healthy4u

Kim Kardashian, Meet Electronic Medical Records

In yet another example of breach of medical record privacy (<a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy</a>), Kim Kardashian's privacy on the birth of her daughter, as well as the privacy of more than a dozen other patients, was violated between June 18 and June 24:   <blockquote class="tr_bq"><a href="http://www.reuters.com/article/2013/07/14/entertainment-us-usa-hospital-privacy-idUSBRE96D00520130714">Workers fired in privacy breach at L.A. hospital popular with stars</a> LOS ANGELES | Sat Jul 13, 2013 (Reuters) - Five medical workers have been fired over a patient data breach at Cedars-Sinai Medical Center, the Los Angeles facility said in a statement, while celebrity website TMZ reported on Saturday that the hacking effort targeted reality star Kim Kardashian. Cedars-Sinai, a favorite destination for celebrities seeking medical care, said in the statement it has a "high standard for security" and "in this case that standard was violated."  [How do ordinary hospital workers, medical assistants, and even a volunteer as below violate a "high standard for security", I wonder? - ed.] Kardashian, the star of the reality television show "Keeping Up With the Kardashians," gave birth on June 15 at Cedars-Sinai to daughter North West, whose father is Grammy-winning rap star Kanye West. Cedars-Sinai officials declined to say whose privacy had been breached, but the hospital said it "informed the affected patients" and apologized to them. The breach of 14 patient records occurred between June 18 and June 24, the hospital statement said. TMZ reported that Kardashian checked out of Cedars-Sinai about a week after she gave birth and was contacted by the hospital and told she was one of the patients whose records were accessed. TMZ, which cited unnamed sources, said Kardashian's family suspected a leak of information at Cedars-Sinai after media reports disclosed details Kardashian had not revealed to anyone. Representatives for Kardashian did not return calls or emails seeking comment on Saturday. The Cedars-Sinai statement said four of the workers who inappropriately logged onto the hospital's information system to access patient records were employees of local physicians with staff privileges at the hospital. The other workers were a medical assistant employed by the Cedars-Sinai Medical Care Foundation and a student research assistant who was a volunteer, the hospital said. As a result of the privacy breach, the five medical workers with ties to Cedars-Sinai were fired and the volunteer barred from working there, it said. Cedars-Sinai said that while it had no indication "any criminal acts were committed by the individuals" it was reaching out to law enforcement agencies in "an abundance of caution."</blockquote> It looks like the "high standard for security" needs some work. (A paper chart could have been sequestered, of course, not permitting its access by riff raff, but then there would not be all the tremendous advantages of today's commercial EHRs such as detailed at <a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html</a>.) -- SS <blockquote class="tr_bq"></blockquote>

Kim Kardashian, Meet Electronic Medical Records

In yet another example of breach of medical record privacy ( http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy ), Kim Ka...

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RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals

Add the following from Sutter East Bay Hospitals to nurses' and physicians' complaints at Marin General Hospital (<a href="http://hcrenewal.blogspot.com/2013/05/marin-general-hospitals-nurses-are.html">http://hcrenewal.blogspot.com/2013/05/marin-general-hospitals-nurses-are.html</a>), Affinity Medical Center (<a href="http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html">http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html</a>), Contra Costa County (<a href="http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html">http://hcrenewal.blogspot.com/2012/08/contra-costas-45-million-computer.html</a>), San Francisco Department of Public Health (<a href="http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html">http://hcrenewal.blogspot.com/2010/11/avatar-fails-no-not-cameron-movie-but.html</a>), and others: <blockquote class="tr_bq">For Immediate Release  July 11, 2013 Contact-  Charles Idelson, 510-273-2246 <h2>RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals</h2>Introduction of a new electronic medical records system at Sutter corporation East Bay hospitals has produced multiple problems with safe care delivery that has put patients at risk, charged the California Nurses Association today. Problems with technology are not unique to health care – pilots of the ill fated Asiana airline that tragically crashed at San Francisco International Airport July 6 told federal investigators that an automatic throttle failed to keep the jetliner at the proper speed for landing, the Los Angeles Times reported July 9.  [What is unique to healthcare IT is the complete lack of regulation - ed.] In over 100 reports submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe. Patient care concerns included computerized delays in timely administration of medications and contact with physicians, ability to properly monitor patients, and other delays in treatment.  Many noted that the excessive amount of time required to interact with the computer system, inputting and accessing data, sharply cuts down on time they can spend with patients with frequent complaints from patients about not seeing their RN.  [Note: patients are not given the opportunity for informed consent about the risks, nor opt-out of EHR use in their care - ed.] "EPIC is a system that is so cumbersome to use for nurses and physicians, that we often feel as though we are caring for a computer, not a patient,” said Thorild Urdal, an RN at Alta Bates Summit’s hospital in Berkeley. “It delays care and treatment, the program is naturally counter-intuitive and it was clearly not designed in concert with nurses and physicians." [Clinicians end up caring for an "iPatient", as others have noted - ed.] "The Epic program developed and implemented by Sutter is neither nurse or patient friendly,” said Alta Bates Summit Oakland RN Mike Hill. “Epic does not enhance my ability to chart instead it takes time away from the bedside and my patients and preventing me from providing the absolute best care that they and I expect from me as a nurse." Sutter CEO Pat Fry last year told the San Francisco Business Times that Sutter will spend $1 billion on Epic, a system that has sparked controversy at several other hospitals, including a Contra Costa facility where several RNs cited serious medical errors in testimony to county supervisors last August. At Alta Bates Summit specific incidents directly related to Epic problems included: • A patient who had to be transferred to the intensive care unit due to delays in care caused by the computer.  [It's happenstance they did not have to be transferred to the morgue - ed.] • A nurse who was not able to obtain needed blood for an emergent medical emergency. • Insulin orders set erroneously by the software. • Missed orders for lab tests for newborn babies and an inability for RNs to spend time teaching new mothers how to properly breast feed babies before patient discharge. • Lab tests not done in a timely manner. • Frequent short staffing caused by time RNs have to spend with the computers. • Orders incorrectly entered by physicians requiring the RNs to track down the physician before tests can be done or medication ordered. • Discrepancies between the Epic computers and the computers that dispense medications causing errors with medication labels and delays in administering medications. • Patient information, including vital signs, missing in the computer software. • An inability to accurately chart specific patient needs or conditions because of pre-determined responses by the computer software. • Multiple problems with RN fatigue because of time required by the computers and an inability to take rest breaks as a result. • Inadequate RN training and orientation. </blockquote>These "incidents" are certainly capable of causing harms or fatalities.  One wonders if hospital executives are providing the usual refrain that these are just "glitches" (<a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>) and that patient care has not been compromised (<a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised</a>). A bit more background follows: <blockquote class="tr_bq">... Hospitals nationally are spending tens of billions of dollars on technology systems, especially on electronic health records (EHR) programs for which they also receive federal financial incentives. EHR programs are paraded as a panacea for reducing medical errors and cutting costs, but in life the promise is falling short in both areas. A RAND corporation analysis earlier this year said visions of savings and improved efficiency in patient care have had what the New York Times called “mixed results, at best.” The U.S. Food and Drug Administration has acknowledged getting hundreds of reports of problems involving health information technology including numerous patient injuries and deaths. Some examples seen at hospitals across the country: • At Marin General Hospital in Northern California, RNs called on the Marin Healthcare District board to delay implementation of their EHR system. "Orders are being inadvertently passed to the wrong patients. People have gotten meds when they've been allergic to them. This is dangerous," Marin RN Barbara Ryan said in comments reported by the Marin Independent Journal. • In Chicago, the Chicago Tribune in 2011 reported on a patient death at Advocate Lutheran General hospital after an automated machine prepared an intravenous solution containing a massive overdose of sodium chloride — more than 60 times the amount ordered by a physician. • At Affinity Medical Center RNs in Massillon, Oh. RNs in June raised multiple objections to the hurried introduction of an EHR system. Subsequently, they have cited medication errors, delays in care, problems with documentation, computers crashing, and other concerns.</blockquote> I am simply the reporter here. -- SS

RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals

Add the following from Sutter East Bay Hospitals to nurses' and physicians' complaints at Marin General Hospital ( http://hcrenewa...

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A "Simply Outstanding," "Superb" Hospital CEO Cops a Plea to Two Felonies

In all the discussions of what is wrong with US health care, very rarely is the quality of the leadership of health care organizations questioned.  In fact, no major US health care organization seems to have leadership that is anything short of brilliant.  The amazing brilliance of these leaders serves as a rationale for the ever increasing <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation </a>that they receive.  Yet while subordinates, friendly members of boards of trustees, and hard working public relations flacks may stress their leaders' wondrous qualities, there rarely is an opportunity to compare their proclamations with results. A few small items in the New York media provide us one case study of how these proclamations may not square with reality. Background In 2005, the CEO of New York's renowned Hospital for Special Surgery announced his retirement.  In a <a href="http://www.hss.edu/newsroom_hss-president-ceo-john-reynolds-succession-plan.asp">hospital news release</a>, we find these pronouncements about outgoing President and CEO John Reynolds, <blockquote class="tr_bq">HSS board Co-Chairman Aldo Papone said, 'John's guidance and devotion to the Hospital for Special Surgery these last two decades have been simply outstanding. Under his watch, the quality of care, fiscal health and scope of treatment for musculoskeletal disease at the hospital have reached the highest level in its history.  While we regret his decision, we can only offer a most grateful expression of thanks...'</blockquote> Also, HSS board Co-Chairman Dean R. O'Hare said, <blockquote class="tr_bq">He is a superb leader and we appreciate his thoughtful approach to succession which is emblematic of his service to HSS.</blockquote> I cannot find anything on the internet about Mr Reynolds' compensation prior to his retirement, but in 2006, after he took on the position of Co-CEO during the transition, a copy of the hospital's 2006 990 form filed with the US Internal Revenue service, (and still available <a href="https://bulk.resource.org/irs.gov/eo/2008_02_EO/13-1624135_990_200612.pdf">here,</a> note though that rather confusingly, the Hospital still files under its archaic original name, "The New York Society for the Relief of the Ruptured and Crippled,") showed that Mr Renynolds' total compensation was $1,310,603 The CEO as Crook Nothing publicly appeared to challenge the notion that Mr Reynolds' leadership was less that "outstanding" and "superb" until a Bloomberg <a href="http://www.bloomberg.com/news/2012-09-26/ex-n-y-hospital-ceo-charged-with-taking-vendor-kickbacks.html">article</a> in September, 2012, . <blockquote class="tr_bq">John R. Reynolds, former chief executive officer of New York's Hospital for Special Surgery, was charged by federal prosecutors with taking $1.4 million in a decade-long illegal-kickback scheme. Reynolds, 63, was arrested at his home in Massachusetts this morning, according to a statement from the office of U.S. Attorney Preet Bharara. An indictment unsealed today in Manhattan federal court charges Reynolds with racketeering and making false statements to the government. He faces as long as 25 years in prison if convicted. Prosecutors claim that, from 1996 to 2007, Reynolds took money from at least two hospital vendors, a hospital employee and an unidentified health-care organization in the U.K.</blockquote> Furthermore, <blockquote class="tr_bq"> The government claims Reynolds took a total of $420,000 in kickbacks from at least two hospital vendors, from 1996 to 2002, in exchange for steering hospital business to them. From 2000 to 2005, he extorted an additional $298,500 from a subordinate at the hospital after negotiating an annual bonus for the employee, according to the charges. Reynolds also received $670,000 for approving a clinical partnership between his hospital and the U.K. health-care organization, prosecutors claim. Reynolds is also charged with lying in 2008 to an agent of the U.S. Department of Health and Human Services inspector general’s office. 'By allegedly exploiting his position at the helm of a world renowned hospital for his own personal gain, John Reynolds tarnished the hospital’s reputation and did a disservice to its employees,' Bharara said in the statement.</blockquote> Not surprisingly, <blockquote class="tr_bq"> 'Obviously, it was a shock to us,' said Deborah Sale, a hospital spokeswoman, referring to the charges.</blockquote> Of course, in the US, people accused of crimes are assumed to be innocent until proven guilty.  So I am now writing about this case because yesterday Bloomberg published the <a href="http://www.businessweek.com/news/2013-07-11/ex-hospital-ceo-reynolds-pleads-guilty-in-kickback-case-1">follow up story</a>, <blockquote class="tr_bq"><div class="">The former chief executive officer of New York’s Hospital for Special Surgery, charged by federal prosecutors with taking $1.4 million in kickbacks, pleaded guilty to two felonies. </div><div class=""> </div>John R. Reynolds, 64, today pleaded guilty to wire fraud and making false statements, admitting that he took payments from a hospital employee and lied to investigators about it.</blockquote> He will be subject to a stiff fine, although less than what he was charged with extracting through his scheme, and may be imprisoned, <blockquote class="tr_bq"> Under a plea agreement with the government, Reynolds will forfeit $718,500. Both sides agreed that federal sentencing guidelines, which are advisory, call for him to serve 27 to 33 months in prison.</blockquote> The story so far has also been covered briefly by two tabloids, the <a href="http://www.nypost.com/p/news/local/manhattan/special_surgery_ex_boss_in_kickback_4chuFeWsk9Hf9yKfiP8lXL">New York Post</a>, and the <a href="http://www.nydailynews.com/new-york/ex-hospital-ceo-pleads-guilty-1-4m-scheme-article-1.1396279">Daily News</a>.  To date, the Hospital for Special Surgery has <a href="http://www.hss.edu/newsroom.asp">not issued a news bulletin</a> on this. Summary So yet another "outstanding," "superb" multimillion dollar CEO turned out to be something rather less, in  fact, to be a criminal. We have frequently discussed how the leaders of large US health care organizations are often hailed as brilliant, and <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensated hugely </a>for their brilliance, but rarely publicly subject to any objective assessment of their performance.  In many cases, they seem unaccountable for leadership that may be <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">ill-informed</a>, <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">hostile to the health care mission</a>, or even <a href="http://hcrenewal.blogspot.com/search/label/crime">criminal</a> or <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">corrupt</a>.  The good news is that this criminal was eventually caught.  The bad news is that it only happened 18 years after he began acting criminally, hardly an example of swift justice.  One wonders how many other brilliant health care leaders will years later turn out not to be so, and how many others' performance will never be publicly assessed.   While we breathlessly await the rigorous prospective study that assesses public assessments of the leaders of large health care organizations against objective results, we are stuck with case studies as a means to do so.  This case study shows a particularly stark contrast between the public relations puffery and the sordid reality.  Instead of "brilliant" leaders paid like royalty, we would do better with competently collegial leaders rewarded reasonably as part of a team all focused on the health care mission, which puts service to patients first.  As long as health care organizations appear to be a path to riches for their leaders, expect the people who want to lead them to be more interested in their own fortunes than patients' and the public's health.  As long as health care professionals, policy makers and the public assume that those who lead health care organizations are fully qualified, fairly paid, and always do what is right, expect the insiders to continue to run things for their own profit.  The qualifications of those who would lead health care, how much they are paid, what they are doing and what the results of their work are ought to be publicly known and publicly discussed.  Health care professionals, policy makers, and the public should demand nothing less.  .

A "Simply Outstanding," "Superb" Hospital CEO Cops a Plea to Two Felonies

In all the discussions of what is wrong with US health care, very rarely is the quality of the leadership of health care organizations quest...

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43% Believe that US Health Care is Corrupt, 64% that Government is Run by a Few Big Interests, Media Shrug

We have noted  (most recently <a href="http://hcrenewal.blogspot.com/2011/05/running-away-from-problem-of-health.html">here</a>),  that health care corruption, particularly its global nature and its presence in developed countries like the US, is a taboo topic and thus remains <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a>.   Transparency International just released its yearly massive <a href="http://www.transparency.org/gcb2013">survey on corruption worldwide</a>.  The results are not pretty for health care and related sectors world wide and in the US.  As expected, these results appear to be causing few echoes.  Global Results Some useful summary statements found in the <a href="http://www.transparency.org/gcb2013/report">written version of the report</a>: <blockquote class="tr_bq">Governments are not thought to be doing enough to hold the corrupt to account.  The majority of people around the world believe that their government is ineffective at fighting corruption and corruption in their country is getting worse. The democratic pillars of societies are viewed as the most corrupt.  Around the world, political parties, the driving force of democracies, are perceived to be the most corrupt institution. Personal connections are seen as corrupting the public administration.  People surveyed regard corruption in their country as more than just paying bribes: almost two out of three people believe that personal contacts and relationships help to get things done in the public sector in their country. Powerful groups rather than the public good are judged to be driving government action.  More than one in two people (54 per cent) think their government is largely, or entirely run by groups acting in their own interests rather than for the benefit of the citizens. </blockquote> The survey included questions about corruption in the health care sector.  Globally, respondents perceived it was a major problem.  On average, 17% said they or their family members had to pay bribes in connection with medical and health care.  The average perception of corruption in medicine and health care across all countries was 3.2, where 1 = not at all corrupt, and 5 = extremely corrupt.  (Scores for the media were 3.1, business sector, 3.3, education system, 3.1, public officials, 3.6, political parties, 3.8, and NGOs, 2.7) US Results While the US did not have the worst results, our numbers were not very good (see US specific results <a href="http://www.transparency.org/gcb2013/country/?country=united_states">here</a>). More than one-third (43%) of respondents thought that US health care is corrupt.  Large numbers of people also thought that related sectors were corrupt (53% thought business in general was corrupt, 34% education, 58% the media, 55% public officials, 61% the legislature, 78% political parties.) For comparison, the proportions of people who thought the health care sector is corrupt were 24% in Canada, 28% in France, 48% in Germany, 47% in Japan, and 19% in the United Kingdom Also, more than half (60%) of respondents said corruption in the US has increased over the last 2 years, almost two-thirds (64%) thought that the US government is run by a few big interests.  Thus, this survey confirmed that health care corruption is a global problem, and that a large proportion of people in the US believe it is a major problem here.  The Media Shrug This would seem to be major news.  However, so far the Transparency International survey results have received little  media attention in the US.  Moreover, what attention they have received in the US makes corruption appear to be some other countries' problem.  . Most of the US media reports avoided mentioning any results that relate directly to the country.  In particular, the <a href="http://www.nytimes.com/2013/07/10/business/global/crisis-struck-europeans-losing-faith-in-governments.html">New York Times</a>, the <a href="http://blogs.wsj.com/riskandcompliance/2013/07/09/survey-finds-one-fourth-of-people-paid-bribes-in-last-year/">Wall Street Journal</a>, <a href="http://www.foxnews.com/world/2013/07/09/corruption-seen-on-rise-global-study-finds/">Fox News</a>, <a href="http://money.cnn.com/2013/07/09/news/corruption-bribes/">CNN</a>, <a href="http://www.nbcnews.com/business/bribery-rise-globally-amid-distrust-government-6C10578435">NBC</a>, and <a href="http://www.reuters.com/article/2013/07/09/us-corruption-transparency-media-idUSBRE96805320130709">Reuters</a> coverage said nothing about the US.  Businessweek provided reports from <a href="http://www.businessweek.com/news/2013-07-09/police-politicians-seen-as-malaysia-s-most-corrupt-in-survey">Malaysia</a> and <a href="http://www.businessweek.com/news/2013-07-09/putin-officials-judges-seen-topping-russia-corruption-in-survey">Russia</a> that focused on those countries' results.  A brief report in the <a href="http://www.latimes.com/news/world/worldnow/la-fg-wn-global-corruption-survey-20130709,0,7195220.story">Los Angeles Times</a> only noted a single US statistic, about the bribery rate, one area in which the US had relatively favorable results.  Only a lonely <a href="http://www.forbes.com/sites/kenrapoza/2013/07/09/transparency-international-spells-it-out-politicians-are-the-most-corrupt/">Forbes blogger</a> alluded to the US results in slightly more detail,  (and then went on to summarize those from Brazil, Russia, India, and Mexico in detail). In contrast, media reports from some other countries, like <a href="http://www.indianexpress.com/news/all-political-parties-are-corrupt-believe-86---indians-transparency-international-survey/1139640/">India</a>, <a href="http://www.ghanabusinessnews.com/2013/07/09/transparency-international-proves-ghana-govts-fight-against-corruption-ineffective/">Ghana</a>, and <a href="http://www.haaretz.com/news/national/world-corruption-survey-most-israelis-believe-government-agencies-promote-foreign-interests.premium-1.534780">Israel</a>, noted their own countries' poor results. Summary So once again we see how <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic</a> are the notions that health care corruption is a severe global problem, and that it affects all countries, including the most supposedly developed.  Of course, the unwillingness to discuss global health care corruption, health care corruption in the US, and the relationship of health care corruption in the US to corruption in other sectors may arise from the fear, as stated by one person interviewed in Charles Ferguson's documentary <a href="http://www.sonyclassics.com/insidejob/">Inside Job</a>, that discussion could lead to investigation, and investigation could "find the culprits". On Health Care Renewal, we try to discuss global <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">health care corruption</a>,.  We were first inspired by the 2006 publication of Transparency International's <a href="http://www.transparency.org/whatwedo/pub/global_corruption_report_2006_corruption_and_health">Global Corruption Report </a>which focused on health care, and documented how health care corruption is global, severe, and not restricted to the poorest countries  (see post <a href="http://hcrenewal.blogspot.com/2006/02/global-corruption-report-2006-focus-on.html">here</a>). This blog focuses on the US, and we  now have in our archives some amazing stories that document various forms of health care corruption in the US, including numerous allegations of misbehavior by large health care organizations ending in <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements</a>, and examples of outright <a href="http://hcrenewal.blogspot.com/search/label/fraud">fraud</a>, <a href="http://hcrenewal.blogspot.com/search/label/bribery">bribery</a>, <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a> and other <a href="http://hcrenewal.blogspot.com/search/label/crime">crimes</a>. On the other hand, we have demonstrated again and again that bad  and corrupt behavior by large health care organizations is a taboo topic.  For example, we could find  very few significant efforts to discuss, teach about, or research ways to fight corruption, or to promote accountability, integrity, transparency, honesty and ethics by academic health care institutions. (See <a href="http://hcrenewal.blogspot.com/2010/11/who-you-gonna-call-how-should-young.html">this post </a>for how difficult it was to find academic institutions' initiatives to resist conflicts of interest.) One can count the conferences, meetings, symposia, and courses on such topics on one's fingers. When I last looked, I could count only a <a href="http://sph.bu.edu/index.php?option=com_sphdir&id=239&Itemid=617263&INDEX=771">single course </a>on fighting corruption at any US medical or public health school (at Boston University, by Prof Taryn Vian). Of course, if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption.  Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage. ADDENDUM (16 July, 2013) - See <a href="http://brodyhooked.blogspot.com/2013/07/the-corrupt-us-health-system-and.html">comments</a> by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.

43% Believe that US Health Care is Corrupt, 64% that Government is Run by a Few Big Interests, Media Shrug

We have noted (most recently here ), that health care corruption, particularly its global nature and its presence in developed countries l...

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Another Attempt to Show the RUC Behind the Curtain

In 2007, readers of the Annals of Internal Medicine could read part of the solution to a great medical mystery.(1)  For years, health care costs in the US had been levitating faster than inflation, without producing any noticeable positive effect on patients.  Many possible reasons were proposed, but as the problem continued to worsen, none were proven. Prices are High Because They are Fixed That Way The article in the Annals, however, proposed one conceptually simple answer. The prices of most physicians' services, at least most of those that involved procedures or operations for Medicare patients, were high because the US government set them that way. Although the notion that prices were high because they were fixed to be so high was simple, how the fixing was done, and how the fixing affected the rest of the health system was complex, mind numbingly complex. Perhaps because of the complexity of its implementation, the simplicity of the concept has not seemingly reached the consciousness of most American health care professionals or policy makers, despite the publication of several scholarly articles on the subject,.<a href="http://hcrenewal.blogspot.com/search/label/RUC">efforts by humble bloggers such as yours truly,</a> a major journalistic expose, and recent congressional hearings.  The lack of discussion of this issue seemed to be a prime example of what we have called the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, that important causes of health care dysfunction whose discussion would discomfit those who are currently personally profiting from the current system rarely produce many public echoes.  (For a review of what is known to date about how the offputtingly named Resource Based Relative Value Scale Update Committee (RUC) works, and previous attempts to makes it central role in fixing what US physicians are paid public, see the Appendix.) The Washington Monthly Pulls Back the Curtain Now another attempt to pull back the curtain that hides the RUC was just made by the Washington Monthly.  A long, detailed, well-written <a href="http://www.washingtonmonthly.com/magazine/july_august_2013/features/special_deal045641.php">article</a> by Haley Sweetland Edwards went through the major points, and included some new discoveries.  She asserted: The RUC is Well Hidden <blockquote class="tr_bq">[The RUC is] probably one of the most powerful committees in America that you’ve never heard of.</blockquote> The RUC Fixes Prices <blockquote class="tr_bq">when a roomful of professionals from the same trade meet behind closed doors to agree on how much their services should be worth. It’s called price-fixing. </blockquote> The Government Enables the RUC to Fix Prices <blockquote class="tr_bq"> this kind of 'price-fixing' is not only perfectly legal, it’s sanctioned by the U.S. government. At the end of each of these meetings, RUC members vote anonymously on a list of 'recommended values,' which are then sent to the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs those programs. For the last twenty-two years, the CMS has accepted about 90 percent of the RUC’s recommended values—essentially transferring the committee’s decisions directly into law.</blockquote> The Government Fixed Prices are Endorsed by the Private Sector <blockquote class="tr_bq"> private insurance companies also use Medicare’s fee schedule as a baseline for negotiating prices with hospitals and other providers. </blockquote> The Price Fixing Drives Up Costs and the Use of Services <blockquote class="tr_bq"> So if the RUC inflates the base price Medicare pays for a specific procedure, that inflationary effect ripples up through the health care industry as a whole.</blockquote> These Incentives Cripple Primary Care <blockquote class="tr_bq"> These manipulated prices are also a major reason why specialists are in oversupply in many parts of the country, while a worsening shortage of primary care providers threatens the whole health care delivery system. </blockquote> These Incentives Benefit Big Corporations, not just Medical Specialists <blockquote class="tr_bq"> the incentives are perfectly aligned: ordering that extra test means more money for a doctor’s practice or hospital, more money for the labs, and often more money for the device makers and drug companies, too. (Oh, and, by the way, the device makers and drug companies are, not incidentally, major funders of the medical specialty societies whose members vote on the RUC.)</blockquote><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHWzSplnD2du3x_SfpKZJ5CaSFXrAoZkdhDxue_1J1f0wQIAV2rbRMgDA-oHz01r7lgv341htPKIV2_EfPKtU_eEAzu6xAn9ZPSUdVYtqfaappwD18k5EziA-KfAvazcaaooKFrlj7doQ9/s1600/SpecialDeal(WashingtonMonthly0713).jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHWzSplnD2du3x_SfpKZJ5CaSFXrAoZkdhDxue_1J1f0wQIAV2rbRMgDA-oHz01r7lgv341htPKIV2_EfPKtU_eEAzu6xAn9ZPSUdVYtqfaappwD18k5EziA-KfAvazcaaooKFrlj7doQ9/s320/SpecialDeal(WashingtonMonthly0713).jpg" width="320" /></a></div> [Art by Monte Wolverton for the Washington Monthly article] What to Do and What Will Happen? We previously wrote,  Economists have beaten us over the head with idea that incentives matter.  The RUC seems to embody a corporatist approach to fixing prices for medical services to create <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse incentives</a> for physicians to do more procedures, and do less conversing with and examining patients, examining the best clinical research evidence about their problems, and rigorously thinking about how best to help them.  More procedures at higher prices helps physicians who do procedures.  It may help even more the corporations that provide the devices and drugs whose use is necessitated by such procedures, and the hospitals who can charge a lot of money as sites for performance of procedures.  It may even help insurance companies by driving ever more money through the health care system, and thus allow rationalization for higher administrative expenses as a function of overall money flow. Yet incentives favoring procedures over all else may lead to worse outcomes for patients, and more costs to patients and society.  If we do not figure out how to make incentives given to physicians more rational and fair, expect health care costs to continue to rise, while access and quality continue to suffer. Ms Edwards ended her article with two specific suggestions: <blockquote class="tr_bq">take the process away from the control of the AMA and put it in the hands of a well-resourced group of experts under the auspices of the federal government. This might take the form of a panel of doctors employed by the government, or of an advisory committee of representatives of different medical societies but with greater representation of primary care doctors.</blockquote> Or <blockquote class="tr_bq"> get Medicare out of the business of funding fee-for-service medicine. </blockquote> I can only hope that the latest Washington Monthly article, which was accompanied by an <a href="http://www.washingtonmonthly.com/magazine/july_august_2013/editors_note/the_doctor_cartel_will_see_you045632.php">editorial</a> and a short first-hand <a href="http://www.washingtonmonthly.com/magazine/july_august_2013/features/a_day_in_the_life_of_a_primary045640.php">account</a> of how difficult is the lot of the modern primary care physician, will succeed in increasing awareness of the RUC and its essential role in making the US health care system increasingly unworkable.  Of course, such awareness may disturb the many people who are making so much money within the current system.  But if we do nothing about the RUC, and about the ever expanding bubble of health care costs, that bubble will surely burst, and the results for patients' and the public's health will be devastating. APPENDIX - Background on the RUC  We have <a href="http://hcrenewal.blogspot.com/search/label/RUC">frequently posted</a>, first <a href="http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html">here in 2007</a>, and more recently <a href="http://hcrenewal.blogspot.com/2010/07/primary-care-and-hc-renewal-ruc-kus.html">here,</a>  <a href="http://hcrenewal.blogspot.com/2010/06/ruc-off-new-england-journal-once-again.html">here</a>, <a href="http://hcrenewal.blogspot.com/2011/02/replace-ruc.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2011/03/getting-out-of-our-ruc-open-letter-to.html">here</a>, about the little-known group that controls how the US Medicare system pays physicians, the RBRVS Update Committee, or <a href="http://hcrenewal.blogspot.com/search/label/RUC">RUC</a>. Since 1991, Medicare has set physicians' payments using the Resource Based Relative Value System (RBRVS), ostensibly based on a rational formula to tie physicians' pay to the time and effort they expend, and the resources they consume on particular patient care activities. Although the RBRVS was meant to level the payment playing field for cognitive services, including primary care vs procedures, over time it has had the opposite effect, as explained by Bodenheimer et al in a 1997 article in the Annals of Internal Medicine.(1) A system that pays a lot for procedures, but much less for diagnosing illnesses, forecasting prognoses, deciding on treatment, and understanding patients' values and preferences when procedures and devices are not involved, is likely to be very expensive, but not necessarily very good for patients.   As we <a href="http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html">wrote before</a>, to update the system, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.shtml">RBRVS Update Committee</a>. The RUC is a private committee of the AMA, <a href="http://www.ama-assn.org/ama1/pub/upload/mm/380/toptenthings.pdf">touted</a> as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments.   However, the identities of RUC members were opaque for a long time, and the proceedings of the group are secret.  As Goodson(2) noted, RUC "meetings are closed to outside observers except by invitation of the chair." Furthermore, he stated, "proceedings are proprietary and therefore not publicly available for review."   In fact, the fog surrounding the operations of the RUC seems to have affected many who write about it. We have posted (<a href="http://hcrenewal.blogspot.com/2007/12/is-sustainable-growth-rate-main-problem.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/12/no-such-ruc-new-england-journal-takes.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2010/06/ruc-off-new-england-journal-once-again.html">here</a>) about how previous publications about problems with incentives provided to physicians seemed to have avoided even mentioning the RUC. Up until 2010, after the US recent attempt at health care reform, the RUC seemed to remain the great unmentionable. Even the leading US medical journal seemed reluctant to even print its name.   That <a href="http://hcrenewal.blogspot.com/2010/10/ruc-it-up-how-us-government-fixes.html">changed</a> in October, 2010.  A combined effort by the Wall Street Journal, the Center for Public Integrity, and Kaiser Health News yielded two major articles about the RUC, <a href="http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html">here</a> in the WSJ (also with two more spin-off articles), and <a href="http://www.publicintegrity.org/articles/entry/2571/">here </a>from the Center for Public Integrity (also <a href="http://www.kaiserhealthnews.org/Stories/2010/October/27/AMA-center-public-integrity.aspx">reprinted</a> by Kaiser Health News.) The articles covered the main points about the RUC: its de facto control over how physicians are paid, its "secretive" nature (quoting the WSJ article), how it appears to favor procedures over cognitive physician services, etc.   In 2011, after the "<a href="http://www.replacetheruc.org/">Replace the RUC</a>" movement generated some more interest about this secretive group, and its complicated but obscure role in the health care system, the current RUC membership was finally revealed.  It was relatively <a href="http://hcrenewal.blogspot.com/2011/04/rucing-about-conflicts-of-interest.html">easy for me to determine </a>that many of the members had conflicts of interest (beyond their specialty or sub-specialty identity and their role in medical societies that might have institutional conflicts of interest, and leaders with conflicts of interest).     Then that year a lawsuit was filed by a number of primary care physicians that contended that the RUC was functioning illegally as a de facto US government advisory panel.  It appeared that things might change.  However, it was not to be.  A judge <a href="http://careandcost.com/2012/05/19/medicare-physician-payment-the-rucs-hollow-victory/">dismissed the lawsuit</a> in 2012, based on his contention that the law that set up the RBRVS system prevented any challenges through the legal system to the mechanism used to set payment rates.  The ruling did not address the legality of the relationship between the RUC and the federal government.  The eery quiet then resumed, only punctuated briefly in early 2013, when a <a href="http://hcrenewal.blogspot.com/2013/01/us-senate-subcommittee-asks-what-ruc-is.html">Senate committee held hearings</a> with no obvious effect.       ADDENDUM (15 July, 2013) - see also <a href="http://brodyhooked.blogspot.com/2013/07/the-ruc-revisited-more-corruption-in.html">comments</a> by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.   ADDENDUM (18 July, 2013) - see also <a href="http://www.nakedcapitalism.com/2013/07/how-the-ama-engages-in-government-sanctioned-price-fixing.html">comments</a> by Yves Smith on the Naked Capitalism blog. References 1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. (Link <a href="http://www.annals.org/content/146/4/301.full">here</a>.) 2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. (Link <a href="http://jama.ama-assn.org/cgi/content/short/298/19/2308">here</a>.)

Another Attempt to Show the RUC Behind the Curtain

In 2007, readers of the Annals of Internal Medicine could read part of the solution to a great medical mystery.(1) For years, health care c...

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More Perversity on Health IT Risks, and ... EHR Sense from Nurses on "Nurse Talk", a Syndicated Radio Show

As I mentioned on July 2 <a href="http://hcrenewal.blogspot.com/2013/07/is-oncs-definition-of-significant-ehr.html">at this post</a>, in a June 25, 2013 Bloomberg News article "<a href="http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html">Digital Health Records’ Risks Emerge as Deaths Blamed on Systems</a>" by technology reporter Jordan Robertson an EHR-harms case in which I am (unfortunately) intimately involved as substitute plaintiff is mentioned: that of the death of my mother. I'd previously written about EHR-related electronic encounters with truly perverse individuals at my Jan. 2010 post "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" at <a href="http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html">http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html</a>. There were quite a few thoughtful comments in the reader comments of the June 25, 2013 Bloomberg article, but also the typical callous, incompetent and/or bizarre comments that an anonymous forum invites (really, semi-anonymous, as the website tracks IP's of commenters).  The anonymous comment below stood out from the rest as a worst-case example of perverse defense of health IT (it may have been removed by now): <blockquote class="tr_bq">Pharm Aid 1 week ago I'm surprised at the poor quality of reporting in this article.  First, Scot Silverstein has been on jihad against electronic medical records LONG before his dear mother passed away in 2011.  According to Silverstein's own website, he opposed EMRs back as far as 2009. Second, the article fails to mention Silverstein's conflict of interest here - he works in this space.  Essentially, Silverstein contacts a vendor of EMRs, offers his "consulting" services.  This totally smacks of a shakedown to me.  If they don't hire him, he criticizes them and claims they are killing people.  Don't take my word for it, check out his website and blog. Third, the number of medical errors from paper-based records is staggering.  According to a study from 7 years ago, a staggering number - 23% - of patients at one health system had medication errors attributed to illegible paper-based charts.  This is roughly consistent with other studies, including the epic IOM report on errors in medicine.</blockquote> Let me point out the perversities.  I am assuming the comment was not simply deliberately false character assassination and that the writer believed what he/she was writing - which if not, would show the industry's cheerleaders in an even worse light than if the assumption is the poster believes what he/she wrote: <ul><li>No expression of sympathy or remorse at my mother's death, whatever the cause.</li></ul><ul><li>Gross and almost humorously silly caricature of my "consulting" (which is as expert witness) and defamatory comments.</li></ul><ul><li>Gross mischaracterization of this blog and my Drexel Univ. healthcare informatics teaching site at <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases">http://www.ischool.drexel.edu/faculty/ssilverstein/cases</a>.</li></ul><ul><li>A mysterious invocation of some unnamed article on paper records at one health system.   I note that N=1 for both the mysterious unnamed study and its subject institution, representing the absolute worst regarding drawing conclusions, especially conclusions that we need to spend hundreds of billions of healthcare dollars on what today is largely bad health IT (see definitions of good and bad health IT at the aforementioned Drexel site).</li></ul><ul><li>An apparent mischaracterization of the "epic" 1999 IOM report "To Err is Human"on errors in medicine (<a href="http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf">http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf</a>).  It's clear that many if not most medical errors have nothing whatsoever to do with documentation, either paper or electronic (I made that point at my Dec. 2010 post "Is health IT the solution to the wrong problem?" at <a href="http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html">http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html</a>).  From that 1999 IOM report's summary:</li></ul><blockquote class="tr_bq">... Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. </blockquote><ul><li> As to "[my] claims that EHRs are [injuring and] killing people", I merely report what others find - that still others deliberately dismiss (e.g., as "anecdotal") - or ignore. Just the latest example is the ECRI Deep Dive study (<a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>).  171 health information technology-related problems voluntarily reported during a nine-week period to the ECRI Institute PSO from just 36 hospitals.  Eight of the incidents reported involved patient harm, and three may have contributed to patient deaths, said the institute.  Other examples appear at HC Renewal.</li></ul> In summary, there is someone out there who reads Bloomberg and who either 1) supports health IT, but lacks empathy, lacks judgment, and lacks scientific and critical thinking skills or 2) is simply a confabulator and liar. Perversity regarding health IT needs sunlight - lots of it. ----------------------- Here's some of that sunlight in a talk program on "Nurse Talk", a nationally syndicated radio show by and for nurses. <blockquote class="tr_bq"><a href="http://nursetalksite.com/">Nurse Talk</a> is heard on the air in major metropolitan areas on both the West and East Coasts, and worldwide on the Internet, and has partnerships with the largest groups of nurses in the country. </blockquote> Listen to the July 3, 2013 program "RNs DeAnn McEwen and Michelle Mahon on Electronic Medical Records" at <a href="http://nursetalksite.com/2013/07/03/rns-deann-mcewen-and-michelle-mahon/">http://nursetalksite.com/2013/07/03/rns-deann-mcewen-and-michelle-mahon/</a>. -- SS

More Perversity on Health IT Risks, and ... EHR Sense from Nurses on "Nurse Talk", a Syndicated Radio Show

As I mentioned on July 2 at this post , in a June 25, 2013 Bloomberg News article " Digital Health Records’ Risks Emerge as Deaths Blam...

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How's this for patient rights? Affinity Medical Center manager: file a safety complaint, and I'll plaster it to your head!

At my June 19, 2013 post "Affinity RNs Call for Halt to Flawed Electronic Medical Records System Scheduled to Go Live Friday" (<a href="http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html">http://hcrenewal.blogspot.com/2013/06/affinity-rns-call-for-halt-to-flawed.html</a>) I noted what appeared to be an imperial hospital leadership recklessly and negligently ignoring their own nurses' concerns about safety of a new EHR system implementation. Now there's this at IndeOnline.com: <blockquote class="tr_bq">"Judge orders Affinity to bargain with union" <a href="http://www.indeonline.com/news/x1808710525/Judge-orders-Affinity-to-bargain-with-union?zc_p=1" target="_blank">(http://www.indeonline.com/news/x1808710525/Judge-orders-Affinity-to-bargain-with-union?zc_p=1</a>) <div class="float_l m5r dateline"></div><div class="float_l m5r dateline">CANTON (OH) — July 2, 2013</div>A judge ruled Affinity Medical Center violated federal labor laws and ordered the hospital to bargain with the registered nurses’ union and reinstate a nurse fired for union activity. Affinity says it will appeal the decision. National Labor Relations Board Administrative Law Judge Arthur Amchan issued a 36-page ruling Monday based on a hearings held April 29 through May 5 in Cleveland. The National Nurses Organizing Committee-Ohio, an affiliate of National Nurses United, filed several labor complaints against Affinity and its parent company, Community Health Systems. The complaints cited the hospital’s refusal to bargain with the union, which was certified last year. ... The judge ordered the hospital to reinstate Ann Wayt, an orthopedic nurse for 23 years, with back pay and restitution of benefit or pension losses, and withdraw efforts to have Wayt’s nursing license pulled by the Ohio State Board of Nursing. Wayt was fired in September and never had been disciplined before that month. “I was confident that the truth would come out,” Wayt said in a statement. “The judge has spoken for me. I want to thank the community, the nurses at Affinity, and the nurses across the country for their support.” The judge also ordered the hospital to stop firing, disciplining or otherwise discriminating against other registered nurses.</blockquote> Mentioned in the article is this: <blockquote class="tr_bq">The judge also ruled that the hospital must end threats and other acts of retaliation against nurses who submit objection forms to the employer documenting assignments they believe are unsafe. The hospital also must stop denying access to the hospital of union representatives ... Two weeks ago, nurses filed an unfair labor practice charge with the NLRB after requesting that the hospital delay a launch of the new electronic health record system, citing inadequate training and short staffing.</blockquote> The nurses began to file objection forms related to the EHR. What really caught my eye was this: <blockquote>... In his ruling, the judge found one Affinity manager violated labor laws by threatening to plaster the objection forms on the forehead of any employee who submitted one. That same manager also began scrutinizing patient charts more closely, stated how much she would enjoy disciplining a prominent union supporter and retaliated against employees by reducing the number of nurses in the intensive-care unit [to make others work harder, patient safety be damned, apparently - ed.], according to the ruling.</blockquote> I dislike stating the obvious, but this manager, a clear bully, is a danger to patient safety and clinician esprit de corps, and needs - at best - sensitivity training, ethics education and perhaps a psychiatric exam. -- SS

How's this for patient rights? Affinity Medical Center manager: file a safety complaint, and I'll plaster it to your head!

At my June 19, 2013 post "Affinity RNs Call for Halt to Flawed Electronic Medical Records System Scheduled to Go Live Friday" ( h...

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