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Patient Safety & Quality Healthcare: "Malpractice Claims Analysis Confirms Risks in EHRs"

Two "EHR beneficence is not exactly as advertised" stories in one day.  It's hard to keep up: After my earlier post today <a href="http://hcrenewal.blogspot.com/2014/02/ehrs-real-story-sobering-assessment.html">"EHRs: The Real Story" - Sobering assessment from Medical Economics</a>, now there's this. From the journal "Patient Safety & Quality Healthcare" (<a href="http://www.psqh.com/%E2%80%8E">PSQH</a>): Malpractice Claims Analysis Confirms Risks in EHRs Jan/Feb 2014 Article available at <a href="http://www.cci.drexel.edu/faculty/ssilverstein/PSQH_MalpractClaimsAnalyConfirRisksEHR.pdf">this link</a>. <blockquote class="tr_bq">[Short header on several EHR-related care foul ups] ... Distressing situations like those described above are happening around the country as healthcare organizations adopt electronic health records (EHRs) in growing numbers. Although these systems promise to reduce costs and improve quality and safety, they’ve also ushered in unintended consequences as a result of human error, design flaws, and technology glitches. Recognizing these emerging risks, CRICO—the patient safety and medical malpractice insurer for the Harvard medical community— is taking action. The Massachusetts-based company has expanded its proprietary coding system to capture EHR-related problems that have contributed to patient harm, and to guide the hospitals, physicians, and other providers it serves toward addressing vulnerabilities in their systems. </blockquote> I had previously written about another Med Mal insurer who had noted these problems at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=norcal">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=norcal</a>. <blockquote class="tr_bq">... CRICO recently analyzed a year’s worth of medical malpractice claims in its comparative database and found 147 cases in which EHRs were a contributing factor. Computer systems that don’t “talk” to each other, test results that aren’t routed properly, and mistakes caused by faulty data entry or copying and pasting were among the EHR-related problems found in the claims, which represented $61 million in direct payments and legal expenses.</blockquote> The article notes this: <blockquote class="tr_bq"> ... Half of the 147 cases resulted in severe injury.</blockquote> Patient deaths were a likely result, too, I note. Note that this is just one insurer's data and assuming a good number of them were local to Massachusetts, could represent a significant percentage of the annual medical malpractice lawsuits in the state (Pennsylvania, a much larger state, has about 1500 med mal lawsuits filed annually).  Note also that most cases of harm never make it to litigation due to the harsh economics of medical malpractice. Numbers such as this will be going up as implementation, driven by HITECH incentives and penalties, accelerates in coming years.  This is especially true as medical centers and physician practices with far less clinical IT expertise and savvy than Harvard's become HIT users, and as the ability to capture such events increases. The ECRI Institute "Deep Dive" study of health IT risk also speaks to a rise in numbers, with its finding of 171 health IT "events" in just 36 hospitals over 9 weeks voluntarily reported (i.e., just a fraction of the total), with 8 injuries and 3 possible deaths as a result (<a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>). <blockquote class="tr_bq">... The team asked its CRICO and Strategies members, “What vulnerabilities are you seeing? What are your risk managers worried about? What are your doctors complaining about?” It used that feedback to draft a set of EHR-specific codes and then tested them in three datasets: CRICO (Harvard users) and two of Strategies’ larger clients, !e Doctors Company and Princeton Insurance. Based on those results, CRICO revised and approved 15 new EHR codes that went “live” in January 2013. That means CRICO’s cadre of nurse coders can now identify EHR as a contributing factor to a malpractice claim, instead of using one of the less specific factors available in the past. [It's about time for a dose of transparency in the health IT sector - ed.]  And they can flag whether the problem involved user issues, system/technology issues, or both. “In some cases,” Sato points out, “the system design sets up humans to make errors.” </blockquote> This should all be no surprise to any reader of this blog.  Read the whole article. A more comprehensive list of "EHR harm modes" are at my posts "Internal FDA memorandum of Feb. 23, 2010 to Jeffrey Shuren on HIT risks. Smoking gun? I report, you decide" (<a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>) and "Cart Before the Horse, Part 3: AHRQ's Health IT Hazard Manager" (<a href="http://hcrenewal.blogspot.com/2012/06/cart-before-horse-part-3-ahrqs-health.html">http://hcrenewal.blogspot.com/2012/06/cart-before-horse-part-3-ahrqs-health.html</a>). The actual Hazards Manager report is at <a href="https://www.blogger.com/null"></a><a href="http://healthit.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf">http://healthit.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf</a>. It contains this summary of known hazards: <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/AVvXsEjBfqMe89ZhrHPmZk_4tCcymGkvz0t0XEm8VSOMumbHa-U2WrdKJeZaZDUb8iQMEr5Y2ZwleIsSrYDanYk9nGbP9UOERnVYtIDNu0dhTodoua_1sfR6nHyVk_98F0eyq2xOjnBa_bjUejjX/s1600/hazman.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="247" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBfqMe89ZhrHPmZk_4tCcymGkvz0t0XEm8VSOMumbHa-U2WrdKJeZaZDUb8iQMEr5Y2ZwleIsSrYDanYk9nGbP9UOERnVYtIDNu0dhTodoua_1sfR6nHyVk_98F0eyq2xOjnBa_bjUejjX/s1600/hazman.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">AHRQ's taxonomy of health IT hazards.  Click to enlarge.</td></tr></tbody></table> ------------------- Having written on these issues since 1998 as a "health IT iconoclast" (<a href="http://rtg.cis.upenn.edu/MDCPS/Posters/IT%20Iconoclasts.pdf">http://rtg.cis.upenn.edu/MDCPS/Posters/IT%20Iconoclasts.pdf</a>) and having been largely ignored by the cognoscenti, can I now say "I told you so?" -- SS

Patient Safety & Quality Healthcare: "Malpractice Claims Analysis Confirms Risks in EHRs"

Two " EHR beneficence is not exactly as advertised " stories in one day. It's hard to keep up: After my earlier post today &q...

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"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics - "EHRs: The Real Story",  pg. 18-27, Feb. 10, 2014, available <a href="http://www.cci.drexel.edu/faculty/ssilverstein/EHRs_Real_Story_Medical%20Economics.pdf">here</a> (PDF). Full issue at <a href="http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf">http://medicaleconomics.modernmedicine.com/sites/default/files/images/MedicalEconomics/DigitalEdition/Medical-Economics-February-10-2014.pdf</a> - it is large, 12 MB: <blockquote class="tr_bq">... "Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research f rm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs."</blockquote> Here are other key findings from this national survey: <ul><li>73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice. </li></ul><ul><li>67% of physicians dislike the functionality of their EHR systems. </li></ul><ul><li>Nearly half of physicians believe the cost of these systems is too high. </li></ul><ul><li>45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse. </li></ul><ul><li>65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as signifcant.</li></ul><ul><li>About 69% of respondents said that coordination of care with hospitals has not improved.</li></ul><ul><li>Nearly 38% of respondents doubt their system will be viable in five years. </li></ul><ul><li>74% of respondents believe their vendors will be in business over the next 5 years.</li></ul> <div>My own views are: While some might dismiss such surveys as well as reports of harms as "anecdotes" (those same persons conflating scientific discovery with risk management, see <a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=LYQ0kvWIAEGlr6MBedQBY4tGF9IZCNEIO-wCybP0fwH6J_hSfD2Oiv3jiryTYaXcgidWN-ajWas.&URL=http%3a%2f%2fhcrenewal.blogspot.com%2f2011%2f08%2ffrom-senior-clinician-down-under.html" target="_blank"></a><a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html</a>), I observe that such articles/surveys are increasing in frequency the past few years and are coming from reasonably capable observers - clinicians - .unlike, say, a Fox News survey of pedestrians on complex political matters. Another physician survey is here:  <a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html.</a> Here's an interesting ad hoc survey of nurses:  <a href="http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html">http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html</a>. . This is not what the Medical Informatics pioneers intended, and is not due to physicians being Luddites (a topic I addressed at <a href="http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html">http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html</a>). In my opinion, organizations that have the expertise to change the current trajectory of this technology such as the American Medical Informatics Association (<a href="http://www.amia.org/">AMIA</a>) needs to leave its tweed-jacket academic comfort zone and become more proactive - or perhaps I should say aggressive - in combating the industry status quo.  </div><div></div><div> The health IT industry trade associations such as <a href="http://www.himss.org/">HIMSS</a> have no such qualms about aggressively and shamelessly pushing their version of EHR utopia, an agenda that has led to massive profits for the industry... but to clinician survey results such as above.  And to injured and dead patients.</div><div></div><div> -- SS </div>

"EHRs: The Real Story" - Sobering assessment from Medical Economics

From Medical Economics - "EHRs: The Real Story" , pg. 18-27, Feb. 10, 2014, available here (PDF). Full issue at http://medicale...

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On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission. This speaks for itself.  I believe there are a great number of medical professionals who would speak out this way, if they did not fear retaliation (as does my colleague, hence anonymity) or if they were not suffering from the syndrome of clinician learned helplessness (<a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html</a>): <blockquote class="tr_bq">Scot, Yesterday I spent some time in a family docs office in [redacted] who has been experiencing an EHR failure in his office. Naturally its messed up his work flow not to mention occupying hours on end of his ostensibly personal time. His reaction was mostly one of frustration. In another situation, the ABMS is acquiring near dictatorial powers over physicians' livelihoods by essentially mandating an expensive, time consuming jumping through of hoops in the form of MOC requirements which may well evolve into MOL. Its a shakedown. Except for a few thousand members of AAPS that is seeking legal redress in Federal court, organized medicine is silent. Physicians who are undoubtedly frustrated just play the game in a grim resignation. Where is the moral outrage? Where is the righteous anger? Another physician, a close friend of mine, feels exactly the same way. This healthcare system is poisoning our souls and is engaged in a full frontal assault against our ability to ply our trade (which we have invested so dearly in) as critical, free thinking human beings. Extortion at its best. More ominously, we are being extinguished, not transformed,  as a profession. Remolded into subservient "providers". With little blow back. Can you even imagine any other profession allowing this to happen? Try bending a lawyer over a barrel. We are exploited blue collar workers without union representation. We are essentially working in a  meatpacking plant that Sinclair Lewis wrote of. I am so tired and ashamed of being associated with a gutless group of people who call themselves physicians. I just had to get it off my chest. </blockquote> If people remain indifferent to having their physicians bureaucratically overburdened and demoralized, the outcome will not be pretty in times of medical extremis. -- SS

On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission. This speaks for itself. I believe ...

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Incoming President of IOM Outed as Member of Boards of Alnylam Pharmaceuticals, Medtronic and Pepsico

We just <a href="http://hcrenewal.blogspot.com/2014/02/the-carefusion-dr-denham-nqf-leapfrog.html">discussed</a> how the new CEO of the National Quality Forum was revealed to be a member of the board of directors of Premier Inc, and discussed the implications of this apparently intense conflict of interest.  Now another new leader of an influential non-profit organization dedicated to improving health and health care has also been shown to have major conflicts of interest. All Hail the New President of the Institute of Medicine In 2010, we <a href="http://hcrenewal.blogspot.com/2010/12/duke-divinity-students-protest-pay-of.html">posted</a> about a student protest of the salaries of some top administrators at Duke University, including then Chancellor of Health Affairs Dr Victor Dzau, at a time when the university was undergoing financial difficulties.  We pointed out that Dr Dzau's income was further increased by compensation received as a member of the boards of directors of multiple corporations, and further that serving as a highly paid steward of health care companies like Alnylam Pharmaceuticals, Genzyme, and Medtronic appeared to be a major conflict of interest.  .   Last week Dr Victor Dzau was hailed as the new president of the Institute of Medicine.  The simple version, <a href="http://www.modernhealthcare.com/article/20140219/NEWS/302199945/duke-ceo-dzau-named-president-of-institute-of-medicine">in Modern Healthcare</a>: <blockquote class="tr_bq"> Duke University Health System President and CEO Dr. Victor Dzau was named president of the Institute of Medicine, succeeding the longtime president, Dr Harvey Fineberg, the National Academy of Sciences announced Wednesday. Dzau, whose six-year term will begin July 1, has done research in the area of treatment for high blood pressure and congestive heart failure and pioneered the use of gene therapy for vascular disease, the institute said in announcing the selection. Dzau served on the IOM Council from 2008 through 2013, Fineberg said in a statement. 'As a physician-scientist and leader in academic medicine, Victor has consistently demonstrated inspirational leadership, innovative thinking and multifaceted achievement. Now, all of us at the IOM, both members and staff, will benefit more fully from his leadership,' said Fineberg, who has served as president of the institute for 12 years. </blockquote> Conflicts of Interest Barely Noted Neither this article, the <a href="http://www.iom.edu/Global/News%20Announcements/IOM-Announces-Next-President.aspx">official Institute of Medicine press release</a>, nor articles in the few media outlets that initially covered this new appointment on 19-20 February, 2014,, including <a href="http://www.boston.com/lifestyle/health/blogs/white-coat-notes/2014/02/19/duke-health-system-ceo-appointed-head-institute-medicine/Tj9E4p3tbDVbJ8W14NseCP/blog.html">the Boston Globe </a>and the <a href="http://www.charlotteobserver.com/2014/02/19/4707500/duke-health-system-president-leaving.html">Charlotte News-Observer</a>, noted Dr Dzau's positions on the boards of directors of <a href="http://investors.alnylam.com/directors.cfm">Alnylam Pharmaceuticals</a>, device manufacturer <a href="http://www.medtronic.com/corporate-governance/biographies/board-of-directors/index.htm">Medtronic</a>, and sugary soft drink maker <a href="http://www.pepsico.com/company/Board-of-Directors-and-Committees">Pepsico</a>. However, <a href="http://www.forbes.com/sites/larryhusten/2014/02/19/newly-elected-president-of-institute-of-medicine-is-on-the-pepsico-board-of-directors/">Forbes blogger Larry Husten</a>, was the first to publicly report these memberships, drawing on our 2010 <a href="http://hcrenewal.blogspot.com/2010/12/duke-divinity-students-protest-pay-of.html"> post </a> on Dr Dzau's conflicts of interest as Duke Chancellor for Health Affairs. Then a <a href="http://www.modernhealthcare.com/article/20140220/BLOG/302209995/possible-conflict-of-interest-for-ioms-dzau-reporter-says">blog post</a> on Modern Healthcare by Steven Ross Johnson added some more detail, <blockquote class="tr_bq">IOM spokeswoman Jennifer Walsh said in an e-mail that Dzau initiated steps to resign from his corporate board positions before Wednesday's announcement and that he has committed to severing the ties by the time he begins his six-year term in July.</blockquote> It did not mention why the IOM press release and the initial news stories did not mention Dr Dzau's board memberships nor his intention to resign from them.  The IOM spokeswoman apparently did not discuss why Dr Dzau was going to resign his board memberships now, while he had maintained them as a member of the IOM Council from 2008 to 2013. Since then, later on 21 February, a single mainstream media article, in <a href="http://www.businessweek.com/articles/2014-02-21/pepsico-director-quitting-to-lead-health-institute-that-touted-soda-tax">Bloomberg,</a> did address Dr Dzau's new job, his corporate board memberships, and his planned resignations, with emphasis on his break from PepsiCo: <blockquote class="tr_bq">The newly appointed president of the Institute of Medicine, which advises government leaders and policymakers on health issues, plans to resign from several corporate boards in advance of taking his new job—including one that might have created a sticky situation. Among the companies that Victor Dzau will sever ties with is PepsiCo (PEP), according to Jennifer Walsh, a spokeswoman for the IOM. 'Dr. Dzau had already decided to step down from corporate boards before he accepted the position,' she says. For Dzau, who’s leaving his position as chief executive officer of the Duke University Health System to head up the IOM, the PepsiCo relationship might have been a problem: Several of the company’s products are among those blamed for contributing to the obesity epidemic in the U.S. The Purchase (N.Y.)-based company is best known for its Pepsi soft-drink line and snacks including Fritos and Cheetos. The IOM, which has identified solving the nation’s weight problem as a top priority, endorsed the idea of a soda tax in a report detailing the 'staggering toll' of obesity. The agency estimates obesity-related illness in the U.S. costs $190 billion a year.</blockquote> The Bloomberg article mentioned his memberships on the Alnylam and Medtronic boards mainly in passing. The Rewards of Board Membership The Modern Healthcare blog post provided a list of recent compensation Dr Dzau received from his board memberships. <blockquote class="tr_bq">According to Pepsico's 2013 proxy statement, Dzau deferred his retainer of $66,667 for the year ending Dec. 29, 2012, in lieu of 944 units of phantom stock, where cash is paid at a future date in an amount equal to the market value of stock shares. <a href="http://www.pepsico.com/Investors/Annual-Reports-and-Proxy-Information"> Dzau also serves on the boards of </a><a href="http://investors.alnylam.com/secfiling.cfm?filingID=1193125-13-170764&CIK=1178670">Alynylam Pharmaceuticals</a> (he was paid $50,000 and received option awards of $89,000 in 2013) and <a href="http://www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@corp/documents/documents/proxy_statement_2013.pdf">medical devicemaker Medtronic (PDF)</a> (he was paid $80,000 and received stock awards worth $140,000 in 2013).</blockquote> It did not mention whether he currently owns any stock, or the equivalent, in any of these companies.  However, the most recent Alnylam, Medtronic, and PepsiCo proxy statements show Dr Dzau's considerable stock holdings in these companies. - According to the <a href="http://investors.alnylam.com/secfiling.cfm?filingID=1193125-13-170764&CIK=1178670">2013 Alnylam Pharmaceuticals proxy statement</a>, he currently owns the equivalent of 90,000 shares today worth $8,070,300 at the current price of $89.67. - According to the <a href="http://phx.corporate-ir.net/phoenix.zhtml?c=76126&p=irol-SECText&TEXT=aHR0cDovL2FwaS50ZW5rd2l6YXJkLmNvbS9maWxpbmcueG1sP2lwYWdlPTkwMjY0MzAmRFNFUT0wJlNFUT0wJlNRREVTQz1TRUNUSU9OX0VOVElSRSZzdWJzaWQ9NTc%3d">2013 Medtronic proxy statement</a>, he currently owns 9636 stock options and 15,200 deferred stock units for total holdings of 25,156 share equivalents today worth $1,450,495 at a current price of $57.66. -  According to the <a href="http://www.pepsico.com/Assets/Download/PepsiCo_Proxy_2013.pdf">2013 Pepsico proxy statement</a>, Dr Dzau currently owns the equivalent of  36,173 shares of Pepsico stock. today worth $2,830,537 given a current price of $78.25.  The Bloomberg article provided a somewhat lower estimate of the value his PepsiCo stock holdings based on an otherwise unidentified 2 December, 2013 filing with the US Securities and Exchange Commission.  It estimated the value of his deferred stock units in Medtronic based on an April, 2013 disclosure, but did not list the stock options which appeared in the July, 2013 proxy statement.  It noted his membership on the Alnylam board but did not mention that he held any shares or the equivalent in Alnylam stock. I cannot find anything public about what, if anything, Dr Dzau plans to do with these not inconsiderable stock holdings in health care and health related corporations.   Note that as we <a href="http://hcrenewal.blogspot.com/2010/12/duke-divinity-students-protest-pay-of.html">posted</a> in 2010, in its last proxy statement before it was acquired by Sanofi, Genzyme declared that Dr Dzau owned the equivalent of 75,137shares as of 2009, which in 2010 were worth approximately $5.3 million.  I cannot tell what Dr Dzau did with these stock holdings after the merger.   Thus while there may be some confusion about this current holdings and their exact value, it seems clear that Dr Dzau has become a multimillionaire by virtue of his holdings of stock or equivalent from the three companies, a drug company, and medical device company, and a company whose products have apparent public health implications, on whose boards he currently sits, and possibly by virtue of his holdings in another drug/ biotechnology company on whose board he previously sat.  .   The Intensity of the Conflicts The acuity of the conflicts presented were the President of the IOM to continue sitting on these boards was emphasized by this description of the influence wielded by the IOM written in an <a href="http://www.heraldsun.com/news/localnews/x147183586/Duke-Health-System-president-Dzau-leaving-for-new-role">article</a> in the Durham (NC) Herald-Sun, <blockquote class="tr_bq"> Under the congressional charter of the National Academy of Sciences, the Institute of Medicine is recognized as a primary source for independent, scientifically informed analysis and recommendations on health issues.</blockquote> Even though Dr Dzau will apparently exit his board memberships before he becomes IOM President, the IOM  has been providing such analysis and recommendations under the supervision of a Council member who had fiduciary duties to the stockholders of two pharmaceutical companies a medical device company, and company that makes sugar-laden soft drinks and snack foods.  It will continue to provide such analysis and recommendations under the supervision of a President who became a multimillionaire by virtue of the stock holdings he acquired through his board positions. In 2006 we first <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">discussed</a> a newly discovered species of conflict of interest in health care, in which leaders of medical or health care organizations were simultaneously serving on boards of directors of health care corporations.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive.  It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. <a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986">Corporate Governance</a>, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management.  However, in any case, the stated or actual interests of a member of the board of a health care corporation, like a pharmaceutical company or medical device company, could be very different and at odds with the mission of an academic medical institution or a non-profit ostensibly dedicated to improving health care quality. Also, this case could be aggregated with that of Dr Cassel, the new CEO of the National Quality Forum (and former CEO of the American Board of Internal Medicine) who was found to be a member of the board of directors of Premier Inc, a for-profit hospital group purchasing organization.(see this <a href="http://hcrenewal.blogspot.com/2014/02/the-carefusion-dr-denham-nqf-leapfrog.html">post</a>).  In my humble opinion, the issue here goes even beyond blatant conflicts of interest.  That top stewards of big for-profit health care corporations could simultaneously be  top leaders of influential non-profit organizations ostensibly dedicated to improving health and health care suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improvement of health care.  As <a href="http://www.propublica.org/article/payments-to-ceo-raise-new-conflicts-at-top-health-quality-group">reported</a> by ProPublica about Dr Cassel's case, <blockquote class="tr_bq">Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious. 'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'</blockquote> How Would Dr Dzau Respond to Criticisms of the Companies He Directs, and How Would His Responses Reflect on the IOM? Even if  Dr Dzau were to resign from all three corporate boards, and sells all his stock holdings in the three companies, as previous board member he was responsible for the stewardship of these four companies for years. Therefore it would not be unfair for someone to ask him to address any questionable actions of those companies that affected patients' and the public's health. For example, as we have discussed <a href="http://hcrenewal.blogspot.com/search/label/Medtronic">here</a>, Medtronic has been involved in a series of recent misadventures, including most recently a settlement between multiple hospitals and the Us Department of Justice of charges that they allowed themselves to be persuaded by executives of Medtronic subsidiary Kyphon to inflate their billings for patients who had a Kyphon device implanted (look <a href="http://hcrenewal.blogspot.com/2013/07/55-of-medtronics-best-hospital-friends.html">here</a>),  and a Senate report that Medtronic manipulated articles in the medical literature to market another of its products (look <a href="http://hcrenewal.blogspot.com/2012/10/marketers-systemic-influence-over.html">here</a>). But the awkward fact is that Dr Dzau, as a board member of Medtronic, can be seen to be a steward of that corporation, and hence responsible for the its overall direction.  Even if he were no longer a board member, he cannot erase his responsibility for Medtronic activities that occurred on his watch.  Thus, Dr Dzau could easily find herself in the uncomfortable situation of having to defend and justify questionable past behavior by Medtronic while simultaneously wearing the hat of President of the IOM.  How that would play out is not obvious. Summary To date, the case of Dr Dzau as incoming president of the IOM and current board member of Alnylam Pharmaceuticals, Medtronic and Pepsico has received little attention, and therefore no ethics expert has gotten a chance to speak up in public about it, as they have about the case of Dr Cassel, the NQF, and Premier Inc.  So I will have to step in. As I have said before,  Dr Joe Collier said, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."  [Collier J. The price of independence. Br Med J 2006; 332: 1447-9. Link <a href="http://bmj.bmjjournals.com/cgi/content/full/332/7555/1447">here</a>.]  To reduce further unclear thinking and its consequences, we again urge that academic medical institutions, and non-profit organizations dedicated to improving patient care and public health forthwith begin real reductions of conflicts of interest affecting all those who make clinical or policy decisions. The IOM ought to consider -  Immediately disclosing conflicts of interest affecting all its members, staff, and leadership in a very clear and accessible manner -  Beginning a gradual but complete phase out of such conflicts Otherwise, we all ought to be concerned that the leadership of medicine and health care is increasingly in the hands of a small group of insiders, interchangeable executives who simultaneously or sequentially lead multiple organizations, and are likely to become more comfortable with the fellow members of this interlocking leadership than with ordinary health care professionals, patients and the public.

Incoming President of IOM Outed as Member of Boards of Alnylam Pharmaceuticals, Medtronic and Pepsico

We just discussed how the new CEO of the National Quality Forum was revealed to be a member of the board of directors of Premier Inc, and d...

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We're Sorry ... Our New EMR May Screw Up Your Care, But Don't Worry ... Patient Safety Has Not Been Compromised

A sign seen at a hospital system recently (name redacted): <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/AVvXsEiFv5Vc8MnAwjhlsEA5uP2zO7n0IiSujhj7kGyn2C6ygwzf714UqSrPgQh4-vNNnHBrY1K4NCiRSY3sAOTaeEcP5UL8R0a5dQRr0ILudU-oWkOnTf9uegkc__nrKq6XV-gyuHLGueztsCJC/s1600/we're+sorry+2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFv5Vc8MnAwjhlsEA5uP2zO7n0IiSujhj7kGyn2C6ygwzf714UqSrPgQh4-vNNnHBrY1K4NCiRSY3sAOTaeEcP5UL8R0a5dQRr0ILudU-oWkOnTf9uegkc__nrKq6XV-gyuHLGueztsCJC/s1600/we're+sorry+2.jpg" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">We're Sorry for any "Delays" as we start using our new EMR system ... But as a patient, you'll notice many benefits.   As to risks, nothing to see here ... move along.   (Click to enlarge)</td><td class="tr-caption" style="text-align: center;"> </td><td class="tr-caption" style="text-align: center;"> </td><td class="tr-caption" style="text-align: center;"> </td><td class="tr-caption" style="text-align: center;"> </td></tr></tbody></table> FirstNet is an EMR system for Emergency Departments. What's missing here is this: <ul><li>While "<a href="http://hcrenewal.blogspot.com/search/label/glitch">glitches</a>" that can harm you can happen anytime with these systems, at startup time <a href="http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html">disruptions and malfunctions</a> that could cause injury or death (as reported by <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">FDA</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Patient%20Safety%20and%20Health%20IT%20prepub.pdf">U.S. Institute of Medicine</a>, ECRI Institute per their <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">Deep Dive study of health IT risk</a> and others) are most common;</li></ul><ul><li>Potentially deadly EHR startup "issues" can number in the many thousands (<a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">as at this link</a>); </li></ul><ul><li>If you don't want to subject yourself to these delays and/or glitches, you are free to select another hospital for your care. </li></ul><ul><li>(If you are injured or die as a result of the "Delays", then ... we're Extra-Special With Sugar On Top Sorry?)</li></ul> In other words, this glib, nonchalant signage is incomplete, and misleading on its face. While I understand its purpose, it ignores patient rights to informed consent and knowledge of a potentially unsafe environment for care, which hospitals have to prevent as an ethical and legal obligation. Of course, "please feel free to ask your caregiver if you have any questions" ... who may in fact be limited by contract or edict to only use "Words That Work" to further soothe unsuspecting patients (<a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">as at this link</a>). -- SS

We're Sorry ... Our New EMR May Screw Up Your Care, But Don't Worry ... Patient Safety Has Not Been Compromised

A sign seen at a hospital system recently (name redacted): We're Sorry for any "Delays" as we start using our new EMR system ....

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The CareFusion/ Dr Denham/ NQF /Leapfrog Goup Case that Would Not Go Away - NQF CEO Outed as Member of Premier Inc Board

The story of the CareFusion/ Dr Denham/ NQF/ Leapfrog Group case refuses to go away, even if it still has not created any echoes in the mainstream media or the medical and health care literature.  Now it appears that the NQF has an even bigger conflict of interest problem than previously reported.  Background As of our <a href="http://hcrenewal.blogspot.com/2014/02/the-implications-of-carefusion-dr.html">last post</a> on 5 February, 2014, the background was- -  The case became public with an apparently routine legal settlement between CareFusion and the US Department of Justice  -  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 and other health care 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 to prevent surgical site infection written by the committee allegedly included the use of ChloraPrep, although mention of that specific medication was removed in a revision -  The Department of Justice alleged that the standard was based on a journal article sponsored by Cardinal Health, from which CareFusion split, and which may have been manipulated by its sponsor -  NQF leaders asserted that after hearing of the case from the DOJ, the organization severed ties with Dr Denham and the non-profit organization he runs,  established a policy not to accept money from funding organizations whose leaders are on its committees, reviewed all the standards set by the committee of which Dr Denham was co-chair, and twice revised its conflict of interest policy. - Despite these efforts by the NQF to remove excess influence by Dr Denham, a specific recommendation to use ChloraPrep, specified by formula but not by name, did appear in another NQF standard, one for preventing central line infections; the NQF logo apparently appeared on at least one educational event run by Dr Denham that advocated the use of ChloraPrep; and CareFusion cited NQF support in at least one promotional brochure -  In retrospect, people who worked with Dr Denham on various health care quality and patient safety projects acknowledged they should have realized something fishy was going on. -  Senator Charles Grassley is now investigating The Conflicts of the NQF CEO In our <a href="http://hcrenewal.blogspot.com/2014/01/our-man-in-nqf-carefusion-settles.html">first post</a> about the case, I noted that at the time that Dr Denham was a committee member, the NQF seemed to have a relatively weak policy on conflicts of interest, although  <a href="http://hcrenewal.blogspot.com/2014/01/putting-in-ski-lifts-national-quality.html">this post</a> noted it was later strengthened somewhat.  I also commented that the organization seemed accommodating of conflicts of interest affecting its board of directors, and to have institutional conflicts of interest in that it accepted funding from health care corporations which might have interests in NQF quality standards being written in their favor.  So maybe it should not be too great a surprise that the latest twist in this case is the revelation that the new CEO of NQF has her own quite significant conflicts of interest.  Last week, ProPublica published a <a href="http://www.propublica.org/article/payments-to-ceo-raise-new-conflicts-at-top-health-quality-group">story</a> about the conflicts of interest of the new CEO of the NQF.  The basics were: <blockquote class="tr_bq"><div class="article">The top executive at the country’s pre-eminent health care quality organization is being paid hundreds of thousands of dollars by two large medical companies that have a stake in the group’s work. The payments to Dr. Christine Cassel raise new conflict-of-interest concerns at the National Quality Forum, which endorses benchmarks that Medicare uses to compensate hospitals based on performance. As <a href="http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group" target="_blank">ProPublica recently reported</a>, the Quality Forum is reviewing its conflict-of-interest policies after being stung by allegations that the former co-chair of one of its endorsement committees had accepted kickbacks to help a drugmaker win favorable treatment. Cassel received about $235,000 in compensation and stock last year as a <a href="https://www.premierinc.com/wps/portal/premierinc/public/aboutpremier/leadership/biographies/christine-cassel" target="_blank">board member for Premier Inc.</a>, a North Carolina company that says it provides group purchasing and performance improvement consulting for an <a href="https://www.documentcloud.org/documents/1013194-premier-comments-august2013.html#document/p1/a143354" target="_blank">alliance of 2,900 hospitals</a> and thousands of nursing facilities and other providers. Cassel also was paid $189,000 as a board member for the Kaiser Foundation Health Plans and Hospitals in 2012, Quality Forum officials confirmed to ProPublica. Kaiser’s tax forms are not available for 2013, but they show that in 2010 and 2011 Cassel received a total of $357,125.</div><div class="article"> Cassel, who declined to be interviewed, took over as chief executive officer last summer after a decade as president and CEO of the American Board of Internal Medicine. </div></blockquote><div class="article"></div><div class="article"> Not unexpectedly, the official position of the NQF was nothing to see here, just move along.</div><div class="article"></div><div class="article"> <blockquote class="tr_bq"><a href="http://www.qualityforum.org/About_NQF/Board/Board_of_Directors_Roster.aspx" target="_blank">The group's chairwoman</a>, Helen Darling, said in an email that the board was 'fully aware' of Cassel’s outside compensation when she was hired in December 2012. Darling, president of the National Business Group on Health, initially agreed to an interview but did not respond to follow-up contacts. Spokeswoman Ann Greiner said the board got a legal opinion and discussed it in depth before agreeing that Cassel could recuse herself 'where her outside board service would be construed as an actual or perceived conflict of interest.' So far that hasn’t happened, Greiner said.</blockquote></div> Note that those defending NQF saw no reason to explain why it had not previously disclosed Dr Cassel's other positions or how the conflicts would be managed.  Perhaps a board that includes executives of large health corporations, of a financial firm with large health care interests, and of a trade associations for large health care corporations would not see a problem with having a CEO who is simultaneously on the boards of a for-profit hospital group purchasing organization and a very large, albeit non-profit health care system. Others were much more skeptical and critical.  <blockquote class="tr_bq">Two ethics experts interviewed by ProPublica said Cassel’s relationships with Kaiser and Premier present obvious conflicts given the Quality Forum’s broad involvement in health care. The Quality Forum maintains a clearinghouse of more than 700 quality measures — covering everything from tracking hospital readmissions to setting information technology standards — that are established by expert committees and widely adopted by U.S. hospitals and other providers. </blockquote> The ethics experts said they were uncertain how Cassel could recuse herself to anything related to Kaiser and Premier and still do her job. <blockquote class="tr_bq">'Would that mean every time somebody said the word ‘hospital’ she would have to say, ‘I can’t be in this conversation?’' said <a href="http://www.instituteforhealthpolicy.org/core_faculty/Campbell" target="_blank">Eric Campbell</a>, a Harvard School of Medicine professor who has published extensively on conflicts of interest. 'Conflict of interest is as much an appearance as it is an effect,' added <a href="http://www.tufts.edu/%7Eskrimsky/bio.htm" target="_blank">Sheldon Krimsky</a>, a medical ethics expert at Tufts University. He called Cassel’s conflicts 'absolutely egregious' Campbell and Krimsky said the cleanest way to eliminate potential conflicts would be for Cassel to resign from the outside boards.</blockquote> The plot thickens because of the amount of influence wielded by the NQF, <blockquote class="tr_bq"> In 2009, Medicare awarded a <a href="https://www.fbo.gov/index?s=opportunity&mode=form&tab=core&id=bf9a9aa4529a19bab87c7c2c09ce2c9f&_cview=0" target="_blank">$40 million contract to the Quality Forum</a> to recommend <a href="https://www.fbo.gov/index?s=opportunity&mode=form&tab=core&id=f5a7e6b022cc2e926efa8dccf90ec220&_cview=0" target="_blank">measures</a>it could adopt. President Obama’s health care reform law accelerated the move to pay-for-performance. Medicare already <a href="http://www.kaiserhealthnews.org/Stories/2013/November/14/value-based-purchasing-medicare.aspx" target="_blank">has begun penalizing and rewarding</a> hospitals based on readmission rates, mortality and patient satisfaction measures. By 2017, it’s expected that <a href="http://www.qualityforum.org/what_we_do.aspx" target="_blank">9 percent of Medicare payments</a> will be based on performance.</blockquote> Having some leverage on that influence would seem to be particularly important to Premier Inc, the now publicly held for-profit group purchasing organization on whose board Dr Cassel sits, <blockquote class="tr_bq"> Premier reported revenues of $869 million in the fiscal year ending last June. It spent more than $1 million on lobbying in 2013, according to OpenSecrets.org. In August and November, the company urged members of Congress to instruct Medicare to <a href="https://www.documentcloud.org/documents/1013194-premier-comments-august2013.html#document/p9/a143149" target="_blank">run any quality measures through the Quality Forum</a>. Premier <a href="https://www.documentcloud.org/documents/1010105-premier-5-31-13-sec-form-s-1-registration.html#document/p173/a143373" target="_blank">featured Cassel’s status</a> as a board member and future top executive of the Quality Forum in documents last May describing its initial public stock offering. In September <a href="https://www.documentcloud.org/documents/1010111-premier-9-27-13-cassel-acquired-3-704-shares.html#document/p1/a143369" target="_blank">Cassel acquired 3,704 shares of Premier</a> stock that were then worth about $100,000. The company’s business involves group purchasing and a consulting arm that uses data analysis to help providers perform better on various quality metrics. In October, a measure sponsored by Premier to track hospital care by the average length of stay <a href="https://www.documentcloud.org/documents/1015398-nqf-ave-los-oct-2013.html" target="_blank">was up for renewal by the Quality Forum</a>.</blockquote> Of course, a Premier Inc spokesperson denied that could be a problem, <blockquote class="tr_bq">[Spokesperson Blair] Childs said Cassel’s role on the Premier board doesn’t pose any conflict of interest, and that her relationship with Premier was vetted carefully by the Quality Forum’s board. Cassel was a good addition to the Premier board because of her commitment to improved care and lower costs, he said.</blockquote>However, I submit that the conflict here is particularly acute because Dr Cassel is not merely a part time consultant or adviser to Premier Inc.  She is on the board of directors.  In 2006 we first <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">discussed</a> a newly discovered species of conflict of interest in health care, in which leaders of medical or health care organizations were simultaneously serving on boards of directors of health care corporations.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive.  It ostensibly requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. <a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986">Corporate Governance</a>, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management.  However, in any case, the stated or actual interests of a member of the board of a health care corporation, like a for-profit hospital purchasing organization, could be very different and at odds with the mission of an academic medical institution or a non-profit ostensibly dedicated to improving health care quality.  However, in my humble opinion, the issue here goes even beyond a blatant and undisclosed conflict of interest.  That a top steward of a big for-profit health care corporation could simultaneously be the top leader of an influential non-profit health care quality improvement organization suggests that increasingly US health care is run by an insular group of insiders whose influence gets ever larger because of their collective power, not necessarily because of their dedication or ability to improving health care.  As ProPublica put it, <blockquote class="tr_bq">Rosemary Gibson, an author and senior adviser to The Hastings Center, a research group dedicated to bioethics in the public interest, said she wasn’t surprised at Cassel’s outside compensation. So much money permeates decision-making in Washington, she said, that participants have become oblivious. 'The insiders don’t see it,' Gibson said. 'It’s like a fish in water.'</blockquote>Additional Questions Finally, the forced disclosure of Dr Cassel's conflicts of interest raise some additional questions.  Did Dr Cassel Have an Equally Severe Conflict as CEO of the ABIM? Dr Cassel was previously the CEO of the American Board of Internal Medicine (ABIM).  This non-profit organization also has a very substantial influence on health care.  Physicians must pass its examinations to become certified as internal medicine specialists or sub-specialists such as cardiologists, gastroenterologists , etc.  Recently certified physicians, and soon all certified physicians will have to participate in ABIM sanctioned "maintenance of certification" activities or risk being flagged as not adequately keeping with the board's concept of medical progress. Thus the content of the ABIM examinations and sponsored activities can influence physicians' thinking and decision making.  How the ABIM under Dr Cassel's leadership dealt with conflicts of interest affecting those who write examinations, provide content, and lead the organization is unclear. Furthermore, it seems possible that Dr Cassel had a conflict of interest generated by her work for Premier Inc while she was still CEO of ABIM.  However, before Premier Inc made its initial public offering, information about its management and governance was scarce.  Whether Dr Cassel was on the board of a precursor to the publicly traded Premier Inc is not easy to ascertain.  Maybe the current ABIM leadership needs to consider whether Dr Cassel had a conflict involving Premier Inc or its precursor while she was CEO of ABIM, and how that conflict could have affected the direction of ABIM at the time.  How Would Dr Cassel Respond to Criticisms of Premier Inc and How Would that Reflect on the ABIM and the NQF? Premier Inc is a hospital group purchasing organizations (GPOs).  GPOs, particularly including Premier Inc, have been criticized for anti-competitive practices that distort the market in health care drugs and devices, for accepting the ethical equivalent of kickbacks, and particularly for generating drug shortages.  For example, an <a href="http://articles.baltimoresun.com/2014-02-07/news/bs-ed-drug-shortage-20140209_1_shortages-supply-chain-drugs">opinion piece</a> in the Baltimore Sun claimed, <blockquote class="tr_bq"> The main reason is that most of these drugs are purchased through a handful of supply chain middlemen called hospital group purchasing organizations, or GPOs, whose anti competitive practices and self-dealing have been documented in Senate antitrust hearings, media reports, government investigations and lawsuits. These buyers' monopolies purchase upward of $300 billion in drugs, devices and supplies annually for about 5,000 private acute care hospitals, including virtually every one in Maryland. Five giants account for roughly 90 percent of all such purchases. [Apparently including Premier Inc - Ed] Under a 'pay-to-play' arrangement, vendors compete not on the basis of who can supply the best product at the best price but on who can pay the biggest fees to these cartels. In return, they receive exclusive contracts. This artificially constrained supply chain is why many drug manufacturers have fled the marketplace, leaving just one or two to produce many drugs. In turn, hospitals receive incentives based on their compliance with contracts the GPOs award to favored suppliers. In 1987, Congress enacted the Medicare anti-kickback 'safe harbor,' which exempted GPOs from criminal penalties for accepting payments from suppliers — payments that in virtually every other industry would be considered unlawful kickbacks.</blockquote> The GPOs trade organization vigorously contested this argument, of course. But the awkward fact is that Dr Cassel, as a board member of Premier Inc, can be seen as a steward of that corporation, and hence responsible for the its overall direction.  Thus, Dr Cassel could easily find herself in the uncomfortable situation of having to defend and justify questionable behavior by Premier Inc while simultaneously wearing the hat of CEO of NQF.  How that would play out is not obvious. Summary So now it appears that the problems with conflicts of interest at the NQF affect not only its standard setting committees, board of trustees, and organizational funding.  They also affect its CEO. Dr Joe Collier said, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."  [Collier J. The price of independence. Br Med J 2006; 332: 1447-9. Link <a href="http://bmj.bmjjournals.com/cgi/content/full/332/7555/1447">here</a>.]  To reduce further unclear thinking and its consequences, we again urge that academic medical institutions, and non-profit organizations dedicated to improving patient care and public health forthwith begin real reductions of conflicts of interest affecting all those who make clinical or policy decisions.    We <a href="http://hcrenewal.blogspot.com/2014/01/putting-in-ski-lifts-national-quality.html">previously suggested</a>: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 I would now add that in my humble opinion, the NQF ought to immediately fully disclose any other conflicts that might exist affecting its committees, staff, board of trustees, or funding, and then begin a progressive but ultimately complete phase out of all significant conflicts affecting these areas.   Roy M. Poses MD for Health Care Renewal

The CareFusion/ Dr Denham/ NQF /Leapfrog Goup Case that Would Not Go Away - NQF CEO Outed as Member of Premier Inc Board

The story of the CareFusion/ Dr Denham/ NQF/ Leapfrog Group case refuses to go away, even if it still has not created any echoes in the main...

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Computer woes hit Banner hospital system: Another large EHR outage ... but patient safety was not compromised

Here is yet another story in the genre of "EHRs go out, but patient care has not been compromised." (See query link at <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>; there are more than 20 posts there now): <blockquote class="tr_bq">Computer woes hit Banner hospital system Ken Alltucker, The Arizona Republic 12:30 a.m. EST February 20, 2014 <a href="http://www.usatoday.com/story/news/nation/2014/02/19/computer-woes-slam-banner-hospital-system/5630829/">http://www.usatoday.com/story/news/nation/2014/02/19/computer-woes-slam-banner-hospital-system/5630829/</a> The Phoenix-based health system used backup paper records to help provide patient care. PHOENIX -- Banner Health grappled with a widespread computer outage Wednesday as hospitals and doctors resorted to backup paper systems to provide care for patients. The Phoenix-based health system did not immediately know what triggered the computer troubles that started just before 10 a.m. PST. An official described the computer troubles as a rolling outage of computer systems at hospitals and other health care facilities in Phoenix, Colorado and Nevada.</blockquote> "Not knowing" means that you are not in control of your life-critical information systems; rather, they are in control of you. <blockquote class="tr_bq">By late Wednesday, a spokesman said, technicians had identified the problem and were fixing it. They expect to investigate the root cause of the problem Thursday.</blockquote> It took from 10 AM to "late Wednesday" to identify a problem causing a mass outage.  That should give anyone pause about dependency on fragile information systems in the hands of hospital IT departments (whose personnel undergo an ocean's less qualification-vetting than the medical personnel who depend on their work product) for one's medical care. <blockquote class="tr_bq"> Banner Health, the Phoenix area's largest health care system, activated "downtime procedures" that included using paper-based systems to track medications and other care provided to patients, officials said. Banner's emergency departments still provided care to patients and accepted new patients. Some non-emergency surgeries and appointments were delayed because of the computer troubles. "There have been some delays and inconveniences, but we are still providing care," said Bill Byron, Banner Health's senior vice president of public relations.</blockquote> In other words, what they are saying is "we really don't need these systems, that cost hundreds of millions of dollars, to provide care with the same degree of safety as with our 'downtime procedures' (a.k.a. paper)" ... and that patient safety was not compromised by this mass outage. <blockquote class="tr_bq">Banner Health, which operates 24 hospitals and several primary-care offices and outpatient centers in more than a half-dozen states, was working to "reboot" the computer systems Wednesday evening through a series of sequential fixes, Byron said. In the meantime, Banner officials were able to retrieve computer-based records that detailed patients' medical histories, including any medications, laboratory results and procedures that were previously performed.</blockquote> Officials?  What about line clinicians?  And when did this capability start if the systems needed to be "rebooted?" <blockquote class="tr_bq">Nurses and doctors shifted to writing on paper records after the computer systems experienced trouble Wednesday morning. Information from those paper charts will be keyed into the patients' computer-based health records after the problem is fixed.</blockquote> Sure, and nothing will be lost that could adversely affect patients in the future.... <blockquote class="tr_bq">Banner Health has been among the most advanced health systems in the nation in converting to computer-based health records. Banner Estrella Medical Center was among the first hospitals to open as an "all-digital" facility in the past decade. Banner's other hospitals have largely completed the final stages of installing computerized record-keeping in areas such as physician order and entry and electronic documentation.</blockquote> If they are the most advanced, what does this event say about those less advanced? <blockquote class="tr_bq">Arizona law does not require hospitals to notify state health regulators in the event of such a widespread outage.</blockquote> Health IT, as usual, enjoys widespread and extraordinary regulatory accommodation. <blockquote class="tr_bq">However, some hospitals have internal policies requiring that they notify health accrediting organizations or federal regulatory agencies, such as the Centers for Medicare and Medicaid Services, an Arizona Department of Health Services spokeswoman said.</blockquote> And how many do?  Not many, I predict. -- SS

Computer woes hit Banner hospital system: Another large EHR outage ... but patient safety was not compromised

Here is yet another story in the genre of "EHRs go out, but patient care has not been compromised." (See query link at http://hcre...

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