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Teaching Would-be Health Care Leaders About Health Care: Why Is This News?

The Wall Street Journal just published <a href="http://online.wsj.com/article/SB10001424052748704398304574598132733849334.html">a story</a> on a big innovation in the business school curriculum: <blockquote>David Song was in the middle of a two-year executive M.B.A. program at University of Chicago's Booth School of Business in February when he got the idea to create a course to help business people better understand the inner workings of medicine. Dr. Song, chief of plastic surgery at the University of Chicago Medical Center, believes the course may help close the gap between such industries as pharmaceutical and biotech, and the medical community they serve. 'Why not help reveal how things run and how we make decisions, particularly in this time of immense overhaul to the system?' says Dr. Song, who began collaborating with one of his marketing professors, Sanjay Dhar, to put together the course, titled 'Understanding the New Breed of Healthcare Decision Makers'—a five-day $7,650 program slated for May. The program is designed to give participants a look at the administrative workings of an academic medical center, including how doctors make decisions about the way to treat patients, and which devices and products they choose to purchase. Booth, like other business schools, is struggling to keep up enrollment in executive education at a time when companies are pulling back on training budgets. Dr. Song's health-care program is the only new addition to the curriculum for the academic year, says Stephen LaCivita, associate dean of executive education. The program is geared toward professionals who work in areas like pharmaceuticals, medical devices and financial services, who may have a limited understanding of the physicians, nurses and other clinicians who are their customers. Some of the issues addressed in the seminars, which will be taught by medical and business faculty, include: how doctors and hospitals define value; how reimbursement strategies work; and how supply chain, purchasing decisions, patient flow and operations are managed. </blockquote> And here is the course's big feature: <blockquote>As an added bonus, on the second to last day students will change into scrubs and observe a surgery, make rounds with doctors and see how patients are prioritized in the emergency room. 'This is getting a glimpse of what it's like and how we make decisions,' says Dr. Song. </blockquote> Earlier this year we <a href="http://hcrenewal.blogspot.com/2009/08/ny-times-proclaims-anyone-can-run.html">noted</a> a NY Times article which breathlessly promoted management jobs in health care, partially by implying that they were available to those who knew little to nothing about what health care actually entails, with, at most "a little studying up." This new article suggests how little "studying up" may actually be needed.  The fact that a five-day course to teach budding MBAs a little bit about health care is considered a newsworthy business education innovation by the Wall Street Journal certainly suggests that the prevailing business culture allows management of heatlh care organizations by people with almost no knowledge of or experience in actual health care. We noted in August that the NY Times article had the whiff of a bubble about to burst.  Indeed, we just <a href="http://hcrenewal.blogspot.com/2009/12/health-care-bubble-parallels-with.html">noted</a> an article that listed some of the salient characteristics of the recently burst financial/ housing bubble, including "major organizations lead by the clueless."  For that post, we used examples of three leaders of huge financial firms that have now failed (that is, are bankrupt or bailed out) who did not understand the complex derivatives their firms were buying and selling.  In the earlier post, we noted examples of leaders of two big American automobile companies that have now similarly failed who seemed to know little about automobiles.  So here we have would-be leaders in pharmaceutical, medical device and other health care corporations "who may have a limited understanding of the physicians, nurses and other clinicians." This reinforces my thesis that health care is now in a bubble that will soon burst.  It also suggests why health care in the US costs so much, out of proportion to the quality or access provided.  Even setting aside how the business culture in the last 20 years has put short-term revenue and personal enrichment ahead of everything else, why would we expect that health care leadership by people who know little about health care, and care less for its values, would be anything but disastrous?

Teaching Would-be Health Care Leaders About Health Care: Why Is This News?

The Wall Street Journal just published a story on a big innovation in the business school curriculum: David Song was in the middle of a two...

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The Door Revolves: Tufts Medical School Dean Goes Back to Merck

A little news item <a href="http://www.nj.com/business/index.ssf/2009/12/new_jersey_drug_maker_lures_tu.html">in the Newark Star-Ledger</a>: <blockquote>Merck announced the appointment of Michael Rosenblatt as executive vice president and chief medical officer. The appointment, which was announced this morning by the company, is effective immediately. Rosenblatt will be responsible for bringing greater focus to Merck’s global medical activities as well as shaping innovative medical strategies. He will report directly to CEO Richard Clark. Rosenblatt has served as dean of Tufts University Medical School since 2003. Earlier, he was senior vice president for research at Merck Sharp & Dohme Research Laboratories, where he co-led the worldwide development team for Fosamax, Merck’s treatment for osteoporosis. </blockquote> A quick Google tour revealed that while he was Dean, Dr Rosenblatt also served as a <a href="http://www.millenniapartners.com/OurTeam/TeamView.asp?TeamMemberID=63">Scientific Advisor</a> to Boston Millenia Partners, a venture capital firm; a Founder and then <a href="http://www.nuvios.com/founders.htm">Scientific Advisor</a> to Nuvios, which now is known as <a href="http://radiuspharm.com/sab.htm">Radius Pharmaceuticals</a>;  an <a href="http://www.puretechventures.com/content/team.asp?mainPage=team&subPage=advisors">Advisor</a> to Puretech Ventures, which <a href="http://www.puretechventures.com/content/strategy.asp?mainPage=about&subPage=strategy">specializes</a>"in company creation and early-stage investment in novel therapeutics, medical devices, diagnostics, and research technologies"; and a <a href="http://www.shire.com/shire/CorporateInformation/directors.jsp?tn=1&m1=3">Director</a> of <a href="http://www.shire.com/shire/CorporateInformation/index.jsp?tn=1&m1=29">Shire</a>, "one of the world’s leading specialty biopharmaceutical companies." This is a reminder how fuzzy the line has become between medical academics and health care corporations.  Here is an example of someone who alternated his main employment between leadership posts in academic medicine and in the pharmaceutical industry, but while in academia maintained a string of part time commitments to a further variety of biotechnology and pharmaceutical companies, and related venture capital firms.  Given all these positions and financial relationships, who knows where his main allegiance was?  I would hope that the Dean of  a medical school would be the primary steward of the academic and clinical missions.  But what kind of stewardship can one expect from someone who came from one lucrative position in the pharmaceutical industry, and was to go back to an even higher level position, and who worked for several biotechnology/ pharmaceutical firms, and venture capital firms on the side? Hat-tip to <a href="http://shearlingsplowed.blogspot.com/2009/12/new-merck-names-new-chief-medical.html">Shearlings Got Plowed blog</a>.

The Door Revolves: Tufts Medical School Dean Goes Back to Merck

A little news item in the Newark Star-Ledger : Merck announced the appointment of Michael Rosenblatt as executive vice president and chief m...

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British Medical Journal Interviews Dr Aubrey Blumsohn

About a year after we started Health Care Renewal, in late 2005, we wrote multiple posts about the complex and unfortunate case of Dr Aubrey Blumsohn's attempts to keep a research project honest.  Our most recent summary of the case was <a href="http://hcrenewal.blogspot.com/2009/09/reappearance-of-ghost-of-seasons-past.html">here</a>.  The case involved suppression and manipulation of research, ghost-writing, institutional conflicts of interest, and attempts to silence a whistle blower. It provides lessons about the downsides of letting commercial firms sponsor and hence control human research designed to evaluate the products or services they sell; and of academic medicine becoming dependent on research money from such firms for such research. The case was just re-capped in some detail on the occaision of an interview of Dr Blumsohn published in the British Medical Journal, just available on-line yesterday.  [Cyer C. Aubrey Blumsohn: academic who took on industry.  Brit Med J 2009; 339:b5293.  Link <a href="http://www.bmj.com/cgi/content/full/339/dec15_1/b5293">here</a>.]  Dr Blumsohn's final words in the interview were: <blockquote>It’s hard to encourage anyone to speak out about poor practice in the current environment. This case sums up what has gone wrong with systems set in place to ensure safety and integrity in scientific medicine. It would help if regulators put as much effort into responding to serious critics and whistleblowers as they do producing glossy brochures and yet more guidance. </blockquote> My hat is off to Dr Blumsohn for his determination to pursue this case, and to the British Medical Journal for getting it into the "main-stream" health care literature. Hat-tip to <a href="http://pharmagossip.blogspot.com/2009/12/dr-aubrey-blumsohn-pharmagossips-person.html">PharmaGossip</a>.

British Medical Journal Interviews Dr Aubrey Blumsohn

About a year after we started Health Care Renewal, in late 2005, we wrote multiple posts about the complex and unfortunate case of Dr Aubrey...

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Web Petition: Transparency and Openness in Electronic Patient Records and Other Healthcare Information Technology Systems

I have created a new Web petition "Transparency and Openness in Electronic Patient Records and Other Healthcare Information Technology Systems." It is at WEBPETITIONS.COM at this link: <a href="http://www.webpetitions.com/cgi-bin/print_petition.cgi?99504454">http://www.webpetitions.com/cgi-bin/print_petition.cgi?99504454</a> Aimed at clinicians, hospital governance personnel and other healthcare stakeholders including patients, the petition states: <blockquote> We, the undersigned, believe in transparency, accuracy, and accountability in scientific research, especially in matters related to healthcare. We believe contractual nondisclosure clauses [1] that prohibit or restrain unfettered disclosure and dissemination of information about healthcare information technology problems related to bugs, design defects, suboptimal user interfaces, other factors that can adversely affect care, and the adverse events and near accidents these problems cause, are unethical. We believe that patients and clinicians have a right to knowledge of healthcare information technology problems and defects that can distract clinicians and/or reduce clinician effectiveness and productivity. We also believe that hospital governance personnel have the fiduciary responsibility as well as obligation under Joint Commission safety standards to protect patients, clinicians and others working within and for their organizations from the potential consequences of healthcare information technology problems [2]. We believe that only through transparency about healthcare information technology can medical ethics be maintained, the rights of patients to the best possible care be protected and medical science advanced. Therefore, we call for such clauses to be refused by governance bodies, vendors of healthcare information technology to refrain from including such clauses in their contracts, and the U.S. Congress to prohibit nondisclosure clauses related to medical devices and healthcare information technology. Furthermore, retaliatory actions against those who in good faith report such matters or incidents should be prohibited. [1] Koppel R, Kreda D. Health Care Information Technology Vendors' "Hold Harmless" Clause: Implications for Patients and Clinicians, JAMA. 2009;301(12):1276-1278. [2] Silverstein S. "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards." Letter to the Editor, JAMA. 2009; 302: 382.</blockquote> The signed petition will be sent to the U.S. Senate Finance Committee (currently investigating healthcare IT), the Secretary of HHS, the Director of AHRQ, the Director of the Office of the National Coordinator for Health IT, and the President of the Joint Commission. Please sign at the WEBPETITIONS.COM link <a href="http://www.webpetitions.com/cgi-bin/print_petition.cgi?99504454">http://www.webpetitions.com/cgi-bin/print_petition.cgi?99504454</a>, and spread the word. -- SS Addendum: as an example of the problems these nondisclosure clauses can create, see my post "<a href="http://hcrenewal.blogspot.com/2009/12/we-are-unable-to-share-documents.html">We are unable to share documents relating to problematic EHR's as our contract with Cerner includes a confidentiality clause</a>."

Web Petition: Transparency and Openness in Electronic Patient Records and Other Healthcare Information Technology Systems

I have created a new Web petition "Transparency and Openness in Electronic Patient Records and Other Healthcare Information Technology ...

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Tensions and Paradoxes in Electronic Patient Record Research: Critical Thinking on Health IT

In "<a href="http://hcrenewal.blogspot.com/2009/11/2009-pivotal-year-in-healthcare-it.html">2009 a Pivotal Year In Healthcare IT</a>" I wrote that: <blockquote>2009 is proving to be a pivotal year in healthcare IT. Recent authoritative articles and reports on health IT problems largely validate the issues presented at this blog and others focusing on health IT issues, and at my <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">academic website on HIT difficulties</a> started over a decade ago, in 1998, freely available to the industry.</blockquote> I then listed some of those articles and reports. 2009 is not over, however, and it has yielded another article, a systematic literature review and somewhat novel analytical approach, that supports the observations of numerous independent-minded investigators that health IT is very, very much harder than it looks, and that irrational exuberance unsupported by robust evidence (but perhaps -- in my own opinion -- supported by the color of money) is the prevalent health IT driver today. The new article is entitled "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method" by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London. The article appeared in the Dec. 2009 <a href="http://www.milbank.org/quarterly.html">Milbank Quarterly</a>, a multidisciplinary journal of population health and health policy published for over eighty years. The study was based on findings from hundreds of previous studies from all over the world. The article is summarized at the Oct. 14, 2009 Healthcare IT News item "<a href="http://www.healthcareitnews.com/news/electronic-health-records-not-panacea-researchers-say">Electronic health records not a panacea, researchers say</a>." The summary includes these key points: <blockquote><ul><li>Large-scale electronic health record projects promise much, but sometimes deliver little, according to a new study.</li><li>Researchers said their findings have implications for President Barack Obama’s election promise to establish electronic health records for every American by 2014, and for other large-scale EHR initiatives around the world.</li><li>EHRs are often depicted as the cornerstone of a modern healthcare, capable of making care better, safer and cheaper. Yet, clinicians and managers the world over struggle to implement EHRs.</li><li>outside the world of the carefully-controlled trial, between 50 and 80 per cent of electronic health record projects fail – and the larger the project, the more likely it is to fail."</li></ul></blockquote> I have reviewed the full article, available free as of this writing at <a href="http://eprints.ucl.ac.uk/18821/">this link</a> (PDF). I note the following. The authors observed that the HIT literature is heterogeneous and at times conflicting (e.g., about benefits, risks and implementation challenges of HIT), not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. The authors used a somewhat novel meta-narrative method of systematic review, and identified over 500 full-text sources. They used ‘conflicting’ findings to address higher-order questions about how the electronic patient record (EPR) and its implementation were differently conceptualized and studied by different communities of researchers. They noted a number of "tensions" in relation to and among: <ul><li>the EPR itself - is it a mere data container or a work-altering and defining ‘itinerary’?; the EPR user; the organizational context of the EPR (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); the process of change including the 'politics' that accompany IT-mediated change; and other factors. </li></ul> In other words (mine), health IT tools are virtual clinical tools for use in complex medical/social environments that happen to reside on a computer, not computer applications that happen to be used by clinicians. The authors found that (emphases mine): <blockquote>... while secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. </blockquote> They concluded that <blockquote>The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. </blockquote>The relevance of that statement towards national HIT initiatives cannot be understated. I am going to highlight some other key points in the paper: <blockquote>... We previously developed the meta-narrative method as a way of systematically making sense of complex, heterogeneous and conflicting bodies of literature (Greenhalgh, Robert, Macfarlane, Bate, and Kyriakidou 2004). We recommend that those unfamiliar with this approach access our methodological paper (Greenhalgh, Robert, Macfarlane, Bate, Kyriakidou, and Peacock 2005) ... ... The meta-narrative should be thought of not as the unified voice of a community of scholars but as the unfolding of what they are currently disagreeing on ... In a synthesis phase, we compared and contrasted the different meta-narratives and exposed tensions and paradoxes; and we sought explanations for these in terms of how researchers had conceptualized the world and chosen to explore it. [See full paper for further details -ed.] </blockquote> While some might consider such analytical methods "soft", unorthodox, and therefore not robust, I counter that traditional methods of analytics and validation in biomedicine right up to and including today's peer review, especially related to issues of power and profit, have come under suspicion of corporate <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulation</a> and other forms of taint. While the methodology will surely be subject to criticism and debate, which I will follow, I welcome possibly disruptively innovative methods that are probably clear of such pecuniary influences. <blockquote>We found a complex and heterogeneous literature characterized by diverse philosophical assumptions about the nature of reality (ontology), how that reality might be known (epistemology), and the preferred research approaches and study designs (methodology) ... Our exploratory reading identified a number of historical roots which informed later research on the EPR, including human-computer interaction (HCI), evidence-based medicine (EBM), symbolic interactionism and ethnomethodology, workplace redesign, safety-critical systems research, the social practice view of knowledge, complexity theory, and science and technology studies (previously known as philosophy of science). </blockquote> This only underscores the true complexity at the intersection of IT and medicine, a complexity I've repeatedly written has been glossed over by (and indeed, due to often narrow and limited backgrounds, may not be comprehensible to) HIT industry pundits and operatives. <blockquote>... The data suggested a significant difference in the likelihood of success between local ‘home grown’ EPR systems (developed in an ad hoc way by clinicians close to the operational detail of key work practices [such as in <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">this personal example</a> I often cite- ed.]), and ‘off the shelf’ systems (developed either as commercial products or as public-sector systems of choice). </blockquote> In other words, local projects led by experts were far more likely to provide major benefits than the extant commercial and industrial models of "shrink wrapped" (and massively expensive) HIT. <blockquote>Studies consistently showed that introducing the EPR in an organization or across organizations is a complex task. It requires a well-articulated vision and strategy, strong leadership, adequate resources, good project management, an enabling organizational culture, effective communication, and attention to human resource issues [e.g., appropriate talent management and organizational structures - ed.]. Even when these preconditions were present, success was not guaranteed... </blockquote>In other words, hospitals, being generally in strained economic conditions and generally being an IT backwaters are highly risky environments for implementing health IT, which are still largely experimental technologies to start with. <blockquote> Information systems (IS) research is a heterogeneous tradition that emerged in business schools to consider the role of technology in business and management ... But very few such studies have been published on the EPR, perhaps because of the complexity and unpredictability of healthcare work and the highly institutionalized nature of the healthcare sector ... We found only three empirical studies ... all of which demonstrated that model-based analyses of the determinants of EPR success left much of the observed variance unexplained.</blockquote> In other words, as much is unknown about "doing HIT right" as is known and further cross disciplinary research is urgently needed. <blockquote> ...there are multiple and conflicting framings of the EPR by users (assumptions about it, expectations of it, versions of the problem to which it is seen as a solution), some of which are explained by deeply-held institutional values (e.g. what counts as ‘professionalism’ amongst doctors or what is seen as ‘good nursing care’); these contrasts partly explain the low adoption and slow spread of the EPR in many healthcare settings.</blockquote> In other words, HIT is primarily about people, not technology and grandiose promises of cybernetic miracles. <blockquote>... individuals, working collectively around common tasks in organizations, actively and explicitly shape both technologies and work routines in a way that is mutually adaptive ... It would appear that in relation to the EPR, this adaptation is not happening – or at least, not happening smoothly or unproblematically ... healthcare work is uniquely complex and dependent on the coordinated practice of multiple actors. Research to date has barely scratched the surface of what the introduction of the EPR means, at the level of fine-grained detail, for a healthcare organization and the staff and patients who practice and interact in that setting – and still less so when the EPR is part of a large-scale regional or national program.</blockquote> In other words, HIT is still largely a social experiment, and we as a society really don't know what we're doing or what the outcomes are likely to be. It raises the issue of slowing down the current locomotive of national HIT diffusion in five years. <blockquote>In ‘failed’ EPR projects, technical designers typically missed these subtleties and produced artefacts that fitted poorly with the situated nature of knowledge and the micro-detail of clinical work practices. Paper records, being flexible, portable and tolerant of ambiguity, support the complex work of clinical practice remarkably well. CSCW [computer supported cooperative work - ed.] studies have highlighted a telling paradox – that high-tech healthcare environments such as intensive care units often make extensive use of paper charts, white boards, sticky notes, and oral communication.</blockquote> In other words, paper has its place in healthcare, always will, and promises of "the paperless hospital" or office are utopian and not pratical. <blockquote> ... technologies reflect the interests and values of those who produce them, hence power struggles between bosses and workers, clinicians and managers, men and women, and the state and the citizen are played out partly through the design and use (or, indeed, non-use) of technology (Zuboff 1988). The EPR may be a focal point around which disputes of professional jurisdiction are fought.</blockquote> In other words, HIT projects are intensely political, especially with regard to medical affairs. (IMO management information systems IT personnel are far out of their league in attempting to lead such projects.) The synthesis in part concludes: <blockquote>Much of the literature covered in this review suggests, conversely, that (a) the EPR may be alternatively conceptualized as an ‘itinerary’, ‘organizer’ or ‘actor’ [in the latter concepts HIT is a medical device -- that should probably be regulated -- not a simple passive tool - ed.]; (b) seamless integration between different EPR systems is unlikely ever to happen because human work will always be needed to bridge the model-reality gap and re-contextualize knowledge for different uses [so much for dreams of 100% interoperability - ed.]; (c) whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work is often made less efficient; (d) the EPR may support, but it will not drive, changes in the social order of the workplace; (e) paper will not necessarily disappear as it offers a unique level of ecological flexibility (though workable paperless systems have been developed in one or two centres); and (f) smaller, more local EPR systems may often (though perhaps not always) be more efficient and effective than larger ones.</blockquote> Each item on this list contradicts nearly every precept of the national HIT initiative now underway in this country, at the expense of tens of billions of dollars. Two of the recommendations made by the authors are of special note: <blockquote>... as a cross-cutting theme in all the above areas, the realpolitik of EPR projects within and between organizations and interest groups should be more explicitly explored ... Orlikowski and Yates have called for more research on the “messy, dynamic, contested, contingent, negotiated, improvised, heterogeneous, and multi-level character of ICTs in organizations” (page 132) (Orlikowski and Yates 2006). We suggest that sponsors and publishers eschew sanitized accounts of successful projects and instead invite studies of the EPR in organizations that “tell it like it is” – perhaps using the critical fiction technique to ensure anonymity (Winter 1986).</blockquote> This recommendation is particularly intriguing to me. I am perhaps one of the few people in the HIT world to have undertaken that approach in the de-identified "tell it like it is" cases at my Drexel U. website "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">Common Examples of Health IT Failure</a>" begun over ten years ago. (I've made the lead author aware of the site and of the new multi author book "<a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=hitormiss">HIT or Miss: Lessons Learned from Failed HIT Implementations</a>" that takes the same approach, to her approval.) <blockquote>... Finally, given the mismatch between what is known about the EPR in organizations and what many policymakers assume is known, there is also scope for research that addresses this mismatch ... The role of the systematic reviewer in this process is itself worth studying, since very little research on knowledge translation to date has addressed such turbulent waters.</blockquote> Yet, our government (and that of the UK as well) feel confident that HIT is such a perfected technology, investment of tens of billions of dollars on a frenetic timeframe will create massive quality improvements and cost savings. This is perhaps the height of magical thinking and political hubris. Finally, the authors identify what does NOT need be done: <blockquote> This review has also identified some areas where more research does not appear to be needed ... [including] simplified experimental studies based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y?” or variations thereof ... the circumstances in which they add value are more limited than is often assumed. We [also] believe that surveys of attitudes of patients or staff towards ‘the EPR’ or ‘computerization’ which are not adequately contextualized have almost no enduring value.</blockquote> I note that these are the types of studies that seem to commonly appear in the soft "throwaway" literature aimed at the hospital governance board, CIO and IT worker. In conclusion, I believe this literature review supports the notion expressed in other studies and opinion pieces here and elsewhere that we really need to SLOW DOWN the current HIT stampede, largely promoted by the HIT industry lobby. We need to take the appropriate time to better understand how to "do HIT well" before plunging in as if we actually know what we're doing. In the authors' own words: <blockquote style="FONT-WEIGHT: bold">"It is time for researchers and policymakers to move beyond simplistic, technology-push models [for HIT] and consider how to capture the messiness and unpredictability of the real world."</blockquote> Indeed. They report, you decide. -- SS Addendum: this paper led me to the massive, near-600 page report "The Impact of eHealth on the Quality & Safety of Healthcare", A Report for the NHS Connecting for Health Evaluation Programme, Car et al., Imperial College, London, March 2008. This report was unknown to me but also validates much of the work of those studying the problems, risks and downsides of HIT. I will post on the report in the near future. It is available (warning - 7 Mb PDF) <a href="http://www.haps.bham.ac.uk/publichealth/cfhep/documents/NHS_CFHEP_001_Final_Report.pdf">here</a>. The executive summary is quite informative.

Tensions and Paradoxes in Electronic Patient Record Research: Critical Thinking on Health IT

In " 2009 a Pivotal Year In Healthcare IT " I wrote that: 2009 is proving to be a pivotal year in healthcare IT. Recent authorita...

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The $9.8 Million Dollar Man

We seem to have a new candidate for the award for best-paid CEO of a not-for-profit academic medical center, as <a href="http://www.nypost.com/p/news/local/sickening_bonuses_8pL0AI56MMF7wcPa3ibFDM">reported in the New York Post</a>, <blockquote>Wall Streeters aren't the only ones raking in big bonuses during tough economic times. Hospital presidents and CEOs also collect fat bonuses and 'incentive payments,' even as health-care systems cry poverty, claiming they struggle to break even against government cutbacks, tightwad insurers and skyrocketing costs. While warning of layoffs and slashed patient services, many hospitals shower their top execs and department heads with bonuses and perks. They include housing allowances, chauffeurs, first-class air travel, tuition for their kids and country-club memberships. Under new IRS rules, the extras are disclosed for the first time in recently filed 2008 tax records obtained by The Post. The filings for the city's biggest and most prestigious private, tax-exempt hospitals show at least a dozen CEOs get compensation of $1 million and up. Some also cash in early on million-dollar pre-retirement payouts while on the job. Dr. Herbert Pardes, who runs the New York-Presbyterian Hospital and its health-care system -- the city's largest private hospital network -- received a $1 million bonus in 2008 on top of his $1.67 million salary. The hospital has a 'pay for performance' philosophy but says even though Pardes met his goals, his bonus was smaller than 2007's to 'reflect the current external environment.' But Pardes' compensation totaled $9.8 million in 2008 because he vested in a retirement plan that will pay $6.8 million when he leaves in 2011. He also received a $93,500 housing allowance and the use of a car and driver. </blockquote> The Post article also listed two other hospital CEOs who got over $4.5 million in compensation, and several other top executives at other hospitals who got substantial compensation despite the hospitals' financial distress or accusations of unethical behavior.  On the other hand, the CEO of the city's Health and Hospital Corporation, with a budget of $6.3 million, got only $291,000. Note that Dr Pardes' total compensation was more than double the compensation for a Boston medical center CEO that I <a href="http://hcrenewal.blogspot.com/2009/09/safety-net-medical-center-ceo-gets.html">thought</a> was so outlandish back in September, 2009. So here is much more evidence about the continually inflating health care bubble.  Not only do executives of big, for-profit drug, device, biotechnology and health insurance companies make seven and eight figure salaries, now it appears executives of ostensibly not-for-profit, charitable organizations can also make this much.  Is it possible that at least Dr Pardes' compensation was a fluke, related to a one-time retirement payment? The answer appears to be negative.  The New York - Presbyterian Hospital's 2007 US Internal Revenue Service (IRS)<a href="http://www.guidestar.org/FinDocuments/2007/133/957/2007-133957095-04a99802-9.pdf"> form 990</a>, which was organized somewhat differently and may have used somewhat different definitions than the 2008 form from which the Post reporters apprently got their information, showed Dr Pardes total compensation to be $4,736,824 plus a $1,433,761 contribution to employee benefit plans and deferred retirement plans in that year. In addition, in 2007, (apparently former) executive Vice President Michael A Berman, MD received $5,949,092 in compensation plus $31,830, current Executive Vice President and Chief Operating Officer Steven J Corwin MD received $2,671,747 plus $455,304, Senior Vice President and Chief Financial Officer and Treasurer Phillis RF Lantos received $2,481,044 plus $336,284, Senior Vice President and Chief Operating Officer Robert Kelly received $1,538,412 plus $271,641, Senior Vice President and Chief Operating Officer Cynthia N Sparer received $1,370,541 plus $307,259, Senior Vice President and Senior Legal Officer Maxine Fass Esq received $1,337,354 plus $257.06, Senior Vice President, Finance Dov Schwartzben received $1,314,960 plus $173,848, Senior Vice President and Chief Nursing Officer Wilhelmina Manzano received $1,218,966 plus $159,555.  In summary, in 2007, the medical center paid at least 10 current and former executives each substantially more than $1 million a year. By my calculations, the medical center paid these ten executives over $26 million a year, approximately equal to 25% of the center's fund excess (e.g., profit equivalent), of slightly over$106 million.  These ten executives received nearly 1% of the entire 16,850 employee institution's budget.  Furthermore, note that in the medical center's 2007 expense statement, general and administrative expenses, over $675 million, made up about 24% of the center's total expenses.  So it appears that gigantic compensation for New York - Presbyterian Hospital executives, which is outsize both in comparison to the Hospital's fund excess and total budget, is part of a long-term trend The Post quoted Brian Conway of the Greater New York Hospital Association with this excuse: <blockquote>There are thousands of 20-somethings on Wall Street making millions who don't have anywhere near the responsibilities or skills of New York hospital CEOs. </blockquote> This fits in our catalog of logical fallacies.  It is an <a href="http://www.nizkor.org/features/fallacies/appeal-to-common-practice.html">appeal to common practice</a>.  Of course, the particular practice to which Mr Conway appealed is the exaggerated executive compensation in finance that many believe was a cause of the global financial melt-down, aka great recession.  One could also argue that not one Wall Street executive has the life and death responsibilities of the typical practicing primary care physician.  I doubt Mr Conway would try to argue that Dr Pardes' job requires 40 times the skill of full-time practicing primary care or cognitive physician. Instead, executive compensation for hospital CEOs seems best described <a href="http://hcrenewal.blogspot.com/2009/12/compensation-madness-insiders-hijacking.html">as Prof Mintzberg described</a> compensation for finance CEOs, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit."  As it did in finance, compensation madness is likely to keep the health care bubble inflating until it bursts, with the expected adverse consequences.  Meanwhile, I say again, if health care reformers really care about improving access and controlling costs, they will have to have the courage to confront the powerful and self-interested leaders who benefit so well from their previously mission-driven organizations.

The $9.8 Million Dollar Man

We seem to have a new candidate for the award for best-paid CEO of a not-for-profit academic medical center, as reported in the New York Pos...

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"Person No. 7," Also Known as the 83rd Richest Man in the World

This one nearly snuck by.  A Settlement and Some Indictments In May, 2009, we <a href="http://hcrenewal.blogspot.com/2009/05/synthes-settles-agrees-to-stop-giving.html">posted</a> that international Swiss-based medical device manufacturer <a href="http://www.synthes.com/html/">Synthes</a> settled charges that it was paying surgeons who conducted clinical trials for the company with company stock, and in June, 2009, we <a href="http://hcrenewal.blogspot.com/2009/06/synthes-indicted.html">posted</a> that Synthes was indicted based on allegations that it had subjected patients to an experimental use of its Norian XR bone cement product on the spinal cord, a use not approved by the US Food and Drug Administration, and that its executives had lied to the FDA about these actions.  It was noteworthy that the indictment named but did not charge the then CEO of the company as "Person No. 7" who allegedly decided not to conduct clinical trials of Norian XR, but rather to have surgeons use it in a case series that was not identified as clinical research.  The company CEO at that time was a Mr Hansjorg Wyss, who is still chairman of the Synthes board, owner of 40% of Synthes stock, and the richest man in the Philadelphia area, worth $5.7 billion according to Forbes magazine, making him the 83rd richest man in the world in 2009, <a href="http://www.forbes.com/lists/2009/10/billionaires-2009-richest-people_Hansjorg-Wyss_QXWP.html">according to Forbes magazine</a>. Four Guilty Pleas Here is what first escaped my attention.  In July, 2009, <a href="http://www.philly.com/inquirer/local/pa/20090721_Synthes_execs_plead_guilty_to_improper_testing.html">the Philadelphia Inquirer reported</a>: <blockquote>Two senior executives of a West Chester-based manufacturer of medical devices pleaded guilty yesterday in connection with illegal clinical trials of a bone cement on about 200 patients, three of whom died. The company, Synthes USA Inc., did not tell the patients that they were participating in what amounted to human experimentation, according to a 97-count indictment filed June 16 by the U.S. Attorney's Office in Philadelphia. Michael D. Huggins, 51, of West Chester, was president and chief operating officer of Synthes' spine division from late 1994 to January 2008. John J. Walsh, 46, of Coatesville, has served as director of regulatory and clinical affairs in the same division since August 2003. Before U.S. District Judge Laurence F. Stengel, each pleaded guilty to a single misdemeanor count of introducing adulterated medical devices into interstate commerce. They face $100,000 fines and a year in prison when they are sentenced Oct. 22. </blockquote>Then, in August, 2009, <a href="http://www.bloomberg.com/apps/news?pid=20601127&sid=a6VrPUsGdkAo#">Bloomberg reported</a>: <blockquote>Synthes Inc. official Richard Bohner pleaded guilty in Philadelphia to charges tied to illegal clinical trials of a bone cement that led to three deaths. Bohner, Synthes’ vice president of operations, is the last of four executives to plead guilty to shipping misbranded Norian XR across state lines. He faces as long as one year in prison plus a $100,000 fine, according to documents made public today in federal court in Philadelphia. Bohner and the other executives, Michael Huggins, John Walsh and Thomas Higgins, promoted the drug through the use of test markets aimed at persuading surgeons to publish the results of their surgeries, according to court documents. Huggins and Walsh, who pleaded guilty July 20, will be sentenced on Oct. 22. </blockquote> So that is four individual guilty pleas so far in this case. The pleas received only scant attention in the local media, and hence slipped by the technology I was using to scan the media at the time. The Richest Man in Philadelphia I got caught up when on 6 December, 2009, the Philadelphia Inquirer published a <a href="http://www.philly.com/philly/business/78620602.html">summary article</a> focused on the "Person No. 7": <blockquote>Wyss also is chairman of Synthes in West Chester, which faces 52 felony counts stemming from allegations that it illegally experimented on patients, three of whom died. Synthes is fighting the charges, and a trial could be held next year. Four of its executives already have pleaded guilty to misdemeanor counts in the case and face sentencing hearings in January. Federal prosecutors in Philadelphia did not name or charge Wyss, but their June indictment describes a "Person No. 7," who was a major shareholder and chief executive officer of the company when the alleged illegal conduct occurred, from 2001 through 2004. A Synthes representative confirmed that Wyss was CEO then. In 2001, the U.S. attorney's indictment says, Person No. 7 decided the company should not pursue the costly and time-consuming clinical trials that the U.S. Food and Drug Administration demanded for the company's bone-cement product, Norian. Instead, according to the indictment, Person No. 7 directed the company to 'get a few sites to perform 60 to 80 procedures and help them publish their clinical results' to help popularize Norian for a use not approved by the FDA. The procedures involved injecting Norian into the spines of patients who had vertebral compression fractures, which are typically caused by osteoporosis. FDA officials had previously approved Norian for other uses, but they demanded trials for that type of surgery, fearing that the cement could perform differently in the spine. Even after tests in pigs showed that Norian could leak from the spine and cause life-threatening blood clots, Synthes continued with surgeries on human patients, who were never told that the procedure was experimental. Three of those patients died, but prosecutors do not know whether Norian played any role in their deaths, because the company and doctors did not immediately report all the fatalities to the FDA. The patients have not been identified. Through a Synthes representative, Wyss initially agreed to be interviewed for this article, but later declined. </blockquote> The Inquirer article seemed to try to balance the allegations about Wyss with his wealth and philanthropy: <blockquote>Wyss grew up in Bern, Switzerland. His father sold mechanical calculators and liked to discuss world events, according to Harvard's Web site. Wyss trained as an engineer in Switzerland and soon began setting up Chrysler manufacturing plants worldwide. In 1965, he earned a master's degree at Harvard's business school. 'I didn't speak in class for the first five weeks,' he told a Harvard Web publication at the time of his gift. 'My classmates were all the crème de la crème, with button-down shirts I had never seen before.' He worked for several large companies, but sold airplanes on the side. One of his buyers was a Swiss surgeon who founded Synthes. That connection eventually led Wyss to become president of the company's U.S. business in 1977. Over time, he became a large shareholder and chief executive. He retired from that post in 2007, but he remains chairman. Forbes Magazine in March estimated Wyss was worth $5.7 billion. His fortune has helped him pursue whatever he wants, including the rehabilitation of the Crooked Tree Golf Course in Tucson, Ariz., and the purchase of the 900-acre Halter Ranch & Vineyard in Paso Robles, Calif. The winery emphasizes organic growing methods and sells many wines, including one named Synthesis. Wyss has given away large chunks of his fortune, mostly to organizations dedicated to his primary passions: science and the environment. His $125 million donation to Harvard funded the Wyss Institute for Biologically Inspired Engineering.... Wyss also established two private foundations. The Wyss Foundation is dedicated to preserving land in the American West. Wyss went hiking there as a student and fell in love, according to Forbes. The Wyss Foundation gave away about $13 million and had about $250 million in assets in 2007, according to tax filings. Wyss also donates heavily from his personal funds. BusinessWeek estimated his total giving from all sources at $277 million from 2004 through 2008. </blockquote> However, some of Wyss' philanthropy seems more designed to benefit his company: <blockquote>Wyss' other foundation, the Hansjörg Wyss Foundation, had about $172 million in assets and gave away $4.9 million in 2007. It focuses mostly on education and training of surgeons, according to the AO Foundation, a Swiss research group with ties to Synthes and Wyss. By funding research and training, Synthes has forged tight relationships with surgeons. The U.S. Attorney's Office alleges that the company paid for trips to educational seminars in San Diego and Charlotte, N.C., where surgeons learned to use Norian in the spine. </blockquote>Marketing Over Research This emphasis on education that actually seems to partake of company marketing is also displayed by Synthes itself.  Per the company's <a href="http://www.synthes.com/html/uploads/media/E_Annual_Report_08.pdf">2008 Annual Report</a>, the company runs a "residency program," <blockquote>The Synthes Resident Program was originally released in the United States in 2007 by Synthes Trauma. It was first developed to train orthopaedic trauma surgical residents and consists of both online training modules and locally offered workshops. In 2008, the Synthes Resident Program was expanded to a selection of European countries with modifications for the needs of specific areas and markets. Furthermore it is now also being offered by Synthes Spine and Synthes CM. </blockquote>This program has achieved remarkable popularity, or should we say "market penetrance?" <blockquote>The Synthes Resident Program has been well accepted in the U.S., with more than 90% of all U.S. orthopedic residents having utilized the program. </blockquote>The company also offers an "Enhanced Surgeon Education Program," and support's the AO Foundation's educational activities. On the other hand, the financial summary provided in the report suggests that research is not what the company emphasizes.  Its 2008 operating expenses included $943.3 million in sales and promotion, $349.4 million in general and administrative, and only $169.9 million in research and development, only 11.6% of total operating expenses. And if you like the report's verbiage about education, you will also appreciate its full page section on "Integrity," which includes the header: <blockquote>Corporate Citizenship. Acting with Integrity. Acting ethically and respectfully is a cornerstone of our business. At Synthes we are committed to responding to the challenges in our business by operating in accordance with the highest levels of professional and ethical standards in our industry. Simply put, we must always act with integrity. </blockquote>It also boasts: <blockquote>Our commitment to abide by the rules and regulations applies throughout Synthes, to all countries and to all employees, and to all our business partners. Acting ethically is highly important for Synthes. Our actions create our reputation. Our good reputation is an integral part of our Synthes brand, and an essential element of our continued success. </blockquote> And finally asserts: <blockquote>Our effort to operate with the utmost integrity begins with the commitment of our Board of Directors and senior managers. [italics added for emphasis]  Our managers are role models for our employees, and lead our efforts to build and to promote a culture that encourages positive ethical conduct and that demonstrates commitment to compliance with the law. </blockquote> Those four now admitted guilty top executives certainly were excellent role models. Even better was "Person No. 7," the current board chairman and former CEO. Summary So here we have all the elements: guilty pleas by top executives in connection with a human experiment whose nature was concealed from patients; allegations about but no charges against a fabulously wealthy company leader; a company that promotes what appears to be marketing in the guise of education; a tremendously profitable company which spends most of its money on marketing, not research; a company that boasts of its integrity and how its leaders are "role models," even as some have pleaded guilty to crimes; and despite the worldwide reach of the company and its products, no national coverage of any of this, the <a href="http://hcrenewal.blogspot.com/2007/08/bling-bling-poltical-correctness-and.html">anechoic effect</a> redux. We have, not only in the US, but in other developed countries (for example, Switzerland, in which Synthes is based), and globally, health care based on marketing and hype, on deception and conflicts of interest, and on making a few privileged insiders fabulously wealthy.  Here is the essence of our health care dysfunction, and the inflating health care bubble.  When would be health care reformer stop arguing about insurance coverage, perhapds they can then pay some attention to these major reasons why health care is so expensive, inaccessible, and often does so little good for patients.  PS - Earlier this year, we <a href="http://hcrenewal.blogspot.com/2009/10/board-of-trustees-or-social-club-for.html">commented</a> on the make-up of the Board of Trustees of the prestigious Hospital for Special Surgery in New York, which seemed split mainly among leaders of finance, including such troubled corporations that contributed to the global financial meltdown as Bank of America, AIG, Citigroup, and Wachovia, and orthopedic surgeons with ties to device makers.  One of the latter was Dr David Helfet, who listed his memberships on advisory boards for OHK Medical Devices Inc, Healthpoint Capital, and Orthobond Corp.  Just to add to the whiffs of lack of full disclosure surrounding this case, Dr Helfet still does not disclose <a href="http://www.hss.edu/physicians_helfet-david.asp">on the hospital web-site</a> that he is on the <a href="http://www.synthes.com/html/Board-of-Directors.7331.0.html?&L=1%25">Board of Directors of Synthes</a>. Note (added 14 December, 2009) - Per comment below, the Vice President of Corporate Compliance and Internal Audit at the Hospital for Special Surgery claimed that an administrative error, not failure of disclosure by Dr Helfet, lead to the omission of the information about his membership on the Synthes board from the Hospital's web-site.

"Person No. 7," Also Known as the 83rd Richest Man in the World

This one nearly snuck by. A Settlement and Some Indictments In May, 2009, we posted that international Swiss-based medical device manufact...

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