NZ Hospital cannot guarantee patient safety because of IT failure

This story has caused a stir in the New Zealand press: bad health IT creates mayhem.

I fear such events are far more common in healthcare than we know, publicity only occurring when someone goes to the press (often at risk to their career, unfortunately).

It appears this hospital went out of its way to violate just about every concept presented in the biomedical informatics literature about the potential risks of clinical IT when developed and managed by non-clinicians.

Bad health informatics can kill, but doctors shouldn't worry about it. As in my posts here and here, doctors can't understand IT because they're too consumed with patient care issues, the rate of change of IT is too fast for their limited minds, and a degree doesn't get you anything, anyway. The IT leaders from the School of Hard Knocks will make it all better, real soon now.

Greymouth hospital not safe: senior doctor

The Ministry of Health is to investigate claims from a senior doctor that Grey Base Hospital cannot guarantee patient safety because of a systems failure.

Dr Judy Forbes, joint head of the anaesthetics department, wrote to the West Coast District Health Board with her concerns about a month ago, and addressed the board in person for three minutes at its last meeting.

A copy of a letter written after that meeting has been leaked, and another Grey hospital doctor says it is "entirely factual".

Dr Forbes' letter makes a number of allegations, and raises concerns about the "endless stream" of locums.

Most concerns relate to a new computer system which was brought in around Easter. The theatre booking system has been moved away from surgeons and replaced by a central booking office at the hospital reception, managed by IT (information technology) staff. [That'll show those pesky surgeons who's best suited for HIT leadership! - ed.]

Dr Forbes said some patients had been put on the surgery list for the wrong procedure with the wrong anaesthetic.

Other allegations included patients receiving appointment letters the day after their appointment, a knee replacement patient receiving a letter for a dental procedure, a patient on the list for a two-hour procedure having it done in another hospital six weeks earlier under contract with the West Coast board and a patient given the wrong medical advice by IT staff to stop medications without clinical consultations.

In another alleged incident, an elderly woman admitted for an incarcerated hernia was sent home for a day or two, awaiting equipment from Christchurch. She contacted the booking office a month later as she still didn't have an appointment.

Dr Forbes, who has worked at Grey Base Hospital for 15 years, said most of her time recently was spent "fighting fires".

"In addition to working with an endless stream of locums, surgeons and anaesthetists with unknown skill and experience, I am often the only New Zealand-qualified doctor involved in the patients' care and thus responsible for the outcome."

She also alleged patients were often seen by the surgeon for the first time in the anaesthetic room.

Dr Forbes told the board the hospital didn't meet the Health and Disabilities Service consumers rights code.

Fellow Greymouth anaesthetist Dr Susie Newton said today the letter was "entirely factual".

To which I can add, I wouldn't have entirely believed it were it not for the fact that I've seen even worse endangerment of patients by bad health IT with my own eyes.

-- SS

Physician Stereotypes and the Failure of Health IT

As a result of my posting "Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare IT", a discussion has started on the HISTalk blog. That discussion thread can be seen in the comments section here.

This posting from a PhD raised my eyebrows (emphases mine):

I have seen many people get hired into IT with degrees in everything from Zoology (really) to other non related fields. Their degree offers no value to the position or the job at hand. I think a physician is no more qualified to run IT than a CIO is qualified to perform brain surgery. I believe in a good mix of clinicians and technical experts makes the best combination on implementation teams. However, running an IT department is completely different than running a medical practice. Physicians who believe they can lead IT in healthcare are as misguided as CIOs who think they can design the perfect EMR. PS - I am a PhD in Information Science and do not presume to cross the line into medical practice.

"Physicians who believe they can lead IT in healthcare are as misguided as CIOs who think they can design the perfect EMR?"

That non-physicians cannot practice medicine (i.e., "CIO's not qualified to perform brain surgery") is axiomatic and irrelevant to the argument. However, to say a physician cannot practice something outside of medicine is a non sequitur (at best).

Has the writer spoken to each and every physician, once-physician, retired physician, physician informaticist, physician MBA, and every other physician on the planet, I ask part tongue in cheek and part dead seriously?

The CIO with medical credentials is as rare as hen's teeth, but as I have pointed out in the past, this is not a symmetrical affair. This is especially true in the culture of medicine, where when the opportunity arises, physicians seek additional education (e.g., in healthcare informatics).

What has led to such stereotypical thinking in our society where physicians are concerned? I find the phenomenon alarming, for I encounter it at least as frequently (if not more) than I did when I wrote this piece - a decade ago! - on stereotypes about physicians and IT.

Importantly, I believe this and related stereotypes about physicians are a driver and an enabler (either through genuine belief or through disingenuous opportunism) of much that ails medicine today through the interference of non-medical outsiders. The fundamental message is that physicians are children who cannot do anything more than medicine, and require "a village" of paternalistic non-medical outsiders to manage their affairs.

My response was as follows. I decided to offer specifics, although it is hard to reason people out of a position they arrived at irrationally:

It appears you just stereotyped physicians, who often have significant predoctoral and other experiences beyond medicine, especially those who’ve pursued graduate and postdoctoral training in informatics.

It it in part through such stereotyping, resulting in the exclusion or marginalization of needed cross-disciplinary domain expertise, that health IT runs into expensive, unnecessary difficulty, or fails.

However, you have not stereotyped CIO’s regarding inability to perform neurosurgery, unless that CIO has an MD and training and boards in neurosurgery.

I am a physician, practiced internal and occupational medicine, so I would appear to fall under your statement. My minor in college was computing, right up to IBM 370 assembler, and I began computing years before college via unfettered access to a DEC PDP-8 and via a Heathkit H-8 I built in medical school for clinical-related experiments, 1978. Also built an infrared-sensing heart monitor in my elective in biomedical engineering at BU School of Medicine.

That background is not entirely atypical for those in medicine who are interested in IT.

Please evaluate my other background items in my online bio, for example, and then tell me why doctors are “unqualified to run IT.” As an information scientist, it should be easy for you to locate that bio.

I await a response.

-- SS

Addendum - I received this response (the person's email address field indicating they are a fellow of HIMSS, the organization that certifies people as "Professionals in Healthcare Information and Management Systems" after a 100-question multiple choice exam):

Understand your comments. I meant to imply, but failed to say, physicians without IT training or CIOs without medical training.

Sorry for the confusion.

Here is a provocative question: was that a genuine clarification, or one done under duress of being challenged? (I believe my points -- in all of my writings including the ones that led to the HISTalk thread -- about the type of physicians best for HIT leadership roles have been extremely clear.)

I will, of course, assume the former as the motivation for the clarification. I replied,

You might add that in a follow up comment.

The problem has become one of stereotypes that are then used (either through genuine belief or disingenuous opportunism) for purposes that serve no one, including patients!

And in fact, the clarification was indeed soon added as a follow up comment by the poster.

-- SS

Addendum: another post appeared, anonymously, focusing on straw arguments, an apparent belief in some sort of symmetry between IT and medical education, a belief that "changes" in IT (largely new programming languages and faster networking and other toys that can be mastered by those already fluent in IT in a short time) outpace those in medicine, that the "hire to the month's technology version du jour" strategy is alive and well in IT, etc. There is real evidence that the cultural divide between IT and the community it purportedly serves - medicine - will not be bridged anytime soon:

From "Preston":

This was a very thought provoking post. After I cooled down a bit I could certainly appreciate your views as true taken from a certain perspective.

Let’s shift that perspective a bit. Consider the nature of the two disciplines with regard to formal education. As a field of study, medical practitioners have the advantage of hundreds of years of collegiate tradition and lexicon with some fundamental concepts so well ingrained into the profession that most TV viewers can rattle them off with ease…breakdowns of anatomy, diagnoses, methodologies, pedagogical structures like “rounds” etc…all substantially similar over decades or hundreds of years.

A key difference in the IT realm is the shear pace of change within the mind-space. Obviously, technological advances in medicine cause rapid change, but I would suggest to you that the speed and scope of changes in IT far outpace and outreach those in medicine.

[Changes in IT are evolutionary - scope and speed, mainly - and in fact from the perspective of EMR's is glacially slow. It's been advances in biomedical informatics that have been revolutionary towards creating effective (potentially) clinical IT. In the realm of awareness of sociotechnical (social, organizational, "people") issues in IT projects, the pace of change in IT can perhaps be measured, but the progress would measured in microns - ed.]

Here is a hypothetical example: A computer scientist who achieved doctoral-level credentials at a college in the late 1970s would have worked primarily in an environment of mainframe computing, focused on centralized data processing using procedural programming languages or machine-level code.

Jump forward to 2008 and the credential that that computer scientist received would provide little practical knowledge pertinent to the implementation of small-scale distributed (or web-based) applications using modular or service-oriented concepts...

[that is, assuming they were Americans, were asleep against a tree like Rip Van Winkle, and had a learning disability keeping them at their 1970s level of knowledge, therefore requiring the hiring of foreign nationals - ed.]

... I would further suggest that the limited value of formal education that we often purport is due to the fluidity of change in the area of concern.

["limited value of formal education"- "a degree doesn't get you anything"- how different this ideology is compared to medicine - ed.]

My IT training was accomplished through self-study. I have a music education degree and a Master of Healthcare Administration and I serve as an IT director for a health plan. I also have a professional certification in information security and I will no-doubt continue to seek further education as I go. However, consider this: My education included an alphabet soup of languages/skills that I don’t use anymore in my daily work. You are going to have a hard time convincing dedicated IT professionals that their lack of a rigid educational achievement indicates that they are not viable contributors because the pace of change thwarts all such efforts.

[A classic strawman argument. My point is that a lack of biomedical education and experience put IT personnel outside their core competencies in healthcare IT leadership roles, not that they are "not viable contributors" to health IT because they lack "rigid educational achievement" (whatever 'rigid' means) - ed.]

I value the input of my medical staff and our business directors for the value that they bring (oddly enough, it hadn’t occurred to me to question or even examine their credentials) and I hope that they judge my value primarily on the basis of their interactions with me and the results that we achieve together.

I value "my" medical staff? For the "value they bring" -- in a healthcare setting, no less? Those phrases alone are revealing about the paternalistic and patronizing attitudes at the heart of the IT-medicine cultural divide.

Such ossified views are also characteristic of what I've described as a power inversion in healthcare such that control by its enablers (clinicians) has been usurped by its facilitators (non-clinicians such as IT personnel) to the point that the latter feel they are absolutely entitled to the leadership role.

In effect, the worst aspects of the IT culture are being inflicted upon the medical profession, and due to their relatively good nature and political naiveté, medical professionals are sitting ducks.

This really must change.

-- SS

A Hospital CEO Censors the Internet, Only to See "the Handwriting on the Medical Chart"

The Fort Worth (Texas) Star-Telegram just ran a six-part series about the misfortunes of the JPS Health Network, a large county hospital network and health care system. The story had several twists. (See this page for links to the latter part of the series and related articles. The first three parts are here, here and here. )

The series emphasized the overcrowding and long waits, problems with equipment and the physical plant, and jaded, demoralized staff that unfortunately fit stereotypes of underfunded public hospitals. Here are some quotes from the introduction to the first part of the series:

The waiting room reeked. Along a crowded hallway, patients lay in beds, with only a thin curtain for privacy. Nurses readying for a new case in surgery noticed blood, bone and globules of fat on the walls and floor and stuck to wheels of carts.

They were greeted last year at an overburdened emergency department where the staff could be robotic and hardened to patients. Sometimes, inexperienced nurses evaluated the sick and suffering.

Some patients were shuffled to a stifling back room to wait. Medical records, crucial lab results -- even patients -- got lost. Staff didn't notice when one Alzheimer's patient walked home in 100-degree heat. Another patient was dismissed because doctors didn't get lab results indicating a life-threatening disease.

The trauma center was described as a war zone. Operating rooms as chaotic. In too many places, instruments were broken, rooms dirty, linens threadbare.

These problems sound unfortunately typical of an impoverished public hospital system trying to care for even more impoverished patients.

But there were several twists to the story. The first is that hospital system executives were instrumental in setting in motion the discovery of these problems, but they then apparently first tried to ignore what was discovered.

Many of the problems were revealed by reports by InSight Advantage, a Houston-based consulting firm paid more than $600,000 by hospital system managers to assess the system's care and condition. However,

[The reports] were never presented to the JPS board. The Star-Telegram recently obtained a copy.

When [JPS Health Systems CEO David] Cecero was asked about the reports' findings, he said he couldn't answer: He hadn't read the documents or been briefed on them.

'I don't think it's my job or my role to read every report that comes through this organization,' he said. 'That's why we have an executive team.'

JPS board Chairman Steve Montgomery said he was unaware of the InSight Advantage study until the Star-Telegram raised questions about it. Then he asked for a copy.

The second twist is that while the reports painted a picture of a (sadly not atypically) impoverished hospital system trying to take care of even more impoverished hospital patients, the Star-Telegram claimed that JPS was far from impoverished.

From the first part of the series:

Boosted by tax funding other local hospitals don't get, JPS has been racking up fat surpluses -- nearly $97 million last year alone.

But the cash has not helped a dedicated core of doctors and nurses overcome the system's callousness, ineptitude and filth. JPS is a hospital that many of its own doctors wouldn't recommend.

In the past six years, Tarrant County property taxpayers have anted up $1.3 billion on the premise that the mission of the public hospital is to treat the indigent and needy. But a four-month Star-Telegram examination found that the Hospital District has squandered opportunities to improve care and compassion as it has chased insured patients pursued by every other Tarrant hospital.

As trash cans overflowed, so did the district's bank accounts. The district's investments swelled to $381 million last year, earning $22 million in interest. But nurses scrambled during surgeries for instruments that low-paid assistants couldn't identify.

Over five years, JPS grabbed $232 million from one federal program for the poor, and administrators said they banked much of it. Meanwhile, needy Tarrant County residents sometimes waited months for appointments, and others went without care because they could not afford the co-payments.

In a supplement to the series appeared:

Net income at JPS Hospital has quadrupled since 2001, and the hospital's investment funds have more than doubled. The nonprofit hospital in 2006 achieved a healthy 16 percent return on equity, the common measure of a hospital's profitability. In comparison, Harris Methodist Fort Worth earned a return on equity in 2006 of 7 percent.


FY 2001, 2002, 2003, 2004, 2005, 2006
Net income (in millions) $17.4, $25.0, $25.0, $45.1, $54.1, $77.7
Investments (in millions) $112.2, $132.6, $159.5, $111.4, $118.0, $255.0
Source: Medicare cost report information from Cost Report Data Resources and American Hospital Directory

It also seemed also that the hospital had become particularly good at raising its "rack rates," that is, the fees it charged uninsured patients (while it negotiated substantial discounts for patients whose insurance companies paid on their behalf.)

Per the third part of the series:

Since 2001, JPS has aggressively pushed up its retail prices, outpacing the rate of increases at eight other Texas hospitals that the Star-Telegram examined. Seven years ago, the hospital's retail price was $1 for every 73 cents in costs, according to reports that JPS filed with the federal government. By 2006, JPS was charging $1 for about every 28 cents in costs - a markup of 257 percent.

This strategy may have been designed to increase Medicaid reimbursement.

JPS officials are frank about saying that the increases were driven by the opportunity to maximize Medicaid revenue, and they don't apologize for that. As JPS' burden of charity care has grown, and as the federal government has clamped down on rates Medicaid pays, administrators say they have had to strategize ways to draw more money from supplemental government funds.

Unfortunately, the higher the "rack rates," the higher the bills faced by uninsured patients, patients who are likely to be poorer than insured patients.

Chief Financial Officer Gale Pileggi says that she is aware the higher charges hurt some people and that the hospital is trying to deal with the dilemma.

The JPS board, she says, understands that 'it has to find a way to help the working poor who still cannot afford the hospital charges.'

JPS board Chairman Steve Montgomery said hospital officials have told him that few people charged at the full rate actually pay the entire bill.

'It's what truly helps me sleep at night,' Montgomery said.

But at many hospitals, some patients do get slapped with the highly inflated retail rate, said Glenn Melnick, a hospital pricing expert at the University of Southern California in Los Angeles. About 5 to 10 percent of all hospital patients are asked to pay the full retail price, he said.

'One of the biggest implications of these rising charges is that while they were driven by hospitals trying to increase their revenue from Medicare and Medicaid, they have this very nasty effect of generating highly excessive prices for the uninsured,' Melnick said.

In addition, the high charges undermine people's faith in hospitals and healthcare, he said.

The third twist occurred after the first stories of the Star-Telegram series appeared. The newspaper's blog reported:

But JPS employees won't be able to read the rest of the series online - not at least while they are at work.

JPS Chief Executive David Cecero and Chief Financial Officer Gail Gale Pileggi decided to block internet access to the Star-Telegram.com site.

'It was a decision that was discussed with the administration, being Mr. Cecero and Gail Pileggi, and how to deal with news issues and how many people have the right to read and do things during the work day,' said JPS spokesman Robert Earley, senior vice president of public affairs and advocacy.

Despite JPS' censorship, dozens of blog postings on the stories were made by people identifying themselves as JPS employees.

JPS Board Chair Steve Montgomery called the move 'stupid.'

Perhaps it should not be a surprise that a CEO whose latest move his board chairman called "stupid" lost his job soon after, although with the now de rigeur generous severance package (again, per a Star-Telegram article):

JPS Health Network CEO David Cecero was surprised by the board decision on Wednesday to cut ties with him, it's only because he refused to read the handwriting on the medical chart.

County taxpayers will have to pay him $775,268 whether he leaves his office tomorrow, on Sept. 30 or at the end of July 2009, as the terms of his negotiated leave-taking call for.

So add David Cecero to our gallery of failed health care executives, hospital and health care system division. His regime shows again how current health care leaders may pursue financial objectives at the expense of access, quality, cost control (for patients, if not for executives), and staff morale. As the Star-Telegram put it, 'the handwriting was on the wall' because

The district might be in the best financial shape it's ever witnessed, but the core mission of providing care to an expanding universe of indigent patients has suffered in the process.

Meanwhile, the story also showed when bad news appears, the first impulse many health care executives now have is to ignore it, their second, to censor it, but not to deal with its cause.

Once again, I will argue that to put patients first, we need to make the governance of health care organizations, starting with not-for-profit hospitals and academic institutions, more representative of key constituencies, accountable, transparent, and subject to clear codes of ethical conduct.

Hat tip: Schwitzer Health News blog.

Now You See Them, Now You Don't: 2007 Lists of Payments Made by Orthopedic Device Companies Vanish Into Cyberspace

Starting last year, we posted (here, here, here, and here) about the payments, often huge, that five manufacturers of prosthetic joints (Biomet, DePuy Orthopaedics (a unit of Johnson & Johnson), Stryker Orthopedics,a unit of Stryker Inc, Zimmer Holdings, and Smith & Nephew) revealed they made to orthopedic surgeons and various academic and other organizations. We also noted that some of the leadership of the major orthopedic societies have received substantial amounts from these companies, as have the societies themselves.

The information we used in those posts about the payments came from lists posted on the internet by the five companies. The lists were posted under deferred prosecution agreements a US Attorney made with four companies (Biomet, DePuy Orthopedics, Smith & Nephew, and Zimmer Holdings) and an agreement allowing federal supervision of Stryker Orthopedics. The companies were charged with violating anti-kickback laws by paying orthopedic surgeons as "consultants" to use their products. The lists on which I based the above posts contained data from nearly all of 2007.

I recently had occasion to revisit this question, and decided to take another look at these lists. But lo and behold, when I used the links from my earlier posts (Biomet, DePuy, Smith & Nephew, Stryker, and Zimmer), I found that two of them now went to lists of data pertaining only to the early part of 2008. No 2007 data was available from the Biomet and Smith & Nephew lists. Furthermore, perusal of those companies' web-sites did not reveal any obvious way to access the 2007 data. [See addendum below. By 12 May, 2008, three days after this was posted, the Smith & Nephew list included all 2007 data, and the Biomet list included all 2007 data, but appears to have truncated its 2008 data alphabetically after "Wo...."]

When I reviewed the 2007 lists, I was struck by how many doctors, academic institutions, and other not-for-profit organizations were on the lists, and how much money some of them received. The potential for payments of hundreds of thousands or millions of dollars to influence the thinking and actions of these people and organizations was obvious. Many of the orthopedic surgeons involved were prominent practitioners or academics. The likelihood that their practice, teaching or research might have been influenced by financial entanglements of this magnitude was obvious. Similarly, the likelihood that large payments to academic institutions or professional societies might influence their actions and policies was also obvious.

But, two of these lists are now lost in cyberspace. So those wishing to use them to inform their thinking about the people and organizations involved are out of luck. Whether by the end of the year the 2008 lists will essentially provide the same information as the 2007 lists is unknown. Even if they do, the loss of the 2007 lists will make it difficult to determine whether the financial relationships revealed in 2008 were new or not. Furthermore, erasing the 2007 data would obviously reduce the perceived overall magnitude of some of the financial relationships. In summary, erasing the 2007 data off the internet suggests that the companies want to provide as little transparency about their payments to orthopedic surgeons, academic institutions, and professional societies as possible, and that the companies want to minimize perceptions of the magnitude and duration about these financial relationships.

We are only making slow progress in making the web of financial entanglements that pervades health care more transparent.

ADDENDUM (12 May, 2008) - As noted in the comments, the 2007 information from Biomet was apparently recently added to the list available on the web. It now begins after item 168, thus apparently truncating the 2008 data for recipients starting with names beginning with alphabetically after "Wo...." Also, Smith & Nephew has also loaded its 2007 information, apparently completely.

SSRIs, Stealth Marketing, and Public Radio

We have previously posted about instances of stealth marketing in public television (here and here.) Now Shannon Brownlee and Jeanne Lenzer have published "Stealth Marketers: Are Doctors Shilling for Drug Companies on Public Radio" in Slate. Their take-home message was:

A few weeks ago, devoted listeners of public radio were treated to an episode of the award-winning radio series The Infinite Mind called 'Prozac Nation: Revisited.' The segment featured four prestigious medical experts discussing the controversial link between antidepressants and suicide. In their considered opinions, all four said that worries about the drugs have been overblown.

The radio show, which was broadcast nationwide and paid for in part by the John D. and Catherine T. MacArthur Foundation, had the air of quiet, authoritative credibility. Host Dr. Fred Goodwin, a former director of the National Institute of Mental Health, interviewed three prominent guests, and any radio producer would be hard-pressed to find a more seemingly credible quartet. Credible, that is, except for a crucial detail that was never revealed to listeners: All four of the experts on the show, including Goodwin, have financial ties to the makers of antidepressants. Also unmentioned were the "unrestricted grants" that The Infinite Mind has received from drug makers, including Eli Lilly, the manufacturer of the antidepressant Prozac.

We don't know just how much funding or when the show last received it, since neither Goodwin nor the show's producers responded to repeated requests for interviews.

In addition,

Goodwin is on the board of directors of Center for Medicine in the Public Interest, an industry-funded front, or "Astroturf" group, which receives a majority of its funding from drug companies.

Regarding the financial ties of panelist Peter Pitts

CMPI President Peter Pitts was one of Goodwin's three guests for 'Prozac Nation.' We don't know which companies fund his group because when we asked him, Pitts said, 'I don't want to go into that.'

Pitts has another title that might have been relevant to The Infinite Mind; he is the senior vice president for global health affairs at the PR firm Manning Selvage & Lee, which represents Eli Lilly Inc., GlaxoSmithKline, Pfizer, and more than a dozen other pharmaceutical companies. Yet on the show, Pitts was identified only by his title as 'a former FDA official.'

Regarding Dr Andrew F Leuchter:

a professor of psychiatry at UCLA who has received research money from drug companies including Eli Lilly Inc., Pfizer, and Novartis.

Finally, regarding Dr Nada Stotland:

Nada Stotland, president-elect of the American Psychiatric Association, has served on the speakers' bureaus of GlaxoSmithKline and Pfizer.

Note that neither Dr Goodwin nor the show's producers agreed to be interviewed by Brownlee and Lenzer.

In my humble opinion, it's great that more and more instances of apparent stealth marketing are being exposed in the media.

It may be that the people introduced as distinguished experts on this show who asserted that the suicide risks of antidepressants were overblown were not the least bit influenced by their financial ties to pharmaceutical companies which make antidipressants. Or maybe they were influenced?

But at least they should have revealed these ties to their listeners. Maybe had the show's producers felt compelled to reveal such conflicts of interest, they might have thought about at least adding some experts who did not have such ties.

Finally, as we have said before, physicians and researchers who are in a position to influence how the media discusses medicine and health care should, at a minimum, fully and completely disclose any financial arrangements they have with organizations with vested interests affected by such media discussions.

ADDENDUM (12 May, 2008) - See also this post by Ed Silverman on PharmaLot, and especially the voluminous and vociferous comments.

BLOGSCAN - LSD and the Corruption of Medicine

On the Scientific Misconduct blog, Dr AubreyBlumsohn has a series of posts (here, here, and here) about a case he considers a major precursor to some of the problems we often discuss: research misconduct, conflicts of interest, and secrecy involving government, foundations, pharmaceutical corporations, teaching hospitals and medical schools, and doctors. The case is not one I would have thought about in this regard. It is about how the US Central Intelligence Agency (CIA) conducted clandestine testing on uninformed, often civilian subjects of psychedelic drugs such as LSD over 30 years ago, under the MK-ULTRA code-name among others. What is particularly relevant, and not widely known, is how the agency funneled funding through not-for-profit foundations, some generally well reputed; how the funds went to prestigious academic medical institutions; how large pharmaceutical corporations cooperated by providing the drugs; and how much of the research was done by well-known academic physicians and researchers.

Payments for the Patient-Centered Medical Home Mired in the RUC

We have posted a number of times, (most recently here, and see links to earlier posts) about the RBRVS Update Committee's (RUC) responsibility for Medicare's relatively poor reimbursement of primary care and other "cognitive" physicians' services compared to procedures. This imbalance has rippled through all of US health care, affecting how private insurers and managed care organizations reimburse physicians, and generally how the US systems favors procedures over talking, examining, thinking, diagnosing, prognosticating, deciding, and prescribing and super-specialization over generalism and primary care.

The RUC ostensibly is just an advocacy group sponsored by the American Medical Association, yet it seems to be the only source of outside input about physicians' reimbursement used by the US Center for Medicare and Medicaid Services (CMS). Given this influence, it is dismaying that it is secretive, unrepresentative, and unaccountable. Neither its membership nor proceedings are public. It is dominated by proceduralists and sub-specialists. It is unaccountable to US physicians, much less the general public.

CMS in its wisdom also put the RUC in charge of figuring out how physicians' practices participating in trials of the patient-centered medical home (PCMH) would be paid. The PCMH has gotten a lot of buzz lately. It purports to be the modern way to characterize a well-functioning primary care practice. Various powers that be that now want to support primary care seem only interested in supporting such care that fits the PCMH model. Yet putting the RUC, which seems to be the single most important cause of the decline of primary care, in charge of payment for this new version of primary care, appears to be a great case of putting the fox in charge of the hen-house. On the Retired Doc's Thoughts blog, Dr James Gaulte first pointed this out.

The RUC just released its report on how physicians providing medical homes ought to be paid. Now, on the Happy Hospitalist blog, this post dissected how the RUC came up with its recommendations, in all their mind-numbing detail. That blog summarized the results as "punching primary care in the face," and furthermore,

The payment rates that are recommended are insulting and downright degrading. Do they think nobody is paying attention? These people have no business trying to create public policy.

Unless I'm completely off base in my interpretation, if I was an outpatient doc, I would run faster than Forest Gump from this proposed financial disaster.

This is a reminder of what can go wrong with a "single-payer health care system," which is what Medicare is. When the government sets what physicians are paid, which is what happens in Medicare, (and de facto happens for our entire health care system, as private insurance companies and managed care organizations seem to slavishly follow the CMS' lead as engineered by the RUC), the government ought to provide a rational, transparent, accountable method of doing so. The current RUC based system is the opposite, irrational, opaque, and unaccountable. If we don't fix it, we can kiss primary care goodbye, with all the negative consequences that would entail. And further woe unto us if the calls for health care reform lead to "Medicare for all," with the RUC based system intact.

Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare Information Technology

5/12/08 A preliminary note:

To those who linked here from the May 12, 2008 HISTalk post that said this...

From Blogreader: "Re: advance degree. See this [Healthcare Renewal] post." ... [the post author] doesn’t usually have good things to say about CIOs and IT departments, so if you don’t want to start your Monday morning sputtering and flinging your coffee at your monitor, don’t click the link. He often makes harsh observations from the context of "the IT people didn’t hire me, so they must be insular fools who hate doctors" angle, but he does make an occasional point.

My actual observation and that of many of my colleagues is that IT leaders, for reasons outlined in empirical research such as in the field of social informatics, don't often hire qualified medical informaticians and/or other physicians into anything but "internal consultant" roles, and their skills are severely underutilized as a result. In fact, such experts when properly empowered reduce clinical IT project costs and timelines by 25 to 75 percent. Since most healthcare organizations can ill afford IT misadventure (many organizations can barely afford care for the underprivileged), this is a rather important point. Since patient lives are also at stake, I'm glad I make an "occasional point" (e.g., based on my experiences saving lives) relevant to the biomedical and informatics-centric knowledge gaps of most health IT leaders. I'm still waiting for someone to reasonably defend the decisions made in the linked ICU case history.

I also welcome comments on this post in the blog comments section, but please stick to these guidelines ...

Now, here is the posting that prompted the above response from the HISTalk blog editor:

Over a decade ago I wrote that my fledgling website on health IT difficulties in large part originated from my personal observations of hospital "I.S." (management information systems) computer personnel leading clinical computing projects and wielding considerable authority over clinicians on decisions affecting medical environments and resources. (The current website version is here.)

I also observed difficulties among the IS personnel in functioning as true team members and collaborators on clinical teams, due to a rigid focus on "business process" and questionable management fads over the clinician goal of "getting results."

These observations led to the questions "who are these personnel, and what exactly is their expertise and educational bona fides? What metrics are applied to ensure such personnel are competent with complex clinical IT in patient care settings?"

I feel the questions in 2008 remain unsatisfactorily answered, and the that answers would likely raise serious concerns among those who believe good, appropriate education and credentialing is inherent to the rigor required for excellence in all aspects of health care. Surely, we as a nation can do better than a 115-question multiple choice exam where 15 questions are giveaways.

Unfortunately, in those days before blogs and before truly widespread internet access, the capability to inform the public, media and governmental authorities about this issue was limited.

That has changed.

I am a strong believer in physicians taking leadership roles in HIT, especially physicians with education and expertise crossing medicine and information technology. An example of such specialists are those with formal medical informatics postdoctoral training, but numerous other examples exist.

Further, in the pharmaceutical industry where I ran a department in the division of Research Information Systems, business IT and scientific IT have long been partitioned and populated by people who generally have the most focused (and especially cross-disciplinary) experience regarding each domain. This was due to a realization that this partitioning was consistent with the mission and with best scientific principles.

In the healthcare provider sector, no such wisdom appears to have developed, and to my knowledge is not even being explored. In fact, quite a different situation exists. My eyebrows were recently raised via reading the apparently patronizing words of a non-medical CIO, Denis Baker, of Sarasota Memorial Hospital, a major medical center on the Gulf Coast of Florida. Baker had this to say regarding physician leadership of HIT in an interview on the HIStalk blog here:

... "I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do." - Denis Baker

I was further startled via a response to my HC Renewal post "On the Pitfalls of Going Electronic: Should Physicians Reject Hospital EMRs" about the recent NEJM editorial on the risks of going electronic. In that post I reproduced the Sarasota CIO's statement as exemplifying one reason why physicians do not hold appropriate leadership roles in HIT. I received the following comment, apparently from another non-medical CIO named Mark Harvey:

Quite an interesting post. If awards (or certifications) existed for hubris and paranoia, the author would certainly qualify ... Who are the “crafters” of the notes and letters in question? Oh, right, it is those “seasoned professionals” who have had their thinking impaired by the insidious EMR ... the responsibility for that documentation [on an EMR] rests upon the professional who is crafting it.

In other words, the customer of IT is responsible for the problems the IT facilitates. You can read the full comment at this link; Mr. Harvey's comment is #7 down the list and my lengthy reply follows.

Now, while being paranoid doesn't mean they're not out to get you, I can assure readers that paranoia is not one of my problems. If it were, I wouldn't be writing blog posts critical of a whole sector of healthcare, now, would I?

(In case you did not notice, that last paragraph was written tongue in cheek.)

Seriously speaking, it is unlikely Mr. Harvey actually read most of my post with its myriad hyperlinks; my critique of questionable aspects of the credentialing process for IT workers in healthcare may have set him off for reasons more clear if you read my reply - and his title.

This all reminds me of comments I saw years ago from the HIT/CIO world about HIT leadership as reproduced in the aforementioned post, and below as well from recruiters such as Hersher and Goodman.

In trying to unify my observations, I am postulating that HIT has created for itself its own closed society with its own value system, credentialing, culture, and power stuctures, which piggyback off the hard labor of clinicians.

The culture of this closed society is at great odds with that of the community it ostensibly serves, medicine. More on why this society is "closed" later.

For the purposes of the comparisons that follow I shall call the medical community "Earth" and the closed HIT society "Htrae" for reasons having to do with the parallel yet opposite cultures. I've written about Htrae before in my posts "Leadership Position in Health Informatics: MD's Need Not Apply" and "Hospital IT: Amateurs welcome":

In the Bizarro world, a cube-shaped planet known as "Htrae" ("Earth" spelled backwards), society is ruled by the Bizarro Code, which states "Us do opposite of all Earthly things! Us hate beauty! Us love ugliness! Is big crime to make anything perfect on Bizarro World!". In one episode, for example, a salesman is doing a brisk trade selling "Bizarro bonds. Guaranteed to lose money for you". Later in this episode, the mayor appoints Bizarro #1 to investigate a crime, "Because you are stupider than the entire Bizarro police force put together". This is intended and taken as a great compliment.

IT personnel may believe the opposite designations are the appropriate ones, but since I am the writer I get to choose the taxonomy :-)

I shall now compare the culture of "Htrae" (HIT) and "Earth" (medicine). Because it's hard to produce a grid on blogger, I shall do it via a list:

1. On formal education:

On Earth, it was decided via the Flexner Report of 1910 that standards for medical education and credentialing had to be scientific and rigorous. Prior to then, anyone could start a medical school or "hang out a shingle", and predictable, disastrous results followed. After that report and certainly now, physicians must complete rigorous academic and applied training (med school, residency, postdoctoral fellowships, etc.), and take rigorous multi-day exams (national boards, specialty boards, subspecialty boards, etc.) in order to receive credentials and licensure.

On Htrae, the creed is something like this:

"I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers.

Healthcare MIS recruiter Betsy Hersher of Hersher Associates , Northbrook, Illinois, agreed, stating "There's nothing like the school of Hard Knocks ."

In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues ," according to Goodman. (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).

In other words it was decided that in HIT, education and credentials were optional, since "a degree doesn't get you anything" and "there's nothing like the school of hard knocks" for CIO leadership and HIT talent, anyway.

A parallel and somewhat bastardized system of getting letters after one's name was created. One can become a "Certified Professional in Healthcare Information and Management Systems" (CPHIMS) through a 115 question multiple choice exam (15 questions are "discounted" to boot).

The series of FCC amateur radio communications exams I took, from "novice" to "general" to "advanced" to "extra" class, were far more rigorous, including electronics theory and math, radio propagation, international radio laws and regulations, safety, etc., plus copying progressively increasing speeds of morse code at higher exam levels, culminating in flawless copy of 20 words per minute for the "extra." Ham radio, of course, is just a hobby generally not affecting people's lives.

In fact, I would make the case that the mirror parallel for the bachelor's degree between Earth and Htrae is that on Earth a bachelor's degree is mandatory for progess to the next level; on Htrae "equivalent experience" (as in "bachelor's degree or equivalent experience", whatever that means) is seen in want ads.

The mirror parallel for the Master's degree is the alphabet soup represented by titles such as "CPHIMS."

The mirror parallel for the Doctorate is "X years experience with vendor product Z." More on that below.

Licensure? Anyone can "hang out a shingle" as an HIT expert.

2. On leadership criteria

On Earth, specialized postdoctoral training in Medical Informatics is funded by The U.S. National Institutes of Health (NIH) at a number of universities, and is provided by other universities via internal funds as well to help improve informatics research and practice such as here (I attended the former and architected the latter).

On Htrae, training is optional. People at all levels in HIT come from a myriad of backgrounds. I've seen healthcare CIO's with no degree, degrees in business of various types or operations engineering, and rarely a higher degree - and rare as hen's teeth, an MD.

3. On hiring

On Earth: One generally gets a medical position through proof of medical education and specialty training, letters of recommendation from senior medical mentors, a check of malpractice claims, and other factors to assure as best as possible the person being hired is competent and ethical. One can generally then adapt to the medical environment into which one is hired; one can move from, say, a clinic or office to an academic or non-academic hospital, and vice versa, depending on one's specialty.

On Htrae: I periodically receive emails like this one, received today, from recruiters:

I have an up and coming project with one of our healthcare clients looking for consultants with both McKesson and Cerner experience. I just wanted to check your status to see if you are available for contract work or know of anyone else currently looking. This project will be starting in about 3-4 weeks and will run 6-12+ months. Please feel free to contact me if you are looking for a position with a healthcare client on the West Coast.

My colleagues and I have been told countless times that "we don't have enough experience" for HIT work because we lacked "experience" in the, say, Acme Anvil EMR. Although we had meta-experience (e.g., formal informatics and CS education, done EMR design, led implementation projects for other vendor's products, understood the unique aspects of HIT environments that lead to success or failure, etc.), because we'd not had "experience" with the Acme Anvil EMR, we were unsuitable.

Now, this is akin to being told that a senior automotive engineer for Ford does not have enough experience to design door locks for General Motors.

In HIT this is a strategic error of major proportions due to the history of HIT difficulties and failure, poor acceptance, and costs.

(Other bizarro world things happen on Htrae as well, such as not knowing what you don't know and not caring that you don't know what you don't know, as in here, and not wanting too much talent in an organization because that's a bad thing in complex, expensive areas prone to mayhem like HIT.)

Let's face it, although Htrae seems to regard "experience with a vendor product" much as medicine considers advanced training and/or a PhD, gaining expert-level experience for leadership of projects of any specific vendor EMR product takes a person such as myself and other medical informaticists perhaps several weeks or a month. I know this because in the"olden days" a decade ago when Htrae was solidifying out of the firmament, I did just that.

... On the other hand, it would take an IT person "considerably longer" to attain a good working knowledge of a medical specialty.

4. On being a closed society:

On Earth: anyone can join the club, if they are academically able to get good grades, prove motivation, and endure training (that sometimes is as rigorous as Marine training, I might add, especially internships).

On Htrae: note the above job solicitation in #3. Where might I go to "get experience" with McKesson? Unlike VisTA, they are a proprietary company producing proprietary products. If "experience with McKesson" is a criteria for hiring, and the only way to get "experience with McKesson" is by getting a job where one works with McKesson products, then we have a little bit of an exclusionary problem (I've often thought this a potentially fruitful conundrum for enterprising government officials on the rise, or even litigation attorneys, to exploit).

5. On knowledge of healthcare:

On Earth: Physicians in the U.S. train via four years spent in medical school, two in a hospital/clinic setting, where they interact extensively with all members of the healthcare clinical team - doctors, nurses, ancillary healthcare personnel, etc. During the three to four year residency, that interaction and interdependency becomes even more intense. During subspecialty training (e.g., ICU medicine, surgical subspecialties, etc.), even more so.

On Htrae: Once doctors get out on their own, in the words of that loveable Htrae imp from the Fifth Dimension, Mister Mxyzptlk, they forget all that and become ineligible for HIT leadership:

... "I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do." - Mr. Mxyzptlk

6. On responsibility and accountability:

On Earth: Physician hurts patient through negligence or perceived negligence. Case goes before M&M conference at very least. More likely, physician gets sued, physician has to spend time in court, physician's name gets entered into national practitioner database, malpractice insurance goes up, physician's reputation is harmed, license can be revoked. With enough cases, physician may be booted out of the job.

On Htrae: Failure leads to promotion or a move to another organization, with no accountability. I can personally think of several CIO's and other HIT workers where this applied.

In one particularly egregious case, a competent cardiac services line manager had to take an inadequate HIT worker out to lunch to "apologize for being so mean" (i.e., demanding results in a life-or-death cath lab). The cardiac manager was eventually booted; the IT person was promoted.

There is another branch of computing that is not on Htrae: computer science. CS is a very academic field. I've often thought that hospital staff and even executives may mistake the business-computing/management information systems (MIS) personnel who inhabit the IS departments to be computer scientists, and treat them accordingly (i.e., with overconfidence in their abilities outside pure business-oriented IT).

However, computer scientists they are not. Business IT personnel do, in fact, generally find computer scientists unsuitable to work in MIS departments (is that a surprise?) As a result, computer scientists are having difficulties getting jobs in recent years. In fact, many more with CS degrees have been applying to my college, Drexel's College of Information Science & Technology, than in past years as a result.

Several additional comparisons may be seen poster-style in a presentation I gave to the IEEE Medical Technology Policy Committee late last year (4 Mb zipped Powerpoint file is here).

In conclusion, with the massive cultural divide between Earth and Htrae, I have but two questions:

1. Why is it demanded of Earthlings that they use products developed and controlled by Htraesians in life-or-death environments?

and

2. Why would anyone expect the products of Htraesians to perform adequately in Terran environments?

-- SS