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Guest Post: A Physician Rebels Against Micromanagement by "'Leadership-Trained' Management Extenders"

Health Care Renewal presents a guest post by <a href="http://imh.utmb.edu/about-us/faculty/howard-brody">Dr Howard Brody,</a> John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at <a href="http://brodyhooked.blogspot.com/">Hooked: Ethics, Medicine and Pharma</a>.   <div class="MsoNormal">I recently heard from a physician whom I knew well in an earlier stage of her training—I’ll call her Pauline. She completed her training at one of the top children’s hospitals in the US, and served in several capacities in academic medical centers before her most recent job with a physician-owned for-profit practice. She called me to express her frustrations and to ask if the right course for her was to quit doing clinical medicine.</div><div class="MsoNormal"> </div><div class="MsoNormal">Pauline had become skilled in her earlier jobs in providing primary care for children with severe chronic conditions. Her reputation was such that when she was settled in her current post, pediatric subspecialists started to refer their difficult cases to her for follow-up. This patient mix did not suit her current employer for two reasons. First, these children were hard to take care of and even though they could have their visits “up-coded” to reflect their complexity, the practice much preferred to see healthy children with colds and earaches that could be moved through quickly and who did not demand much staff time and attention. Second, most of these children with special needs were on state insurance, which did not pay as well (even after up-coding) as the private insurance the practice coveted.</div><div class="MsoNormal"> </div><div class="MsoNormal">Pauline found herself constantly struggling with her co-workers and superiors in order to deliver all of her patients—not just the special-needs kids—the quality of care she had been trained to demand. As far as the practice was concerned, it was Pauline, and the medically complex kids she was attracting into the practice, who were the problem.</div><div class="MsoNormal"> </div><div class="MsoNormal">One recent incident had especially concerned Pauline. She had set up a visit to see a new medically complex patient and had blocked off 40 minutes, the amount of time she felt she needed to do a good job. The child had a complex genetic disorder, cerebral palsy, and heart, lung, and kidney problems.  Both the cardiologist and the nephrologist had called asking her to take this patient.  She agreed.  After she had scheduled the visit, a manager called her and told her that she was being allowed only 15 minutes to see that patient. After some fruitless discussion with him, Pauline finally said, “Okay, I guess that means that you’ll be seeing the patient instead of me, right?” The shocked voice at the other end of the phone line replied, “What do you mean? I don’t know how to take care of patients.” “That’s exactly my point,” Pauline put in. </div><div class="MsoNormal"> </div><div class="MsoNormal">Pauline explained that this manager assigned to her office is not even a college graduate. Physicians cannot access the schedule electronically and have no control over scheduling. These functions are controlled by the office manager and (amazingly) by some of the medical assistants who have received some “leadership” training. These medical assistants are even allowed to evaluate the clinical competency and skills of the physicians.</div><div class="MsoNormal"> </div><div class="MsoNormal">Now, at this stage, I can imagine a response from a management-trained person. Pauline is obviously one of those starry-eyed idealist physicians who believe that money grows on trees and that costs should never be a factor in caring for patients. Somebody who actually knows what it means to make a payroll and keep the lights on has to step in and rein in these physicians. There has to be somebody in the system someplace with a head for business, who can recognize the stark realities of what today’s practice demands from all parties. Physicians should get off their high horses and stop imagining that they can give orders to everyone else.</div><div class="MsoNormal"> </div><div class="MsoNormal">So let me add a further nugget about Pauline’s background. In one of her previous jobs, she was made the manager of a pediatric outpatient center within a county hospital caring for a largely indigent population. This center had been running in the red for a good while. Pauline took over and within 28 months she’d streamlined the place and had them running well in the black, while still administering a quality of care that Pauline and her colleagues could be proud of. In short, Pauline could probably tell the managers of her current practice a thing or two about how to optimize patient scheduling without compromising care or cost —if they’d listen.</div><div class="MsoNormal"> </div><div class="MsoNormal">Pauline probably has a nearly-unique skill set in her community and has put in a lot of years of training and experience to get there. Due to the present state of American medicine, and those who want to run it as if it were an industrial operation to make a profit, Pauline is thinking about leaving clinical practice altogether despite her relatively young age – and she has several colleagues, who trained in the same way that she did, who are considering this option.</div><div class="MsoNormal"> </div><div class="MsoNormal">Fortunately, Pauline has at least for now postponed any final decision about leaving clinical medicine entirely. Here’s what she last told me:</div><div class="MsoNormal"> </div> <blockquote class="tr_bq"><div class="yiv528586260msonormal" style="background: white; margin-bottom: 12.0pt;">I am leaving the organization - I cannot remain in an organization where profit comes ahead of quality - and as a former medical director who had financial accountability/responsibilities, I know it does not HAVE to be a choice.  I do not know what my next steps will be from here.  For me, working with integrity, compassion and a desire for excellence is not negotiable.</div><div class="yiv528586260msonormal" style="background: white; margin-bottom: 12.0pt;">Physicians MUST become better advocates for our profession.  For too long, we have been asleep at the wheel while insurance companies and corporations shaped the environment in which we practice.  We cannot allow this to continue.  We are professionals, not vocationally educated medical automatons  who need every moment of work day micromanaged by 'leadership-trained' management extenders who have no idea what it means to take responsibility for patients.  </div></blockquote> <div class="MsoNormal">Dr Howard Brody</div>

Guest Post: A Physician Rebels Against Micromanagement by "'Leadership-Trained' Management Extenders"

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institut...

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Tales of the Wayfaring Generic Manager - from Ritz Carlton Hotels to Henry Ford West Bloomfield Hospital to Cancer Treatment Centers of America

In 2006, we <a href="http://hcrenewal.blogspot.com/2006/03/putting-on-ritz.html">wondered</a> what a former hotel manager, Mr Gerard van Grinsven, admittedly known for putting the "wow" back in the Detroit Ritz-Carlton, would be doing as a hospital CEO.  This seemed at the time like a real "wow" example of how <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic managers </a>were taking over health care.  Mr Grinsven had extensive experience in the hospitality field, but no known background in health care.  Organic Local Produce, "Wellbeing Centers," Gourmet Dining, Wedding Receptions, and Corporate Functions Over the next few years, Mr van Grinsven's Henry Ford West Bloomfield hospital did make a name for itself.  In 2009, Becker's Hospital Review <a href="http://www.beckershospitalreview.com/news-analysis/ceo-gerard-van-grinsven-explains-how-henry-ford-west-bloomfield-hospital-reinvents-the-community-hospital.html">reported</a> on some of Mr Van Grinsven's innovations.  First, he lead an apparent change in the hospital's mission from acute care to recreating: <blockquote class="tr_bq">the hospital experience into one focused on promoting wellbeing and healthy living. The hospital has already begun to realize its mission statement, which reads 'to take health and healing beyond the boundaries of imagination.'</blockquote> The new hospital apparently was designed to look like a luxury hotel: <blockquote class="tr_bq">The hospital is located on 160 acres of woodlands and is designed to resemble a Northern Michigan lodge. The facility also features a retail 'main street' which looks like an actual main street in a Northern Michigan town and includes stores focused on sleep, pregnancy, organic food and healthy cooking as well as a pharmacy.</blockquote> Apparently it is now a favored site for weddings: <blockquote class="tr_bq">The hospital also holds free concerts for the community and has already received nine wedding inquiries. </blockquote> It had a "wellness center" <blockquote class="tr_bq">Henry Ford West Bloomfield also features a unique, integrated wellness center called Vita. Vita offers acupuncture, therapeutic message, yoga and relaxation classes, an aqua therapy suite, a spa and health coaches who provide lifestyle and exercise consultations. In addition to offering one-time services, the hospital offers memberships to community members to encourage frequent use of the center. </blockquote> What really stood out was its food service: <blockquote class="tr_bq">Henry Ford brought in top Michigan chef Matt Prentice to transform traditional hospital food service. The hospital features 24-hour room service for patients, all of which is served by the hospital's on-site gourmet, organic restaurant, Henry's. All food served in the hospital is organic, promotes sustainable agriculture and, in many cases, is procured from local farmers.</blockquote> A 2011 <a href="http://management.fortune.cnn.com/2011/03/02/what-hospitals-can-learn-from-the-ritz/">article</a> in Fortune noted that <blockquote class="tr_bq">the hospital is on track to generate millions of dollars a year hosting and catering functions for companies and community groups.</blockquote> It all sounds great, if it were describing a luxury hotel. The Fortune article ended with the gushing summation: <blockquote class="tr_bq">While it will be years before anyone can say whether this model works, there's no question that it captures a spirit of innovation that just might be a cure for what ails so many organizations. We are living today through the age of disruption. You can't do big things if you're content with just doing things a little better than everyone else or a little differently from how you've done them in the past. In an era of intense competition and non-stop reinvention, the only way to stand out from the crowd is to stand for something special. Originality has become the acid test of strategy.</blockquote> Neither it nor the Becker's rather uncritical discussions dealt with what any of this had to do with the fundamental mission of a hospital, to care for the sick, what it has to particularly do with quality of care, especially care of severely acutely or chronically ill patients, traditionally those whom hospitals were meant to serve.  Would a patient desperately sick from a myocardial infarction (heart attack), stroke, sepsis (bacterial blood stream infection) or the other major ills that bring people to hospitals really care that if he or she were to survive without major sequelae, organic, locally grown food would be served in the hospital's fancy restaurant?  Is there any evidence that provision of any of these fancy hotel amenities would affect important clinical outcomes for such patients?  Could the funds needed for all these fancy hotel services be better spent to improve patients' the the population's health? On to a More Ethically Challenged Environment We may never know.  But what we do know is that Mr van Grinsven, having brought "wellness" centers and organic, locally grown, gourmet food to an acute care hospital, is now moving on. Crain's Detroit Business just <a href="http://www.crainsdetroit.com/article/20130426/NEWS/130429902/henry-ford-west-bloomfield-hospitals-van-grinsven-resigns-as-ceo">reported</a>: <blockquote class="tr_bq">Henry Ford West Bloomfield Hospital President and CEO Gerard van Grinsven has resigned from the position effective June 1, according to an internal email sent Friday to employees from Henry Ford Health System President and COO Bob Riney. Van Grinsven is leaving the hospital to become the president and CEO of Chicago-based Cancer Treatment Centers of America, Riney said in the email. He will oversee the CTCA's five hospitals and medical centers in Illinois, Pennsylvania, Oklahoma, Arizona and Georgia. The CTCA is expected to announce van Grinsven's new position later today.</blockquote> Henry Ford Health System CEO Bob Riney saluted van Grinsven thus, <blockquote class="tr_bq">'Gerard's leadership talents and his tremendous global experience made the transformation of this innovation and distinctive vision a reality,' Riney told employees in the email.</blockquote> He did not apparently mention anything about the quality of care for acutely and chronically ill patients.  The <a href="http://www.prnewswire.com/news-releases/stephen-b-bonner-assumes-new-role-as-ctca-executive-chairman-gerard-van-grinsven-succeeds-as-president--ceo-204883721.html">press release</a> from CTCA proclaimed <blockquote class="tr_bq">'Gerard's arrival is an exciting and dramatic step in the evolution of our leadership that will herald new opportunities for all of our talented Stakeholders and the thousands of patients we serve,' said [executive chairman and former CEO Stephen B] Bonner. 'Our expertise in Patient Empowerment Medicine® and track record implementing change is unparalleled. Nothing we do today is the same as we did two years ago. Gerard is uniquely qualified to provide the leadership required to advance our commitment to patient-centered care in all we do,' concluded Bonner.</blockquote> Of course, there was nothing about how van Grinsven's expertise in wellness centers and organic produce would be useful to an organization supposedly devoted to cancer patients, whose care may involve risky treatment choices and who may become desperately ill. There was also nothing about how van Grinsven's background would help CTCA to avoid new ethical misadventures.  Earlier this year, we <a href="http://hcrenewal.blogspot.com/2013/03/the-dangers-of-big-corporate-health.html">posted</a> about issues involving CTCA making unsubstantiated survival claims; promoting "integrative" treatments that are unsupported by evidence; and manipulating survival statistics, in part by turning away patients with poor prognoses.  Of course, it is not clear that given van Grinsven's background he would even understand why such behavior is unethical.  Summary As a physician, it is hard not to laugh at all this, at least to keep from crying.  As we have noted frequently, health care has been taken over by generic hired managers.  At best, while well meaning, many of them seem clueless about the nature and context of health care, and health care professionals' values.  At worst, the <a href="http://hcrenewal.blogspot.com/search/label/managers%27%20coup%20d%27etat">manager's coup d'etat</a> has turned managers into manager-kings, queens and nobles, while driving up health care costs, and sacrificing the health of patients and the public.  The depth of this phenomenon is demonstrated by the absolute lack of skepticism about the worthiness of a former Ritz-Carlton executive to run either a community hospital or a system of cancer treatment centers. I say once again that true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.

Tales of the Wayfaring Generic Manager - from Ritz Carlton Hotels to Henry Ford West Bloomfield Hospital to Cancer Treatment Centers of America

In 2006, we wondered what a former hotel manager, Mr Gerard van Grinsven, admittedly known for putting the "wow" back in the Detr...

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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 a...

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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?

(NOTE: this post, being about minor matters like death and financial mayhem, is particularly and unusually [even for me] biting and lacking...

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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 " ...

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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...

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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 week...

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