EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals, Perhaps The Most Wired Hospitals in the World, Suggest the True Value of Information Technology in Healthcare Has Been Grossly Exaggerated

The Wall Street Journal somehow managed to get access to internal VA patient care quality data and published the following article:<br /><blockquote class="tr_bq"><br /><a href="http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely-in-patient-care-1401753437">http://online.wsj.com/articles/veterans-affairs-hospitals-vary-widely-in-patient-care-1401753437</a></blockquote><blockquote><b>Veterans Affairs Hospitals Vary Widely in Patient Care</b><br /><i>Internal Records Show Facilities Such as Phoenix Have Far Higher Death Rates Than Peers</i><br />Thomas M. Burton and Damian Paletta<br />June 3, 2014 <br /><br />The Phoenix facility at the heart of the crisis at the Department of Veterans Affairs is among a number of VA hospitals that show significantly higher rates of mortality and dangerous infections than the agency's top-tier hospitals, internal records show.<br /><br />The criticism that precipitated last week's resignation of VA Secretary Eric Shinseki has focused largely on excessive wait times for appointments across the VA's 150-hospital medical system.<br /><br />But a detailed tabulation of outcomes at a dozen VA hospitals made available to The Wall Street Journal illustrates a deeper challenge: vastly disparate treatment results and what some VA doctors contend is the slippage of quality in recent years at some VA facilities.<br /><br />Some of the discrepancies are stark, especially for an agency known for offering high-quality care in 50 states.</blockquote><br />Yet, these are highly wired hospitals, perhaps the most highly wired in the world, with one EHR, VistA CPRS, allegedly among the best EHRs in the world developed over decades, and allegedly used by 100% of the clinicians.<br /><br />How can this be?  <br /><br /><blockquote class="tr_bq">... Scott McRoberts, spokesman for the Phoenix VA Health Care System, said on Monday the database "is an internal measurement system to benchmark our improvement, and is not for public consumption."<br /><br />The rate of potentially lethal bloodstream infections from central-intravenous lines was <b>more than 11 times as high among patients at the Phoenix facility than it was at top VA hospitals</b>, data from the year ended March 31, 2014, show.<br /><br />... The findings come from a nonpublic VA database called Strategic Analytics for Improvement and Learning, known as SAIL. SAIL tracks procedure outcomes and ranks VA hospitals on a scale of five stars, the best, to one star, the lowest. <br /><br />... In other examples of variations in care, the Atlanta VA Medical Center, a two-star hospital for quality, has more than <b>three times the rate of central-IV infections than the average</b> of five-star VA hospitals. Houston's VA hospital, ranked as a two-star hospital, had a <b>47% higher acute-care mortality rate than the five-star hospital rate.</b></blockquote><br />A 47% higher acute-care mortality rate?<br /><br />Hospitals are willing to go into tens of millions of dollars of debt and knowingly endanger patients (see e.g. "<b>In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red</b>" at <a href="http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html">http://hcrenewal.blogspot.com/2014/06/in-fixing-those-9553-ehr-issues.html</a>), and even attempt to stifle clinician conversation on drawbacks (e.g. see "<b>Words that Work</b>" at <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>), to attain this technology on the stated reason of "improving patient safety" and "saving money."<br /><br />Former ONC Chair Blumenthal stated explicitly in <span style="font-size: 100%;">the NEJM article "<span style="font-weight: bold;">The 'Meaningful Use' Regulation for Electronic Health Records</span>", Blumenthal</span> and Tavenner (10.1056/NEJMp1006114, July 13, 2010):<br /><div class="PlainText" style="font-family: arial;"><span style="font-size: 100%;"><br /></span></div><blockquote dir="ltr" style="font-family: arial; margin-right: 0px;"><div class="PlainText"><span style="font-size: 100%;">... EHRs <u><b>will</b></u> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <u><b>will demand</b></u> nothing less from their providers. </span></div></blockquote><br />There is no doubt expressed there. <br /><br />The industry itself has convinced the Federal Government to spend tens of billions of taxpayer dollars on this technology via HITECH incentives, and to start penalizing non-adopters via Medicare cuts.  The Government has bought into the hyper-enthusiasm hook, line and sinker, when the same money might have been spent elsewhere such as on care of the underserved...or on our Veterans.<br /><br />Yet the data from a highly-computerized organization like the VA <b>show that these systems cannot be all they are made out to be</b>.  They do not automatically "improve caregivers' decisions and patients' outcomes." This is an on its face observation.<br /><br />They are simply a tool, and in absence of appropriate human staffing, expertise, and conducive work environment, <b>they mean significantly "less than advertised</b>" in terms of improving care quality and outcomes.  <br /><br />Finally, as the VA has gotten busier due to factors such as the return of veterans from recent wars, one must also ask if the loss of productivity, cognitive burden, and other factors caused by needing to interact with a computer rather than paper has made the computer systems more of an impediment to good care rather than a facilitating tool.<br /><br />I think it's time the Government start to reform the industry hype surrounding this technology with far more sober predictions that would facilitate far more cautious implementations.<br /><br />No "revolutions" are happening soon, at least not due to information technology in healthcare. <br /><br />Finally, note that EHR oversell and <i>exceptionalism</i> has been going on for <b>decades.   </b>Donald A. B. Lindberg M.D. (<a href="http://www.nlm.nih.gov/od/roster/lindberg.html">http://www.nlm.nih.gov/od/roster/lindberg.html</a>), Medical Informatics pioneer and Director of the U.S. National Library of Medicine at NIH, observed in 1969 that:<br /><blockquote class="tr_bq"><br />"The [second] reason for the dearth of significant success of computers in medicine has been the <b>flagrant and consistent "over sell" of capability on the part of manufacturers and computer enthusiasts."  </b></blockquote><br />Read his full quote by clicking on the page below, from Morris Collen's book "<a href="http://www.amazon.com/History-Medical-Informatics-United-States/dp/0964774305">A History of Medical Informatics in the United States: 1950 to 1990</a>."<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrRIuVMu4XQOTRYpbyXb2-IXrnM019VAdbzcR3D8wVVCDQtXDkhG6UlZTWtBpmUKH7s4QnIHjxuyp65kccko4iKwx6nGV3Cxu8kZ75Fss742dcTMln77zZw4tJOu25MXPfH9Oq1F-i5egc/s1600/collen168.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrRIuVMu4XQOTRYpbyXb2-IXrnM019VAdbzcR3D8wVVCDQtXDkhG6UlZTWtBpmUKH7s4QnIHjxuyp65kccko4iKwx6nGV3Cxu8kZ75Fss742dcTMln77zZw4tJOu25MXPfH9Oq1F-i5egc/s1600/collen168.jpg" width="263" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Informatics pioneer Dr. Donald Lindberg's 1969 observations on health IT oversell.  Click to enlarge.</td></tr></tbody></table><br /><br />Sadly, nothing has changed in health IT, at least since the year we landed on the Moon.<br /><br />-- SS<br /><br />

EHR Exceptionalism Debunked: Care Quality Variances Among VA Hospitals, Perhaps The Most Wired Hospitals in the World, Suggest the True Value of Information Technology in Healthcare Has Been Grossly Exaggerated

The Wall Street Journal somehow managed to get access to internal VA patient care quality data and published the following article: http://o...

Đọc thêm »

Fool Me Twice? - Boehringer Ingelheim, Medtronic Settle Lawsuits Alleging Deceptive Marketing

It seems like it has been really quiet on the legal settlement front in the US, but maybe corporate executives wanted to wait until things calmed down after the unofficial start of summer to let out news that some people might not think reflected well on them.  So this week it was time to announce two new legal settlements of allegations of bad behavior by corporate health were announced, as we will list in alphabetical order....<br /><br /><b>Boehringer Ingelheim Settles Suits Alleging it Hid Data About Pradaxa Harms</b><br /><br />As <a href="http://www.bloomberg.com/news/2014-05-28/boehringer-pays-650-million-to-end-blood-thinner-cases.html">per Bloomberg</a>,<br /><br /><blockquote class="tr_bq">Boehringer Ingelheim GmbH, the German family-owned drugmaker,<i> agreed to pay $650 million to settle the majority of lawsuits filed over its blood thinner Pradaxa, which has been linked to more than 500 patient deaths.</i></blockquote><br />The major allegations were about deception,<br /><br /><blockquote class="tr_bq"> Patients and their families alleged<i> Boehringer executives knew Pradaxa posed a deadly risk to some consumers when they brought it to the U.S. market in October 2010.</i></blockquote><br />In particular, as we <a href="http://hcrenewal.blogspot.com/2014/02/cant-this-be-avoided-how-corporate.html">discussed</a> in more detail in February, 2014, <br /><br /><blockquote class="tr_bq">Documents made public as part of patients’ Pradaxa suits showed <i>Boehringer officials didn’t disclose to U.S. regulators a data analysis that indicated the blood-thinning drug may have caused more fatal bleeding</i> after it was cleared for sale than in a study used to win approval.  </blockquote><br /><a href="http://www.nytimes.com/2014/05/29/business/international/german-drug-company-to-pay-650-million-to-settle-blood-thinner-lawsuits.html">Per </a>the New York Times, Boehringer Ingelheim executives continued to maintain<br /><br /><blockquote class="tr_bq">that it stood behind the safety and efficacy of Pradaxa and continued to believe that the lawsuits lacked merit, but that settling the case <i>allowed the company to move on.</i> 'Time and again, the benefits and safety of Pradaxa have been confirmed,' said Desiree Ralls-Morrison, senior vice president and general counsel of Boehringer Ingelheim USA.</blockquote><br />This is typical of most legal settlements involving large health care organizations, whether they end lawsuits brought by private parties or by the US government.  The settlements often allow the parties to continue to disagree, do not establish guilt or innocence, but leave one to wonder why executives would pay so much of admittedly other peoples' money just to "move on" without upholding their or their companies' honor, especially when documents revealed and legal findings made in cases prior to settlement remain unchallenged.<br /><br />So this settlement also comes after December, 2013, as we discussed <a href="http://hcrenewal.blogspot.com/2013/12/a-second-order-cover-up-judge-finds.html">here</a>, December, when a judge<br /><br /><blockquote class="tr_bq">ordered Boehringer to pay a $931,000 fine in December for <i>failing to preserve 'countless' files on Pradaxa’s development and marketing. Patients’ lawyers say Boehringer should have placed an effective 'litigation hold' on the documents</i>, forcing employees to preserve them.</blockquote><br />(The above <a href="http://www.bloomberg.com/news/2014-05-28/boehringer-pays-650-million-to-end-blood-thinner-cases.html">per Bloomberg</a>.)  That finding, which the settlement does not dispute, does not fill one with confidence about the openness and transparency of Boehringer Ingelheim managers.<br /><br />Also the settlement does not refute documents released during this litigation which suggested that Boehringer Ingelheim personnel tried to influence, or manipulate a company sponsored research paper to prevent it from contradicting the company's official marketing message that Pradaxa administration does not require monitoring of patients with blood tests (as we discussed <a href="http://hcrenewal.blogspot.com/2014/02/cant-this-be-avoided-how-corporate.html">here</a>).     <br /><br />Note further that this case comes only a few years after a case in which Boehringer Ingelheim settled allegations of deceptive marketing of drugs other than Pradaxa, as we discussed <a href="http://hcrenewal.blogspot.com/2012/10/just-another-day-at-office-boehringer.html">here</a>. <br /><br /><b>Medtronic Settles Suit Alleging Kickbacks to Physicians</b><br /><br />The most extensive and colorful <a href="http://www.startribune.com/business/260978651.html">report</a> was in the Minneapolis Star-Tribune, <br /><br /><blockquote class="tr_bq"><i>Medtronic Inc. will pay the U.S. Justice Department $9.9 million to settle a whistleblower lawsuit that accused the company of paying kickbacks to doctors for using its defibrillators and pacemakers.</i><br /><br />The alleged kickbacks, according to the newly unsealed suit, included '<i>gifts of wine and alcohol</i>' and '<i>trips to strip clubs</i>' paid for by the Fridley-based company. The lawsuit also says Medtronic paid to fly doctors to events in San Francisco, Las Vegas, New Orleans, New York, Minneapolis and other cities that some physicians used as 'a free vacation.'</blockquote><br />More colorful details,<br /><br /><blockquote class="tr_bq">The lawsuit, whose details remained secret until Tuesday, describes Medtronic <i>business plans with names such as 'Project Wildfire' that had sales representatives offer 'cash payments, expensive trips and meals, expensive gifts and entertainment to physicians as kickbacks in exchange for the physicians’ agreement to implant Medtronic devices.'</i><br /><br />The lawsuit alleged that Medtronic '<i>funneled millions of dollars in unrestricted grant money to physicians</i>' to get them to encourage the use of Medtronic defibrillators and pacemakers in patients whose 'mild heart failure symptoms did not meet [Food and Drug Administration] criteria for an implantable device.'<br /><br />Those procedures were not only unnecessary, the suit alleged, but potentially dangerous.<br /><br />The suit describes <i>payments of thousands of dollars in speaking fees to doctors for attending dinners at which they spoke for only a few minutes</i>, if at all. In other cases, <i>Medtronic allegedly prepared entire presentations that physicians offered almost verbatim.</i><br /><br />The suit talks of a plan that 'instructed sales representatives to personally review patient charts in friendly doctor’s offices' and to flag those patients the sales representative 'felt should receive an implant.'</blockquote><br />Note that commercially supplied "unrestricted grant money" is now the lifeblood of many ostensibly academic continuing medical education (CME) programs, but this case suggests that corporate executives may believe they are paying such money to get doctors to use their products.  Note further that many physicians defend their receipt of money in payment of talks they have given on behalf of commercial firms as fair payment for providing unbiased education, but this case suggests that corporate executives may believe they are paying such money for marketing, and/or to get the supposedly unbiased physician speakers to use their products.  <br /><br />Once again, the settlement did not resolve the allegations. <br /><br /><blockquote class="tr_bq"> Medtronic said it <i>did not admit that any of its activities were improper or illegal</i> and that the settlement would bring to a close a long-running review of events dating from 2001 to 2009.</blockquote><br />Also,<br /><br /><blockquote class="tr_bq"> Asked to comment specifically on the strip club allegations and the accusation that it financially facilitated unnecessary implantations, Medtronic<i> reiterated that its $9.9 million payment was not an admission that it had done anything illegal or improper.</i></blockquote><br />See my comments above.  Why would executives with even the slightest ability to feel shame not contest such allegations if they were untrue?  But maybe many of today's corporate health care executives are not capable of feeling shame, and of course they get to pay off these lawsuits with other peoples' money.<br /><br />By the way, this is just one of many Medtronic settlements.  As Bloomberg <a href="http://www.bloomberg.com/news/2014-05-28/medtronic-settles-suit-over-heart-device-kickback-claims.html">summarized</a>,<br /><br /><blockquote class="tr_bq"> Medtronic agreed in 2007 to <i>pay about $130 million to settle consumer suits accusing the device maker of hiding defects in its defibrillators</i>. The company agreed to a <i>$268 million settlement of suits in 2010 over allegations that fractured wires in another line of defibrillators caused at least 13 patient deaths.</i></blockquote><br />In fact, Medtronic has provided our blog with <a href="http://hcrenewal.blogspot.com/search/label/Medtronic">lots of material</a>.  We first <a href="http://hcrenewal.blogspot.com/2006/01/medtronics-payments-to-doctors-too.html">discussed</a> detailed and vivid allegations that Medtronic had been paying off doctors starting in 2003 here in 2006.  Medtronic has been involved in other lawsuits alleging various kinds of deception. <br />-  In 2011, it settled for $23.5 million two other federal lawsuits alleging it paid kickbacks to encourage physicians to implant its devices (look <a href="http://hcrenewal.blogspot.com/2011/12/medtronic-settles-yet-again.html">here</a>).   <br />- In 2008, Medtronic subsidiary Kyphon settled a suit for $75 million and signed a corporate integrity agreement for allegations that it defrauded Medicare through a scheme that lead to excessive hospitalization for patients who received the company's spine surgery device (link <a href="http://hcrenewal.blogspot.com/2008/05/corporate-integrity-agreement-for.html">here</a>)<br />- In 2006, Medtronic subsidiary Sofamor Danek settled for $40 million allegations that it gave kickbacks to doctors in the form of sham consulting fees and lavish trips (look <a href="http://hcrenewal.blogspot.com/2011/12/medtronic-settles-yet-again.html">here</a>). <br /><br />Yet we are now writing at the end of May, 2014, and Medtronic is still settling lawsuits involving vivid allegations of payoffs to physicians, and its executives are still saying nothing to see here, move on.<br /><br /><b>Summary</b><br /><br />These sorts of cases provide evidence that large health care corporations, including not just pharmaceutical companies, but biotechnology and medical device companies, commonly use deceptive and unethical practices to market their products.  Such marketing lets them charge high, even outrageous prices and sometimes results in patients getting expensive treatments that do them no good, or worse, that do more harm than good.  Some of the executives of these companies doubtless got large bonuses, and may have gotten millions in compensation partially because of the sales generated by these practices.  However, they get to walk away from such lawsuits without any personal accountability, just by paying out a few millions, or billions, of the company's, that is, other peoples' money.  They get do pay that money without any other explanation that it eliminates distractions and allows them to move on (with whatever they have already made).<br /><br />The more this goes on, the more health care dysfunction continues, and the more the health care oligarchy prospers.  As we have written many times,<br /><br /><blockquote class="tr_bq">penalties that only appear to be (relatively small) costs of doing business are unlikely to deter future bad behavior. Until the people who actually authorized, directed and implemented the bad behavior have to suffer some negative consequences, expect the bad behavior to continue.  Note that each of the companies discussed above have had their previous ethical lapses discussed in previous Health Care Renewal posts. <br /><br />The continuing march of <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">settlements</a>, and sometimes <a href="http://hcrenewal.blogspot.com/search/label/crime">criminal</a> convictions involving major health care organizations should be regarded merely as providing a floor to estimates of the extent of bad behavior by large health care organizations. Bad behavior may not be reported, or lead to legal action, and legal action may not lead to settlements or convictions. However, it is amazing how many organizations that were once regarded as exemplary have had to settle, or plead guilty, or been convicted.<br /><br />When it comes to health care's leadership, society seems to have acceded to defining deviancy down. Until we start holding health care leaders to high standards, expect their organizations not to uphold high standards.</blockquote><br />(That version was from 2010, posted <a href="http://hcrenewal.blogspot.com/2010/10/last-weeks-scandals.html">here</a> re Medtronic's 2010 settlement. You heard it here first.  Medtronic is still settling, and according to its <a href="http://phx.corporate-ir.net/phoenix.zhtml?c=76126&p=IROL-secToc&TOC=aHR0cDovL2FwaS50ZW5rd2l6YXJkLmNvbS9vdXRsaW5lLnhtbD9yZXBvPXRlbmsmaXBhZ2U9OTAwMDI5NiZzdWJzaWQ9NTc%3d&ListAll=1">most recent proxy</a>, from 2013, the annual total compensation of its CEO was last reported to be <b><i>$8,975,886</i></b>.) <br /><br /><br />

Fool Me Twice? - Boehringer Ingelheim, Medtronic Settle Lawsuits Alleging Deceptive Marketing

It seems like it has been really quiet on the legal settlement front in the US, but maybe corporate executives wanted to wait until things c...

Đọc thêm »

In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red

At my Nov. 9, 2013 post <style type="text/css">H3 { margin-bottom: 0.08in; }H3.cjk { font-family: "Droid Sans Fallback"; }H3.ctl { font-family: "Lohit Hindi"; }P { margin-bottom: 0.08in;</style>"<b>We’ve resolved 6,036 issues and have 3,517 open issues" </b>(<a href="http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html">http://hcrenewal.blogspot.com/2013/11/weve-resolved-6036-issues-and-have-3517.html</a>) I wrote about "issues" (i.e., "glitches" including potentially injurious or deadly bugs and malfunctions) the organization was having with a new EHR at University of Arizona Health System.<br /><br />Now we know part of the cost of resolving those 9,553 "issues."<br /><br /><blockquote class="tr_bq"><a href="http://azstarnet.com/news/science/health-med-fit/tucson-area-s-largest-area-network-racks-up-nearly-million/article_44d05d04-0acf-5fbc-8561-68d4bef3b577.html">http://azstarnet.com/news/science/health-med-fit/tucson-area-s-largest-area-network-racks-up-nearly-million/article_44d05d04-0acf-5fbc-8561-68d4bef3b577.html</a><br /><b>Tucson area's largest health network racks up nearly $30 million in losses</b></blockquote><div class="publish-meta clearfix"><blockquote><div class="date left"><span class="pubdate">June 01, 2014 </span> •  <span class="byline">By <a class="open-tooltip" href="http://azstarnet.com/users/profile/Emily%20Bregel">Emily Bregel</a>, <a class="open-tooltip" href="http://azstarnet.com/users/profile/Stephanie%20Innes">Stephanie Innes</a></span></div></blockquote><div class="date left"><blockquote><span class="byline"> <style type="text/css">P { margin-bottom: 0.08in; }A:link { }</style> </span><br /><div style="margin-bottom: 0in;">Southern Arizona’s largest health network <b>is $28.5 million in the red so far this fiscal year, and officials say a costly electronic medical records system is largely to blame.</b></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The operating loss is unprecedented for the four-year-old University of Arizona Health Network, which includes two local hospitals.</div><div style="margin-bottom: 0in;"></div></blockquote><br />Stellar management was clearly responsible for this wonderful outcome.  When will the layoffs start, I ask? That's the usual managerial solution for financial losses, and in this case I feel particularly worried about employees who did not obey the "suggestion" to only use "<b>Words that Work</b>" about this EHR (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>). <br /><br /><blockquote class="tr_bq"><div style="margin-bottom: 0in;">The electronic records system, from Wisconsin-based Epic Systems, has cost an estimated <b>$115 million</b>, including <b>$32 million in unbudgeted costs for the first eight months of the fiscal year,</b> which ends June 30, financial documents show. The extra costs are due primarily to a delay in getting the system live and funding additional training and support, officials said. It was supposed to be up and running by Sept. 1, but wasn’t operational until Nov. 1.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">$32 million to fix 9,553 "issues", most likely due to implementation incompetence, plus some that perhaps the seller should have at least been partially responsible for...such as these:</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><ul><li>Pharmacy Medication Mapping Errors <span style="color: red;"></span></li></ul><ul><li>Microbiology Results Mapping Incorrectly </li></ul></blockquote><blockquote class="tr_bq"><ul><li>Prescription printing bugs</li></ul><ul><li>Errors transmitting prescriptions </li></ul></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">I note that real, live patients were the unwitting experimental subjects in this little software debugging project.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">I also note that $115 million <b>could have paid for an entire new hospital or wing</b> - and these startup costs are just the beginning... </div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... There are other reasons for the network’s weak finances. UA Health Network officials say uninsured patients aren’t getting health insurance coverage through the federal Affordable Care Act as quickly as they’d anticipated, resulting in $11 million less than expected in patient revenue through February.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The network also lost federal dollars from a program that helped bridge the funding gap created by Medicaid rate cuts and a rise in uninsured patients. The Safety Net Care Pool, which also included Maricopa Integrated Health System and Phoenix Children’s, pumped $33 million into the UA hospitals for the first six months of the fiscal year. But that infusion ended Dec. 31 to coincide with greater health insurance availability through the Affordable Care Act.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">It's not like these events were entirely unpredictable.  Perhaps priorities could have been rearranged, rather than dumping millions into a known money pit, the implementation of enterprise clinical information technology?</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">... “The issue is more about where we are going and what things are in place to change the trajectory,” Lynn said. “It was an especially difficult time financially because of Epic, there was no choice in the matter. That period of time has fortunately passed and now we can do much better.”</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">There certainly was "choice in the matter."  I also suggest to Mr. Lynn that the "trajectory" might end up being a ballistic one.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... A financial report presented to the network’s board of directors on April 24 says the Epic system’s higher-than-expected expenses this fiscal year were due to “implementation delays, additional training support and planned schedule reductions.” Some of the expenses were originally supposed to be in the prior fiscal year.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">The report attributes $6.8 million of the current year’s losses to physicians spending enough time training to use the new system that they couldn’t see as many patients between November and January. Schedules were back to normal as of February.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">One wonders just how much increased stress and pressure there is on clinicians with the new system in place.   </div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... Implementing the new system has hit the network’s finances hard, but over time it <b>should improve patient safety</b> by cutting down on unnecessary testing and medication errors, among other things, officials say. Eventually it is <b>expected to save money</b> because of its added efficiency.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"Should?"  Considering the issues I've outlined at this blog and my Drexel University Healthcare Informatics site (<a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>), this seems a type of wishful-thinking due diligence performed by those who believe in fairy tales and bargain sales of bridges like the one at <a href="http://www.distancesfrom.com/us/Brooklyn-Bridge-latitude-longitude-Brooklyn-Bridge-latitude-Brooklyn-Bridge-longitude/LatLongHistory/24244.aspx"><span id="MC_GMD_lblLatitude">latitude 40.7045096 N, longitude </span></a><span id="MC_GMD_lblLongitude"><a href="http://www.distancesfrom.com/us/Brooklyn-Bridge-latitude-longitude-Brooklyn-Bridge-latitude-Brooklyn-Bridge-longitude/LatLongHistory/24244.aspx">73.99480549999998 W</a>.</span></div><div style="margin-bottom: 0in;"></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Let me make a realistic projection:  No money will be saved, e.g., see the opinions from Wharton at <a href="http://hcrenewal.blogspot.com/2009/06/wharton-on-healthcare-it-can-i-go-home.html">http://hcrenewal.blogspot.com/2009/06/wharton-on-healthcare-it-can-i-go-home.html</a>.  </div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Another projection:  safety will be adversely affected, e.g., see the <b>ECRI Deep Dive study</b> at <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html">http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html</a>, the <b>Top Ten Healthcare Technology Risks for 2014</b> at <a href="http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html">http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html</a> and the FDA Internal Memo on H-IT Risks at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, to name a few sources repeatedly mentioned here.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">At the UA Medical Center’s south campus, the Epic system has taken doctors from paper charts and uncoordinated computer records to having all patient information — from angiogram and CT scan results to billing updates — in one place, accessible via iPhone.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Try doing medicine on an iPhone screen area...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">“This is the future. We have to have electronic medical records,” said Dr. Kwan S. Lee, a cardiologist who is medical director of the UA Medical Center’s south campus.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"This is the future!!  We just <i><b><u>have</u> </b></i>to do it!!"  Dr. Lee, I admire your exceptionally well-reasoned and thorough budget justification for putting your healthcare system $30 million in the red.  Congratulations!</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">... Lee cited a recent case where a patient who had been previously treated at Tucson Medical Center came to the UA Medical Center’s emergency room, having an acute heart attack. The standard of care in such cases is opening the artery within 90 minutes. In a rush against the clock, Lee was able to click on the patient’s record from TMC and see the area where the patient had prior surgery.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">“The patient had consented to share information from Tucson Medical Center and it helped us immensely,” Lee said. “We would have possibly wasted a lot of time. The patient did very well.”</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">A far, far less expensive document image management system could have accomplished exactly the same goal.</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">One con is that the system is <b>“a little overly complicated”</b> because it tries to be all things to all people, he said.  “It was painful ... <b>A lot of us are technophobes,</b>” he said. “But there was no way we could move forward without adopting it.” </div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"A little overly complicated?"  Gee, I guess that's why physicians at Athens Regional Medical Center revolted as at <a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html</a>.  The system was just "a little overly complicated!"</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"A lot of us are technophobes?"  How about "A lot of us are not EHR hyper-enthusiasts, but pragmatists?" (<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>).</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><blockquote class="tr_bq"><div style="margin-bottom: 0in;">Chief Information Officer Critchley agreed, saying that with the infrastructure in place, the system will be improved as needed over time.</div><div style="margin-bottom: 0in;"><b><br /></b></div><b></b><br /><div style="margin-bottom: 0in;"><b>“For better or worse</b>, only when it’s live are you going to get the doctors and staff to engage and do the fine tuning <b>of what it really means</b>, and what they want to see happen,” Critchley said.</div></blockquote></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">This is a political statement at best.  The assumption here is that this technology itself is some sort of miracle worker, just needing "fine tuning" to reveal its miracles.  In fact, most medical inefficiencies and dangers have nothing to do with documentation at all (e.g., see "<b>Is healthcare IT a solution to the wrong problem?</b>" at <a href="http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html">http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html</a>).</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;"><b>The only miracle so far has been to put the system $30 million in the red</b>, with more to follow.</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">... The UA Health Network, which began its Epic implementation in 2012, receives a little over $1 million per year in incentive payments, Critchley said.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">That's nice.   They spent $115 million to qualify for a $1 million annual incentive?  Makes perfect sense to me ...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><b>Adoption of electronic records is voluntary</b>, but hospitals that don’t make the switch by October face Medicare payment cuts of about 1 percent, and increasing reductions each year.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">At least one reporter reports this factoid accurately.  Hospital and industry execs are fond of misstatements that "EHRs are mandatory."</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Critchley has worked on at least four other Epic installations around the country as part of his consulting work and says <b>the UA Medical Center’s has been the least expensive</b>, with the most aggressive timeline. He has worked on projects that cost more than <b>a half billion dollars</b>.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">"Least expensive?"  "Half a billion dollars?"  It sounds like first class care for every underserved person in the United States could have been paid for instead of dumping the money into an unproven, experimental computer technology...</div><div style="margin-bottom: 0in;"><br /></div><blockquote class="tr_bq"><div style="margin-bottom: 0in;">At Tucson Medical Center, a $31 million upgrade to its electronic medical records system — also the Epic system — began to reduce expenses <span style="color: red;"><i><b>[overall net expenses, or just on a limited per-account, cherry-picked basis?  I suspect the latter - ed.]</b></i></span> almost immediately after it went live in 2010. TMC is among 3 percent of hospitals nationwide at the highest stage of electronic records adoption, based on an electronic records ranking system.</div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">“We started to see efficiencies the first day,” said Frank Marini, TMC’s chief information officer. <b>Transcription expenditures dropped by half, as doctors who had previously dictated patient notes instead documented them directly into the electronic record, he said.</b></div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">And they had to type and/or manually edit the results of Dragon or some other VR software.  That's wonderful!  Save money by firing transcriptionists and <i>making the physicians spend their valuable time and attention on clerical work.</i>  Fine business!</div><blockquote class="tr_bq"><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">TMC began its push to upgrade its partial electronic records system in 2009. The hospital’s early investments in infrastructure, starting in 2002, lowered the cost of adopting a comprehensive system, he said.</div></blockquote><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">Thus, in fact, overall expense was probably <i><b>several times the $115 million quoted.  Say, perhaps, half a billion dollars?</b></i></div><div style="margin-bottom: 0in;"><br /></div><div style="margin-bottom: 0in;">To any U. Az healthcare employee reading this - remember, if you are experiencing EHR difficulties, only use Words that Work!</div></div><div class="date left"></div><div class="date left"><span class="byline"><br /></span></div><div class="date left"><span class="byline">-- SS</span></div><div class="comment-count right"></div><div class="comment-count right"></div><div class="comment-count right"></div></div>

In Fixing Those 9,553 EHR "Issues", Southern Arizona’s Largest Health Network is $28.5 Million In The Red

At my Nov. 9, 2013 post " We’ve resolved 6,036 issues and have 3,517 open issues" ( http://hcrenewal.blogspot.com/2013/11...

Đọc thêm »

Sovaldi - a "Revolution" in Clinical Care, or in Marketing and Public Relations?

The continuing public discussion of the sky high price Gilead has set for Sovaldi (sofosbuvir,) its new antiviral drug for hepatitis C, continues to avoid considering the lack of good evidence that the drug is as safe and effective as its proponents claim.<br /><br />We first <a href="http://hcrenewal.blogspot.com/2014/03/too-good-to-be-true-sovaldi-kerfuffle.html">posted</a> about the Sovaldi debate on March 27, 2014, and its focus on price rather than the quality of the evidence underlying loud claims about the miraculous qualities of the drug.  We suggested that there is no good evidence supporting claims that most hepatitis C patients have very bad outcomes if untreated, treatment prevents most bad outcomes, Sovaldi cures nearly all patients, and Sovaldi has very few side effects.<br /><br />In a subsequent post we wrote that initially, "no one but your humble blogger seemed to be <a href="http://hcrenewal.blogspot.com/2014/04/knee-deep-in-hoopla-triumph-of-medical.html">publicly skeptical </a>about published assertions that the drug was some sort of modern miracle, and a triumph of medical science."<br /><br />On May 7, we <a href="http://hcrenewal.blogspot.com/2014/05/some-authoritative-skepticism-about.html">noted</a> an assessment by the German Institute for Quality and Efficiency in Health Care (IQWiG) of information submitted by "industry" (presumably Gilead) to the German government.  This assessment found multiple problems with the evidence, including limited generalizability, problems with randomization, lack of information about important outcomes, and lack of ability to quantify benefit.   Also  the US based Institute for Clinical and Economic Review noted that there was little evidence that compared to previous treatments, Sovaldi is better, and no evidence that Sovaldi produces cures in the long term.<br /><br />Nonetheless, the notions that the evidence supporting Sovaldi (and perhaps other similar drugs) is weak, and that the drugs therefore should not yet be considered miracle cures have not seemingly affected the public discussion.  <br /><br /><b>Examples of the Latest Discussion</b><br /><br /><u>Washington Post/ Kaiser Health News</u><br /><br /><br />On May 12, 2014, in an <a href="http://www.kaiserhealthnews.org/stories/2014/may/12/medicare-struggling-with-hepatitis-c-cure-costs.aspx">article</a> on the dilemma the drug's US price of $1000/ pill presents to Medicare, Richard Knox wrote this about a patient with the infection:<br /><br /><blockquote class="tr_bq">Previous drug treatments didn't clear the virus from Bianco's system. But it's <i>almost certain that potent new drugs for hep-C could cure him. </i></blockquote><br />In other words, the article asserted that Sovaldi and similar drugs cure nearly everyone with hepatitis C, even those not cured by previous treatment. <br /><br /> <u>Reuters</u><br /><br />On May 20, 2014, in an <a href="http://www.reuters.com/article/2014/05/20/us-insurance-gilead-sciences-drugcosts-idUSKBN0E029U20140520">article</a> about how US health insurers are balking at the price of Sovaldi, was this statement by the main trade organization for US for-profit health care insurers, America's Health Insurance Plans (AHIP),<br /><br /><blockquote class="tr_bq"><span id="articleText">Sovaldi has <i>shown tremendous results</i>, and it's the kind of medical innovation we need to sustain. </span></blockquote><br /><span id="articleText">In the article's text was the assertion,</span><br /><span id="articleText"></span><br /><br /><blockquote class="tr_bq">The new drug has demonstrated an ability to <i>cure well over 90 percent of patients in just 12 weeks </i>or less with few side effects.<br /><br />Prior to the Sovaldi approval, <i>hepatitis C treatments took 24 or 48 weeks, cured about 75 percent of patients and involved many more pills as well as injectable interferon that causes flu-like symptoms and other side effects that led many people to avoid or discontinue treatment.</i></blockquote><br />In other words, the article asserted that Sovaldi can cure over 90% of patients compared to the cure rate of 75% provided by previously available treatments, and implied Sovaldi has fewer side effects. <br /><br /><u>CNBC</u><br /><br />On May 22, 2014, in an <a href="http://nbr.com/2014/05/22/the-84000-question-will-focusing-on-drug-prices-rein-in-costs/">article</a> on the high costs of new drugs, a quote from Dr Douglas Dieterich, "a liver disease specialist at Mount Sinai Hospital," who "has consulted for pharmaceutical companies, including Gilead," appeared,<br /><br /><blockquote class="tr_bq">I don’t think there’s any question that treating patients with hepatitis C will lower overall health-care costs in the coming 20 years,...<br /><br />If <i>we could get rid of the liver disease in these patients with hepatitis C, prevent them from dying of liver cancer, cirrhosis and liver failure</i>, then there’s no question the cost will be less.</blockquote><br />The implication was that the new drugs can get rid of the disease, that is, cure it, and in doing so prevent early mortality, cirrhosis, and liver failure.<br /><br /><u>CTV</u><br /><br />The discussion of Sovaldi in Canada seems similar. On May 25, 2014, an <a href="http://www.ctvnews.ca/health/hepatitis-c-drugs-show-promise-but-price-is-too-high-for-most-patients-1.1837917">article</a> on the high cost of hepatitis C drugs in Canada from CTV, "Canada's largest private broadcaster," (look<a href="http://www.ctv.ca/About/Corporate-Info/About.aspx"> here</a>) quoted a Canadian physician,<br /><br /><blockquote class="tr_bq"> Dr. Curtis Cooper, director of the viral hepatitis program at the Ottawa Hospital, said the drugs Sovaldi and Galexos <i>offer a revolution for patients with the hepatitis C virus (HCV).</i><br /><br />'It only requires 12 weeks of treatment and (they) are <i>producing cure rates of 90 to even 100 per cent</i>,' he told CTV News.</blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><br /><br />And later, addressing the treatment of a particular patient,<br /><br /><blockquote class="tr_bq">We're talking about <i>curative therapies, which could potentially save her from liver failure, save her from liver cancer</i></blockquote><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Again, the assertions were that the drug cures 90%, maybe 100% if patients, and that cure will prevent liver failure and cancer.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><b>Is There Any Good Evidence?</b></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">Again, while there is much discussion, and some outrage over the $1000 per pill price of Sovaldi in the US (in Canada, a bargain at Canadian $650 per pill), all the discussion seems to assume that the pill is really a "revolution" (as per CTV), that provides</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">- cure rates of 90 - 100%, much better than previously available treatments</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">- lower adverse effect rates than than those caused by previously available treatments</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">-  prevention of complications of hepatitis C, including cirrhosis, liver failure, liver cancer, and early death.</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">I have found just one recent media article that throws a bit of evidence-based cold water on these claims, and refers to a new systematic review that should be generating a lot of interest, and provoking much more skepticism about the drug, but so far is not.<br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><u>The Single Skeptical Article</u><br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">On May 22, 2014, a MedPage Today article noted a new systematic review of sofosbuvir (Sovaldi) that had a very different message from the articles above.  In summary,</div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><blockquote class="tr_bq">The <i>evidence base for one of the star hepatitis C drugs is poor and the guidelines for its use are flawed</i>, according to a report obtained by the <a href="http://medicaiddirectors.org/about" target="_blank">National Association of Medicaid Directors</a>.<br /><br />According to the report, studies of sofosbuvir (Sovaldi) are <i>generally of poor quality</i>, mostly directed by the drug's maker, and <i>don't answer key questions, including whether the drug is better and safer than the current standard of care.</i><br /><br />The only available guidelines for its use -- guidelines created by the <a href="http://www.aasld.org/" target="_blank">American Association for the Study of Liver Diseases</a> and the <a href="http://www.idsociety.org/" target="_blank">Infectious Diseases Society of America</a> -- are <i>'methodologically flawed</i>,' according to the report, which was prepared by the<a href="http://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/" target="_blank"> Center for Evidence-Based Policy</a> at Oregon Health and Science University in Portland (OHSU).<br /><br />In addition, their authors and sponsors had '<i>multiple and significant conflicts of interest</i>,' the report argued.</blockquote><br /><u>The Report from the Center for Evidence-Based Policy </u><br /><br />The report is public, available without cost direct form the Center (email < centerebp@ohsu.edu> ), although not yet directly available on the web.  It directly addresses all four of the major claims made about Sovaldi that we discussed in our <a href="http://hcrenewal.blogspot.com/2014/03/too-good-to-be-true-sovaldi-kerfuffle.html">first post</a> n the topic.<br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">- <i>Most hepatitis C patients have very bad outcomes if untreated</i><br /><br /><br />The report cited the best data about outcome prevalence,<br /><br /><blockquote class="tr_bq">approximately 15% to 25% of people infected with HCV will clear the virus during the acute stage without treatment.  Seventy-five to 85% of infected individuals will develop a chronic HCV infection, and 60% to 70% of patients with chronic infection will develop chronic liver disease.  Over 20 to 30 years, 5% to 20% of infected patients will develop cirrhosis and 1% to 5% will die of cirrhosis or liver cancer.</blockquote><br />Although a majority of chronically infected patients will develop some liver disease, only a minority will develop cirrhosis or liver cancer.<br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">- <i>Treatment prevents most bad outcomes</i><br /><br /><br />The report stated,<br /><br /><blockquote class="tr_bq">Because of the slow progression of the disease, clinical trials have not evaluated these patient-important conditions [cirrhosis, hepatocellular carcinoma, decompensated liver disease, liver transplant, or death] as trial outcomes.  Instead a surrogate endpoint of sustained virologic response (SVR) has been used to measure success of treatment.  The SVR is defined as undetectable HCV-ribonucleic acid (RNA) levels.  The standard measure of treatment success has been SVR at 24 weeks post treatment (SVR24).<br /><br />Several long-term studies of patients with chronic HCV infection have shown an association between achieving SVR24 and patient-important clinical outcomes.</blockquote><br />So there is no direct evidence that treatment prevents any of the bad outcomes.  There is only indirect evidence that treatment may reduce the rate of some bad outcomes.  For example,<br /><br /><blockquote class="tr_bq">A 2014 observational study of a VA population found that ... the 5180 (4%) of patients who were able to achieve an undetectable viral load with interferon-based treatment had a 45% reduction in the risk of death ... and 27% reduction in the composite clinical endpoint ... of newly diagnosed cirrhosis, HCC [hepatocellular carcinoma], or liver related hospitalization.</blockquote><br />However, at best, based on an observational analysis that could have been biased, treatment only may have prevented a minority of bad outcomes. <br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">- <i>Sovaldi cures nearly all patients</i></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"><br /><br />As we noted earlier, there have been only two randomized controlled trials published that compared sofosbuvir with anything else.  One compared it to placebo, and one was the trial we discussed earlier that compared it sofosbuvir with ribavirin to pegylated interferon with ribavirin.  (Look <a href="http://hcrenewal.blogspot.com/2014/03/too-good-to-be-true-sovaldi-kerfuffle.html">here</a>.)   <br /><br /><blockquote class="tr_bq">All other studies were designed to refine drug dose, drug combination or duration of treatment.</blockquote><br />Also,<br /><br /><blockquote class="tr_bq">All studies were rated as having a high risk of bias.  No study was judged to have good applicability....  The overall summary judgement for each of the published studies yielded a rating of poor.</blockquote><br />Furthermore, the review found even more problems with the only study that compared sofosbuvir to active treatment (peg-interferon) than we did.  In particular, that study did not compare sofosbuvir with ribavirin to the current standard regimen of PEG plus weight-based ribavirin.  Instead, it compared it to a regimen that included low dose ribavirin.  By comparing sofosbuvir plus a higher dose or ribavirin, an active drug, to a peg-interferon plus a lower dose of ribavirin, the study design seemed designed to artificially enhance the efficacy of the sofosbuvir containing regimen.   Furthermore, the study did not assess the measure of sustained viral response at 24 weeks currently accepted as the best surrogate variable.  Instead it used SVR at 12 weeks, which may be correlated with SVR24 but is often higher. Thus this choice of endpoint seemed designed to increase the apparent efficacy of the regimens it evaluated.  <br /><br />So sofosbuvir has so far been compared to another active anti-viral regimen against hepatitis C in only one study.  That study was poorly designed and implemented, and its problems seemed likely to enhance the apparent efficacy of sofosbuvir.  Nonetheless, that one study did not show that sofosbuvir was more efficiacious, or safer than peg-interferon.<br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;">-<i> Sovaldi has very few side effects.</i><br /><br /></div><div style="background-color: white; border: medium none; color: black; overflow: hidden; text-align: left; text-decoration: none;"></div>The review had this summary,<br /><br /><blockquote class="tr_bq">The FDA compiled reports of adverse events from four trials....  There were no treatment-related deaths reported [note that we found there were deaths in the one trial that compared sofosbuvir to PEG, look <a href="http://hcrenewal.blogspot.com/2014/04/knee-deep-in-hoopla-triumph-of-medical.html">here</a>].<br /><br />Approximately 78% of patients receiving placebo, 88% of patients on SOF + RBV treatment and 95% of patients receiving PEG + SOF +RBV reported a side effect from treatment.  The most common side effects were fatigue, anemia, nausea, rash, headache, insomnia and pain....</blockquote><br />Thus it seems likely that Sovaldi has a lot of side effects, and whether it has fewer than standard treatment is unclear.  Furthermore,<br /><br /><blockquote class="tr_bq">studies on sofosbuvir were small, included populations that were healthier than the general hepatitis C population, were of short duration and had limited follow-up.  In many of the studies, the manufacturer was responsible for recording and reporting adverse events.  In general, reporting of adverse events is often incomplete and discrepancies between clinical trial reports and publications are common....  All of these factors would lead to a <i>bias in under-reporting the true nature of adverse events.</i></blockquote><br />Thus there is no good evidence that sofosbuvir has few side effects, or is dramatically safer than older treatments.<br /><br /><b>Summary</b><br /><br />While there continues to be concern, if not outrage, that the latest treatment for hepatitis C is priced at $1000 per pill, most of those expressing concern seem to assume that the pill is a wonder drug, promising nearly everyone a cure without major side effects.  However, as we first noted in March, 2014, there is no strong evidence to that effect.  In fact, now three skeptical looks at the evidence by people with more resources and perhaps more expertise than we possess have shown similar conclusions.<br /><br />It is a tribute to the power of the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> that there has been almost no recognition by physicians and other health professionals, journalists, and most amazingly, insurance companies who stand to lose billions paying for Sovaldi, that there is little good evidence that Sovaldi works, much less is superior to previous treatments.  Instead, even America's Health Insurance Plans thought the drug had "tremendous results," not very different from the assertion by the drug's manufacturer that the drug provides "a finite cure," (as reported by Reuters).  One might think that the insurance companies have enough money to invest in some real evidence-based medicine experts who could provide a skeptical assessment of the pricy new drugs and devices for which these companies may pay.  Is it that the commercial insurers are so now so dominated by generic managers who know nothing about health care, medicine, or biomedical science, much less evidence-based medicine that they are unable to resist the marketing and public relations hype?<br /><br />The Sovaldi case is a signal example of how our health care system is awash in marketing hype and public relations buzz that has swamped rational skeptical thinking about logic and evidence.  That marketing and PR is ever enriching managers while it will send the rest of us, health care professionals included, to the poor house.  And all the money we spend will not buy us the promised miracles and triumphs.<br /><br />As we have said until blue in the face, true health care reform would bring some skeptical thinking and regard for evidence and logic into the health policy discussion.   <br /><br />

Sovaldi - a "Revolution" in Clinical Care, or in Marketing and Public Relations?

The continuing public discussion of the sky high price Gilead has set for Sovaldi (sofosbuvir,) its new antiviral drug for hepatitis C, cont...

Đọc thêm »

"Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says" - Can Reports About the Benefits of EHRs at the VA Healthcare System Be Trusted?

More and more is leaking out about alleged executive malfeasance at the Veteran's Administration healthcare system in the U.S.<br /><br />This article just appeared:<br /><br /><blockquote class="tr_bq"><b>Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says</b><br />May 27, 2014<br /><br /><a href="http://www.thedailybeast.com/articles/2014/05/27/exclusive-texas-va-run-like-a-crime-syndicate-whistleblower-says.html">http://www.thedailybeast.com/articles/2014/05/27/exclusive-texas-va-run-like-a-crime-syndicate-whistleblower-says.html</a><br /><br />For years, employees at a Texas VA complained that their bosses were cooking the books. For years, the VA insisted there was no widespread wrongdoing. <br /><br />New whistleblower testimony and internal documents implicate an award-winning VA hospital in Texas in widespread wrongdoing—and what appears to be <b>systemic fraud</b>.<br /><br />Emails and VA memos obtained exclusively by The Daily Beast provide what is among the most comprehensive accounts yet of how high-level VA hospital employees conspired to game the system.<b> It shows not only how they manipulated hospital wait lists but why—to cover up the weeks and months veterans spent waiting for needed medical care. If those lag times had been revealed, it would have threatened the executives’ bonus pay.</b><br /><br />What’s worse, the documents show the wrongdoing going unpunished for years, <b>even after it was repeatedly reported to local and national VA authorities.</b> That indicates a new troubling angle to the VA scandal: that the much touted investigations may be incapable of finding violations that are hiding in plain sight.  <br /><br />“For lack of a better term, you’ve got an organized crime syndicate,” a whistleblower who works in the Texas VA told The Daily Beast. “People up on top are suddenly afraid they may actually be prosecuted and they’re pressuring the little guys down below to cover it all up.”</blockquote><br />Read the linked article in its entirety.  It contains document images of altered electronic orders, the EHR system apparently being used for "creative storytelling" to allow for "good metrics", and an employee "performance plan" evaluation submitted by a whistleblower containing perverse incentives:<br /><br /><blockquote class="tr_bq"><a href="https://www.documentcloud.org/documents/1174555-4-performanceobjs.html" target="_blank">... The VA’s 2012 performance plan</a>, provided to The Daily Beast by the whistleblower, contains five critical elements to evaluate success, each one containing multiple sub-criteria. But critical element No. 5, the “Results Driven” component that contains the “wait time” criteria,<b> is worth 50% of the overall score</b>. That’s as much as all the other elements combined.</blockquote><br />I won't delve into the gory details of the article further...read it yourself...but I do raise the following issues:<br /><br />1.  The VA EHR system VistA CPRS has been touted as among the best EHR's in the world, based on reports that come out of the VA.<br /><br /><ul><li><b>Can these reports on the benefits and safety of VistA CPRS be trusted</b>, considering what may be going on systemically regarding altered data related to "making the numbers" and getting bonuses? </li></ul><ul><li>It is well known that EHRs slow clinicians down, through annoying alerts and reminders and other decision support, cryptic and complex order-entry processes, and the general need to navigate multiples screens and templates to perform what used to take seconds on pen and paper.   Is it also possible that the inability of the VA system to meet its care obligations in a timely manner is related to <b>adverse effects on productivity of the EHR system itself?</b></li></ul><br />2.  EHR <b>audit trails</b> are an automatically-generated log of user activities, such as viewing, printing, altering or deleting an electronic document or other data.  They are the only way to authenticate an electronic record as complete and unaltered, since all paper/handwriting cues are gone in the computer world.<br /><br /><ul><li>It may be of interest to investigate the electronic audit trails generated by the VA electronic health records (EHRs)... or the lack thereof, for as I understand it those audit trails are often only active for VIPs ("very important persons") in the VA VistA CPRS EHR system. </li></ul><ul><li>Even worse, in the commercial sector hospitals admit they can alter or delete the EHR system audit trails - see my post at <a href="http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html">http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html</a>.  It's likely the same applies in the VA, and it would be of concern that any <b>audit trails of test and visit scheduling or other activities </b>could be undergoing a "disappearing act" in the wake of this scandal, in addition to the actual test/scheduling data itself.</li></ul><br />It is unfortunate that this scandal sheds doubt on claims made about activities, including EHR use, at the VA hospitals.  I myself have taught my students that the VA model has been a model for others to emulate, at least as far as EHRs are concerned.<br /><br />-------------<br /><br />As an important aside:<br /><br />I am personally familiar with very odd events at the VA, namely in 1995.  At <a href="http://hcrenewal.blogspot.com/2009/06/computer-and-other-mysteries-at.html">http://hcrenewal.blogspot.com/2009/06/computer-and-other-mysteries-at.html</a> regarding the computer-related radiation brachytherapy debacle at the Philadelphia VA Hospital I wrote [and I am adding some additional comments now in brackets]:<br /><br /><blockquote class="tr_bq">... I have some familiarity with odd events at the Philadelphia VA Hospital. (Not including the fact that I spent a few months there as a medical intern in the early 1980's). In the mid 1990's I took my father there for evaluation for increased service-related disability. He had been treated for skin lesions in the Army in WW2 and after by the VA with <a href="http://en.wikipedia.org/wiki/Fowler%27s_solution">Fowler's solution</a> (an arsenical) and as a consequence of this (even then-outdated and dangerous) treatment, had developed widespread basal cell carcinomatosis over a major portion of his body, with chronic bleeding and discomfort.<br /><br />I accompanied my father to the exam but did not identify myself as an MD, only as his son. [I was on vacation and was rather casually dressed.  I looked like any other schlep bringing his elderly veteran father in for care.]<br /><br />My father was seen in an evaluation by several physicians and students (arsenic-caused basal cell carcinomatosis is quite rare now) in my presence, and he was then handed his (paper) chart to take with him back to the main desk.  [As we were walking] I told my dad I wanted to look at the note. The note by a physician who'd seen him stated (paraphrasing):<br /><br /><blockquote class="tr_bq">"Mr. Silverstein <b>said he'd taken more than the prescribed dose of arsenic for years, and even shared it with his wife</b>."</blockquote><br />My father and I were shocked and dumbfounded. He'd said no such thing, and being a retired pharmacist of 40+ years, thought anyone making such a statement would have had to have been insane. (My mother had even harsher words when she heard about this.) [Along the lines of, "ARE THEY CRAZY???"]<br /><br />Needless to say, I was upset. I [identified myself and] confronted the physician who wrote the note, but that physician [a relatively young woman] would not change it, bizarrely claiming that they "remembered my father telling that story in a visit<i> several years prior." </i>Needless to say, such a claim violated all the precepts of medical information integrity of which I was familiar.  [I wondered to myself, "what type of utter imbecile would even say such a thing to a Yale physician/medical informatics faculty member?"]<br /><br />In an initial attempt to counteract this disability exam sabotage, I actually crossed out the statement in the chart, writing "this is untrue" or words to that effect <b>and signed my <i>own</i> name.</b><br /><br />The head of the Philadelphia VA Hospital would not return my calls on this matter.<br /><br />That is, until <a href="http://en.wikipedia.org/wiki/Jesse_Brown">Jesse Brown, then Secretary of the Department of Veterans' Affairs</a>, inquired directly a few days later.<br /><br />Unknown to the VA examiners, my father had been sent for the disability exam <b>after reporting problems to Sen. Jay Rockefeller's office about prolonged delays in having his case heard</b>.  Sen. Rockefeller's staff [specifically, Ms. Charlotte Moreland, <a href="http://votesmart.org/public-statement/25153/retirement-of-charlotte-moreland">http://votesmart.org/public-statement/25153/retirement-of-charlotte-moreland</a>, who my mother had befriended through many telephone conversations] had set up the exam!<br /><br />Sen. Rockefeller's staff was rather upset at the story I reported upon my return to New Haven about the bizarre chart fabrication at my father's VA disability exam, and apparently relayed the story up the chain of command, as it were.<br /><br />After that, the head of the Philadelphia VA Hospital <b>really, really</b> wanted to speak to me and called me at Yale several times. He wanted to set up a phone conference between me, himself, and the doctors who'd seen my father. I told his administrative assistant that there was "<b>nothing to talk about</b>", and that the false statement in my father's chart would be removed. <b>Period.</b><br /><br />I think it was. My father's increased disability was granted in the end, but what was going on here with disability exams was never fully investigated to my knowledge (having done disability exams myself years prior for the regional transit authority, police, fire etc. in Philadelphia, I suspected an "incentive" program to deny vets a disability determination). If I had not examined my father's chart, we might have never known a reason for his being turned down.<br /><br />A culture of honesty and accountability seemed lacking then, and seems lacking now.</blockquote><br />In retrospect, it seems <b>there may indeed have been an "incentive program" for, in essence, limiting positive disability determinations by sabotage, thus causing negative determinations on benefits</b>. <br /><br />Ironically, among other experiences, it was the impoverished experiences at the Phila. VA as an intern in 1981, with a decade of computer experience under my belt at that time, that led me to pursue a career in Medical Informatics.<br /><br />With inadequate staff and resources, especially at night when a medical student and I and a minimum of nurses covered something like 50 patients - and at that early stage of my career I am honestly admitting that I did not know what I was doing, really - and large amounts of time wasted on paperwork, I thought there had to be a better way via computing.<br /><br />I never expected that computers in medicine could become a tool for <i>"creative data alteration" for executive enrichment</i>, an impediment to good care, and a risk in and of itself, as was outed by a whistleblower recently in Athens, Georgia as at <a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html</a>.<br /><br />-- SS<br /><br /><b>May 28, 2014 Addendum:  </b><br /><br />Also see "<b>How VA Clinics Falsified Appointment Records</b>" at <a href="http://www.huffingtonpost.com/2014/05/28/va-clinics-falsified-records_n_5402547.html">http://www.huffingtonpost.com/2014/05/28/va-clinics-falsified-records_n_5402547.html</a><br /><br />-- SS<br /><br />

"Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says" - Can Reports About the Benefits of EHRs at the VA Healthcare System Be Trusted?

More and more is leaking out about alleged executive malfeasance at the Veteran's Administration healthcare system in the U.S. This arti...

Đọc thêm »

Athens Regional Medical Center: Hospital management is "addressing computer problems" AFTER patients are put at bodily risk, not before, only in response to irate clinicians; then claiming everything will be fixed soon while doctors resign.

<div style="text-align: center;"><span style="font-size: x-small;">(Note: also see my June 16, 2014 followup post at <a href="http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html">http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html</a>)</span> </div><br />Maybe hospital management gurus could address these computer problems BEFORE turning them loose on patients?<br /><br />Physicians in Georgia seem to have more guts than their colleagues elsewhere.  Rather than letting patients be guinea pigs for the naive fantasies of hospital executives about health IT, these physicians said "get these [expletive] computer systems out of our hospital"...<br /><br />Then they started <i>resigning their appointments: </i><br /><br /><blockquote class="tr_bq"><b>Athens Regional addressing new computer system problems encountered by doctors</b><br /><br />By Donnie Z. Fetter<br />Friday, May 23, 2014<br /><br /><a href="http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors">http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors</a><br /><br />Doctors affiliated with Athens Regional Medical Center (<a href="http://www.athenshealth.org/">http://www.athenshealth.org/</a>) have expressed concerns that<b> a computer system installed this month at the hospital endangers patients.</b></blockquote><br />Not "may endanger patients."  "Endangers patients."  That's quite direct. <br /><br /><blockquote class="tr_bq">However, the hospital's chief executive said Athens Regional is taking "swift action" to address those concerns.</blockquote><br />I'm not impressed.  The executives should perhaps have done due diligence and taken action <b>BEFORE this bad health IT was set loose on live, unsuspecting patients</b>.<br /><br />It's not as if the issues are unknown (as Google or anyone who actually knows what they're doing regarding health IT will easily demonstrate).  Further, those executives have the legal obligation to maintain a safe healthcare environment.<br /><br /><blockquote class="tr_bq">In a letter dated May 15 and provided to the Athens Banner-Herald this week, multiple doctors noted such concerns as<b> “medication errors ... orders being lost or overlooked ... (emergency department) patients leaving after long waits; and of an inpatient who wasn’t seen by a physician for (five) days.”</b></blockquote><br />Any of these issues and the multitude more I can predict exist can lead to severe injury or death, especially in fragile patients and the elderly.  Trust me, I know both professionally and personally... <br />  <br /><blockquote class="tr_bq">The letter was addressed to ARMC President and CEO James G. Thaw and <b>Senior Vice President and CIO Gretchen Tegethoff.</b> It was signed by more than a dozen physicians, including Carolann Eisenhart, president of the medical staff; Joseph T. Johnson, vice president of the medical staff; David M. Sailers, surgery department chair; and, Robert D. Sinyard, medicine department chair.<br /><br />The doctor who provided the letter to the Banner-Herald<b> refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues.</b></blockquote><br /><b>Refused a request to openly discuss the issues with the computer system and asked to remain anonymous at the urging of his colleagues ... </b>due to fear the executives would then return the doctor's concerns with genuine love and appreciation, and give him or her a generous promotion and pat on the back, no doubt.  (Actually, quite likely was a fear of retaliation, e.g. sham peer review as at <a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians">http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians</a>.)<br /><br />Note the educational background of CIO Gretchen Tegerhoff, the executive with fiduciary obligations to implement health IT of the highest quality and to have robustly researched all of the issues involved (and whom the Board should have thoroughly vetted as to required background for health IT leadership):<br /><br /><blockquote class="tr_bq">University of Georgia<br />Terry College of Business, Executive Program, Finance<br />2014 – 2014 (expected)<br /><br />The George Washington University - School of Business<br />Master of Science, Information Systems Technology<br />2001 – 2003<br /><br />West Virginia University<br />BS, Medical Technology<br />1993 – 1997 </blockquote><br />Note the career progression that is the envy of, say, someone who's completed the rigors of medical training (premed, medical school, internship/residency, clinical postdocs) and beyond that, completed an additional PhD, MS or post-doctoral fellowship in Medical Informatics at unknown universities such as Harvard, Yale, Stanford, Johns Hopkins, Columbia, etc. (reverse chrono):<br /><br /><blockquote class="tr_bq">Technical Analyst<br />STG (9 months)<br />[Provided U.S. Department of State with systems support and application maintenance.]<br /><br />Clinical Systems Analyst<br />George Washington University Hospital (3 years 8 months)<br /><br />Technical Support Specialist/Installer<br />Intellidata, Inc. (9 months)<br /><br />Clinical Research Associate<br />QUINTILES, INC. (9 months)<br /><br />Information Specialist<br />THE EMMES CORPORATION (1 year 8 months)<br /><br />Writer/Editor<br />ASPEN SYSTEMS CORPORATION (7 months)<br /><br />Medical Technologist<br />PROVIDENCE LABORATORY ASSOCIATES (8 months) </blockquote><br />This background led directly to:<br /><br /><blockquote class="tr_bq">Chief Information Officer<br />George Washington University Hospital (6 years 8 months) </blockquote><br />and then the current role:<br /><br /><blockquote class="tr_bq">Athens Regional Health System<br />Vice President and Chief Information Officer<br />Athens Regional Health System</blockquote><br />If you believed that the qualifications required for medical practice - let alone medical leadership roles - is at least an order of magnitude more robust, you'd not be mistaken.<br /><br />Perhaps even worse, business-IT amateur meddlers in clinical affairs sell the "best practices" that lead to debacles like this, and perhaps to IT-related patient injury and death, via their alphabet-soup "leadership" organizations.  This CIO also holds this credential:<br /><br /><blockquote class="tr_bq"><style type="text/css">H3 { margin-bottom: 0.08in; }H3.cjk { font-family: "Droid Sans Fallback"; }H3.ctl { font-family: "Lohit Hindi"; }P { margin-bottom: 0.08in; }</style> <br /><div class="western">Faculty</div><div class="western">CHIME Healthcare CIO Boot Camp (8 months) </div></blockquote><br />It should be noted, and scandalously so considering the negligence that leads to patient endangerment and this kind of physician revolt from the outset, that IT-related patient harms are not uncommon.  For example, per the Harvard community's med mal insurer CRICO, see "<b>Malpractice Claims Analysis Confirms Risks in EHRs</b>" at<br /><a href="http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html">http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html</a>, the ECRI Institute, see "<b>ECRI Deep Dive Study of Health IT harms</b>" at <br /><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> as well as "<b>ECRI Institute's 2014 Top 10 Patient Safety Concerns for Healthcare Organizations</b>" at <br /><a href="http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html">http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html</a>, "<b>FDA Internal Memo on H-IT risks - for internal use only</b>" (uncovered by investigative reporter Fred Schulte) at <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html">http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html</a>, and others as posted at this blog.<br /><br /><blockquote class="tr_bq">“From the moment our physician leadership expressed concern about the Cerner I.T. conversion process on May 15, <b>we took swift action and significant progress has been made toward resolving the issues raised</b>,” Thaw wrote Thursday in an email. “Providing outstanding patient care is first and foremost in our minds at Athens Regional, and we have dedicated staff throughout the hospital to make sure the system is functioning as smoothly as possible through this transition."</blockquote><br />This raises several questions: <br /><br /><ul><li>How about the moments <i><b>from the time of decision to acquire the technology?  What safety consideration were in effect during that time?</b></i><i><b> </b></i></li></ul><i><b></b></i><br /><ul><li><i><b>What if the "significant progress" is insufficient to prevent a patient from being maimed or killed due to toxic effects of bad health IT?  Who's responsible?</b></i><i><b> </b></i></li></ul><i><b></b></i><br /><ul><li><i><b>Perhaps most importantly from the human rights perspective - are patients being provided informed consent about these "issues raised" and are they afforded the opportunity to seek care elsewhere until the "swift progress" is completed? </b></i> </li></ul><br />One wonders if the executives were aware of analytic work on Cerner ED systems such as performed by U. Sydney professor Jon Patrick at <b>"A study of an Enterprise Health information System", </b> <span class="Apple-style-span" style="font-size: x-small;"></span><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>; or this site on health IT difficulties:  <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/">http://cci.drexel.edu/faculty/ssilverstein/cases/</a>, or this blog and others.<br /><br />It's not as if a simple Google search won't find them, such as <a href="https://www.google.com/search?q=healthcare+IT+failure">https://www.google.com/search?q=healthcare+IT+failure</a>.  Perhaps they need to read more...or hire experts BEFORE go-live.<br /><br />Back to the article:<br /><br /><blockquote class="tr_bq">The intended goal of the system designed by health care information technology company Cerner is to improve efficiency and connectivity by providing doctors, nurses and other medical professionals with a shared data set and to eventually allow patients online access to their medical records, Athens Regional executives previously said.</blockquote><br />Good intentions or not, badly designed and/or implemented technology harms or kills, and those harmed, or the dead, really don't care what the system is 'intended to do.'  Patients are not guinea pigs towards an IT company's or hospital's experiments with computers - regarding which the executives are usually in to at a level way over their collective heads.<br /><br /><blockquote class="tr_bq">But doctors noted the new system<b> often proved too cumbersome to be effective at the time the letter was written.</b><br /><br />“The Cerner implementation <b>has driven some physicians to drop their active staff privileges at ARMC,</b>” noted the letter. “<b>This has placed an additional burden on the hospitalists, who are already overwhelmed.</b> </blockquote><br />That's just <i>horrendous</i> for safety.<br /><br /><b>Joint Commission, where are you?</b><br /><b> </b> <br /><blockquote class="tr_bq">Other physicians are directing their patients to St. Mary’s (hospital) for outpatient studies, (emergency room) care, admissions and surgical procedures. ... Efforts to rebuild the relationships with patients and physicians (needs) to begin immediately.”</blockquote><br />Doctors voted with their feet.  Bravo.<br /><br />I suggest they consider the following remedies as well if appropriate, from my post 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>:<br /><br /><blockquote class="tr_bq">... When a physician or other clinician observes health IT problems, defects, malfunctions, <a href="http://www.tinyurl.com/hostileuserexper">mission hostility</a> (e.g., poor user interfaces), significant downtimes, lost data, erroneous data, misidentified data, and so forth ... and most certainly, patient 'close calls' or actual injuries ... they should (anonymously if necessary if in a hostile management setting):<br /><br />(DISCLAIMER:  I am not responsible for any adverse outcomes if any organizational policies or existing laws are broken in doing any of the following.) <br /><br /><br /><ul><li>Inform their facility's senior management, if deemed safe and not likely to result in retaliation such as being slandered as a "<a href="http://www.jpands.org/vol9no3/huntoon.pdf">disruptive physician</a>" and/or or being subjected to sham peer review (<a href="http://www.aapsonline.org/index.php/article/sham_peer_review_resources_physicians/">link</a>).</li></ul><ul><li>Inform their personal and organizational <span style="font-weight: bold;">insurance carriers</span>, in writing. Insurance carriers do not enjoy paying out for preventable IT-related medical mistakes. They have begun to become aware of HIT risks. See, for example, the essay on Norcal Mutual Insurance Company's newsletter on HIT risks<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=norcal"> at this link</a>. (Note - many medical malpractice insurance policies can be interpreted as <span style="font-style: italic; font-weight: bold;">requiring</span><span style="font-weight: bold;"> </span>this reporting, observed occasional guest blogger <a href="http://hcrenewal.blogspot.com/search/label/Dr.%20Scott%20Monteith">Dr. Scott Monteith</a> in a comment to me about this post.)</li></ul><ul><li>Inform the Joint Commission (or similar national accreditor of hospital safety if not in the U.S.) via their complaint site at <a href="http://www.jointcommission.org/report_a_complaint.aspx">http://www.jointcommission.org/report_a_complaint.aspx</a> . Also consider writing the JC senior officers (<a href="http://www.jointcommission.org/about_us/joint_commission_officers.aspx">link to officer's list</a>), whose awareness of HIT issues I can personally attest to via our correspondences.</li></ul><ul><li>Inform the FDA (or similar healthcare regulator if not in the U.S.) via the FDA Medwatch Form 3500 reporting site at <a href="https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm">https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm</a>. An example of such an adverse event report I filed myself (when the involved hospital refused) is <a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/Detail.CFM?MDRFOI__ID=1729552">at this link</a> in the FDA MAUDE (Manufacturer and User Facility Device Experience) database.</li></ul><ul><li>Inform the State Medical Society and local Medical Society of your locale.</li></ul><ul><li>Inform the appropriate Board of Health for your locale.</li></ul><ul><li>If applicable (and it often is), inform the Medicare Quality Improvement Organization (QIO) of your state or region. Example: in Pennsylvania, the QIO is "<a href="http://www.qipa.org/Home.aspx">Quality Insights of PA</a>."</li></ul><ul><li>Inform a personal attorney.</li></ul><ul><li>Inform local, state and national representatives such as congressional representatives. Sen. Grassley of Iowa is aware of these issues, for example.</li></ul><ul><li>As clinicians are often forced to use health IT, at their own risk even when "certified" (<a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html">link</a>), if a healthcare organization or HIT seller is sluggish or resistant in taking corrective actions, consider taking another risk (perhaps this is for the very daring or those near the end of their clinical career). Present your organization's management with a statement for them to sign to the effect of:</li></ul><blockquote><span style="font-style: italic;">"We, the undersigned, do hereby acknowledge the concerns of [Dr. Jones] about care quality issues at [Mount St. Elsewhere Hospital] regarding EHR difficulties that were reported, namely [event A, event B, event C ... etc.]</span><br /><br style="font-style: italic;" /><span style="font-style: italic;">We hereby indemnify [Dr. Jones] for malpractice liability regarding patient care errors that occur due to EHR issues beyond his/her control, but within the control of hospital management, including but not limited to: [system downtimes, lost orders, missing or erroneous data, etc.] that are known to pose risk to patients.</span> <span style="font-style: italic;">We assume responsibility for any such malpractice.</span><br /><br style="font-style: italic;" /><span style="font-style: italic;">With regard to health IT and its potential negative effects on care, Dr. Jones has provided us with the Joint Commission Sentinel Events Alert on Health IT at </span><a href="http://www.jointcommission.org/assets/1/18/SEA_42.PDF" style="font-style: italic;">http://www.jointcommission.org/assets/1/18/SEA_42.PDF</a><span style="font-style: italic;">, the IOM report on HIT safety at </span><a href="http://www.modernhealthcare.com/Assets/pdf/CH76254118.PDF" style="font-style: italic;">http://www.modernhealthcare.com/Assets/pdf/CH76254118.PDF</a><span style="font-style: italic;">, and the FDA Internal Memorandum on H-IT Safety Issues at </span><a href="http://www.scribd.com/huffpostfund/d/33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology" style="font-style: italic;">http://www.scribd.com/huffpostfund/d/33754943-Internal-FDA-Report-on-Adverse-Events-Involving-Health-Information-Technology</a><span style="font-style: italic;">.</span><br /><br style="font-style: italic;" /><span style="font-style: italic;">CMO __________ (date, time)</span><br /><span style="font-style: italic;">CIO ___________ (date, time)</span><br /><span style="font-style: italic;">CMIO _________ (date, time)</span><br /><span style="font-style: italic;">General Counsel ___________ (date, time)</span><br /><span style="font-style: italic;">etc."</span></blockquote><ul><li>If the hospital or organizational management refuses to sign such a waiver (and they likely will!), note the refusal, with date and time of refusal, and file away with your attorney. It could come in handy if EHR-related med mal does occur.</li></ul><ul><li>As EHRs remain experimental, I note that indemnifications such as the above probably belong in medical staff contracts and bylaws when EHR use is coerced.</li></ul><br style="font-weight: bold;" />These measures can help "light a fire" under the decision makers, and "get the lead out" of efforts to improve this technology to the point where it is usable, efficacious and safe.</blockquote><br />More from the article:<br /><br /><blockquote class="tr_bq">Doctors called the time line to install the EHR system too “aggressive” and said there was a “lack of readiness” among the intended users.</blockquote><br />For financial incentive reasons in part, I'm sure.  Computers, after all, seem to have more rights than patients...or than physicians and nurses.<br /><br /><blockquote class="tr_bq">Since receiving the letter, Thaw said Athens Regional has added "specialized staff" to meet daily with physicians to discuss computer system and safety issues.</blockquote><br />Again, the key word is "AFTER."   A good move, considering the hospital will be up to its head in defections, accreditation inspections and hearings, and possible medical malpractice and corporate liability lawsuits otherwise.<br /><br /><blockquote class="tr_bq">"Regardless of what system we are using, <b>our focus on patient safety is unwavering</b>, and we will never put a system ahead of doing what is right for our patients," Thaw said. "Our team is working around the clock to resolve any remaining issues, and we remain dedicated to delivering outstanding patient care every step of the way."</blockquote><br />Feel-good executive boilerplate and an outright lie on its face.  If the focus on safety was unwavering, this problems would not now need emergency remediation.  As I had written many years ago here: <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story</a>, this type of shallow executive puffery and rhetoric only makes clinicians angrier.<br /><br />And while events like this go on, the industry pundits suggest all that's needed is a Health IT 'Safety Center' instead of regulation like the rest of the healthcare industry (<b>"Feds Call For Health IT Safety Center"</b>, May 20, 2014,<a href="http://www.govhealthit.com/news/feds-call-hit-safety-center?topic=,26#.U4FVDnYsC"> http://www.govhealthit.com/news/feds-call-hit-safety-center?topic=,26#.U4FVDnYsC</a>).  This is sort of like putting the safety of our country's hospitals in the hands of Consumer Reports.<br /><br />That's not exactly the ticket to a rapid cure to these problems, which are more common than most physicians have the bravery (or career options in the face of retaliation) to admit.<br /><br />At least nurses' unions are taking action, as at<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> and <a href="http://hcrenewal.blogspot.com/2014/05/a-nurses-union-national-nurses-united.html">http://hcrenewal.blogspot.com/2014/05/a-nurses-union-national-nurses-united.html</a>.<br /><br />Additional thought:  at least the writer of the article did not use the customary euphemism for problems with patient-endangering bad health IT, specifically: "glitches" (<a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>). <br /><br />-- SS<br /><br /><b>May 27, 2014 Addendum</b>:<br /><br />The CEO has apparently resigned, see <a href="http://onlineathens.com/local-news/2014-05-23/thaw-resigns-athens-regional-ceo">http://onlineathens.com/local-news/2014-05-23/thaw-resigns-athens-regional-ceo</a>.  <br /><br />I also solicit physicians from the area of this hospital to contact me regarding any patient harms that did occur as a result of this debacle, via my email address located here: <a href="https://www.blogger.com/profile/03994321680366572701">https://www.blogger.com/profile/03994321680366572701</a>.  I will forward any reports through appropriate legal channels to attorneys who can take action, which in 2014 is probably the only language this industry will actually listen to.<br /><br />-- SS<br /><br /><b>May 27, 2014 Addendum 2:</b><br /><br />The reader comments at <a href="http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors">http://onlineathens.com/health/2014-05-22/athens-regional-addressing-new-computer-system-problems-encountered-doctors</a> are interesting, and distressing.<br /><br />-- SS<br /><br /><b>May 29, 2014 Addendum:</b><br /><br />More here:  <a href="http://flagpole.com/news/in-the-loop/james-thaw-out-as-armc-ceo">http://flagpole.com/news/in-the-loop/james-thaw-out-as-armc-ceo</a><b> </b><br /><br />If I were that's hospital's new leadership, I'd immediately go back to whatever system (whether paper or not) was in place before this implementation, and <b>take the time to implement new health IT properly, safely and carefully.</b><br /><br />For at this point, if patient injury or death occurs as a result of a system flaw (whether in design or implementation), I believe charges of criminal negligence against the organization and its leaders would be justified.<br /><br />The following is an example of one state's statute defining criminal negligence:<br /><br /><blockquote>''A person acts with 'criminal negligence' with respect to a result or to a circumstance described by a statute defining an offense when he fails to perceive a substantial and unjustifiable risk that such result will occur or that such circumstance exists. The risk must be of such nature and degree <b>that the failure to perceive it constitutes a gross deviation from the standard of care that a reasonable person would observe in the situation.</b>''</blockquote><br />I believe other states' statutes are similar.<br /><br />-- SS<br /><br /><b>June 13, 2013 Addendum:</b><br /><br />My post on Athens Regional Medical Center's physician revolt was accessed today by someone at Cerner; note the referring link:  <a href="http://cerner.vertabase.com/project/document/index.cfm?&0.12455576848">http://cerner.vertabase.com/project/document/index.cfm?&0.12455576848</a><br /><br />Vertabase (<a href="http://www.vertabase.com/">http://www.vertabase.com/</a>) makes project management software.<br /><br />Cerner.vertabase.com/project/document is some sort of password-protected document resource.<br /><br />I find that interesting - perhaps it's for internal communications and they are learning something from me. <br /><span style="font-family: inherit;"></span><b><br /><br /><span class="HOEnZb"></span></b><br /><table border="0" cellpadding="1" cellspacing="1" style="width: 450px;"><tbody><tr bgcolor="#F5F5E2"><td align="right" width="150"><span style="font-family: Arial;">Domain Name</span></td><td align="center" width="10"></td><td width="290"><span style="font-family: Arial;"> (Unknown) </span></td></tr><tr><td align="right" valign="top"><b><span style="font-family: Arial;">IP Address</span></b></td><td align="center"></td><td><b><span style="font-family: Arial;">159.140.254.# (Cerner Corporation)</span></b></td></tr><tr bgcolor="#F5F5E2"><td align="right"><span style="font-family: Arial;">ISP</span></td><td align="center"></td><td><span style="font-family: Arial;">Cerner Corporation</span></td></tr><tr><td align="right" valign="top"><span style="font-family: Arial;">Location</span></td><td align="center"></td><td><table cellpadding="0" cellspacing="0"><tbody><tr><td><span style="font-family: Arial;">Continent</span></td><td> : </td><td><span style="font-family: Arial;">North America</span></td></tr><tr><td valign="top"><span style="font-family: Arial;">Country</span></td><td valign="top"> : </td><td><span style="font-family: Arial;"><a href="http://www.sitemeter.com/?a=stats&s=s20hcrenewal&v=100&country=US&vlr=14&pg=21&r=76" target="_blank">United States</a> <a href="http://www.sitemeter.com/?a=stats&s=s20hcrenewal&v=100&country=US&vlr=14&pg=21&r=77" target="_blank"><img border="0" height="12" src="https://blogger.googleusercontent.com/img/proxy/AVvXsEjqRg30-NBYCTvdB5xbLIeWb8pInOkPdRZk2QQR2-V1aYwwwkKPVx8XWaG3Pc8GRDYGnkcPfOIZBAzBPLDYY7EhDVN0UO6vMyU8u-Zqgv165Xdliu3lU51bGzEAUayvD-YcR61pttguytcd5RQ=s0-d-e1-ft" width="18" /></a> <a href="http://www.sitemeter.com/?a=stats&s=s20hcrenewal&v=100&country=US&vlr=14&pg=21&r=78" target="_blank">(Facts)</a></span></td></tr><tr><td><span style="font-family: Arial;">State</span></td><td> : </td><td><span style="font-family: Arial;">Kansas</span></td></tr><tr><td><span style="font-family: Arial;">City</span></td><td> : </td><td><span style="font-family: Arial;">Kansas City</span></td></tr><tr><td><span style="font-family: Arial;">Lat/Long</span></td><td> : </td><td><span style="font-family: Arial;">39.1111, -94.6904 <a href="http://www.sitemeter.com/?a=stats&s=s20hcrenewal&r=75&pg=21&vlr=14&v=100" target="_blank">(Map)</a></span></td></tr></tbody></table></td></tr><tr bgcolor="#F5F5E2"><td align="right" valign="top"><span style="font-family: Arial;">Language</span></td><td align="center"></td><td><span style="font-family: Arial;">English (U.S.)<br /><small>en-us</small></span></td></tr><tr><td align="right"><span style="font-family: Arial;">Operating System</span></td><td align="center"></td><td><span style="font-family: Arial;">Macintosh MacOSX</span></td></tr><tr bgcolor="#F5F5E2"><td align="right" valign="top"><span style="font-family: Arial;">Browser</span></td><td align="center"></td><td><span style="font-family: Arial;">Safari 1.3<br /><small>Mozilla/5.0 (Macintosh; Intel Mac OS X 10_8_5) AppleWebKit/536.30.1 (KHTML, like Gecko) Version/6.0.5 Safari/536.30.1</small></span></td></tr><tr><td align="right" valign="top"><span style="font-family: Arial;">Javascript</span></td><td align="center"></td><td><span style="font-family: Arial;">version 1.5</span></td></tr><tr bgcolor="#F5F5E2"><td align="right" valign="top"><span style="font-family: Arial;">Monitor</span></td><td align="center"></td><td><span style="font-family: Arial;"><table cellpadding="0" cellspacing="0"><tbody><tr><td><span style="font-family: Arial;">Resolution</span></td><td><span style="font-family: Arial;"> : </span></td><td><span style="font-family: Arial;">1440 x 900</span></td></tr><tr><td><span style="font-family: Arial;">Color Depth</span></td><td><span style="font-family: Arial;"> : </span></td><td><span style="font-family: Arial;">24 bits </span></td></tr></tbody></table></span></td></tr><tr><td align="right"><span style="font-family: Arial;">Time of Visit</span></td><td align="center"></td><td><span style="font-family: Arial;"><span title="Jun 13 2014 11:47:42">Jun 13 2014 11:47:42 am</span></span></td></tr><tr bgcolor="#F5F5E2"><td align="right"><span style="font-family: Arial;">Last Page View</span></td><td align="center"></td><td><span style="font-family: Arial;"><span title="Jun 13 2014 11:47:42">Jun 13 2014 11:47:42 am</span></span></td></tr><tr><td align="right"><span style="font-family: Arial;">Visit Length</span></td><td align="center"></td><td><span style="font-family: Arial;">0 seconds</span></td></tr><tr bgcolor="#F5F5E2"><td align="right"><span style="font-family: Arial;">Page Views</span></td><td align="center"></td><td><span style="font-family: Arial;">1</span></td></tr><tr><td align="right" valign="top"><b><span style="font-family: Arial;">Referring URL</span></b></td><td align="center"><b><br /></b></td><td><b><span style="font-family: Arial;"><a href="http://cerner.vertabase.com/project/document/index.cfm?&0.12455576848" target="_blank" title="http://cerner.vertabase.com/project/document/index.cfm?&0.12455576848">http://cerner.vertabase.com/<wbr></wbr>project/document/index.cfm?&0.<wbr></wbr>12455576848</a></span></b></td></tr><tr bgcolor="#F5F5E2"><td align="right"><span style="font-family: Arial;">Visit Entry Page</span></td><td align="center"></td><td><span style="font-family: Arial;"><a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html" target="_blank" title="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/<wbr></wbr>2014/05/i-could-not-make-this-<wbr></wbr>up-if-i-tried.html</a></span></td></tr><tr><td align="right"><span style="font-family: Arial;">Visit Exit Page</span></td><td align="center"></td><td><span style="font-family: Arial;"><a href="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html" target="_blank" title="http://hcrenewal.blogspot.com/2014/05/i-could-not-make-this-up-if-i-tried.html">http://hcrenewal.blogspot.com/<wbr></wbr>2014/05/i-could-not-make-this-<wbr></wbr>up-if-i-tried.html</a></span></td></tr><tr bgcolor="#F5F5E2"><td align="right"><span style="font-family: Arial;">Out Click</span></td><td align="center"></td><td></td></tr><tr><td align="right" valign="top"><span style="font-family: Arial;">Time Zone</span></td><td align="center"></td><td><span style="font-family: Arial;"><a href="http://www.sitemeter.com/?a=stats&&s=s20hcrenewal&v=100&vlr=14&pg=21&r=31" target="_blank">UTC-6:00</a></span></td></tr><tr bgcolor="#F5F5E2"><td align="right" valign="top"><span style="font-family: Arial;">Visitor's Time</span></td><td align="center"></td><td><span style="font-family: Arial;"><span title="Jun 13 2014 10:47:42">Jun 13 2014 10:47:42 am</span></span></td></tr><tr><td align="right"><span style="font-family: Arial;">Visit Number</span></td><td align="center"></td><td align="left"><span style="font-family: Arial;">1,342,222</span></td></tr></tbody></table><br /> -- SS<br /><br />Note: also see my June 16, 2014 followup post at <a href="http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html">http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html</a>

Athens Regional Medical Center: Hospital management is "addressing computer problems" AFTER patients are put at bodily risk, not before, only in response to irate clinicians; then claiming everything will be fixed soon while doctors resign.

(Note: also see my June 16, 2014 followup post at http://hcrenewal.blogspot.com/2014/06/masters-of-obvious-aat-athens-regional.html ) Maybe...

Đọc thêm »