The Mystery of the Fugitive Founder (and Longterm President of an Offshore Medical School for US Students)

We recently <a href="http://hcrenewal.blogspot.com/2013/09/quality-vs-costs-of-us-corporate-owned.html">wrote</a> about for-profit medical schools located offshore from the US, but catering to American students, not students from the countries in which they operate.  Now some new media reports raise further questions, if not mysteries about another set of such schools.   <br /><br />Two Bloomberg articles on a trial underway focused on the alleged use of offshore accounts to avoid US taxes.  These accounts were connected to the former long-term President and founder of two offshore medical schools, and his spouse, a dean at one of the schools.   <br /><br /><br />The <a href="http://www.bloomberg.com/news/2013-10-08/caribbean-medical-school-founder-faces-trial-over-swiss-accounts.html">first Bloomberg article</a> opened thus:<br /><br /><br /><blockquote class="tr_bq">Patricia Hough, according to her lawyers, is an altruistic <i>psychiatrist who helped her husband build two Caribbean medical schools.</i> To prosecutors, she is a <i>tax cheat who used offshore accounts to avoid paying taxes on millions of dollars from the schools’ sale.</i> <br /><br />Jury selection began today in federal court in Fort Myers, Florida, where Hough, 67, is accused of using accounts at UBS AG, the largest Swiss bank, and elsewhere to hide assets and income from the Internal Revenue Service, <i>including almost $34 million she and her husband made when the schools were sold in 2007. </i></blockquote><br />The Bloomberg article asserted,<br /><br /><blockquote class="tr_bq"> At the heart of the case is <i>whether she misused accounts associated with the Saba University School of Medicine Foundation. </i></blockquote><br />The main question to me is not whether Dr Hough is guilty or innocent, which I cannot tell.  There are more intriguing  mysteries raised by this case.<br /><br /><b>How Did Non-Profit Medical Schools Become For-Profit?</b><br />  <br />According to Bloomberg,<br /><br /><blockquote class="tr_bq">  Hough’s lawyers say she helped [her husband, David] Fredrick <i>build Saba University School of Medicine, on the island of Saba in the  Netherland Antilles, and the Medical University of the Americas, or MUA, on Nevis in the West Indies.</i></blockquote><br />To do so,<br /><br /><blockquote class="tr_bq"> <i>Through the Saba foundation,</i> which they first funded in 1988, according to a government trial brief filed Oct. 3, <i>the couple opened the Saba University School of Medicine in 1993. Fredrick served as president and a foundation director. Hough was associate dean for clinical medicine. </i></blockquote><br />Also, <br /><br /><blockquote class="tr_bq"><i>In 1999, Fredrick and Hough began the Medical University of the Americas, a for-profit school on Nevis </i>in the West Indies, according to the government filing. </blockquote>There seems to be no question that the schools were started by a foundation based in the Netherland Antilles.  A <a href="http://www.mbc.ca.gov/applicant/site_visits_saba.pdf%E2%80%8E">report of a site visit</a> of the Saba University School of Medicine by the Division of Licensing of the Medical Board of California in 2004 summarized this history,<br /><br /><blockquote class="tr_bq"><i>In 1986, the government of the Netherlands Antilles proposed to a group of American educators that a medical school be established on the small island of Saba, N.A. </i> It was to be relatively small, of high quality and established for the dual ppurpose of benefiting the economy of the island (of only 1500 population) and <i>attracting N.A. citizens to medical careers in the N.A. </i><br /><br /><i>A committee of Dutch citizens from Curacao, the seat of the N.A. government, approved the preliminary plans and the school was founded as a non-profit foundation under Dutch law..</i>..</blockquote><br />The Saba University <a href="http://www.saba.edu/saba/index.php/about-saba/about-saba-university/accreditations">website</a> still states that the school is accredited in the Netherlands,<br /><br /><blockquote class="tr_bq">Saba University School of Medicine’s Doctor of Medicine (M.D.) program <i>is accredited by the <a href="http://nvao.net/" target="_blank">NVAO</a> (in Dutch: Nederlands-Vlaamse Accreditatieorganisatie). </i>The NVAO is the Accreditation Organization of the Netherlands and Flanders. This organization was established by international treaty and ensures the quality of higher education in the Netherlands and Flanders.</blockquote><br /><br /><br />So apparently Saba University was started as a non-profit organization meant to focus on medical education for the Netherlands Antilles, and thus accredited there.  But then, somehow,  according to Bloomberg.<br /><br /><br /><blockquote class="tr_bq"><i>Equinox Capital, a private-equity firm based in Greenwich, <a href="http://topics.bloomberg.com/connecticut/">Connecticut</a>, bought the Saba school and MUA for $36 million in 2007.</i> The transaction included $34 million for land held in the name of Fredrick’s daughter from an earlier marriage, according to prosecutors. <br /><br />Hough and Fredrick didn’t tell the IRS about most of the proceeds of the sale and transferred money among various undeclared accounts to buy the plane and real estate, make gifts to family members and pay personal expenses, prosecutors said.</blockquote><br />There also seems to be no question that Equinox Capital did buy the schools.  The <a href="http://mandasoft.com/1/13007/equinox_capital_inc_acquired_saba_university_school_of_medicine">summary of a 2007 press release</a> from the company stated,<br /><br /><blockquote class="tr_bq"> <i>Equinox Capital III, L.P. announced that it has completed the recapitalization of Saba University School of Medicine B.V. ('Saba')</i>. Founded in 1986, Saba is a leading for-profit university that awards four-year graduate degrees in Doctors of Medicine (M.D.). </blockquote><br />A <a href="http://www.prairie-capital.com/mobile/funds/r3.html">statement from Prairie Capital,</a> which is now an investor in the schools, noted that now<br /><br /><blockquote class="tr_bq"> <span class="contentBodyProfessionalsTextGray"><i>R3 Education is a Massachusetts-based holding company that controls The Saba University School of Medicine ('Saba'), The Medical University of the Americas ('MUA') and St. Matthew University ("SMU")</i>.</span></blockquote><br /><span class="contentBodyProfessionalsTextGray">After,</span><br /><br /><blockquote class="tr_bq"><span class="contentBodyProfessionalsTextGray"> </span><i><span class="contentBodyProfessionalsTextGray">Prairie Capital partnered with Equinox Capital to acquire the three universities. </span></i></blockquote><br />It is enough to cause some dizziness.  Let me recap.  Mr Fredrick and Dr Hough somehow founded two medical schools apparently under the auspices of a foundation, the Saba University School of Medicine Foundation, which the couple ran.  The goal of the foundation was to attract Netherland Antilles citizens to medical careers in the NA.   However, the Saba University school became an off-shore facility for US medical students.  The two schools were later acquired by Prairie Capital and Equinox Capital, and they are now run as for-profit operations by R3 Education.<br /><br />So somehow Saba University transitioned from being a non-profit meant to serve the medical education needs of the Netherlands Antilles to a for-profit owned by US private equity firms (and apparently now focused on serving Americans.)<br /><br />How did that happen?  What was the rationale for the change?  Did any Dutch authorities consider the implications for their country?  Did any American organizations concerned with the quality of education and credentials of US physicians consider the implications? <br /><br /><b>Where Did the Money Go?</b><br /><br />According to Bloomberg, US prosecutors made some striking allegations,<br /><blockquote class="tr_bq"><br />Both the foundation and MUA failed to tell the IRS about accounts held at UBS, Liechtenstein Landesbank and other banks, the U.S. charges. <br /><br />Singenberger and Luetolf helped the foundation and MUA move money through British Virgin Islands or Hong Kong entities they controlled called Top Fast Finance Ltd., Ample Dynamic Trading Ltd., New Vanguard Holdings Ltd. and Apex Consultants Ltd., according to prosecutors. <br /><br />'<i>Hough and Fredrick were the beneficial owners of and had signatory authority over all over these accounts and owned and controlled each of them,'</i> prosecutors said in their brief. </blockquote><br />The prosecution also alleged that Mr Fredrick and Dr Hough spent the money they allegedly got from selling the two medical schools rather lavishly.  Per the <a href="http://www.bloomberg.com/news/2013-10-08/caribbean-med-school-founder-didn-t-cheat-irs-jury-told.html">second Bloomberg article</a>,<br /><br /><blockquote class="tr_bq">[Prosceutor] Kessler said Hough and her husband used the proceeds of the school sales to<i> buy a $1.6 million airplane, a $1.1 million house in Asheville, North Carolina, a $590,000 house in Greenville, North Carolina, and an $800,000 condominium in Sarasota, Florida. </i>She said they also gave money to relatives. </blockquote><br />The prosecutors charged that the money the private equity firms paid went to Mr Fredrick and Dr Hough.  But while Mr Fredrick was President of Saba University, and apparently ran the foundation that was supposed to support it, he did not own either.  So why would the money go to him, and his wife?  If the money did not go to them, where did it go? <br /><br />As the trial continued, as documented in a <a href="http://www.businessweek.com/news/2013-10-08/caribbean-med-school-founder-didn-t-cheat-irs-jurors-told">second Bloomberg article</a>, Dr Hough's lawyer denied that she got the money,<br /><br /><blockquote class="tr_bq">Dan Saunders, an attorney for Hough, said his client never believed the money held at UBS AG (UBSN), the largest Swiss bank, and in other offshore banks belonged to her. Rather, he said, she thought it belonged to the foundation that ran the schools.<br /><br />'It wasn’t her money, and she never believed it was,' Saunders said in his opening statement. </blockquote><br />If that is true, however, why is money that supposedly belongs to a foundation sitting quietly in a Swiss bank? <br /><br />Dr Hough's lawyer said,<br /><br /><blockquote class="tr_bq"> Saunders said the accounts did serve a business purpose: <i>to protect the assets of their nonprofit foundation from people attempting a hostile takeover.</i></blockquote><br />Hostile takeovers of publicly held corporations do occur, of course.  However, how could a hostile takeover of a foundation occur, and who would possibly want or be able to do so?<br /><br />So thus far, no one has offered a rationale explanation for how the schools were sold, why they were sold, and where the money resulting from the sale went.<br /><br /><b>Where in the World is Mr Fredrick?</b><br /><br />So far, while the defendant is Dr Hough, the role of her husband, Mr Fredrick, apparently the President of Saba University from its founding at least until 2007, seems key.  Yet little of the coverage focused on Mr Fredrick.  The reason for that suggests the next mystery, per  the first Bloomberg article,<br /><br /><blockquote class="tr_bq">Fredrick vanished after the indictment, leaving Hough to face trial alone. U.S. District Judge John Steele, who is overseeing the trial, has declared Fredrick a fugitive.</blockquote><br />So why did Mr Fredrick flea, and of course, where did he go?<br /><br />Obviously, the fact that Mr Fredrick, who was the President of Saba University for many years, chose not to defend himself against charges that he hid the money he somehow obtained from the sale of that and another medical school, but rather fled, suggests that he may not have had a very good defense against those charges.  What does that say about the leadership of these medical schools? <br /><br /> <b>Summary</b><br /><br />So the coverage of this intriguing trial, when added to some other publicly available information, suggests a wealth of mysteries about the founding, current nature, and leadership of two Caribbean medical schools which currently are run as for-profit firms and owned by US private equity firms, and whose student bodies come almost exclusively from the US.<br /><br />So the really big mysteries are those about the implications for the medical education these schools provide, the students they attract, the physicians who graduate from their programs, the US patients of such physicians, and the US government which largely provides the loans which paid for these students' education (look <a href="http://www.bloomberg.com/news/2013-09-10/devry-lures-medical-school-rejects-as-taxpayers-fund-debt.html">here</a>).<br /><br />Despite the extraordinary nature of this case (again, involving the longterm president of an offshore medical school that sought to educate a substantial number of US physicians, and who is now a fugitive from justice), the only interest in it so far seems to be its implications for US prosecutions of hidden offshore accounts.<br /><br />This case illustrates why we must reexamine our fascination for "market based" approaches to health care, when almost nothing about any part of health care resembles, or could resemble a free market (see <a href="http://hcrenewal.blogspot.com/2010/08/how-fallacy-of-perfect-health-care.html">this post</a>).  We need to make health care more transparent, and shine more sunshine on the nooks and crannies, like off-shore but US corporate owned medical schools.  We need to facilitate health care leadership and governance that puts patients' and the public's health first, way ahead of the personal enrichment of the participants.   <br /><br /><br /><br /><br />ADDENDUM (29 October, 2013) - Dr Hough was convicted of defrauding the IRS and income tax evasion, see the <a href="http://www.bloomberg.com/news/2013-10-24/caribbean-medical-school-founder-guilty-at-florida-tax-trial-1-.html">Bloomberg article</a>.  So far I see no response, certainly no apology or disavowal, by the current managers and owners of the medical school. 

The Mystery of the Fugitive Founder (and Longterm President of an Offshore Medical School for US Students)

We recently wrote about for-profit medical schools located offshore from the US, but catering to American students, not students from the c...

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Louise Schaper, PhD, CEO, Health Informatics Society of Australia: "What's Missing From the Health IT Investment? - Health Informatics"

Louise Schaper, PhD, CEO of the <b>Health Informatics Society of Australia</b> (HISA, <a href="http://www.hisa.org.au/">http://www.hisa.org.au/</a>), graciously extended an invitation in 2011 that I could not attend, and again in 2012 (that I accepted) to give a keynote presentation at HISA's annual convention, Healthcare Informatics Conference (HIC).  A writeup of my HIC2012 presentation in Sydney is at <a href="http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html">http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html</a>.<br /><br />I unfortunately could not make it Down Under for HIC2013 in Adelaide.  However, HISA has posted videos of a number of presenters.<br /><br />One of the presenters is Dr. Schaper.  Her presentation "<b>Health Informatics: A megatrend driving investment, careers & delivering the future of healthcare</b>" is at <a href="http://www.hisa.org.au/page/hic2014videos">http://www.hisa.org.au/page/hic2014videos</a> (bottom video).  It is well worth watching.<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtb74lZXAe1diMqwSJ8Nh11TljYQA3a9eG0zcSSZCmTvUsW1j3QWjHr4C_R07npu3SqbGa7olG-QMFLGFBygsO6e4l5ucGzyT6ACyIe7tEg4Ia3AulBRshz-tCBQvjME5Rlso_X65vobWD/s1600/schaper_louise.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtb74lZXAe1diMqwSJ8Nh11TljYQA3a9eG0zcSSZCmTvUsW1j3QWjHr4C_R07npu3SqbGa7olG-QMFLGFBygsO6e4l5ucGzyT6ACyIe7tEg4Ia3AulBRshz-tCBQvjME5Rlso_X65vobWD/s200/schaper_louise.jpg" width="152" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Louise Schaper PhD, CEO, Health Informatics Society of Australia</td></tr></tbody></table><br />After reviewing the potential benefits of heathcare IT, Dr. Schaper asks what I consider the most critical question of all. <br /><br />At 08:20 she asks:  <b>"What's missing from this [multi-billion dollar] investment?"</b><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYPjXC9te_7YpCosQhbRBYckorMvRZTXeCMvtJaYGopDXMrFiQYw5w0Hsa_gF8HnVoqqR9vETX6fPwgfqP9WXx0Nn3RF9Mr-_rmBYDwFkSHv6GYoMykqKJDHWEXot7lPb074Q01cgNH8Ab/s1600/whats_missing1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="286" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYPjXC9te_7YpCosQhbRBYckorMvRZTXeCMvtJaYGopDXMrFiQYw5w0Hsa_gF8HnVoqqR9vETX6fPwgfqP9WXx0Nn3RF9Mr-_rmBYDwFkSHv6GYoMykqKJDHWEXot7lPb074Q01cgNH8Ab/s400/whats_missing1.jpg" width="400" /></a></div><br /><br />The answer is <b>"Health Informatics."</b><br /><br />Dr. Schaper then indicates the real-world implications of the field of commercial health IT largely missing its critical founding scientific discipline:<br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEie2q-fIpGGRJYOnqjN5GOjMKeoiJJqLjSYpFBKR23egeQoA0H0Y85IpcpMgAeNkzgfsO4eVk4soHm7GLy5dJc5OO3_ZBJYxyd191_hGmPRpCqiSH7ZO39f0jsWjLtifGkEnm9bivs4ZyfN/s1600/whats_missing2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEie2q-fIpGGRJYOnqjN5GOjMKeoiJJqLjSYpFBKR23egeQoA0H0Y85IpcpMgAeNkzgfsO4eVk4soHm7GLy5dJc5OO3_ZBJYxyd191_hGmPRpCqiSH7ZO39f0jsWjLtifGkEnm9bivs4ZyfN/s400/whats_missing2.jpg" width="400" /></a></div><br /><br />At 13:00 she amplifies the point further:  We are not learning our lessons!  The themes of that slide are familiar to readers of this blog, and to current health IT users:<br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6WEbveq_WErWzYy8pmfhKxv-6HHyQCMdwqb_pfPM2hSuHyYbxOa4wBtFzI_PDqj8GZMhRao2_0sDEhcVqqpPWUhuLddFuR3sqfkhRHFR0IA94ZC4hGX9TnezRPoFMHTQYmwQdq8d6nFNv/s1600/whats_missing3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="275" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6WEbveq_WErWzYy8pmfhKxv-6HHyQCMdwqb_pfPM2hSuHyYbxOa4wBtFzI_PDqj8GZMhRao2_0sDEhcVqqpPWUhuLddFuR3sqfkhRHFR0IA94ZC4hGX9TnezRPoFMHTQYmwQdq8d6nFNv/s400/whats_missing3.jpg" width="400" /></a></div><br /><br />Dr, Schaper then goes on to cover some real-world issues related to impediments to meaningful health informatician engagement in health IT design, implementation and other aspects of leadership.<br /><br />The presentation is worth watching in its entirety.  The issues in health IT of meaningful involvement and leadership by those with expertise in healthcare informatics (as compared to, for example, those in manufacturing, mercantile, and management computing whose experience is often ill-suited for high-level roles in healthcare projects) are truly international.<br /><br />Finally, for those in the U.S. not used to Australian accents, Dr. Schaper's is quite enjoyable to listen to. <br /><br />-- SS

Louise Schaper, PhD, CEO, Health Informatics Society of Australia: "What's Missing From the Health IT Investment? - Health Informatics"

Louise Schaper, PhD, CEO of the Health Informatics Society of Australia (HISA, http://www.hisa.org.au/ ), graciously extended an invitation...

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Drudge Report, Oct. 10, 2013, 9 AM EST: All that needs to be said about government, computing and healthcare

Per <a href="http://www.drudgereport.com/">Drudge Report</a>. Oct. 10, 2013, 9 AM EST:<br /><br />From the same people who brought us HITECH, the stimulus bill for rapid rollout of commercial electronic medical records, order entry, results reporting and other components of enterprise clinical "command and control" software for hospitals through which every transaction of care must pass.<br /><br />More IT malpractice.  The Drudge links, as they appear on the page: <br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="font-size: small;"><b><b><a href="http://www.digitaltrends.com/opinion/obamacare-healthcare-gov-website-cost/">Obamacare website cost more than FACEBOOK, TWITTER, LINKEDIN, INSTAGRAM...</a><br /><a href="http://thehill.com/video/house/327489-boehner-obamacare-threatens-fines-but-fails-to-deliver-care">'How can we tax people for not buying a product from a website that doesn't work?'</a><br /><a href="http://www.elpasotimes.com/politics-national/?third_party=many-tried-to-warn-officials-of-obamacare-website-jam"> Major insurers, Dem allies repeatedly warned Obama admin...</a><br /><a href="http://www.foxnews.com/tech/2013/10/09/3-million-obamacare-website-may-face-months-glitches-experts-warn/">REPORT: WH knew site might not be ready...</a><br /><a href="http://bigstory.ap.org/article/poll-rollout-health-exchanges-gets-thumbs-down#overlay-context=article/anti-government-protesters-dog-taiwan-national-day">POLL: Just 1 in 10 report success...</a><br /><a href="http://www.mediaite.com/tv/debbie-wasserman-schultzs-shocking-insufficient-rambling-response-to-msnbc-on-obamacare-enrollees/">DNC head says site designed for 50,000 max...</a><br /><a href="http://www.infowars.com/once-you-get-into-the-obamacare-website-you-cant-get-out/">Once you get in, you can't get <i>out...</i></a><br /><a href="https://www.healthcare.gov/marketplace/global/en_US/registration.js">Crazzzzzzzy code...</a><br /><a href="http://www.cbsnews.com/8301-505269_162-57606633/obamacare-website-looks-like-nobody-tested-it-programmer-says/">'It looks like nobody tested it'...</a><br /><a href="http://www.washingtonpost.com/business/technology/some-say-health-care-sites-problems-highlight-flawed-federal-it-policies/2013/10/09/d558da42-30fe-11e3-8627-c5d7de0a046b_story.html?hpid=z3">WASHPOST: Not code, but 'outdated, costly, buggy technology'...</a><br /><a href="http://washington.cbslocal.com/2013/10/09/carney-i-dont-know-if-obama-has-used-health-care-website/">CARNEY: 'I Don’t Know' If Obama Has Tried Website...</a><br /><a href="http://washington.cbslocal.com/2013/10/10/hawaii-relaunching-obamacare-exchange-after-not-selling-any-health-insurance-due-to-software-problems/">Hawaii forced to relaunch after zero sign-ups...</a></b></b></span></span></blockquote><br /><br />I won't comment any further; I don't think I need to.<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioxvlYhb12vWVBwgfbAaRyFwgypKV8y0E58B8ndx9GQ10QJ2Z_aOyJsdVFRsFs6jv8GM3TsIVJ06wIU3ADiSUO8Kh8uOVTzEVjheehWDk6xSre92w_Rlew0e-EPt9MY09j06M1CL-ekt02/s1600/drudge_computers.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="260" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioxvlYhb12vWVBwgfbAaRyFwgypKV8y0E58B8ndx9GQ10QJ2Z_aOyJsdVFRsFs6jv8GM3TsIVJ06wIU3ADiSUO8Kh8uOVTzEVjheehWDk6xSre92w_Rlew0e-EPt9MY09j06M1CL-ekt02/s400/drudge_computers.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Drudge Report, Oct. 10, 2013, 9 AM EST.  <b>Click to enlarge.</b></td></tr></tbody></table><br /><br />Of course, the Anecdotalists [1] and Denialists [2] will probably say this is all a "glitch" and that things will be great in ver. 2.0.<br /><br />Fools all.<br /><br />Oh, and the cost, via Drudge, per the linked story.  A mere:<br /><br /><br /><div style="text-align: center;"><span style="font-size: x-large;"><tt><b><tt><b><span style="font-family: ARIAL,VERDANA,HELVETICA;"><a href="http://weaselzippers.us/2013/10/09/gross-u-s-taxpayers-shelled-out-634320919-to-build-obamacare-website/">$634,320,919</a></span></b></tt></b></tt></span> </div><br />-- SS<br /><br /><span style="font-size: small;">[1]  See "<b>Health IT: On Anecdotalism and Totalitarianism</b>" at  <a href="http://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html">http://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html</a>) </span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">[2]  See "<b>The Denialists' Deck of Cards: An Illustrated Taxonomy of Rhetoric Used to Frustrate Consumer Protection Efforts</b>" by Chris Jay Hoofnagle, available at <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=962462">http://papers.ssrn.com/sol3/papers.cfm?abstract_id=962462</a>)</span><br /><br /><b><span style="font-size: small;">Oct. 10, 2013 addendum:</span></b><br /><br /><span style="font-size: small;">Also see "<b>Analysis: IT experts question architecture of Obamacare website</b>" at <a href="http://uk.reuters.com/article/2013/10/05/us-usa-healthcare-technology-analysis-idUKBRE99407T20131005">http://uk.reuters.com/article/2013/10/05/us-usa-healthcare-technology-analysis-idUKBRE99407T20131005</a>.  If the allegations here are even partially true, every programmer and manager who ever worked on this system should be summarily fired and never permitted to touch another computer involved in healthcare - ever.</span><br /><span style="font-size: small;"><br /></span><span style="font-size: small;">-- SS</span><br /><br />

Drudge Report, Oct. 10, 2013, 9 AM EST: All that needs to be said about government, computing and healthcare

Per Drudge Report . Oct. 10, 2013, 9 AM EST: From the same people who brought us HITECH, the stimulus bill for rapid rollout of commercial e...

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Quality and Safety Implications of Emergency Department Information Systems: ED EHR Systems Pose Serious Concerns, Report Says

A report "<b>Quality and Safety Implications of Emergency Department Information Systems</b>"<br />appeared in the Oct. 2013 issue of "Annals of Emergency Medicine."  It is available fulltext at <a href="http://www.annemergmed.com/article/S0196-0644%2813%2900506-4/fulltext">http://www.annemergmed.com/article/S0196-0644%2813%2900506-4/fulltext</a>, or in PDF via the tab, free as of this writing.<br /><br />First, a preamble:  I once tried to alert a hospital where I'd trained decades before, Abington Memorial Hospital (<a href="http://www.amh.org/">http://www.amh.org/</a>), of impediments to safe care I'd noted in their EHR's, predominantly their ED EHR.  They did not listen.  In fact, their response to my concerns was characterized by an apparent incompetence regarding conduct of safety investigations.  For instance, to my written concern in an April 2010 letter to the CEO and CMO about the ED EHR that:<br /><blockquote class="tr_bq"><br />... I've also had to stop administration [to my mother] of an antibiotic (Levaquin) in the recent past in the ED that she has had an adverse reaction to (torn rotator cuff), despite my having told ED intake she was allergic to it. She relates that administration of Levaquin was then almost repeated on the floor until she herself refused it during that past admission.</blockquote><br />This was the sworn testimony in May 2013 about the "investigation" that resulted, from the hospital's VP of Risk Management, <a href="http://www.corporationwiki.com/Pennsylvania/Abington/regina-sturgis/81813980.aspx">Regina Sturgis</a>:<br /><br /><blockquote class="tr_bq">A:      Deborah [hospital General Counsel] asked me to investigate the Levaquin issue which I did.<br />Q:      Did you do that on your own or did you delegate some of the --<br />A:      No.  I did it on my own.<br />Q:      Do you know whether any of the IT folks were ever brought in to look at the -- the EMR issues referenced in this letter?<br />A:     No, I do not.  I know that I was asked to look at the Levaquin because of my clinical background.<br />Q:      Okay.  Did you come up with any conclusions?<br />A:      Yes.<br />Q:      What was your conclusion?<br />A:     <b> That she had been ordered Levaquin in the ETC </b>[Emergency Trauma Center a.k.a. ED]<b>, that it had been discontinued about a very short period of time later, under a half an hour, and that she never received it. </b></blockquote><br />So, the investigation of a complaint that family and then the patient themselves had to stop the administration of a drug whose staff and EHR had been informed of an allergy consisted of confirming that the medication was never given.  No problem, the ED EHR is safe.<br /><br />(I am not joking; that is the testimony given.  Imagine such an investigation and conclusion about, say, reported aircraft flaws, or, in the industry in which I was once a safety officer, public transit vehicle defects and dangers.)<br /><br />However, when competent people investigate similar issues, the findings are concerning.  From Modern Healthcare (<a href="http://www.modernhealthcare.com/">http://www.modernhealthcare.com/</a>), a publication for healthcare executives, on the new <i>Annals of Emergency Medicine </i>article:<br /><br /><blockquote class="tr_bq"><span style="font-size: large;"><a href="http://www.modernhealthcare.com/article/20130624/NEWS/306249952/">ED EHR systems pose serious concerns, report says</a></span><br /><br />By <a href="mailto:jconn@modernhealthcare.com" target="_blank">Joseph Conn</a><br />Modern Healthcare<br /><br /><div>June 24, 2013</div></blockquote><blockquote>Electronic health-record systems used in <a href="http://www.modernhealthcare.com/section/articles?tagID=5739" target="_blank">emergency</a> departments are beset with poor data displays, loaded with so many alerts warning of potential <a href="http://www.modernhealthcare.com/section/articles?tagID=51" target="_blank">patient-safety issues</a> that they can lead to user alert fatigue, and may be generating incorrect physician orders, according to a <b>report by two emergency physicians' study groups. </b><br /><br />Meanwhile, providers wanting to address these <a href="http://www.modernhealthcare.com/section/articles?tagID=975" target="_blank">EHR</a> issues are <b>hampered by a lack of research and solid evidence of the extent of the problem with these systems</b>, and by <b>contract provisions with EHR vendors that stymie the free flow of information about system-linked safety concerns</b>, the report authors say. </blockquote><br />So, ED's across the country are rolling out technology, often taking advantage of ARRA's HITECH incentives ... but there is a lack of research and solid evidence into the risks.  Allow me to opine - that's simply crazy.<br /><br /><blockquote class="tr_bq">The groups found that “poor data display is a serious problem with many of today's EDISs,” while “the sheer volume” of alerts that range from the “completely irrelevant to life threatening”<span style="color: red;"><i><b> [or lack of appropriate alerts to relevant, simple issues such as data input errors - ed.] </b></i></span>can “dull the senses, leading to a failure to react to a truly important warning.” <b>They also found that “an alarming number of clinicians are anecdotally reporting a substantial increase in the incidence of wrong order/wrong patient errors while using the computerized physician order entry component of information systems.</b>”</blockquote><br />The word "anecdote", as I have written, is being misused.  The reports are not "anecdotes."  They are <i>risk management-relevant incident reports.</i>  (See "<b>From a Senior Clinician Down Under: Anecdotes and Medicine, We are Actually Talking About Two Different Things</b>" at <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html</a>.)<br /><br /><blockquote class="tr_bq">Two study groups from the American College of Emergency Physicians have recommended a program of systemic vigilance over electronic health-record systems used in emergency departments to improve patient safety and enhance quality of care.<br /><br />ACEP workgroups on informatics and on quality improvement and patient safety published their findings in an article, “<a href="http://www.annemergmed.com/article/S0196-0644%2813%2900506-4/abstract" target="_blank">Quality and Safety Implications of Emergency Department Information Systems</a>,” in the current issue of the Annals of Emergency Medicine. </blockquote><br />Post marketing surveillance, a standard for decades in other healthcare sectors, has been absent from health IT due to a long-obsolete special regulatory accommodation afforded that industry.  This accommodation was initiated when systems were simple and merely advisory - not the comprehensive enterprise clinical resource and clinician command-and-control systems they are today.  Now, clinician investigators of the technology such as the authors of this study are realizing that continuing this accommodation is a mistake.<br /><br /><blockquote class="tr_bq">It follows in the wake of, and references, an Institute of Medicine report from 2011, “Health IT and Patient Safety: Building Safer Systems for Better Care.” That report concluded that “<span style="color: red;"><b>current market forces are not adequately addressing the potential risks associated with the use of health IT.</b></span>” It also comes eight months after the New England Journal of Medicine published “<a href="http://www.nejm.org/doi/full/10.1056/NEJMsb1205420" target="_blank">Electronic Health Records and National Patient-Safety Goals</a>,” which warned that recent evidence “<span style="color: red;"><b>has highlighted substantial and often unexpected risks resulting from the use of EHRs and other forms of health information technology.”</b></span></blockquote><br />I note that if you frequent this blog, you likely read material similar to the bolded red statements above here first, as authored by me, dating to the founding of this blog in 2004.<br /><br /><blockquote class="tr_bq">... “The rush to capitalize on the huge federal investment of $30 billion for the adoption of electronic medical records led to some unfortunate and unintended consequences, particularly in the unique emergency department environment,” said Dr. Heather L. Farley, the lead author of the report, in a news release. “The irreversible drive toward EDIS implementation should be accompanied by a constant focus on improvement and hazard prevention." <b> Farley is assistant chairwoman of the Department of Emergency Medicine at Christiana Care Health System in Newark, Del.</b></blockquote><br />Ironically, I note in Dr. Farley's statement some of my own advice, given to ED staff when I was Chief Medical Informatics Officer at Christiana Care 1996-8.   I had in that time period advised <a href="http://www.christianacare.org/bodymod.cfm?id=169&action=detail&ref=1909">Charles Reese IV, MD</a>, Chair of Emergency Medicine, to not implement EHRs or, at best, implement document imaging systems (since ED charts are not that long or complex), not full field-based EHRs, due to the "unfortunate and unintended consequences" of bad health IT in such an environment I recognized even then.  It was only a few years ago that my advice was finally overturned. <br /><br /><blockquote class="tr_bq">The authors also report “(t)here are few consistent data on how commonly these errors occur, and few studies are actually focused on collecting evidence of these errors.” Meanwhile, “<b>there is currently no mechanism in place to systematically allow, let alone encourage, users to provide feedback about ongoing safety issues or concerns” with EHRs in general, and EDISs specifically.</b></blockquote><br />On its face, that is not a safety-conscious environment and the rollout and use of such systems seems a fundamental violation of patient's rights, made worse by the fact that there is no informed consent process whatsoever to ED EHR use.<br /><br /><blockquote class="tr_bq">The workgroups came up with seven recommendations: appointing an emergency department “clinician champion,” creating within healthcare delivery organizations an EDIS performance improvement group and an ongoing review process, paying timely attention to EDIS-related patient-safety issues raised by the review process, disseminating to the public lessons learned from performance improvement efforts, distributing vendors' product updates in a timely manner to all EDIS users and removing the “hold harmless” and “learned intermediary clauses” from vendor contracts. </blockquote><br />Many of these issues have been discussed on this blog.<br /><br /><blockquote class="tr_bq">“The learned intermediary doctrine implies that the end users (clinicians) are the medical experts and should be able to detect and overcome any fallibility or contributing factor of the product,” the authors said.</blockquote><br />I have also pointed out the absurdity of such a "doctors are clairvoyant" attitude, e.g., at my 2011 post on basic common sense on IT adverse consequences at <a href="http://hcrenewal.blogspot.com/2011/04/common-sense-on-side-effects-lacking-in.html">http://hcrenewal.blogspot.com/2011/04/common-sense-on-side-effects-lacking-in.html</a>.<br /><br /><blockquote class="tr_bq">They conclude that the “lack of accountability for vendors through hold harmless clauses and the shifting of liability to the clinicians through the learned intermediary doctrine are significant and additional impairments to safety improvement. Electronic health records and EDISs are sufficiently complex that<b> the physician and other users cannot be expected to anticipate unpredictable errors.” </b></blockquote><br />That aligns with the work of Dr. Jon Patrick in Sydney, whose treatise <b>"A study of an Enterprise Health information System</b>" on the Cerner FirstNet ED EHR is available here: <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a><br /><br /><blockquote class="tr_bq">Earlier this month, the Electronic Health Record Association, an EHR developers trade group affiliated with the Chicago-based Healthcare Information and Management Systems Society, announced the<b> launch of a voluntary “<a href="http://www.modernhealthcare.com/article/20130611/NEWS/306119952/ehr-trade-group-issues-code-of-conduct-to-improve-patient-safety" target="_blank">code of conduct</a>”</b> in which adherents would agree to drop “gag clauses” in the contracts with their provider customers. </blockquote><br />Great.  Per the wonderful 2007 article "<b>The Denialists' Deck of Cards: An Illustrated Taxonomy of Rhetoric Used to Frustrate Consumer Protection Efforts</b>" by Chris Jay Hoofnagle, available at <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=962462">http://papers.ssrn.com/sol3/papers.cfm?abstract_id=962462</a>, as of this writing free: <br /><blockquote class="tr_bq"><br />... At this point [of losing the argument], the denialist must propose "self regulation" to deal with the problem that doesn't exist. The cool thing about self regulation is that it cannot be enforced, and once the non-existent problem blows over, the denialist can simply scrap it! [20]<br /><br /><span style="font-size: x-small;"><i>[20] In the runup to passage of bank privacy legislation, data brokers created a group called the "Individual Reference Services Group" that promptly disappeared after the legislation passed.</i></span></blockquote><br />("Denialism" is the use of rhetorical techniques and predictable tactics to erect barriers to debate and consideration of any type of reform, regardless of the facts.)<br /><br />IMO 'self regulation' of healthcare is, on its face, a deception.  There are simply too many conflicts of interest.<br /><br />On use of "integrated" big systems:<br /><br /><blockquote class="tr_bq">“These systems do have <b>glitches</b> [indeed - see <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a> - ed], <b>but it can be plain and simple bad design that can lead to clinical errors</b>,” Cozzens said.  But ED physicians, he said, are “having the enterprise systems forced upon them. To think you can take one system and adapt it to those different environments is totally wrong. That's why you see low physician satisfaction and the productivity is going down, all for the sacrifice of having an integrated system.”</blockquote><br />In fact, so-called "best of breed" systems can be bad health IT as well.  See the aforementioned evaluation by Dr. Patrick in Australia.<br /><br /><blockquote class="tr_bq"><span style="color: black; font-family: Arial; mso-bidi-font-weight: bold;"><b>Bad Health IT</b> ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, hard to customize, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for <span class="SpellE">hypervigilance</span> (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.<span style="mso-spacerun: yes;">  </span></span></blockquote><br /><br />Through my own work, I've seen bad health IT result in patient harm and death.  It's just unfortunate that I got started in this line of work by being, in effect, shot out of a cannon.  That is, my own mother was a victim.<br /><br />-- SS<br /><br /><b>Addendum 10/8/13:</b><br /><br />From the article:<br /><br /><blockquote class="tr_bq"><b>End-User Recommendation 4:</b> EDIS-related patient safety concerns identified by the review process should be addressed in a timely manner by ED providers, the EDIS vendors, and hospital administration. Each of these processes should be performed in full transparency, specifically with openness, communication, and accountability. </blockquote><br />I'm not sure the aforementioned levaquin near-accident "investigation" meets these standards.<br /><br />-- SS

Quality and Safety Implications of Emergency Department Information Systems: ED EHR Systems Pose Serious Concerns, Report Says

A report " Quality and Safety Implications of Emergency Department Information Systems " appeared in the Oct. 2013 issue of "...

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Marketing Bad Health Care Decisions as a New Form of Stealth Health Policy Advocacy

A remarkable set of video advertisements appeared a few weeks ago that seem designed to frighten people into making bad health care decisions.<br /><br /><b>The "Bad Uncle Sam" Advertisements </b><br /><br />As <a href="http://www.businessweek.com/articles/2013-09-20/the-creative-minds-behind-the-new-ghoulish-anti-obamacare-ads">described</a> by Businessweek,<br /><br /><blockquote class="tr_bq">In the first ad, dubbed '<a href="http://www.youtube.com/watch?v=R7cRsfW0Jv8">The Exam</a>,' a young woman who has signed up for Obamacare arrives at a medical facility and changes out of her clothes and into a flimsy hospital gown. Following the instructions of a doctor, she reclines on a hospital bed and spreads her legs into a pair of stirrups. The doctor leaves the room. Then, suddenly a mascot wearing a plastic Uncle Sam mask and sporting an unwavering grin—Creepy Uncle Sam!—pops up between her legs. As she screams, the ad pans out. 'Don’t let government play doctor,' reads the kicker.</blockquote><br />The final message, for some reason not described by Businessweek, was<br /><br /><blockquote class="tr_bq"><b>Opt out of ObamaCare</b></blockquote><br /><br /><iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/R7cRsfW0Jv8" width="420"></iframe> <br />Similarly,<br /><br /><blockquote class="tr_bq">A second spot, entitled '<a href="http://www.youtube.com/watch?v=BsN75nt1aUU">The Glove</a>,' follows a similar narrative arc. A young man sits in an examination room and tells a doctor that he’s signed up for Obamacare. 'I saw the ads and figured, why not?' he says. 'Okay,' says the doctor. 'Take your pants off.' The man drops his trousers, reclines on the hospital bed, and brings his knees to his chest. The doctor leaves the room. Behind the young man, Creepy Uncle Sam pops up, raises his hand into the air, snaps on a latex medical glove, and wiggles his fingers menacingly.</blockquote><br />Once again, the final message is<br /><br /><blockquote class="tr_bq"><b>Opt out of ObamaCare</b></blockquote><br /><iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/BsN75nt1aUU" width="420"></iframe> <br /><br /><b>The Ostensible Message of the Advertisements </b><br /><br />Again per Businessweek, the ads were sponsored by " <a href="http://generationopportunity.org/who-we-are/#axzz2fRyKxa6K">Generation Opportunity</a>, a Virginia-based conservative organization <a href="http://www.prwatch.org/news/2013/09/12247/breaking-new-list-dark-money-shell-game-groups-connected-kochs">funded</a> in part by Charles and David Koch,..."  According to an <a href="http://www.theatlanticwire.com/politics/2013/10/group-telling-young-people-opt-out-obamacare-still-working-math/70079/">article</a> on the Atlantic website, Generation Opportunity means to be<br /><br /><blockquote class="tr_bq">urging Millennials not to sign up for insurance on the health care exchanges created by the Affordable Care Act. It claims that paying the individual mandate's tax penalty and buying insurance that doesn't meet government coverage rules is a 'better deal' for young people.</blockquote><br />As many have noticed, that is not the implication of the visuals.  As an <a href="http://www.nationaljournal.com/politics/right-wing-ad-equates-obamacare-and-rape-20130919">opinion piece</a> in the National Journal put it,<br /><br /><blockquote class="tr_bq"> the message is that the government is trying to forcibly rape women with a blunt metal instrument.</blockquote><br />Furthermore, the final written message of both advertisements is not a nuanced one about where one should seek to go to buy health insurance.  It is simply "opt out of ObamaCare."<br /><br /><b>A Nonsensical Premise </b><br /><br />Also, the premise of the advertisements is nonsense, to put it politely.<br /><br />ObamaCare does require health insurance to pay for various kinds of preventive care without requiring patients to pay deductibles.  It does not make physicians and nurses provide these services.  Whether a patient gets, for example, a pelvic exam, is up to that patient and her doctor or nurse practitioner, not the government.  Of course, the legislation does not remotely suggest creepy government agents should perform pelvic or rectal exams.  <br /><br />Thus, the entire point of these advertisements seems to be to generate irrational fears that will drive young people away from health insurance now available through ObamaCare.<br /><br /><b>Stealth Health Policy Advocacy by Means of Marketing Bad Personal Health Care Decisions</b><br /><br />In the US, the Affordable Care Act, aka ObamaCare, still arouses a lot of controversy.  There are many people who have been critical of various aspects of the law.  (In fact, we <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">criticized </a>it for not addressing most of the issues about which we write on this blog.)  Furthermore, there is at least a large minority who want to repeal the law.  So there has been an ongoing barrage of persuasive messages meant to support or criticize various aspects of the law, and to support or discredit the entire law.<br /><br />However, the "Bad Uncle Sam" advertisements are different.  They do not urge people to vote for any particular person or initiative.  They do not urge people to express their own policy views.  They do not ask for contributions to political or advocacy organizations.<br /><br />Instead, they urge people to make particular health care decisions.  Despite the more nuanced messages espoused by Generation Opportunity when interviewed, their advertisements try to irrationally scare people away from purchasing health insurance made available by ObamaCare.<br /><br />They are aimed at young adults, who are less likely to have spare funds to pay for expensive health insurance, less likely to get sick or injured, and more likely to feel relatively invincible.  However, were an uninsured person, even a young one, to suffer a significant illness or injury, the resulting costs in our dysfunctional and extremely expensive health care system could drive them bankrupt.  This is all the more likely since the uninsured are likely to be charged "rack rates" for health care, while insurance companies negotiate discounts for their subscribers.  Furthermore, uninsured people may put off needed tests and treatments due to financial concerns, yet doing so may lead to worse health care results, or even death. <br /><br />An <a href="http://www.stltoday.com/business/columns/jim-gallagher/should-young-people-get-health-insurance/article_157c7d91-543b-5724-a560-c3f6eb34fae7.html">article</a> in the St Louis Post succinctly listed the costs associated with some unlucky outcomes for uninsured young people, for example,  <br /><br /><blockquote class="tr_bq">Suppose you twist your knee playing soccer. Without coverage, fixing it will be at least $20,000 to repair the ACL ligament, according to an estimate from <a href="http://health.costhelper.com/" title="http://health.costhelper.com/">Costhelper.com.</a><br /><br />Can’t pay it? Buy some crutches. They run about $30. You’ll also take on the <a href="http://www.nlm.nih.gov/medlineplus/ency/article/007208.htm" title="http://www.nlm.nih.gov/medlineplus/ency/article/007208.htm">risk of tissue damage and early arthritis</a>.</blockquote><br />Personal finance columnist Jim Gallagher concluded,<br /><br /><blockquote class="tr_bq"> although the vast majority of young adults stay healthy, serious trouble is not rare. Those without insurance are playing the odds. If they win, they’ve saved the insurance premiums. If they lose, they’re ruined.</blockquote><br />Generation Opportunity may <a href="http://generationopportunity.org/who-we-are/">claim to be</a><br /><br /><blockquote class="tr_bq"> a free-thinking, liberty-loving, national organization of young people promoting the best of Being American: opportunity, creativity and freedom. </blockquote><br />However, what it appears to be doing is urging bad health care choices  based on a false premise to serve an ideological agenda.<br /><br />Thus, its advertisements are a unique and uniquely bad mixture of marketing (of bad decisions) and <a href="http://hcrenewal.blogspot.com/search/label/stealth%20health%20policy%20advocacy">stealth health policy advocacy</a>.  If they want to publicly oppose ObamaCare, that is their right.  Fooling people into making bad decisions in the hopes that this will financially burden ObamaCare is completely unethical and amounts to <a href="http://hcrenewal.blogspot.com/search/label/disinformation">disinformation</a>, in my humble opinion.  The leadership and funders of Generation Opportunity ought to be ashamed of themselves. <br /><br />The US has many major health care problems.  They deserve discussion and debate.  Disinformation that tries to confuse people into making bad personal health care decisions is likely to make our health care dysfunction even worse.   <br /><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><br />

Marketing Bad Health Care Decisions as a New Form of Stealth Health Policy Advocacy

A remarkable set of video advertisements appeared a few weeks ago that seem designed to frighten people into making bad health care decision...

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Use of Psychological Manipulation of Physicians to Sell Pharmaceuticals: The Drug Representative as "Den Mother"

We have discussed, most recently <a href="http://hcrenewal.blogspot.com/2013/09/vested-interests-and-their-influence-on.html">here</a>, how marketers of health care goods and services use <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a> and psychological manipulation to sell their goods.  Physicians, of course, are particular targets of marketers of drugs and devices. <br /><br />A vivid anecdote showing how this works just <a href="http://well.blogs.nytimes.com/2013/10/03/for-med-students-love-from-the-drug-rep/">appeared</a> on a New York Times blog.  It may be easier to recall that psychological theories:<br /><br /><blockquote class="tr_bq">In the social and culinary wasteland that was residency training, it had been easy for Cheryl, a bubbly brunette in her mid-30s, to <i>become our den mother</i>. She <i>never tired of listening to our grousing,</i> had unerring taste in take-out, made it a point to come to our parties when invited and every so often <i>brought in a plate of her homemade brownies</i>.<br /><br /> But Cheryl was no den mother. She was a pharmaceutical rep.<br /><br /> That she managed to <i>slip a plug for her wares into every conversation</i> or <i>tuck copies of studies promoting her product into our white coat pockets </i>as we polished off her brownies <em>was</em> awkward. But we always overlooked the salesmanship because it was such a familiar part of our residency routine. As trainees in a large teaching hospital, we knew numerous sales reps by name and the products they peddled; and it was odd, even disappointing, to go to an educational conference where one of them was <em>not</em> standing next to a table laden with tchotchkes, information brochures and free take-out.<br /><br /> But in retrospect, such docile acceptance was problematic. In an environment where no one, including senior doctors, ever questioned the presence of sales reps, <i>we didn’t think too hard about why they might have been as friendly and helpful as they were.</i> We didn’t ask where the money for all these giveaways was coming from and we were rarely curious about who these reps actually were (I only ever knew their first names).<br /><br />It wasn’t that I or the other residents preferentially prescribed their products. But I do know that more than once <i>when faced with a decision about what to prescribe, the first thought that came to mind was <b>not what I needed to do to find the latest evidence-based recommendation, but what Cheryl had just told us over lunch. </b></i><br /><br /> All of this became painfully clear after Cheryl suddenly disappeared. At first, the other trainees and I thought she had been fired, so we avoided bringing her absence up with the rep who replaced her. But when I ran into someone from her company at a national medical conference a year later, I learned otherwise.<br /><br /> 'Oh, she got promoted,' the rep said, smiling broadly. 'Now <i>she’s an executive in the central office</i>.' </blockquote><br />Since Ahari and Fugh-Berman wrote and testified about the cynical tactics used in the marketing of drugs and other medical products years ago (look <a href="http://hcrenewal.blogspot.com/2007/05/fool-me-once-shame-on-you-fool-me-twice.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/03/what-drug-reps-really-care-about.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2008/04/more-about-cynical-world-of-drug-reps.html">here</a>), it is now inexcusably naive for doctors to believe that drug (or device) representatives are their friends, no matter how friendly they appear.  Drug and device reps are trained to appear to be likable.  They may look like sympathetic friends, glamorous companions, or in this case, den mothers.  But as Sah and Fugh-Berman noted (look <a href="http://hcrenewal.blogspot.com/2013/09/vested-interests-and-their-influence-on.html">here</a>), likability is a ruse to sell products.  Brownies are supplied to give the appearance of warmth and comfort, and to generate feelings of reciprocity. <br /><br />How well it works appears above: "the first thought that came to mind was not what I needed to do to find the latest evidence-based recommendation, but what Cheryl had told us over lunch."  That it works well is demonstrated by Cheryl's promotion to an executive office.<br /><br />As long as physicians remain trusting, naive, or foolish in their approach to deceptive marketing, there will be more use of needlessly expensive, and sometimes needlessly toxic drugs, and more drug reps made into well-paid executives. 

Use of Psychological Manipulation of Physicians to Sell Pharmaceuticals: The Drug Representative as "Den Mother"

We have discussed, most recently here , how marketers of health care goods and services use deception and psychological manipulation to sel...

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Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In effect, when under orders to only speak positively about a hospital or its technology, saying anything bad could very likely get clinicians labeled as 'troublemakers' or 'disruptive clinicians.'  Sometimes - in a sadly real example at Affinity Health - it may even get threats of having complaints plastered to one's forehead (see <a href="http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html">http://hcrenewal.blogspot.com/2013/07/hows-this-for-patient-rights-affinity.html</a>), a threat answered to by a judge.<br /><br />The 'disruptive' label usually does not have a good effect on one's evaluations and job (or, for doctors, even career) longevity.  See, for example, the resources at <a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/">http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/</a> on <b>sham peer review.</b><br /><br />At <a href="http://www.uahealth.com/">University of Arizona Health Network (UAHN)</a>, clinicians are being told to promote the EPIC EHR.<br /><br />The campaign is under the aegis of executives who know, should know, or should have made it their business to know the mayhem caused at other medical centers by EPIC and other major clinical IT systems (see for example query links <a href="http://hcrenewal.blogspot.com/search/label/EPIC">http://hcrenewal.blogspot.com/search/label/EPIC</a> and <a href="http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties">http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties</a>).<br /><br />Here's what clinicians are bring told in the Oct. 3, 2013 "Weekly update for UAHN employees":<br /><blockquote class="tr_bq"><br /><h1 style="color: #606060 !important; display: block; font-family: Helvetica; font-size: 40px; font-style: normal; font-weight: bold; letter-spacing: -1px; line-height: 125%; margin: 0; text-align: left;"> <span style="font-size: 18px;"><span style="color: #1c3e71; font-family: verdana, 'helvetica neue', helvetica, sans-serif; line-height: 18px;">Words that Work </span></span></h1><div style="color: #505050; line-height: 13px;"><br />Talking positively to our patients about our new Electronic Health Record system is important! Here are some key words and phrases you can use to emphasize the many benefits of the new system:</div><ul><li style="color: #505050; line-height: 13px;"> Electronic health record (not ‘Epic’ or ‘EHR’)</li><li style="color: #505050; line-height: 13px;"> One comprehensive record</li><li style="color: #505050; line-height: 13px;"> Coordinated care</li><li style="color: #505050; line-height: 13px;"> Improves patient safety & quality</li><li style="color: #505050; line-height: 13px;"> Convenient, easy patient portal </li><li style="color: #505050; line-height: 13px;"> Private and secure</li></ul><div style="color: #505050; line-height: 13px;"><a href="https://www.uahealth.com/pdf/Epic_Words_That_Work.pdf" style="color: #1c3e71; font-weight: normal; text-decoration: underline; word-wrap: break-word !important;" target="_self"><b>Click here</b></a> for more words and behaviors to inspire confidence in our patients (and ourselves) as we transition to this new system.</div></blockquote><br />The link to "more words" produced this PDF:<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s1600/words+that+work.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OOVivF_6D2GEFgUm6ujfKdJjMf4UMwoxX7ZECU7351gCph46CpKY7tryUY2qq63Q7Snl9fy1SNKk9QOxUyXfhgON7lm2W2MO_Sgin5pPxl4Rf6OR78MIdzjuQrxPDCBQ4ri6BeN3YxKn/s400/words+that+work.jpg" width="311" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><b>"Words that Work"</b> - If I worked there, I would be concerned that that using "words that don't work" about a project that probably cost hundreds of millions of dollars would likely injure my career. <b> Click to enlarge.</b></td></tr></tbody></table><br />This is shameless.  Many of these claims are unsubstantiated or in significant doubt in the literature.<br /><br />First:<br /><br />They left out issues such as these:<br /><br /><blockquote class="tr_bq">• The software is tested and validated for safety by nobody, including traditional medical device safety testers.<br /><br />• No postmarket surveillance for problems, either.<br /><br />• Transparency about problems that can cause patient harm is severely impeded by systematic impediments to information flow (as per <b>IOM's 2012 study of health IT safety</b> 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>, <b>FDA via their leaked Internal Memo</b> on HIT safety as at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, the <b>Joint Commission in their Sentinel Events Alert on Health IT </b>as at <a href="http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html">http://hcrenewal.blogspot.com/2008/12/joint-commission-sentinel-events-alert.html</a>, and others.)<br /><br />• Problems known are only the <b>"tip of the iceberg"</b> (FDA, ECRI Institute), as at <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html">http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html</a> and <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> </blockquote><blockquote class="tr_bq"><b>(Mar. 2014 addendum:</b> add to that list the revelations of med mal insurer CRICO, that EHR technology has contributed to a substantial fraction of the medical malpractice suits in Massachusetts: <a href="http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html">http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html</a>)</blockquote><br />Of the claims they do make:<br /><br /><blockquote class="tr_bq">• <span style="color: red;"><b><i>Efficient</i></b></span> - see aforementioned links as well as "Common Examples of Healthcare IT Difficulties" at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a><br /><br />• <span style="color: red;"><b><i>Convenient</i></b></span> - as above.  According to whom?  Compared to what?  Pen and paper?<br /><br />• <span style="color: red;"><b><i>Improves patient safety and quality</i></b></span> - see IOM report post at <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html">http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html</a> .  We as a nation <b>are only now studying safety of this technology</b>, and the results are not looking entirely convincing, e.g.<b> ECRI Deep Dive Study</b> of health IT safety at <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 IT mishaps in 36 hospitals, voluntarily reported over 9 weeks, with 8 reported injuries and 3 reported possible deaths is not what I would call something that "improves patient safety and quality" without qualifications.<br /><br />• <i><span style="color: red;"><b>The Cadillac of its kind</b></span></i> - according to whom?<br /><br />• <i><span style="color: red;"><b>Patients at hospitals using this system love it</b></span> </i>-  Do most patients even know what it, or any EHR, looks like?  Have they provided informed consent to its use?<br /><br />• <span style="color: red;"><i><b>Exciting </b></i></span>- clinician surveys such as by physicians at <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> and by nurses at <a href="http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html">http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html</a> shed doubt on that assertion.  </blockquote><blockquote class="tr_bq">(<b>Addendum:</b> also see what nurses think about these systems at "<b>Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications Only a Matter of Time in Open Letter</b>", <a href="http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html">http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html</a>)<br /><br />• <span style="color: red;"><i><b>The best thing for our patients</b></i></span> - again, according to whom?<br /><br />• <b><span style="color: red;"><i>Sophisticated new system</i></span></b> - "New"?  Not so much, just new for U. Arizona Health.  "Sophisticated", as if that's a virtue?  Too much "sophistication" is in part what causes clinician stress and burnout, raising risk; see this summary of a new, not-free JAMIA article "<b>Electronic medical records and physician stress in primary care: results from the MEMO Study</b>", J Am Med Inform Assoc amiajnl-2013-001875 at <a href="http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html">http://www.beckershospitalreview.com/healthcare-information-technology/the-relationship-between-emrs-and-physician-stress.html</a>.   From that summary:<br /><br /><blockquote class="tr_bq">... Compared with physicians at clinics with low-function EMRs,<b> physicians at clinics with moderate-function EMRs experienced significantly more stress and had a higher rate of burnout. </b>Additionally, physicians at clinics with moderate- or high-function EMRs felt less satisfied with their current position overall. </blockquote>and:<br /><blockquote class="tr_bq">... Results also showed a significant relationship between time pressure and physician stress in the cohort with high-function EMRs, and only in this cohort, <b>suggesting physicians at these clinics may be particularly pressured for time during patient encounters in the face of a large number of EMR functions</b>. "This 'made sense' to us in thinking about the possibility that those in the high-use group had more to do in the EMR" [say the authors].<b> </b></blockquote><br />• <span style="color: red;"><b><i>Smartest program out there</i></b></span> - "Smartest" meaning what, exactly?  According to whom?  Who performed the comparison?<br /><br />• <i><b><span style="color: red;">Streamlined</span></b> </i>- compared to what?<br /><br />• <b><span style="color: red;"><i>Thank you for your patience</i></span></b> - even if the effects on clinicians gets you or your loved ones maimed or killed?<br /><br />• <span style="color: red;"><b><i>Safe and secure network</i></b></span> - really?  No break ins, ever, considering multiple breach stories like those at <a href="http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy">http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy</a>?<br /><br />• <span style="color: red;"><b><i>Keeping you informed is our priority</i></b></span> - informed of what?<br /><br />• <span style="color: red;"><b><i>Specially trained staff</i></b></span> - like these:  <a href="http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html">http://hcrenewal.blogspot.com/2010/08/epics-outrageous-recommendations-on.html</a>?</blockquote><br />and this:<br /><br /><blockquote class="tr_bq">• <span style="color: red;"><i><b>Take Responsibility</b></i></span> - I ask, should clinicians "take responsibility" for IT-related disruptions that impair care such as "use error" (as opposed to user error), i.e., what the National Institute of Standards and Technology has called operator error due to poor usability and other features of bad health IT?  (See "<b>NIST on the EHR Mission Hostile User Experience</b>" at <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a>.)  What about <b>"glitches"</b> and bugs that corrupt or lose data?  Should clinicians also 'take responsibility' for those?  (See for example the posts on the wild things that happen when IT malpractice leads to clinical mayhem at <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>.)</blockquote><br />It appears to me that this vendor is using its client hospitals' management to enforce an "acceptable point of view" clinicians must proffer to patients about EHRs (which they must call "health" records), despite well-known contradictory findings.  This is, in effect, forced marketing of a device.<br /><br />Trying that for a drug or a conventional medical device (e.g., a particular stent) would be on its face unethical and likely illegal.<br /><br />Finally, critical thinking is what keeps patients alive and safe.  Marketing measures like this (some might call it "propaganda"), espousing and enforcing 'EHR exceptionalism', in my opinion, damage critical thinking and expression, and are thus unacceptable to push on clinicians and on patients.<br /><br />I add that requiring clinicians to promote deceptive propaganda the clinicians themselves know is untrue, from painful experience, is degrading, intimidating and destroys morale.  It is axiomatic that clinicians (or anyone) operating under such conditions cannot perform at their best.<br /><br />Thus the management geniuses who came up with these instructions (if not outright vendor-ghostwritten as at the Aug. 2012 "<b>Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists</b>", <a href="http://www.tinyurl.com/epic-stealth">http://www.tinyurl.com/epic-stealth</a>) are by their actions increasing risk of patient harm. <br /><br />The nurses' unions at 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> have it right, in my view:  complain about the disruptions this technology causes, and complain loudly, if at the very least to make sure the problems are out in the open.<br /><br />-- SS<br /><br /><b>Note: </b>also see the followup Nov. 2013 post "<b>We’ve resolved 6,036 issues and have 3,517 open issues: extolling EPIC EHR virtues at University of Arizona Health System</b>" at <a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html</a><br /><br />

Words that Work: Singing Only Positive - And Often Unsubstantiated - EHR Praise As "Advised" At The University Of Arizona Health Network

When clinicians are told to promote a technology in no uncertain terms, that puts a chilling effect on critical thinking and discourse.  In ...

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