NIH Update: Resistance Against New Conflict of Interest Rules Continues

The New England Journal of Medicine this week has a good summary by Robert Steinbrook of the latest developments at the NIH. In particular, it has a clear table of the new, more stringent regulations temporarily put in place by Director Zerhouni.
These included:

• Prohibition of employment with pharmaceutical and biotechnology companies, research institutions that receive NIH grants and contracts, health care providers and insurers, and related trade, professional, or similar associations
• Prohibition of compensated teaching or writing for these organizations
• Prohibition of self-employed business activity involving sale or promotion of products or services of a pharmaceutical or biotechnology company or a health care provider or insurer
• Prohibition of holding stock in biotechnology or pharmaceutical companies for employees who must file financial disclosure reports, a $15,000 limit in holdings in any one company for other employees
• Prohibition for senior employees only of the receipt of most awards worth more than $200, and a similar prohibition for all employees of such awards from an organization which is involved with the employees work
• In general, outside teaching, clinical, scientific writing, and scientific editing activities are permitted as long as they comply with other standards.

It also includes a narrative of how Zerhouni changed his mind about the need for such regulations. Much of its contents has already appeared on Health Care Renewal, but it does have some important new items.
One is that the new regulations at the NIH parallel those already in place at regulatory agencies, such as the Food and Drug Administration and the Securities and Exchange Commission. This was in part driven by the realization that NIH decisions can have "increasingly powerful influence ... on financial markets." Moreover, Zerhouni felt the regulations were in response to activities by high NIH officials that "really were purely and imply what you would call product-endorsement activities, speaking for a company on behalf of a product to entice physicians to prescribe that product at greater levels."

The article also mentions the opposition to these new regulations that Zerhouni has encountered. Furthermore, yesterday, the Washington Post reported that apparently a physician recently nominated to head the National Institute of Environmental Health Sciences now has "serious concerns about taking the job under the new rules." "His primary concenr is that he would be unable to recruit or retain top talent."

The NIH is, as Steinbrook stated, is "regarded as the world's premier biomedical research institution." So, it amazes me that some people don't think the could manage to work in full-time leadership positions at the NIH because they no longer could also work for certain outside organizations, or simultaneously pursue self-employed business activity involving the products of such organization. Are NIH salaries really so low that its high level employees need second jobs to get along economically? Or do people now feel so entitled to lucrative side-employment with industry that the notion of loyal service to the public means nothing? But maybe such people are not those who should be working at "the world's premier biomedical research institution."

HCA leads campaign to curb doctor-owned hospitals

An interesting article on the competition between physicians opening specialty hospitals owned by themselves and corporate medicine. Big-business medicine whines that physician-owned specialty centers gives physicians an "unfair advantage." I would classify this story under the heading "The World's Smallest Violin."

Big-business medicine claims physicians "cherry-pick" the best-insured patients for their centers. However, managed care and for-profits tend to try exactly the same thing to minimize care delivery, maximize corporate profit and shareholder value, and minimize physician income in the bargain to add insult to injury.

Businessmen need to realize that in essence, clinicians are the true owners of hospitals. As I've often said, in a somewhat tongue-in-cheek example, even if hospitals all burned to the ground in some hypothetical apocalypse, clinicians could still take care of patients to a good extent in tents using primitive equipment. They are enablers of healthcare; everyone else is a facilitator. (If only clinicians would become more politically astute and use this realization more aggressively.)

Dear HCA, welcome to the true marketplace of competition from those who actually know what they're doing in medicine, its practitioners.

-- SS

HCA leads campaign to curb doctor-owned hospitals (excerpts)
By TODD PACK
Staff Writer, Tennesean.com

Before many of its heart surgeons left to become owners in a nearby specialty hospital, Oklahoma University Medical Center admitted 150 heart patients a month. Soon afterthe doctor's hospital opened, OU's cardiovascular admissions fell to zero.I t was a drop in business that has cost OU nearly $12 million since 2002 and threatened its ability to care for Oklahoma's most critically injured patients, OU's chief medical officer said. ''Simply put, these facilities drain essential resources from full-service community hospitals,'' said Dr. Andy Sullivan, chief medical officer of the OU Medical Center, a teaching hospital that operates under a joint agreement between the school, the state and Nashville-based HCA Inc.

HCA, which runs 190 hospitals in the United States and overseas, has become one of the leaders in the campaign to curb expansion of physician-owned specialty
hospitals across the country. ''This is a hugely important issue,'' HCA Senior Vice President Victor Campbell said.

What makes it important to companies such as HCA is that doctors are allowed to refer patients to facilities the doctors also own.Critics such as the American Hospital Association say this ''self-referral'' gives doctors an unfair advantage because they refer patients to their own hospitals and take the best-insured patients.

... But proponents of the hospitals dismiss such arguments as self-serving.''They bring competition to the community and bring a new way of thinking of health care,'' said Jim Grant, president of the American Surgical Hospital Association and a Nashville resident. ''They should be promoted.''

... Speaking recently before a House subcommittee looking at the issue of specialty hospitals, one AMA trustee said simply, ''Competition works.'' ''In the hospital industry, the addition of specialty hospitals to the mix gives patients more choice, forcing existing hospitals to innovate to keep patients coming to them,'' said the trustee, William Plested, a Santa Monica, Calif., heart surgeon who isn't affiliated with a specialty hospital.

Health Care Renewal Bloggers to Speak

Kim Atwood and Tim Gorski will be speaking at a conference entitled "Curing the Ills of Alternative Medicine and Questionable Mental Health Practices." The date is May 21, 2005, and the location is Amherst, NY. Atwood will be talking about “Naturopathic Medicine: Politics Trumps Science” and Gorski, “They Ain’t Measuring What They’re Measuring.”
Wally Smith and I will be giving a Special Symposium entitled "External Threats to Professionalism in a Chaotic Health Care Environment, Thursday, May 12, 2005 at the Society for General Internal Medicine annual meeting in New Orleans. Note that the meeting theme is Out of Chaos: The Critical Role of Generalists. The meeting dates are May 11-14, 2005.

How Academic Health Centers' Advertising Put Their Interests Ahead of Those of Patients

An important article was just published in the Archives of Internal Medicine on the use of advertising by academic health centers (AHCs). [Larson RJ et al. Advertising by academic medical centers. Arch Intern Med 2005; 165: 645-651.] (For a typical media report on it, go here.)
The authors surveyed marketing departments of 17 top rated (by US News and World Report) AHCs to assess the process used to construct advertisements. They then searched for print advertisements placed by the AHCs in local newspapers, and did a structured assessment of each ad.
Let me quote from their results section (with italics added for emphasis). First, the process of development and approval of the ads was almost never supervised by physicians:

• "About two thirds of the marketing department representatives were familiar with their institutional review board's process for assuring fair, balanced, and straightforward content in advertising to attract research participants. None of the marketing departments had a similar process for reviewing ads to attract patients for health services."
• "Only 1 center had a mechanism in place for obtaining medical approval from a person outside the department being advertised."

Now, re the ads themselves:

• The ads promoted dubious services, "Of the 21 ads for single [clinical] services,.... 19 single-service advertisements were for procedures considered cosmetic ..., having limited (or no) efficacy data, ... or lacking consensus."
• The ads played on patients' emotions, "Most of the institutions' slogans emphasized cutting-edge care and institution status.... The remaining slogans tended to use emotional themes." "Advertising headlines ... commonly mentioned symptoms or diseases or used strategies that might appeal to patients' emotions or fears."
• The ads exaggerated benefits while avoiding mention of harms, "While more than three quarters of the single-service ads highlighted potential benefits of the services promoted... none quantified their positive claims. Only 1 ad mentioned or implied potential harms of the service...."

And their summary included:

• "Given the prestige of academic medical centers ... consumers may have great confidence in the quality , accuracy, and underlying altruistic motivations of any information with which the institutions are associated. Because of this trust, consumers may not recognize the different between information intended to inform the public and advertising designed to generate revenue."
• "Second, many of the ads seemed to foster the perception that more and higher-technology medicine is always better." "As a result, patients may be given false hopes and unrealistic expectations."

Finally, they concluded with this:

• "If academic medical centers are to continue with advertising to attract patients, we believe they must be more sensitive to the conflict of interest between public health and making money."

Their abstract's conclusion was even more blunt:

• "Many of the ads seem to place the interests of the medical center before the interests of the patients."

This is a terrific article, providing new awareness of yet another way in which important medical organizations are straying from their mission, with patients as the biggest losers.

From Harvard: Bigotry, the Disabled and Slippery Slopes

The Philadelphia Inquirer has not replied to me nor, as far as I know, retracted its statement published on two consecutive days that in euthanasia, "Even a normal, healthy person would feel little discomfort after the first few days of thirst."

Perhaps they should read this article from the Harvard Crimson by a student with severe cerebral palsy. I agree with its author that judges, politicians and the mainstream media are driving healthcare down some very slippery slopes.

Of note towards lack of discomfort via starvation is this link cited in the Harvard Crimson article.

-- SS

Pain Management Caught in the Cross-Fire

An op-ed in the NY Times about how doctors (and patients) are caught in the cross-fire when the issue is control of pain. Zealous enforcement of the law means doctors whose patients abuse prescribed narcotics are liable to face criminal charges. Meanwhile, advocacy groups have been pushing for more aggressive treatment of pain, and physicians have certainly faced malpractice suits for perceived undertreatment of pain as well. Certainly, physicians should neither over- nor under-treat pain. But also we certainly need a more rational way to set standards for pain treatment that make medical sense and put patients' welfare first.

Doctors call dehydration a 'peaceful' way for normal people to die?

In the Philadelphia Inquirer article "Doctors call dehydration a 'peaceful' way to die" (Sat, Mar. 26, 2005), staff writers Stacey Burling and Michael Vitez seem to quote Ira Byock, director of palliative medicine at the Dartmouth Hitchcock Medical Center in New Hampshire, John Hansen-Flaschen, chief of pulmonary, allergy and critical care at the University of Pennsylvania Medical Center, and Paul Marik, director of the division of pulmonary and critical care at Thomas Jefferson University Hospital as saying "Even a normal, healthy person would feel little discomfort after the first few days of thirst." From the article:

... Schiavo, who could begin her eighth day without nutrition or water who this afternoon, will die of dehydration, not starvation, the doctors said. It will cause her kidneys to fail. Toxins will build up in her blood, eventually causing her heart to stop beating.

Dehydrated patients gradually weaken, drift into a coma, and appear to die painlessly, Marik said."It's a very painless and very compassionate way of dying," he said. Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors [Byock, Hansen-Flaschen and Marik] said.

WHAT?

I am hoping this is a misinterpretation by the Philadelphia Inquirer authors of the physicians' statements. Even a cursory search on google.com, let alone a more comprehensive search of the biomedical literature via specialized tools such as Medline and others, shows that there is a significant amount of controversy on the topic of palliative care and side effects of dehydration and withholding of intravenous fluids. Clicking on the following URL initiates a search via the simplest of strategies [ "palliative care" AND "intravenous fluids" ]: http://www.google.com/search?q=%22palliative+care%22+%22intravenous+fluids%22&hl=en&lr=&start=20&sa=N ).

From just the first few pages of over 8,000 hits from this topic, for example, appears this statement from the official journal of the American Society for Clinical Oncology :

Dehydration can result in serious symptoms in an otherwise healthy person, causing profound fatigue, postural hypotension, renal failure, delirium, and ultimately death. ("To Hydrate or Not to Hydrate: How Should It Be?", Journal of Clinical Oncology, Vol 18, Issue 5, March, 2000: 1156-1158.)

For a more diverse view from another country, Robin L. Fainsinger, M.D., Director, Palliative Care Program, Division of Palliative Medicine, Department of Oncology, University of Alberta, writes in "When to Treat Dehydration in the Terminally Ill Patient?":

Our palliative care group has argued that the viewpoint that dehydration in dying patients is never a cause of symptom distress, overlooks the fact that: - 1) dehydration is well recognized in nonterminal patients to cause confusion and restlessness, problems often reported in terminally ill patients; 2) reduced intravascular volume and glomerular filtration rate caused by dehydration is accepted as a cause for prerenal failure, with opioid metabolite accumulation in the presence of renal failure causing confusion, myoclonus and seizures, having been well documented (1, 2, 3).

I am inviting the authors and those quoted in the Philadelphia Inquirer to respond to the seemingly-fantastic statement that "even a normal, healthy person would feel little discomfort after the first few days of thirst."

It seems not only incredibly counterintuitive but also contradicted (or at the very least shown extremely debatable) in even the most cursory, third-grade-level information search. I am hoping this is just a a case of sloppy journalism, not unusual in the world of today's mainstream media.

-- SS

-----------------------------------

Update, Satuday Mar. 26: I received a reponse from Dr. Byock. He writes:

It [the Philadelphia Inquirer quote] is a misstatement. It would be true if the article had said, "Even a normal, healthy person would feel little discomfort after the first few days of hunger." A normal, healthy person would need fluids to avoid feeling persistent thirst.

(Not to mention profound fatigue, postural hypotension, renal failure, delirium, and other not-very-pleasant sensations.) My response to him was:

I'm glad it's a misstatement. However, the article does say: "Schiavo, who could begin her eighth day without nutrition or water who this afternoon, will die of dehydration, not starvation, the doctors said. It will cause her kidneys to fail. Toxins will build up in her blood, eventually causing her heart to stop beating. Dehydrated patients gradually weaken, drift into a coma, and appear to die painlessly, Marik said. "It's a very painless and very compassionate way of dying," he said. Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors said", the article seemingly being very precise about the matter of hydration.

I wonder how such a statement got into print. With the Schiavo case being a hotly-contested issue and a cause of hot emotions across the political spectrum internationally, it seems major newspapers need to take significantly more care in what they publish.

Certainly a major correction by the newspaper is in order. Will it happen?

-- SS

-----------------------------------

Update, Sun. March 27: Dr. Marik also responded and said the statement was in error. However, instead of correcting the article, the Philadelphia Inquirer republished it almost verbatim in the Sunday, Mar. 27 edition under the title "Dehydration death seen as peaceful." The bizarre statement that "Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors said" is repeated.

I'd sent an email about the error with a link to this blog post directly to the Inquirer reporters just after writing the post yesterday, about 10:30 AM EST. Apparently reporters are delayed in reading their email, don't work on weekends, or perhaps stick by their quotation.

What's amazing is that print newspapers still wonder why people are turning to the Blogosphere for information and away from old media. In the blogosphere, feedback and corrections to errors are rapid.

-- SS

Survival of AHCs: Why Do They?

In a series of interviews conducted last year (2004), Drs. Hamilton Moses and Samuel Thier, along with David Matheson, Esq., asked 23 leaders in 15 academic institutions to address this ingenious and properly-ingenuous question. (Why do they survive? That is, of what use are they, these days?) Essentially, another SWOT analysis. This is one of the best articles in this genre that I've seen in quite a while.

Answers were revealing, beyond the round-up-usual-suspects identification of lesions such as reimbursement issues, problems with community outreach, and perversities in both the internal and external environments.

Of note, unless I missed something staring me in the face, Moses et al. chose to keep their informants--and their institutions--anonymous. OTOH such anonymity no doubt did promote candor. One of the nifty things about blogs is that we don't need to take the classic review-panel high-science approach and take them so much to task in demanding such detail from a JAMA "Special Communication" piece.

The article nicely combines elements of the diagnostic and the prescriptive. What's wrong? What's right? And how to fix what's wrong? It is also a welcome call to arms, when the authors (at least implicitly) revert to their own voices.

The authors say their informants came "from all walks of life," to paraphrase; translate: more than just the ivory tower.

But we may legitimately ask: how many came from institutions that had failed, or were about to fail? I see an interesting defect here, by no means fatal for their arguments and recommendations, but still a potential skew-factor.

Namely, tellingly, included amongst their informants, did they include anyone from AHCs that were, or are, nearing the unlovely status of non-survivorship? There's a thread woven through the piece suggesting that AHCs survive in part because they do a lot of things right, and by contrast other sorts of organizations (industry, CBOs, CROs, etc.) don't always do much any righter!

Thus do the AHCs limp along. ("The Paradox: Survival Against the Odds.")

Yet we might add: not always. The first tier institutions have more money, more lucrative clinical specialty cadres, and bigger research portfolios--they have, that is, a lot of ballast and momentum. But not all of them have been surviving. Witness the recent demise of what was once the Medical College of Pennsylvania (the hospital and most of the faculty are gone, and a vestige lives on on the stationery of Drexel Med). It's not quite cricket for those doing better, for now, to assume that any part of their business-as-usual will guarantee future survival. Seems a bit circular.

With this caveat, I suspect that many of this group of authors' conclusions can be considered to be well taken and useful to ponder. (Though, true, they often verge on bromides.) "Do, don't just preach." "Position yourself as honest information brokers." "Get leaders with experience outside the AHC."

Finally, Moses and his colleagues advocate two "fundamental changes." They are (1) enhance ties with the community and (2) simplify the "organizational labyrinth."

These are interesting, if not wholly new. Below the elite tier, one might point out, such ties, paradoxically and perhaps only because of economic and organizational necessity, are already in place. (That's another minor glitch in the argument, but one that's ultimately unexceptionable.)

The biggest issue, then, is how AHCs are themselves governed--here I think again of Pogo, "we have met the enemy...."

Ultimately, institutions, like families, ultimately fall victim to their own contradictions. The perversities of AHC organization, even in best-of-breed AHCs, are nicely laid out in this article, and paramount among them is probably the huge array of disincentives for true collaboration at all levels.

Ultimately, a question and an opportunity stand out. The opportunity: with outpatient medicine becoming more and more important, as the authors note, AHCs have a great chance, if they find ways to seize it, to take over from the hospital as the traditional framework for improved links with the community. Bingo! Eureka! Touché!

The question: who will give the New Leaders, the cadre of community-, market-, and business-savvy deans and chairs and directors that Moses et al. call for here, the Archimedean lever with which to effect all the changes they call for?

The Costs of Computer Based Medical Technology

My take on Arnold Kling's article on the "Myth of Massive Health Care Waste" has generated quite a bit of discussion on Kling's EconBlog, here. What generated the most interest was the question of whether the cost of computer based medical technology was too high. (The example used was the CT scanner.)
Some of the main conceptual points raised were:

• One needs to separate the costs of the equipment and its maintenance from the other costs incurred by hospitals or offices in doing CT scans, and these, in turn, need to be separated from the actual price of CT scans
• Hardware costs need to be adjusted for inflation, but more important, the increasing capabilities of the hardware need to be taken into account

Some striking opinions were:

• "I think you'll find that in real dollars, the price of CT equipment and technology as well as the cost per procedure has dropped substantially...."
• "The PC hardware is a small part of the technology."
• "GE Medical dominates the market and can charge pretty much what it wants."
• "as quality/performance rises, 'prices' don't necessarily fall continually...."
• "If high fixed costs are the problem, more volume (more patients, more procedures) will lower the cost per procedure."
• "I was part of a design team for a CAT scanner.... I proposed many approaches that would have saved quite a bit in both hardware and software costs without reducing functionality, reliability, and performance. I was frequently met with the answer, 'We want it to be expensive.' The medical technology marketplace is a perverse marketplace. There are too many docs involved in the process and they don't respect anything unless it's expensive."

To make this discussion a bit more data driven, I was able to find some about the economics of CT scans over time. [Stockburger WT. CT imaging, then and now. Radiology Management, November/December, 2004. On the web here.]
From 1974 to 2004, the list price of a CT scanner has gone up faster than inflation (from $385K to $2200K, 471% increase, versus 342% increase in consumer price index). So has the acquisition cost ($385K to $1600K, 416%). However, revenue obtained per CT scan has gone up even faster (the Medicare payment for a CT scan of the head without contrast increased 700%.) Finally, and perhaps most importantly, the amount to be made by CT scanning facilities has risen even faster, because, as noted above, it is now possible to do more CT scans per unit time. In 1974, by my calculations, the typical profit of a single-scanner facility would have been $56700 in 1974 dollars. In 2004, it would have been $577,900 in 2004 dollars! Even adjusted for inflation, that's a big increase (1030% unadjusted, 298% adjusted for inflation)!
So, to summarize, my hypothesis that the costs of CT scanners over the last 30 years have become exaggerated in the face of the vast increase in computer performance/ price, given that the "C" in CT stands for computer, remains unproven. However, there is anecdotal evidence (from the comments above) that suggests that these prices may have been artificially elevated by a less than competitive marketplace plus the industries interest in wanting it to be expensive.
More importantly, the data from the article above suggests the larger problem. Despite the rise of managed care and of government efforts to contain costs, reimbursement for CT has risen faster than costs and inflation, and given that CT scans can be done more and more quickly, which raises volume while it further reduces the fixed costs associated with each scan, the amount of money made by CT scan facilities has risen even faster.
So the big question remains. If managed care was supposed to restrain costs by using a more business-like approach, and more attention to the economic issues, why has it so massively failed to restrain these sorts of costs?

Now, doctors DO things with computers

In my writing I've long called for substantive leadership roles and titles for medical informaticists in healthcare, where the attitudes are slowly evolving from the "doctors don't DO things with computers" attitudes (meaning they should be advisors or internal consultants, not leaders) I observed in entering medical informatics. At long ago as 1998 I wrote in a piece called "Ten critical rules about job structure and reporting for applied informatics positions" that:

"Informaticists should aim for positions at the Assistant V.P. level or higher. Director-level (or worse, manager-level) positions often lack real authority and executive presence. Such characteristics are often essential for success in a cross-disciplinary, cross-territorial area such as applied medical informatics. If a position being considered is at the director or manager level, an inquiry as to why it is rated at such a low level may be helpful in understanding the true feelings of the senior executive team about medical informatics leadership."

Today, March 24, 2005, for the first time (in my personal experience) I've seen a free-standing hospital actually offer an informaticist an advanced title: VPMIO.

Position Title: Vice President, Medical Information Officer (M.D.)
Organization Name: (witheld)
Location: (the South)

Job Description: Multi-specialty medical center located on the Gulf of Mexico, in one of the fastest growing areas in the South, seeks an experienced Vice President – Medical Information Officer. This modern facility, with over 400 beds, is in the forefront of modern healthcare delivery with a medical staff comprised of nearly 300 physicians representing more than 40 medical specialties. This hospital offers some of the most advanced information technology and medical services available in the country. The Vice President – Medical Information Officer (VPMIO) is a member of senior management and is responsible for IT strategic planning, medical informatics, and clinical implementation of data, information and knowledge.

This position reports directly to the Chief Executive Officer and frequently works in coordination with the Director of Information Systems. The VPMIO serves as a liaison between the administrative and information technology planning groups. This position is responsible for leading the IT initiatives of the hospital while optimizing use of operating resources and capital financial resources to ensure efficient operation and proper support of clinical and administrative functions. The VPMIO facilitates the overall information management processes of the hospital, as well as the promotion and implementation of these processes, as they relate to the medical staff. The VPMIO must be a visionary and maintain a “hands on” understanding of information technologies.

Required Education: Medical Degree. Board certification in chosen medical field. Preferred Education: Master’s Degree in Medical Informatics, Management and Information Systems, Information Technology, or related field. Required Experience: Five years healthcare experience in an executive leadership role. Preferred Experience: Previous experience in executive IT role—CIO, Director of Medical Informatics, etc.

Now here is an organization that knows what it's doing in clinical IT.

-- SS

Now, doctors DO things with computers

In my writing I've long called for substantive leadership roles and titles for medical informaticists in healthcare, where the attitudes are slowly evolving from the "doctors don't DO things with computers" attitudes (meaning they should be advisors or internal consultants, not leaders) I observed in entering medical informatics. At long ago as 1998 I wrote in a piece called "Ten critical rules about job structure and reporting for applied informatics positions" that:

"Informaticists should aim for positions at the Assistant V.P. level or higher. Director-level (or worse, manager-level) positions often lack real authority and executive presence. Such characteristics are often essential for success in a cross-disciplinary, cross-territorial area such as applied medical informatics. If a position being considered is at the director or manager level, an inquiry as to why it is rated at such a low level may be helpful in understanding the true feelings of the senior executive team about medical informatics leadership."

Today, March 24, 2005, for the very first time (in my personal experience) I've seen a healthcare organization actually offer an informaticist an advanced title: VPMIO.

Position Title: Vice President, Medical Information Officer (M.D.)
Organization Name: (witheld)
Location: (the South)

Job Description: Multi-specialty medical center located on the Gulf of Mexico, in one of the fastest growing areas in the South, seeks an experienced Vice President – Medical Information Officer. This modern facility, with over 400 beds, is in the forefront of modern healthcare delivery with a medical staff comprised of nearly 300 physicians representing more than 40 medical specialties. This hospital offers some of the most advanced information technology and medical services available in the country. The Vice President – Medical Information Officer (VPMIO) is a member of senior management and is responsible for IT strategic planning, medical informatics, and clinical implementation of data, information and knowledge.

This position reports directly to the Chief Executive Officer and frequently works in coordination with the Director of Information Systems. The VPMIO serves as a liaison between the administrative and information technology planning groups. This position is responsible for leading the IT initiatives of the hospital while optimizing use of operating resources and capital financial resources to ensure efficient operation and proper support of clinical and administrative functions. The VPMIO facilitates the overall information management processes of the hospital, as well as the promotion and implementation of these processes, as they relate to the medical staff. The VPMIO must be a visionary and maintain a “hands on” understanding of information technologies.

Required Education: Medical Degree. Board certification in chosen medical field. Preferred Education: Master’s Degree in Medical Informatics, Management and Information Systems, Information Technology, or related field. Required Experience: Five years healthcare experience in an executive leadership role. Preferred Experience: Previous experience in executive IT role—CIO, Director
of Medical Informatics, etc.

Now here is an organization that knows what it's doing in clinical IT.

-- SS

Wash. Post on Cedars-Sinai CPOE failure

For anyone who doubts clinical IT is an area where angels fear to tread, there's this story in the Washington Post:

Cedars-Sinai Doctors Cling to Pen and Paper
By Ceci Connolly, Washington Post Staff Writer
Monday, March 21, 2005

Excerpts, with notable passages in bold and my interspersed comments in italics:

... For every doctor, nurse and executive here, there is a different explanation of what went wrong. The technology, created in-house, was clunky and slow. Only a fraction of the 2,000 doctors with privileges at the hospital were involved in developing the system, even though they faced a dramatic change in the way they practiced medicine, from jotting notes on a clipboard to logging onto a computer to type in their treatment and medication orders. Training was insufficient, and administrators opted for what Hackmeyer called a "big bang" implementation rather than switching one ward at a time.

Now, two years later, the hospital often viewed as an industry leader is being held up as a cautionary tale in the drive toward bringing medicine into the computer age, and officials here say they have no intention of trying again for at least a year.
(note: my opinion on their initial remediation plans were published in Health-IT World in Sept. 2004 -- SS)
The marriage of information technology and medicine is all the rage in health policy circles. Five years after the Institute of Medicine issued a landmark report cataloguing the life-and-death consequences of medical errors, corporate leaders, politicians and physicians are embracing computer-assisted health care.

Yet the spectacular failure at Cedars-Sinai -- described by Bush's technology guru as "the worst case" he has seen -- demonstrates how difficult it can be to make the transition. Even well-financed, sophisticated hospitals face enormous hurdles moving from the Marcus Welby era of pen and paper to one in which doctors spend precious minutes entering data into a machine that never went to medical school and does not have the flexibility to make nuanced judgment calls.
(Neither did most of the IT people developing and leading implementation of such machines, but that seems a problem that is rarely addressed -- SS.)
... "The important lesson of the Cedars-Sinai case is that electronic health record implementation is risky," David J. Brailer, national coordinator for health information technology, said in an interview. "Up to 30 percent fail."
(We're talking billions of dollars of capital and expense dollars that hospitals simply do not have an abundance of -- SS)

... Each time a patient arrived, pulmonary specialist Andrew S. Wachtel would have to find a computer (preferably one of the newer, faster ones), log in and begin checking boxes in at least a half-dozen categories to indicate the patient's symptoms, allergies, diagnosis, tests and medications. A task that once took three minutes to scribble shorthand at the patient's bedside suddenly devoured 30 to 40 minutes, he said.
(Reminds me of the passage in the book "House of God" about finding a medical student who only triples an intern's work - SS)

... even techies found flaws. The system refused to recognize even slight misspellings, so Hackmeyer's efforts to order the laxative Dulcolax -- easily understood by nurses even if he was off by a letter or two -- were thwarted by the computer. It was also impossible to use it to order "clear liquids and advance diet as tolerated," another routine instruction when easing a patient back to solid foods, he said.
(Even Microsoft Word does a better job on typos than that -- SS)
... But the biggest complaint -- with potentially dangerous implications -- involved the automatic alerts that flashed on the screen every time a doctor made an out-of-the-ordinary request. Designed to catch errors before they occur, the alerts became an unending series of questions, reminders and requests on fairly basic decisions.
Infectious disease specialist Stephen Uman said he went around in circles trying to give patients the antibiotic Vancomycin. Although the recommended dosage is 928 milligrams, Uman knows to round up to 1 gram because pharmacies dispense the medication in multiples of 250 milligrams. But when he typed 1 gram into the computer, the machine rejected the request.

Cedars-Sinai was unable to strike a balance between useful computer warnings and a machine that seemed to constantly cry wolf, acknowledged Harold, the former chief of staff. "Buried in those annoying alerts is probably one life-saving alert," he said.
("Unable" to strike a balance? That sounds like an interesting story in itself. -- SS)
... Even with that data, Cedars-Sinai is in no rush to try again. The hospital is waiting for the technology to improve and perhaps for more young, tech-savvy doctors to arrive. In the meantime, Neil Romanoff, the physician who oversees safety procedures here, said the hospital relies on extra layers of staff to double- and triple-check its procedures.

The technology will improve when those behind it have a better grasp of the complexities of medicine. Pioneers in EMR such as Morris Collen, Donald Lindberg, Octo Barnett, and others published guidelines on how to best implement clinical IT that warned against the cornucopia of problems mentioned in this article. Sadly, they did so starting in -- and perhaps even before -- the 1960's.
A good source on references to the wisdom of the pioneers is "A History of Medical Informatics in the United States 1950-1990, by Morris Collen MD, section 3.4. For example, Octo Barnett's clinical IT "10 Commandments" (written in 1970) as reproduced in Collen's book on page 169, as well as 1960's and 70's material by Lindberg, Lamson, Collen, Davis, Baker, and numerous others address many of the substantial problems encountered by Cedars-Sinai in 2003 as documented above.

Medical informaticists are specifically educated in the necessity of minimizing the problems mentioned above, I should add, yet often are not sufficiently empowered to effect change. In my case, efforts to avoid such issues in clinical IT projects were often resisted by IT personnel who "knew better" than the "informatics guy" whose ideas were "way out there" (the actual words of an executive in charge of IT, as reported to me by people who disliked his micromanagerial and bullying style. Of note, that executive is now a CEO at a major healthcare facility).

-- SS

Clarification on VA Hospital System IT initiatives

In response to my postings on the Penn CPOE controversy such as here, where I included a reference to the Bay Pines VA Hospital IT system failure, a VA official involved in IT pointed out that this system, known as CoreFLS, was a financial IT system, not a CPOE or clinical IT system.

I should clarify that the VA’s VistA system and its EMR module (CPRS) are exceptionally well-regarded in the healthcare IT community and are actively promoted by the open-source community especially, and are distinct from the CoreFLS initiative.

I should also point out that my critiques are not of CPOE or EMR or clinical IT in general, but of the leadership model of healthcare IT.

(Note: I define clinical IT as IT utilized in actual clinical interactions between a provider and patient such as EMR, CPOE, decision support, enduser clinical data repository, concurrent-care knowledge management apps, etc. Healthcare IT is a broader domain that subsumes clinical IT but also includes Management Information Systems or MIS applications in hospitals, such as financial, registration, master patient index and other administrative systems. Others' precise definitions may vary.)

My opinion on healthcare IT leadership is summarized by a major point I raise in my web site on Healthcare IT failure :

"The belief that mastery of IT process and repetition for management information systems implementation entitles IT personnel to lead and control implementation and operationalization of essential tools in complex domains such as medicine (for example, electronic medical records systems) is presumptuous and creates an environment strongly misaligned with the business of healthcare delivery."

I consider an enterprise hospital financial system to be an essential tool for healthcare delivery. In my website on Healthcare IT Failure, I presented another example of a situation where mismanagment of a healthcare financial system by those without clinical knowledge led to dire consequences: "Insufficient IT management depth results in Justice Department investigation."

I included the CoreFLS failure in my critiques of healthcare IT leadership based partly on the fact that the failure of that financial system had a major impact on clinical operations at Bay Pines due to resulting inventory ordering problems (preventing surgery from being performed, for example), and partly on an article in The Tampa Tribune, "VA Faults Training At Bay Pines" (Richard Lardner, Mar 24, 2004) that states, among other factors:

… the VA inspector general released an interim report of an investigation into Bay Pines and CoreFLS. The report criticized weak hospital leadership, poor staff training and ``serious deficiencies'' in the sterile surgical supply process. Before joining the department, Campbell [VA assistant secretary for management] was chief financial officer for the Coast Guard, where he oversaw the implementation of a system similar to CoreFLS. ``It is a failure on my part, having done this [implemented a financial IT system] at another agency [Coast Guard]. I did not anticipate the complexity [of the system] and the difficulty of training,'' he said.

My point is that one might not anticipate the complexity of healthcare environments when one is not a healthcare professional. The admission of a project leader of a major IT initiative not understanding the complexity of a healthcare environment is an illustration of what I've been teaching in medical informatics for a number of years, that multidisciplinary training that includes a healthcare background helps a person better understand the complexities of healthcare.

Hence my view is that high-level leadership roles in healthcare IT initiatives (and especially clinical IT initiatives) should be very carefully defined with regards to experience and skill sets.

Organizations that ignore this do so at their peril, in my opinion, and sooner or later I predict provider-side and R&D sector (e.g., pharma) litigation that will be based on patient harm and/or financial losses that result from inadequacies in healthcare IT leadership.

-- SS

Massive Health Care Waste? - Follow-Up

For Kling's response on the EconLog blog to the post below about waste in health care, go here. (For some comments on his Tech Central Station article, go here.) He raises some interesting issues on the cost of old technology versus "high technology." It will be interesting to see whether this generates any comments from those more expert in the economics end of this.

Is Massive Health Care Waste a Myth?

There is an interesting contrarian piece on the costs of health care by Arnold Kling on Tech Central Station, which was also picked up by Tyler Cowen on Marginal Revolution.

Like some other comments by libertarian economists on health care, I found it intersting and provocative. I also found myself agreeing with some, and strongly disagreeing with other points he made.

To summarize, he contends that the US spends more than other countries on health care, but also provides significantly better health care. He thinks that the "usual subjects" rounded up in arguments to support the massive inefficiency of US health care are not guilty as charged. These suspects include spending on the last year of life, drug company profits and overhead, and administrative overhead. Finally, he thinks we spend too much on physician compensation and high-technology procedures.

My comments, point by point, are

• Paying More to Get More - I think this idea is defensible, and I would like to see it discussed better and more often in the medical and health care literature. Surely, we can now cure illnesses that we couldn't cure before, and we can substantially improve the lots of patients with many other illnesses whom we couldn't effectively treat in the past.
• Spending in the Final Year of Life - His arguments are reasonable, and again, I would like to see this issue discussed more clearly and rationally in the literature, with a bit more attention to the clinical context and the clinical epidemiological issues.
• Drug Company Profits - This industry is often made into the bogey-man. In our criticisms of it, we should not ignore the fact that the industry provides us with many of the means to treat illness and alleviate suffering that we use to such good effect. On the other hand, their have been numerous abuses perpetrated by drug companies, some of which we have discussed on this blog. Furthermore, this is a bit of a straw man argument. I do think that if one considers the total profits and overhead not only of drug companies, but also of device manufacturers, information technology providers, managed care and health insurance companies, hospitals and hospital systems, and all the other miscellaneous players in our horribly complex US system, they would clearly in toto be excessive. Then, if you consider the various ways some of these organizations have acted in conflict with physicians' core values, the problem is even greater.
• Administrative Overhead - Admittedly, the data about this issue is not very good. But I suspect the reason it is not very good is that researchers have been timid about addressing the issue, not because there is not a lot of administrative waste and inefficiency. My personal observation is that physicians, especially primary care physicians are drowning in paperwork and bureacracy, and so are hospitals. I did find one study of interest. MGMA compiled detailed data on the administrative and bureaucratic tasks that physician group practices must perform. They found that group practices were spending about $24,750 per physician on some specific "unnecessarily complex or redundant administrative tasks." I suspect that the more researchers look for administrative and bureaucratic tasks that physicians, other health professionals, and hospitals must undertake, the more they will find. Adminstrative and bureacratic methods to control costs may cost more than they are worth. Yet the administrative and bureaucratic load on physicians seems to continue to climb.
• Physicians' Compensation - I am not sure where Kling got his numbers. My sense, and a brief web search suggests that the compensation primary care and "cognitive" physicians receive is comparable to that of physicians in other developed countries. For example, here is data on the compensation of UK physicians in 2002. Note that consultants, i.e., physicians who have finished their hospital training, get from 52,000 to 133,000 pounds sterling. On the other hand, here is data on average levels of physician compensation in the US in 2002 by specialty. Note that internists, family practitioners, and pediatricians average about $150,000 to $160,000. Correcting for the exchange rate in 2002, this would have been quite comparable to what UK physicians got. Of course, "procedural" specialists like anesthesiologists got much more. Kling suggested reducing physician compensation to levels comparable to those in other developed countries. My best guess is this would have little effect on "primary care" and "cognitive" as opposed to "procedural" physicians, perhaps even raising some of their pay. It would have major effects on "procedural" physicians. Its effect on total health care costs would be considerably less than Kling expects.
• High-Technology - Here I suspect Kling is very much on target. The question is why such interventions are so expensive. It's interesting that the examples he used, CT scans, MRI scans, and open-heart surgery, were of technologies developed 30+ years ago. CT scans, for example, were developed in the 1960's by Sir Godfrey Hounsfield. So his examples are actually of mature, not "high-" technologies. Outside of medicine, the price of technologies drop as they age. Admittedly, there have been many incremental improvements in CT scans, but there have been no revolutionary changes. In particular, the "C" in "CT" stands for computer. CT scans use computers to process multiple x-ray images into the images of body slices which we are familiar. The original CT scanners used main-frame computers to do the image processing. Main-frames were very expensive in the 1960's. Yet now one can get a personal computer that is just as powerful for a many orders of magnitude lower price. Since a large part of the expense of CT scanning used to be computer hardware and software, why hasn't the price dropped like the prices of other computer hardware and software? The biggest failure of managed care and government efforts to control costs seems to be their failure to address the huge costs of "high-" or old technology. One possible explanation is that the people charged with controlling costs in managed care organizations and the government don't really understand the technologies for which they pay. Thus, they don't realize it when specific ones are drastically over-priced.

I hope we can engage folks like Kling in some creative thinking about ussues like this related to health care dysfunction.

BC/BS employs non-credentialable person to do their credentials

I couldn't invent a better story.

BC/BS of Mass,( and many other health plans across the country) use a credentialing service for radiologists called: Radiology Management Sciences, LLC. Finding them is difficult as they operate in stealth mode, but the are apparently located in Menlo Park, Calif.

They are ? owned by, and certainly run by, one Stephen Bloch, MD.

Bloch has his bio on the net on the website of his venture capital firm, www.canaan.com/team_bloch.html . Bloch is listed as someone who "was a practicing radiologist".

Going to the website of the Mass Medical Board, one finds from his profile that Dr. Bloch is NOT board certified in radiology. It is odd that someone would complete the Mass General program in radiology and not get boarded, isn't it? Maybe he didn't finish? I don't know.

I phoned Dr. Bloch, after he signed a letter of denial for credentials for radiology for my office (we employ boarded radiologists to read our films, but BC/BS wants me to apply for credentials, which they won't grant since I'm an internist). I caught him in his Connecticut VC office, busily doing VC work. Guess what, Bloch never read my letter of appeal from their rigid rules. We have quality films, done in a state-licensed facility, done by licensed techs, and read by boarded radiologists. The issue was how to bill for this service without making the patients jump through hoops. Bloch didn't even see my letter, yet he sent a letter to me denying my appeal.

Another gem I gleaned from Bloch's bio is that the he founded TeleRad, a teleradiology services company.

I guess that means he might compete with those he credentials (or doesn't).

I suppose one might conclude that he might have a bit of a conflict of interest.

Bloch and Co. wrote a paper in Radiology in 1999 where they indicated that they save 2% of total radiology costs by denying credentials to some people. They claim this is all for quality, but don't show how quality was affected by their denial. Thus, the health plans must like Dr. Bloch, and Dr. Bloch noted in his paper that the cost of his program is only 20% or so of the savings. Thus, the health plans save 1.8% on radiology costs by employing him. Measured across all the radiology expenses this is a large number.

I'm all for quality measures and ensuring quality. But should it be on the backs of doctors like me who are trying to do the right thing, but just don't fit the box BC/BS wants to keep us in.

Last time I checked we still had free speech in this country. If anything I've written is not factual I will be happy to correct it upon presentation of evidence that I am incorrect.

These are the opinions of:

Robert S. Baratz, MD, PhD, DDS

On the Terri Schiavo case

On the Terri Schiavo case, I post a question above and beyond its being taken over from clinicians (as seems to occur in healthcare more often in the past few decades) by politicians and lawyers:

In my medical training and experience, while feeding tubes may have been removed from terminal patients (e.g., with cancer or post-stroke), an IV with basic fluids was not.

To my knowledge, Ms. Schiavo is not receiving IV fluid hydration such as normal saline solution. If anyone knows differently, please correct me.

The body loses significant fluid each day from respiratory losses, perspiration, etc. Without replacement, death will occur via dehydration long before it occurs from starvation.

Dying of dehydration was considered inhumane, at least in the medical world I trained in. I ask, somewhat rhetorically, if this has changed in the past decade since I left clinical practice for Medical Informatics.

-- SS

My opinions on Penn CPOE controvery published in Health-IT World

My opinion piece on the JAMA article on the Hospital of the University of Pennsylvania's CPOE system problems has been published in Health-IT World. My piece is at "HITW Readers' Take on JAMA's CPOE Article" (second item).

They published almost verbatim my hcrenewal blog posting that I submitted for Health-IT World's consideration. They have published opinion pieces from me in the past.

I have yet to hear from JAMA on publication of a similar letter to the editor I submitted.

-- SS

What Mercy Will the Uninsured Patients of Mercy Health Systems Get?

A story from Arkansas about hospitals billing uninsured patients at higher "rack rates" than they bill insured patients contains some important insights about this increasingly recognized problem.
Lawyers for St. Mary's Hospital, one of the hospitals under fire for its billing practices, defended its actions thusly, "Just as a company that buys 100 widgets from a seller will get a better price than a company that buys just one widget from the seller, a managed care plan that 'buys' St. Mary's services for hundreds of patients can legitmately expect to pay less for St. Mary's services than patients such as plaintiffs who buy St. Mary's services only for themselves."
The analogy is not a good one because one can produce a lot of widgets at a cheaper unit cost than one can produce one widget. But health care must be customized for each patient, so how would knowing that a group of patients are insured by a particular company lower the costs of caring for them enough to justify a volume discount?
Furthermore, the communications director for Mercy Health System, of which St. Mary's is a part, said the system agrees with "the American Hospital Association's stance on the issue of uninsured billing." That stance is apparently that the federal government should keep its hands off the issue. On the other hand, former Secretary of Health and Human Services Tommy Thompson wrote to the AHA that "hospitals charging the uninsured the highest rates is a serious issue that demands all of our attention." He called the AHA's position "not correct and [it] certainly does not reflect [Health and Human Services] policy.... I strongly encourage you to work with the AHA member hospitals to take action to [end the situation] where ... uninsured Americans and others of limited means are often billed and required to pay higher charges."
But the real issue here is not the pricing of widgets, or even whether the federal government or the states should have roles regulating the prices hospitals charge uninsured patients.
Mercy Health System's mission statement says that it "is committed to the ministry of health and healing for all God's people, with particular concern for the economically poor." By charging the uninsured the full rack rate, and then vigorously defending this pricing scheme as documented above, the hospital and system leadership appears to be in fundamental conflict with their own stated worthy mission.
This is another striking example of a fundamental problem in the US health care system (and perhaps in other countries as well.) Health care organizations' actions are more and more in conflict with their stated values.
So what mercy will the uninsured patients of Mercy Health Systems get?
(Thanks to the Health Business Blog for the reference to this article.)

Generous CEO Compensation and Corporate Governance

Re some previous posts in which we noted that managed care CEOs who publicly champion cutting health care costs often seem to command disproportionately high personal compensation (e.g., see the posts here on United Healthcare and here on Harvard Pilgrim)....
The NY Times just ran a commentary by Nicholas Kristof about how exceedingly generous levels of CEO compensation seem to better correlate with corporate governance problems than with corporate financial performance. (Some of the scholarly articles he mentioned can be found here, by Grinstein and Hribar, and here, by Bebchuk and Fried.) One striking figure he mentioned was that public corporations now devote 10% of their total profits to the compensation of their top five managers, up from 6% in the 1990's. Also, "another study found that of the 1,000 largest companies, two-thirds claimed to have outperformed their peers. That's the 'Lake Wobegon effect': all CEOs in America are paid as if they were above average."
In that context, managed care CEOs with million dollar plus compensation packages berating physicians and patients for excess health care costs just adds insult to injury.

AMIA on the JAMA CPOE article controversy

A reasonable assessment of the recent CPOE controversy by Don Detmer, MD, the President and CEO of the American Medical Informatics Association, is below. He writes that healthcare IT is of great value, is moving forward, and that those in clinical IT need to rigorously assess issues and problems and correct them iteratively, as in any evolving field. He is confident that AMIA and its researchers, clinicians, and educators are committed to these objectives and will continue to raise the performance bar for clinical IT. I heartily agree, as does Ross Koppel, the author of the AMIA article that caused the controvery on CPOE (see the end of this blog entry).

A Statement from the AMIA President and CEO
March 15, 2005

In politics and marketing it is often said, “all headlines are good headlines.” There certainly have been a lot of headlines lately about health care IT. The March 9 issue of the Journal of the American Medical Association included two articles on the state of computerized clinical decision support and computerized physician order entry systems and an editorial on the state of computer technology in clinical work more generally (Garg et al., 2005; Koppel et al., 2005; Wears and Berg, 2005). And this week, the British Medical Journal published the results of an extensive review of clinical decision support systems while AMIA announced the availability of a white paper on clinical decision support in electronic prescribing (Kawamoto et al., 2005; Joint Clinical Decision Support Workgroup, 2005).

The JAMA articles as well as those in the BMJ have generated a lot of interest and debate within the medical informatics community. A careful reading of these articles provides us -- the developers, purchasers, users, and advocates for these system -- with a fresh perspective on how to evaluate our past efforts and frame our future work. Some readers can miss what may be the deeper message of the recent JAMA articles and editorial. As a result, they may reach the conclusion that once again the information technology in health care has been oversold and that there is no reason to attend to or invest in the current generation of information technology. I would in particular like to take issue with Wears and Berg’s suggestion that computer technology and clinical work are like Estragon and Vladimir of Beckett’s Waiting for Godot. Although we are by no means where we want to be with respect to the development and implementation of electronic health records, clinical decision support, computer physician order entry systems or a national health information infrastructure, we are also by no means still in the same place as where we started.

Progress in any complex environment comes in steps, but progress has been achieved over the past two decades. The progress in computer-based health records is now sufficiently successful that newer versions of older legacy systems such as those reviewed in JAMA have left the centers of these early adopters and innovators – the enthusiasts – and are entering mainstream care. Meanwhile, some of the innovating institutions are just now upgrading from their legacy systems. Like the older systems, these newer ones also involve substantial transformations in practice behavior. And, like the older systems, the newer ones also come with human adaptation risks that sometimes create new problems as well as new solutions. Further, there is always pushback from those clinicians who simply don’t wish to change. Historically, most substantial changes to clinical practices that are resisted by clinicians appeal to a concern that the quality of patient care is being compromised. This was noted as long ago as the origins of the use of the stethoscope.

Not all change is progress, but some of it actually is. The informatics community does need to keep its focus not upon simply putting heretofore paper processes into a computer format but to redouble its resolve to create evidence-based applications that do indeed transform care by involving patients themselves in utilizing personal health records, by enhancing safety, by increasing the timeliness of care through use of the Internet, and by enhancing efficiency. Further we need to continue to reinforce the message so aptly stated by Wears and Berg, “any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at the organizational level and the national level …” Thus, we must continue to advocate for other system changes that are needed for health care transformation – including the creation of appropriate incentives through reimbursement mechanisms and a workforce trained to use developing information technologies effectively.

While there is much work yet to be done, the optimism remains that the use of communications and information technology will greatly improve both care and human health. Emerson noted that in nature, nothing is free. While there are real prices to be paid as a result of experimentation, at time things actually do get better. What we need to do is to continue to assess rigorously the balance between the sunny and shady sides of IT innovation and ‘stick to our knitting’. I am confident that AMIA and its researchers, clinicians, and educators will remain committed to these objectives and will continue to raise the bar for our performance.

Don E. Detmer, MD, MA, FACMI
AMIA President and CEO

The only addition I'd make to Dr. Detmer's assessment would be to the statement "any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at the organizational level and the national level." I would add that "organizational change" should include investigation into change in the leadership and management of clinical IT projects towards leadership by cross-disciplinary experts, in recognition that those solely of a Management Information Systems (MIS, or business computing) background often do not have adequate knowledge and expertise to effectively lead major change trajectories in scientific computing, of which clinical computing is a subset.

It has often seemed unreasonable to me that the leadership and process models of business computing could be deemed adequate for the needs of major change trajectories in clinical medicine. Via an internet collaboration several years ago, I and other medical informaticists documented our own examples where the unidisciplinary MIS leadership model has not only been inadequate, but actually harmful.

I think the Koppel JAMA article does reflect what happens in real life in today's medical centers. The UPenn authors advise appropriate caution in implementing any clinical IT. They state that "with any new technology, initial assessments may insufficiently consider risks and organizational accomodations." I agree. It then goes on to suggest how organizational and risk issues should be handled, including the "need for continuous revisions and quality improvement."

It's not simply a question of obsolete software versioning either, as some have stated. As Joan Ash, Ph.D. noted at Oregon Health & Science University in a 2003 study “Most hospitals don't use latest ordering technology” (http://www.eurekalert.org/pub_releases/2003-11/ohs-mhd112403.php ), "patient care information systems like CPOE also can create unintended or "silent" errors, according to a separate study conducted by Ash and colleagues in The Netherlands and Australia. This study also was published in the online version of JAMIA.

The study's authors divide these silent errors into two main types: errors during data entry and retrieval, and errors in the communication and coordination process. Both types of errors occur because the systems simply don't take into account the work atmosphere most health care professionals experience, according to Ash, also lead author of this study ... "many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients. Instead these are designed for people who work in calm and solitary environments … some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."

Attempts to develop a CPOE system internally, such as at Cedars-Sinai Medical Center in Los Angeles, have also not been entirely successful (AMA News, Feb. 2003, "Doctor Pull Plug on Paperless System"), subtitled "California's Cedars-Sinai turns off its computerized physician order entry system after physicians revolt, demonstrating that implementing new technology is easier said than done." I was not sanguine about the planned remediation attempts, either ("How to Avoid CPOE Failure a Second Time"), which seemed more focused on the traditional MIS "process analysis" than on the organizational and sociotechnical issues that likely led to unusability and revolt in the first place. As Berg noted, "The depictions of the formal workflow of medical work are often not realistic; for example, the task boundaries between doctors and nurses are not always tightly drawn. Translating professional knowledge and workflow processes into some automated record is not impossible, but much care and evaluation must be taken for it to not be hazardous to a healthcare environment." ("Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context", Berg M. et al, International Journal of Medical Informatics, 1998;52:243-251)

An interesting collection of related articles on sociotechnical aspects of clinical IT can be seen via a PubMed search initiated by clicking on this link .

I think any controversy about the UPenn article is coming from emotions, not logic, as a result of the Penn authors having critiqued "established wisdom" (i.e., dogma) on CPOE, and from vendors who see it as putting even more doubt in the minds of capital-strapped hospital executives.

In other words, it is a political controversy, not a rational, scientific one.

The article "Experts Expect CPOE Adoption To Continue Despite Study on Errors" by Fanen Chiahemen, iHealthBeat staff writer, is also worthwhile. Of note are the following excerpts:

Ross Koppel, a sociologist at the University of Pennsylvania School Medicine and the study's lead author, conceded that there initially was some fear that the health care industry would now "go slow" on CPOE adoption, but he said "that would be like throwing the baby out with the bathwater." Koppel said that the study was not intended to discourage the adoption of CPOE and that the authors are in favor of the technology. "We're very much pro-CPOE, but we're against arrogant CPOE," Koppel said. "Do I want to go back to a system where somebody scribbles on a piece of paper? No," he added.

... Paul Tang, the chief medical information officer at the Palo Alto Medical Foundation, said he hopes the study will increase awareness about what is required to implement IT in health care. "Successful implementation of CPOE and realization of the safety benefits from using the technology requires good software design, a clinically led implementation effort and good training," he said. "It would be a shame if we lost sight of the lifesaving potential of CPOE because of a report of one experience in which many of the critical success factors -- good product design, good implementation strategy and good training -- were not in place," he said.

Wears said training plays a role in enhancing the effectiveness of such systems, but he believes the real issue is better system design. "If you need a lot of training to take young, computer-savvy, highly motivated people to get them to use this thing to do their work, that should tell you something," he said. "These are not the kind of people that should normally take a lot of training if the tool actually helps them," he said.

Building on that notion, Suzanne Delbanco, CEO of the Leapfrog Group, said the study could put a little bit more pressure on vendors to develop systems that have all the capabilities that benefit patients as much as possible.

However, [Upenn author] Koppel stressed that even new systems have to be thoroughly investigated and constantly evaluated because "every change has cascading changes." He said he has been looking at some new systems that have "tons of foolish programming and poor integration issues." Therefore, health care practices that choose to adopt CPOE not only have to closely monitor how physicians and nurses use the systems, but they also have to "be a lot more humble and a lot more vigilant," Koppel said.

I strongly agree with that assessment. I also believe Medical Informatics specialists (MD's, PhD's, nursing informaticists, etc.) need to take genuine leadership roles in clinical IT initiatives if these initiatives are to succeed in a time frame and at a cost acceptable to those who provide the capital and expense dollars. By leadership I mean substantive control of vendor product evaluations, project hiring (including personnel evaluations), major decisions affecting clinical care, and other factors that distinguish leaders from what I once termed "Directors of Nothing."

The MIS mantra "doctors don't do things with computers" may or may not have been appropriate in the days when the MIS department was referred to as "Data Processing", but as I pointed out in a 1998 webpage on stereotypes of medical informaticists, is entirely inappropriate today [note: I have not maintained that old site; some links will not work]. This is especially true now that the U.S. and other countries such as the UK are embarking on national EMR initiatives.

-- SS

Students Warned of Lawsuits for Failing to Tell Patients That They Are Fat

From the Washington Times, trial lawyer and George Washington University Professor John Banzhaf III warned students attending the American Medical Student Association meeting that they could be sued if they fail to tell their obese patients that they obese, or do not advise "appropriate treatments or behavioral programs" (apparently regardless of the data that currently available weight loss programs and treatments are rarely very effective.)
Banzhaff also said "unfortunately, one of the ways to make serious changes in society is through a lawsuit." Whether such changes would be good or bad is another question. And how much money lawyers might earn from such lawsuits, given the prevalence of obesity, is another.
Now all we need is to find out that someone has sued a physician for low self-esteem after being informed he was fat ;-) Actually, that's not funny at all.
But this is just another nearly ludicrous example of how physicians and patients can be caught in the cross-fire among powerful forces that may really not have the patients' or physicians' best interests at heart.

BJC HealthCare Drops United Healthcare Contract Over "Garbage In, Garbage Out" Pay for Performance Plan

The St. Louis Post-Dispatch reported that the area's largest hospital system, BJC HealthCare, is terminating its contract with the United Healthcare managed care organization because of objection's to United's new "pay for performance" program. This program is supposedly a response to "employers' frustration over the inconsistent cost and quality of health care in the face of rapidly rising costs." (Its another question whether a company like United is really focused on cutting costs, given that its CEO, William McGuire, made over $7.5 million in 2003, plus over $84 million profits realized on stock options, according to American Medical News.)
Be that as it may, hospital leaders suggested that United's methods for assessing performance amounted to "garbage in, garbage out." Problems with the plan included inability to determine which doctor of a multi-physician group should be linked to a particular patient's data, unavailability of any quality data for certain patient conditions (so that physicians who see patients with those conditions would only be rated on "efficiency,") failure to adjust outcomes data for differences across physicians in patients' characteristics, and over-emphasis of cost over quality data. So "pay for performance" here looks like it might just lead to perverse incentives.

Telemedicine in Decline?

Telemedicine in Decline? What does that even mean? Decline from what? Did we ever really have it?

Nonetheless, the National Health Service of the UK is to be commended for truth-telling. In a study authored by Carl May of Newcastle upon Tyne for the prestigious Economic and Social Research Council, we are told that

"Telemedicine'" is disappearing, in stark contrast to the apparent
success of telephone services on which clinical staff decide the urgency of
patients' injuries or illnesses, and advice lines such as NHS Direct.

While we may ask whether telemedicine--the putative benefits of real-time, technology-enhanced health-care-at-a-distance that were hugely touted in the mid- to late-1990s--was ever anything more than chimerical, we may still laud this ESRC group for its exercise in truth-telling.

We may also be tempted to extrapolate. Are other technologies--even, shudder, the Electronic Health Record (EHR) itself--susceptible to this same sort of phenomenon? If so, the corrective came, in part, from the recent JAMA piece on the EHR's limitations. That it had some validity and hit a nerve was evident from the instant, vociferous backlash from the vendors, via HIMSS--all of whom think this is, finally, their Big Day.

Which, in some way, undoubtedly, it will be: 2005-2006 may be the Year of the EHR, which now seems inevitable despite many problems with EHR implementation. And this makes us wonder why telemedicine is looking like the Betamax to the EHR's VHS--all the while even more wondrous high-tech gizmos are being assayed over in Iraq despite many troops' lack of basic low-tech armor.

(But see Don Detmer's well reasoned riposte from the loftier reaches of AMIA, on the subject of the EHR.)

What shall we call this phenomenon? Some might call it the Triumph of the Technocentric over the Infocentric and the Human-centric models of information use. Others might just call it the Triumph of Greed.

Despite which, Don Detmer's and other's pleas are probably valid: don't throw out the baby with the bath water. At least for the EHR. But maybe it would be ok if we had a little more body armor and a little less telemedicine.

Hospital Leaders Leery of Error Reporting

I've observed, and lecture on, the behavorial "drivers" of stakeholders in clinical IT such as the EMR. In my talks I speak of a resistance of hospital executives at the C-level and in middle management (including medical staff) towards clinical IT on the basis of what I term the "report card fear." This fear involves the exposure of medical errors and the effects on a medical center's reputation, with all that implies. In that light, I find this article interesting and confirmatory of my empirical observations:

Hospital Leaders Leery of Error Reporting
Tue Mar 15
By LINDSEY TANNER, AP Medical Writer

CHICAGO - Many hospital administrators are leery of the push toward mandatory reporting of medical errors, saying such practices will lead to more lawsuits and ultimately less openness without improving patient safety, a survey found.

The 2002-03 survey of 203 chief executives and chief operating officers was published in Wednesday's Journal of the American Medical Association . More than 80 percent said if reporting to a state agency were required, the identities of the offending hospitals and doctors should be kept confidential.

Almost 70 percent said a state-run, mandatory, nonconfidential reporting system would make doctors and other hospital staff less likely to reveal their own errors.

Only 28 percent said a nonconfidential system would benefit patient safety, and 79 percent said such a system would encourage lawsuits, despite evidence that patients are less likely to sue if doctors admit their mistakes and apologize.

"That message has not gotten out to the hospital community," said lead author Joel Weissman, a researcher at Massachusetts General Hospital's Institute for Health Policy.

At least 21 states had mandatory reporting systems when the study was conducted and at least 11 protected the confidentiality of those involved, the researchers said.

The Institute of Medicine, an independent group that advises the government, in 1999 recommended establishing both mandatory and voluntary reporting systems to reduce medical errors, which it said kill up to 98,000 hospitalized Americans each year.

Dr. Carolyn Clancy, director of the federal Agency for Healthcare Research and Quality, which funded the survey, said the findings highlight the conflict facing hospital administrators.

"There's a big push for transparency" in health care, Clancy said. And while patients should be told about errors, she said, whether that information should be made public is an open question.

Dr. Peter Slavin, president of Massachusetts General Hospital, said mandatory reporting promotes accountability, but if done with the intent to punish, it can "send a lot of people underground" and make them reluctant to disclose a mistake.

"The real challenge is finding the right balance," said Slavin, who was not surveyed. Administrators in Colorado, Florida, Georgia, Massachusetts, Pennsylvania and Texas were surveyed by telephone.

Participants from states that had mandatory reporting were generally more supportive of nonconfidential reporting than those from states without, Weissman said. "Familiarity breeds acceptance," he said.

When presented with hypothetical scenarios about medical errors, nearly all participants said they would tell patients and the state, if mandatory reporting existed, about errors resulting in serious harm, such as a severe reaction to the wrong antibiotic. Fewer said they would report less serious errors.

-- SS

HealthLeaders Magazine: Do MDs or MBAs Make Better Leaders?

My belief is that physicians with appropriate cross-disciplinary expertise make better leaders than MBA's (in informatics, computer personnel) with unidisciplinary backgrounds.

Excerpts from the article:

When David B. Nash was applying to medical schools back in 1976, he informed admissions officers that he was interested in pursuing a business degree as well as a medical education. Big mistake.

Most scoffed at the idea. His colleagues ostracized him, and Nash eventually learned to keep his mouth shut when it came to the topic of business. More than 25 years later, much has changed for Nash and other physicians. No longer a pariah, Nash holds both an MD and an MBA, and is a leading advocate for combining medical and business education as chair of the Department of Health Policy at Thomas Jefferson University in Philadelphia.

The concept of the physician executive, meanwhile, has migrated from the fringe of healthcare to its core. Today's physician leaders are seen as key players in the ongoing effort to reinvent the struggling healthcare system.

This transformation of the physician executive from outcast to savior reflects a widespread belief that doctors bring vital skills to the executive suite. For one, physician leaders are more connected to the daily grind of healthcare. From a clinical perspective, they know what needs to happen. And perhaps most importantly, they have an automatic "in" with the prime moneymakers: their fellow physicians.

That being said, are physicians better suited for the corner office? Or is the MBA, whose sole career has been focused on the business side of healthcare, better positioned to run a healthcare organization in today's complex financial environment?

"Physicians have blood under their fingernails," says Roger Schenke, executive vice president with the American College of Physician Executives, an organization focused on physician-executive education. "They understand the product, they understand its delivery and they know what it's like sitting across the table from the customer. They also understand the way other physicians think. Do these attributes make them good leaders? Not necessarily. But they certainly can help."

Many industry insiders agree that physicians who receive rigorous financial and leadership training, either via an MBA program or through any of the myriad other educational opportunities available today, are just as qualified to lead healthcare organizations as their gray-suited brethren.

... there has been a substantial increase in the number of physician executives in hospital positions other than the CEO, from the chief medical officer down to the senior managerial level. "What's happening is that there is a building-up of physician executives who will be qualified to lead the hospital, so I would expect we'll see the overall number of physician CEOs trend up from here ...

... Hands-on clinical experience also is a major asset, according to Cropp of Independent Health. "Knowing what takes place in the interaction between the patient and the physician, having an understanding of what happens in a microsystem like a physician's office and what happens within the hospital...you have a better feel for where the opportunities for improvement really do lie."

... the best physician leaders understand what all good leaders come to realize: Leadership is a "team sport." This is particularly true in healthcare, given the exponentially increasing complexity of the industry, he says. "Physicians can bring value to leadership roles, but we also need to be cognizant of and understand the skills that other members of the team bring," he says. "Just as I wouldn't think of practicing medicine without competent nurses and other clinicians, I also wouldn't think of fulfilling the role I'm in now without a talented financial staff or human resources team."

Schenke, with the American College of Physician Executives, says he's not aware of any studies that have attempted to quantify the performance of physician executives. Nonetheless, 30 years in the industry has given him a few insights. "If you think of the most respected, trusted healthcare organizations in the country-Mayo, Cleveland Clinic, Mass General, Johns Hopkins-you find a physician leader at the heads of those organizations," he says. "That doesn't mean that one necessarily has to be a physician to be a good leader of a respected institution. But there is ample evidence that physicians are doing a good job."

Message to healthcare MBA's without scientific or medical backgrounds regarding this growing trend: if you want to play doctor, you need to go to medical school.
-- SS

New Study Shows Limited Use of Electronic Medical Records

Do we here have an estimated cost of the sociotechnical and organizational factors that impede Healthcare IT success? See following two articles.

Article one:

New Study Shows Limited Use of Electronic Medical Records
Wednesday, March 15, 2005

Use of Computerized Clinical Support Systems in Medical Settings: United States, 2001-03. Advance Data Number 353. 9 pp. (PHS) 2005-1250.

Less than a third of the nation’s hospital emergency and outpatient departments use electronic medical records, and even fewer doctors’ offices do, according to a report released today by the Centers for Disease Control and Prevention (CDC).

About 31 percent of hospital emergency departments, 29 percent of outpatient departments, and 17 percent of doctors’ offices have electronic medical records to support patient care, as reported in CDC’s ambulatory medical care surveys, conducted from 2001 to 2003.

The use of electronic records in health care lags far behind the computerization of information in other sectors of the economy. In health care, billing applications were the first to be computerized. Electronic billing systems are used in three-quarters of physician office practices, but computerization of clinical records has been much slower.

To help bring health care into the information age, President Bush called for the majority of Americans to have electronic health records within 10 years and established the role of a National Coordinator for Health Information Technology in order to realize this goal. “Electronic medical records and computerized systems offer opportunities to improve the quality of medical care in all settings as health care providers learn the potential of these systems and how to use them,” said Catharine W. Burt, Ed.D., lead author of the study. “The majority of ambulatory care in this country is provided in physicians’ offices but less than one in fivedoctors is using electronic medical records."

The survey measured the use of systems to improve the accuracy and safety of prescription drug use. About 8 percent of physicians use a computerized physician order entry system (CPOE), in which orders for drugs and diagnostic tests are entered electronically rather than on prescription pads. In these electronic systems, the computer compares the order against standards for dosing, checks for allergies or drug interactions, and warns of potential patient problems.

The study found younger physicians, those under 50 years of age, were twice as likely as physicians age 50 or over to use this computerized system for ordering prescriptions. About 40 percent of hospital emergency departments use automated drug dispensing systems (ADD), compared to about 18 percent of outpatient departments. Other studies have shown that automated drug dispensing systems, that operate like vending machines where the order is written and the machine dispenses the correct drug and dosage for patients, can reduce medical errors. These automated systems were more likely to be in use in emergency departments located in metropolitan areas and those with the highest volume of patients. For outpatient departments, medical school affiliation was associated with use of automated drug systems.

“While national adoption rates for health information technology are slowly climbing, we are seeing a widening gap between larger hospitals and physician groups and their smaller counterparts,” said Dr. David Brailer, National Coordinator for Health Information Technology. “Physicians and providers face many barriers to adopting health information tools. We need to create incentives for providers to adopt electronic medical records and ensure the products they buy will do the job.”

The National Ambulatory Medical Care Survey of the care provided by office-based physicians and the National Hospital Ambulatory Medical Care Survey, covering hospital emergency and outpatient departments regularly report on the characteristics of patients, including diagnosis and symptoms, as well as the diagnostic and therapeutic care provided to track trends in the patterns and quality of medical care. Items on the use of electronic medical records were added to thesecomprehensive surveys of medical care providers to track important changes in their use of information technology.

“Use of Computerized Clinical Support Systems in Medical Settings: United States, 2001-2003” is available at CDC/NCHS Web site.

Article two:

Inefficiencies Cost Healthcare $100 Billion Yearly, Says HSS

Improved coding and streamlined claims submission could save the healthcare industry upwards of $100 billion a year in unnecessary costs, a reimbursement management firm claims in a new report, America's Hidden Healthcare Crisis. However, the convoluted and ever-changing nature of payment rules, combined with the high cost and glacial pace of implementation of information technology make for a daunting challenge says the report's author, consultant firm HSS.