Friday, April 16, 2010

Healthcare IT Corporate Ethics 101: 'A Strategy for Cerner Corporation to Address the HIT Stimulus Plan'

Combination in restraint of trade: An illegal compact between two or more persons to unjustly restrict competition and monopolize commerce in goods or services by controlling their production, distribution, and price or through other unlawful means. Such combinations are prohibited by the provisions of the Sherman Anti-Trust Act and other antitrust acts.


I have written on these blog pages that the IT industry has staged an invasion of the healthcare professions.

One of these invasions has to do with the ethics of the IT industry, ethics at odds with medical ethics and the Hippocratic oath. The HIT industry is characterized by an overarching interest in profits and cavalier attitudes towards HIT-related adverse clinical events through sales of inferior products (domestically as well as abroad) based on archaic technologies, exaggerated claims of benefits, ultra-aggressive marketing, and legalized suppression of adverse events information about unproven, non-secure, largely experimental health IT medical devices.

I find it truly remarkable, more than 20 years into consumer availability of the GUI, that in the 2009 publication "Principles and Proposed Methods of EMR Usability Evaluation and Rating" (PDF) the major HIT trade group HIMSS admits that:

Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.

Unbelievable. What has this industry been doing for the past few decades?

Worse, the health IT industry is entirely unregulated and has pushed to maintain that status quo. Now the HIT industry may be clamoring for industry regulation as a means of restraint of trade as described below.

The public is beginning to wake up to the vendor and HIT trade group puffery, at least with regard to security hazards and exaggeration of the benefits:

Electronic health records prompt security, costs concerns
Richmond Times-Dispatch
By Tammie Smith

The thought of one's personal medical information being just a computer click away does not sit well with many consumers. In a March 2009 survey of 1,238 randomly selected adults by the Kaiser Family Foundation, the Harvard School of Public Health and National Public Radio, 59 percent of respondents didn't think confidentiality of electronic medical records could be assured ... 76 percent thought it was likely that an unauthorized person would get access to medical records online.

... While there are anecdotal stories of electronic health records improving outcomes, the data are mixed on whether they save money. A Harvard Medical School study published in the American Journal of Medicine last year linked 2003-2007 cost and quality data for 4,000 hospitals, including the 100 "most wired" hospitals. The researchers concluded that the electronic health records systems in place so far "might modestly improve" quality quality but produced no savings on administrative or overall costs.


'Anecdotal'? 'might'? 'modestly'?
Is that worth spending hundreds of billions of dollars on, at a time when the healthcare system is struggling to make ends meet, I ask?

Unfortunately, the public and healthcare regulators need a further awakening about the Healthare IT industry's ethics.

A profoundly disappointing lesson in the ethics of the healthcare IT sector (and the B-schools as well) can be gleaned from the following, a paper written by a Cerner employee and two health industry colleagues for a Duke Fuqua School of Business course.

The course is "Health Economics & Strategy (HLTHMGMT 326), Distance Executive MBA" (syllabus here in PDF). The course's stated purpose:

We will apply the tools of economics and strategy to address the challenges and opportunities of today's health care managers and policy makers. We will begin most classes with analysis of recent news, then discuss a case, and conclude with additional insight on the application of economics and strategy.

The paper is entitled -

"
A STRATEGY FOR CERNER CORPORATION TO ADDRESS THE HIT STIMULUS PLAN" (PDF).

*** April 18 NOTE
: the paper apparently has been scrubbed and is no longer available from the above link as it was on April 16. A copy is here (PDF).

It is actually highlighted at Duke professor David Ridley's page "Duke University Fuqua School of Business: Past Papers."

*** April 18 NOTE:
the "Past Papers" page has also seemingly been scrubbed. This is how it looked two days ago:

(click to enlarge)

This appears to be a Final Paper for an online MBA program course for executives. These are therefore not just students in the academic sense; as in my own healthcare informatics courses, I've had 'students' who concurrently were executives and managers in healthcare companies and organizations.

All three authors are listed at business networking site LinkedIn.com:

  • Dan Aycock - appears as Business Strategist at Cerner
  • Aparna Prasad - MBA Candidate at The Fuqua School of Business, Duke University
  • Barri Stiber - Administrative Fellow at Legacy Health - formerly Senior Analyst at The Advisory Board Company

The paper is emblazoned with the Cerner corporate logo on its cover page and could be mistaken for an official document:


Paper's cover page. Click to enlarge


From the paper, an example of HIT corporate ethics (and business school ethics as well):

Electronic health records (EHRs) have the potential to improve the healthcare system through several means including reduced medical errors, better coordination of care, and reduced costs. However, adoption of EHR systems in the U.S. has been slow; only 1.5% of acute care hospitals have comprehensive EHR systems.

While the Bush administration made efforts to spur adoption of these systems, the Obama administration’s American Recovery and Reinvestment Act of 2009 (ARRA) has pushed EHR adoption to the fore with over $20 billion dollars in incentives. With such a large infusion into a relatively small market the effects of the stimulus package have enormous strategic implications for EHR vendors.

This paper seeks to clarify these implications, understand the strengths and weaknesses of various players in the industry and recommend a strategy for Cerner Corporation to maximize its profit from the stimulus package and thereby secure a dominant position in the HIT industry.

... We recommend that Cerner collaborate with other incumbent vendors to establish high regulatory standards, effectively creating a barrier to new firm entry. Other strategic recommendations to capture market share, facilitate EHR adoption, and improve Cerner’s operational readiness are detailed and framed within an implementation plan.

I am going to highlight one key sentence for emphasis:

We - recommend - Cerner - collaborate - with - other - incumbent - vendors - to - establish - high - regulatory - standards, effectively - creating - a - barrier - to - new - firm - entry.

Did I read that correctly?

The paper goes on to explain:

... With the introduction of stimulus funding, this industry is ripe for disruptive innovation, which could significantly change the competitive landscape. Examining Christensen’s work on disruptive innovation outlined in Figure 6, the primary factor that will influence the entry of new HIT vendors is regulation.

Therefore, the technology standards and definitions of “meaningful use” which are under development have the potential to raise or reduce barriers to entry, limiting or enhancing the ability for disruptive innovations to enter at a lower performance point. When asked about which competitors the organization is most concerned about, a Siemens Executive indicated “it is these new guys who could come in and undercut prices with substandard products.”

["New guys" ="substandard"? This from a company that apparently fired an informatics physician for raising concerns that a substandard ICU system was
going to kill patients - ed.]


Therefore, incumbent firms, like Cerner, have strong incentives to influence regulation in their favor, keeping barriers to entry high.

[Influence in their favor, not in the favor of patients, to maintain the industry oligarchy? - ed]

In other words, to stifle disruptive innovation and prevent newcomers from entry into the HIT business, large HIT vendors should influence regulation towards high standards impossible for newcomers to meet.

NOT that they should influence regulation for the sake of patient safety!

This student is apparently a Cerner strategist seeking an MBA. His colleague Barri Stiber was a Senior Analyst at The Advisory Board Company, a company that serves "nearly 3,000 progressive organizations worldwide—health care, health benefits, and educational organizations alike—providing innovative solutions to their most pressing challenges such that they can “hardwire” best-practice performance."

This paper raises a number of questions:

  • Does this paper reflect a strategy that would amount to illegal restraint of trade and/or fall under the federal RICO act, through knowingly and willfully advancing a lobbying strategy to strangle fair competition?
  • Were any of these authors on Cerner's payroll when this was written?
  • Are Mr. Aycock or other authors giving such advice to Cerner management presently?
  • Did or does Cerner use this paper or derivatives thereof internally?
  • Does this paper reflect on the business ethics of Cerner or other large HIT vendors? Will they openly condemn its ideas as both wrong minded and monopolistic, using their influence to create a market adverse to smaller competitors - not to mention the paper's seeming lack of concern for what really matters - the "customer" (patients)?
  • Did or does this paper reflect a more widespread healthcare IT large player collusion on restraint of trade?
  • Is this how the Advisory Board company conducts its business in advising healthcare organizations?
  • What type of professor would exalt a paper via posting it as an example for other students to emulate, a paper whose basic premise is unethical, or at the very least on the precipice of unethicality?
  • Does this professor teach such ethics?
  • Why was this paper not returned to its authors with a big, red "F" on it? That's what I would have done.
  • What other papers are accepted by this professor that demonstrate similar business "strategies" in other sectors?

Finally, and perhaps most importantly:

  • Does this paper reflect, or did it influence, current Cerner or other large HIT vendor business strategy?
Recent developments are consistent with that, i.e., Cerner starting to acknowledge need for regulation, per the Feb. 2010 story "FDA Considers Regulating Safety of Electronic Health Systems" by the Huffington Post Investigate Fund, http://huffpostfund.org/stories/2010/02/fda-considers-regulating-safety-electronic-health-systems).

From that article:

.... Yet some inside the industry favor stepped-up scrutiny. One major vendor, Cerner Corporation, which has voluntarily reported safety incidents to the FDA in recent years, signaled its support for a rule that would make those reports mandatory. Cerner has reported potential safety concerns because it is the “right thing to do,” a company official said.

I was puzzled by that turnaround.

Perhaps now I know from where it arose.

It certainly is the "right thing to do." It's the right thing to do to enhance profits and enforce restriction of market entry by "disruptively innovative" newcomers.

Those newcomers might actually hold the answers to improving healthcare IT and reducing costs through fair, free market competition, saving lives and money the healthcare system dearly needs. (For example, see my post "Hospitals Under the Knife: Sacrificing Hospital Jobs for the Extravagance of Healthcare IT".)

-- SS

Addendum Apr. 16 -

A commenter speculates that:
... When I did my MBA, back in the day, we were one of the first programs to have a working business background as a requirement for admission. From that base I would make the following guesses:

  • The people were not only on the company payroll, but also were having their tuition paid for by the company.
  • This document was widely circulated within the company,
  • The document was highlighted as a means for the university to curry favor with the company thus increasing recruits or for financial gain.

... The modern remote MBA program is in many instances simply a way to check a box for employees on the fast track to senior management. Often papers are written with the support of the company and access to department heads who contribute to material turned in.

From my experience this is not some theoretical exercise, but a document that, even retiled, will be used internally to drive policy.


While that is speculation, it is certainly plausible; nothing would surprise me in the health IT industry.

Addendum Apr. 19 -

A former HIMSS staffer related to me that I am likely blacklisted from the HIT vendor industry as a result of my writings on health IT on this site and at my academic site dating to 1999, via verbal exchanges and even in writing among HIT organizations. It could explain why my CV's been uniformly ignored by that industry since the early 2000's.

If so, so be it. Who else might be on that blacklist, I wonder?

Also, didn't Richard Nixon get into a bit of trouble for maintaining such a list after it was discovered?

-- SS

10 comments:

Anonymous said...

Dangerous and despicable conduct affecting patients' lives.

Anonymous said...

Oh come now... methinks thou dost protest too much... after all, doctors in the U.S. have maintained high regulatory barriers to keep others -- mostly nurses but also foreign medical graduates -- from entering into competition with them. It's disingenuous to complain about commercial firms doing what is in their best interest when doctors, lawyers, and engineers have been doing this -- successfully -- for years!

Anonymous said...

I have read this post several times , at first with the affect of astonishment that such a paper was actually excavated from the behind the veil of secrecy and surveillance operatives working within the EHR Industry.

Excuse me for saying this as I do not want my words to be misunderstood or counter-argued in other forums of exchange , but, this is clear cut prima facie evidence for the FBI to go in and seize records , apply RICO investigation protocols and breakdown the the organized crime activities and the players with an indictment.

Rumors of rumors indicate these sorts of documents, as seen here, and more also include a secret list of known persons considered as adversaries to the industry.In other words, a BLACKLIST. It is known that Trade Secret documents are held in repository by the EHRA located at 230 e. Ohio St Chicago at HIMSS headquarters. The EHRVA is the locus of control to which many of the executives mentioned here take orders from. Anti-trust, Sherman and Clayton Acts do not even begin to address the gravity of this situation. This makes Teapot Dome look like a tea-party.

Rumors of rumors also indicate the FBI and Secret Service may be trying to hire an agent into HIMSS open positions for the Davis Garrets Analytics Intelligence Agency positions.

Anonymous said...

We need the FBI and RICO statutes applied now.

Anonymous said...

When I did my MBA, back in the day, we were one of the first programs to have a working business background as a requirement for admission. From that base I would make the following guesses:

• The people were not only on the company payroll, but also were having their tuition paid for by the company.

• This document was widely circulated within the company,

• The document was highlighted as a means for the university to curry favor with the company thus increasing recruits or for financial gain.

• The instructor may not have any real life experience or comes from a morally corrupt background.

We ate up a couple of instructors that did not meet the standards of our program. One PhD admitted he was not prepared to challenge such an accomplished class.

Another instructor was dealing with the collapse of his career after overselling his ability, thus leading to a drinking problem. Yes I paid the price of having my grades marked down resulting in the need to take additional courses in order to graduate without any special consideration.

I was also working full time and dealing with the personal need to pay all of my educational expenses. Something my classmates were not dealing with as they were all on tuition reimbursement programs.

The modern remote MBA program is in many instances simply a way to check a box for employees on the fast track to senior management. Often papers are written with the support of the company and access to department heads who contribute to material turned in.

From my experience this is not some theoretical exercise, but a document that, even retiled, will be used internally to drive policy.

Steve Lucas

Roy M. Poses MD said...

Anonymous (of April 16, 12:17 PM) -

But doctors, lawyers, and engineers all go through rigorous training, have fairly clearly stated codes of ethics. Doctors and lawyers take formal oaths to put the interests of their patients or clients first. Doctors and lawyers are subject to licensing boards, and can lose their licenses due to unethical conduct.

MedInformaticsMD said...

Anonymous April 16, 2010 12:17:00 PM EDT wroteL:

Oh come now... methinks thou dost protest too much... after all, doctors in the U.S. have maintained high regulatory barriers to keep others -- mostly nurses but also foreign medical graduates -- from entering into competition with them. It's disingenuous to complain about commercial firms doing what is in their best interest when doctors, lawyers, and engineers have been doing this -- successfully -- for years!

I apologize to the readers of this blog that idiots who proffer useless information like this have access to computers.

-- SS

MedInformaticsMD said...

Aonymous at 1:06 PM writes:

Rumors of rumors indicate these sorts of documents, as seen here, and more also include a secret list of known persons considered as adversaries to the industry.In other words, a BLACKLIST.

The existence of a word-of-mouth health IT blacklist against those who take a critical approach to health IT would not surprise me.

As to the other comments about secret documents held by EHRA etc., it's simply hard to imagine an industry group being reckless enough to leave secret documents around.

But who knows? The author of the paper that is the topic of this blog let it lay around for discovery via Google. That being the case, anything is possible.

-- SS

Anonymous said...

Oh come now... methinks thou dost protest too much... after all, doctors in the U.S. have maintained high regulatory barriers to keep others -- mostly nurses but also foreign medical graduates -- from entering into competition with them. It's disingenuous to complain about commercial firms doing what is in their best interest when doctors, lawyers, and engineers have been doing this -- successfully -- for years!

"I apologize to the readers of this blog that idiots who proffer useless information like this have access to computers.

-- SS"

Name calling does indicate that you have a strong argument in favor of your opinions.

The commenter's point was very simple : take it easy - entry to barriers exist in your own very profession - if you care to look at it from outside in.

But you would rather indulge in name calling.

MedInformaticsMD said...

Anonymous April 25, 2010 9:48:00 PM EDT attempts puerile spin control, claiming "I doth protest too much."

Then makes the truly stunning statement that "It's disingenuous to complain about commercial firms doing what is in their best interest when doctors, lawyers, and engineers have been doing this -- successfully -- for years!"

Oh, really? You don't say?

Thanks for that heapin' helpin' of moral relativity, clownie.

Likely a corporate shill.

This poster lacks two important attributes, in anonymously trying to defend a despicable paper:

1. courage
2. ethics

Only weasels try to defend questionable ethics behind a cloak of anonymity.