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"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the American Medical Association: <a href="http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0">http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0</a> <blockquote class="tr_bq">Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems' October 18, 2013 - 10:17 AM By Susan Jones</blockquote><blockquote> Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association. Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association. The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said. The <a href="http://www.rand.org/pubs/research_reports/RR439.html" target="_blank">study</a>, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction. Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found. Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.</blockquote> I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems".  The academic-style fudge words "may be" and "early" are disposable. <blockquote class="tr_bq">"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients." </blockquote> Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician).  That is, making a statement that seems to speak for all physicians, and then for "most" physicians.  Clearly he didn't interview "most" physicians.  I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime. <blockquote>... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."</blockquote> Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which). For 2014, some commonsense observations and recommendations on EHRs: 1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation.  The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014.  (I was taught Medical Informatics by some of those pioneers.) 2) The pioneers never intended to add uncompensated burdens onto clinicians.  They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion. 3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (<a href="http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html">http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html</a>) and of IT usability by NIST (<a href="http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html">http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html</a>) in just the past few years. With these factors in mind: <blockquote class="tr_bq">... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry. </blockquote> Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent.  The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows:  1)  Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely.  Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).   2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.   3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, <a href="http://www.emc.com/enterprise-content-management/documentum-platform.htm">http://www.emc.com/enterprise-content-management/documentum-platform.htm</a>; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription.  The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information. 4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort.  See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story</a>.  The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care. 5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated.  Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters.  I think physicians should do at least as well.  (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.) 6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.        a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place. 7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties. -- SS

"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the Amer...

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"Emotion, not Information" - the Lucrative Deceptive Marketing of Hospice, and its Potentially Fatal Consequences

One of the real recent advances in health care, in my humble opinion, was the organization of compassionate, palliative care for people at the end of life.  During my training and early career I saw too many patients with terminal illness getting aggressive, sometimes very painful treatments which at best only offered hope of briefly prolonging their lives.  Some patients chose such treatments with full knowledge of the implications, at times with the hope that they might survive until some significant event, for example, the birth of a grandchild.  Many patients, however, seemed to be suffering with no purpose. The hospice and palliative care movement, however, offered true comfort to those with little hope of prolonged survival.  Good hospice care eased the final days of patients with advanced disease for whom no definitive treatments could be found. Hospice seemed like a great alternative for such patients, but its reasonable use depended on physicians' abilities to identify patients who really were at the end of life, and for whom aggressive treatment would be futile.  The Achilles Heel of the hospice movement remained health care professionals' inability to reliably identify such patients.  The big problem is that putting a patient who actually potentially could survive for a long time in hospice will doom that patient were he or she to develop an acute illness for which treatment is available, like a bacterial pneumonia that might respond to antibiotics, because in hospice antibiotics are not given for acute infections. So the development of hospice had a downside which could be fatal for some patients.  I think most physicians hoped, however, that we could minimize the number of such patients by trying hard to make accurate predictions, and that in the future, better technology would lead to better predictions. The Rise of Corporate Hospices Back in the 1980s, however, I did not anticipate that hospices might become parts of for-profit corporations, and that such corporations might be able to make more money by admitting more patients, even patients who really were not at the end of life.   Starting in 2011, however, we started to find cases in which that appeared to be what was going on (look <a href="http://hcrenewal.blogspot.com/2011/07/prepare-them-to-die-for-profit-hospices.html">here</a>, then <a href="http://hcrenewal.blogspot.com/2012/03/gentivas-odyssey-healthcare-settles.html">here</a>, <a href="http://hcrenewal.blogspot.com/2012/05/who-cares-if-patients-die-apparently.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2012/09/more-hospices-pretending-patients-are.html">here</a>). In 2013, more cases appeared, listed in chronologic order - Hospice of Arizona LC and American Hospice Management LLC - Per a <a href="http://www.justice.gov/opa/pr/2013/March/13-civ-326.html">news release</a> from the Department of Justice, these entities settled litigation that alleged, among other things, that they "submitted or caused the submission of false Medicare claims between Sept. 1, 2002, and Dec. 31, 2010, for Hospice of Arizona patients who did not need end of life care...."  Hospice Care of Kansas, and parent company Voyager HospiceCare - Per a Topeka (Kansas) Capital-Journal <a href="http://cjonline.com/news/state/2012-06-21/kansas-hospice-firm-pays-61-m-settlement">article</a>, these entities settled to resolve allegations that they "submitted inappropriate claims between January 2004 and December 2008 for patients without a terminal prognosis of six months or less." Hernando-Pasco Hospice - <a href="http://www.tampabay.com/news/health/hernando-pasco-hospice-agrees-to-pay-1-million-to-settle-false-billing/2132592">Per the Tampa Bay Times</a>, " Hernando-Pasco Hospice has agreed to pay $1 million to settle allegations that it billed the Medicare and Medicaid programs for patients who did not need end-of-life care, the U.S. Attorney's Office for the Middle District of Florida announced Monday.  The not-for-profit Hernando-Pasco Hospice, which goes by HPH Hospice, is accused of admitting ineligible patients in order to meet targets imposed by its management team, federal authorities said in a statement." These were all small settlements, that is, less than $15 million, reported in relatively small media outlets. This week the issue was in the media spotlight courtesy the Washington Post, in <a href="http://www.washingtonpost.com/business/economy/medicare-rules-create-a-booming-business-in-hospice-care-for-people-who-arent-dying/2013/12/26/4ff75bbe-68c9-11e3-ae56-22de072140a2_story.html">an article</a> which provided yet more data and vivid examples suggesting that for-profit hospices were putting money ahead of vulnerable patients' well-being.    The Post added to the background we provided above, <blockquote class="tr_bq">Medicare began paying for hospice care in 1983, following a resurgence of interest in end-of-life care, sparked in part by the publication of '<a data-xslt="_http" href="http://www.amazon.com/gp/product/0684839385?ie=UTF8&camp=1789&creativeASIN=0684839385&linkCode=xm2&tag=thewaspos09-20">On Death and Dying</a>' by Elisabeth Kubler-Ross. 'We can give families more help with home care and visiting nurses, giving the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home,' Kubler-Ross testified to the Senate Special Committee on Aging in 1972.</blockquote> After this well-intentioned beginning, there was a rapid increase in the use of hospice, and hence its costs, <blockquote class="tr_bq">The benefit was quickly embraced by Americans and continues to grow, with Medicare paying for hospice care for more than 1.2 million people annually. In 2000, Medicare spent $2.9 billion on the hospice benefit. By 2012, that figure has risen fivefold, to $15.1 billion. But as more Americans have taken up hospice care, a profound change has been underway: Big businesses have moved in.</blockquote> In parallel, the nature of hospices changed, going from being predominantly local non-profit organizations to predominantly corporate, <blockquote class="tr_bq">When Medicare paid its first hospice benefit, the vast majority of hospice-care providers were nonprofit groups. Over the past decade, however, the for-profits have come to dominate the industry. In 2000, 70 percent of hospices were run by nonprofit organizations or government agencies. Today, nearly 60 percent are for-profit companies, and they may account for an even larger share of patients.</blockquote> They really were for-profit, <blockquote class="tr_bq">The profit margins as measured by MedPAC, the Medicare watchdog, climbed to 8.7 percent in 2011. The per-patient operating profit has risen from $353 in 2002 to $1,975 in 2012, according to the analysis of California data.</blockquote> Big money lured aggressive players, in particular, private equity, <blockquote class="tr_bq"> The returns have attracted some prominent financial firms, whose analysts have run the numbers and decided to invest. Among the private investment companies that have put down bets on hospices in recent years are Kohlberg Kravis Roberts & Co., KRG Capital Partners and Summit Partners.</blockquote> As we have discussed <a href="http://hcrenewal.blogspot.com/2012/07/private-equity-vs-patient-care-bainful.html">elsewhere</a>, the private equity model involves not long term management, but trying to make big money in the short term, either by directly extracting it from the companies taken over, of by rapidly selling them, if necessary, piece by piece.  Financial Incentives to Enroll the Wrong Patients Keep in mind that the revenue fueling the uber capitalists involved in for-profit hospices came predominantly from the US government, and depended on the rules set by the government to pay for hospice, <blockquote class="tr_bq">The vast majority of those profits flow from the U.S. government and Medicare, which makes an estimated 85 to 90 percent of all payments to hospices.</blockquote> The payments provide more profit from patients with the longest stay in hospice, <blockquote class="tr_bq">The reason that longer stays are more profitable is that hospice companies typically spend more on patients at the beginning of their care and then again at the end of their lives. When a patient is first enrolled, the hospice often must diagnose the patient’s illness, set up home equipment and get them stabilized. Then, during the last week of life, a hospice typically must pay for more frequent home visits by the nurse, aides and others. As a result, patients who live a longer time — and for whom there is a long, stable period in the middle — generate more profits.</blockquote> There is evidence that for-profit hospice management has reacted to these incentives to enroll patients who would live a long time, despite the fact noted above that hospice was intended for patients who were at the end of life, and were obviously thus expected not to live for a long time, <blockquote class="tr_bq">Indeed, it has been an open secret in the industry that, because of the method of payment, the way to run a hospice profitably is to enroll patients who stay for a long time. The <a data-xslt="_http" href="http://www.wikinvest.com/stock/VistaCare_%28VSTA%29/Filing/10-K/2007/F3366157">annual report in 2004 for one large hospice provider, VistaCare</a>, noted that its fortunes depended on its ability to manage costs and 'maintain a patient base with a sufficiently long length of stay.' The company also warned that 'cost pressures resulting from shorter patient lengths of stay . . . could negatively impact our profitability.' 'It is common knowledge in the industry that a longer length of stay is going to be more lucrative,' said Rachel Mason, who worked in marketing at Delta Hospice in California, where one of the company’s branches had one of the highest discharge rates of living patients in the state last year — 63 percent. 'If they come in very sick and die right away, it’s difficult to run a business that way.'</blockquote> So, in the aggregate, stays have gone up, costs have increased, partially because there are more hospice ''urvivors," that is, patients who actually were admitted to hospice not at the end of life, survived much more than the six months which was supposed to have been their expected lifespan, and thus ended up graduating from hospice, a service meant originally for the terminally ill, <blockquote class="tr_bq">over the past decade, the number of 'hospice survivors' in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require fewer visits and stay enrolled longer. The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012, according to a Post analysis of more than 1 million hospice patients’ records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry. The average length of a stay in hospice care also jumped substantially over that time, in California and nationally, according to the analysis. Profit per patient quintupled, to $1,975, California records show.</blockquote> Yet, while Medicare administrators have been warned about these perverse incentives, they have done nothing to fix them, <blockquote class="tr_bq">For five years, Medicare’s watchdog group has been recommending that the payments to hospice companies be revised to eliminate the financial incentive for improper care, but Medicare has not yet done so. To ensure that patients are appropriately selected for hospice care, Medicare relies on strict medical documentation requirements, a spokesman said. </blockquote> Perhaps Medicare administrators are listening harder to for-profit hospice executives than to their own advisory committee, <blockquote class="tr_bq"> The hospice industry is opposed to fundamental changes to the payment system. Jonathan Keyserling, senior vice president of health policy at the <a data-xslt="_http" href="http://www.nhpco.org/">National Hospice and Palliative Care Organization</a>, an industry group, said that the current payment system is sound and that tampering with it could have unintended consequences. </blockquote> Furthermore, <blockquote class="tr_bq">because of the large sums of money at stake, <a data-xslt="_http" href="http://www.medpac.gov/documents/Jun13_EntireReport.pdf" target="_blank">MedPAC in June added a sense of urgency</a> to its recommendation. 'Given the magnitude of hospice spending devoted to long-stay patients, who are more profitable under the current payment system than other patients, it is important that an initial step toward payment reform be taken as soon as possible,' MedPAC wrote.</blockquote> Yet Medicare administrators still seemed to feel no sense of urgency, and are not eager to address the specifics of the MedPac recommendations, <blockquote class="tr_bq">A spokesman for Medicare said the agency is considering hospice payment reform but that no such changes will happen in fiscal 2014. 'While the Medicare hospice benefit provides a choice for beneficiaries to seek the care that best meets their care needs and desires, Medicare has and will continue to take actions to safeguard this benefit from inappropriate use,' said <a data-xslt="_http" href="http://www.cms.gov/About-CMS/Leadership/jonathanblum2.html">Jonathan Blum</a>, principal deputy administrator of the Centers for Medicare and Medicaid Services, said in a statement. </blockquote> So to recap so far, the hospice movement devolved from one involving non-profit organizations providing care to the terminally ill to ever larger corporations providing care to the less ill, paid largely by the US government under rules from a simpler era.  However, since hospice provides only palliative care, this transition meant that some patients who were not terminally ill may have died from illness that would have been treated in an environment other than hospice. Vivid Anecdotes of the Deceptive Marketing of Hospice The Washington Post article summarized allegations from multiple legal actions that provided a disturbing tapestry of deceptive marketing deployed to recruit patients unsuitable to hospice care, <blockquote class="tr_bq">While the lawsuits against the for-profit hospices vary in the details, as a whole they depict an industry in which companies compete for new patients and provide services to patients who are not eligible for them. Hospice 'outreach specialists' and 'community education representatives' seek out patients in a variety of ways: They solicit doctors and hospitals who might regularly deal with the terminally ill; they make connections at nursing homes, assisted-living developments and Meals on Wheels groups. They show up at the 'health fairs' held at senior centers with, for example, machines that test blood pressure. For families struggling to take care of a loved one, they offer the promise of extra help. At AseraCare, officials gave advice to their recruiters on how to close a deal with families who are 'not ready yet' for hospice, according to a company presentation for Alabama employees. It instructed recruiters to 'focus families' by stressing the urgency of a decision, and saying things like, 'We only have 10 minutes left.' 'Effective communication is the transfer of emotion, not information,' the presentation said. At Odyssey Healthcare, one of the nation’s largest hospice companies, representatives earned bonuses if they met their goals for new patients, according to that complaint. The case led to a $25 million settlement with the company. At <a data-xslt="_http" href="http://www.vitas.com/Aboutus/Newsroom/ParentCompany.aspx">Vitas</a>, a division of Chemed, a company that also owns the Roto-Rooter plumbing service, the corporate culture encouraged staff members to admit as many patients as possible, regardless of whether they were eligible for hospice care, according to the lawsuit. The lawsuit said the company paid bonuses based on the number of patients enrolled. One former manager said that the company philosophy was 'sign everybody up' and that medical staffers felt pressured to admit patients regardless of whether they were appropriate. And at Angels of Hope hospice in LaGrange, Ga., audio recordings cited in the complaint described how some salespeople found patients: by cruising neighborhoods, looking for elderly people with disabilities.</blockquote> The article coned down on specific litigation about AnseraCare, <blockquote class="tr_bq">One of the primary lawsuits against AseraCare was initiated by Dawn Richardson, a clinical manager at the company, and Marsha Brown, the former executive director at the company’s Monroeville, Mobile and Foley, Ala., outlets. There was steady pressure for AseraCare managers to find more patients, the lawsuit said. An executive who did not meet a quota was penalized, according to the lawsuit, and the company offered a massage chair for the person who brought in the most hospice patients. 'In order to make our admission goal for the month, we are down to the wire, and need today to be a huge admit day for every region,' a regional vice president wrote in an e-mail, according to the lawsuit. 'Mobilize your teams, get them into the game this morning . . . when we call on them, they always respond with referrals and a push to convert those referrals into admits ASAP.' 'We had a director who would be like, ‘Get a patient, get a patient, get a patient,’ ' Michael Bonham, a Lutheran minister who worked as a chaplain at the company in Alabama, said in an interview. He is not a party to any of the lawsuits. These demands for patients were sometimes met with people who were sickly but not dying, according to the federal lawsuit, which outlines five examples. One patient was supposed to have had end-stage heart disease and thus would have had trouble breathing and walking, according to the lawsuit. He left the nursing home for his granddaughter’s graduation and for Christmas, had a good time and ate a lot, according to notes from hospice workers cited in the lawsuit. Another, diagnosed with end-stage 'debility,' was not losing weight as is typically the case, according to the legal filing, and instead went out for a trip to Wendy’s and another to go birdwatching.</blockquote> Hospice firms' public relations departments provided the usual high minded statements that did not address specific allegations about the marketing of hospice, for example, <blockquote class="tr_bq">'AseraCare provides an important and valuable service to patients and their families facing difficult end-of-life decisions,' the company said in a statement. 'Our policies and programs comply with the Congressional intent of the hospice benefit to reduce the stress and anxiety of the end of life of a loved one,' the company said. 'Doctors for each patient in question determined that the patient needed hospice care, and expressed their clinical judgment by signing the required physician certifications. Other independent and well-qualified physicians reviewed the charts of these patients, and overwhelmingly agreed with the original conclusions that these patients were entitled to receive the hospice benefit.' The company declined to identify the doctors who certified the patients in Alabama.</blockquote>That seems about as relevant as the <a href="http://www.goldenliving.com/about-us.aspx">mission and values statements of Golden Living,</a> AseraCare's parent corporation, <blockquote class="tr_bq"><h3>Our Mission</h3>To share our passion for improving quality of life through innovative healthcare — one person, one family and one community at a time. <h3>Our Values</h3>Make integrity and accountability your pledge. Share our passion for excellence. Be uncompromising in delivering quality care.</blockquote> Summary <blockquote class="tr_bq">Yet somehow our society must make it right and possible for old people not to fear the young or be deserted by them, for the test of a civilization is in the way that it cares for its helpless members. </blockquote> Pearl S Buck, My Several Worlds, 1954, p 377 (see <a href="http://en.wikiquote.org/wiki/Civilization">Wikiquote</a>) I also was once taught that the true test of a doctor is his or her care of the sickest and most vulnerable patients.  By this token,  how the hospice movement in the US evolved into corporate health care delivery which generates tremendous revenues from the most vulnerable patients, and in some cases may condemn ill but not terminal patients to death from treatable disease marks how badly US health care has failed. The story combines many of the themes we have sounded before - <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">Perverse Incentives</a> - a reimbursement scheme that made sense when hospices were local community non-profit organizations now provides incentives for commercial hospices to enroll patients who are not terminally ill, putting them at risk of inadequate care should they develop a new serious but treatable problem. Money Before Mission - For-profit hospices which market themselves as equivalent to their community non-profit forerunners, are run, as is suggested above, to maximize revenue no matter the effect on mission. Presumably this is justified by the fallacy of <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">maximizing shareholder value</a>, which really means maximizing apparent short-term revenue in order to maximize executive compensation, no matter what the collateral damage. <a href="http://hcrenewal.blogspot.com/search/label/impunity">Impunity</a> - Although hospice enrollment of unsuitable patients not only may defraud the government, but may put such patients at risk of their lives, the only regulatory or law enforcement actions against big corporate hospices so far involve corporate fines that are small in comparison with revenues, but not penalties imposed on any individuals who authorized, directed or implemented such patient enrollment, even when patients wrongly enrolled have died from lack of treatment of potentially treatable problems. <a href="http://hcrenewal.blogspot.com/search/label/corporatism">Corporatism</a> - Government agencies which could seriously challenge corporate hospices' actions have been curiously inert, perhaps because agency leaders feel more sympathetic to their fellow managers within corporate hospices than to the citizens whose interests they are supposed to protect. Because of their potentially severe adverse effects on our most vulnerable patients, reform of hospices should be at the forefront of true health care reform.  At the least, we need vastly tougher regulation of corporate hospices, removal of perverse incentives for them from the government payment system, and vigorous law enforcement when their leaders induce them to misbehave.  Leaders of corporate hospices need to be held accountable for their actions, and must be pushed towards putting their patients' health ahead of all other considerations, including the leaders' personal enrichment. Furthermore, the story of corporate hospices shows that while turning direct health care over to poorly regulated for-profit corporations may have been increased efficiency, been "disruptive" and lead to innovations, the efficiency, disruption and innovation have mainly lined the pockets of corporate insiders, and not improved patients' or the public's health.  We ought to give strong consideration to banning corporate hospices, and banning all forms of the <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">corporate practice of medicine </a>and corporate health care "delivery." Given how many insiders make so much money from the current version of laissez faire capitalism in health care, however, I would expect strong resistance should such apparently "radical," but actually conservative proposals actually get any mainstream attention.

"Emotion, not Information" - the Lucrative Deceptive Marketing of Hospice, and its Potentially Fatal Consequences

One of the real recent advances in health care, in my humble opinion, was the organization of compassionate, palliative care for people at t...

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Out Goes 2013. Some Year-End Observations on Healthcare IT: The Data Granularity Theater of the Absurd, Be Careful What You Ask For, And a Little Totalitarianism from HIStalk Blog

As 2013 comes to a close, here are some year-end observations on Healthcare IT: From the Dec. 30, 2013 New York Times article "Roughed Up by an Orca? There’s a Code for That" (<a href="http://www.nytimes.com/2013/12/30/technology/medical-billing-nears-a-new-era-of-ultra-specific-codes.html" target="_blank">http://www.nytimes.com/2013/12/30/technology/medical-billing-nears-a-new-era-of-ultra-specific-codes.html</a>): 1) ICD-10: the Data Granularity Theater of the Absurd <blockquote class="tr_bq">... ICD-9 [used in the United States for medical statistics since 1979 and for billing since 2002] ... has about 14,000 codes to specify diagnoses and 3,000 to specify inpatient procedures. <div itemprop="articleBody">ICD-10, with codes containing up to seven digits or letters, will have about 68,000 for diagnoses and 87,000 for procedures. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">While ICD-9 had a single code for certain repairs to blood vessels in the head and neck, ICD-10 allows specification of the particular vein or artery and the particular procedure used. Extra codes allow recording of whether a patient was visiting the doctor for the first time or a subsequent time for a particular problem, and whether broken arms and some other injuries occur on the left or right side of the body. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">There are dozens of codes dealing just with the big toe — contusion of the right great toe, contusion of the left great toe, with damage to the nail or without, initial encounter or subsequent encounter, blisters, abrasions, venomous insect bites, nonvenomous insect bites, lacerations, fractures, dislocations, sprains and amputation, not to mention the vague “acquired absence of unspecified great toe.” </div><div itemprop="articleBody"> </div><div itemprop="articleBody">ICD-10 has been the <a href="http://www.healthcareitnews.com/infographic/infographic-top-zaniest-icd-10-codes" title="List of 8 zaniest ICD-10 codes.">subject of jokes</a>, however, for its catalog of possible injury causes, like those burning water skis. There are codes for injuries incurred in <a href="http://online.wsj.com/news/articles/SB10001424053111904103404576560742746021106" title="Article on colorful medical events. ">opera houses</a> and while knitting, and one for sibling rivalry. </div></blockquote> Codes for - injuries in opera houses?  Knitting?  Sibling rivalry?  Right toe vs. left toe contusions?  ... Having been witness/participant in development of a number of taxonomies in specialized areas of medicine, e.g., invasive cardiology, and in genomics, where at least there is significant advantage to a good degree of granularity, I think it can not too unfairly be said that the proponents of ICD-10 are - let's just say, anal fanatics. <blockquote class="tr_bq">... ICD-10 has already been postponed by a year. It was originally scheduled to go into effect this past Oct. 1, which would have coincided with the rollout of the insurance website. </blockquote> The delays have largely been due to end user difficulties in implementation in the real world, but imagine if the ICD-10 rollout had coincided with the Obamacare insurance website debacle.  The fireworks would have been truly spectacular. One wonders if there's an ICD-10 code for "injuries to the genitals from medical experiments conducted by space aliens after abduction."  (I guess we'd need several codes - one for each gender at the very least.) <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/AVvXsEhHN7nytJ7htWeVcANBLJD7XRFekBIEIHpO8WkEobwXX2QXsU_jfMj-hjZBqrsC_sAoulGqslQJT7bcigISYsRZW9o4rFlpS5sOelSa-JkWeohWXVBNrp9aHqg7BSwxXQyo7gIpo8DhmJpY/s1600/loki.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHN7nytJ7htWeVcANBLJD7XRFekBIEIHpO8WkEobwXX2QXsU_jfMj-hjZBqrsC_sAoulGqslQJT7bcigISYsRZW9o4rFlpS5sOelSa-JkWeohWXVBNrp9aHqg7BSwxXQyo7gIpo8DhmJpY/s320/loki.JPG" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">What's the ICD-10 code for injuries from experiments conducted after <a href="http://www.gateworld.net/sg1/s7/703.shtml">abduction by space aliens</a>?</td></tr></tbody></table> 2)  Be Careful What You Ask For <div itemprop="articleBody">In the aforementioned New York Times article,  John Halamka, who in my opinion may qualify for the title "the Galloping Gourmet of Clinical Cybernetics" (a description that occurred to me after seeing him speak a few years ago, see <a href="http://www.youtube.com/watch?v=4mY4Qi7J4ag">http://www.youtube.com/watch?v=4mY4Qi7J4ag</a>) said this:</div><div itemprop="articleBody"> </div><blockquote class="tr_bq"><div itemprop="articleBody">... Dr. John D. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, said the need to prepare for I.C.D.-10 and the Affordable Care Act and to achieve so-called meaningful use of electronic health records all at once could overwhelm computer staffs throughout the health care industry. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">“It’s just this collective sum of activities that exceeds the capacity of the system to absorb it simultaneously,” he said. </div><div itemprop="articleBody"> </div><div itemprop="articleBody">He said his hospital was spending $5 million this year on I.C.D.-10, $7 million for the Affordable Care Act, $2 million on meaningful use, and $3 million to comply with a federal health care privacy law. “Basically, I’m not doing anything but federal regulatory mandates,” he said. </div></blockquote> (Bureaucracy given an inch, and now wanting a light year?  Whoda thunk it?) Reminds me of the saying: "be careful what you wish for." I also really don't think the hospital can complain about the millions being spent to satiate the bureaucrats.  After all, think of all the "Billjuns and Billjuns" of dollars they're saving from these EHRs! <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/AVvXsEiLeNLBFdcAntzOhUvup2ce997xJ1zjshC1NnpGQNzzJ6lHHi7-Qm7jhQ3mkX90je0ySfSfcKhC6E-4gEuCm8D6HmcIn08cXoT5u8MHH-zdcATzrVQiGQH8wzd2tdLrRfluCPrK_iXSLmT6/s1600/Carl-Sagan-portrait.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLeNLBFdcAntzOhUvup2ce997xJ1zjshC1NnpGQNzzJ6lHHi7-Qm7jhQ3mkX90je0ySfSfcKhC6E-4gEuCm8D6HmcIn08cXoT5u8MHH-zdcATzrVQiGQH8wzd2tdLrRfluCPrK_iXSLmT6/s320/Carl-Sagan-portrait.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Why is Dr. Halamka complaining about a few million dollars spent on satiating the bureaucrats?  After all, these EHR systems are supposedly saving Billions Upon Billions of <s>Stars</s>, er - dollars.  Right? </td></tr></tbody></table> I also note the "could overwhelm computer staffs."  How about overwhelming the people who actually take care of patients? Statements like this give real meaning to my quasi-satirical observation that "computers seem to have more rights than clinicians or patients." Finally: 3)  A Little Totalitarianism from HIStalk Blog  In the HIStalk post "Curbside Consult with Dr. Jayne 12/30/13" <a href="http://histalk2.com/2013/12/30/curbside-consult-with-dr-jayne-123013/" rel="bookmark" title="Permanent Link to Curbside Consult with Dr. Jayne 12/30/13"></a> (<a href="http://histalk2.com/2013/12/30/curbside-consult-with-dr-jayne-123013/">http://histalk2.com/2013/12/30/curbside-consult-with-dr-jayne-123013/</a>) the semi-anonymous blogger “Dr. Jayne” notes that getting physicians to enter data into the EHR is difficult: <ul><li>We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant. </li></ul> What a novel concept – paying extremely skilled professionals for their time and labor. Imagine that! Dr. Jayne, I ask you - can you be just a little more patronizing? You’re just too nice in your attitudes towards skilled professionals and compensation for the mass time-add of EHR use. <ul><li>Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards [i.e., to use whatever lousy EHR we throw at them - ed.] to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.</li></ul> How generous of your organization’s <s>Commissars</s> – oops, I mean executives to not deny a doctor a living because they can't or won't become slaves to some lousy EHR designed with little or no attention to providing a good user experience, or to clinical time-based realities. I guess said executives also never heard of what can happen to a clinician whose loss of hospital privileges gets into the National Practitioner Data Bank (<a href="http://www.npdb-hipdb.hrsa.gov/">http://www.npdb-hipdb.hrsa.gov/</a>). Here is a little New Year's hint from <a href="http://www.walterhav.com/pubs/winter10.pdf">http://www.walterhav.com/pubs/winter10.pdf</a> by Ohio lawyers Michael J. Jordan and John E. Schiller, from SideBar, a publication of the Federal Litigation Section of the Federal Bar Association: <blockquote class="tr_bq">... Under many circumstances, federal law requires the hospital to report a reduction or revocation of a physician’s medical staff privileges to the National Practitioner Data Bank (NPDP). The NPDP was created two decades ago, when Congress enacted the Health Care Quality Improvement Act of 1986 (HCQIA). ... A report to the NPDB can, for all intents and purposes, end a physician’s career, because without hospital privileges, most physicians have substantially reduced earning capacity. The last hope for a physician who faces the loss of privileges is an action in court. In contesting a loss of privileges in state or federal court a physician immediately faces a hospital’s claim of protection under HCQIA. This protection comes in the form of a limited review of the hospital’s conduct, designed to encourage open and candid self-policing by hospital physicians who serve on peer review committees. </blockquote> I note that attitudes like this are typical of IT geeks and health IT hyper-enthusiasts, whose arrogance knows few bounds.  Such are the people who dismiss reports of patient injuries and deaths such as 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> and <a href="http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html">http://hcrenewal.blogspot.com/2011/06/babys-death-spotlights-safety-risks.html</a> as necessary sacrifices to the <a href="http://en.wikipedia.org/wiki/Lords_of_Kobol">Lords of <strike>Cobol</strike> Kobol</a>, and genuine concerns about the negative consequences of Bad Health IT (which in their minds does not exist, as IT can only create miracles) - as coming from "disruptive physicians." This may have to do with poor socialization of data processing personnel and computer geeks, and how it impairs their being a true part of the medical team (e.g., see <a href="http://dl.acm.org/citation.cfm?id=563354&coll=portal&dl=ACM">http://dl.acm.org/citation.cfm?id=563354&coll=portal&dl=ACM</a>). Lastly, some patriotic music for Dr. Jayne and her imperious organizational leaders for the New Year: <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="http://www.youtube.com/watch?v=7SYCCY7TIXo" style="margin-left: auto; margin-right: auto;"><img border="0" height="138" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5mtGnSvjYyo3OqdPT_W46MELuxp57tvQkBFlGY_tams3EFLQs4-uFZalRs3_V0nEKo7ITz59c_97mvjLCTMN0J60tz13RXxh_aWDUL2zzCMpRVH6chjTb9xLJ2NKOYw9LffH2i3PgbK_i/s200/ussr.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Click for Patriotic music!</td></tr></tbody></table><div style="text-align: center;"><a href="http://www.youtube.com/watch?v=7SYCCY7TIXo" style="margin-left: auto; margin-right: auto;"></a> </div> And with that, Happy New Year, all! -- SS 12/31/13 addendum: A commenter made me aware of this ICD-10 code: <a href="http://www.icdvalidator.com/Medical_Data/ICD10/DiagnosisV9733XD.html" rel="nofollow">http://www.icdvalidator.com/Medical_Data/ICD10/DiagnosisV9733XD.html</a> <blockquote class="tr_bq">ICD-10 Code : V9733XD (V97.33). Sucked into jet engine, subsequent encounter General information on the “V9733XD” code Revision: 10th Revision</blockquote><blockquote>ICD-10 Code: V9733XD (V97.33) Code Type: Diagnosis Description: Sucked into jet engine, subsequent encounter Chapter/Section : External causes of morbidity (V00-Y99) Section/BodyPart : Air and space transport accidents Note : The code is valid for submission on a UB04  </blockquote> I will surely sleep well tonight knowing this code exists, and still more soundly since I imagine there are separate codes for "sucked into jet engine, initial encounter" as well as for injuries by propeller blades and by rocket engines. -- SS 1/1/14 Addendum: A physician reader, extremely technologically savvy and a fellow Ham Radio enthusiast, had this to add: <blockquote class="tr_bq">Happy New Year Scot. Yes, that was MY New Year's Eve blog comment rant last night. As you can imagine, I am totally disgusted with my role as an enslaved peon in this cyclopean madness. I suppose it has something to do with my INTP personality. What's happening is a Bataan style death march for the medical profession. </blockquote> I opine the infringements on the practice of medicine by bureaucrats and fools also represents a Bataan style death march for very sick patients. -- SS

Out Goes 2013. Some Year-End Observations on Healthcare IT: The Data Granularity Theater of the Absurd, Be Careful What You Ask For, And a Little Totalitarianism from HIStalk Blog

As 2013 comes to a close, here are some year-end observations on Healthcare IT: From the Dec. 30, 2013 New York Times article " Roughed...

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No Needle, but the Damage was Done - A New Example of Suppression of Research about Adverse Effects of Prescription Narcotic Analgesics

This story feels personal, since as a physician who trained starting in the 1970s, figuring out how to manage patients who desperately wanted narcotics, whether to relieve pain, relieve addiction, or relieve financial distress has been a constant challenge. Background  - Treating Pain while Avoiding "the Needle and the Damage Done" Almost as soon as I started clinical training in medical school I came up against the problem of narcotics.  In the 1970s, narcotic addiction was a pressing problem that threw a dismal shadow over society..  In the hospital and emergency room we daily saw overdoses and the complications of narcotics addiction, including some particularly nasty infections like bacterial endocarditis,  While dealing with these, we tried to do our best to manage the severe pain of cancer and other relentless diseases with limited tools, narcotics being the most potent. We knew that we should not let our bleak experiences with addiction to illicit narcotics prevent us from giving adequate pain medication to those with metastatic cancer.  However, it was never clear how to best to help people with chronic pain from diseases that were not so immediately deadly.  And whatever it took we wanted not to promote "the needle and the damage done." <iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/k0t0EW6z8a0" width="420"></iframe> Things did not become easier in the 1990s when we  incessantly heard about under-diagnosis and under-treatment of  pain, and how we should not be so afraid of addiction and other adverse effects when prescribing legal narcotics.  As we heard this, however, it seemed that more people with less well-defined chronic pain were coming to us seeking relief, sometimes while preoccupied with narcotics as the solution to their problems.  Yet many of these patients seemed at risk of addiction, appeared already addicted, or even appeared to be seeking drugs so they could sell them to others. In my most recent clinical position, it seemed I was always dealing with new patients with years of obscure musculoskeletal pain who felt I was the miracle physician they were seeking, often specifically to prescribe something like Vicodin, Percodan, or Oxycontin.  When on weekend call I inevitably hear from some poor patient who had somehow run out of or lost an important medication, which turned out to be Vicodin, Percodan, or Oxycontin, and just needed a simple refill without the bother of actually seeing a doctor.  Etc, etc, etc. How could I relieve real suffering without becoming the pusher man?  The Over Promotion of Narcotic Pain Treatment   Then the realization began to dawn that patients, doctors and society were being victimized by a new type of pusher man, this time dressed in a suit and working for an "ethical" drug company.  In the earlier days of Health Care Renewal, we first <a href="http://hcrenewal.blogspot.com/2006/11/cephalons-promotion-of-actiq.html">posted</a> (in 2006) about allegations of deceptive and unethical promotion of fentanyl by Cephalon that lead to its overuse by patients beyond those with cancer who were its ostensible target population.  Then in 2007 came the <a href="http://hcrenewal.blogspot.com/2007/05/guilty-pleas-for-purdue-pharmas.html">spectacular case</a> of guilty pleas by a subsidiary of Purdue Pharma and several of its executives for "misbranding" Oxycontin,  that is, promoting it far beyond any medically legitimate use in severe chronic pain.  Following that various investigations, <a href="http://www.jsonline.com/news/health/99478824.html">well chronicled in the Milwaukee Journal Sentinel</a>, showed how pharmaceutical companies employed deceptive marketing techniques, subverting medical education and research, and creating conflicted key opinion leaders and institutionally conflicted disease advocacy groups, to push more "legal" narcotics  For example, see the Journal Sentinel reports the subversion of :  <a href="http://www.jsonline.com/watchdog/watchdogreports/119130114.html">medical schools and their faculty</a>; .<a href="http://www.jsonline.com/watchdog/watchdogreports/painkiller-boom-fueled-by-networking-dp3p2rn-139609053.html">medical societies, disease advocacy groups, and foundations</a>; and <a href="http://www.jsonline.com/news/health/doctors-with-links-to-drug-companies-influence-treatment-guidelines-ki7pjr6-184041791.html">guideline writing panels</a>.  In 2012, we <a href="http://hcrenewal.blogspot.com/2012/12/the-king-of-pain-recants-pharmaceutical.html">posted</a> about how a drug company paid key opinion leader admitted to second thoughts about his role promoting narcotics. The realization that that overtreatment of chronic pain, no<strike>w</strike> matter how sketchy, never mind the adverse effects of narcotics, was driven by greed and marketing did not make managing chronic pain and patients who wanted narcotics easier. One strategy we used was to try to find drugs nearly as effective as narcotics (although we began to realize that narcotics are also no<strike>tw</strike> as effective as we thought) but less addictive.  The <a href="http://www.jsonline.com/watchdog/watchdogreports/drug-tramadol-escapes-stricter-regulation-b99158486z1-236900801.html">latest story</a> by the indefatigable John Fauber of the Milwaukee Journal-Sentinel suggests that strategy too was subverted.  Suppression of Research about Addiction to Tramadol One workaround I sometimes attempted was to prescribe tramadol (e.g., Ultram, Janssen), an opioid which was promoted as non-narcotic and non-addicting.  However, like many quick pharmaceutical solutions to difficult problems promoted in the last few years, that did not often seem to work as well as expected.  Now, per Mr Fauber, it appears that <blockquote class="tr_bq">the FDA failed to heed a key piece of research indicating tramadol had the potential to be abused when it first appeared on the U.S. market in 1995. The drug was not placed under the Controlled Substance Act. Despite recent research affirming its abuse potential, restrictions on prescribing it are no more stringent than for Lipitor or Viagra. The Controlled Substance Act places drugs into five progressively restrictive categories based on their abuse potential. At the top of the list are drugs such as heroin. At the other end are cough medicines with limited amounts of codeine. In deciding tramadol need not be on the list, the FDA based its decision largely on research in which the drug was injected as well as reports from Europe, where it had been on the market for years, that showed very little abuse. However, the agency also had unpublished research showing that when given to opioid abusers orally in high doses, rather than being injected, it produced opiate-like effects that were similar to those from oxycodone, the narcotic in OxyContin, one of the most abused drugs in America. </blockquote> Oops.  Here is more detail about the suppressed research, <blockquote class="tr_bq">Tramadol was first introduced in Germany in 1977. Data from Germany had suggested it was only about one-tenth as potent as morphine when injected. Other data showed that after years of use in Germany and other countries there was very little abuse of the drug. However, in the early 1990s, researchers at Johns Hopkins University did a study in which high doses of the drug were given orally to opioid abusers. Taken that way, tramadol acted much differently than when injected. At very high doses it produced opiate-like effects that were similar to high-dose oxycodone. Taken by mouth, the drug is transformed in the liver to a metabolite known as M1, which is able to attach to and activate opioid receptors in the brain. It is M1 that is believed to produce the desirable, opiate-like effect. In 1994, Ortho-McNeil, part of the R.W. Johnson Pharmaceutical Research Institute of Johnson & Johnson, sought approval from the FDA to sell its brand-name version of the drug, Ultram, in the United States. The Johns Hopkins study never was published, but the company said it was provided to the FDA.</blockquote> Also, oops.  The FDA decided not to list the drug as a controlled substance, realized more thought might be needed in the future, but did not appear too worried about who would be doing the thinking.   <blockquote class="tr_bq">That was when the FDA allowed Ortho-McNeil to fund its own committee, separate from the FDA, that would monitor the country for problems with the drug. While it was called an 'independent steering committee,' Ortho-McNeil paid for the group's work and also paid consulting fees to its members. Sidney Schnoll, a former member of the committee, said he could not remember how much the committee members were paid. In total, the program cost Ortho-McNeil about $15 million a year, said Schnoll, now an executive with Pinney Associates, a Bethesda, Md., company that works with drug and opioid companies. 'There was absolutely nothing independent about this group,' said Andrew Kolodny, a New York addiction specialist and advocate of tighter controls on opioids. From early on, Ortho-McNeil's marketing plan for tramadol meant keeping it off the list of controlled substances where it would have difficulty competing against other narcotic painkillers such as Tylenol 3 and Tylenol 4, Schnoll said in a 2009 interview. Both Tylenol products contain codeine and are schedule 3 drugs. The Schnoll interview was done by two professors, one from the University of Florida and one from Rensselaer Polytechnic Institute in New York, as part of a project at University of Michigan Substance Abuse Center. 'There were equally good products that were cheaper on the market,' Schnoll said, according to a transcript of the interview. 'So they really wouldn't have much of the market. They wanted to see if it would be possible to get the drug onto the market as a non-controlled substance.' After a decade, the eight-member Ortho-McNeil committee dissolved itself in December 2005, without ever having recommended that tramadol be put under the Controlled Substances Act.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Oops, again.  Meanwhile, the adverse effects of tramadol were becoming more apparent.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">An analysis by the Journal Sentinel and MedPage Today found that tramadol use is up dramatically since 2008, the earliest year for which data is available. It rose from 25 million prescriptions that year to nearly 40 million in 2012, according to data from IMS Health, a market research firm. In 2011, the drug was linked to 20,000 emergency department visits around the country. In Florida alone, there were 379 overdose deaths involving tramadol that year, up from 106 in 2003, according to the DEA. In Milwaukee County, 20 people died of a drug overdose involving tramadol from 2010 through October 2013, according records from the Medical Examiner's Office. In most of those cases, tramadol was one of several opioids that had been taken.</blockquote> Final oops.  Perhaps no needles were involved, but the damage was being done.   Summary - Goddam the Pusher Man The over-promotion of addictive narcotics for pain relief has become an instructive example of <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> and unethical practices used by commercial health care firms seeking revenue no matter what it takes to get it.  Just the latest article on tramadol illustrated the use of paid <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leaders</a> and more broadly, the creation of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicted</a> medical academics for marketing objectives (here, apparently, obfuscating the dangers of the product); the <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression of clinical research</a> (for the same reason); and at least raised the possibility of <a href="http://hcrenewal.blogspot.com/search/label/regulatory%20capture">regulatory capture</a>.  It seems unlikely that whoever made the decisions to use the tactics worried about adverse effects including loss of the integrity of research, subversion of academic medicine, ;undermining medical decision making, and obviously most importantly direct harm to patients.  (I would note that the decision makers appeared to be working for <a href="http://hcrenewal.blogspot.com/search/label/Johnson%20and%20Johnson">Johnson and Johnson</a>, a company which seems to have a growing history of questionable behavior.)   Health care professionals should at least learn that the pusher man does not always look like a character out of Easy Rider. </div><iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/Z-9iNVoeghI" width="420"></iframe>

No Needle, but the Damage was Done - A New Example of Suppression of Research about Adverse Effects of Prescription Narcotic Analgesics

This story feels personal, since as a physician who trained starting in the 1970s, figuring out how to manage patients who desperately wante...

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Another Reason to Put Everyone's Confidental Medical Information Into Today's Massively Secure (Surely They Are, No?) EHR systems

Office of Inspector General Department of the Treasury Oct. 17, 2013 Audit report INFORMATION TECHNOLOGY: OCC's (Office of the Comptroller of the Currency) Network and Systems Security Controls Were Deficient PDF available at: <a href="http://www.treasury.gov/about/organizational-structure/ig/Audit%20Reports%20and%20Testimonies/OIG-14-001.pdf">http://www.treasury.gov/about/organizational-structure/ig/Audit%20Reports%20and%20Testimonies/OIG-14-001.pdf</a> Highlights: <blockquote class="tr_bq">... To accomplish our objective, we performed a series of internal and external vulnerability assessments and penetration tests on OCC’s workstations, servers, network-attached peripherals (such as cameras and printers), infrastructure devices, and Internet websites. ... We determined that OCC’s security measures were not sufficient to fully prevent and detect unauthorized access into its network and systems by internal threats,or external threats that gained an internal foothold. Also, OCC’s security measures were not adequate to fully protect personally identifiable information (PII) from Internet-based threats. We found that default factory-preset administrative usernames and passwords were present in OCC’s systems. In one test we conducted, we discovered a default username and password of an internal service account on an OCC server which had local administrator privileges. We used those privileges and deployed our penetration test tool’s agents to the host server. That server contained password hashes for local and domain administrator accounts. Using these hashes, we obtained a domain administrator’s password, which we then used to log on to the network domain controller. With full access given to a typical domain administrative account, we created a domain administrator account and thereby had full control of OCC’s network. ... In accordance with our Rules of Engagement, we did not attempt to perform actions that would disrupt OCC’s operations, such as deleting data, powering off servers or other resources, locking out accounts, and similar activities, any of which could have resulted in interruption or shutdown of devices or services. However, malicious attackers would have no such restrictions against performing these actions ... Because systems and devices connected to OCC’s internal network could freely communicate between one another, with very little internal partitioning, we successfully attacked multiple OCC systems in a very short amount of time from a single workstation. </blockquote> I offer no additional comments other than, if Treasury's IT security is this lax, just imagine how secure your health information is, sitting on servers at Podunk Hollow General Hospital. -- SS

Another Reason to Put Everyone's Confidental Medical Information Into Today's Massively Secure (Surely They Are, No?) EHR systems

Office of Inspector General Department of the Treasury Oct. 17, 2013 Audit report INFORMATION TECHNOLOGY: OCC's (Office of the Comptroll...

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Health Care Experience? - Hospital CEOs Don't Need No Stinkin' Health Care Experience

It looks like the complete takeover of health care by generic managers is nigh.  Who Are Now Candidates to be Hospital CEOs? On PRWeb is a <a href="http://www.prweb.com/releases/2013/12/prweb11421983.htm">summary</a> of data about what sort of CEO candidates hospitals' boards of trustees are seeking: <blockquote class="tr_bq">A Black Book Rankings poll of 1,404 healthcare provider organizations’ human resources officers and board members revealed the developing trend affecting the way headhunters will seek candidates. Black Book estimates that two-thirds of CEOs hired in 2014 will have little to no healthcare sector experience, in favor of non-industry productivity, business development and financial management experts with heavy technological expertise. </blockquote> From where are the new CEOs coming? <blockquote class="tr_bq"> Among survey respondents, the most intriguing new hospital CEO candidates are emerging from the Venture Capital, Private Equity industry (idealized by 42% of survey participants), Finance and Accounting (40%), Banking (32%), Technology (22%), Marketing and Sales (19%), Not-for-Profits ( 14%), and Pharma/Biotech (12%).</blockquote> Note that the CEO candidates did not seem particularly intimidated by running a hospital without any relevant experience, knowledge, or possibly values. <blockquote class="tr_bq"> 94% of new CEOs without extensive hospital backgrounds indicate they do not believe healthcare expertise is required for replacing other senior leadership team members after a management overhaul.</blockquote> Why Are Health Care Naive CEOs Increasingly Common? What is causing the attractiveness of candidates without background in, knowledge of, to particular agreement with the values of health care? <blockquote class="tr_bq">'An outside hire will not have developed hospital management skills from within or understand an organization's unwritten rules at first, but that’s not a bad thing either as more hospitals face fresh ideas to avoid bankruptcy, expedite smoother consolidations, conquer payment reform, and productivity issues,' said Doug Brown, Managing Partner of Black Book™.</blockquote> In addition, <blockquote class="tr_bq">A new CEO’s first decisions are often distruptive to a hospital’s staff, particularly the incumbent management team. 'An outsider's perspective on hospital operations will be controversial but often credited in several facility turnarounds for bolstering organizational financial stability, and ultimately profitability,' noted Brown.</blockquote> It is not just Mr Brown's opinion, <blockquote class="tr_bq">89% of board members hiring outsiders agree that broad business operational expertise and singular vision pays off with fresh perspectives on efficiencies, value, cost savings, and the goodwill to the community.</blockquote> What particular circumstances might prompt hospital boards to look for health care naive CEO candidates? <blockquote class="tr_bq"> 'Hospitals facing stalled growth or new competitive challenges need fresh thinking. Hiring internal candidates with the same norms and values as your current team will not meet the long term strategic growth needs of the hospital organization. Relevant outside thinking makes a valuable contribution, enhancing business vitality, longevity and sustainability. Staying contemporary, revitalizing your brand, enhancing products and expanding into new markets all begin with the next person you interview and add to your senior leadership team,' added Brown.</blockquote> By the way, similar surveys suggest the same trend affecting other parts of health care, <blockquote class="tr_bq">Payers, chains, ancillaries, ACOs, support firms, vendors, medical product manufacturers and pharmaceutical firms are tapping other business’ top talent, a major shift from the 'healthcare industry experience only' mindset for executive placement that has prevailed since the 1970’s, according to corresponding Black Book 2013 surveys.</blockquote> Discussion  In 1988, Alain Enthoven advocated in <a href="http://www.amazon.com/gp/product/0444703594/102-6581115-0444916?n=283155">Theory and Practice of Managed Competition in Health Care Finance</a>, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the "physicians' guild" and replace leadership by clinicians with leadership by managers (see 2006 post <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-breaking-physicians.html">here</a>). Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">here</a>). As we noted <a href="http://hcrenewal.blogspot.com/2013/09/a-plague-of-bureaucrats-now-10-per.html">here</a>, the growth continued, so there are now 10 managers for every US physician. Health care went from being controlled by clinicians to controlled by a growing volume of managers.  Most of these managers were <a href="http://hcrenewal.blogspot.com/search/label/generic%20managers">generic</a>, in that they had little if any knowledge of, experience in, or sympathy to the values of health care. These generic managers have used the same techniques advocated for the management of supermarkets or automobile manufacturers to manage health care organizations, despite all the obvious differences in context, goals, values, and people involved.  They also have been trained in theory of <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">maximizing shareholder value</a> (even though non-profit health care organizations have no shareholders), which actually means maximizing short-term revenue (<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>), and then using that revenue as an excuse to <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">plutocratic pay packages for management</a>. The survey results above say the takeover is nearly complete.  The majority of top hospital management recruits are now generic.  It appears that the majority of top management recruits  in health insurance, medical device, pharmaceutical, and other health care corporations are also now generic  The reasons for their recruitment suggest that those exerting stewardship over hospitals are completely abandoning interest in improving health care, patients' outcomes, clinical practice, or anything related.  Instead, look at the wording (highlighted in color thus above) reflecting their concerns. This is all about <blockquote class="tr_bq"> productivity issues long term strategic growth business vitality revitalizing your brand efficiencies  cost saving profitablity</blockquote> Nobody is talking about quality of care, improving practice, patients' outcomes, public health, or about honesty, integrity, and particularly not about putting patients first. Instead, it is now going to be all about the money.  So of course the US has the most expensive health care (non) system in the world, and that system manages to at best be mediocre by nearly every measure of health outcomes.  I say once again that true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty. But this sort of reform would challenge the interests of the generic managers who are getting very rich off the current system.  So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes.

Health Care Experience? - Hospital CEOs Don't Need No Stinkin' Health Care Experience

It looks like the complete takeover of health care by generic managers is nigh. Who Are Now Candidates to be Hospital CEOs? On PRWeb is a s...

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EHR cut-and-paste problem is only one of the several mechanisms to clone documentation - and facilitate fraud

In my Dec. 10, 2013 post "44% of hospitals reported to HHS that they can delete the contents of their EHR audit logs whenever they'd like" (<a href="http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html">http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html</a>) I observed that the "money quote" of the Modern Healthcare article that prompted the post, "Feds eye crackdown on cut-and-paste EHR fraud" by <a href="mailto:jcarlson@modernhealthcare.com" target="_blank">Joe Carlson</a> was not the issue of EHR cut-and-paste features and billing fraud, but EHRs and audit trail alteration. Dr. Stephen R. Levinson, an E/M compliance and healthcare quality expert among other areas of expertise (see <a href="http://www.linkedin.com/in/stephenlevinson">http://www.linkedin.com/in/stephenlevinson</a>), wrote me with the following regarding the issue I glossed over in favor of the audit trail concerns, namely, EHR cloning. Reproduced with Dr. Levinson's permission: <blockquote class="tr_bq">This long-recognized and high-profile problem [EHR cut and paste, copy forward, etc. - ed.] covers only one of the several mechanisms EHRs provide to create CLONED Documentation. Other non-compliant short-cuts include documentation by exception (auto-entry of extensive negative history reviews and normal comprehensive examinations), use of restricted pick list words and phrases, and "translation." Translation is my own terminology for taking actively entered "yes" or "no" responses in medical history (and "normal" or "abnormal" findings in physical exam) and using pre-loaded software to convert (i.e., translate) the response to a long pseudo dictation paragraph. For example, check a box for lungs being "normal" may automatically appear in a paragraph as "lungs clear to percussion and auscultation; respiratory effort is normal on inspiration and expiration with normal excursions of the diaphragm; there are no rales or rhonchi, and no wheezes are present." This extended statement will appear identically in patient after patient and visit after visit, regardless of whether this level exam was performed. Further, the likelihood of every patient having completely normal lungs is non-existent.  [This is one mechanism by which reams of "legible gibberish" are produced even with modest hospital stays, e.g., see my Feb. 27, 2011 post "Two Weeks, Two Reams" at <a href="http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html">http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html</a> - ed.] Finally, although cloned documentation is egregious, there are four other equally egregious non-compliant documentation and coding features, common to most EHRs, that are being totally ignored by OIG. These 4 features are: 1) non-compliant coding engines (including failure to consider medical necessity of the level of care) 2) Replacing narrative documentation of differential diagnoses with billing codes (ICD-9) and billing semantics 3) Failure to document the qualitative components of E/M coding, while addressing only quantitative components (e.g., when patient has a positive response to review of systems question on chest pain, compliance (and quality care) requires further investigation and documentation of further details; most current systems either lack ability to document these details or fail to guide and require physicians to document them) 4) Failure to incorporate consideration of "medical necessity" (indicated in E/M coding as the "nature of the presenting problems") into care, documentation, and coding</blockquote> As evidenced by these explanations, common commercial EHRs in use today were either designed by amateurs or by crooks, with the gatekeepers turning a blind eye towards abuses since at least 2007 (per commenter and EHR compliance expert Dr. Reed Gelzer who, at <a href="http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html">http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html</a>, indicated ONC and OIG knew of these issues since a 2007 report he contributed to). The gatekeepers have turned a blind eye, that is, until now when they've finally opened one eye very slightly, like a ten-day-old puppy, as the abuses become more widely known. <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/AVvXsEhdGG663K2XijBFNigZfHwVmLpFLgpCBrFX0e5PhiNJncsHPqiOqeB4XYVVBnDx17jKEBObsuCBriTk4wzIYibrxTW8zOoHH84Rizg0YHVbEn59H-wqeC_O9ozMcYdy99UrcXKebsr1GoFC/s1600/week2-puppy2eyes.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="151" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdGG663K2XijBFNigZfHwVmLpFLgpCBrFX0e5PhiNJncsHPqiOqeB4XYVVBnDx17jKEBObsuCBriTk4wzIYibrxTW8zOoHH84Rizg0YHVbEn59H-wqeC_O9ozMcYdy99UrcXKebsr1GoFC/s200/week2-puppy2eyes.gif" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Young puppy begins to open its eyes.</td></tr></tbody></table> -- SS

EHR cut-and-paste problem is only one of the several mechanisms to clone documentation - and facilitate fraud

In my Dec. 10, 2013 post " 44% of hospitals reported to HHS that they can delete the contents of their EHR audit logs whenever they...

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