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A very short observation on EHRs and the Veterans Administration healthcare scandal

As has been in the news lately, it has been revealed that U.S. veterans' medical care was being delayed at a number of Veteran's Administration-run hospitals, perhaps many others as well not yet known. A timeline for the Veterans Administration medical scandal is here:  <a href="http://www.usatoday.com/story/news/politics/2014/05/21/veterans-healthcare-scandal-shinseki-timeline/9373227/">http://www.usatoday.com/story/news/politics/2014/05/21/veterans-healthcare-scandal-shinseki-timeline/9373227/</a> <blockquote class="tr_bq">The Obama administration is facing a serious scandal in which government officials are alleged to have falsified data to hide how long veterans were waiting to see doctors at VA hospitals. The controversy has led to calls for the resignation of Veterans Affairs Secretary Eric Shinseki, who has served for five years. Here is a timeline of events leading up to the current situation, which President Obama on Wednesday called "intolerable" and "disgraceful."</blockquote> I will not comment on the issues per se. I will only make this pithy observation: The VA system possesses the best electronic medical records systems in the world, VistA CPRS, and is unhampered by EHR sellers' issues and agendas as the VA created it themselves over decades.  You can even download VistA CPRS and explore it with fictitious patients and medical data from test servers set up for that purpose, at <a href="http://www.ehealth.va.gov/EHEALTH/CPRS_demo.asp">http://www.ehealth.va.gov/EHEALTH/CPRS_demo.asp</a>. EHR's and other clinical IT, according to not-very-impartial organizations such as the industry trade group HIMSS, the sellers themselves, and a whole cadre of pundits highly invested in the technology and its implementation, are purportedly going to "revolutionize" medicine (rather than the somewhat less grandiose purpose of merely facilitating clinicians in providing better care). The "revolution" includes reducing the need for human resources, increasing efficiency, saving gobs of money, and according to one billionaire, allowing a small group of doctors to remotely manage the care for an entire city's patients.  (See my Jan. 20, 2014 post "Computers + a few docs can manage 'an entire city', and other cybernetic miracles" at <a href="http://hcrenewal.blogspot.com/2014/01/computers-few-docs-can-manage-entire.html">http://hcrenewal.blogspot.com/2014/01/computers-few-docs-can-manage-entire.html</a>; I am not making that up.) Yet here we have the VA, highly computerized - but instead of being the medical utopia promised by the information technology hyperenthusiasts, the VA is unable to even guarantee patients a two-week waiting period for care, with delays leading to possible patient injuries and deaths. Thus, to those who promote the meme that spending hundreds of billions of dollars on this technology will 'revolutionize' medicine, increase "efficiency", reduce errors, reduce costs etc. and realize all the other fantastical claims made for the technology, I say, "sure, and I have a bridge for sale in Brooklyn." <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/AVvXsEhA3XNDg0DloxZAjRbNKM7INHWPOgAkdnazZOqRu1PYqgvv-QgjncHQDCyIeejK7jIGyQsOoDh3TpeQ_Ql6ezFNIzIRgUrTKTdWiX2D2Mz6CQ4ha5K74uE8Ww7Cxk3WU6zaY3gLwkbB-kH2/s1600/Brooklyn_Bridge_Postdlf.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="161" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhA3XNDg0DloxZAjRbNKM7INHWPOgAkdnazZOqRu1PYqgvv-QgjncHQDCyIeejK7jIGyQsOoDh3TpeQ_Ql6ezFNIzIRgUrTKTdWiX2D2Mz6CQ4ha5K74uE8Ww7Cxk3WU6zaY3gLwkbB-kH2/s1600/Brooklyn_Bridge_Postdlf.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">This bridge at <a href="https://www.google.com/search?q=40.7057%C2%B0+N%2C+73.9964%C2%B0+W">40.7057° N, 73.9964° W</a> is for sale to the highest-bidding hospital.  Its purchase, plus a few hundreds of millions of dollars of IT thrown into the bargain, will revolutionize healthcare at the lucky hospital with the winning bid.</td></tr></tbody></table>  -- SS

A very short observation on EHRs and the Veterans Administration healthcare scandal

As has been in the news lately, it has been revealed that U.S. veterans' medical care was being delayed at a number of Veteran's Adm...

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More Stories of Million Dollar Plus Hospital Executives, but Now the NY Times Challenges the Talking Points

It is spring, time for birds to sing, flowers to bloom, and hospital executives to get more money.  As we do periodically, we have amassed a series of media accounts of the big to enormous compensation paid to top non-profit hospital leaders.  These reports follow a certain pattern, but this year's spring crop included something different. The Pattern In the groundbreaking science fiction series "Fringe," "The Pattern" was a series of apparently inexplicable events which eventually pointed to the existence of a parallel universe. <iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/i8DqLs7254E" width="560"></iframe> In non-profit hospitals, The Pattern of the discussion of executive compensation is this.  Nearly all non-profit hospitals must release minimal data on the total compensation of a few of the highest paid executives.  When these reports come out, sometimes the local media take a look, either at an individual hospital or hospital system, or at a number of local hospitals.  They almost inevitably find that some, usually most executives make what appears to be lots of money.  This could be hundreds of thousands of dollars at small community hospitals, or millions of dollars at larger hospitals and hospital systems.  Sometimes the reports end there.  Sometimes the reporters ask hospital representatives or local experts to explain the apparently exalted compensation figures.  The explanations are usually very similar, and so we have called this part of The Pattern The Talking Points. The Talking Points It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy.   We first listed the talking points <a href="http://hcrenewal.blogspot.com/2011/09/talking-points-sans-original-thought-to.html">here</a>, and then provided additional examples of their use <a href="http://hcrenewal.blogspot.com/2011/09/more-repeats-of-talking-points.html">here</a>, <a href="http://hcrenewal.blogspot.com/2012/03/example-of-how-complex-takes-control.html">here</a> <a href="http://hcrenewal.blogspot.com/2012/12/health-care-hired-managers-not-playing.html">here,</a> <a href="http://hcrenewal.blogspot.com/2013/05/executive-compensation-as-legal.html">here</a>, <a href="http://hcrenewal.blogspot.com/2013/06/no-blues-but-lots-of-green-for-st-louis.html">here,</a> and <a href="http://hcrenewal.blogspot.com/2013/08/should-we-cry-for-non-profit-hospital.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2013/08/the-long-con-charitable-hospitals-make.html">here</a>.  They are: - We have to pay competitive rates - We have to pay enough to retain at least competent executives, given how hard it is to be an executive - Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job). The talking points are usually supplied by hospital public relations personnel, sometimes by hospital trustees or executives, sometime by various health care consultants.  The talking points are rarely questioned. So let us look at some recent media articles for The Pattern, grouped in chronological order, to illustrate. Jersey Boys On April 6, 2014, Crain's New York Business<a href="http://www.crainsnewyork.com/article/20140406/HEALTH_CARE/140409916/hospital-execs-receive-sky-high-payouts"> reported</a> some of the biggest yearly compensation figures seen for non-profit hospital CEOs.   <blockquote class="tr_bq">Ronald Del Mauro, the former president and chief executive of Barnabas Health, pulled in almost $22 million in 2012, the year after he retired from New Jersey's largest health system. Joseph Trunfio, president and chief executive at Atlantic Health, made $10 million. Never before have such outsized compensation packages appeared on Crain's <a href="http://www.crainsnewyork.com/data-lists/business-lists/details/30/2962924" target="_blank" title="Crain's list of top-paid health care executives">annual list of top-paid hospital executives</a></blockquote> The explanations fit the pattern.  First from a Barnabas spokesperson, <blockquote class="tr_bq">'When Mr. Del Mauro began his career, Saint Barnabas Medical Center was a stand-alone community hospital,' she said, adding that Barnabas is 'well positioned both financially and operationally, despite significant industry challenges. His retirement package is a function of over four decades of service ... and reflects his exceptional legacy.'</blockquote> He was just another brilliant executive, in other words. Then about Mr Trunfio, <blockquote class="tr_bq">In a statement, Karen Kessler, board chair of Atlantic Health System, said that while Mr. Trunfio's 'current agreement does not have these bonus provisions, his compensation is performance-based, aligned with industry standards and intended to assure we retain top executive talent to provide the best quality of care to the communities we serve.'</blockquote> There in italics were the competitive market rates and retention arguments, and a repeat ("top talent") of the brilliance argument. Meanwhile, on April 28, 2014, NJBiz had its own <a href="http://www.njbiz.com/article/20140428/NJBIZ01/304259991/What%27s-fair-pay-at-nonprofits?-When-it-comes-to-hospitals-a-proper-diagnosis-is-difficult">report</a> on non-profit executive compensation in the state.   Their summary included, <blockquote class="tr_bq">Heading up the list is Robert C. Garrett, CEO of the Hackensack University Health Network at $2.12 million, followed by Richard P. Miller, Virtua Health ($1.99 million); John K. Lloyd, Meridian Health System ($1.68 million); Barry H. Ostrowsky, Barnabas Health ($1.67 million); and Stephen K. Jones, Robert Wood Johnson Health System ($1.55 million). Several New Jersey multi-hospital systems paid several top executives more than $1 million in 2012. Hackensack, for instance, has two executives over the million-dollar mark.</blockquote> [It is not clear why the two different reports listed two different people from Barnabas - Ed] Then came The Talking Points, for example, from Hackensack Hospital, <blockquote class="tr_bq">'The pay for HackensackUMC's executives reflects its complexity and is consistent with those levels paid to executives in other similarly situated not-for-profit academic and integrated health systems,' Hackensack said in a statement. "The compensation philosophy is to provide market-competitive base salaries....</blockquote>  The bit about complexity implies the brilliance argument, since only a brilliant CEO could cope with such complexity.  Then we had two versions of the competitive market based payment argument.   Here is another version of the same thing, this time from one "Joel Cantor, director of the Center for State Health Policy at Rutgers University," <blockquote class="tr_bq">On the other hand, hospital systems are large, complex organizations. Ultimately, CEO compensation is driven by the market for senior talent.  </blockquote> My favorite version of the brilliance argument came from one Ms Betsy Ryan, president of the New Jersey Hospital Association, <blockquote class="tr_bq">They literally are on call 24/7, 365 days a year and they are running an institution where lives are at stake</blockquote>  More on that later..... Smatterings of Data from Connecticut and Pennsylvania There were a series of reports that simply noted large amounts, but did not look for explanations.   HartfordBusiness.com<a href="http://www.hartfordbusiness.com/article/20140512/PRINTEDITION/305099967/15-ct-hospital-execs-paychecks-top-1m"> recounted</a> a state report of the top 10 most highly paid executives of individual hospitals (but did not account for the pay given to executives of hospital system).  The figures started at $3.26 million for the CEO of Yale-New Haven Hospital, and finished with $1.48 million for the senior vice-president and chief of staff at the same institution. The Pittsburgh Post-Gazette <a href="http://www.post-gazette.com/business/businessnews/2014/05/15/Former-president-CEO-was-highest-paid-West-Penn-Allegheny-Health-System-employee-in-2012/stories/201405150395">reported</a> pay at the West Penn Allegheny Health System, including that given to a former CEO, $1.89 million, and to a former chief administrative officer, $1.29 million.     Then the Pittsburgh Tribune <a href="http://triblive.com/business/headlines/6100989-74/million-2012-upmc">noted</a> even bigger compensation given out at competitor UPMC. <blockquote class="tr_bq"> <div class="News-body-text">UPMC CEO Jeffrey Romoff got an 8 percent raise two years ago, placing his generous compensation package near the top of the nonprofit hospital industry. </div><div class="News-body-text"> </div><div class="News-body-text">The 68-year-old Romoff, who leads the largest integrated health system in Western Pennsylvania and one of the biggest in the nation, brought in $6.6 million in 2012, up from $6.1 million in 2011, according to tax documents UPMC made public on Friday. </div></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Also,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"> </div><blockquote class="tr_bq"><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">UPMC paid 30 other executives and doctors more than $1 million each in 2012, up from 21 employees who were in the $1 million club the year before.</div></blockquote> Wake Forest Baptist The Winston-Salem Journal <a href="http://www.journalnow.com/news/local/wake-forest-baptist-releases-annual-regulatory-filing/article_f0db42e0-dc9e-11e3-a040-0017a43b2370.html">reported</a> details of executive compensation at Wake Forest Baptist on May 16, 2014.  Its CEO, Dr John McConnell, had "total compensation [which] rose 0.8 percent to $2.06 million in 2012."  Then, however, "Donny Lambeth, the former president of N.C. Baptist, had a 52 percent drop in total compensation to $1.18 million."  Also, "Dr. Thomas E. Sibert, president of Wake Forest Baptist Health and chief operating officer, received a 10 percent drop in total compensation to $1.02 million."  Then, "Edward Chadwick, chief financial officer, had a 2.3 percent drop in total compensation to $956,465."  It is interesting that some executives actually saw small decreases.  Then again, the system lost $4.5 million for fiscal 2012-2013. The article also offered up the usual explanations, first provided by the hospital system itself, <blockquote class="tr_bq">there are few executives with the required skill set to manage and provide leadership for an integrated (center) such as ours</blockquote> There goes another version of the brilliance argument.  Then, <blockquote class="tr_bq">Its executive compensation packages, it said, 'are fiscally responsible, appropriate for the marketplace and an essential part of the effort to recruit and retain skilled executives and visionary leaders for the medical center.'</blockquote> Those included the competitive market rates and the retention arguments, plus the ante for brilliance was upped to the visionary level. The article ladled on one another version, this time supplied by "John Challenger, chief executive of outplacement consultancy Challenger, Gray & Christmas," <blockquote class="tr_bq"> 'Communities who want the best health-care system they can get should support paying the compensation levels required to attract top talent,' Challenger said. 'Cutting salaries will result in an exodus of top talent to systems that will pay it,...'</blockquote> So "top talent" = brilliance argument, threatening an "exodus" = retention argument. So there they go again, again. Something Different: the New York Times Challenges the Pattern  We have previously challenged the talking points.  For example, in August, 2013 we <a href="http://hcrenewal.blogspot.com/2013/08/the-long-con-charitable-hospitals-make.html">wrote</a>, <blockquote class="tr_bq">As we have <a href="http://hcrenewal.blogspot.com/2013/08/should-we-cry-for-non-profit-hospital.html">noted before</a>, there is little evidence in support of these talking points.  What evidence there is on the topic suggests there is no real free market in interchangeable CEOs, and that CEOs are not very mobile, especially not across different kinds of organizations (look <a href="http://hcrenewal.blogspot.com/2012/10/more-reasons-to-doubt-how-ceos-are.html">here</a>).  There is little evidence that hospital (or other health care) executives are particularly brilliant, or any more brilliant than multitudes of physicians, nurses, and other health care professionals who work hard to make their institutions run.</blockquote>Yet most discussions of executive compensation in hospitals, and indeed in health care, follow The Pattern. So it was refreshing in this season of outsized compensation reports is that the New York Times ran an <a href="http://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-not-the-big-cost.html">article</a> that challenged The Pattern, albeit with limitations.  The most obvious problem with the pattern is that the arguments are out of context, and not challenged in context.  However, in the NY Times, <blockquote class="tr_bq">Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack. <div class="story-body-text story-content" data-para-count="134" data-total-count="471" itemprop="articleBody">That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.</div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.</div></blockquote><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">Note that this comparison only refers to salaries, not total compensation, so</div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><blockquote class="tr_bq"><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation.</div></blockquote><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">We just saw examples of non-profit hospital CEOs making over $1 million to over $6 million in total compensation.  That would imply that non-profit CEOs may make from three times to over thirty times the total compensation of a surgeon, and from over five times to over thirty-five times the compensation of a general internist.  (And the ratio for such outliers as Mr Del Mauro above would be even higher.)  </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">So is a hospital CEO thirty times more brilliant than a general internist?  </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">That suggests also that we go back to another version of the brilliance argument found in one article above.  In the NJBiz article, the NJ Hospital Association President said, about CEOs, not physicians,</div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><blockquote class="tr_bq"><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">They are literally on call 24/7, 365 days a year and they are running an institution where lives are at stake.</div></blockquote><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">They may be on call in a sense, but they are never on first call.  Their decisions may ultimately affect lives, and perhaps put lives at risk.  But they never have to make a decision about a patient that could literally cost that patient his or her life.  And they almost never have to be accountable for what happens to individual patients.  </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">It is easy to argue that physicians' responsibilities for life and death decisions are much more direct.  Explain, then, those pay ratios again.  </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody">Actually, in an <a href="http://www.fiercehealthfinance.com/story/could-watson-replace-high-paid-hospital-execs/2014-04-21">opinion piece</a> about executive compensation in FierceHealthFinance, Ron Shinkman described the life of a typical seven-figure a year hospital executive,</div><div class="story-body-text story-content" data-para-count="418" data-total-count="889" itemprop="articleBody"> </div><blockquote class="tr_bq">While the days of seven-figure club members are long, they are also predictable--check the census and cash flow reports, confer with the medical staff, get updates on supplies, negotiate with payers, have some meetings on long-term planning. If it is a large hospital in a large market, those meetings are likely focused on site expansion and acquisition. If it is a medium-sized facility, tI expect they spend their time focused on finding a larger partner. Breakfast and dinner meetings and events switch focus to development and fundraising. There may also be some meetings on quality initiatives, but they are of nominal consequence. Members of the seven-figure club enjoy little to no accountability from their customers.</blockquote> So is executive compensation in hospitals, or other parts of the health care system, based on executives' brilliance.  Or is it based on their ability to be rentiers, rent-seekers, who can control the choke points of money flow, and make sure they get more than their share before what is left can go to real health care?  Of course, hospital executives and their ubiquitous spokespeople do not discuss what they do day to day.  Maybe they need to, and also need to address the implications of these statements in the NY Times article, given that the US has the highest health care costs of any developed country, but nowhere near the best results, <blockquote class="tr_bq"><div class="story-body-text story-content" data-para-count="372" data-total-count="4255" id="story-continues-3" itemprop="articleBody">And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to <a href="http://www.commonwealthfund.org/%7E/media/Files/Publications/In%20the%20Literature/2013/Nov/PDF_Schoen_2013_IHP_survey_chartpack_final.pdf">a study by the Commonwealth Fund</a>.</div><div class="story-body-text story-content" data-para-count="372" data-total-count="4255" id="story-continues-3" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="274" data-total-count="4529" itemprop="articleBody">As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the 'navigators' created by the Affordable Care Act.</div><div class="story-body-text story-content" data-para-count="189" data-total-count="4718" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="189" data-total-count="4718" itemprop="articleBody">Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.</div></blockquote><div class="story-body-text story-content" data-para-count="189" data-total-count="4718" itemprop="articleBody"> </div><div class="story-body-text story-content" data-para-count="189" data-total-count="4718" itemprop="articleBody">We had <a href="http://hcrenewal.blogspot.com/2013/08/the-long-con-charitable-hospitals-make.html">previously argued</a> (see above) against the talking points, and specifically that there is nothing to suggest that hospital executives are any more, much less an order of magnitude more brilliant than physicians or other health care professionals. But I confess as a physician I did not have the courage to extend that argument to a direct comparison of executive versus health care professional pay. The Times article, written by someone who is not a physician, did not have to worry about appearing self-serving.  I am glad, for it is high time to discuss the degree that the incentives produced by executive pay in health care have become perverse, and how to change these incentives to make health care leaders more accountable for health, and less focused on their own riches.  </div><div class="story-body-text story-content" data-para-count="189" data-total-count="4718" itemprop="articleBody"> </div>

More Stories of Million Dollar Plus Hospital Executives, but Now the NY Times Challenges the Talking Points

It is spring, time for birds to sing, flowers to bloom, and hospital executives to get more money. As we do periodically, we have amassed a...

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Is this Any Way to Discuss Health Care Policy? - Television Advertising about US Health Care Reform Cost $445 Million from 2010 -2014

Every now and then, we get an anonymous comment criticizing our "lack of balance" or words to that effect, maybe because we criticized some action by a big, often but not always for-profit, health care organization.  We usually respond that we have no obligation to be balanced, since - We publish opinion, not hard news -  It is questionable that even hard news reporters must report all opinions on an issue, if some of those opinions are demonstrably less credible -  There are far more voices extolling the wonderful "innovations" provided by our current "best health care system in the world," than providing our sorts of criticism. To expand on that last point - a recent news item suggests how much of the health care policy debate is paid marketing and public relations, rather than individual voices of citizens, health care professionals, or even health care policy experts. From the AP, <a href="http://www.seattlepi.com/news/article/Study-Political-TV-ads-on-health-law-total-445M-5483653.php">via the Seattle Post -Intelligencer</a>, <blockquote class="tr_bq">A new analysis finds the nation's health care overhaul deserves a place in advertising history as the focus of extraordinarily high spending on negative political TV ads that have gone largely unanswered by the law's supporters. The report, released Friday by nonpartisan analysts Kantar Media CMAG<a href="http://www.seattlepi.com/?controllerName=search&action=search&channel=news%2Fpolitics&search=1&inlineLink=1&query=%22Kantar+Media+CMAG%22"></a>, estimates $445 million was spent on political TV ads mentioning the law since the enactment of the Affordable Care Act in 2010. Spending on negative ads outpaced positive ones by more than 15 to 1.</blockquote> In particular, <blockquote class="tr_bq">In the 2014 congressional races, 85 percent of the anti-Obama ads were also anti-'Obamacare' ads, the analysis found. In some competitive races, 100 percent of the pro-Republican TV ads aimed at Democrats contained anti-health law messages. Over the four years, an estimated $418 million was spent on 880,000 negative TV spots focusing on the law, compared to $27 million on 58,000 positive spots, according to the analysis. Nearly all of the spending was on local TV stations, in races ranging from state offices such as treasurer and governor to Congress and the presidential election.</blockquote> That is just amazing. My concern is not so much that much of this advertising is against "Obamacare."  We have not often written about the Affordable Care Act (ACA), aka "Obamacare," and what we wrote at best was mild praise.  As I <a href="http://hcrenewal.blogspot.com/2010/03/health-care-reform-bill-and-health-care.html">posted</a> back in 2009, very little of the law had anything to do with the issues we discuss on Health Care Renewal.  In my humble opinion, since the law went into effect, it has increased access to health insurance, especially for certain groups of people that commercial health care insurers previously spurned, e.g., older people and people with pre-existing diseases.  It also contained provisions that might increase disclosure of conflicts of interest, and foster comparative effectiveness research.  On the other hand, the law has done nothing to reduce <a href="http://hcrenewal.blogspot.com/search/label/concentration%20of%20power">concentration of power</a> in health care.  It has done nothing to make health care leaders more <a href="http://hcrenewal.blogspot.com/search/label/accountability">accountable</a>, especially for their organization's unethical or even <a href="http://hcrenewal.blogspot.com/search/label/crime">criminal</a> behavior, decrease their ability to <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">line their pockets</a> regardless of such behavior, and thus reduce their <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity.</a>  It will not obviously decrease <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest </a>affecting those who make decisions about patient care or health policy, lock the <a href="http://hcrenewal.blogspot.com/search/label/revolving%20doors">revolving door</a> between government and the health care industry, end <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation of clinical research</a> to serve vested interests, or <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppression of research</a> whose results offend such interests, etc, etc.  So there is plenty to discuss about health care reform and related matters of health care policy. Yet a major venue of US public discussion about health care policy, at least having to do with health care reform legislation, appears to be 15 -60 second paid television advertisements.  Often who pays for these ads are obscure, as certainly are the identities of the advertising or public relations firms that actually craft them.  Certainly, the ads do not explain who might profit were what they urge be implemented. The ads may appeal to emotion, or engage in logical fallacies.  And they appear in millions of peoples homes day in and day out. Such advertising, added to all the other billions of dollars worth of <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> and <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> that swirl around health care, make any sort of intelligent discussion very difficult.  The advertising frenzy renders the voices of individual citizens, health care professionals, and even health policy experts  whispers in comparison. While there are ostensible free speech advocates who defend these advertisements, and maybe who promote the free speech rights of corporations as the same as those of human citizens (without, of course, many of the responsibilities of citizens), none of these vocal self-proclaimed civil libertarians seem to be doing anything to defend the audibility of the voices of individuals in the health care policy debate. So we will continue to do what we can to bring some healthy skepticism about loud proclamations in health care made by people who stand to gain financially from their effects.  But is it any wonder that our voices create <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">so few echoes</a>?

Is this Any Way to Discuss Health Care Policy? - Television Advertising about US Health Care Reform Cost $445 Million from 2010 -2014

Every now and then, we get an anonymous comment criticizing our "lack of balance" or words to that effect, maybe because we critic...

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The Continuing Mystery of the Fugitive Founder and Missing Money - What it Says About the Opacity of Offshore Medical Schools

The next chapter in the bizarre tale of the fugitive founder of an off-shore (from the US and Canada) Caribbean medical school, and his now convicted spouse, do not solve any mysteries, but raise larger concerns about the accountability, or lack thereof, of leaders of important health care organizations. Introduction: the Fugitive Founder and Convicted Spouse As we <a href="http://hcrenewal.blogspot.com/2013/10/the-mystery-of-fugitive-founder-and.html">posted</a> in October, 2013, drawing an amazing for us number of comments, the couple who founded two Caribbean medical schools which catered almost entirely to US and Canadian students ran into significant legal trouble.  Founder David Leon Fredrick and his wife, Dr Patricia Lynn Hough were indicted for tax evasion for failing to report income from the two medical schools they allegedly owned, and later sold. The schools were Saba University School of Medicine, on Saba, and the Medical University of the Americas, on Nevis.  The initial legal proceedings revealed that while Saba University School of Medicine was apparently first set up by a non-profit foundation (or NGO) run by the couple, somehow it became for-profit owned by Mr Fredrick and Dr Hough, and Saba and the Medical University of the Americas were subsequently sold to a private equity group, Equinox Capital. Before jury selection started, Mr Fredrick disappeared.  Dr Hough was eventually convicted of defrauding the US Internal Revenue Service, and income tax evasion, after trial testimony to the effect that the couple concealed money in a Swiss bank, got $36 million from the sale of the schools, and bought an airplane, two houses, and a condominium. Left mysterious at that time were Mr Fredrick's whereabouts, where the money that the couple derived from the sale of the medical schools went, and how a school that began as a non-profit organization became a for-profit corporation owned by the couple.  The case should have lead to some concerns about the leadership and governance of the off-shore medical schools that now train increasing numbers of would be US and Canadian physicians. However, after Dr Hough was convicted, there was little public discussion of these issues, at least until Dr Hough's recent sentencing.  (There were some interesting comments made on our blog post, many from anonymous erswhile defenders of Saba University and/or Mr Fredrick and Dr Hough.  While they expressed some interesting opinions, in my humble opinion they did not add any substantive facts to the discussion.) Latest Developments in the Case In the past few weeks the case got a little more public notice in terms of reporting of the legal proceedings leading to the sentencing of Dr Hough   They brought to light some additional contentions by the prosecution, which deserve some attention because after all, they won their case. The Amount of Money the Couple Made As <a href="http://www.heraldtribune.com/article/20140509/ARTICLE/140509637">reported</a> by the Sarasota (FL) Herald-Tribune,  Dr Hough was sentenced to two years in federal prison, three years of supervised release, and to repay $15 million to the IRS.  In addition, <blockquote class="tr_bq"> Prosecutors say Hough and Fredrick sold the schools and associated real estate in April 2007 for more than $35 million. An IRS agent testified last Thursday that Hough also made more than $12 million in income from the two schools from 2003 until 2007.</blockquote> How much Mr Fredrick made was not discussed since it was not relevant to Dr Hough's sentencing.  The Effort that Went into the Plot According to <a href="http://www.businessweek.com/news/2014-05-09/caribbean-medical-school-founder-hough-gets-2-years-in-tax-case">Bloomberg</a>, <blockquote class="tr_bq">'Hough’s crimes were neither impulsive nor isolated but required sophisticated transactions, coordination with foreign bankers, annual lies to the federal government, and by her own admissions, trips to Switzerland,' prosecutors wrote in a sentencing memo on April 14. 'Hough made calculated decisions to cheat, over and over again.'</blockquote> Also, <blockquote class="tr_bq">Prosecutors accused the couple of crafting their scheme with UBS AG (UBSN) banker Dieter Luetolf and Swiss financial adviser Beda Singenberger, both unindicted co-conspirators. Singenberger, who was separately charged with helping 60 U.S. clients hide $184 million in offshore accounts, hasn’t responded in federal court in New York.</blockquote> In more detail, <blockquote class="tr_bq">Prosecutors said the couple used an array of accounts in the names of businesses to hide their money and employed 'e-mails, telephone calls and in-person meetings to instruct Swiss bankers and asset managers to make investments and transfer funds from their undeclared accounts at UBS.' </blockquote> The Mysteries Remain Where Did the Money Go? As noted above, the sale of the two medical schools netted Mr Fredrick and Dr Hough about $35 million.  Where that went is still unclear. How Did Mr Fredrick and Dr Hough Become Owners of a Previously Non-Profit Medical School? As noted above and in our previous post, Saba University School of Medicine began as a non-profit managed by Mr Fredrick and Dr Hough.  Somewhere along the way, the couple assumed ownership of the school.  There seems to be no record and no discussion of how this happened.  In the US, a conversion of a substantial non-profit, like a medical school, to a for-profit, ordinarily would require some regulatory approval and public discussion.  Furthermore, in most cases, non-profit conversions to for-profit would require some sort of protection of the assets of the former non-profit, often leading to a spin-off of a new non-profit foundation.   None of this apparently happened in this case (which admittedly did not occur in the US.)  How did Mr Fredrick and Dr Hough just take over a non-profit, sell it, and keep all the money involved? Where is Mr Fredrick and Why did He Flee? We need Sherlock Holmes for this.  What Does This Case Say About the Leadership and Governance of Offshore Medical Schools? So the latest details revealed suggest a fairly intricate plot by the American couple who founded two Caribbean medical schools.  The plot allegedly netted them millions, and now resulted in one of the couple remaining a fugitive, and the other convicted of federal crimes. The biggest issue raised by this case, in my humble opinion, is not about financial crimes, tax-evasion, or the hiding of assets in Swiss banks.  It is about the leadership and governance of offshore Caribbean medical schools, and by extension, of academic medicine and health care.  In 2010, Eckhert documented that the number of offshore medical schools, "for-profit institutions whose purpose is to train U.S. and Canadian students who intend to return home to practice," but not to train physicians to practice in the countries in which these schools are located, was rapidly growing.(1)  By 2010, there were 33 such schools, 20 of which were new since 2000. These offshore medical schools are not accredited in the US or Canada, and such accreditation is currently not required for individual graduates of such schools to be admitted to US house-staff programs or for US licensure.  So perhaps it is not surprising that little is known about these schools. How they choose students, the qualifications, or even names of their faculty, their curriculum, how they supervise clinical training (which is mostly done by affiliated North American hospitals), and what happens to their graduates are boscure.  Eckhert attempted to describe what is known, but noted "variability exists in the availability of information on faculty; where data exists, it is noted that most of the permanent on-site basic science faculty are internationally trained, many have no documented medical education experience in the United States, and it is not uncommon for them to be OMS [offshore medical school] alumni." Even less is known about who leads these schools, who if anyone is responsible for their stewardship, and even who owns them.  The current case suggests that Saba University School of Medicine was run by couple who mysteriously assumed ownership of the school after leading it as a non-profit organization, then sold it to private equity for millions in a transaction that eventually left one a convicted criminal and the other a fugitive.  Yet none of this came to light until the federal government launched an investigation not of offshore medical schools, but of offshore money laundering and happened to catch the couple in the investigational web. No regulatory process, no watchdog organization in the US or Canada, or on Saba apparently found this out until it was revealed in an investigation by the US federal government that had nothing specifically to do with health care or offshore medical schools.  This suggests that offshore medical schools now can be lead and run by anyone, qualified or not, honest or criminal, without any oversight or accountability.   For example, even today little is known about the leadership of Saba University School of Medicine.  The school currently <a href="http://www.saba.edu/faculty/administration">provides</a> only minimal biographical information on its administration.  Its President is listed as Joseph Chu MD MPH, who appears to have the same educational credentials (MD from Georgetown, MPH from University as Washington) as one <a href="http://depts.washington.edu/epidem/fac/facBio.shtml?Chu_Joseph">Joseph Chu</a> who is apparently a Clinical Associate Professor of Epidemiology at the University of Washington.   Dr Chu's specialty and previous experience are not apparent.  Whether the Dr Chu at University of Washington is the same as the President of Saba is unclear.  If they are the same, how Dr Chu holds down these two jobs is not clear. For comparison, most US schools provide extensive information about their leadership.  Just as an example, see the <a href="http://www.uwmedicine.org/about/administration/paul-ramsey">introductory page</a> on the Dean of the University Washington medical school. Even less is known about the stewardship or governance of Saba University School of Medicine.  Many US medical schools have their own boards of trustees who are supposed to provide stewardship. For example, the UW board is <a href="http://www.uwmedicine.org/about/board">here</a>.  Their membership is generally known.  Furthermore, most US medical schools report to university leadership, again whose identity is known, and are subject to governance by a university board of trustees.  We have certainly criticized the leadership and governance of US academic medicine.  At least, however, it is possible to find out the names of the people responsible.  However, while Saba University School of Medicine is still apparently owned by Equinox Capital according to the latter's <a href="http://www.equinox-capital.com/index.php/select-transactions">website</a>, to whom Dr Chu reports at Equinox Capital is unclear.  Whether Saba has a board of trustees, or any such similar stewardship mechanism, is unclear.  So who is ultimately accountable for Saba is unclear.  Probably just as unclear is who leads, who stewards, and who is accountable for the leadership of most other offshore medical schools. While Eckhert wrote in 2010 that the increasing presence of offshore medical graduates in the US "obligates U.S. medicine to take a closer look at these educational programs," no such scrutiny has occurred since then.  While offshore medical schools account for the training of an increasing proportion of US (and presumably Canadian) physicians, we know next to nothing about their leadership and governance.  This seems to be just another part of the decreasing accountability of the leadership of US health care, and the increasing opacity of the governance and stewardship of US health care organizations.  True US health care reform would make leadership transparent and accountable.          Reference  1.  Eckhert NL.  Private schools of the Caribbean: outsourcing medical education.  Acad Med 1010; 85: 622-630.  Link <a href="http://www.ncbi.nlm.nih.gov/pubmed/20354377">here</a>.

The Continuing Mystery of the Fugitive Founder and Missing Money - What it Says About the Opacity of Offshore Medical Schools

The next chapter in the bizarre tale of the fugitive founder of an off-shore (from the US and Canada) Caribbean medical school, and his now ...

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A Nurse's Union, National Nurses United, Takes On Bad Health IT

National Nurses United (<a href="http://www.nationalnursesunited.org/">http://www.nationalnursesunited.org/</a>), a nurse's union, takes on bad health IT with both satire and seriousness: <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/AVvXsEiprlRmvgYeCeaqg0b0eMZaZW0WhnmaZfgnqn_j_OomQKEPdpVwk4ocZbdHMFms5H7G1sfoxiJW6t-Eu_s7FVF_IfLsopQ6KH3J6WhshWpBNFydN06dQlyQE1Dna3YqEEZiWDWdfw2eJnyC/s1600/hey+dude.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiprlRmvgYeCeaqg0b0eMZaZW0WhnmaZfgnqn_j_OomQKEPdpVwk4ocZbdHMFms5H7G1sfoxiJW6t-Eu_s7FVF_IfLsopQ6KH3J6WhshWpBNFydN06dQlyQE1Dna3YqEEZiWDWdfw2eJnyC/s1600/hey+dude.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Hey dude!  I'm your highly-cost effective computer technician Steve.  Tell me what's hurtin' and I'll program it into Frank, our computerized doctor and nurse replacement. (YouTube video at <a href="https://www.youtube.com/watch?feature=player_embedded&v=YthF86QDOXY">https://www.youtube.com/watch?feature=player_embedded&v=YthF86QDOXY</a>.)</td></tr></tbody></table> See their page at <a href="http://www.nationalnursesunited.org/site/entry/insist-on-an-rn">http://www.nationalnursesunited.org/site/entry/insist-on-an-rn</a> I note that nature abhors a vacuum, and since medicine's watchdogs (e.g., FDA), physicians and their organizations, the Medical Informatics community and others who know better have left a deep vacuum over health IT problems, I'm glad unionized nurses have stepped up to the plate. -- SS

A Nurse's Union, National Nurses United, Takes On Bad Health IT

National Nurses United ( http://www.nationalnursesunited.org/ ), a nurse's union, takes on bad health IT with both satire and seriousnes...

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Cerner: "It’s in the DNA of our company to have the vision and passion to fix what’s broken in health care." Maybe they should fix their software first?

I point out this hyper-exuberant piece on health IT in the St. Louis Post-Dispatch. Clearly someone at Cerner thinks they're going to cure the world with "population health" and their computer software: <blockquote class="tr_bq">With its Healthy Nevada initiative, Cerner Corp. cultivates a culture of health St. Louis Post-Dispatch Diane Stafford,  Kansas City Star May 11, 2014 <a href="http://www.stltoday.com/news/special-reports/mohealth/updates/with-its-healthy-nevada-initiative-cerner-corp-cultivates-a-culture/article_8cc3168f-fd9f-5e7e-ba80-cc05dd6a35f9.html">http://www.stltoday.com/news/special-reports/mohealth/updates/with-its-healthy-nevada-initiative-cerner-corp-cultivates-a-culture/article_8cc3168f-fd9f-5e7e-ba80-cc05dd6a35f9.html</a> Cerner Corp. employees started visiting Nevada, Mo., in 2011, looking to adopt a community as a testing ground for theories to control skyrocketing medical costs. At the outset, “our discussions were marked by a lot of confusion,” recalled City Manager John David Kehrman. “We thought of Cerner as a data company. We didn’t understand what they wanted.” The North Kansas City-based company, grown to global prominence by selling health care information technology to hospitals and doctors, aimed to reach a broader audience with a message: You have to take more responsibility for your own health. ... the company’s bigger evolution is that it’s investing millions in its next-generation software, dubbed Healthe Intent, which tracks individual and group health and treatment results. It re-imagines jobs in the health care industry and eventually will reach into patients’ homes. If the initiatives blossom, Cerner executives believe they will boost the company’s revenue by billions of dollars a year ... “Cerner’s founders never saw themselves being a health care IT company,” Swindells asserted. “They saw themselves fixing health care.”</blockquote> Wow.  That's a neat trick for a health IT company. (As I asked of health IT company CEOs making similar statements back at a 1997-or-so Microsoft Healthcare Users Group meeting, "How are you going to revolutionize healthcare when you and nearly everyone at this meeting has no actual healthcare experience?"  They had no rational answer.  See "Broken Chord", Healthcare Informatics, Feb. 1999, archived <a href="https://web.archive.org/web/19991005222815/http://www.healthcare-informatics.com/issues/1999/02_99/postmark.htm">at this link</a>.) I won't comment further on the content of the St. Louis Post-Dispatch piece, which is marketing agitprop.  It's their right to produce such material, after all.  Read it for yourself and learn of our glorious Cerner-driven health utopia. I will comment, however, on one line in the piece, namely: <blockquote class="tr_bq">... “It’s in the DNA of our company to have the vision and passion to fix what’s broken in health care,” said Matthew Swindells, Cerner’s head of population health and global strategy. </blockquote> Considering the broken health IT this company introduces into the market upon unsuspecting physicians, nurses and patients [e.g., see notes 1-6], perhaps they should consider fixing what's broken in health IT before releasing to market, and certainly before attempting to tackle the infinitely harder task of "fixing what's broken in health care." -- SS Notes: [1]  November 17, 2013. "Another 'Survey' on EHRs - Affinity Medical Center Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter", <a href="http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html">http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html</a>    [2] January 19, 2012. "[British MP] Bacon calls for halt on [Cerner] Millennium", <a href="http://www.ehi.co.uk/news/acute-care/7471/bacon-calls-for-halt-on-millennium">http://www.ehi.co.uk/news/acute-care/7471/bacon-calls-for-halt-on-millennium</a> [3]  January 21, 2011.  "MAUDE and HIT Risks: What in God's Name is Going on Here? [Cerner health IT defects reports]", <a href="http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html">http://hcrenewal.blogspot.com/2011/01/maude-and-hit-risk-mother-mary-what-in.html</a> [4]  March 4, 2011. "A study of an Enterprise Health information System [Cerner Firstnet]", Prof. Jon Patrick, Univ. of Sydney, <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146">http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146</a> [5] Oct. 20, 2010.  "Medical center has more than 6000 "issues" with Cerner CPOE system in four months", <a href="http://hcrenewal.blogspot.com/2010/10/medical-center-has-more-than-6000.html">http://hcrenewal.blogspot.com/2010/10/medical-center-has-more-than-6000.html</a> [6] 2009.  "The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee" [on Lorenzo and Cerner Millenium], UK National Programme for Health IT in the NHS (now defunct), <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm">http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm</a>

Cerner: "It’s in the DNA of our company to have the vision and passion to fix what’s broken in health care." Maybe they should fix their software first?

I point out this hyper-exuberant piece on health IT in the St. Louis Post-Dispatch. Clearly someone at Cerner thinks they're going to cu...

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EHR Story for Mother's Day 2014: Even The Formerly Simple Act Of Giving IV Fluids in ICU's Can Kill Babies. But's Let's Be Objective and Happy!

<div style="text-align: center;">[Note to the humorless:  this post is satirical and sardonic to make a very serious point about the perversity of downplaying/ignoring health IT risks, issues too often ignored by those who know better.  If you don't like satire, don't read it.] </div> I've been critiqued for posting in too gloomy a manner for some's taste, even those who like me are in the Medical Informatics field.  For example, in the Feb. 2013 Kaiser Health News article "Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes" at <a href="http://www.kaiserhealthnews.org/stories/2013/february/18/scot-silverstein-health-information-technology.aspx">http://www.kaiserhealthnews.org/stories/2013/february/18/scot-silverstein-health-information-technology.aspx</a>: <blockquote class="tr_bq">... Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn’t comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.</blockquote> Of course, if a close relative of these unnamed "many" were killed by, say, a drunk driver (something this unobjective group of mothers takes seriously:  <a href="http://www.madd.org/">http://www.madd.org/</a>), or if their child were abducted and decapitated (<a href="http://en.wikipedia.org/wiki/Murder_of_Adam_Walsh">http://en.wikipedia.org/wiki/Murder_of_Adam_Walsh</a>), or if something like this event (<a href="https://www.youtube.com/watch?v=55XJivhjB4U">https://www.youtube.com/watch?v=55XJivhjB4U</a>) happened, their response would surely be "oh well, stuff happens, let's all be 'objective', not 'personalize' things, not advocate with our personal stories, and above all, be happy!    <div class="separator" style="clear: both; text-align: center;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgz2Sc_Ep0eHVvzgNTK2PPqnYAKho1OUX3pg4Y8MMphHPtZ3nKt71CbjXSeq3PvKwzIPeU6vw8CW5WskPOtYVfQe2bYtIbV9DW-T1KShF-n_EMiMdFwTzT_HR-m58p4oHUhj1JuMVtKbhpg/s1600/smiley.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgz2Sc_Ep0eHVvzgNTK2PPqnYAKho1OUX3pg4Y8MMphHPtZ3nKt71CbjXSeq3PvKwzIPeU6vw8CW5WskPOtYVfQe2bYtIbV9DW-T1KShF-n_EMiMdFwTzT_HR-m58p4oHUhj1JuMVtKbhpg/s1600/smiley.jpg" /></a></div> I really do admire the unnamed "many" for their ability to detach, so am presenting the following story of "anecdotal" patient harm to a child in a pediatric ICU in the spirit of happiness, joy, and Mother's Day love! <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1nVbtntosQYTim-y3sdm6vTMvInD2jgP1ZlsrcxGevCVfigNMgPvzd8HUqh4qznVDYUP4YCPDpMpgcXg4RaT3XCIO4RjdDTdAPL_aExrCYK3A5ePMQZwv8cEk2lGgbZspCOR74YLbtkRd/s1600/vintage_housewife_cook.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1nVbtntosQYTim-y3sdm6vTMvInD2jgP1ZlsrcxGevCVfigNMgPvzd8HUqh4qznVDYUP4YCPDpMpgcXg4RaT3XCIO4RjdDTdAPL_aExrCYK3A5ePMQZwv8cEk2lGgbZspCOR74YLbtkRd/s1600/vintage_housewife_cook.jpg" width="175" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBVdvcXC2vRHlGd1UhzTgr2F7Ut7bWo3S_ppYkE1Ji-F5AMjm1uHvJx2apITS82nBcYMZDHEVDUwW7IUVMpLLc22Y-7Q318dPGia2NwyjsGojNmzNO4Hpsovvd2f9c42UgYEeaEuEq755A/s1600/smiley1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"> </a></div> Here's the event we should all be happy about, reported via FDA - I note the FDA's said these devices are not "sufficiently risky" to warrant a high level of their attention even though they secretly admitted in an internal memo that there's no way to really know te true level of risk and harm (<a href="http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html">http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html</a>), so clearly they're all a really jolly bunch: <blockquote class="tr_bq"><a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?id=117690">http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?id=117690</a> FDA MedSun report Type of device: medical device data system Device brand name: PowerChart Device manufacturer's name: Cerner Corporation Date of this report: (mm/dd/yyyy) 03/04/2014 Describe the event or problem:     Medication Error. This event was related to Health Information Technology. Specifically, the manner in which the system processed an order for free water replacement. Order was intended to be 20ml/hr for 6 hours for a total of 120ml. It was a 1000 ml bag so first they put 20ml/hr which would have defaulted the infuse over time to 50 hrs. They tried to change the infuse over to 6 hours which then changes the ml/hr rate to 167 ml/hr. They did not notice this had changed. </blockquote> Well, that's WONDERFUL!!  :-)  that the computer recalculates the flow rate for them when they change the infusion time, by paternalistically assuming that's what they wanted to do - change the RATE of infusion - when what they actually did is manually change the TIME (duration) of infusion.  How LOVELY of some programmer to have given them this FANTASTIC convenience!! <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/AVvXsEi8yEnZHeor2UZZlhUf4qKrE_4fxFfxrQna0eHhEQagUgU-_a9j1wpRZEfLCAMhkhyphenhyphenOsXIplxq3wLZU4cE3m0rrvjUniE-RugNfZbwUtYsoZXALSsI9k4Grh7jfb78Uc0hHnW_Eh6NGrjDg/s1600/behappy.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8yEnZHeor2UZZlhUf4qKrE_4fxFfxrQna0eHhEQagUgU-_a9j1wpRZEfLCAMhkhyphenhyphenOsXIplxq3wLZU4cE3m0rrvjUniE-RugNfZbwUtYsoZXALSsI9k4Grh7jfb78Uc0hHnW_Eh6NGrjDg/s1600/behappy.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Aren't computers wonderful!!!</td></tr></tbody></table> Even the following should not be cause for ardent technophiles to wipe the smile from their downside-ignoring faces!! <blockquote class="tr_bq">... They did not realize that they needed to go into details tab to show the time frame so the patient got 167ml/hr instead of 20ml/hr for 6 hours. </blockquote> How obvious!!!  Every doctor, nurse, medical student and janitor knows from time immemorial knows you have to go into the detail tab to show the time frame!  (Smile) <blockquote class="tr_bq">... Order was verified by pharmacy and administered at that rate via peripheral IV. After approximately 1L of fluid had infused, patient showed seizure activity.  PICU (pediatric ICU) team called to bedside. Treatment provided for seizures and critical sodium and potassium. </blockquote> Awww ...  some seizures and critical sodium and potassium levels in the PICU.  Awww.....too bad!!!  We should be happy anyway!  For if this child died...the sacrifice would have been WORTH IT for the betterment of electronic medical records worldwide, and the parents no doubt would be flattered and joyous about their contribution to computing science.  After all, how better to figure out how to make this technology work?? After all, it takes a few broken eggs to make an omelette, and a few bumps in the road (like grave mounds) should be of little concern. Because, remember ... w.e. c.a.r.e! <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/AVvXsEiyOy_d372Rp11w3A5pCQBf6qnkp-yS-f-doYNL_pYtAkTMY8Rzj24CbQOHIUMcYdrEvM8d38R1Y1DKCwpakFqeoc3ZHv67S5PpRuDwz-sq_fpE3DstFh_OLkzQGej3MaZbuWAuHH8BQPTe/s1600/words+that+work.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyOy_d372Rp11w3A5pCQBf6qnkp-yS-f-doYNL_pYtAkTMY8Rzj24CbQOHIUMcYdrEvM8d38R1Y1DKCwpakFqeoc3ZHv67S5PpRuDwz-sq_fpE3DstFh_OLkzQGej3MaZbuWAuHH8BQPTe/s1600/words+that+work.jpg" width="155" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">i c.a.r.e!!!!  As at U. Arizona Healthcare System, let's only use Happy Words with our patients about these systems! (click to enlarge, see <a href="http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html">http://hcrenewal.blogspot.com/2013/10/words-that-work-singing-only-positive.html</a> )</td></tr></tbody></table> Further, we should use only Words That Work to describe the wonders of these systems in their current state!!! <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/AVvXsEjgAtZ_SQ0RVtQt8McdXxf2OEPLie5Sk706vuqci5i-jIWHJpJS0iZa7s09yVFO41Bbwq4GvWWpzRRMw9AxeldgzFHxb18eCHSaTtZn73KyFqrypUR2XyQHFf_UhSsRPXw0U5t4WQSm3fFv/s1600/flowers.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgAtZ_SQ0RVtQt8McdXxf2OEPLie5Sk706vuqci5i-jIWHJpJS0iZa7s09yVFO41Bbwq4GvWWpzRRMw9AxeldgzFHxb18eCHSaTtZn73KyFqrypUR2XyQHFf_UhSsRPXw0U5t4WQSm3fFv/s1600/flowers.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Some flowers from Cerner CEO Patterson to momma to make up for her little baby having seizures and critically deranged potassium and sodium levels from those big, bad doctors' EHR mistake!</td></tr></tbody></table> <blockquote class="tr_bq">... The Cerner powerchart software system has functionality for continuous medications/fluid ordering that does not prevent "user error." </blockquote> Ut oh ... Looks like I'm going to have to be a sourpuss for just a moment and re-introduce the nasty, ill-tempered, non-objective idea of what the dastardly National Institute of Technology and Standards (NIST) calls "use error" (as opposed to "user error", A.K.A. "Blame the User",  <a href="http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html">http://hcrenewal.blogspot.com/2011/10/nist-on-ehr-mission-hostile-user.html</a>): <blockquote class="tr_bq">... The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized. [3] “Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions - ed.], misuse of color-coding conventions [see below], omission of information, etc. </blockquote> Awwwwww....aren't I just mean and non-objective? <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/AVvXsEh8h7Y65reXdJO632szxyY2e3UhlY3P8xr5VhF4vPIz_8cTZXCU_8L4DKIks0v0LLVJwWrKKd9BzQKa7OJpJv5NXGJkqpvjMd7xKU1mjfEaUD6F7MkhesXaq0Gw_4wHcv1DTduyxsr3atPO/s1600/frown.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="165" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8h7Y65reXdJO632szxyY2e3UhlY3P8xr5VhF4vPIz_8cTZXCU_8L4DKIks0v0LLVJwWrKKd9BzQKa7OJpJv5NXGJkqpvjMd7xKU1mjfEaUD6F7MkhesXaq0Gw_4wHcv1DTduyxsr3atPO/s1600/frown.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"> </td></tr></tbody></table> That mean doctor Silverstein's just not happy and objective!!  Bad, bad, bad man! <blockquote class="tr_bq">... When the provider orders the fluid, example is D5W, the screen opens to a "continuous details" ordering window. Within the screen, the ordering provider is presented with a preselected bag volume and type of fluid with a brownish background. They have the ability to modify bag volume but it was made this color to discourage that change by Cerner. </blockquote> Golly gee!  There's something to be happy about once again!  Brown, the universally-understood color, in any language, means "Warning, do not change this value, it could kill someone!!!" See how GOOD this technology really is!!!  Why use alerts and confirmation dialogs when a mere COLOR like brown suffices!! <blockquote class="tr_bq"> ... The rate and "infuse over" fields are a yellow color to show that they need to be completed. The intent [of the programmer, clearly an expert in human-computer interaction and communication by color and smoke signals - ed.] is for an ongoing continuous fluid and not to limit the time. </blockquote> Golly Gee Times Two!  Yellow, the absolutely universal color for "Warning, you need to complete this to prevent killing someone!"   <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/AVvXsEiB07i36jmKHcewYx3Gz9u_Dn1b_sU77r5meRSlFySibvF182tqSVyjtTqOuue6t6pDz1RWP6W580szZKrms1eEmRSb_RIpzZGgVfKNduKoAx7uHGW2dKivEC1nq0UCSXHoKm4H1Q_gHPfw/s1600/yellow-light.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="133" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiB07i36jmKHcewYx3Gz9u_Dn1b_sU77r5meRSlFySibvF182tqSVyjtTqOuue6t6pDz1RWP6W580szZKrms1eEmRSb_RIpzZGgVfKNduKoAx7uHGW2dKivEC1nq0UCSXHoKm4H1Q_gHPfw/s1600/yellow-light.jpeg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Yellow!  Don't you just think every time you see this color that "warning, you need to complete data entry to avoid killing someone?  Who needs WORDS?</td></tr></tbody></table> It's all so CLEAR!!!! <blockquote class="tr_bq">... Providers can misinterpret this field to mean the length of time they want the order to infuse over, when the system intent for that field is to be the system-calculated length of time until the next bag supply will need to be sent to maintain the continuous infusion.  </blockquote> See how simple!!!!   Isn't it OBVIOUS!!!! <blockquote class="tr_bq"> The completed fields turn white. Cerner does not have an intermittent fluid administration order [who the hell needs that, says Cerner and the hospital executives who bought this package for the PICU!! Never a need for that in ICU's!! - ed] so providers are expected to go to a second tab, the "details" tab, where they have the options for identifying the duration of the infusion in terms of # doses or time. If the provider does not have awareness of this intent and modifies the "infuse over" field from the "continuous details" tab, they may inadvertently order a higher rate than intended.</blockquote> Ha ha!  Those silly doctors can't even figure out a simple thing like that!!  What stooges they are!! <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/AVvXsEhT3rcoW8Gw85QLLLUqEtmVvyIqCGPmTDBoLqWmwLa5zC0a-4ORhr7iLkFrSZBeA02TCfVLzn5pqH7WxtywG0kyZt54ExddyyuDE_UjALynE545TJIgb5SaosZIC6vFUiC9jt6yhyphenhyphenPpqf5i/s1600/three-stooges.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="156" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhT3rcoW8Gw85QLLLUqEtmVvyIqCGPmTDBoLqWmwLa5zC0a-4ORhr7iLkFrSZBeA02TCfVLzn5pqH7WxtywG0kyZt54ExddyyuDE_UjALynE545TJIgb5SaosZIC6vFUiC9jt6yhyphenhyphenPpqf5i/s1600/three-stooges.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">NYUK NYUK NYUK ... Hey Moe!!  Those silly doctors and nurses cannot understand the simple fact that Cerner does not have an intermittent fluid administration order so providers are expected to go to a second tab, the "details" tab, where they have the options for identifying the duration of the infusion in terms of # doses or time. If the provider does not have awareness of this intent and modifies the "infuse over" field from the "continuous details" tab, they may inadvertently order a higher rate than intended.  </td></tr></tbody></table> See how much FUN health IT problems can be?  After all, in this ANECDOTAL case, all that happened was: <blockquote class="tr_bq">The device(s) may have caused or contributed to: Potential for patient harm, Serious Injury </blockquote> But nobody died of this particular problem (that we know of), so this technology is SAFE!!!! <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNHrlprFiMwMg8w-uhH23RA1KLiJ7O5qDqdj547Mc40zYY4nDhmNEqZ_d5163YRafaQ34simadB6lLrldXAktiWpOZNGbn2kctTetmpIBNH6FhjjBEO7ZIqwQm9Lgo68p7sjlS1Z5FofgT/s1600/Happy-Mothers-Day.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNHrlprFiMwMg8w-uhH23RA1KLiJ7O5qDqdj547Mc40zYY4nDhmNEqZ_d5163YRafaQ34simadB6lLrldXAktiWpOZNGbn2kctTetmpIBNH6FhjjBEO7ZIqwQm9Lgo68p7sjlS1Z5FofgT/s1600/Happy-Mothers-Day.png" width="320" /></a></div> Happy mother's day!!! -------------------- Additional not-so-funny thought:  depending on brown, yellow etc. instead of clear, written alerts/warnings, plus the fact that the system likely "knew" the weight of the child and should have alerted that the infusion of a liter was a very dangerous thing, reflect Bad Health IT on its face: <blockquote class="tr_bq">Bad Health IT ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.   </blockquote> Had I been a pre-marketing tester of this system working for FDA, those fluid-ordering characteristics would have been changed before the system would have been released to market. Oh, wait ... there is no premarketing testing process for health IT, and FDA, via advice from the FDASIA committees as in the linked FDA-related post above, writes that none is really needed. And who wants to damage TRUE INNOVATIONS like this - turning something that takes 5 seconds for a clinician to write, "D5W, 20 ml/hr x 6 hrs" (meaning dextrose 5% in water, 20 milliliters per hour for 6 hours) into a cryptic and muddled exercise with tabs, colors and numerous caveats - via regulation? -- SS

EHR Story for Mother's Day 2014: Even The Formerly Simple Act Of Giving IV Fluids in ICU's Can Kill Babies. But's Let's Be Objective and Happy!

[Note to the humorless: this post is satirical and sardonic to make a very serious point about the perversity of downplaying/ignoring heal...

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