healthy4u

Martin Health System, Florida: Our EHRs were out for two days, but patient care has not been compromised, sayeth Pinocchio

This is yet another post in my ever-growing "our EHRs went out due to IT incompetence, and chaos ensued, but patient care has not been compromised" series (see query link: <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised">http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised</a>): <div class="fontStyle4 storyFontResize"><div class="story last"> <blockquote class="tr_bq">Martin Health System looking into network outage that slowed hospital operations Posted: 01/24/2014 By: Meghan McRoberts <a href="http://www.wptv.com/dpp/news/region_martin_county/martin-health-system-looking-into-network-outage-that-slowed-hospital-operations">http://www.wptv.com/dpp/news/region_martin_county/martin-health-system-looking-into-network-outage-that-slowed-hospital-operations</a> MARTIN COUNTY, Fla.-- Martin Health System is looking into what caused some computer hardware to fail Wednesday, leading to network outage in all of the Martin Health System hospitals. Things were back to normal Friday morning, according to hospital spokesperson, Scott Samples. </blockquote> Translation: for two days there was a complete network outage, with no EHRs, email, CPOE etc. <blockquote class="tr_bq">But since Wednesday night patients say the atmosphere around the hospital was chaotic.</blockquote> Patients likely noted doctors and nurses running like headless chickens.  I note that chaos and safe medical care are not good bedfellows. <blockquote class="tr_bq">Hospital staff, doctors and nurses access the computer system to read patient charts and medical information. Without it, they were left digging into paper documents.</blockquote> The paper documents left laying around would have best had scanty, sparse patient information, since the computer in computerized hospitals has become the primary source of truth.  (One might think such a system, including the network, would be hardened against failure, but a two-day outage, as per other outages at the query link above, show this is often not the case.) <blockquote class="tr_bq">Samples says this led to some minor inconveniences around the hospitals, where some patients received their meals later than normal. Some outpatient appointments could not be scheduled, and extra nurses and administrative staff were brought in to help with the increased work load. No medication or treatment was jeopardized.</blockquote> There we have it.  In Pinocchio-like fashion we hear the obligatory "we lost all our information systems, which are our central nervous system for patient care, but patient care has not been compromised" statement from hospital PR.  This statement is questionable on its face.  The risk of accident was significantly increased on its face. <blockquote class="tr_bq">New patients information was taken down on paper, and put into the system on Friday. Samples says there was a back up computer for data from former patients.</blockquote> The future will be in question depending on the quality, or lack thereof, of this "backload" of patient information that was collected during what patients themselves described as "chaos." Of course, according to the IT pundits paper itself, even under ideal circumstances, is so risky that tens or hundreds of millions of dollars per hospital has been spent to replace it.  Someone is not being truthful. <blockquote class="tr_bq">The hospitals that experienced the outage were Martin Medical Center, Martin Hospital South, and Tradition Medical Center.</blockquote> But patient safety risk was not compromised at any of them, so sayeth the figure below. <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/AVvXsEijzbyCRlWSocm_NxvqQwFGt3O9mxxjuSB3JRvq8pGtmEXlJvFwuCpQUINhi6ytR9f43tEIvHDKYNM0BIvvoMEfHnmmIlBzNkAq_yNGg7JYQx2M3b2TR_ViEXeUXiQEEg29GDSf72wQfK3i/s1600/Pinnochio.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijzbyCRlWSocm_NxvqQwFGt3O9mxxjuSB3JRvq8pGtmEXlJvFwuCpQUINhi6ytR9f43tEIvHDKYNM0BIvvoMEfHnmmIlBzNkAq_yNGg7JYQx2M3b2TR_ViEXeUXiQEEg29GDSf72wQfK3i/s1600/Pinnochio.jpg" width="152" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">All our EHRs and other clinical IT were unavailable for two days ... patients reported chaos ... we had to delay or cancel appointments and bring in extra clinical staff to maintain order ... but patient safety was not compromised, except for some late lunches!</td></tr></tbody></table> Pinocchio must be working at a lot of hospitals. When EHRs are out, patient safety is compromised. This is not open for debate, it is an "on its face" issue. These systems need hardening so as to be up and available 100%. Period. People responsible for outages need to be held accountable, including in a court of law if patients are injured or die as a result. Period. Finally I note that, with the corporatization of healthcare and with population of executive offices by lightweights with unquestioning faith in "cybernetic miracles", the credo of my early 1970's medical mentor, cardiothoracic surgery pioneer and educator Victor P. Satinsky, MD (<a href="http://articles.philly.com/1997-09-13/news/25550525_1_cardiovascular-institute-cardiovascular-surgery-programs-for-young-people">link</a>) - "Critical thinking, always, or your patient's dead" - is more valuable than ever. -- SS <div><div class="fontStyle10" id="copyrightStoryModule"> </div></div></div></div>

Martin Health System, Florida: Our EHRs were out for two days, but patient care has not been compromised, sayeth Pinocchio

This is yet another post in my ever-growing "our EHRs went out due to IT incompetence, and chaos ensued, but patient care has not been ...

Đọc thêm »

WINDY CITY BLUES

<div class="MsoNormal">WINDY CITY BLUES<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">There is an academic ethics mess brewing in the windy city… at The University of Chicago. It involves a start-up Chicago corporation, a star statistician in the medical school, seed money in the form of NIH research grants, the American Psychiatric Association, and the chairman of the APA’s DSM-5 Task Force. It involves the appearance of self-interested bias in the DSM-5 process. It involves a recidivist pattern of failure to disclose material conflict of interest. And it involves academic journal editors (JAMA and JAMA Psychiatry) who did not do the right thing when the perps were outed.<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">I broke the story <a href="http://hcrenewal.blogspot.com/2013/11/when-is-disclosure-not-disclosure.html">on this site</a> back in November, right after a <a href="http://archpsyc.jamanetwork.com/article.aspx?articleID=1780020">confession</a> appeared on-line in JAMA Psychiatry by the gang of five perps (Robert Gibbons, Ellen Frank, David Kupfer, Paul Pilkonis, and David Weiss) . Indeed, it was I who had alerted the journal. Others have since weighed in <a href="http://1boringoldman.com/index.php/2013/12/29/insider-trading/">here</a> and <a href="http://www.behaviorismandmentalhealth.com/2013/12/23/dsm-5-dimensional-diagnoses-more-conflicts-of-interest/">here</a> and <a href="http://www.psychologytoday.com/blog/saving-normal/201401/holding-psychiatry-much-higher-ethical-standard">here</a>, for instance. The definitive summary and Timeline were the work of Dr. John M. (Mickey) Nardo <a href="http://1boringoldman.com/index.php/2014/01/21/open-letter-to-the-apa/">here</a>. Of course, readers of JAMA Psychiatry would never know that the authors were outed. The editors (Howard Bauchner for JAMA and Joseph Coyle for JAMA Psychiatry) allowed the authors to make it seem like they were making a spontaneous admission of nondisclosure, and they acquiesced in the withholding of key information that I had given to the journal.<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">It gets worse. We now know that the chair of the DSM-5 Task Force (Dr. David Kupfer) failed to disclose his financial conflict of interest on at least 4 occasions (#s 13, 15, 16, 19 in the Nardo <a href="http://1boringoldman.com/index.php/2014/01/21/open-letter-to-the-apa/">Timeline</a>). On two of those occasions he was representing the DSM-5 team and the APA! These lapses undermine his repeated assurances that COI issues were under control in DSM-5. If the chairman of the DSM-5 Task Force does not have his own act together concerning COI disclosures, then what are his assurances worth? Nevertheless, the APA released a <a href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0CDgQFjAC&url=http%3A%2F%2Fwww.psych.org%2FFile%2520Library%2FAdvocacy%2520and%2520Newsroom%2FLetter-to-Assembly-20140114.pdf&ei=8ZTaUoLaGfSrsQSJ14GgDQ&usg=AFQjCNE--psrRvauH2Ow3Xu9VKYfv9AItQ&sig2=WFYXTx1QYMMKjrS0DfMANQ&bvm=bv.59568121,d.cWc">statement</a> that tried to whitewash Dr. Kupfer’s nondisclosures. They need to recalibrate their ethical compass.<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">The methods adopted in this affair are classic: Peddle unproven psychiatric screening scales backed up by black box statistics (a distressing specialty of Dr. Gibbons); publish a glowing report in JAMA Psychiatry, which you have infiltrated (Ellen Frank and Robert Gibbons are on the editorial board); get your corporate people inside the DSM-5 process (David Kupfer, Robert Gibbons, Paul Pilkonis); slant the DSM-5 process to endorse, however weakly, the kind of products you intend to market; start a corporation without telling anybody and establish a <a href="http://www.adaptivetestingtechnologies.com/">website </a> with advance marketing that touts your new academic publication in JAMA Psychiatry while <a href="http://www.adaptivetestingtechnologies.com/our-people.html">highlighting</a>Dr. Kupfer’s key role in DSM-5; loudly <a href="http://www.cmeinstitute.com/psychs-talk/#top">proclaim</a> (see page 4) the advent of population-wide screening but before doing any serious field trials or acknowledging that most positive screens will be false positives. This is the usual dodgy hand waving of wannabe entrepreneurs, whose vision is obscured by dollar signs. Oh, and did I mention regulatory capture of NIMH for <a href="http://1boringoldman.com/index.php/2014/01/19/what-2/">over $11 million</a> in funding while not producing a product worth a tinker’s damn? <o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">In response to all this adverse commentary, the authors and the journal editors have gone to radio silence. They must be hoping it will blow over.  If anything, their silence has provoked even more searchlight questions that focus on what is happening at The University of Chicago. <o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">For instance, who is bankrolling this start-up corporation? Last summer they brought on board an executive named Yehuda Cohen who is a mover and shaker in Chicago business circles. I am sure he doesn’t work for peanuts. He set up a <a href="http://www.adaptivetestingtechnologies.com/">website</a> that must be staffed to respond to queries from consumers and professionals. Plus, the corporate office appears to be located in prime commercial space at 217 N Jefferson #600, Chicago IL 60661; phone 312-878-6490. E-mail: <a href="mailto:info@adaptivetestingtechnologies.com">info@adaptivetestingtechnologies.com</a>(from the website: you can find a picture of the neighborhood on Google). So, they are racking up significant operating expenses already. Heaven forfend that these expenses might be covered directly or indirectly by their NIMH funding! Are the responsible administrators at NIMH and at The University of Chicago looking and auditing?<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">It is also unclear whether they have a sound or even a legal business plan. Where will the high powered computing needed for their expansive applications be conducted? Do they have a computing facility at the corporate office? Or do they intend to perform the commercial computing through the NIH-supported Center for Health Statistics at The University of Chicago, which Dr. Gibbons personally directs? If so, did the University sign off on that plan? Is NIH aware of the plan?<o:p></o:p></div><div class="MsoNormal"> </div><div class="MsoNormal">In late November I asked NIH about the ownership of the data bases and algorithms on which the corporation relies for the business plan. I received a reply from NIH outlining the applicable federal policy and stating “We understand that the data are deposited and made available to the community per request through the Center for Health Statistics.” That had to be what Dr. Gibbons told them. Notice that no mention was made of the algorithms. I have replied to NIH, asking them to clarify the status of the algorithms, without which the data bases alone are of little use. I also pointed out to NIH that there is no mention of this public access option in any of the publications from these authors or on the corporate website. This situation is typical of the dissembling style we have seen before from Dr. Gibbons and Dr. Kupfer – lacking in candor and transparency.</div> <div class="MsoNormal">The more one looks, the more questions arise. Is The University of Chicago being taken for a ride? Is NIMH being taken for a ride? Are we all being taken for a ride? Can we please have some transparency here? Can we please have some psychometric standards here? Will the APA step up to the plate? Will NIH step up to the plate? Will The University of Chicago step up to the plate?<o:p></o:p></div>

WINDY CITY BLUES

WINDY CITY BLUES There is an academic ethics mess brewing in the windy city… at The University of Chicago. It involves a start-up Chicago co...

Đọc thêm »

Physician whose mother had heart surgery reflects on sane EHR use

The following from a physician I know, an ED physician, on the care their mother received at a major academic medical center's teaching hospital using EHR. Emphases mine: <blockquote class="tr_bq">Mom just had aortic valve at hospital [name redacted] associated with [redacted] Medical School.  EHR used was [major EHR vendor name redacted] but it clearly had been pushed into the background...... 1) Every ICU patient also had a printed chart in a notebook (paper) medical record book kept at the nursing station.  Just like the old days. It was the most commonly used source of info to the residents and staff. 2) Not once did I see an EHR physically come between a patient and a staff member (as opposed to nearly every encounter where I work). 3) Mom's (and every ICU patients) plan for the day was outlined in magic marker directly on the glass doors and windows and updated during rounds....available for immediate reference, not buried in an EHR. 4) Her clinical info was accurate....... it was dictated and not fabricated from pick lists or dot phrases. 5) Clerks put in the data and Dr's orders......apparently they long ago figured out the nonsense called CPOE and let the clerks do it. I suspect many major University hospitals have worked around the workflow barriers and most egregious documentation sins.  The doctors there (at least in that Cardiothoracic ICU) have enough clout that they can just say HELL NO.  Those of us working for less astute/ non cutting edge community hospitals run by "also ran" healthcare corps are left to bear the crosses ONCHIT and the EHR industry have dumped upon us. I am grateful to the folks at [hospital] for an excellent job on my mom and demonstrating that efficient healthcare pushes the EHR (as currently sold and configured) to the back burner. Oh, [EHR name redacted] still is loaded with those prefilled templates and copy/ paste pull forward geared for upcoding.....but these "top of the food chain" docs just didn't waste their time with them.</blockquote> Having had to gut and remediate really, really terrible health IT for invasive cardiology and cardiac surgery years ago (<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>), and revise workflows to relieve busy clinicians with critically-ill patients from the stupidity and time-sink of fiddling with balky computers with poorly-designed software, I identify with this physician's observations and beliefs. As I've stated in previous posts, most clinicians need to be relieved of clerical tasks associated with computers, especially data entry and ordering, not just surgeons. If the data is really that valuable, hiring clericals to do clerical work should remain a true bargain, with massive return on investment. If that is not the case, then the data is really not that valuable. -- SS

Physician whose mother had heart surgery reflects on sane EHR use

The following from a physician I know, an ED physician, on the care their mother received at a major academic medical center's teaching ...

Đọc thêm »

Putting in the Ski Lifts - National Quality Forum Leaders Improve Conflict of Interest Policies in Response to CareFusion Case

The complex case that came to light with reports of a legal settlement by CareFusion of allegations that it paid kickbacks to promote its ChloraPrep product just got even more complex, but now also a bit more hopeful, and hence much more hopeful than most of the cases we discuss.. Background As we <a href="http://hcrenewal.blogspot.com/2014/01/our-man-in-nqf-carefusion-settles.html">noted yesterday</a>, the CareFusion settlement seemed routine when it was first briefly reported in the media.  Then Modern Healthcare published a series of articles about its ramifications, the <a href="http://www.modernhealthcare.com/article/20140123/NEWS/301239944">latest appearing today</a>. In summary prior to the latest article, -  the CareFusion settlement for $40.1 million was made in response to allegations that kickbacks were made to promote <a href="http://www.carefusion.com/medical-products/carefusion-brands/chloraprep/">ChloraPrep</a>, a solution meant for preoperative skin cleaning -  the Department of Justice <a href="http://www.justice.gov/opa/pr/2014/January/14-civ-021.html">news release</a> also alleged that payments were made to a corporation called Health Care Concepts to conceal kickbacks made to its owner, Dr Charles Denham -  the implication was that Dr Denham was supposed to influence a standard writing committee run by the National Quality Forum, a well known organization that promotes quality improvement, issues authoritative practice standards, a form of clinical practice guidelines, and has contracts with the US government for quality of care activities -  the draft of the standard written by the committee allegedly included the use of ChloraPrep, although mention of that specific medication was removed in a revision We noted that the NQF policy on conflicts of interest for its standard writing committees seemed somewhat weak.  The <a href="http://www.qualityforum.org/docs/CDP_Conflict_of_Interest_Policy.aspx">current (October, 2013) policy</a> asks members to internally disclose conflicts and recuse themselves from " discussion of the applicable measure or measures, and in some instances competing and related measures."  However it does not ban members with conflicts, nor require public disclosure of conflicts.  We also noted that NQF has several board members who have full-time leadership positions with health care corporations, financial firms that invest in health care, or health care trade associations, and NQF received funding from pharmaceutical companies and their in-house foundations.  Thus NQF appears to have its own institutional conflicts of interest.  So we thought that the case raised questions about how well NQF standards are protected from the influence of conflicts of interest, and whether they should remain so influential in the absence of stronger protections? NQF Clarifies its Conflicts of Interest Policies As <a href="http://www.modernhealthcare.com/article/20140123/NEWS/301239944">reported</a> by Modern Healthcare, it took only a day for the NQF to issue yet <a href="http://www.qualityforum.org/News_And_Resources/Press_Releases/2014/NQF_Statement_on_Department_of_Justice_Settlement.aspx">another press release</a> to clarify its conflict of interest polcies.  In particular, <blockquote class="tr_bq">I n response to concerns that the community raised about the evidence base underlying Safe Practice #22 and Dr. Denham’s inordinate interest in this particular Safe Practice, NQF took the following steps in early 2010: <ul><li>Severed its relationship with Dr. Denham who has not been involved in any other NQF work since March 2010;</li><li>Made a decision to refuse offers for financial support from Dr. Denham’s foundation, discontinuing a 2008 - 2013 grant agreement that had more than three years remaining ;</li><li>Determined that it would not enter into grant agreements where the funder is on the endorsement committee, even as a non-voting member;</li><li>Reviewed committee reports that Dr. Denham was involved in to be certain that he did not influence their outcome; NQF staff believe that he did not; and </li><li>Updated and enhanced its conflict of interest policy – in 2010 and again in 2013;</li></ul></blockquote> So NQF appeared to react ad hoc to concerns that Dr Denham was too avid about the use of a particular product.  Its response included strengthening its COI policy and banning one particular type of conflict, receiving funding from an organization controlled by a member of a standard writing committee.  However, as we noted above, the 2013 policy still has its weaknesses.   Furthermore, an NQF executive volunteered to inform me that while the current written COI policy does not require public disclosure, in practice the organization requires public verbal disclosure of conflicts at the beginning of each committee meeting, and that the transcripts of these disclosures are available on the organization's website.  However, how to reach these disclosures is not obvious, and I so far have not been able to find the transcript that supposedly contains the disclosures for the meeting which Dr Denham co-chaired Summary and a Few Optimistic Thoughts (Rare as They are for Us) What I must say is now most unusual in the CareFusion/ Dr Denham/ NQF case is that NQF leadership, rather than  hunkering down in a defensive posture we have seen many other leaders adapt, seems to be trying to take steps toward addressing problems posed by conflicts of interest affecting its standard setting, guideline development, and quality assurance.  First, it is clear that NQF leaders did react to concerns about Dr Denham, and did somewhat tighten up their conflict of interest policies in response to them.  Second, it is clear that they are willing to listen to public questions and criticism, and at least consider further change in response to them.  They thus appear far more open than do leaders of many other organizations. IMHO, NQF leadership is to be congratulated for this more transparent approach.  If only the leaders of other health care organizations would do as much.  Since they do seem open to criticism and change, in the spirit of constructive criticism, I do hope that NQF leaders might also consider: -  further strengthening their conflict of interest policy for standard setting committees, particularly by minimizing the number of committee members with conflicts, and banning individuals with conflicts from chairing committees, as per the <a href="http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">IOM report on standards for trustworthy clinical practice guideline development</a> -  increasing transparency about conflicts of interest, particularly by making disclosures for all projects available without complex web searching -  decreasing institutional conflicts of interest by refusing funding from health care corporations whose revenues might be affected by the content of standards and guidelines, and reducing conflicts affecting NQF board members and executives Health care leaders who see transparency and reduction of conflicts of interest as important goals show us that true health care reform might actually be possible. ADDENDUM (24 January, 2014 - I was told that many people may need an explanation of the title.  "Putting in the ski lifts" is a shortened version of an old college saying.  The location for the ski lifts was a place that is traditionally very hot, think fire and brimstone.  The phrase refers to an extremely improbably event.  Sorry about any confusion.

Putting in the Ski Lifts - National Quality Forum Leaders Improve Conflict of Interest Policies in Response to CareFusion Case

The complex case that came to light with reports of a legal settlement by CareFusion of allegations that it paid kickbacks to promote its Ch...

Đọc thêm »

Our Man in the NQF? - CareFusion Settles Kickback Allegations for $40.1 Million and Government Alleges They Meant to Manipulate National Quality Forum Standards

What appeared to be yet another entry in the <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">march of legal settlements</a> turns out to be more interesting than it first appeared. The Basic Story: Off-Label Marketing  The story was initially briefly reported in the media.  A <a href="http://blog.seattlepi.com/boomerconsumer/2014/01/09/company-to-pay-40-1-million-to-settle-medicaid-fraud-kickback-charges/">report</a> in the Seattle Post-Intelligencer on 9 January, 2014, was perhaps the most complete, <blockquote class="tr_bq">CareFusion, a manufacturer of medical and surgical supplies and medical devices, has agreed to settle charges of illegal marketing practices and kickback payments for promoting sales of the company’s surgical preparation solution, Chloraprep. Under the terms of the settlement with Washington, other states, and the federal government, CareFusion will pay a total of $40.1 million.</blockquote> In particular,   <blockquote class="tr_bq">When the FDA approves a surgical solution such as Chloraprep as safe and effective, its manufacturer can’t market or promote it for an 'off-label' use – any use not approved by the FDA. Chloraprep was approved for specific inpatient hospital procedures, including the preparation of a patient’s skin prior to surgery or an injection. The FDA rejected its use for prepping the skin prior to inserting catheters into veins for administering medications, or cleaning the skin as part of closing wounds. The lawsuit alleges that from Sept. 1, 2009 to Aug. 31, 2011, CareFusion promoted Chloraprep for improper uses. CareFusion also allegedly publicized unverified information about Chloraprep during the same time period, Ferguson said.</blockquote> So this follows a template we have seen before, most recently <a href="http://hcrenewal.blogspot.com/2014/01/more-pharmaceutical-misadventures.html">here</a>.  A company promotes a drug or device for "off-label" uses.  While physicians are legally allowed to prescribe a drug or use a device for reasons other than its official indications, companies are not legally allowed to promote such uses.  Sometimes it turns out that the drug has benefits that outweigh its harms when used off-label, in which case the violation could be considered technical.  In other cases, the drug might turn out to be useless or even net harmful when used off-label, so the violation indicates putting revenue ahead of patients' welfare.   The reporting on the CareFusion Chloraprep settlement did not clearly suggest that the off-label use was harmful to patients. Allegations of Kickbacks to Promote Off-Label Use, but How? It gets more interesting.  The Post-Intelligencer also noted, <blockquote class="tr_bq">The states also contend that in 2008 CareFusion’s predecessor corporation entered into agreements that CareFusion assumed legal and financial responsibility for. This included payments to Health Care Concepts Inc., payments that were allegedly made to hide kickbacks to the physician-owner of HCC for promoting and influencing providers to use Chloraprep, he said. This violates federal and state anti-kickback laws.</blockquote> Now the allegations also include kickbacks to the "physician-owner" of a company to facilitate off-label promotion.  So the issue goes beyond a technical violation of the law.  The Post-Intelligence report, however, did not make clear what Health Care Concepts Inc actually did to contribute to off-label promotion. A quick attempt to find out more about this company via the web was not fruitful.  There are lots of companies/ organizations called Health Care Concepts or some variant.  The most relevant may be<a href="http://www.hcc1.com/"> this one</a>, which lists CareFusion as a "partner" on its main web-page.  What this company actually does is a bit unclear.  Its business model is <a href="http://www.hcc1.com/node/3">described</a> as "a private incubator of early products, services, and technologies, as well as an accelerator of mature solutions that will be taken to scale." What that has to do with off-label promotion of a product of a big established company like CareFusion is not clear.  How this company could have influenced providers is not clear, given that it is not an advertising firm, public relations firm, or medical education and communication company (MECC). So what is going on here?   Allegations of a $11.6 Million Payment to Manipulate the National Quality Forum Standards Yesterday, 21 January, 2014, Modern Healthcare began to <a href="http://www.modernhealthcare.com/article/20140120/NEWS/301209952/nqf-committee-member-paid-11-6m-by-carefusion-to-influence-panels">explain</a> the mystery.    <blockquote class="tr_bq">Many healthcare companies have been accused of paying kickbacks to influence physicians' medical decisions, but one major supplier allegedly tried to steer an entire industry by influencing the recommendations of the National Quality Forum The NQF, which reviews medical evidence and makes recommendations for improving healthcare, acknowledges that a well-known patient safety advocate is alleged to have received millions of dollars to promote a surgical sterilization product while co-chairing an NQF committee that suggested hospitals use that product.  Federal officials say Dr. Charles Denham, co-chair of NQF's Safe Practices Committee in 2010, received $11.6 million from San Diego-based CareFusion to promote the company's ChloraPrep line of skin-preparation products. Denham's committee at the NQF also recommended surgeons use ChloraPrep products to prevent surgical infections, the NQF said. </blockquote> The allegations about the role of Dr Denham in the NQF also did appear in the the official US Department of Justice <a href="http://www.justice.gov/opa/pr/2014/January/14-civ-021.html">press release</a>. Allegations of Bogus Contracts, and Non-Denial Denials The allegations produced some <a href="http://en.wikipedia.org/wiki/Non-denial_denial">non-denial denials</a> (in the phrase found in All the President's Men). Dr Denham responded, but through a lawyer: <blockquote class="tr_bq">A statement from Denham's attorney, Larry Gondelman of Powers Pyles Sutter & Verville in Washington, said reports that the underlying lawsuit involved Dr. Denham were 'blatantly false.' Denham was not accused of wrong-doing in the whistleblower lawsuit, and Gondelman said Denham has and continues to cooperate with investigators in the case.</blockquote> Note that while the attorney denied that Dr Denham was named in the underlying lawsuit, he did not apparently specifically deny the allegations. The NQF also reponded, <blockquote class="tr_bq"> An NQF review committee removed the reference to the specific product before final publication of '<a href="http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx">Safe Practices for Better Healthcare</a>' in 2010. 'An NQF ad hoc review did not find sufficient evidence to support one skin preparation over another,' <a href="http://www.qualityforum.org/News_And_Resources/Press_Releases/2014/NQF_Statement_on_Department_of_Justice_Settlement.aspx">a statement from the organization said</a>. 'The ad hoc review effectively served its role of rapidly responding when a potential issue is identified.'</blockquote> Note that the <a href="http://www.qualityforum.org/News_And_Resources/Press_Releases/2014/NQF_Statement_on_Department_of_Justice_Settlement.aspx">NQF press release</a> did not deny that the CareFusion money was given to Dr Denham's organization, nor that the NQF report might have promoted the use of a class of products in which CareFusion's Chloraprep resides. A <a href="http://www.modernhealthcare.com/article/20140121/NEWS/301219952/nqf-panel-member-admits-he-got-11m-from-carefusion-but-calls">follow-up story</a> in Modern Healthcare noted that Dr Denham confirmed the payment of the money to his company, but not its purpose, <blockquote class="tr_bq"> Renowned quality expert Dr. Charles Denham confirms that CareFusion paid his company more than $11 million, but Denham says he was surprised to see the U.S. Justice Department describe the money as kickbacks intended to influence national quality-of-care guidelines published by the National Quality Forum.</blockquote> Dr Denham's lawyer confirmed the payment, but did not further explain it: <blockquote class="tr_bq">Denham's lawyer, Larry Gondelman of Powers Pyles Sutter & Verville in Washington, acknowledged that CareFusion did pay Denham's company under two contracts. </blockquote> And, <blockquote class="tr_bq">Gondelman said the $11.6 million paid to Denham's company covered 'an array of services' and that he could not elaborate.</blockquote> Again, note that Mr Gondelman did not specifically deny that the money served as a kickback. Meanwhile, the Department of Justice alleged something more elaborate, and nefarious,  <blockquote class="tr_bq">The Justice Department, though, says the contracts were written to look as though CareFusion was buying consulting, software development and strategic marketing services, as well as the completion of three unnamed projects. The value of the deals, the government alleges, far exceeded the fair-market costs of those services, and that one of the actual purposes of the deals was to conceal kickbacks to Denham while he served on the National Quality Forum.</blockquote> Interval Summary So what is clear so far is that: -  CareFusion agreed to a $40.1 million settlement of allegations that it provided kickbacks to promote off-label use of its product. -  CareFusion paid $11.6 million to Health Care Concepts -  Health Care Concepts is run (and possibly owned) by Dr Charles Denham, who chaired a National Quality Forum committee that recommended use of CareFusion's product ChloraPrep in a performance standard and the final version of the NQF standard recommended use of a group of products including ChloraPrep We have frequently discussed how health care corporations may promote goods, particularly drugs and devices and services through <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> and unethical practices, including inducements ranging form creation of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> to outright <a href="http://hcrenewal.blogspot.com/search/label/bribery">bribes </a>and <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a>.   We have also discussed the influence of individual and <a href="http://hcrenewal.blogspot.com/search/label/institutional%20conflicts%20of%20interest">institutional conflicts of interest</a> on <a href="http://hcrenewal.blogspot.com/search/label/guidelines">clinical practice guidelines</a>.  This has become an important enough problem for the US Institute of Medicine to weigh in with <a href="http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">standards for trustworthy guidelines</a> that markedly limit such conflicts of interest.  This case seems notable because it may link the problems of <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> and unethical promotion with the influencing of clinical practice guidelines.  It is particularly notable because the organization generating the guidelines in question, the National Quality Forum, has become large, influential, and authoritative.  Re the latter point, the latest Modern Healthcare article affirmed, <blockquote class="tr_bq">The NQF is a standards-setting organization for the healthcare provider industry. It holds the exclusive contract to provide Medicare and Medicaid with recommendations on a national quality-of-care strategy and the measures used to gauge improvements.</blockquote> In fact, while the NQF performance standards can function as guidelines, they also may be bases for <a href="http://hcrenewal.blogspot.com/search/label/pay%20for%20performance">pay for performance</a> schemes that attach real incentives to guidelines, which could become <a href="http://hcrenewal.blogspot.com/search/label/perverse%20incentives">perverse</a> if the guidelines have been manipulated. Can the NQF Defend Against Conflicts, and If Not, Should it Remain So Authoritative? So the big question is whether the NQF, given its unique influence, has any meaningful approach to prevent its standards from being influenced by conflicts of interest? The NQF does have a <a href="http://www.qualityforum.org/docs/CDP_Conflict_of_Interest_Policy.aspx">recent conflicts of interest policy</a>. However, according to my reading, it neither bans committee members with conflicts of interest, nor even requires public disclosure of conflicts of interest.  All it seems to require is that committee members disclose conflicts internally and <strike>voluntarily</strike> recuse themselves from deliberations which may be affected by them.  Although the policy states that conflicts of interest may be made public, I could find nothing in the <a href="http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx">report</a> which Dr Denham co-authored about conflicts of interest or competing interests affecting any of the authors, including Dr Denham Furthermore, a very quick look at information publicly available on the NQF web-site suggests the organization itself may have major institutional conflicts of interest.  The NQF is one of those "public-private partnerships" that have become all the rage.  Several members of its <a href="http://www.qualityforum.org/About_NQF/Board/Board_of_Directors_Roster.aspx">board of directors</a> have leadership positions in large health corporations, financial firms with large health care interests, or trade associations for large health care corporations:  <a href="http://www.qualityforum.org/About_NQF/Board/Elizabeth_Fowler.aspx">- Elizabeth J. Fowler</a>, PhD, JD, is Vice President, Global Health Policy, in the Government Affairs & Policy group at Johnson & Johnson. - <a href="http://www.qualityforum.org/About_NQF/Board/Robert_Galvin.aspx">Robert Galvin</a>, MD, is Chief Executive Officer, Equity Healthcare, at The Blackstone Group.  - <a href="http://www.qualityforum.org/About_NQF/Board/Karen_Ignagni.aspx">Karen Ignagni</a>, President and Chief Executive Officer of America’s Health Insurance Plans (AHIP), is the voice of health insurance plans.... - <a href="http://usa.healthcare.siemens.com/infrastructure-it/healthcare-it/about-health-services/leadership-profile-healthcare-it">J Mark Overhage</a> MD, PhD,  Chief Medical Informatics Officer, Health Services, Siemens Healthcare Thus it is conceivable that they could personally profit, and that their organizations could institutionally profit from standards that favor their organizations' interests.   Furthermore, NQF receives <a href="http://www.qualityforum.org/About_NQF/Funding.aspx">funding</a> from the US government and private foundations, but also from pharmaceutical companies and their in-house foundations: <blockquote class="tr_bq">the Bristol-Myers Squibb Foundation, the Cardinal Health Foundation, Pfizer Inc., Sanofi-aventis,...</blockquote> Unless the current case leads to big changes in the prevalence of conflicts of interest among the NQF board, the continuation of its institutional conflicts of interest generated by its sources of funding, and its weak policy on conflicts affecting committee members, the question becomes whether it should continue to have such an authoritative role? As we have said over and over, pervasive conflicts of interest affect health care decision-makers and policy makers and the organizations within which they function.  Such conflicts threaten to put various private interests way ahead of patients' and the public's health.  If we really want health care that will put patients' and the public's health first, we need to end such arrangements that favor private gain.    Roy M. Poses MD on Health Care Renewal ADDENDUM (23 January, 2014) - A closer re-reading of the NQF conflict of interest policy made it clear that recusal is not voluntary, and that conflicts of interest may be revealed publicly, but that such disclosure is not mandatory.  The paragraph above dealing with these issues was revised accordingly.

Our Man in the NQF? - CareFusion Settles Kickback Allegations for $40.1 Million and Government Alleges They Meant to Manipulate National Quality Forum Standards

What appeared to be yet another entry in the march of legal settlements turns out to be more interesting than it first appeared. The Basic ...

Đọc thêm »

Five Years Into Compelled National Adoption of Electronic Medical Records, Which Were Advertised As Capable Of Only Good, ONC Issues Safety "Suggestions"

Ten years after creation of the ONC office, and almost five years into compelled national adoption of health IT under HITECH (financial penalties soon start to accrue for non-users or non-adopters of "certified" systems and in at least one state, denial of medical licensure), the HHS's Office of the National Coordinator for health IT released the cutely-named "SAFER" guides ("Safety Assurance Factors for EHR Resilience"). That's progress.  (A previous ONC leader, for instance, had opined that the FDA’s injury findings related to health IT that appeared in the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-IT.pdf">Internal FDA memorandum on HIT risks</a> were merely “anecdotal and fragmentary”;  see my April 2, 2011 post "Making a Stat Less Significant: Common Sense on 'Side Effects' Lacking in Healthcare IT Sector" 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>.) While these Guides are a welcome first step, I observe: These Guides are really an admission HHS and the pundits have been pushing a technology, at best, of an unknown safety profile onto medicine and onto the public.  (The harm profile is becoming better understood, e.g., see the ECRI Institute Deep Dive Study on health IT risk 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>, a study not just remarkable for its results but also for its strange regulator and press invisibility).  I guess that's par for the course in today's world. I also opine these guides would not have appeared at all, if not for grass-roots efforts in exposing health IT dangers over the years. That said, more on the guides, and a link to them: <blockquote class="tr_bq"><a href="http://www.healthit.gov/policy-researchers-implementers/safer">http://www.healthit.gov/policy-researchers-implementers/safer</a> SAFER Guides The SAFER guides consist of nine guides organized into three broad groups. These guides enable healthcare organizations to address EHR safety in a variety of areas. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. The guides identify recommended practices to optimize the safety and safe use of EHRs. The content of the guides can be explored here, at the links below, or interactive PDF versions of the guides can be downloaded and completed locally for self-assessment of an organization’s degree of conformance to the Recommended Practices. The downloaded guides can be filled out, saved, and transmitted between team members.</blockquote> The overall purpose: <blockquote class="tr_bq">This guide is designed to help safely manage the individual and organizational responsibilities in a complex "sociotechnical" healthcare organization. </blockquote> (I note that "sociotechnical" is not really a decriptor of an organization; rather, it is a descriptor of inter-related issues in a healthcare organization.  More properly, a healthcare organization is an entity where implementation of health IT requires "consideration of many sociotechnical issues", or, "is an organization that is sociotechnically complex".  I also note a somewhat loose use of the scientific term "Informatics" in the guides, e.g., "Informatics-type department."  But, whatever.  When a word is used in healthcare today, it means, paraphrasing what a character in a Lewis Carroll book said to a woman named Alice, just what the healthcare leadership chooses it to mean - neither more nor less. (The irony is that Medical Informatics is a field that has as one of its major core competencies the defining of precise language and definitions.) Read the Guides at the above link, but these "guides" are really a set of "Health IT 101", Masters-of-the-Obvious rules of thumb, presented in a "sparse display" format. For instance: <ul><li>The highest-level decision makers (e.g., boards of directors or owners of physician practices) are committed to promoting a culture of safety that incorporates the safety and safe use of EHRs.</li></ul><ul><li>An effective decision-making structure exists for managing and optimizing the safety and safe use of the EHR.</li></ul><ul><li>Staff members are assigned responsibility for the management of clinical decision support (CDS) content.</li></ul><ul><li>Practicing clinicians are involved in all levels of EHR safety-related decision making that impact clinical use.</li></ul> I won't display them further. While this is not an unwelcome development, here are the caveats: 1.  Disclaimer on page 1 of "Organizational Responsibilities" document: <blockquote class="tr_bq">In some instances, Meaningful Use and/or HIPAA Security Rule requirements are identified in connection with recommended practices. The SAFER Guides are not intended to be used for legal compliance purposes, and implementation of a recommended practice does not guarantee compliance with Meaningful Use, HIPAA, or other laws. The SAFER Guides are for informational purposes only and are not intended to be an exhaustive or definitive source. They do not constitute legal advice or offer recommendations based on a healthcare provider’s specific circumstances. Users of the SAFER Guides are encouraged to consult with their own legal counsel with regard to compliance with Meaningful Use, HIPAA, and other laws.</blockquote> "For informational purposes only?" Wow.  I feel SAFER already ... (too late for my mother, though). <table cellpadding="0" class="Bs nH iY" role="presentation"><tbody><tr><td class="Bu">Who is going to evaluate whether hospitals are carrying out these recommendations properly?    Joint Commission?  FDA?  As it appears now, the answer is ... nobody.  </td></tr></tbody></table> In effect, these "guidelines" are issued for "self-assessment" in a regulatory vacuum, with no validation of compliance, no reporting requirements, no formal surveillance, etc.  Hiring the right people, doing all these things, and doing them effectively, is not cheap. Translation: these guidelines are safely ignored, to be put on a shelf somewhere. 2.  The focus of these documents seems to put the responsibility for health IT safety on the customer/user.  Problem is, the ability to compensate for the deficits of fundamentally poorly designed and bad health IT is limited, just as a "safe flying practices" manuals for pilots cannot compensate completely for faulty aircraft design.  Especially if the manuals are for "self assessment" and there is no FAA-mandated oversight, testing and operational surveillance ... 3.  Thus, these guides appear to be a "baby step" in the true sense of the word, and "tension management" in the political sense, a term used by my claimed-Communist sociology professor several decades ago to refer to government actions that made it appear, falsely, that the government was truly "doing something" for the people.  While I am certainly not a Communist, he had a point... <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWSGFFdv9UG9AMt1HpcQpSULolTX-pATxEc9hW4tQJiNySMgmh3P8MjLvCnvrqc2bXIClwbKrJs4_UHUN_mFdTJps6bwhtffM3I2Ftgl4xzfTyfFlIUNWR5o3uwlnTApItIDurTvsb3mJT/s1600/caspar.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWSGFFdv9UG9AMt1HpcQpSULolTX-pATxEc9hW4tQJiNySMgmh3P8MjLvCnvrqc2bXIClwbKrJs4_UHUN_mFdTJps6bwhtffM3I2Ftgl4xzfTyfFlIUNWR5o3uwlnTApItIDurTvsb3mJT/s1600/caspar.jpg" width="145" /></a></div> In summary, while welcome, at best a "milk and toast" award needs to be given to HHS and its health IT arm, ONC for these guidelines. -- SS

Five Years Into Compelled National Adoption of Electronic Medical Records, Which Were Advertised As Capable Of Only Good, ONC Issues Safety "Suggestions"

Ten years after creation of the ONC office, and almost five years into compelled national adoption of health IT under HITECH (financial pena...

Đọc thêm »

Computers + a few docs can manage "an entire city", and other cybernetic miracles

The computing aboard the Apollo spacecraft, that provided computation and electronic interfaces for guidance, navigation, and control of the spacecraft that went to the moon, was primitive by today's standards.   From Wikipedia (<a href="http://en.wikipedia.org/wiki/Apollo_Guidance_Computer">http://en.wikipedia.org/wiki/Apollo_Guidance_Computer</a>): <blockquote class="tr_bq">The Apollo flight computer was the first to use integrated circuits (ICs). While the Block I version used 4,100 ICs, each containing a single 3-input NOR gate, the later Block II version (used in the crewed flights) used 2,800 ICs, each with dual 3-input NOR gates.  [Today's CPUs alone have millions of logic gates and can have billions of transistors, <a href="http://en.wikipedia.org/wiki/Transistor_count">http://en.wikipedia.org/wiki/Transistor_count</a> - ed.]  The ICs, from Fairchild Semiconductor, were implemented using resistor-transistor logic (RTL) in a flat-pack. They were connected via wire wrap, and the wiring was then embedded in cast epoxy plastic. ... The computer had 2048 words [2K - ed.] of erasable magnetic core memory and 36 kilowords of read-only core rope memory. Both had cycle times of 11.72 micro-seconds. The memory word length was 16 bits: 15 bits of data and 1 odd-parity bit. The CPU-internal 16-bit word format was 14 bits of data, 1 overflow bit, and 1 sign bit (ones' complement representation).</blockquote> Today's computers that you buy in WalMart have several million times more memory and long term storage, and are thousands or millions of times faster.  Very roughly, a cycle time of 11.72 microseconds or 0.00001172 seconds/cycle translates out to about 85,324 cycles/second = 85 KHz = 0.085 MHz.  Today's computers have clock speeds in the GHz (1 GHz = 1,000 MHz = 1,000,000 KHz) and do far more per clock cycle than the Apollo guidance and navigation computers. Therefore, we should be going to the moon millions of times faster, and millions of times cheaper, requiring millions of less man-hours of work, now than in 1969, no? This, of course, is bizarre and absurd, but it is the type of wild (il)logic received by Presidents and Congress and other national leaders regarding healthcare computing: <blockquote class="tr_bq"><a href="http://www.healthcareitnews.com/news/mu-creates-medical-bridges-nowhere">http://www.healthcareitnews.com/news/mu-creates-medical-bridges-nowhere</a> MU creates 'medical bridges to nowhere' Clinton Foundation event draws industry heavyweight who would change meaningful use if he could January 15, 2014 As far as Patrick Soon-Shiong is concerned, the $34 billion health IT and electronic medical record incentive program was a grave misstep for the healthcare industry -- but not necessarily for the reasons one might think. Soon-Shiong, MD, who serves as chairman and chief executive officer of healthcare IT company NantHealth and heads the Chan Soon-Shiong Family Foundation, said one of the biggest failures that led to the creation of the Meaningful Use EHR Incentive Program was an inherently flawed mindset of how we view the healthcare industry. "Nobody has looked at healthcare as a systems approach," he said, speaking at the Clinton Foundation's 2014 Health Matters Conference Tuesday.</blockquote> I don't think that "nobody" has looked at healthcare via a systems approach, but the point is well-taken. <blockquote class="tr_bq">... The meaningful use program, Soon-Shiong opined, incentivized providers with a process issue, not an outcomes issue -- so what big effect does that have on patient care? The effect, he said, could be much bigger.  </blockquote> All we need is to do a few things with computers and interopearability, and... <blockquote class="tr_bq">... Soon-Shiong then opted to act on his own, privately. He sold two of his companies, Abraxis BioScience and American Pharma Partners, took $1 billion from the sales and starting building an integrated, interoperable clinical operating system. This system, he says, talks to any software.   </blockquote><blockquote>The operating system has been up and running for three million people with cancer and used by some 8,000 oncologists for the past three years, said Soon-Shiong. "We've built in a software system that actually takes 10,000 cancer protocols and provides for the doctor in real time the knowledge of which cancer protocol to give to the patient."   He then went further, inking deals with Verizon and AT&T to build an electronics company that created boxes that could talk to each other -- blood pressure machines, pulse oximeters, you name it. Soon-Shiong and his team wrote to the APIs of 6,000 medical devices made from every different vendor, and went into hospitals with a real-time wireless, biometric connect box. "We are now capturing 3 billion vital signs, real-time, self-populating in the electronic medical record," he explained. Device connectivity is now operational at more than 250 hospitals, according to NantHealth officials, 120 of those being Epic sites. </blockquote> And now ... Presto! <blockquote class="tr_bq">... Soon-Shiong and his team also have an Internet-based telemedicine device with a four-to-five way video conferencing ability. "If you look at this from a systems perspective, if you can now manage a patient from a home, a clinic, hospital and through a supercomputer do the genomic analysis in 47 seconds, which we've now accomplished," said Soon-Shiong, "you then have an engineered system for the nation." </blockquote> Here's where we go off the cliff of Cybernetic Miracles: <blockquote>... He continued, "You have the ability to create what I call, 'NORADs' of healthcare. You then have the ability to create a building with three cardiologists, 10 oncologists, two pathologists, one pediatrician that can manage an entire city."  </blockquote> 3 cardiologists, 10 oncologists, 2 pathologists, 1 pediatrician + computers can manage an entire city. Remotely. Strap yourself in for the next departure from your local spaceport to the moon.  We have the high-speed computing and the Internet, after all ... For related health IT and moon illogic, see my 2007 presentation to the IEEE Medical Technology Policy Committee "To The Moon In A Hot Air Balloon:  Why Is Clinical IT Difficult?" at <a href="http://www.cci.drexel.edu/faculty/ssilverstein/IEEE_12102007.zip">http://www.cci.drexel.edu/faculty/ssilverstein/IEEE_12102007.zip</a>. -- SS

Computers + a few docs can manage "an entire city", and other cybernetic miracles

The computing aboard the Apollo spacecraft, that provided computation and electronic interfaces for guidance, navigation, and control of the...

Đọc thêm »