Wednesday, February 29, 2012

Infanticide As A Right: Killing Babies No Different From Abortion, "Experts" Say?

Holy Hippocrates...

This is nihilism at its finest. This is what happens when "education" turns into madness. Infanticide of newborns becomes a right:

The Telegraph
Feb. 29, 2012

Parents should be allowed to have their newborn babies killed because they are “morally irrelevant” and ending their lives is no different to abortion, a group of medical ethicists linked to Oxford University has argued.

The article, published in the Journal of Medical Ethics, says newborn babies are not “actual persons” and do not have a “moral right to life”. The academics also argue that parents should be able to have their baby killed if it turns out to be disabled when it is born.

The journal’s editor, Prof Julian Savulescu, director of the Oxford Uehiro Centre for Practical Ethics, said the article's authors had received death threats since publishing the article. He said those who made abusive and threatening posts about the study were “fanatics opposed to the very values of a liberal society”.

The article, entitled “After-birth abortion: Why should the baby live?”, was written by two of Prof Savulescu’s former associates, Alberto Giubilini and Francesca Minerva.

They argued: “The moral status of an infant is equivalent to that of a fetus in the sense that both lack those properties that justify the attribution of a right to life to an individual.”

Rather than being “actual persons”, newborns were “potential persons”. They explained: “Both a fetus and a newborn certainly are human beings and potential persons, but neither is a ‘person’ in the sense of ‘subject of a moral right to life’.

My observations:

1. These medical ethicists should keep their "ethics" within their own families.

2. One wonders if the current non-consensual human subjects experimentation known as "health IT" is justified by the same "ethicists."

-- SS

Addendum March 1, 2012:

We've been here before.

From another blog: Tacitus, a.k.a Publius (or Gaius) Cornelius Tacitus (AD 56 – AD 117) was a senator and a historian of the Roman Empire. Tacitus criticized the "rebels" of the time for, among other things, their refusal to kill newly born babies: . See section 5.

Such a practice was apparently no big deal then.

This "ethics" proposed at Oxford represents a return to uncivilizedness.

-- SS

Semi-Retirement of a Salesman - Weldon to Retire as Johnson and Johnson CEO

The extremely well compensated CEO and Chairman of Johnson and Johnson, the huge and recently hugely troubled US based pharmaceutical and device company, is going to retire, at least as CEO.  Reporting on this event may shed a little more light on the sorts of leadership problems that now commonly afflict health care organizations.

The Credo

Johnson and Johnson was once one of the US' most respected companies.  Its credo, written in 1943 by Robert Wood Johnson, bravely begins:
We believe our first responsibility is to doctors, nurses and patients, to mothers and fathers, and all others who use our products and services. In meeting their needs, everything we do must be of high quality.
Dishonoring the Credo

Yet in the last few years the company has not honored this credo.

It seems to have lost the ability to manufacture high quality products. It has had to make 30 separate product recalls since 2009. The latest was Liquid Infant Tylenol. (The current WSJ Health Blog list of recalls can be found here.)

Johnson and Johnson also has an amazing recent record of ethical lapses and guilty pleas, including:
- Convictions in two different states in 2010 for misleading marketing of Risperdal
- A guilty plea for misbranding Topamax in 2010
- Guilty pleas to bribery in Europe in 2011 by J+J's DePuy subsidiary
- A guilty plea for marketing Risperdal for unapproved uses in 2011 (see this link for all of the above)
- Accusations that the company, which makes smoking cessation products, participated along with tobacco companies in efforts to lobby state legislators (see post here)
- A guilty plea to misbranding Natrecor by J+J subsidiary Scios (see post here)
-  Most recently, in 2012, testimony in a trial of allegations of unethical marketing of the drug Respirdal (risperidone) by the Janssen subsidiary revealed a systemic, deceptive stealth marketing campaign that fostered suppression of research whose results were unfavorable to the company, ghostwriting, the use of key opinion leaders as marketers in the guise of academics and professionals, and intimidation of whistleblowers.  After these revelations, the company abruptly settled the case (see post here).

Disconnect Between Leadership Performance and Rewards

Nonetheless, until very recently, the top leadership of the company continued to collect outrageous compensation, and to be regarded as a font of health care wisdom, even by the current US administration.

In 2010, the company gave CEO and Chairman William Weldon over $29 million in compensation, saying he "met expectations," (see this post).

In 2011, just days after the company pleaded guilty in the Risperdal marketing case (above), CEO and Chairman Weldon was invited to the White House to discuss health care (see this post.)

Just after his resignation was announced a few days ago, the Wall Street Journal reported that Weldon would get an increased bonus for 2011 ($3.1 million, up from $1.98 million in 2010), and an increased base salary ($1.97 million up from $1.92 million.)  His total compensation for 2011 was not yet revealed. 

Swapping One Salesman for Another

A single New York Times article suggested one reason why Weldon's reign was ultimately so unsuccessful, and perhaps why his successor may not do better.
Alex Gorsky, the newly named chief executive of Johnson & Johnson, shares a crucial biographical detail with William C. Weldon, the man he is succeeding. Both got their starts as pharmaceutical sales representatives, a notoriously grueling job that — because it demands stamina, charisma and a near devotion to making the sale — has become a crucible for future drug company executives in recent years.

Indeed, Mr Weldon's official biography indicates he "served in several sales, marketing and international management positions." The official biography of CEO-to-be, Alex Gorsky, stated he "began his Johnson & Johnson career as a sales representative with Janssen Pharmaceutica in 1988. Over the next 15 years, he advanced through positions of increasing responsibility in sales, marketing, and management." Previously, he earned "a Bachelor of Science degree from the U.S. Military Academy at West Point, N.Y., and spent six years in the U.S. Army, finishing his military career with the rank of Captain. Alex earned a Master of Business Administration degree from The Wharton School of the University of Pennsylvania in 1996."

Apparently neither current nor nominated CEO had any direct experience in patient care, nor in biomedical or clinical science, nor in chemistry, engineering or manufacturing. So both are generic managers, that is, health care leaders without any direct experience in health care, or in the science and technology underlying it.

"Making the Numbers" Versus the Credo

Moreover, they are both a particular type of generic manager, salespeople. As the Times reported:
Mr. Gorsky, who is 51, fits the mold of someone who once 'carried the bag' — industry slang for working as a sales representative. He is known as a polished speaker and an intense yet likable manager who is a quick study when it comes to learning new topics.

However, while sales people may be personable, they often have goals that have nothing to do with responsibilities "to doctors, nurses and patients, to mothers and fathers,...." As the Times article also noted,
But the ethos of the sales representative may not be what Johnson & Johnson needs right now, said Erik Gordon, who teaches business at the University of Michigan. 'That culture was very much the Weldon culture writ large — we will make our numbers for the analysts, period,' he said. 'And if that means we have to cut costs on things that affect quality, then by God, we’re going to make those numbers.'

So while Johnson and Johnson for years prided itself as a company that put the needs of patients and health professionals first, it hired leaders from the culture of sales where the impetus is to "make the numbers," to fulfill short term revenue goals, no matter what. This illustrates how generic management given perverse incentives in an era that honors greed and puts short-term economic goals ahead of all others had hollowed out health care.

We wish Mr Gorsky well, but worry that if he too focuses just on making the numbers, the result will be only mischief.

The Moral of the Story

Health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Tuesday, February 28, 2012

BLOGSCAN - Keeping the Echoes Alive

We frequently discuss the anechoic effect, how many of the cases and issues of interest to Health Care Renewal, which conversely may be troubling to the powers that be in health care, often fail to inspire as much discussion, or the echoes that they deserve, either in the "main-stream media," or in the medical and health care literature.  A new post on the 1BoringOldMan blog likened the anechoic effect to the "flooding" phenomenon seen in psychotherapy, basically how patients seek to change the subject when a particularly troubling issue comes up.  Furthermore, the semi-anonymous blogger, "Mickey," is hopping on our tiny bandwagon for those dedicated to keep these troubling topics from completely fading from public view. 

Monday, February 27, 2012

True or Not? Death By Deletion, Adventist Health System IT Whistleblower Patricia Moleski Speaks Out

Not sure what to make of this yet:

A former hospital IT worker claims very deliberate mass spoliation (e.g., deletion) of electronic medical record evidence to limit her (ex)-employer's liability for EHR-related medical malpractice on patients and injured workers who were entitled to workers compensation, as well as EHR defects.

She alleges that IT personnel are used as naïve accomplices to perform the spoliation acts. She grew suspicious when she was asked to delete nursing information about a patient who committed suicide by jumping out a hospital window after an EHR-related drug overdose.

The video is over an hour long and is worth listening to.

She made these claims to the FBI and alleged to have suffered retaliation including firing, and possible terroristic activities directed against her.

A Feb. 2010 letter to Gov. Crist, Sen. Grassley and many other government officials, a 9th Judicial Circuit court document for Orange County, FL (PDF), and other details - some scary - can be found via a google search on this person's name: .

A Feb. 2010 letter to Sen. Grassley, former Fla. Governor Crist, various other senators, news media, etc. alleging serious, systematic, purposeful HIT evidence tampering and erasure. Click to bring up full letter.

This could be the "Libby Zion" (or Bernard Madoff?) case of the health IT world if these allegations are true.

-- SS

Health IT Culture: Severe Overconfidence (Arrogance?) Shows In The Industry's Very Terminology For Their Deliverables

Health IT commentator Neil Versel notes in his piece "HIMSS12 notes" at his site Meaningful Health IT News that:

I am in 100 percent agreement with something Dr. Wendy Sue Swanson, a.k.a. Seattle Mama Doc, said during an engaging presentation Monday at the HIMSS/CHIME CIO Forum. She made the astute observation that there needs to be better distinction between expertise and merely experience when it comes to celebrities being held up as “experts” in healthcare and medicine. Let’s just say that Swanson, as a pediatrician, is no fan of some of the things Jenny McCarthy and Dr. Mehmet Oz have told wide audiences.

He posted a link to his piece in a social networking site we both visit. I commented:

To that, I add "healthcare IT" where it seems anyone who's done anything with a computer in some medical setting can get away with calling themselves a "medical informatics expert" or "health IT expert." As in ham radio levels of just a few years ago, we need distinctions between novice class, technician class, general class, advanced class, and extra class.

In his piece Neil also linked to what he correctly termed "scathing critique" of the venue for HIMSS 2012 at my HC Renewal post "
HIMSS Annual Meeting in Las Vegas - Fitting for People Who Gamble With People's Lives to Make a Buck?"

I replied to him via the social networking site that:

"I like to point out ironies that seem to escape others, although I have heard from other colleagues that I was not alone in finding Las Vegas a somewhat peculiar place for a medical meeting about improving health! However, others' mileage may vary."

Neil noted that he likes pointing out ironies, too, and gave as an example as the meetings held at the Loews Hotel near Vanderbilt University Medical Center, being that Loews Hotels is a corporate cousin of Lorrilard Tobacco.

Finally, Neil comments:

Popular topics this year were the expected meaningful use and ICD-10, plus the buzzwords of the moment, business analytics and big data. I’d be happy I never hear the word “solution” as a synonym for “product” or “service” again. To me, that represents lazy marketing. Get yourself a thesaurus.

I agreed, and replied that:

"Solution", the common term in IT for anything an IT department or company provides, is a one-word example of a language usage akin to 'begging the question.'

This term, in one mere word, reflects a stunning arrogance within the IT culture.

I also noted that:

... there needs to be terminological consistency. If the IT vendors can call their wares "solutions", then doctors should call their treatments and drugs "cures." Come to my office for your cure; I am a curer; I write cures, not prescriptions.

I also noted that the term "meaningful use" phrase selected by the U.S. government/HHS for EHR adoption according to printed guidelines is another example of terminology that, ante hoc, assumes its semantics are correct.

How do we know the use is "meaningful" until such use is studied rigorously and outcomes, costs. etc. assessed?

Answer: we don't.

And this administration criticized the previous one for politicizing science ... George Orwell could not have selected better terms than "meaningful use", "certified EHR", and "solution" as examples of "Newspeak" in 1984.

-- SS

Sunday, February 26, 2012

Three Facets of One Hospital: Coddling the Rich, Hounding the Poor, and Crooked Executives

Juxtaposing three news stories from the past few months raises disturbing questions about the priorities of the leaders of one of the US' more prestigious hospitals.

"Chefs, Butlers, Marble Baths: Hospitals Vie for the Affluent"

 This 21 January, 2012 article from the New York Times focused on the ritzy comforts now provided for wealthy (but perhaps not very sick) patients at the renowned New York Presbyterian/ Weill Cornell Hospital.  It opened,
The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: 'This is like the Four Seasons — where am I?'

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble. Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, 'I’ll be your butler.'

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital. Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such 'amenities units,' often hidden behind closed doors at New York’s premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

Additional amenities include:
A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium....

the visitors’ lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand....

An architect who specializes in designing such luxury facilities for hospitals noted:
'These kinds of patients, they’re paying cash — they’re the best kind of patient to have,' she added. 'Theoretically, it trickles down.'

Note that the article also mentioned other hospitals which offered similar luxuries, including Johns Hopkins Hospital in Baltimore, Cedars-Sinai Medical Center in Los Angeles, and Mount Sinai Medical Center in New York.

On the other hand,....

Hounding the Poor for Payment While Getting Government Money for Indigent Care

On 12 February, the New York Times published an article about how New York Presbyterian/ Weill Cornell deals with patients with fewer resources than those discussed above:
For most of her life, Hope Rubel was a healthy woman with good medical insurance, an unblemished credit history and a solid career in graphic design. But on the day an ambulance rushed her to a Manhattan hospital emergency room shortly after her 48th birthday, she was jobless, uninsured and having a stroke.

Ms. Rubel’s medical problem was rare, a result of a benign tumor on her adrenal gland, but the financial consequences were not unusual. She depleted her savings to pay $17,000 for surgery to remove the tumor, and then watched, 'emotionally paralyzed,' she said, as $88,000 in additional hospital bills poured in. Eventually the hospital sued her for the money.

Yet that year the hospital, NewYork-Presbyterian/Weill Cornell, had already collected $50.2 million from the state’s so-called Indigent Care Pool to help care for people like Ms. Rubel who have no insurance and cannot pay their bills.

Note that the article also included other New York hospitals that allegedly used aggressive collection tactics on poor patients even though they too collected government money for indigent care. These included NYU Langone Medical Center and State University of New York Downstate Medical Center.

And one more...

Kickbacks for Hospital Executives

For some reason, the only media coverage of this story was not in New York, but by the Philadelphia Inquirer on 13 February, 2012.
The FBI said that ... [Michael Yaron] he received asbestos-removal and construction contracts at New York Presbyterian Hospital for two of his companies, Cambridge Environmental & Construction Corp. and Oxford Construction & Development Corp., because he paid about $2.3 million in kickbacks starting in 2000.

Neither Yaron, a resident of Meadowbrook, Montgomery County, nor his attorneys could be reached for comment yesterday. No one answered at Yaron Properties, his offices on Arch Street in Old City.

Bucks County native Moshe Buchnik, a president of two asbestos-abatement companies, was also convicted after the four-week trial. Santo Saglimbeni, a former vice president of facilities operations at the hospital, and Emilio 'Tony' Figueroa, a former director of facilities operations at the hospital, were also convicted. The FBI said the two former hospital employees steered contracts to Yaron and Buchnik in exchange for the kickbacks.

The Inquirer apparently covered the story because Yaron lives in Philadelphia. Thus it treated the convictions of a former vice president and former director of facilities operations at New York Presbyterian/ Weill Cornell Hospital as afterthoughts.


Thus, in the last six weeks, we have been treated to stories that showed how New York Presbyterian/ Weill Cornell Hospital has devoted substantial resources to create luxury suites for rich patients, presumably because they may pay cash; while simultaneously hounding poor patients who could not pay their large medical bills, even though the hospital was receiving government funds for indigent care; and until recently was employing some executives now shown to have abused their authority.

The themes of the three individual stories should be familiar.

The first story was a reminder that the very rich are different from you and me in how they interact with the health care system. In many ways, the rich and powerful - some might call them the one percent - are personally protected from various aspects of health care dysfunction. For example, here we have discussed how wealthy executives seem to be able to obtain health insurance with benefits unheard of by the more common folk, and here we discussed how the wealthy and influential may get preferential hospital treatment. Thus, even one percenters who are not otherwise involved in health care may not be inclined to lend their support to any efforts to really reform the system.

Aggressive bill collection practices by hospitals which are supposed to serve the poor are also old news. We first discussed such practices occurring in New York City in 2004 - yes, this blog is that old. We also discussed such practices in Baltimore in 2008. Such practices are an example of mission-hostile management.

Finally, we have commented many times about misbehavior by health care executives, and discussed examples of fraud, kickbacks, and health care corruption. It has been unusual, however, for individual executives to actually suffer negative consequences when they induce systemic misbehavior in their organizations. Instead, the results are often legal settlements that only lead to financial penalties on the organizations that are no more than costs of doing business.

However, the juxtaposition of stories that a hospital has been coddling the rich, and simultaneously hounding the poor while it was lead by at least a few criminal executives is unusual. One would think that they should lead to an in-depth look at the leadership and governance of the institution in question, perhaps even to some reform of same. (By the way, one area of interest to such an investigation should be the presence of several former and current leaders of some of the failed financial firms that lead us into the global financial crisis or great recession on the board of that hospital, as we discussed here and here.)

However, so far I seem to be only one to note the inter-relationships of these stories, and their implications, while obvious, therefore remain anechoic.

So I get to repeat.... Health care organizations need leadership that understands, and knowledgeably upholds the organizations' missions and patients and the public's health. The leaders should be subject to incentives that align with these responsibilities, and should not be given opportunities to personally profit from activities hostile to the mission.

Proposed new Consumer Privacy Bill of Rights: Is It Too Late For Healthcare?

From the White House:

The White House
Office of the Press Secretary
For Immediate Release
February 23, 2012

Plan to Protect Privacy in the Internet Age by Adopting a Consumer Privacy Bill of Rights


The Consumer Privacy Bill of Rights applies to personal data, which means any data, including aggregations of data, that is linkable to a specific individual. Personal data may include data that is linked to a specific computer or other device. The Administration supports Federal legislation that adopts the principles of the Consumer Privacy Bill of Rights. Even without legislation, the Administration will convene multi-stakeholder processes that use these rights as a template for codes of conduct that are enforceable by the Federal Trade Commission. These elements—the Consumer Privacy Bill of Rights, codes of conduct, and strong enforcement—will increase interoperability between the U.S. consumer data privacy framework and those of our international partners.

  1. INDIVIDUAL CONTROL: Consumers have a right to exercise control over what personal data companies collect from them and how they use it. Companies should provide consumers appropriate control over the personal data that consumers share with others and over how companies collect, use, or disclose personal data. Companies should enable these choices by providing consumers with easily used and accessible mechanisms that reflect the scale, scope, and sensitivity of the personal data that they collect, use, or disclose, as well as the sensitivity of the uses they make of personal data. Companies should offer consumers clear and simple choices, presented at times and in ways that enable consumers to make meaningful decisions about personal data collection, use, and disclosure. Companies should offer consumers means to withdraw or limit consent that are as accessible and easily used as the methods for granting consent in the first place.
  2. TRANSPARENCY: Consumers have a right to easily understandable and accessible information about privacy and security practices. At times and in places that are most useful to enabling consumers to gain a meaningful understanding of privacy risks and the ability to exercise Individual Control, companies should provide clear descriptions of what personal data they collect, why they need the data, how they will use it, when they will delete the data or de-identify it from consumers, and whether and for what purposes they may share personal data with third parties.
  3. RESPECT FOR CONTEXT: Consumers have a right to expect that companies will collect, use, and disclose personal data in ways that are consistent with the context in which consumers provide the data. Companies should limit their use and disclosure of personal data to those purposes that are consistent with both the relationship that they have with consumers and the context in which consumers originally disclosed the data, unless required by law to do otherwise. If companies will use or disclose personal data for other purposes, they should provide heightened Transparency and Individual Control by disclosing these other purposes in a manner that is prominent and easily actionable by consumers at the time of data collection. If, subsequent to collection, companies decide to use or disclose personal data for purposes that are inconsistent with the context in which the data was disclosed, they must provide heightened measures of Transparency and Individual Choice. Finally, the age and familiarity with technology of consumers who engage with a company are important elements of context. Companies should fulfill the obligations under this principle in ways that are appropriate for the age and sophistication of consumers. In particular, the principles in the Consumer Privacy Bill of Rights may require greater protections for personal data obtained from children and teenagers than for adults.
  4. SECURITY: Consumers have a right to secure and responsible handling of personal data. Companies should assess the privacy and security risks associated with their personal data practices and maintain reasonable safeguards to control risks such as loss; unauthorized access, use, destruction, or modification; and improper disclosure.
  5. ACCESS AND ACCURACY: Consumers have a right to access and correct personal data in usable formats, in a manner that is appropriate to the sensitivity of the data and the risk of adverse consequences to consumers if the data is inaccurate. Companies should use reasonable measures to ensure they maintain accurate personal data. Companies also should provide consumers with reasonable access to personal data that they collect or maintain about them, as well as the appropriate means and opportunity to correct inaccurate data or request its deletion or use limitation. Companies that handle personal data should construe this principle in a manner consistent with freedom of expression and freedom of the press. In determining what measures they may use to maintain accuracy and to provide access, correction, deletion, or suppression capabilities to consumers, companies may also consider the scale, scope, and sensitivity of the personal data that they collect or maintain and the likelihood that its use may expose consumers to financial, physical, or other material harm.
  6. FOCUSED COLLECTION: Consumers have a right to reasonable limits on the personal data that companies collect and retain. Companies should collect only as much personal data as they need to accomplish purposes specified under the Respect for Context principle. Companies should securely dispose of or de-identify personal data once they no longer need it, unless they are under a legal obligation to do otherwise.
  7. ACCOUNTABILITY: Consumers have a right to have personal data handled by companies with appropriate measures in place to assure they adhere to the Consumer Privacy Bill of Rights. Companies should be accountable to enforcement authorities and consumers for adhering to these principles. Companies also should hold employees responsible for adhering to these principles. To achieve this end, companies should train their employees as appropriate to handle personal data consistently with these principles and regularly evaluate their performance in this regard. Where appropriate, companies should conduct full audits. Companies that disclose personal data to third parties should at a minimum ensure that the recipients are under enforceable contractual obligations to adhere to these principles, unless they are required by law to do otherwise.

For an example of some of the major problems with healthcare data, see my Oct. 2009 post "Health IT Vendors Trafficking in Patient Data?"

I like the proposals.

The question is, regarding electronic health data: are these Federal proposals too little, too late?

Complex systems such as massive computer networks (with myriad stakeholders seeking to 'game' the system, skirt the boundaries of the law, and make handsome profits) can become uncontrollable.

-- SS

Saturday, February 25, 2012

It's Remarkable That EHRs Can't Do What Med Students Are Taught in PGY3-4 ... And Remarkable That Academics Don't Push This Information to the Public

The following article's full text from the journal Applied Clinical Informatics (ACI) is not freely available, but the abstract says all that needs to be said:

Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records (Vol. 3: Issue 1 2012)

A. Laxmisan (1), A. B. McCoy (2), A. Wright (3), D. F. Sittig (2)

(1) Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX; (2) School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; (3) Brigham and Women’s Hospital, Harvard Medical School, Boston, MA


Objective: Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems.

Methods: We compared different aspects of general clinical summary screens used in twelve different EHR systems using a previously described conceptual model: AORTIS (Aggregation, Organization, Reduction, Interpretation and Synthesis).

Results: We found a wide variation in the EHRs’ summarization capabilities: all systems were capable of simple aggregation and organization of limited clinical content, but only one demonstrated an ability to synthesize information from the data. Conclusion: Improvement of the clinical summary screen functionality for currently available EHRs is necessary. Further research should identify strategies and methods for creating easy to use, well-designed clinical summary screens that aggregate, organize and reduce all pertinent patient information as well as provide clinical interpretations and synthesis as required.

Put more directly, EHRs were poor at presenting relevant clinical information in summary form at the point of care.

(They're even worse after care is finished; see my Feb. 2011 post "Electronic Medical Records: Two Weeks, Two Reams" on the piles of 'legible gibberish' put out as official medical records of entire hospital admissions.)

The implications are that these systems cause physicians to waste time, weed through inordinate amounts of data in seeking what's important to help patients - and prevent errors. Thus, they are highly likely to increase clinician cognitive burdens and quite possibly reduce the quality of care.

But don't just take my word for that.

The 2009 National Research Council report made similar observations about EHRs in research overseen by two of HIT's preeminent pioneers, Drs. Octo Barnett and William Stead. See "Current Approaches to Healthcare Information Technology are Insufficient" and the accompanying full NRC report here that states:

"Current efforts aimed at the nationwide deployment of health care information technology (IT) will not be sufficient to achieve medical leaders' vision of health care in the 21st century and may even set back the cause ... The report describes difficulties with data sharing and integration, deployment of new IT capabilities, and large-scale data management. Most importantly, current health care IT systems offer little cognitive support; clinicians spend a great deal of time sifting through large amounts of raw data (such as lab and other test results) and integrating it with their medical knowledge to form a whole picture of the patient. Many care providers told the committee that data entered into their IT systems was used mainly to comply with regulations or to defend against lawsuits, rather than to improve care. As a result, valuable time and energy is spent managing data as opposed to understanding the patient."

I find several aspects of the new ACI study and its findings remarkable:


Clinical summarization is an essential skill for patient pickups (e.g., taking over the care of a hospitalized patient or performing a consult on them), patient handoffs (such as when put in care of a covering physician), and other related informational reasons.

It is a skill taught (at least when I attended medical school) in the third and fourth years, also known as PGY3 and PGY4 (postgraduate years 3 and 4).

I was tested on my ability to perform this task adequately, and the quality of my clinical summaries were also evaluated during internship and residency training as one of many criteria for successful completion.

The author's results, therefore, indicate that EHR designers and implementers cannot, or will not, incorporate the skills of clinical summarization required of PGY3-4 medical students and interns into their products, even after several decades of product manufacturing.

I find this astonishing.


While I applaud the authors of the new ACI study for performing such work, which in the current environment of hyper-enthusiastic cybernetic technophilia in medicine might cause negative industry pushback, I find another aspect of their work astonishing (perhaps 'disappointing' is a better term):

They only published their findings in ACI.

ACI is an excellent new journal, but as it is a relatively specialized journal in a specialized domain, its content will reach probably on the order of thousands of people in a substantive way.

This very blog has surpassed one million "hits", we estimate; my Drexel University site on HIT difficulties (including its predecessors) has probably surpassed the quarter million mark.

My point is that, at a time when the Institute of Medicine, NIST and others have advised further study of health IT to decide if HIT is safe and efficacious (because they don't really know) in order to decide if FDA or other governmental regulation is needed, research findings such as that of Archana Laxmisan, M.D, Dean Sittig PhD, and Adam Wright PhD, deserve far wider dissemination than in a highly specialized, relatively new informatics journal.

Let me further go on to say that physicians, by the nature of their MD degree, and non-physician informaticists such as Sittig and Wright, should feel ethically compelled to actively diffuse this type of finding about an experimental, suboptimal and potentially dangerous medical device (as per FDA CDRH's designation as such) more widely.

They should not leave it to bloggers such as myself to do that work for them.

This is not to single out these authors, this journal or this article; the phenomenon is common. Health IT research findings of potential great import sit in scientific journals that rarely if ever get seen by the lay citizenry, despite the importance to their being informed about the technology's actual and potential downsides.

How about the New York Times or Wall Street Journal? Even YouTube? These observations are not at all to impugn publication in ACI in any way, whose editor in chief I deeply respect for publishing articles that could be viewed as "negative" about HIT. Wider diffusion in non-academic print media and/or "New Media", however, would get messages such as in the clinical summarization deficiency study out in a way that would have far more social impact - and help protect patients.

In other words, the authors of informatics studies need to actively "get out more."

After all, the industry and government spare no effort in positive publicity, even making unabashed marketing claims not backed by the scientific literature, such as in the Feb. 24, 2012 HHS press release at this link:

“We know that broader adoption of electronic health records can save our health care system money, save time for doctors and hospitals, and save lives,” said [HHS] Secretary Sebelius."

Unlike the relationships between, say, hydrochlorothiazide diuretics and reductions in blood pressure, or sterile techniques in surgery lessening infection, I don't think that in 2012 we "know" that at all (link).

-- SS

Feb. 26, 2012 addendum:

Regarding my final point about the HHS statement, a reader who wishes to remain unnamed, familiar with efforts outside the US, offers the following interesting observations:

"This [HHS statement from Sebelius] is political spin to try to keep some momentum in a project that is obviously failing. What is more they KNOW it is failing and can read the IOM report and the negative US and UK reports on EHR's.

The White House is clearly desperate to calm voter and healthcare professional opinion and this is another naked attempt to project the inevitable crisis to beyond the end of this year...well at least early November.

I know that this is true because Sebelius' language is exactly the same as that used by the UK Dept. of Health just before NPfIT completely folded...

Also, implementation rates of HIT projects must also be carefully scrutinized as they reflect the percentage of hospitals where something, usually anything has been switched on rather than the proportion where a full EHR, PACS, CPOE etc. has been achieved. A good question to ask is how many units are now paperless?"

-- SS

Wednesday, February 22, 2012

HIMSS Annual Meeting in Las Vegas - Fitting for People Who Gamble With People's Lives to Make a Buck?

The setting for the Feb. 2012 annual meeting of HIMSS (the Health Information Management Systems Society, the gargantuan health IT trade group), ongoing as of this writing, is the Venetian Sands Expo Center in Las Vegas, NV.

Judging by the pictures posted at the HisTALK blog here of the event, now ongoing, it seems to be one big, happy party:

Rolling the dice at HIMSS 2012, Las Vegas.

This is ironically apopos for an organization whose leaders beg for special accommodation for a technology they know their industry has not learned how to "do right" after decades of profiteering (at patient's expense), thus gambling with live, unconsenting people as the poker chips:

Barry Chaiken, former HIMSS Chairman of the Board, July 2010 interview: "We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better." [While the systems remain in use on live, unconsenting patients - ed.]

It is difficult to imagine such a statement coming from the aviation, nuclear energy or other lives-at-risk industries.

HIMSS 2012 really seems to be a fun party. Even Elvis was in attendance:

Elvis, a fitting icon for an industry trade show on health IT? Journalist Tony Scherman wrote that by early 1977, "Elvis Presley had become a grotesque caricature of his sleek, energetic former self. Hugely overweight, his mind dulled by the pharmacopoeia he daily ingested, he was barely able to pull himself through his abbreviated concerts."

Sounds like what the commercial health IT sector has done to the good intentions and well-thought out applications created by the health IT pioneers.

I note that prostitution is legal in Las Vegas as well. This allows making money from objectification of human beings, although at least the latter give consent to the exploitation of their bodies.

Final thought:

What was missing from HIMSS was the ED EHR Slot Machine of Risk. (From my March 2011 post "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.")

The ED EHR Slot Machine. Click to enlarge. You've hit the ED EHR mis-processing jackpot! Perhaps today is a good day to die...

-- SS

Tuesday, February 21, 2012

BLOGSCAN - Television Advertising Revenue and the Anechoic Effect

We have often discussed the anechoic effect, how cases involving or discussions of the topics we address on Health Care Renewal, the concentration and abuse of power in health care, fail to produce any responses, or echoes.  Two recent blog posts discussed one way in whicht the anechoic effect might be generated.

A post by Dr Steven Greer on CurrentMedicine.TV, enlarged upon by Alison Bass on the Alison Bass blog, discussed a segment on 60 Minutes yesterday that dealt with the evidence that anti-depressant drugs may not be efficacious for mild to moderate depression.  Since this evidence is about four years old, the question is why it has only made it to the main-stream media now?  Both Dr Greer and Ms Bass think it may be because the patents on most of the newer, mainly selective serotonin reuptake inhibitor (SSRI) type anti-depressants have run out.  Therefore, their manufacturers may no longer be interested in using the clout they derive from paying millions for television advertising to keep programs critical of these drugs off the air.  The implication is that large health care organizations may often use threats to withdraw advertising to forestall criticisms of their products or their agendas in the media, hence increasing the anechoic effect.

ADDENDUM (27 February, 2012) See also comments on the 1BoringOldMan blog. 

Is ONC Stonewalling on the issue of HIT Certification, Safety and Liability?

At my Feb. 16, 2012 post "Hospitals and Doctors Use Health IT at Their Own Risk - Even if Certified" I wrote that an ONC-ATCB (Authorized Testing and Certification Body) replied to my email inquiry about health IT certification, safety and liability indemnification by stating that:

What was suggested in the email below (freedom from liability for users of the system, etc.) would be out of scope for ONC-ATCB testing based on the given criteria.

[That is, the criteria used in testing
here - ed.]

What I did not include in that post was the fact that some months ago, I had emailed ONC directly with the same questions, and then called them on the phone with those questions at about the same time as I inquired of the ATCB.

ONC itself never responded.

There are several possibilities:

  • They don't know the answer.
  • They don't want to respond.
  • They don't care to respond.

Dismissing possibility #1, these civil servants appear to be stonewalling on the issue.

It would be nice to hear ONC itself admit the term "certification" is a gossamer guarantee of health IT safety, efficacy and indemnification of purchasers, implementers and users from potential EHR-related liability.

I am not holding my breath.

-- SS


An ONC representative did get back to me on Feb. 27, but I told them my question had already been answered by ONC ATCB's.

Monday, February 20, 2012

Two Steps Back: International Council on Human Rights Policy Closes, Dutch Healthy Skepticism Ends Domestic Focus

We have noted the paucity of organized efforts to combat health care corruption and related phenomena.  What efforts exist tend to focus on corruption elsewhere, as if no one is willing to admit it can occur in their back yard.  Now one organization that has made some efforts in this sphere is closing, and another will explicitly focus its efforts on problems elsewhere.

International Council on Human Rights Policy Closes

The ICHRP was located in Geneva.  It had a wide focus, but was willing to consider how corruption could affect human rights.  Its publication, Corruption and Human Rights: Making the Connection, explicitly noted the threat of corruption to the right to health.  (Note that in international policy, this right is not considered to be to unlimited health care, but to "attainment of the highest available standard of physical and mental health.")  It went on to list a variety of ways in which government corruption, or corruption of health care leaders or organizations outside of government could harm health.  (Full disclosure: I participated in a meeting the IHCRP convened to review a draft of this publication.)

Now, as announced in the IHCRP blog, the IHCRP will close at the end of this month:
The decision to close was taken by the Executive Board primarily due to continued financial difficulties, largely a result of the difficult funding climate, especially for human rights and even more so for human rights policy research. It is especially regrettable because for more than a decade the ICHRP stimulated co-operation and exchange across the non-governmental, governmental and inter-governmental sectors, and strove to mediate between competing perspectives.

Healthy Skepticism in the Netherland to Only Focus on Problems "Abroad"

Today I got a press release (as of 21 February available here) from the Dutch Institute for Rational Use of Medicine (IVM), that stated:
The Dutch Institute for Rational Use of Medicine (IVM) is changing the course of its renowned Healthy Skepticism programme, which has critically monitored the pharmaceutical industry’s impact on the use of medication over the past ten years. Healthy Skepticism will be shifting attention away from its activities in the Netherlands, choosing to focus instead on supporting initiatives abroad.

The immediate reason seemed to be lack of funding, like the reason advanced for the closing of the ICHRP:
The change is prompted by the fact that the Dutch Ministry of Health, Welfare and Sport has eliminated funding for the programme....

The announcement first suggested that the change of focus came about because the initiative had attained its original goals:
another factor is the radical change that has occurred in the pharmaceutical industry’s attitude and conduct over the past decade.

Commenting on the change, IVM director Ruud Coolen van Brakel stated: 'Although there are still some problem areas, overall the industry has become more mature and more responsible’.

However, later in the announcement the implication was stronger that this lack of funding may have resulted from how the program challenged the powers that be, perhaps those who were personally profiting the most from the status quo:
The impact of Healthy Skepticism’s initiatives has not been unequivocally positive. IVM met with considerable resistance, which at times even became personal, and, because of its critical attitude, often became the target of aggressive attacks that also compromised its funders, the Ministry of Health, Education and Sport and the Healthcare Inspectorate.


We noted most recently (here, December, 2011) most of the organizations one might have expected would have provided some response to health care corruption instead have largely treated it as at best a nuisance. Specifically, there is almost no teaching or research on corruption in health care academics (including medical and public health schools, and programs in health care research and policy.)  There is almost no mention of corruption by health care professional associations.  There are almost no initiatives to fight corruption on the part of health care charities and donors.  There is almost no interest in corruption among patient advocacy organizations.  (See previous discussion here.)

Furthermore, I also postulated that at least in the US context, this lack of interest in corruption may partially be explained by these organizations' institutional conflicts of interest and the individual conflicts of interest affecting their leaders. It may be further explained by the exposure of some leaders to the irresponsible, if not amoral culture that now currently pervades finance, which may have in turn been one cause of the great recession, or global financial collapse.

The ICHRP and the Dutch Healthy Skepticism program seemed to be happy exceptions.  However, both of them depended on outside government or non-profit organizations for funding.  In both cases, these outside funders seem to have lost enthusiasm, maybe for reasons discussed above.

At least the ICHRP archives remain available, and Dutch Healthy Skepticism may be able to make some useful contribution outside the Netherlands.

There is increasing evidence that health care corruption may end up killing people.   I still hope that the courage of those who have tried to increase awareness of health care corruption, the conflicts of interest that can increase its likelihood, and surrounding phenomena, will not be in vain.  I still hope that some academic health care institutions, professional societies, health care charities and donors, and patient advocacy groups will gain enough fortitude to stand up for accountability, integrity, transparency, and honesty in health care.

The First State's Deadest (Deadliest?) Duck - Is This ED EHR Harming or Killing Anyone in NSW?

Nobody seems to be asking this simple question:

Is This ED EHR harming or killing anyone in NSW?

It cannot be "not compromising patient care" on first principles.

This type of practical and ethical question seems to never get asked, while what appears to be a tit-for-tat political kerfuffle goes on.

This is due in part to the baffling special accommodations afforded worldwide towards an extremely profitable but potentially extremely dangerous medical device, as well as due to the issues I described in my post about reckless technophilia and the accompanying disregard for rights of others here.

The Register

NSW government accused of dodgy software cover-up

FirstNet: the First State's deadest duck [or "deadliest duck?" - ed.]

The buggy FirstNet emergency department software has become the subject of a political argument in NSW. [What about a clinical and ethical argument? - ed.]

In one of those paradoxes of democracy, an opposition which, in government, was responsible for a now-despised implementation is now using the IT project as a stick to beat a government which was in opposition when the system was chosen.

Last week, the Sydney Morning Herald obtained a report into the system by Deloitte, under a freedom of information request. It says [1] the Deloitte report criticises FirstNet because it is:

- Is chronically under-funded;

- Produces inadequate records;

- Was unreliable in delivering messages, and did not provide alerts when messages failed to reach their destination; and

- Demanded excessive amounts of screen time from clinicians.

[But is it harming or killing anyone? Are those statistics being collected robustly and scientifically, or are self-serving statements by hospital executives that "care was never compromised, and nobody was injured" simply being taken at face value?

Further, the obvious increased risk of harm due to deficient IT currently in operation is being cavalierly ignored. This is alien to medicine, and could cause career termination or land people in jail in fields such as aviation if planes with known potentially-dangerous avionics software or other defects are kept flying - ed.]

In spite of its inadequacies, the Deloitte report seen by the SMH said the $AU100-plus million Cerner FirstNet system is too entrenched to abandon.

[I'm quite sure dead or injured patents would not appreciate that explanation - ed.]

Over the weekend, opposition health spokesperson Dr Andrew McDonald issued a statement accusing NSW health minister Jillian Skinner of covering up the report since August 2011.

However, other published studies into FirstNet, such as a detailed investigation by Sydney University e-health expert Professor Jon Patrick here [2], identify problems similar to those apparently cited by Deloitte. This study was undertaken to investigate issues with FirstNet outlined in November 2008 in a special commission of review, conducted by Peter Garling,

While noting that FirstNet represented an improvement on some aspects of its predecessor, Garling said the system attracted complaints that it was unfriendly to users, that the vendor and Health Department did not respond to complaints about the software, and that emergency department patients were being held in triage for excessive times, while clinical staff fought with the software.

[What sane patient would want such a system used in their care? - ed.]

Deloitte, on the other hand, was far less critical of FirstNet in 2008, when in a review [3] of triage benchmarks it managed to turn up a downtime issue, difficulty in uploading triage data to the Health Department, and the identification of the wrong doctor or nurse with a patient’s records.


On the argument that "the older system was worse", or the corollary argument that "paper harms and kills too", I suggest anyone who proffers that argument should realize VIOXX (refoxicib) helped far more people than it harmed in reducing pain while sparing them from GI side effects compared to "older" drugs.

Over 84 million people were prescribed rofecoxib at some time and only mere thousands, or tens of thousands, are presumed to have been injured or died.

Therefore, following their own illogic and ethical (dis)orientation, they should put all their family members on the drug - especially the elderly with cardiovascular disease - to benefit from pain relief and VIOXX's other miraculous effect, suppression of colonic polyps.

Surely those benefits outweigh the risks, and therefore it is ethical to do so, no?

Of course not.

Health IT, as I've written in many posts on this blog, has a magnitude of harms that is admittedly unknown. Health IT needs significant further study and improvement, certainly before national rollouts, and before decisions are made that particular systems are "too entrenched to abandon."

-- SS

Sunday, February 19, 2012

Health IT Ddulites and Disregard for the Rights of Others

At my Feb. 8, 2012 post "Health IT: Ddulites and Irrational Exuberance " I defined a "Ddulite" (Luddite with the first four characters reversed) as the opposite of a Luddite, specifically:

Hyper-enthusiastic technophiles who either deliberately ignore or are blinded to technology's downsides, ethical issues, and repeated local and mass failures.

An astute reader points out that "opposite" may be an incomplete description, as the Luddites:

"were a social movement of 19th-century English textile artisans who protested – often by destroying mechanized looms – against the changes produced by the Industrial Revolution, which they felt were leaving them without work and changing their way of life. The movement was named after General Ned Ludd or King Ludd, a mythical figure who, like Robin Hood, was reputed to live in Sherwood Forest."

In other words, they were merely trying to save their jobs, and their actions did not cause life-threatening adverse events, such as death by freezing due to lack of warm garments.

Ddulites, on the other hand, ignore the downsides (patient harms) of health IT.

This is despite being already aware of, or informed of patient harms, even by reputable sources such as FDA (Internal FDA memo on H-IT risks), The Joint Commission (Sentinel Events Alert on health IT), the NHS (Examples of potential harm presented by health software - Annex A starting at p. 38), and the ECRI Institute (Top ten healthcare technology risks), to name just a few.

In fact, the hyper-enthusiastic health IT technophiles will go out of their way to incorrectly dismiss risk management-valuable case reports as "anecdotes" not worthy of consideration (see "Anecdotes and medicine" essay at this link).

They will also make unsubstantiated, often hysterical-sounding claims that health IT systems are necessary to, or simply will "transform" (into what, exactly, is usually left a mystery) or even "revolutionize" medicine (whatever that means).

This is despite the fact that many of this mindset are medical and/or Medical Informatics professionals who know better. They also ignore the draining waste of resources of failed or ineffectual IT ("bad health IT"), potentially depriving patients of the best healthcare possible.

Thus, as the reader pointed out, there could be an element of psychopathy or, at best, reckless disregard for rights of others in their thinking.

Reckless disregard: An act of proceeding to do something with a conscious awareness of danger, while ignoring any potential consequences of so doing. Reckless disregard, while not necessarily suggesting an intent to cause harm, is a harsher condition than ordinary negligence.

In my opinion, at a time of mass funding and pressure for rapid rollout of health IT in its present state of experimental development, this is not an observation that should be casually dismissed.

-- SS

Saturday, February 18, 2012

A Camel Through the Eye of a Needle - at Non-Profit Health Insurers

It is time to drag out that well-worn phrase,...  sometimes you just cannot make this stuff up. 

Recently, the New York Post reported about executive compensation at some non-profit health maintenance organizations/ health insurance companies in New York.  To wit,


At one Catholic-run health insurer for the needy, charity starts in the executive suite.

Mark Lane, the CEO of the Fidelis Care/New York State Catholic Health Plan, receives a $1.1 million salary plus another $864,000 in retirement pension and other benefits, The Post has learned.

His total compensation comes to nearly $2 million.

Fidelis is a tax-exempt, not-for-profit HMO serving 750,000 patients throughout the city and state who mostly qualify for Medicaid, the public insurance program for the needy. That means nearly all of Fidelis’ revenues come from taxpayers.

Meanwhile Fidelis’ executive vice president and chief operating officer, the Rev. Patrick Frawley, an ordained Catholic priest, is paid $587,249.

Frawley received more than $900,000 in other retirement and deferred benefits — raising his total compensation to $1.54 million, according to IRS filings.

That’s a lot of pennies from heaven.

'It’s shocking to me,' said a source familiar with Catholic health charities.
Amazingly, the justification that was trotted out in this case was just of the "our CEO is brilliant" variety, but in this case, provided by a Bishop:
Fidelis defended the salaries of its top officers, who oversee a $3 billion operation.

Bishop Joseph Sullivan, a member of Fidelis’ board of trustees who formerly served as chairman, called the compensation 'generous but fair.'

He said the goal is for salaries to be at the '75th percentile' of rivals.

“Our ability to continue to grow is based on the quality of leadership. You get what you pay for. Lane and Father Frawley are worth every penny,” Sullivan said.

Fidelis also issued a statement explaining that Frawley, after serving in pastoral roles for 25 years, was granted release from his priestly assignment to pursue a career in health care.

So much for a vow of poverty, even at a non-profit providing health care mainly to the poor.


On the other hand, executives of secular, but still non-profit health insurers do even better,
Anthony Watson, CEO of EmblemHealth, gets a compensation package of $8.5 million — about half in salary and bonuses and the rest in retirement and deferred benefits, according to IRS filings.

Two other EmblemHealth executives also snagged multimillion-dollar compensation packages.

We have noted before how the "peer benchmarking process," setting executive (but not necessarily other) compensation based on a comparison with compensation at other, often highly selected organizations, coupled with the "Lake Wobegone Effect," the belief that one's own executives are always above average, will lead to inexorable rises in executive pay, regardless of performance, or whatever else is going on in the world. The Bishop's assertion that Fidelis' executive compensation should be at the seventy-fifth percentile, because of the "quality of leadership," not further described, is a perfect example of these phenomena.

It is striking to see these phenomena at a non-profit organization whose mission is:
to ensure that every resident, regardless of income, age, religion, gender, or ethnic background, has access to quality health care, provided with dignity and respect.

So, ad infinitum, I repeat.... health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Friday, February 17, 2012

The Bloat Continues: More Tales of Non-Profit Hospital Executive Compensation

While unemployment remains high, and mortgage foreclosures continue in the US, nothing seems to stop the rise of health care costs, lead by compensation for top health care leaders. So, it is time once again for a round-up of inflated executive compensation at non-profit and government hospital systems.  We will describe the bloat in order of the appearance of the information in public.


The December, 2011, the Cincinnati Business Courier tabulated the pay of the best compensated hospital employees, and discussed the results in an accompanying article.  By my count, 19 local hospital employees made more than $1 million in 2010.  These included 6 system CEO, 4 division CEOs, 5 chief level executives or vice presidents, 1 clinical department chair, and 3 doctors.  The top compensation went to Kenneth Hanover, CEO of Health Alliance/ UC Health, $2,799,338. Three others made more than $2 million.

Western New York

In January, 2012, Buffalo Business First reported:
The top hospital administrators in Western New York took home more than $53 million in compensation during 2010, with four executives earning $1 million-plus paydays.

Hospital presidents and chief executives at the region’s two largest health systems were among the top earners, with James Kaskie, president and CEO of Kaleida Health , earning $2.36 million; and Joseph McDonald, president and CEO at Catholic Health , earning nearly $1.1 million.

Kaskie’s compensation, as well as Kaleida executives Connie Vari, Robert Nolan and Margaret Paroski, included a deferred retirement plan payout. All four were among the top five earners for 2010, the most recent year for which complete data is available.

The life of a top hospital executive near Buffalo was not quite as plush as in Cincinnati. Only 4 made more than $1 million, including the CEO, Chief Medical Officer/ Executive Vice President, and Chief Operating Officer of Kaleida Health, and the CEO of Catholic Health System. Eleven more executives got more than $500,000.

North Carolina

It was a very good year for executives from some of the state's biggest health care systems, per a February, 2012 article in the Charlotte Observer.
Carolinas HealthCare System paid its CEO $4.2 million in 2011, $523,000 more than the year before, as the system celebrated a profitable year and met all of its systemwide goals, according to hospital officials.

Chief Executive Officer Michael Tarwater, 58, who has led the $6 billion public hospital system for 10 years, received a base salary of about $1 million, two bonuses totaling $2.5 million, and other compensation, including retirement and health benefits, of about $700,000.

That represents a 9 percent increase in base salary and a 14 percent overall increase compared to 2010, when Tarwater's salary was $986,172 and total compensation was $3.7 million.

Meanwhile, at Novant Health,
The most recent compensation figures for Novant executives are from 2010. In that year, Novant's CEO Paul Wiles, 64, received total compensation of $3.2 million, including his salary of $1 million, a bonus of about $837,000, and $1.37 million in other income, including retirement and health benefits.

Wiles retired at the end of 2011 and was succeeded by Carl Armato, who was previously chief operating officer for Novant.

A data table within the article showed that there were 10 employees, all executives, at Carolinas Healthcare System in 2011, and 6, again all executives, at Novant Health in 2010, who got more than $1 million in compensation.

Why did the Carolinas CEO warrant a multi-million dollar pay package? One of his employees endeavored to explain,
'We've had extremely good performance,' said Debra Plousha Moore, the system's chief of human resources. 'All performance goals this year were either met or exceeded.'
Why the credit for that performance should not be spread amongst more hospital employees, especially those who actually took care of patients, she did not explain.
Northern New York City Suburbs

In February, 2012, reported:
Eight executives from 15 Lower Hudson Valley hospitals received more than $1 million in salary, bonuses, benefits and other pay in 2010 at a time when the state struggled to control health-care costs.

The details included:
Three executives received more in total compensation than Westchester Medical Center CEO Michael Israel, who earned $1.3 million and oversees a hospital that’s more than twice the size of other facilities in the region.

The highest-paid hospital employees include White Plains Hospital CEO Jon Schandler with $1.6 million in total compensation, Dr. Edward Lundy at Good Samaritan Hospital in Suffern with $1.48 million and Edward Dinan, CEO of Lawrence Hospital in Bronxville, with $1.41 million.

Others in the million-dollar range include John Federspiel, president of Hudson Valley Hospital Center in Cortlandt; Joel Seligman, CEO of Northern Westchester Hospital in Mount Kisco; and Keith Safian, CEO of Phelps Memorial Hospital Center in Sleepy Hollow. A year earlier, Federspiel received a compensation package of nearly $2 million due partly to an $800,000 deferred compensation payout.

The average CEO compensation rose 13 percent from 2009, to $939,751.

Ten hospitals paid $7.7 million in bonuses to top executives, an increase of 15 percent over 2009. White Plains Hospital alone distributed $2.1 million in bonuses, including $650,000 to Dr. Jesus Jaile-Marti, chief of neonatology, and $575,000 to Schandler.

This article highlighted the contrast between compensation for executives and for employees who provide front line care:
The high salaries also come as hospitals pressure many employees for wage freezes, rising insurance costs and watered-down pensions, said Deborah Elliott, a nurse and deputy executive officer of the New York State Nurses Association, a statewide union representing nurses at Sound Shore, Mount Vernon, St. John’s Riverside, St. Joseph’s and Nyack hospitals as well as Westchester Medical Center.

'It never ceases to amaze me that we sit at the bargaining table with these executives who are making $1 million and they give us such a hard time about a half-percent increase for a nurse who is making $63,000,' Elliott said. 'It’s galling.'
Again, contrast that one half percent with the average chief executive increase of 13%.

While it is a rare hospital that would disparage the performance of its dedicated nurses and physicians, somehow executive talent seems to matter more. For example, here is how Hudson Valley Hospital Center president John Federspiel's compensation was justified by his board chair:
Edward B. MacDonald Jr., chairman of Hudson Valley Hospital Center’s board of directors, said Federspiel deserves his paycheck. The hospital has earned a profit for 22 of the 25 years that Federspiel has been at the helm and has expanded both its services and payroll in that time, he said.

'He’s the best administrator, planner and motivator I have ever had the privilege to work with,' MacDonald said. 'I wish I could pay him more.'
Again, why the CEO, but not the nurses and doctors deserves the credit for the hospital's performance was not stated.

It all gets so tedious, doesn't it? CEOs of all but the smallest non-profit hospitals now seem entitled to at least $1 million a year. At larger systems, multiple executives per system seem entitled to that level of compensation, and CEOs may get multiple millions a year. Yet these are ostensibly non-profit organizations dedicated or providing care to their communities, and often to serving the poor. Thus the health care bubble continues to inflate, and executives are ever more distracted by money, and seem less focused on mission.

Note that reporting of this ever rising compensation seems to be becoming more perfunctory as the results seem more routine (and tedious). Two of the four articles noted above did not provide any justifications for the high pay, while two only trotted out brief versions of the "our CEO is so brilliant" meme.

As I said in December, in a health care system with ever rising costs, declining access, and stagnant quality, we no longer can tolerate the perverse incentives generated by unaccountably high compensation to top executives. As long as top executives continue their sense of "self-entitlement," and can continue their current management practices reinforced by ever rising pay checks, expect poor leadership to undermine any attempts to improve health care. Tired repetitions of the usual rationales, that the CEOs are brilliant and hard-working, and that their compensation is mandated by the market do not make these rationales true.

We need health care leadership that has compassion for the increasing hardships that their patients have to endure, and that puts doing the right thing for patients' and the public's health ahead of self-interest.

Generic Leadership Fine for EHR Implementation in High Acuity, High Risk Areas Such as an Emergency Department?

At my Feb. 16, 2012 post "Hospitals and Doctors Use Health IT at Their Own Risk - Even if 'Certified'" I established that buyers and users of EHR systems do so at their own risk with regard to implementation problems or outright defects resulting in patient harm.

As I've also written at my April 2011 post "FDA Decides Regulating Implantable Defibrillator Medical Devices a Political Hot Potato; Demurs", FDA has admitted health IT is a medical device that they shy away from regulating because it's politically expedient not to do so. (The area is a "hot potato" per the Director of FDA's CDRH, the Center for Devices and Radiological Health, so FDA stays away.)

Yet FDA knows of the stakes. As I observed at my Aug. 2010 post "Internal FDA memorandum of Feb. 23, 2010 to Jeffrey Shuren on HIT risks" and elsewhere, patient harm is occurring due to these devices and FDA is aware. Due to admitted impediments to information diffusion, however, even FDA, IOM, The Joint Commission (due to a "dearth of data" as in their 2008 Sentinel Events Alert On Healthcare IT) and others do not know the true magnitude of the problem.

From the FDA internal memo at the preceding FDA memorandum link:

Limitations of the MAUDE [Manufacturer and User Facility Device Experience database] search and final subset of Medical Device Reports (MDRs) include the following:

1. Not all H-IT safety issue MDRs can be captured due to limitations of reporting practices including

... (a) Vast number of H-IT systems that interface with multiple medical devices currently assigned to multiple procodes making it difficult to identify specific procodes for H-IT safety issues;
... (b) Procode assignments are also affected by the ability of the reporter/contractor to correctly identify the event as a H-IT safety issue;
... (c) Correct identification by the reporter of the suspect device brand name is challenged by difficulties discerning the actual H-IT system versus the device it supports.

2. Due to incomplete information in the MDRs, it is difficult to unduplicate similar reports, potentially resulting in a higher number of reports than actual events.

3. Reported death and injury events may only be associated with the reported device but not necessarily attributed to the device.

4 Correct identification by the reporter of the manufacturer name is convoluted by the inability to discern the manufacturer of the actual H-IT system versus the device it supports.

5 The volume of MDR reporting to MAUDE may be impacted by a lack of understanding the reportability of H-IT safety issues and enforcement of such reporting.

... The results of this data review suggest significant clinical implications and public safety issues surrounding Health Information Technology. The most commonly reported H-IT safety issues included wrong patient/wrong data, medication administration issues, clinical data loss/miscalculation, and unforeseen software design issues; all of which have varying impact on the patient’s clinical care and outcome, which included 6 death and 43 injuries. The absence of mandatory reporting enforcement of H-IT safety issues limits the number of relevant MDRs and impedes a more comprehensive understanding of the actual problems and implications.

Finally, as I pointed out in my Dec. 2009 post "ONC Defines a Taxonomy of Robust Healthcare IT Leadership", the Office of the National Coordinator for Health IT at HHS (ONC) had published the following with regard to the qualification of those who could "lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States":

Clinician/Public Health Leader: By combining formal clinical or public health training with training in health IT, individuals in this role will be able to lead the successful deployment and use of health IT to achieve transformational improvement in the quality, safety, outcomes, and thus in the value, of health services in the United States. In the health care provider settings, this role may be currently expressed through job titles such as Chief Medical Information Officer (CMIO), Chief Nursing Informatics Officer (CNIO). In public health agencies, this role may be currently expressed through job titles such as Chief Information or Chief Informatics Officer. Training appropriate to this role will require at least one year of study leading to a university-issued certificate or master’s degree in health informatics or health IT, as a complement to the individual’s prior clinical or public health academic training. For this role, the entering trainees may be physicians or other clinical professionals (e.g. advanced-practice nurses, physician assistants) or hold a master’s or doctoral degree(s) in public health or related health field. Individuals could also enter this training while enrolled in programs leading directly to degrees qualifying them to practice as physicians or other clinical professionals, or to master’s or doctoral degrees in public health or related fields (such as epidemiology). Thus, individuals could be supported for training if they already hold or if they are currently enrolled in courses of study leading to physician, other clinical professional, or public-health professional degrees.

Here, though, is a more typical reality in today's hospitals, the background of an EHR deployment leader in one of the most risk-prone and difficult environments in healthcare, the Emergency Department (ED) in a large hospital of which I am aware:

Clinical Systems Analyst
January 2004 – Present
Project manager for implementation of an ED EHR [vendor name redacted]
Responsible for all aspects of implementation including build and process design, report build, testing, training, and go-live support.
Extensive knowledge ADT processes, HL7, and CPOE.
Manage software patches and upgrades.
Experience in HTML, SQL and SAP.

Financial Systems Analyst
November 2001 – January 2004
Project Team Lead for implementation of Patient Accounting system.
Responsible for system development and system build, training, testing, and reporting.


[Regional university in the lower 50% of US News rankings in the region, name redacted]
B.S., Management Information Systems
2000 – 2003

[Name redacted] Community College
Associates Degree, Business Administration

So, ED physicians (with many years of doctoral and post-doctoral training and experience, boards testing their competence, etc.) may be placing the lives of patients and their careers in the hands of:

  • An experimental medical device,
  • unregulated by anyone,
  • in a field whose qualifications for leadership are unregulated by anyone,
  • devices known to be risky,
  • but without anyone knowing the magnitude of that risk,
  • whose implementation is led by a generic 'clinical' systems analyst "responsible for all aspects of implementation" with a Bachelor's degree in MIS from a second-tier institution, an Associates degree from a community college, and no medical or Medical Informatics education or experience whatsoever.

Further, that project lead jumped from financial systems analyst to 'clinical' analyst/leader of an ED EHR implementation.

One should also ask

  • Who was the hiring manager who hired such a person and put them in the role?
  • On what credentials and experience was the decision based?
  • What were the hiring manager's own credentials?

I leave it to the reader to decide if this is an appropriate arrangement, and if they would place their trust in an ED whose activities center around a cybernetic system implemented in this manner.

-- SS

Feb. 17, 2012 Addendum:

At least in this case the person has degrees.

Per several prominent healthcare IT recruiters in the past in the article "Who's Growing CIO's" in the journal Healthcare Informatics, as mentioned at my Sept. 2009 post "Correcting historical information from the recruiter component of the Health IT Ecosystem", the School of Hard Knocks was plenty good for health IT leadership roles:

I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.

-- SS