Wednesday, September 18, 2013

An Open Letter to the Joint Commission on Their Fiduciary Responsibilities Concerning Health IT

An open letter to the Joint Commission. Emphasis in the original:

From: S Silverstein
Sent: Friday, October 14, 2011 9:21 AM
To: MGiuntoli, Anita; Chassin, Mark; Legaspi, Shirley; McKee, Ana; Schyve, Paul [Joint Commission leaders - ed.]
Cc: [State senator aware of the situation, who was seeking votes at a nursing home/ rehab center while my mother was being treated - ed.]
Subject: "Diary of EHR-Initiated Tragedy"

Dear Joint Commission,

Now that Medicare's [state] QIO has found my mother to have been a victim of care that "did not meet applicable professionally recognized standards of health care" (as at, I am making available an overall detailed account of what occurred to her. The account, though anonymous as to hospital, location, clinician ID's etc., is at this link:

I should let you know that the Drexel URL's readers are tracked (by IP only); in other words, I will be able to tell if JC looked at it or not.

It is my opinion that the JC and its leaders have a primary fiduciary responsibility to prevent such mishaps from occurring, through significantly tighter oversight of hospital's use of IT, which in reality are experiments on human subjects without informed consent.

Please consider yourselves informed of these views.

Scot Silverstein, MD
Drexel University
Philadelphia, PA

I don't believe any further explanations are necessary.

Oct. 14, 2011 Addendum:

We've corresponded before, the JC and I, after my letter "
Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in the Journal of the American Medical Association in July 2009, JAMA. 2009; 302(4):382. doi:10.1001/jama.2009.1041, and again after my mother was injured in 2010.

In that 2009 JAMA letter I'd opined:

... When hospital leadership signs agreements specifically excluding the sharing of information about HIT defects and user complaints, it seems they have violated these standards. [That is, Joint Commission Safety Standards such as LD.01.03.01 and LD.03.04.01 that I cited earlier in the letter; see above link to an extract of the letter - ed.] Nondisclosure seems to violate the standards’ spirit and letter.

Signing such HIT contracts may also represent a violation of the legal and fiduciary duties of hospital administrations to protect not just patients but also employees from undue physical and legal jeopardy. Placing the entire burden of liability for HIT malfunctions on clinicians, and not obtaining informed consent from patients for use of these systems, seems a major deviation from the responsibilities of persons with legal and fiduciary obligations to discharge faithfully a responsibility of trust toward others, including safety.

This was nearly a year before my mother became injured.

-- SS

Oct. 16, 2011 addendum:

See what the President of the American College of Physicians (ACP) thinks about today's health IT via my post here.

-- SS


Anonymous said...

In my consulting work for plaintiffs, I will make it a point to advise that the Joint Commission and its leadership be named in suits involving injury due to defects and flawed design in CPOE devices.

The Joint Commission has failed to investigate the adverse impact of CPOE and the disruptive conduct of hospital administrators who purchase it with resultant patient injury.

InformaticsMD said...

Anonymous October 15, 2011 9:10:00 AM EDT writes:

In my consulting work for plaintiffs, I will make it a point to advise that the Joint Commission and its leadership be named in suits involving injury due to defects and flawed design in CPOE devices.

Its leaders, as I point out, in being the organization that accredits hospitals for operation, hold fiduciary responsibilities. If they cannot honor those responsibilities, they should face the consequences, just as physicians face the consequences for violating their responsibilities to patients.

(Interestingly, the latter face the consequences of error, even if it was health IT at fault or contributing to errors.)

-- SS