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Candid Nurse EHR Opinions at Facebook Page "Friend a Nurse" Are Not So Friendly

At my Jan. 2010 post "An Honest Physician Survey on EHR's" (<a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html</a>) I wrote: <blockquote class="tr_bq"> I often believe surveys of physicians about EHR's do not present the results candidly, but rather are selective in what is reported - and what is omitted - and generally sugar-coated. </blockquote> I then presented a candid physician survey on EHR's that was not very complimentary of the technology's value to real-world practicing physicians. The following candid, informal nurse's survey about EHR's came to my attention the other day via Google.  The thread is on Facebook in the "Friend a Nurse" group pages and can be read at <a href="https://www.facebook.com/friendanurse/posts/654085127954821">https://www.facebook.com/friendanurse/posts/654085127954821</a>. Apparently the thread got underway after someone posted the question "What do you think of electronic medical record systems? How was it implemented in your facility? Has it helped or hurt patient care? If so, how?" and a link to the June 25, 2013 Bloomberg News article "Digital Health Records’ Risks Emerge as Deaths Blamed on Systems" (<a href="http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html">http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html</a>) that mentioned my mother's experience. <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/AVvXsEgXvDHdnfSrvRyIThkDBvD3NOYfBAcQRbsoDeWEpvaTPF4t8nOiN5-sYtSAzJE5eYlhYR3FDwJoIeF0li8i0UpHhIrcLl8c1dWuRDwoNkhRHFaOS8fVIskBYHwqmgXQAstKtWy1zi6WbyE_/s1600/friend_a_nurse.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXvDHdnfSrvRyIThkDBvD3NOYfBAcQRbsoDeWEpvaTPF4t8nOiN5-sYtSAzJE5eYlhYR3FDwJoIeF0li8i0UpHhIrcLl8c1dWuRDwoNkhRHFaOS8fVIskBYHwqmgXQAstKtWy1zi6WbyE_/s1600/friend_a_nurse.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">The EHR question posed on the "Friend a Nurse" Facebook page at <a href="https://www.facebook.com/friendanurse/posts/654085127954821">https://www.facebook.com/friendanurse/posts/654085127954821</a>.  Click to enlarge, or click Facebook link, which is public as of this writing.</td></tr></tbody></table> I note that I had no knowledge of this, nor do I know the responders.  I did add a link to my Drexel website on health IT difficulties at the end of the thread, however, after I discovered it. Here are the comments from both female and male nurses who belong to this Facebook group.  I redacted the names, however they can be seen at the Facebook page itself at the link above. <blockquote class="tr_bq">------------------------ Big problems when you have unexpected "downtimes". July 15 at 1:10pm · 4 It is an absolute train wreck, I havent seen one record of mine that is not riddled with mistakes. Especially the allergies, they show me taking meds Im allergic too and not taking meds Im actually on.. A true mess!!And now the records are all intertwined. I dont like it at all!! July 15 at 1:10pm It is a nightmare! July 15 at 1:18pm I retired just in time so I don,t have to deal with this fiasco July 15 at 1:19pm via mobile IT SUCKS July 15 at 1:19pm I don't like them; my doctors don't like them; how it will affect patient care is still a 'jury out' matter, but we can guess it will NOT help. July 15 at 1:30pm our Rural Community Healthcare system is just now switching over to this..along with our hospital switching over to a totally new computer system..the 2 systems do not talk to each other..In my personal experience I find that the "computer" world takes us away from Direct Patient Care.(to busy playing "ring around the Rosie" on the computer.. July 15 at 1:40pm I like them, but it is frustrating having "downtime." July 15 at 1:41pm I hear patients stating things like "my doctors don't know who I am because they don't look at me they are glued to the computer". It saddens me patients feel less valued. I've worked in places where they've had paper charts and places computerized. Seems the computers are redundant and I personally prefer paper charts. Chart one assessment not one assessment 4 different places. July 15 at 1:44pm via mobile It looks to me like physicians are cutting and pasting old histories and physicals, complete with the errors. Doctors in a local ER charted complete physicals on me when they did not get closer that 5 feet away. The records are difficult to read, difficult to find information, and not number in chronological order. July 15 at 1:47pm I dislike it . Besides the down time find it very impersonal . I don't feel as if I am giving my full attention to my pt, nor do I feel my PCP is hearing what I ' m saying . They are to busy putting in info on the computer . As for the down time you then have to work late to put in the info gathered while the system is down. July 15 at 1:47pm via mobile Electronic charting takes the skilled nurse away from the patient and puts them in front of a computer. Its NOT best for the patient or staff - the people who build the programs have not been at the bedside for eons....so the programs are time consuming, redundant, and inefficient. July 15 at 1:51pm I like EMR very much. The system we use is Allscrips, it is not perfect, but the benefits outweigh the problems. For example, I find most issues are human errors, such as poor spelling, incorrect entry in the proper records, entering incorrect doses. I love the fact that I can actually read and do not spend time deciphering not only the doctors writings, but my coworkers. I like having all the records in one place. There are issues for sure, but some of the issues is from companies who chooses to,purchase low quality EMR packages with poor support. The systems also need to be more standardized and "speak" to each other better. And folks at the end of the day it is your license at risk, do the things you were trained to do in nursing school, the 5 Rs remember those? July 15 at 1:53pm via mobile we are starting on it, let you know July 15 at 1:53pm In general I dislike it. If it 'goes 'down', you end up being unable to obtain vital information. With the federal system we did have both the computer records and the paper records. This was fine with inpatient informaton. I dislike it when my computer crashes and I can't get anyone to come look at it or fix it. They had a message line which we never had a call back from. I'd have a whole dept be down and non one to repair it. It's very frustrating on a triage line. This made scheduling appts impossible. Lack of vital information could be lethal to critical care patients...Far less pro's than con's. It's just a bad decision all together.. July 15 at 2:01pm if THE GOVERNMENT CAN GET INTO YOUR RECOREDS SO CAN ANYONE they can hack anywhere now a days and it is scary/// July 15 at 2:05pm anyone over 25 most likely hates it July 15 at 2:09pm I quit 2011...did CPOE no issue but more more is coming seems like q mo. or so keeps adding dig. stuff...hosp. worked with kept changing sys...used to ask myself why fix when not broken also once you got use to it thats when they change...they shld hire more nurses aux. ppl...do not know what to do with their money. Stressout...no more nursing for me . New grads savvy but this boomer did it for 38 yr. Enough is enough!! July 15 at 2:14pm via mobile Takes time away from pt care too much:-) July 15 at 2:34pm I work in a hospital and I hate it! I feel like I spend more time looking at the computer than at the patient. We have to document the same thing in multiple areas...big waste of time! Also our ER and OR's use a different program and we are not able to access this information when a patient is admitted to the floor. We also use Physician OE and the system we have it is hard to get back to look at an already viewed order. I feel this is dangerous and orders are missed all the time. It is just a ticking time bomb before someone is going to get hurt! July 15 at 2:35pm The med was there then disappeared.....software is only as good as the person using it. A PERSON DELETED THE MED! Pharmacies, nurses, and MDs use the computer did it as an excuse. Never understood how I corrected MARs every month and they were worse the next month...the computer did not do it alone. I dislike the MD playing on the computer and half listening to me. July 15 at 2:38pm Recently I have had md's not put a patient back on home meds because he/she could put them in correctly. I had to call the doctor on call at night to get these medications in place. The pt was also missing vital medications they needed for their diagnosis. I feel like in some cases emr is not safe. There however some cases where emr is helpful. July 15 at 2:43pm it will get better with time... July 15 at 2:45pm I worked at a VA until I retired, and I loved it. It is so much easier. Lets face it, anyone that wants your information is going to get it anyway. July 15 at 2:57pm I have used EMR in hospitals, home health and hospice for the past 20 yrs. When used within the same corporation w many offices it is very efficient. In that state corrections dept it was very helpful w continuity of care. the medical record follows the inmate to what ever unit they may transfer to. HIPPA is even more important with the EMR systems. July 15 at 3:14pm We just changed our system to a new one. It took a large group of staff over 18 months to develop our documentation system. The nursing portion is great. The med ordering part is difficult to use. The docs are all complaining about the system. They want to continue writing their orders. July 15 at 3:17pm via mobile We have had epic for over 5 yrs it is a great system.just wish computers worked better always having to shut down and reboot. Has saved us a few times with preventing med errors.covenant healthcare did a great thing when they got this system July 15 at 3:18pm via mobile I think it is an injustice to the Patients We are more than a computer file July 15 at 3:24pm It helps with a history when a patient is unable to provide July 15 at 3:29pm via mobile Plus it may have contacts address patients previous baseline behavior I'm a psych nurse so we utilize this type of system July 15 at 3:30pm via mobile Takes time away from patients, goes down too often, difficult when hospitals change systems. There should be a universal system, so info can be shared. July 15 at 3:40pm via mobile EPIC is terrible when it comes to outpatient chemotherapy and research. It is cumbersome and takes so much time away from patients. EMR's are here to stay and I think it's a great thing, for the most part, but sheesh make it easy on the provider, will ya? July 15 at 4:07pm we fear medication errors because some doctors start up home meds that are no longer correct. getting used to it is the hardest. the younger nurses are much more efficient and comfortable with it. July 15 at 4:16pm via mobile I agree with Noelle, it took focus away from the patient because it was cumbersome and repetitious, and because of the environment we had to keep the people moving through recovery....so it was dreadful. I was happy to retire and leave it to others to deal with. July 15 at 4:30pm I've worked with electronic T-system, Promed blue, Meditech, etc and all have their advantages and disadvantages, but the major disadvantage is that we don't do patient care anymore...we do computer care...I could also go on and talk about the fact we also don't get to spend as much time with our patients because of patient ratios and patient loads and the computer charting we have to get back to... July 15 at 4:32pm via mobile you are right on target here.....I retired because of this, there is very little patient care, it is indeed computer care ! July 15 at 5:00pm · 1 Nursing Informatics Institute How has nursing been involved in the planning and implementation of these systems? Feel free to share your experiences, it is very interesting to hear about your practice. July 15 at 5:15pm I love the electronic records. I do not love all the different styles ect programs out there. So many glitches. Patient's need to be proactive and as involved in their healthcare and that of their loved ones as possible. That means bringing ALL of your med bottles with you to each and every doc visit you go to. I don't care how many times or how many diff docs you see in a week, ALWAYS take ALL of your meds in the ORIGINAL bottles. Where I work there is 100+ doc's in this group, each doc office has access to same record I see when the patient comes to us. Each doc office can ad or make changes to the chart accordingly, so if you don't bring your meds with you to each visit and doc A changed a med and made the notation in the chart we see it but can't verify it. ALWAYS keep an updated list of meds in your wallet/purse for those emergencies when you don't have your meds. Include on this list, your surgical history, your medical history(Diabetes, hypertension ect ect ect), who your PCP is and a #, allergies, blood type, your wishes as far as DNR ...... It will save your loved ones precious time and allow them to focus on you, and not that new pill doc so & so started you on for her diabetes, I think. Anyway, with so many spoons in our medical records here, I catch mistakes all the time where a med has been deleted/added ... By another office. Usually because the patient did not bring the meds, or the patient is a poor historian of their own medical history and the family has no clue. Be proactive people, don't trust us to do it all. Get the dam electronic records fixed so they make sense, and stops all this confusion ..... Why so many different types and formats are needed is beyond me. July 15 at 6:01pm  not the systems that cause the problems, staffers that program only what they think is important when making diagnosis. July 15 at 6:37pm Love it - but when they go down..... July 15 at 6:39pm Mostly like it. Rather type than write. Does take more time than paper note, but overall I like it. I agree when I see patients & when I or my family is the patient, MD hardly looks at you; too busy inputting data. July 15 at 6:52pm via mobile No Comment. July 15 at 6:52pm  it is a huge improvement! and a potential life saver - no more figuring out what that handwriting is saying. July 15 at 7:13pm I generally like EMRs but some programs are so damned redundant (charting the same IV start every time you admin an IV med?) and/or lacking in -- how do I put it? -- intuitiveness. Sometimes I really wonder if anyone actually working with patients was involved in the design or implementation of some of the programs we use. July 15 at 7:31pm  Has it's good points and bad points. But I spend more time on the computer, then at the bedside. July 15 at 7:55pm I think computer charting has went way overboard and takes the nurse away from the bedside. How does family view nurses that are at the desk on the computer all the time? July 15 at 8:27pm it is disconcerting to the patient and or family if the health care provider starts firing questions and then spends the entire visit looking through the chart instead of listening to the patient's effort to provide a history of symptoms. No eye contact diminishes the interaction significantly! July 15 at 9:15pm for some things they are O.K. but everything no. Maybe scanned for some things. Now I have not thought out a plan for which, maybe someone with more time than I have could do a better job. July 15 at 11:36pm Haven't seen it work too well. July 16 at 1:04am It takes a lot of patience to get it implemented into a facility. The inservices that we have had are few and basically it is a learn as you go. When everyone is finally sure of how to do it, it will be OK but is taking a long time for all of it to be taught to us July 16 at 7:31am mountains of paper, I mean mountains... July 16 at 10:22am as nurses, we are buried in paperwork... so are the docs... looking for a way out, we all THINK the digital answer with EMR is THE way... BUT nobody has proved it is superior, or really saves time or workload... and now the GOVERNMENT is pushing us into a costly and complex system July 16 at 11:14am ------------------------ </blockquote> I think the comments (largely negative with several "positive but with significant concerns") more accurately reflect EHR reality "in the trenches" than the marketing propaganda emanating from government, the health IT manufacturers, the academic pundits, and other "see no evil, hear no evil, speak no evil" triple-simian hyper-enthusiasts. <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/AVvXsEgGzWbqR5GNZVwQ_cRd4yYKCeW30XOOoa8b3qLx99vRowJpoZ_ynwDsgLV3Ob3ldKrsJVVt86Lzy5C_Q7FTEQcFYTqC4TURmBrcySb5fZG84fS0XsA3MOQBrjCoRkWzMbVgOhJwYFmF_caY/s1600/Hear-No-Evil-See-No-Evil-Speak-No-Evil.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGzWbqR5GNZVwQ_cRd4yYKCeW30XOOoa8b3qLx99vRowJpoZ_ynwDsgLV3Ob3ldKrsJVVt86Lzy5C_Q7FTEQcFYTqC4TURmBrcySb5fZG84fS0XsA3MOQBrjCoRkWzMbVgOhJwYFmF_caY/s320/Hear-No-Evil-See-No-Evil-Speak-No-Evil.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">On EHRs:  see no evil, hear no evil, speak no evil</td></tr></tbody></table> Of course, the hyper-enthusiasts will call these opinions "anecdotal", but as one investigative reporter who does work in the EHR sector opined when sent the Facebook page:   "That's a lot of anecdotes." -- SS

Candid Nurse EHR Opinions at Facebook Page "Friend a Nurse" Are Not So Friendly

At my Jan. 2010 post "An Honest Physician Survey on EHR's" ( http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-...

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Why Do People Think US Health Care is Corrupt? - The Examples of Amgen, Mallinckrodt Settling Charges of Giving Kickbacks to Doctors to Induce them to Prescribe Their Products, While No Individual Suffers Negative Consequences

We recently <a href="http://hcrenewal.blogspot.com/2013/07/43-believe-that-us-health-care-corrupt.html">posted </a>a discussion of the results of <a href="http://www.transparency.org/gcb2013">Transparency International's 2013 corruption barometer</a>, focusing on the US results.  43% of survey respondents thought US health care is corrupt.  Our coverage, apparently the only substantial discussion of the US results published in the US, got star ranking for a while <a href="http://www.reddit.com/r/politics/comments/1iw48a/43_believe_that_us_health_care_is_corrupt_64_that/">on Reddit</a>.  But many anonymous commentators dismissed the survey results as coming from a naive public who does not understand health care economics. I submit that one can recognize corruption without a degree in economics.  In fact, as we discussed in the initial post, there is a lot of evidence for the prevalence of health care corruption in the US, other developed countries, and globally.  It is just that such evidence rarely gets discussed in public (the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, as we say on this blog), probably because doing so might make those who are profiting from the corruption uncomfortable. So today let me summarize just the latest evidence about US health care corruption, as defined by Transparency International as the abuse of entrusted power for private gain.  (Note that the Transparency International definition of corruption, which is an ethical, not necessarily a legal definition, at least in most jurisdictions.) Amgen An <a href="http://www.toacorn.com/news/2013-07-25/Front_Page/Amgen_pays_15_million_in_whistleblower_lawsuit.html">article</a> in the Thousand Oaks [CA] Acorn described the legal settlement, <blockquote class="tr_bq">Amgen Inc. paid the United States more than $15 million this month as part of a settlement agreement to resolve allegations that the biopharmaceutical company used financial kickbacks to persuade doctors to prescribe the cancer drug Xgeva to their patients. The settlement resolves a qui tam, or 'whistleblower,' lawsuit filed Jan. 20, 2012, in federal court by William Davis and Spencer Miller—two Amgen employees who work at the company’s Thousand Oaks headquarters. Davis, sales planning director for Amgen’s oncology business unit, and Miller, a senior marketing manager at the company, alleged their employer violated both the Medicare Anti- Kickback Statute and False Claims Act—two laws that aim to prevent Medicare fraud and abuse.</blockquote> The allegations were that Amgen used a somewhat complex and deceptive strategy to pay doctors who prescribed its drug, using a survey about practice patterns as a cover story, <blockquote class="tr_bq">According to the U.S. attorney’s office, Amgen used what the company called 'Deep Dive' contracts—or data purchase agreements—in an effort to boost sales of Xgeva, which was approved by the FDA in late 2010 for use by certain cancer patients undergoing chemotherapy. The drug is most commonly prescribed to prevent bone fractures in patients who have been diagnosed with a certain type of tumor after it has spread to the bones. Under Amgen’s original Deep Dive program, the company paid doctors to fill out an Internet-based survey, which asked how they were treating patients with bone cancer and which drugs they used. 'That’s not illegal to do,' said Abraham Meltzer, assistant U.S. attorney in the Los Angeles civil fraud section. 'A lot of pharmaceutical companies purchase data legitimately on how various conditions are treated.' But Amgen altered its Deep Dive program, Meltzer said, by increasing the amount of money it offered to pay the doctors who specifically prescribed Xgeva to their patients.</blockquote> Also, <blockquote class="tr_bq"> The U.S. attorney’s office also alleged that Amgen paid oncologists and urologists to participate in market research surveys, audience response sessions and advisory programs that publicized the benefits of Xgeva.</blockquote> As is typical in such cases, the settlement did not require any contrition on Amgen's part.  Instead, <blockquote class="tr_bq">In a prepared statement emailed to the Thousand Oaks Acorn on Tuesday, Amgen denied all allegations of wrongful conduct. 'Amgen settled this matter to avoid the delay, uncertainty, inconvenience and expense of protracted litigation,' the statement read.</blockquote> As is also typical, there seemed to be no negative consequences for the human beings who must have engineered the "Deep Dive" contracts and the payments to the oncologists and urologists.  Nor was there any overt consideration of Amgen's sketchy recent ethical record, as described by the Acorn, <blockquote class="tr_bq">This month’s settlement is not the first time the biopharmaceutical giant has been held to answer for kickback allegations or false claims charges. In December 2012, Amgen pleaded guilty to illegally selling the drug Aranesp, an anti-anemia drug, for uses or doses not approved by the FDA, according to the U.S. Department of Justice. As part of the false claims case, which was also brought on by a whistleblower lawsuit, Amgen agreed to pay a $612-million civil settlement to the U.S. and individual states, as well as $150 million in criminal penalties. Then in April, the Thousand Oaks-based company paid the U.S. another $24.9 million to settle whistleblower allegations that it gave financial kickbacks to long-term care pharmacy providers in exchange for switching Medicare and Medicaid benefi- ciaries from a competing drug to Aranesp, a DOJ press release states.</blockquote> We <a href="http://hcrenewal.blogspot.com/2013/05/amgen-ceos-prosper-despite-or-because.html">discussed</a> the guilty plea in the cases of Aranesp misbranding and alleged kickbacks to pharmacists.  Also, in 2013, we noted that Amgen settled allegations that it overpriced its products sold to government health programs in 36 states.  We also noted that despite, or perhaps because of all this misbehavior, the current CEO of Amgen received over $13 million in compensation in 2012, while his predecessor walked away with over $9 million that year. Mallinckrodt A small news item from the Associated Press, <a href="http://www.nanaimodailynews.com/business/st-louis-drug-maker-mallinckrodt-to-pay-feds-3-5m-to-settle-lawsuit-over-doctor-kickbacks-1.543318">via</a> the Nanaimo (MO) Daily News, outlined this legal settlement, <blockquote class="tr_bq">A St. Louis-based drug maker will pay $3.5 million to settle allegations that it paid doctors to prescribe 'outdated, third rate' antidepressants and sleep aids, the U.S. attorney's office in San Francisco announced.</blockquote> In particular, <blockquote class="tr_bq">The lawsuit alleged the company targeted doctors who prescribed the type of antidepressants and sleep pills Mallinkrodt manufactured.</blockquote> Again, the company was allowed to settle without admitting anything. <blockquote class="tr_bq">'While we deny the allegations in this matter, we are glad they are resolved,' company spokeswoman Erica Abbett said in a statement. </blockquote> Again, although human beings would have had to engineer any payments to the doctors to induce them to prescribe, no human beings suffered any consequences as a result of this settlement. Mallinckrodt, a storied corporate name, had been acquired by Covidien, and then was spun off again as a separate company in June, 2013 (look <a href="http://www.stltoday.com/business/local/mallinckrodt-pharmaceuticals-declares-its-independence-again/article_24973adf-37ef-5d86-b81b-a441edd4289d.html">here</a>).  It had been acquired in 2000 by Tyco International, which later spun off its health care operations as Covidien.   According to its <a href="http://services.corporate-ir.net/SEC/Document.Service?id=P3VybD1hSFIwY0RvdkwyRndhUzUwWlc1cmQybDZZWEprTG1OdmJTOWtiM2R1Ykc5aFpDNXdhSEEvWVdOMGFXOXVQVkJFUmlacGNHRm5aVDA0TmpZNU16QTNKbk4xWW5OcFpEMDFOdz09JnR5cGU9MiZmbj1Db3ZpZGllbnBsY19ERUYxNEFfMjAxMzAxMjQucGRm">2013 proxy statement</a>, Covidien's CEO received over $10 million in total compensation in 2012. [Note that Tyco was the subject of one of the major scandal stories of the early 21st century.  In 2005, at a time when law enforcement authorities were still pursuing actions against elite corporate executives,  its former CEO and CFO were convicted of stealing millions from it (see USAToday <a href="http://usatoday30.usatoday.com/money/industries/manufacturing/2005-06-17-tyco-timeline_x.htm">summary</a>)]. Summary - Why do People Think US Health Care is Corrupt?   Again, the Transparency International definition of corruption is abuse of entrusted power for private gain.  I would argue that pharmaceutical companies are entrusted with the power to honestly sell drugs whose benefits to patients outweigh their harms.  I would further argue that paying physicians, who are entrusted with providing the best possible care to each individual patient, to prescribe drugs which may not be the best treatment for individual patients is an abuse of both the company's and the physicians' entrusted power.  Further, such payments provide private gain to the physicians.  They also may increase revenues for the company who makes these payments, and very likely these increased revenues lead to better compensation for those in the company who authorized, directed or directly provided the payments, that is to private gain for these corporate insiders.  Thus it seems that kickbacks to physicians to prescribe drugs is a form of corruption. While both cases above were settled without admissions of guilt, such settlements do not refute the contentions that kickbacks were given.  Why would the law enforcement officials have brought the cases in the absence of evidence, and why would the companies have settled if the cases were completely baseless?  So I would argue that these settlements provide evidence, although not legal proof, that kickbacks were given.  People with far more legal knowledge than I possess have remarked on the absurdity of settling cases of alleged wrongdoing without any acknowledgement or statement of the facts (see posts <a href="http://hcrenewal.blogspot.com/2009/09/biovail-settles-and-judge-explains-why.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/11/will-citigroup-ruling-challenge-health.html">here</a>). We have posted lots of instances of conflicts of interest affecting health care, many of which likely involved payments providing private gain that raised the risk of abuse of entrusted power.  We have also discussed many instances of <a href="http://hcrenewal.blogspot.com/search/label/crime">crime</a>, <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a>, <a href="http://hcrenewal.blogspot.com/search/label/bribery">bribery</a>, <a href="http://hcrenewal.blogspot.com/search/label/fraud">fraud</a> other kinds of <a href="http://hcrenewal.blogspot.com/search/label/health%20care%20corruption">health care corruption</a>. So were the people who answered the Transparency International survey naive and foolish about health care corruption?  Or did they have reasonable beliefs about a topic that the powers that be really do not want to discuss?

Why Do People Think US Health Care is Corrupt? - The Examples of Amgen, Mallinckrodt Settling Charges of Giving Kickbacks to Doctors to Induce them to Prescribe Their Products, While No Individual Suffers Negative Consequences

We recently posted a discussion of the results of Transparency International's 2013 corruption barometer , focusing on the US results. ...

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EHR importance vastly oversold? Community health center battles for electronic patients' records - but patient care goes on anyway

There are two lessons from the Milwaukee Journal Sentinel story below. 1) Beware outsourcing the ownership of your hospital or clinic's medical records. 2) The value of EHRs has been massively and repeatedly exaggerated.  Milwaukee Health Services have been operating without access to electronic patient charts for almost a month, yet there are no reports of massive casualties.  There are numerous reports on this blog of EHR system downtimes lasting weeks, loss and sabotage of electronic records, and other mishaps, yet patient care is claimed to have not been compromised.  Perhaps those who make such claims need to be taken at face value. It follows that expenditures of hundreds of billions of dollars for EHR systems is simply unnecessary and the technology's importance vastly oversold. Excerpts are below; read the full story at the hyperlink. -- SS <blockquote class="tr_bq"><a href="http://www.jsonline.com/business/community-health-center-battles-for-patients-records-b9957634z1-216291331.html">Community health center battles for patients' records</a></blockquote><blockquote class="tr_bq">By Guy Boulton of the Journal Sentinel July 20, 2013 Doctors at Milwaukee Health Services have not had access to the medical records of 40,000 patients since June 30, when an Atlanta company cut off the community health center's access to its electronic medical records after their contract ended. Milwaukee Health Services sued Business Computer Applications Inc., the Atlanta company, last week in federal court and is seeking a court order to restore access to patients' medical records. The records include patients' medications, problem lists, allergies, immunization records, treatment plans and other clinical information. The doctors and other health care providers at the community health center can get key information, such as medication lists and lab results, from pharmacies and other sources, said Tito Izard, a physician and chief executive of Milwaukee Health Services. But access to patients' medical records is "obviously important," Izard said. Milwaukee Health Services sought a court order last week to require Business Computer Applications, known as BCA, to restore access to the medical records, contending that the safety of patients was at serious risk. The court denied the request for a temporary restraining order. ... Milwaukee Health Services, which provides care to about 30,000 people a year and has medical records for about 40,000 people, entered into a five-year agreement with BCA on July 1, 2008. The community health center contends that BCA's system was not fully functional after paying the company $3.1 million over the past five years. "There was a never-ending request for more money to fix the system," Izard said. ... In its complaint, Milwaukee Health Services alleges BCA violated the Wisconsin law that requires health care records to be released upon the request of a health care provider in the care of patients. The community health center plans to seek a court order in the next several weeks that requires BCA to provide access to the medical records of its patients.</blockquote> More here:  <a href="http://www.courthousenews.com/2013/07/17/59431.htm">http://www.courthousenews.com/2013/07/17/59431.htm</a>.  Looks like the patients affected are predominantly poor and/or minorities: <blockquote class="tr_bq">... A computer firm is "jeopardizing the health and safety of about 40,000 people" - many of them uninsured or underinsured - by freezing a hospital out of access to its own medical records because of a billing dispute, the hospital claims in court ...  Milwaukee Health Services Inc. "specializ(es) in the care of underserved populations," the hospital says in its complaint. It says it "serves everyone regardless of income or third party coverage." </blockquote> -- SS

EHR importance vastly oversold? Community health center battles for electronic patients' records - but patient care goes on anyway

There are two lessons from the Milwaukee Journal Sentinel story below. 1) Beware outsourcing the ownership of your hospital or clinic's ...

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Electronic siloing: An unintended consequence of the electronic health record - Cleveland Clinic Journal of Medicine

EHR systems have largely been designed by those of a manufacturing, mercantile, and management computing background, largely due to abdication of responsibility and acquiescence by medical professionals, and political impotence of organized medicine and medical informatics organizations. The results were predictable - a toxic effect on healthcare.  One such toxic effect is an impairment of essential communications between caregiving personnel - exactly the opposite effect the hundreds of billions of dollars spent on today's health IT was intended to improve. <blockquote class="tr_bq">From the Cleveland Clinic Journal of Medicine: <a href="http://www.ccjm.org/content/80/7/406.full">Electronic siloing: An unintended consequence of the electronic health record</a> July 2013</blockquote><blockquote>JAMES K. STOLLER, MD, MS Chair, Education Institute; Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic; Jean Wall Bennett Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH For all the purported benefits of the electronic health record (EHR), an unintended adverse effect is “electronic siloing.” I define electronic siloing as the isolating effect of the EHR on clinical workflow that drives caregivers to work in silos, ie, alone at their workstations, thereby discouraging spontaneous interaction. To the extent that increasing evidence supports the importance of interaction among clinical colleagues and of teamwork to optimize clinical outcomes, electronic siloing threatens optimal practice and quality.</blockquote> Not only does it "threaten" optimal quality, it causes that quality to deteriorate to the point where a recent volunteer study at 36 hospitals by the renowned ECRI Institute (<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>) found more than 170 health IT-related mishaps in a mere 9 weeks, 8 of those incidents resulting in patient harm and 3 possibly contributory towards patient death. <blockquote class="tr_bq">... THE EHR BRINGS CHANGES, GOOD AND BAD [the latter especially from bad health IT - ed.] The EHR represents a major change in health care, with reported benefits that include standardized ordering, reduced medical errors, embedded protocols for guideline-based care, data access to analyze clinical practice patterns and outcomes, and enhanced communication among colleagues who are geographically separated (eg, virtual consults). On the basis of these benefits and the federal Medicare and Medicaid financial incentives associated with “meaningful use,” the EHR is being increasingly adopted.</blockquote> The literature supporting those benefits is scarce, of poor quality, and refuted by other literature by credible authors - not the optimal environment to justify spending hundreds of billions of dollars (e.g., see <a href="http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html">http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html</a>). <blockquote class="tr_bq"> Yet for all these benefits and the promise that technology can enhance interaction among health care providers, unintended risks of the EHR paradoxically threaten optimal clinical care.6Recognized risks include the threat to care should the EHR fail, the time and inefficiency costs of typing and multiple log-ons, and the perpetuation of errors in the medical record caused by the cutting and pasting of clinical notes.</blockquote> To name just a few, all covered on this blog in various posts. <blockquote class="tr_bq"> ... Niazkhani et al noted that computerized ordering can change communication channels and collaboration mechanisms. More specifically, they point out that these systems can “replace interpersonal contacts that may result in fewer opportunities for team-wide negotiations."</blockquote> This is, in fact, obvious to any practicing physician or nurse and requires no academic "proof." <blockquote class="tr_bq"> Similarly, Ash et al cited the unintended consequences of patient care information systems, especially increased overreliance on the system to communicate, which can undermine direct communication between healthcare providers ... Taken together, these observations suggest that the EHR and computerized order entry in particular can disrupt interaction between physicians and other health care providers, such as nurses and pharmacists.</blockquote> Similarly, that this needs to be stated in 2013 is akin to stating that it's a good idea to use sterile technique in surgery. <blockquote class="tr_bq"> ...  the EHR can inadvertently lessen spontaneous interaction between physicians as they care for outpatients. I have proposed the term electronic siloing to reflect the isolating impact of the EHR on clinical workflow that drives caregivers to work alone at their workstations, thereby discouraging spontaneous interaction between colleagues (eg, between primary care physicians and subspecialists, and between subspecialists in different disciplines). Because spontaneous face-to-face encounters and conversations among clinicians can encourage clinical insights that benefit patient care, electronic siloing can undermine optimal care. My thesis here is that the EHR predisposes to electronic siloing and that the solution is to first recognize and then to design care to prevent this effect.</blockquote> The solution is first to force the industry and its pundits to admit the problem is poor design and hyper-enthusiasm that resulted in a premature national program for health IT diffusion, and abandon claims that clinicians are "Luddites" (see "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>). <blockquote class="tr_bq">Defenders of the EHR will point out that the EHR does not preclude such face-to-face encounters.</blockquote> "Defenders of the EHR" will frequently default to fictitious and often ad hominem "blame the user" canards, since their scientific rationale for the proliferation of today's very poor systems is very weak. <blockquote class="tr_bq"> While technically this is correct, it is also equally true that such encounters are less likely because they no longer flow naturally from the workflow of writing a note side-by-side with colleagues with the films displayed nearby. Pressured for time, clinicians learn efficiency of motion and are simply less likely to leave their workstations to seek another colleague who, in turn, may be tethered to a workstation and absorbed in keyboarding and monitor-watching. The net effect is that such spontaneous face-to-face encounters are clearly less common in the EHR era.</blockquote> Again, this thinking will be countered by the hyper-enthusiasts by blaming users.  My response is that good health IT never depends on users to compensate for poor design or implementation, and there's nothing else to debate on that point. <blockquote class="tr_bq">... So, given the many clear benefits of the EHR and its current wave of adoption in health care, how can we maximize the benefits of the EHR while minimizing the adverse effects of electronic siloing?</blockquote> Reasonable suggestions follow; see the article at the link above.  The problem is that the reasonable suggestions are being proffered in an unreasonable, industry-dominated environment. The first step is political action and activism by clinicians to take charge of the clinical information technology playing field.  Until and unless that occurs, even thoughtful articles from Cleveland Clinic, Harvard, Yale etc. will simply be shelved. -- SS

Electronic siloing: An unintended consequence of the electronic health record - Cleveland Clinic Journal of Medicine

EHR systems have largely been designed by those of a manufacturing, mercantile, and management computing background, largely due to abdicati...

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Pharmaceutical Industry "'Mobilised' an Army of Patient Groups to Lobby Against" Improving Clinical Research Integrity

I had guessed that this sort of thing was going on all the time, but being kept very well hidden.  Now we have some more evidence. An<a href="http://www.guardian.co.uk/business/2013/jul/21/big-pharma-secret-drugs-trials"> article</a> in yesterdays Guardian showed how the pharmaceutical industry is using pet patient advocacy groups in a public relations campaign to defeat calls for for measures against <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression</a> and <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> of clinical research. In summary, <blockquote class="tr_bq">The pharmaceutical industry has 'mobilised' an army of patient groups to lobby against plans to force companies to publish secret documents on drugs<a href="http://www.guardian.co.uk/science/drugs" title="More from guardian.co.uk on Drugs"></a> trials.</blockquote> More specifically, <blockquote class="tr_bq">The strategy was drawn up by two large trade groups, the <a href="http://hcrenewal.blogspot.com/search/label/PhRMA">Pharmaceutical Research and Manufacturers of America (PhRMA)</a> and the European Federation of Pharmaceutical Industries and Associations (EFPIA), and outlined in a memo to senior industry figures this month, according to an email seen by the Guardian.  The memo, from Richard Bergström, director general of EFPIA, went to directors and legal counsel at <a href="http://hcrenewal.blogspot.com/search/label/Roche">Roche</a>, <a href="http://hcrenewal.blogspot.com/search/label/Merck">Merck</a>, <a href="http://hcrenewal.blogspot.com/search/label/Pfizer">Pfizer</a>, <a href="http://hcrenewal.blogspot.com/search/label/GlaxoSmithKline">GSK</a>, <a href="http://hcrenewal.blogspot.com/search/label/AstraZeneca">AstraZeneca</a>, <a href="http://hcrenewal.blogspot.com/search/label/Eli%20Lilly">Eli Lilly</a>, <a href="http://hcrenewal.blogspot.com/search/label/Novartis">Novartis</a> and many smaller companies. It was leaked by a drugs company employee. The email describes a four-pronged campaign that starts with 'mobilising patient groups to express concern about the risk to public health by non-scientific re-use of data'. Translated, that means patient groups go into bat for the industry by raising fears that if full results from drug trials are published, the information might be misinterpreted and cause a health scare. The lobbying is targeted at Europe where the European Medicines Agency (EMA) wants to publish all of the clinical study reports that companies have filed, and where negotiations around the clinical trials directive could force drug companies to publish all clinical trial results in a public database.</blockquote> The argument for continuing to allow clinical trials to be suppressed was to be, <blockquote class="tr_bq">The patient groups focus on the concern that if companies release all of their clinical trials data, the information might be misconstrued, or intentionally cherry-picked, and spark damaging health scares around certain drugs or vaccines.</blockquote> The Guardian story did not disclose which patient groups were cooperating with this effort. By the way, the other parts of this strategy involved using scientific associations and academics to push the pharmaceutical companies' agenda, <blockquote class="tr_bq"> Two other strands of the campaign include discussions with scientific associations about the risks of data sharing, and work with other businesses that are concerned about the release of trade secrets and confidential data. The final strand calls, in the long term, for a network of academics across Europe that can be called on to correct false interpretations of the data. </blockquote>Several of the large multinational drug companies contacted by the Guardian issued the usual non-denial denials <blockquote class="tr_bq">In response to queries from the Guardian, GSK said: 'This is not something we are doing. One of the reasons we're involved in this is we want more companies to move towards greater transparency. I don't think it's for us to be mobilising patient groups to campaign on a negative level.' A Roche spokesperson said the company consulted patient groups to understand their concerns about clinical trials, but 'to our knowledge Roche has not been involved in any EFPIA's potential activity in mobilising patient groups to express concern about the risk to public health by non-scientific re-use of data'. A Lilly spokesman said: 'Lilly is committed to working with Europe-based patient advocacy organisations for the benefit of patients in a way that is true to the EFPIA code of practice and Lilly's integrity in business policy.'</blockquote> Summary We have long discussed and decried how vested interests, chiefly health care corporations with services and products to sell, have<a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research"> manipulated clinical research</a> to make their wares look better, and <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed research </a>whose results, even if manipulated, could not be made sufficiently favorable. This has resulted in making drugs and devices look more efficacious and/or less hazardous than they really are.  See <a href="http://hcrenewal.blogspot.com/2013/06/a-call-to-restore-integrity-of-clinical.html">this post</a> for our latest discussion, and information on the latest effort to counter suppression and manipulation of clinical research. It is not surprising that pharmaceutical companies do not want to have to publish every clinical trial they sponsor, or expose their manipulations of these trials.  Instead, the Guardian article suggests that companies and their trade associations, including the US based pharmaceutical trade association, and several large US companies, and well as large companies based elsewhere, are using a third-party public relations strategy.  Wendell Potter's muckraking book on the US commercial health care insurance industry, Deadly Spin, revealed how similar strategies were used by US based health insurance companies to defeat the Clinton administration's attempt at health care reform, and other measures targeted to make the US commercial health care insurance system more equitable and ethical  (see post <a href="http://hcrenewal.blogspot.com/2011/02/health-care-corporate-disinformation.html">here</a>).  Third party strategies are fundamentally deceptive.    The current alleged use of the third party strategies by pharmaceutical companies to support ongoing suppression and manipulation of clinical research is more than just deceptive.  It is corrupt. Patient advocacy groups are usually believed to represent patients' interests.  For such groups to support a public relations campaign that could allow ongoing harm of patients (by suppressing and manipulating evidence to prevent it from being used to forestall excess use of ineffective, dangerous drugs) is abuse of their entrusted power.  To do it for money, money used to support these groups, or help underwrite generous compensation for their executives, fits the definition of corruption used by Transparency International - abuse of entrusted power for private gain. Note that the Guardian provided this viewpoint, <blockquote class="tr_bq">Tim Reed, of Health Action International, a group that has previously exposed the pharmaceutical industry's financial links with patient groups, said: 'It's incredibly ironic that this is a transparency initiative and we've now got clear indications that the pharmaceutical industry is ready to use patient organisations to fight their corner. 'It underlines the fact that patient groups who are in the pay of the pharmaceutical industry will go into battle for them. There's a hidden agenda here. The patient groups will say they think it's a great idea to keep clinical trials data secret. Why would they do that? They would do that because they are fronts for the pharmaceutical industry. 'Patient groups get traction because they are assumed to represent the voice of the suffering. But industry uses them to say we're not going to get innovative medicines if the industry is deterred from investing by having to be transparent about their clinical trials,' he added.</blockquote> We have previously noted isolated examples of evidence that particular US based <a href="http://hcrenewal.blogspot.com/search/label/patient%20advocacy%20groups">patient advocacy groups</a> were being supported by commercial firms presumably to aid their marketing.  We have also found examples of conflicts of interest affecting<a href="http://hcrenewal.blogspot.com/search/label/medical%20societies"> medical societies</a>, and <a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest">many affecting</a> non-profit hospitals and academic medical institutions, and<a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest"> their staff and faculty</a>.  I begin to wonder if most health care non-profit organizations in the US, and now it appears maybe in UK and in Europe, have been paid off to support marketing and/or public relations interests of health care corporations. This latest example suggests that health care worldwide has become deeply corrupt, even more corrupt than <a href="http://hcrenewal.blogspot.com/search/label/Transparency%20International">Transparency International</a>'s <a href="http://www.transparency.org/whatwedo/pub/global_corruption_report_2006_corruption_and_health">Global Report on health care corruption in 2006</a>, or the those responding to Transparency International's <a href="http://hcrenewal.blogspot.com/2013/07/43-believe-that-us-health-care-corrupt.html">global corruption survey in 2013</a>, could envision. I only hope that the pile up of new examples - each seemingly worse than the one before - of health care corruption, will be sufficient to overcome the anechoic effect, and create enough global outrage to give us a chance to clean up our corrupt health care before it destroys our health. ADDENDUM (25 July, 2013) - See also <a href="http://brodyhooked.blogspot.com/2013/07/the-astroturf-speaks-out-more-industry.html">comments</a> by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.  ADDENDUM (29 July, 2013 - See the <a href="http://1boringoldman.com/index.php/2013/07/28/a-closing-argument/">comment</a> on the 1BoringOldMan blog.

Pharmaceutical Industry "'Mobilised' an Army of Patient Groups to Lobby Against" Improving Clinical Research Integrity

I had guessed that this sort of thing was going on all the time, but being kept very well hidden. Now we have some more evidence. An artic...

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Johnson and Johnson Settles Suit Alleging Management Incompetence and Deception, Managers Continue to Prosper

Very quietly, pharmaceutical/ biotechnology/ medical device corporate giant Johnson & Johnson just settled another lawsuit. The most pithy version is <a href="http://www.pharmalive.com/jj-pays-23m-to-settle-class-action-suit-over-otc-troubles">by Ed Silverman on Pharmalot</a>, although <a href="http://www.reuters.com/article/2013/07/18/us-johnson-recall-settlement-idUSBRE96H01S20130718">Reuters</a> and <a href="http://www.bloomberg.com/news/2013-07-17/j-j-agrees-to-pay-22-9-million-to-settle-case-over-drug-recalls.html">Bloomberg</a> published short accounts. The New Settlement Per Mr Silverman, the gist is: <blockquote class="tr_bq">The health care giant agreed to resolve the dispute brought over allegations that J&J management shirked their responsibilities and allowed a chain of events that resulted in congressional probes; lost market share, consumer confidence and revenue, and a consent decree with the FDA. In the lawsuit, a shareholder charged that J&J bungled the integration of the Pfizer consumer health acquisition, placed inexperienced execs in charges of its OTC unit and cut costs so drastically that quality control suffered. The lawsuit, which was brought by Ronald Monk, alleged that the health care giant made misleading statements about its products before disclosing problems with the Fort Washington plant and another in Puerto Rico. He also maintained that J&J withheld material information before its decision three years ago to shut down the Fort Washington plant, where contamination led to the unpublicized recall of defective Motrin tablets in 2009. In agreeing to the settlement, J&J refused to admit any wrongdoing</blockquote> So let me review. The allegations in this case were all about problems with the management of Johnson and Johnson.  They included allegations that management was incompetent and deceptive.  The incompetence was in handling the core functions of the company, assuring that its drug products were pure and unadulterated.  The deception was of patients, the public, and the nominal owners of the company to whom management is supposed to report, and allegedly included an attempt to cover up concerns about the purity of its drug products. The proposed settlement follows the current practice of allowing the defendant not to admit the allegations, leaving their truth unproven.  However, one wonders, given that the allegations are about the core responsibilities of management and were leveled by the company owners, why the management would not defend their honor more forthrightly. The Company's Sorry Legal Record Furthermore, this settlement also follows the current practice of being made without reference to any other seemingly relevant legal proceedings.  In fact, it is just the latest of a long string of settlements and other resolutions of legal actions, including guilty pleas, by Johnson and Johnson management.  As we summarized most recently <a href="http://hcrenewal.blogspot.com/2012/09/how-many-legal-settlements-does-it-take.html">here</a>, these included: - Convictions in two different states in 2010 for misleading marketing of Risperdal - A guilty plea for misbranding Topamax in 2010 - Guilty pleas to bribery in Europe in 2011 by Johnson and Johnson's DePuy subsidiary - A guilty plea for marketing Risperdal for unapproved uses in 2011 (see <a href="http://hcrenewal.blogspot.com/2011/08/why-cultivate-weldons-confidence-ceo.html">this link</a> for all of the above) - A guilty plea to misbranding Natrecor by J+J subsidiary Scios (see post <a href="http://hcrenewal.blogspot.com/2011/09/johnson-and-johnson-pleads-guilty.html">here</a>) - In 2012, testimony in a trial of allegations of unethical marketing of the drug Risperdal (risperidone) by the Janssen subsidiary revealed a systemic, deceptive stealth marketing campaign that fostered suppression of research whose results were unfavorable to the company, ghostwriting, the use of key opinion leaders as marketers in the guise of academics and professionals, and intimidation of whistleblowers. After these revelations, the company abruptly settled the case (see post <a href="http://hcrenewal.blogspot.com/2012/02/texas-tmap-trials-as-illustration-of.html">here</a>). -  Also in 2012,  Johnson & Johnson was fined $1.1 billion by a judge in Arkansas for deceiving patients and physicians again about Risperdal (look <a href="http://hcrenewal.blogspot.com/2012/04/once-more-with-feeling-johnson-and.html">here</a>). -  Also in 2012, Johnson & Johnson announced it would pay $181 million to resolve claims of deceptive advertising again about Risperdal (see this <a href="http://hcrenewal.blogspot.com/2012/09/how-many-legal-settlements-does-it-take.html">post</a>). Even though the record includes a number of settlement in which management did not have to admit guilt, the company has made a surprising number of guilty pleas in just the last few years.  Despite all this evidence of poor, that is incompetent or unethical management, Johnson and Johnson managers have been getting very rich. As we mentioned <a href="http://hcrenewal.blogspot.com/2012/03/despite-recalls-legal-settlements-and.html">here</a>, Mr William Weldon, the outgoing CEO on whose watch most of the misbehavior resulting in the legal actions above occurred, retired with a huge retirement package, after receiving extremely generous compensation prior to that.  The new CEO as of April, 2012,  Mr  Alex Gorsky, per<a href="http://www.investor.jnj.com/common/download/download.cfm?companyid=JNJ&fileid=644762&filekey=44D6D309-4972-4DAE-97C5-60157E6C6CD1&filename=JNJ_2013_Proxy_Statement.PDF"> the company's 2013 proxy statement</a>, already owns more than 190,000 Johnson and Johnson shares,  and received $10,977,109  total compensation in 2012.  Mr Weldon received over $29 million in total compensation just for 2012, the year in which he retired.  Other top executives received from over $3.5 million to over $8 million.  Summary So why do the stockholders, the owners of Johnson and Johnson continue to pay so much to an executive team on whose watch so many bad things have happened?  Why did law enforcement authorities allow the company to continue to plead guilty or settle cases without imposing any negative consequences on these executives?  Maybe only <a href="http://en.wikipedia.org/wiki/The_Shadow">the Shadow</a> knows. Of course, the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">lack of any discussion </a>beyond that on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>, that puts each new settlement or guilty plea in the context of the ones before, and juxtaposes them to the rewards of given to management, may not help.  As we <a href="http://hcrenewal.blogspot.com/2012/09/how-many-legal-settlements-does-it-take.html">said the last time</a> we addressed the contrast between Johnson and Johnson's sorry legal record and its voluminous payments to executives, we have <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">noted again and again and again</a> that many of largest and once proud health care organizations now have recent records of repeated, egregious ethical lapses. Not only have their leaders have nearly all avoided penalties, but they have become extremely rich while their companies have so misbehaved. These leaders seem to have become like nobility, able to extract money from lesser folk, while remaining entirely unaccountable for bad results of their reigns. We can see from this case that health care organizations' leadership's nobility overlaps with the supposed "royalty" of the leaders of big financial firms, none of whom have gone to jail after the global financial collapse, great recession, and ongoing international financial disaster (look <a href="http://hcrenewal.blogspot.com/2012/08/duchess-of-wellpoint-abdicates-likely.html">here</a>). The current fashion of punishing behavior within health care organization with fines and agreements to behave better in the future appears to be more law enforcement theatre than serious deterrent.  As Massachusetts Governor Deval Patrick exhorted his fellow Democrats, I exhort state, federal (and international, for that  matter) law enforcement to "<a href="http://www.washingtonpost.com/blogs/election-2012/wp/2012/09/04/patrick-it-is-time-for-democrats-to-grow-a-backbone/">grow a backbone</a>" and go after the people who were responsible for and most profited from the ongoing ethical debacle in health care. As we have said before, true health care reform would make leaders of health care organization accountable for their organizations' bad behavior.

Johnson and Johnson Settles Suit Alleging Management Incompetence and Deception, Managers Continue to Prosper

Very quietly, pharmaceutical/ biotechnology/ medical device corporate giant Johnson & Johnson just settled another lawsuit. The most pi...

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More than Just a Conflict of Interest? - Should Rutgers University's Own Contract Research Organizations Report to the Board of Covance?

Transparency International's 2013 global survey showed that over 40% of Americans think the country's health care is corrupt (see <a href="http://hcrenewal.blogspot.com/2013/07/43-believe-that-us-health-care-corrupt.html">this post</a>).  <a href="http://www.transparency.org/">Transparency International</a> defines corruption as abuse of entrusted power for private gain.  It is likely that one reason many US citizens feel this way is that they have become aware of the web of conflicts of interest that now permeates health care. The Institute of Medicine <a href="http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">defined</a> conflicts of interest in medicine as occurring "when an individual or institution has a secondary interest that creates a risk of undue influence on decisions or actions affecting a primary interest."  Since the primary interest of physicians is to provide good care that puts patients' interests first, and the primary interests of academic medicine are to provide education and research of quality and integrity, conflicts of interest affecting physicians or academic medical institutions increase the risk of abuse of the entrusted power defined by these primary interests. The most striking conflicts may occur when one person simultaneously runs two different health care organizations whose missions and interests are at odds.  For example, we have been documenting <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">since 2006</a> how some top leaders of academic medicine simultaneously sit on boards of directors of health care corporations.  Thus, <a href="http://hcrenewal.blogspot.com/2011/09/director-of-bristol-myers-squibb-to-run.html">for example</a>, the dean of a prestigious medical school may sit on the board of a large pharmaceutical company.  That person is supposedly responsible both for the honest education of students, including unbiased education about the use of drugs, and for a company whose revenue depends on selling more drugs at higher prices. Rutgers University President, Director of VWR International and Covance Such conflicts attracted little public notice when we first blogged about them, but now occasionally attract more attention.  For example, the NorthJersey.com just <a href="http://www.northjersey.com/news/education/Barchi_draws_pay_from_two_companies_that_do_business_with_Rutgers.html">reported</a> on the conflicts affecting the President of Rutgers University, which includes two medical schools and many other academic health care components, <blockquote class="tr_bq">As he leads the transformation of the state’s flagship university into a medical research hub with national aspirations, Rutgers University President Robert Barchi is also collecting hundreds of thousands of dollars for privately advising two firms that do millions of dollars of business with Rutgers related to scientific research.</blockquote> In particular, <blockquote class="tr_bq">both firms have a business relationship with Rutgers. Those relationships predate Barchi’s appointment. They could expand, however, with Rutgers’ recent merger with most of the University of Medicine and Dentistry of New Jersey. Rutgers has paid VWR International, a publicly traded lab supply company, and its subsidiaries a total of $15 million since 2008, records show. It is on pace to pay the company $2 million this calendar year, even though a contract with the firm expired in 2012. A university spokesman said the deal was extended, but an official who handles public records requests said a copy of the extension was not on file. Covance Inc., a pharmaceutical research firm, has been paid about $100,000 by Rutgers since 2008. It supplies products and services used in biological research. Those two companies paid Barchi a combined $317,000 in fees and stock awards last year to sit on each company’s board, part-time advisory positions he has held more than seven years. Barchi has also accumulated stock in both companies — in the case of Covance, worth the equivalent of $2.5 million as of Friday, according to corporate filings. The annual fees supplement Barchi’s annual pay at Rutgers, which is worth up to $747,000 after bonuses. </blockquote> Dr Barchi argued that since he had disclosed these relationships to the university board of governors, it is all good, <blockquote class="tr_bq">'I disclosed my membership on the board fully during the search process, both on my résumé and in discussions with Rutgers board of governors members,' Barchi wrote in a statement issued in response to questions and an interview request submitted through a spokesman. 'Rutgers University recognizes the value of having its chief executives serve on corporate boards. ... Recognizing the potential for a conflict, however, since becoming president at Rutgers I have not been involved in any decisions at Rutgers involving' the companies. </blockquote> Members of the university governing board did not seem too troubled either. <blockquote class="tr_bq">'It was fully disclosed,' said Gordon MacInnes, a member of the governing board. 'I don’t see any inherent conflict.' </blockquote> However, NorthJersey.com found some people who thought there could be a real issue since the university has direct financial relationships with both companies on whose board Dr Barchi sits. <blockquote class="tr_bq">Cary Nelson, a past president of the American Association of University Professors who has written a dozen books on higher education policy and conflicts of interest, said Barchi’s arrangement 'is not an ambiguous case, unfortunately,' calling it a clear conflict. There’s a danger of impropriety, Nelson said, even if Barchi never actively exerts influence on behalf of the companies he advises. For example, officials who make large buying decisions for the university may choose contracts with the companies to curry favor with the president or because they 'don’t want to make waves,' he said. Nelson is the co-author of an extensive report for the professors’ association due out at the end of this year that will suggest university policies to avoid such problems. 'What we say is that no administrator should serve on a corporate board or have any kind of financial relationship with a company that does business with the university,' he said. 'That’s a fundamental principle that has to be honored.'</blockquote> Public Notice Unlike some cases we have previously discussed (for example, <a href="http://hcrenewal.blogspot.com/2006/01/california-nightmares-more-troubles-at.html">here</a> and <a href="http://hcrenewal.blogspot.com/2011/09/director-of-bristol-myers-squibb-to-run.html">here</a>), this one produced an immediate kerfuffle, if not an uproar.  The New York Times reported on it.  Already editorialists (e.g., <a href="http://news.google.com/news/url?sr=1&sa=t&ct2=us%2F0_0_s_7_0_t&usg=AFQjCNHWcgGT8g4KHN66hDJCq4_ZGE-0aQ&did=c47cdb7d453db56d&cid=52778199768898&ei=vpPlUaCzI4jcggfD9wE&rt=STORY&vm=STANDARD&url=http%3A%2F%2Fwww.northjersey.com%2Fnews%2Fopinions%2F215623061_The_Record__Barchi_and_boards.html">here</a>) and a few politicians (look <a href="http://www.nj.com/news/index.ssf/2013/07/rutgers_president_barchi_faces_calls_to_resign_from_paid_posts_on_corporate_boards.html">here</a>) have called for Dr Barchi to step down from his corporate board positions. For example, <a href="http://www.northjersey.com/news/Rutgers_president_Barchis_side_pay_draws_criticism_from_lawmakers_experts.html">per</a> again NorthJersey.com, <blockquote class="tr_bq">'This is a two-way financial arrangement that creates a textbook example of a conflict of interest,' said Senate Majority Leader Loretta Weinberg, a Teaneck Democrat, who called on him to resign from his advisory posts for the companies, VWR International and Covance Inc. 'The president of the university is on the payroll of companies that are paid millions of dollars by the school. Even if Mr. Barchi avoids direct involvement in business decisions between Rutgers and these firms, the appearance of a conflict could undermine his credibility at a key time in the evolution of the university.' </blockquote> Some Additional Perspective Dr Barchi's conflicts of interest have drawn considerable more coverage than similar conflicts of other academic health care leaders whom we have discussed in the past. Unlike these previous cases, they have also provoked upset, if not some outrage. Yet there could be more outrage, because this case is actually worse than it has been so far publicly described. First, the public discussion seems not to have taken into account the nature of Dr Barchi's responsibilities to VWR International and Covance.  He is not on advisory boards to these two companies, as implied by the initial NorthJersey.com report.  He is a member of both these companies' boards of directors. As we <a href="http://hcrenewal.blogspot.com/2008/05/worse-variant-of-new-species-of.html">noted in 2008</a>,  the issue goes beyond just the often generous payments board service entails. The important consideration is that directors of public for-profit corporations have a duty to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. <a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986">Corporate Governance</a>, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]   (Many people would now argue that many current corporate directors function more like cronies of top management than representatives of the shareholders). But the important message is the boards of directors are responsible for the governance and overall direction of the company.  For example, the 2<a href="http://services.corporate-ir.net/SEC/Document.Service?id=P3VybD1hSFIwY0RvdkwyRndhUzUwWlc1cmQybDZZWEprTG1OdmJTOWtiM2R1Ykc5aFpDNXdhSEEvWVdOMGFXOXVQVkJFUmlacGNHRm5aVDA0T0RFNU16YzVKbk4xWW5OcFpEMDFOdz09JnR5cGU9MiZmbj04ODE5Mzc5LnBkZg==">013 Covance proxy statement </a>includes, "The Board of Directors provides oversight of senior management in its operation of the Company."   The members of the board have a fiduciary duty to align with the companies' interests which goes beyond whatever loyalty their compensation from the company ought to inspire.  Thus, the extreme conflict between, for example, one person's roles as a university president responsible for education, including unbiased education of physicians about drugs,  and a director of a drug company ought to be obvious. Dr Barchi, is not a director of a drug company, but the director of a contract research organization.  The description of Covance in the NorthJersey.com article above was incomplete.  In fact, the Covance web-site describes the company as "one of the world’s largest and most comprehensive drug development services companies."  In particular, Covance functions as a contract research organization (CRO).  Its work includes running clinical research for pharmaceutical and biotechnology companies, including "Early Patient Studies,Clinical Development (Phase II-III)." As university president, Dr Barchi is simultaneously responsible for educating students about clinical research, and for the integrity of clinical research performed within the university.  More acutely, however, he actually is responsible for several contract research organizations that appear to be competing with Covance. As more clinical research has been taken over by CROs, some academic institutions have decided to compete directly with CROs.  In particular, Rutgers University, in particular, seems to have its own CROs.  First, as <a href="http://shrp.rutgers.edu/dept/biopharma/">proclaimed </a>by its Biopharma Educational Initiative, "Rutgers Biomedical and Health Sciences is one of the largest health care research institutions in the US with our own (emerging) contract research organization."  The Rutgers Clinical Research Organization <a href="http://cro.rbhs.rutgers.edu/aboutUs.html">asserts</a> "Rutgers CRO connects industry, patients and academic collaborators with the University's state-wide academic resources."  Meanwhile the Rutgers New Jersey Medical School Institute of Genomic Medicine <a href="http://njms.rutgers.edu/genesweb2/services.cfm">states</a> "the IGM functions as an academic contract research organization (CRO) dedicated to biomarker discovery and the clinical evaluation of biomarkers.". Thus, not only does Dr Barchi's role in the governance of Covance seem to present a conflict with his role in upholding the integrity of research at Rutgers, but it could conceivably be anti-competitive.  While one may question whether university's should directly compete with CROs, as long as they do, it seems they ought not to be run by those responsible for the governance of the CROs with which they are ostensibly competing. Summary As the web of conflicts of interest that entangles health care becomes more visible, the risks of corruption that it generates become more obvious.  I hope as disclosure improves, public outrage about health care corruption will increase.   Ultimately, true health care reform requires more than disclosing conflicts of interest. The IOM  <a href="http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">report </a> on conflicts of interest suggested full disclosure of all payments that could be considered conflicts of interest, banning clinical research by conflicted individuals, prohibiting academic physicians from giving "drug talks" whose content was provided by industry, and developing methods to fund continuing medical education independent from industry.  This report, and its recommendations have gotten scant attention, maybe because they would threaten a status quo that enriches conflicted health professionals and the companies that create these conflicts.  However, in my humble opinion, implementing all the report's recommendations would only be a beginning down the road of restoring the integrity of clinical care, teaching, and research. Hat tip to Prof Margaret Soltan <a href="http://www.margaretsoltan.com/?p=40518">on the University Diaries blog.</a> See also the <a href="http://loathingbioethics.blogspot.com/2013/07/what-does-rutgers-president-have-in.html">comments </a>by Dr Carl Elliott on the Fear and Loathing in Bioethics blog.   ADDENDUM (24 July, 2013) - see additional comments <a href="http://www.margaretsoltan.com/?p=40606">here</a> and <a href="http://www.margaretsoltan.com/?p=40613">here</a> by Prof Margaret Soltan on the University Diaries blog.

More than Just a Conflict of Interest? - Should Rutgers University's Own Contract Research Organizations Report to the Board of Covance?

Transparency International's 2013 global survey showed that over 40% of Americans think the country's health care is corrupt (see th...

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