <blockquote class="tr_bq">EHRs are also driving the industry toward charts that look remarkably similar because they’re based on templates created by the technology vendors — that includes often using the same words. And that threatens to make doctors appear to be committing fraud by the practice of record cloning, or cutting and pasting from one record to another, when they are not, in fact, acting fraudulently. </blockquote> I guess putting patients in mortal danger from note cloning (and to those too stupid to understand why that is, get off your rear end and look it up, I'm not going to spoon-feed you) is a step better than acting fraudulently... <blockquote class="tr_bq">Alongside the federal mandate to implement an EHR under threat of a monetary fine, that creates what Stack called “an appalling Catch-22 for physicians.” Put another way: The government mandates that doctors use an EHR, the EHR vendors’ templates can sometimes create an appearance of fraud and that, in turn, opens the door for payers to decline reimbursement or, even worse, the government to prosecute doctors for the crime.</blockquote> I guess actual fraud is just anecdotal. <blockquote class="tr_bq">As dire as that sounds, it's an exception that belies the unproven perception that EHRs perpetuate fraud. “Upcoding does not necessarily equate to fraud and abuse,” said Sue Bowman, AHIMA’s senior director of coding and compliance at the same event. “This is an area where more study is needed. We really need to know the causes. Further research is needed on the fraud risk of using EHRs.”</blockquote> Sure, let's study while rolling this stuff out as frantically as we can.  We'll fix it later -- and Jesus, I guess, will heal and reanimate any patients actually harmed by the technology (<a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">link</a> to ECRI Institute Deep Dive Study: 36 hospitals!  Nine weeks!  171 health information technology-related problems voluntarily reported!  Eight injuries!  Three possible deaths!  All mere "anecdotes", of course). <blockquote class="tr_bq">Indeed, Jacob Reider, MD, CMO of ONC, explained that the government and industry do not have good data right now proving whether or not EHRs trigger fraud and abuse.</blockquote> Per the IOM, the same industry does not have good data on harms levels.  (The previous link to a recent small ECRI "Deep Dive" study's probably the most robust we've got on that score, and the figures are not encouraging). So - let's review - <ul><li>poor data on harms, </li><li>poor data on benefits, </li><li>poor data on fraud and abuse.</li></ul>  The logical, ethical course of action thus is: <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/AVvXsEgzFC_WsPusjorZPhSFY5JNJs4lrt-V5x8PZiENWJVqP7gPQUwxbtq0bhjwtsjUvHuXdwrMUrEOAhghWrHjEV5pRduQIHRcyj9uMkKL4OC1x87NkSBUQTkZ2MFlroX8uK0YIz8pxcKCC1jP/s1600/homer-simpson.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzFC_WsPusjorZPhSFY5JNJs4lrt-V5x8PZiENWJVqP7gPQUwxbtq0bhjwtsjUvHuXdwrMUrEOAhghWrHjEV5pRduQIHRcyj9uMkKL4OC1x87NkSBUQTkZ2MFlroX8uK0YIz8pxcKCC1jP/s200/homer-simpson.gif" width="165" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">D'OH!  LET'S ROLL THE TECHNOLOGY OUT AS FAST AS WE CAN, AND PENALIZE NON-ADOPTERS BESIDES!</td></tr></tbody></table> See how simple logic, ethics and clear thinking can be? <blockquote class="tr_bq">“There is concern that some doctors are using the EHR to obtain payments to which they are not entitled,” said Mickey McGlynn of Siemens Medical Solutions and HIMSS EHR Association. “Any fraud is an important issue and we, as the vendor community, take that very seriously.”</blockquote> Only after independent whistleblower investigations by <a href="http://www.publicintegrity.org/health/medicare/cracking-codes">Fred Schulte of the Center for Public Integrity ("Cracking the Codes")</a>, and by <a href="http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?_r=0">New York Times reporters Reed Abelson and Julie Creswell</a>, that is... <blockquote class="tr_bq"> AMA’s Stack offered a triptych of suggestions to CMS and ONC: address EHR usability concerns, provide guidance on EHR use for coding and billing, and make meaningful use stage 2 more flexible for providers. “My purpose is not to denigrate EHRs,” Stack said, explaining that he believes CMS and ONC are genuinely trying to better the current situation.</blockquote> Nice to have <a href="http://en.wikipedia.org/wiki/Caspar_Milquetoast">Caspar Milquetoast </a> on the side of EHR criticism. Knock knock, anyone home, McFly? <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/AVvXsEhtRtjpOxhXTclN2k84gzTCHH0QfGVK4EArboCbP3IGByDNyfeuK8KnsHHBwxufCjhZMfBaX_fi2c3IJcMZ0Ld8LH_e9O9fNum3CO4Vrr-U1ZhuGyPRyBVFK3qZ_kYUNFkVGqyPAHOgcBZO/s1600/hello-mcfly1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="177" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtRtjpOxhXTclN2k84gzTCHH0QfGVK4EArboCbP3IGByDNyfeuK8KnsHHBwxufCjhZMfBaX_fi2c3IJcMZ0Ld8LH_e9O9fNum3CO4Vrr-U1ZhuGyPRyBVFK3qZ_kYUNFkVGqyPAHOgcBZO/s320/hello-mcfly1.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Knock knock, anyone home, McFly?</td></tr></tbody></table> Today's EHR systems, for the aforementioned reasons above and more, deserve denigration for patients' sake. <blockquote class="tr_bq"> There are efforts underway, within the government and industry, to more comprehensively understand the unintended consequences of EHR implementation.</blockquote> But let's keep rollin' em out, anyway.  Wheeee!  What fun! Class action attorneys, are you listening? -- SS

AMA says EHRs create 'appalling Catch-22' for docs - And just how many experts does it take to screw in a light bulb, anyway?

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05 May 2013

Financial woes at Maine Medical Center: Reading this blog might have saved them millions of dollars, and prevented massive "cost saving initiatives"

In this article, the euphemistic and almost endearing term "hiccup" is used instead of the more traditional "<a href="http://hcrenewal.blogspot.com/search/label/glitch">glitch</a>" to describe obvious major information technology malfunctions.  It is likely the knowledge at this blog and at my <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">health IT dysfunction teaching site</a> could have helped prevent most of these problems: <blockquote class="tr_bq"><a href="http://www.healthcarefinancenews.com/news/financial-woes-maine-medical?topic=03,22">Financial woes at Maine Medical Center</a> New England health system facing $13 million loss, initiates plan to save $15 million NEW GLOUCESTER, ME | May 2, 2013 In a memo to its employees last week, one of Maine’s largest health systems said it has suffered an operating loss of $13.4 million in the first half of its fiscal year. “Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Petersen, president and CEO of the medical center, wrote in the memo to employees. A copy of the memo was sent to MedTech Media, publisher of Healthcare Finance News.</blockquote> A "negative financial position" (translation: we lost big money) that it has not witnessed in recent memory?  What are the reasons? <blockquote class="tr_bq">In order to bring the medical center to breakeven by year’s end, the health system’s leadership has determined $15 million needs to be saved. In the memo, Petersen said the operating loss is due to declines in inpatient and outpatient volumes because of the hospital’s efforts to reduce readmissions and infections; “unintended financial consequences” due to the roll out of the health system’s Epic electronic health record and problems associated with being unable to accurately charge for services provided; an increase in free care and bad debt cases; and continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program.</blockquote> That rings a familiar tune - from the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Insufficient%20IT%20management">mid 1990's</a> at Yale, as well as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/DUCOM_EMR_Complaint.pdf">more recently</a>. <blockquote class="tr_bq">Many of the reasons for Maine Medical’s financial woes are similar to those hospitals across the country are facing. A recovering national economy, continued budget restrictions and restraint and the realization that, while electronic health records may have efficiencies and cost savings over time, the costly transition to EHRs may take years to recoup.</blockquote> Especially when not done well. <blockquote class="tr_bq">In his memo to employees, Petersen said the hospital has identified many of the hiccups contributing to the charge capture problems and a team of hospital employees and Epic technicians are working to resolve those issues. In the meantime, the remaining roll out of the Epic EHR to the rest of the health system is on hold.</blockquote> Hiccups? Health IT has a euphemistic language all its own.  Only apostates would dare to call the "hiccups" for what they really are, in medical parlance:  IT malpractice. <blockquote class="tr_bq"> To save $15 million by year’s end, Maine Medical is immediately instituting a number of cost-saving initiatives including selective travel and hiring freezes, putting the operating contingency budget on hold and reducing overtime. Petersen appealed to employees to curb discretionary spending and contact management with any cost-saving ideas.</blockquote> All, of course, will have no impact on patient care.... <blockquote class="tr_bq"> “I’m confident that we’ll confront this test, beat back the issues we face, and reverse this negative financial picture,” Petersen wrote in the conclusion to the memo.</blockquote> Test?  Test of what, IT competence? Of course, "C" officers would never write that "I'm not confident we'll confront our screwups." <blockquote class="tr_bq">Maine Medical did not reply to an interview request by deadline. The Maine Hospital Association declined to comment for this story. </blockquote> Silence is golden. A newspaper letter from Stuart Smith, Selectman, Town of Edgecomb, St. Andrews Regional Task Force (a software developer himself) tells more: <blockquote class="tr_bq"><a href="http://www.boothbayregister.com/affiliate-post/stuart-smiths-letter-register/13586">STUART SMITH'S LETTER TO THE REGISTER</a> Wednesday, May 1, 2013 - 7:30pm Save St. Andrews Hospital As the Boothbay Peninsula moves forward with the effects of a MaineHealth/Lincoln County HealthCare decision to close St. Andrews Hospital, I have served on the 4 Town Regional Task Force. This has been an unprecedented cooperation between 4 towns in this region that has generated many continuing activities that will benefit all towns in our region.</blockquote> Apparently an entire hospital is closing as a result of these debacles. [May 8, 2013 addendum: a family physician in Lincoln County where St. Andrews hospital is located and a member of the Board of Trustees, Dan Friedland, M.D., writes me that the EHR had nothing to do with the hospital closing - ed.] <blockquote class="tr_bq">But let me get back to the MH/LCH decision. We are told that MaineHealth has spent over $150 million on an Electronic Medical Records (EMR) system that helps all of its “subsidiaries.” I can appreciate this because my work is in software development. I do question the $150 million figure. I think it is extremely high and Portland has had a real failure in its implementation. So much so that it looks like LCH will not have a real integrated EMR until 2015 and financial software problems exemplify a major failure of MH to create any real benefit to the State. Millions of dollars have been charged to member hospitals and staff time (salaries and mileage) over the past 2-3 years with no benefit.</blockquote> I'd questioned the high cost of these commercial EHR systems as far back as 2006 ("<a href="http://msnbc.msn.com/id/11693923/">Yet another clinical IT controversy: UC Davis</a>" and "<a href="http://hcrenewal.blogspot.com/2007/06/oversight-needed-for-hospital-emr.html">External oversight needed for hospital EMR implementation?</a>" - Lancaster General Hospital and "<a href="http://hcrenewal.blogspot.com/2006/10/70-million-for-electronic-medical.html">$70 million for an Electronic Medical Records system [quasi endpoint]?</a>- Geisinger). One might think healthcare systems have money to burn ... <blockquote class="tr_bq"> The system failure also adds operational costs going forward that were not planned for and regional consolidation of finance will now be delayed. The cost to Maine Health Center is huge in improper service and supply charges. Information Technology leadership has been fired, but MH administration is truly accountable.</blockquote> For once, someone in IT leadership did not get a a <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">promotion for failure</a>.  It is true that MH administration is accountable, however - they had the fiduciary responsibility to hire the best talent, and to oversee that talent as needed to assure success.  If "C" leadership didn't understand IT, that's their failure as well.  In my view in 2013 everyone in a position of organizational responsibility should have a good understanding of IT, which is now, after all, a commodity. I'm hopeful EPIC, with its apparently <a href="http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html">revolutionary hiring practices</a> akin to the hiring of physicians, will have the "hiccups" fixed in no time.  From <a href="http://histalk2.com/2010/08/14/monday-morning-update-81610/">this link</a> at the "Histalk" site on staffing of health IT projects, Aug. 16, 2010. Emphases mine: <blockquote class="tr_bq">Epic Staffing Guide A reader sent over a copy of the staffing guide that Epic provides to its customers. I thought it was interesting, first and foremost in that Epic is so specific in its implementation plan that it sends customers an 18-page document on how staff their part of the project. Epic emphasizes that many hospitals can staff their projects internally, choosing people who know the organization. However, they emphasize choosing the best and brightest, not those with time to spare. Epic advocates the same approach it takes in its own hiring: don’t worry about relevant experience, choose people with the right traits, qualities, and skills, they say.  The guide suggests hiring recent college graduates for analyst roles. Ability is more important than experience, it says. That includes reviewing a candidate’s college GPA and standardized test scores.</blockquote> I am forwarding links to this post, blog, my teaching site (begun in 1998) and additional material to Selectman Smith. I'd offer to help, but the management of the organization would likely find, as did <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=leadership">management at this one</a> (a major denominational chain), that I have too much experience for the organization. -- SS

Financial woes at Maine Medical Center: Reading this blog might have saved them millions of dollars, and prevented massive "cost saving initiatives"

In this article, the euphemistic and almost endearing term "hiccup" is used instead of the more traditional "glitch" to describe obvious major information technology malfunctions. It is likely the kn…

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04 May 2013

Health Information Technology: Blessings, Disasters, and Recommendations: An Interview with Scot M. Silverstein, MD

I was recently interviewed by <a href="http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=eas2150&DepAffil=Psychiatry">Dr. </a><a href="http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=eas2150&DepAffil=Psychiatry">Elizabeth Saenger</a> for <a href="http://www.coalitionny.org/the_center/">The Center for Rehabilitation and Recovery</a> regarding use of healthcare information technology in provision of mental health services.   The Center, part of the <a href="http://www.coalitionny.org/">Coalition of Behavorial Health Agencies Inc.</a>, provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects. The interview is here: <a href="http://coalitionny.org/the_center/recovere-works/RECOVERe-worksApril2013.html#DrSilverstein">http://coalitionny.org/the_center/recovere-works/RECOVERe-worksApril2013.html#DrSilverstein </a> The themes I discussed will be familiar to readers of this blog. -- SS

Health Information Technology: Blessings, Disasters, and Recommendations: An Interview with Scot M. Silverstein, MD

I was recently interviewed by Dr. Elizabeth Saenger for The Center for Rehabilitation and Recovery regarding use of healthcare information technology in provision of mental health services. The Cente…

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04 May 2013

Repost: Health IT Ten Commandments (1970) v. Health IT Truisms (2012)

I believe this Oct. 2012 post bears repeating, especially in view of the recent <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">ECRI Deep Dive study</a> of health IT risk (36 hospitals/9 weeks/volunteer reporting/171 health IT-related problems/8 incidents of harm/3 possible deaths): In 1970, health IT pioneer Dr. Octo Barnett at Harvard/MGH wrote his "Health IT Ten Commandments" (from Collen's "<a href="http://www.amazon.com/History-Medical-Informatics-United-States/dp/0964774305">A history of Medical Informatics in the United States, 1950-1990</a>"):  <blockquote class="tr_bq">1. Thou shall know what you want to do 2. Thou shall construct modular systems - given chaotic nature of hospitals 3. Thou shall build a computer system that can evolve in a graceful fashion 4. Thou shall build a system that allows easy and rapid programming development and modification 5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use 6. Thou shall have duplicate hardware systems 7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems 8. Thou shall be concerned with realities of the cost and projected benefit of the computer system 9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization 10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.</blockquote> Four decades later, I write the following 2012 "Health IT Truisms" (perhaps more to follow).  Many of the points summarized here can be found in the past 8 years of my writing on this blog: <blockquote class="tr_bq">1.  Health IT in 2012 remains experimental, not proven effective or safe, with actual results conflicting. 2.  Health IT is costly, not money-saving, diverting scarce healthcare resources away from actual healthcare provision to the IT industry. 3.  "EHR" is an anachronistic term (that disarms the uninformed, who "see" an innocuous file system)  for what is now an enterprise medical resource and workflow control system. 4.  The proper framework in which to view "resistance" to health IT is not Luddite clinicians vs. IT modernists.  It's pragmatist clinicians (with ethical and legal obligations and responsibilities), vs. IT hyper-enthusiasts who ignore or are blinded to the ethical considerations and downsides, and whose actions are based not on science, but on faith in technology and self interest. 5.  HIT can be partitioned into good health IT (GHIT) and bad HIT (BHIT) - see definitions at the introduction to  <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases">http://www.ischool.drexel.edu/faculty/ssilverstein/cases</a>. 6.  BHIT prevails due to its being far cheaper to produce than GHIT and due to lack of meaningful industry regulation of quality, usability and safety. 7.  The lack of HIT regulation, post-market surveillance, formal validation and accountability is a special accommodation that is unprecedented in modern medicine. 8.  Underlying HITECH and "Meaningful use" is the assumption that all HIT is good HIT. 9.  A good or even average paper system is better for patients than a bad health IT system. 10.  The incentives and coercive aspects of HITECH would not be needed if GHIT prevailed. 11.  The coercive force of government should have been directed not at users, but at sellers, to produce GHIT and to abolish BHIT. 12.  The term "meaningful use" is political rhetoric whose criteria were decided by committee and industry influence; nobody knows if meeting the criteria will prove truly "meaningful" or not.  (That medical informaticists placidly accepted the term is a disgrace to a field that strives for terminological precision; "good faith use" would have been precise.) 13.  Human research protections are given the blind eye with respect to commercial health IT. 14.  Health IT being used safely is currently by happenstance and via compensation for flaws by clinicians who improvise (which itself introduces risk and is stressful), not by design. 15.  Business IT a/k/a MIS personnel have far too narrow an education and experience to make pronouncements about health IT "transforming" medicine. 16.  IT personnel should be part of the medical team, including liability for IT-related failure. 17.  The commercial health IT sector is not an evidence-based domain. 18.  A cybernetic "Libby Zion" catastrophe is unavoidable, and probably the only way to "transform" the health IT industry into an evidence-based industry - essential before that industry can even begin to "transform" (i.e., facilitate improvement of) medicine.</blockquote> Had Dr. Barnett's Ten Commandments not been disobeyed in favor of cybernetic idolatry, the Health IT Truisms in 2012 would appear far different. -- SS

Repost: Health IT Ten Commandments (1970) v. Health IT Truisms (2012)

I believe this Oct. 2012 post bears repeating, especially in view of the recent ECRI Deep Dive study of health IT risk (36 hospitals/9 weeks/volunteer reporting/171 health IT-related problems/8 incide…

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04 May 2013

UnitedHealth CEO Continues to Prosper While His Company's Behavior Appears to Contradict its Mission Statement

Tis spring, the season in the US for legal settlements, government findings, and proxy statements revealing executive compensation.  Therefore, maybe there should be no surprise that we are seeing a series of cases in which health care corporate leaders continue to enrich themselves while their organizations' behavior raises ethical questions. Following on the <a href="http://hcrenewal.blogspot.com/2013/05/amgen-ceos-prosper-despite-or-because.html">Amgen example</a>, we now present the latest UnitedHealth example (in a post organized similarly.) The CEO Gets Richer Last week, the Associated Press (<a href="http://articles.washingtonpost.com/2013-04-25/business/38810785_1_medicare-advantage-insurer-compensation">via the Washington Post</a>) summarized UnitedHealth CEO Stephen J Hemsley's growing pile of money: <blockquote class="tr_bq"><div class="mod-washingtonpostarticletext mod-tribunearticletextimpl mod-articletext" id="mod-a-body-first-para">UnitedHealth Group Inc. kept CEO Stephen J. Hemsley’s salary stable in 2012 but bumped up his total compensation for a year in which the nation’s largest health insurer grew earnings and enrollment and launched a major acquisition. The Minnetonka, Minn., insurer gave its top executive a compensation package valued at about $13.9 million last year, according to the company’s proxy statement filed with the Securities and Exchange Commission. That’s up 4 percent from the $13.4 million total he received last year. Hemsley, 60, received a $1.3 million annual salary in 2012, like he has the past several years. He also received $7 million in stock awards, which is the same total as 2011. But his performance-based bonus climbed 7 percent to $5.3 million, and he received $287,443 in other compensation, up from $154,804 in 2011. Other compensation included savings plan contributions and a $125,000 Hart-Scott-Rodino Antitrust Improvement Act filing fee payment UnitedHealth made on behalf of the CEO so he could maintain and increase his stock ownership in the company.</div></blockquote> At the same time, Hemsley continued to cash in stock options which also added to his riches:   <blockquote class="tr_bq">Outside AP’s calculation of his 2012 total compensation, Hemsley also acquired 284,836 shares that had vested with a value of $15.3 million. He also exercised options to acquire 600,000 shares and realized a value of $12.5 million. Those options and stock awards had been previously given to the executive. The proxy said Hemsley directly owned UnitedHealth shares valued at about $140 million, as of March 1.</blockquote> The Mission Promises Much but the Company Delivers Less On one hand, the rate of rise of Hemsley's compensation at least seemed comparable to the company's financial performance: <blockquote class="tr_bq">Overall, UnitedHealth shares climbed 7 percent to close 2012 at $54.24, a smaller gain than the 13.4 percent advance from the Standard & Poor’s 500 index.</blockquote> On the other hand, the largess given to the CEO ought to be contrasted with the how UnitedHealth failed to deliver what its mission promised.   Most recently, a jury found the company failed to live up to its legal obligation (in the state of Nevada) to review the quality of the clinicians on its panel.  As <a href="http://www.bloomberg.com/news/2013-04-04/unitedhealth-units-told-to-pay-24-million-over-hepatitis-doctor.html">reported</a> by Bloomberg, <blockquote class="tr_bq">Two UnitedHealth Group Inc (UNH)  units must pay $24 million in damages for failing to properly monitor a doctor who gave two colonoscopy patients hepatitis C by employing substandard medical practices, a Nevada jury ruled. Jurors in state court in Las Vegas deliberated about five hours over two days before finding officials of Health Plan of Nevada and Sierra Health Services were negligent in their oversight of Dipek Desai.  The former gastroenterologist has been blamed for infecting patients with hepatitis C by reusing vials of the anesthetic Propofol and failing to sterilize equipment. The panel ordered the two UnitedHealth units to pay $15 million in compensatory damages to Bonnie Brunson and her husband and $9 million to Helen Meyer. The two women contend they got hepatitis during colonoscopy procedures at Desai’s clinic. Their lawyers said earlier in the case they may ask the jury to award more than $1 billion in punitive damages. The verdict reflects 'what’s wrong with health insurance companies in the U.S.' Robert Eglet, Brunson’s lawyer, said in an interview after the verdict was announced. 'They put profit before patient safety.'</blockquote> Note that the state of Nevada does explicitly hold managed care organizations accountable for the clinical quality of its health care professionals' practice,   <blockquote class="tr_bq">Meyer and Brunson sued under a Nevada law requiring HMOs to file annual reports showing officials reviewed the quality of health services provided to their members. The women’s lawyers argued officials of the UnitedHealth units knew Desai had a reputation for sloppy practice before giving him a contract to handle colonoscopies and then didn’t check the quality of his work. At one point, Desai was a member of Nevada's Board of Medical Examiners,  which oversees the licensing of doctors in the state. The plaintiffs contend the insurer didn’t properly monitor Desai’s practices and procedures even though they received complaints about his practices. During the trial, witnesses said Desai adopted a cavalier attitude toward patient safety, speeding through procedures so he could see as many as 20 patients in a three-hour period. The women’s lawyers argued the insurers’ executives had an obligation to insure Desai was providing quality care to their HMO members and were required to vet his practices before hiring him.</blockquote> Also note that managed care organizations and other health insurers often boast about the quality of their provider panels. For example, see the UnitedHealth <a href="http://www.unitedhealthgroup.com/About/MissionValues.aspx">mission statement</a>: <blockquote class="tr_bq">- Our mission is to help people live healthier lives. Our role is to help make health care work for everyone.  - We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions. </blockquote> It seems reasonable to interpret the italicized parts above as a statement of accountability for the quality of care provided by the health care professionals within the United network. To reinforce that accountability, a subsequent Bloomberg <a href="http://www.bloomberg.com/news/2013-04-09/unitedhealth-to-pay-500-million-over-hepatitis-doctor.html">story </a>added, <blockquote class="tr_bq">Two UnitedHealth Group Inc (UNH) units must pay $500 million in punitive damages for failing to oversee a doctor blamed for giving colonoscopy patients hepatitis C through shoddy medical practices, a Nevada jury found. Jurors in state court in Las Vegas deliberated more than six hours yesterday before handing down the punitive-damages award against Health Plan of Nevada and Sierra Health Services for turning a blind eye to Dipak Desai's actions. </blockquote> Furthermore, the lofty UnitedHealth mission statement should be compared to two recent government findings. In the state of California, as<a href="http://articles.latimes.com/2013/may/01/business/la-fi-unitedhealth-rates-20130502"> reported</a> by the Los Angeles Times, <blockquote class="tr_bq">California Insurance Commissioner Dave Jones said the nation's largest health insurer, UnitedHealth Group Inc., is imposing unreasonable rate hikes on about 5,000 small businesses.  Jones said Wednesday that UnitedHealth couldn't justify the average annual increase of nearly 8%, which reflects both higher premiums and a reduction in benefits. He said the rate hike, which went into effect Wednesday, affects up to 45,000 small-business employees and dependents and represents $12.5 million in higher costs. 'At a time when small businesses are struggling to survive, UnitedHealthcare's rate increase is just one more unwarranted economic burden on California's small business owners and their employees,' Jones said. </blockquote> Such behavior seems to contradict the mission statement's assurance that the company will seek to provide health care at "an affordable price." Meanwhile, Bloomberg just published a <a href="http://www.bloomberg.com/news/2013-05-03/pentagon-blames-unitedhealth-for-failures-under-contract.html">story</a> about how UnitedHealth has been running an insurance program for US military families. <blockquote class="tr_bq">The Pentagon rebuked UnitedHealth (UNH) Group Inc, the nation’s largest insurer, after military families began experiencing long delays getting medical-care referrals from the company.  The backlogs occurred almost as soon as Minnetonka, Minnesota-based UnitedHealth took over a contract, valued as much as $20.5 billion, from TriWest Healthcare Alliance Corp. It assumed responsibility on April 1 for the western region of the military’s health-care system, known as Tricare. UnitedHealth’s 'failure to meet contractor requirements' has prevented a large number of beneficiaries in one Tricare health plan from obtaining timely access to specialty care, Jonathan Woodson, assistant secretary of defense for health affairs, said in a memo yesterday to other military leaders. Woodson, calling the situation 'extraordinary,' said the Pentagon stepped in to grant a temporary waiver so the plan’s members in the western region could get specialty care without UnitedHealth’s authorization and not incur penalties.. </blockquote> This behavior seemed to contradict the mission statement's assurance that the company seeks to "expand access to quality health care." The Song Remains the Same  Of course, UnitedHealth actually has a very long record of preaching about its aspirational mission, while paying its top hired managers extraordinary amounts and contradicting that mission, and at times ethical norms. Our posts on UnitedHealth are here. Recently we wrote,  UnitedHealth would be the company whose CEO once was worth over a billion dollars due to back dated stock options, some of which he had to give back, but despite all the resulting legal actions, was still the ninth best paid CEO in the US for the first decade of the 21st century (look <a href="http://hcrenewal.blogspot.com/2010/08/despite-scandal-former-unitedhealth-ceo.html">here</a>). UnitedHealth would be the company whose then CEO made a cool $106 million in 2009 (look <a href="http://hcrenewal.blogspot.com/2010/08/can-1-billion-group-of-babies-provide.html">here</a>). Moreover, UnitedHealth would also be the company known for a string of ethical lapses: - as <a href="http://www.courant.com/business/hc-natbizdigbrf0530.art2may30,0,109447.story">reported</a> by the Hartford Courant, "UnitedHealth Group Inc., the largest U.S. health insurer, will refund $50 million to small businesses that New York state officials said were overcharged in 2006." - UnitedHalth promised its investors it would continue to raise premiums, even if that priced increasing numbers of people out of its policies (see post <a href="http://hcrenewal.blogspot.com/2008/05/commercial-managed-care-organizations.html">here</a>); - UnitedHealth's acquisition of Pacificare in California allegedly lead to a "meltdown" of its claims paying mechanisms (see post <a href="http://hcrenewal.blogspot.com/2008/01/bungled-not-brilliant-results-of.html">here</a>); - UnitedHealth's acquisition of Sierra Health Services allegedly gave it a monopoly in Utah, while the company allegedly was transferring much of its revenue out of the state of Rhode Island, rather than using it to pay claims (see post <a href="http://hcrenewal.blogspot.com/2007/03/unitedhealth-declares-health-care.html">here</a>) - UnitedHealth frequently violated Nebraska insurance laws (see post <a href="http://hcrenewal.blogspot.com/2007/01/on-performance-on-one-supposedly.html">here</a>); - UnitedHealth settled charges that its Ingenix subsidiaries manipulation of data lead to underpaying patients who received out-of-network care (see post <a href="http://hcrenewal.blogspot.com/2009/01/unitedhealth-and-ingenix-settles.html">here</a>). - UnitedHealth was accused of hiding the fact that the physicians it is now employing through its Optum subsidiary in fact work for a for-profit company, not directly for their patients (see post <a href="http://hcrenewal.blogspot.com/2011/07/here-comes-your-new-doctor-brought-to.html">here</a>). Summary The US dysfunctional health care system has produced a long string of big corporations that promise warm and fuzzy health care yet deliver something less, all the while mightily enriching their top hired managers. Given the deadly serious nature of the health care system, these companies' promises, marketing, public relations and mission statements cannot be dismissed as fluff and puffery. Market fundamentalists and executive apologists have touted our system as market based. If patients must act as consumers, they cannot make good consuming decisions if they are awash with deceptive marketing and advertising. It is one thing for Hollywood to advertise blockbuster movies that are duds. It is another for health care corporations to advertise quality care and deliver bad care. As we have said far too many times, we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

UnitedHealth CEO Continues to Prosper While His Company's Behavior Appears to Contradict its Mission Statement

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03 May 2013

Amgen CEOs Prosper Despite (or Because of) Continuing Ethical Questions

This is becoming a familiar narrative on<a href="http://hcrenewal.blogspot.com/"> Health Care Renewal</a>: top health care leaders continue to enrich themselves while their organizations' behavior continues to raise ethical questions. For our latest example we return to the ongoing adventures of biotechnology giant <a href="http://hcrenewal.blogspot.com/search/label/Amgen">Amgen</a>. CEOs Get Richer An AP story (<a href="http://www.latimes.com/business/la-fi-amgen-ceo-20130408,0,1832506.story">via the LA Times</a>) documented the continuing enrichment of its current CEO: <blockquote class="tr_bq">Amgen Inc's new chief executive, Robert A. Bradway, received total compensation of $13.6 million in 2012, more than his predecessor, according to an analysis of a company regulatory filing. Bradway, who was promoted from chief operating officer to chief executive May 23, saw his compensation nearly double from $7.1 million in 2011. Last year Bradway, 50, was paid a salary of $1.26 million and received stock awards worth $8.57 million, incentive payments of $3.32 million and miscellaneous compensation totaling $420,059. That included nearly $314,000 in retirement plan contributions, $65,000 for personal use of company aircraft, more than $20,000 for his personal expenses and those of guests during business travel, and $15,000 for financial planning services.</blockquote> The former CEO also did very well in his final year in office. <blockquote class="tr_bq">Former CEO Kevin W. Sharer, who stepped down from his seat on Amgen's board when he retired Dec. 31, received compensation totaling $9.13 million last year. Sharer was paid a 2012 salary of $1.81 million and received stock awards worth $3.66 million, incentive payments of $2.31 million and miscellaneous compensation totaling $1.36 million. That included $801,000 in retirement plan contributions, nearly $262,000 for personal use of company aircraft, more than $38,000 for his personal expenses and those of guests during business travel, $15,000 for financial planning services and more than $255,000 for secretarial, information technology and travel support. Much of that support runs through 2017.</blockquote> You would think they could both afford financial planning on their own. Legal Settlements Pile Up Keep in mind that as we discussed in <a href="http://hcrenewal.blogspot.com/2012/12/amgen-settles-pleads-guilty-to.html">late 2012</a> and <a href="http://hcrenewal.blogspot.com/2013/01/how-revolving-door-and-other-aspects-of.html">early 2013</a>, Amgen pleaded guilty to a charge of misbranding for promoting its epoetin drug Aranesp for unapproved indications, and settled allegations of giving kickbacks to physicians to increase the drug's use, among other charges, for a total of $762 million. Furthermore, soon after the CEOs' compensation was announced, tiny articles in local media announced two more settlements by Amgen. A small AP story (again <a href="http://www.latimes.com/business/la-fi-amgen-20130416,0,4959804.story">via the LA Times</a>) noted another settlement regarding allegations of unethical promotion of Aranesp: <blockquote class="tr_bq">The US Department of Justice<a class="taxInlineTagLink" href="http://www.latimes.com/topic/crime-law-justice/u.s.-department-of-justice-ORGOV0000160.topic" id="ORGOV0000160" title="U.S. Department of Justice"></a> said Tuesday that biotech drug maker Amgen Inc. will pay $24.9 million to resolve claims it paid kickbacks to increase sales of its anemia<a class="taxInlineTagLink" href="http://www.latimes.com/topic/health/physical-conditions/anemia-HEPHC0000047.topic" id="HEPHC0000047" title="Anemia"></a> drug Aranesp. The Justice Department said Amgen paid kickbacks to Omnicare Inc<a class="taxInlineTagLink" href="http://www.latimes.com/topic/economy-business-finance/omnicare-incorporated-ORCRP011399.topic" id="ORCRP011399" title="Omnicare Incorporated">.</a> and PharMerica Corp., which sell drugs to long-term care providers such as nursing<a class="taxInlineTagLink" href="http://www.latimes.com/topic/health/medical-specialization/nursing-HEMSP000015.topic" id="HEMSP000015" title="Nursing"></a> homes and hospitals, and Kindred Healthcare Inc., which runs long-term acute-care hospitals and nursing and rehabilitation centers. Amgen wanted the companies to switch Medicare and Medicaid beneficiaries to Aranesp from competing drugs and tried to get consultant pharmacists and nursing home staffers to encourage the use of Aranesp in patients who didn't have anemia associated with kidney failure, the Justice Department said. The Thousand Oaks company made payments based on the sales volume or market share of Aranesp, the agency said.</blockquote> Then a few days ago, a <a href="http://www.sfvbj.com/news/2013/apr/29/amgen-reaches-11-million-settlement-over-medicaid-/">story</a> in the San Fernando Valley Business Journal described yet another Amgen settlement:   <blockquote class="tr_bq">Thousand Oaks biotech Amgen Inc. has reached an $11 million settlement with 36 states over charges it inflated pricing data and caused Medicaid to overpay for six of its drugs, the New York State Attorney General said Monday. The charges allege Amgen inflated cost benchmarks for drugs used to treat kidney disease and cancer patients. The drugs involved were Aranesp, Enbrel, Epogen, Neulasta, Neupogen and Sensipar. Those benchmarks are used to set pharmacy reimbursement rates for drugs dispensed to state Medicaid beneficiaries.</blockquote> Keep in mind that all these recent settlements involved allegations of efforts made to oversell Aranesp.  As we noted previously, this drug carries a "black box" warning about serious and potentially fatal side effects.  The <a href="http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/103951Orig1s5173_103951Orig1s5258lbl.pdf">official Aranesp label</a> states (in a black box warning, in capital letters): <blockquote class="tr_bq"> ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE</blockquote> So the overselling of Aranesp not only appeared unethical, it seemed to put short term revenue ahead of patient safety, and could conceivably have lead to patients dying so that the company could make more money.    Summary So while the evidence mounts that health care organizations, and in this case, Amgen, continue to aggressively pursue short-term revenue even is their means of doing so endangers patients.  However, <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal efforts</a> to challenge such reckless practices continue to fail to impose any negative consequences on those who personally profited from this behavior, and particularly those corporate executives who authorized and directed the bad behavior.  Moreover, while such evidence mounts, the top leaders of these organizations continue to pile up riches.  It seems that CEOs of health care organizations continue to prosper despite, or perhaps because of their organizations' continuing unethical and dangerous behavior. As we have said far too many times, we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

Amgen CEOs Prosper Despite (or Because of) Continuing Ethical Questions

This is becoming a familiar narrative on Health Care Renewal: top health care leaders continue to enrich themselves while their organizations' behavior continues to raise ethical questions.For our lat…

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02 May 2013

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