The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging

In recent days, I've posted about current articles on the destructive nature of today's vastly over-complex, burdensome EHR technology.  These posts included "Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records" at http://hcrenewal.blogspot.com/2018/01/physicians-harassed-by-onerwhelming.html
and "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html.

There are many other earlier articles of a similar nature discussed on this blog, e.g., the May 2017 post  "Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records" at http://hcrenewal.blogspot.com/2017/05/death-by-thousand-clicks-leading-boston.html for one, and others retrievable by query links http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20dissatisfaction, http://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20failure and similar.

Here's another recent article along the same lines that just appeared in the prestigious New England Journal of Medicine:

Perspective
Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians
Alexi A. Wright, M.D., M.P.H., and Ingrid T. Katz, M.D., M.H.S.
January 25, 2018
N Engl J Med 2018; 378:309-311
http://www.nejm.org/doi/full/10.1056/NEJMp1716845

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

I note that, unlike this primary care physician, many physicians have to learn numerous EHR's and use them simultaneously if they provide services at different healthcare systems. 

Channeling the satirical medical internship novel "House of God" and its "law #11" (https://en.wikipedia.org/wiki/The_House_of_God, full movie at https://www.youtube.com/watch?v=bPllfH9YREA), these poor souls are probably constantly thinking "find me the EHR that only triples my work and I'll kiss your feet."

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

That is a prescription for suboptimal performance and increased risk of harm, on its face.  There is little to argue on that point.  I personally would not want an airline pilot, let alone a physician, providing me services who is "disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

Increasing clerical burden is one of the biggest drivers of burnout in medicine. Time-motion studies show that for every hour physicians spend with patients, they spend one to two more hours finishing notes, documenting phone calls, ordering tests, reviewing results, responding to patient requests, prescribing medications, and communicating with staff.¹ Little of this work is currently reimbursed. Instead, it is done in the interstices of life, during time often referred to as “work after work” — at night, on weekends, even on vacation.

That is, quite frankly, an absurd workload deleterious to provider AND patient well-being.

“EHRs can be a double-edged sword, because they give you more flexibility about where you work, enabling physicians to get home for dinner,” argues Tait Shanafelt, professor of medicine at Stanford University and a leading researcher on physician burnout. “But physicians are working a staggering number of hours at night, and this has enabled organizations to continuously increase productivity targets without changing the infrastructure or support system, effectively adding a whole extra workweek hidden within a month.”

Imagine trying to force "a whole (uncompensated) extra workweek hidden within a month" to the workload of a union member of, say, the Transport Worker's Union.  It would result in an instant labor strike ... or worse.

... Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.³

I rest my case on the increased-risk-of-harm issue.

I seem to be one of the first to recognize, or at least start writing openly about, the bad leadership of the health IT field and the dangers of the bad health IT produced as a result.  My observational skills and critical thinking capabilities led me to start writing on these issues circa 1999, after my experiences as postdoc and faculty in Medical Informatics at Yale School of Medicine/Yale-New Haven Hospital and then as CMIO at the Christiana Care Health System in Delaware. 

That writing is largely retained at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases, in a website I have not updated in several years due to time constraints related to the EHR forensics work I have been doing in the legal and law enforcement sectors.

It is clear my concerns are now proven correct and are now being echoed by large sectors of the physician and nursing communities.   My concerns were obvious, I opine, to anyone of reasonable critical thinking and observational skills, who were not affected by conflict of interest.  That is, those without profitable connections to the health IT industry.

I now make a prediction for the future that, once again, seems obvious to me:

Today's EHRs, especially the sections for narrative clinician documentation, will be downgraded from their "template madness" time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper.  Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s' as at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html, but paper nonetheless.  Data extraction of these notes for financial purposes will be done, once again, by coders.

A small sample of why physicians and nurses burn out from EHRs.

Debate if you will, but that is my prediction for the future.  I feel it inevitable considering the unintended/unexpected terrible consequences and realities of this technology.  "New curtains" (that is, tidying up the user interfaces) will not suffice.  This is a prediction from one of the first Medical Informatics professionals to start openly writing about EHR difficulties almost two decades ago. 

-- SS

Burnout Returns to Center Stage

A recent Mayo Clinic Proceedings guest editorial, by Yale University physician Kristine Olson, asks the question--to some of us it's far from a rhetorical one--whether burnout among her fellow physicians is in fact "A Leading Indicator of Health System Performance?"

Seems to me that her gist is: yes, it surely must be just such an indicator. If she's right, then our system's performance is in a heap of trouble.

What is burnout? Our fearless editor, Dr. Poses, has addressed it repeatedly, including a few months ago here in these pages. But burnout is actually hard to delineate and hard to quantify. People quitting? People getting a lot less efficient once they see they're on the hamster-wheel? Getting lousy performance ratings because they're forced to hang in? (Wishing they had another option?) Leaving front line medicine to go to industry? Leaving to clip coupons and bicycle in Provence?

Well, to quote Justice Potter Steward in his inimitable pronouncement for his short concurrence in the 1964 SCOTUS obscenity proceedings, "I know it when I see it."

I know burnout when I see it. So do you. You want a physician who loves her job enough to get good at it, because lives depend on that. How's that going for you?

I've watched my best and brightest colleagues--or those who could find a nonclinical job or afford to retire--leave in droves. Now the waves of new investigations of burnout are coming at us thick and fast. What's striking about the latest spate of writings on burnout is what it doesn't try to say. Which is to say: back at the turn of the century, or just before that, or just after that, the preponderance of published sentiment was on reinforcing providers' resilience. Essentially, pep talks disguised as exegeses on "professionalism." "Stiff upper lip, remember your values and for heaven's sake, keep your professional wits about you.

That's now changed. The surfeit of real, serious challenges--external threats--from HIT FAN (Health IT FAke News) to the opioid crisis to maldistributed resources, are now finally being examined. We'll come back to whether it's too late for any of this. So here are some recent chances for readers to get, usually without a paywall, a look-see.

• The redoubtable New England Journal has several recent entries in its 25 January 2018 number dealing forthrightly with the "crisis level" of the problem, beginning with a perspectives piece from National Academy of Medicine authors Victor Dzau et al., including colleagues from most of the major national organizations involved in training and accrediting physicians and their organizations. I hope they read this blog.
• The article cited above embeds an excellent and downloadable audio interview with Tait Shanafelt, MD, of Stanford University, also on burnout. He helpfully points out how front line doctors--those in primary care fields like internal medicine, family medicine and pediatrics--bear the brunt of the burden. That is, they bear the burden reflected in the alarming rate of especially experienced practitioners peeling off rather than continuing to put up with the (now my words) losses of autonomy and coherence. More later on autonomy and coherence.
  
  (At Stanford, Shanafelt holds the title of "Chief Wellness Officer." That tells us something right there. At a website tied to fitness, the CWO is defined as somehow hired  to "create work culture for employees to not only show up and perform, but thrive." Hey, any port in a storm. If removing noxious threats such as those above can be compared to wellness threats on exercise machines, like coach-driven anabolic steroids, then we're all for it. Let's get rid of the bullying managers along with the bullying coaches. Can Chief Wellness Officers effect such a change?)
• In the same number of the Journal, one finds another superb piece by the now long established team of physician-journalists Alexi Wright and Ingrid Katz. Gott sei dank for the impact of young persons and women on health policy around medical worklife. Wright and Katz title their piece "Beyond Burnout -- Redesigning Care," not the shopworn twentieth century "Be More Professional" meme. They go on at length on the cost of losing experienced doctors, and describe one means of addressing the crisis created at the University of Colorado. In the so-called Colorado APEX project, which started (as many innovations do) in Family Medicine, then spread to other departments and institutions, they show how certain burnout measured were cut dramatically.
  
  They conclude, though, with an admonition: "how [can] physicians can reclaim joy in the practice of medicine?" They're not sure, nor am I, whether managerial redesign of care, by itself, can "restore meaning and sanity" to the lives of providers.
  
  And this is not just about--in the main this is not about--making doctors' lives better. Not the real point. Doctors flake off, patients have longer wait times then have access to less and less experienced ones when they finally get to see them. Doctors lose that passion for the art when they're overwhelmed with prescriptive guidelines around the "science." Unclear which is more dangerous: doctors who burn out and leave, or those who burn out and stay behind.
• Wright and Katz and a number of other observers cite what's turning out to be a seminal study published last fall in Mayo Clinic Proceedings. Authored by a team led by prominent internist Christine Sinsky, the piece provides all the evidence anyone will ever need to understand the magnitude of the crisis as well as some of its causes. Chief among those causes, a topic repeatedly and eloquently underscored (most recently here) in these blog pages by our own InformaticsMD, is the Electronic Health Record, or EHR. The blog post just quoted actually harks back, through a report in Medical Economics, to the same Sinsky piece mentioned at the start of this bullet.

There's been a lot of inkshed lately about the EHR as a cause of burnout. But what seems most likely is a murkier picture that means we have to look both across the causal spectrum and across the political spectrum.

Does having your practice swamped by addiction-crisis patients contribute as well to burnout? In an earlier blog we pointed to the phenomenon of physicians across the country "learning" about opiates, first becoming "convinced" of the non-addictive properties of drugs like OxyContin. In a word, later, realizing they'd been snookered--a real blow to the joy and coherence of medical practice. Not to mention the end-effect of whole practices being consumed by drug- and doctor-shopping by patients totally convinced that they "needed" continued use of these drugs to avoid pain relapse.

But wait. Burnout is multicausal. Physicians trained to practice public health and physiologically-based internal medicine are stymied by loss of control of their practice, as the managers insist on crowding their schedules with all comers. No choice. Firing a patient is well nigh impossible.

They're also stymied by the bizarre contradictions--see above and all the new articles--of the technology imposed by managerialism. Why is it imposed? The physicians know why, and there's nothing they can do about it.

1. It allows managers to "watch"--using all the wrong metrics--their performance.
2. It gives managers the illusion of control by means of counting--which in fact EHR does very badly--adherence by clinicians to clinical guidelines, even when the latter are ill conceived.
3. It allows managers to draw in more dollars through "compliance" with government-imposed standards, out of the Office of the National Coordinator (ONC) for Health Care IT, including the now justifiably much-maligned Meaningful Use standards. Some standards we came to know well, allowing managers to capture more dollars, include things such as the following.

-- pushing out end-of-encounter "Clinical Summaries" that contain nothing but erroneous lists of medications, and no plan, then leaving these near-worthless paper documents on printers when they were destined for patients

-- striving perversely to push out "eScripts"--electronic prescriptions--for a certain percentage of patients during encounters, requiring first the e-prescription followed by a web-page button indicating "I wrote this prescription electronically," followed by billing for an eScript: except that most patients already got their meds renewed outside of in-office encounters
-- push doctors to "upcode" from lower- to high-reimbursement level billing codes for greater charge capture, requiring nothing more than gross importation of macros and text blocks
-- this list goes on and on; this writer knows inside out the perversities of the EHR

So the opiate crisis and the technology crisis have converged with still other forces that now  becoming rampant. Chief among these is the much slower-simmering crisis of hyperspecialism. Students who would become great generalists cannot afford to do so because of crushing debt burdens. Their institutions impose drastic inflated costs on medical students while pushing, through both cultural and institutional pressures, these students to hyper-specialize in procedure-driven specialties whereupon they, too, can become part of the problem.

This last problem has been discussed on occasion over the years in HCRenewal by its editor, Dr. Poses, in his discussions of the secretive AMA-designated panel known as the RUC, the Resource Utilization Committee. RUC exposés are rampant--see here and here--and nothing new. But the result is that the AMA's efforts on behalf of its own heavily specialty-weighted membership have created within medicine an auto-cannibalistic food chain within which the profession, including academic medicine, essentially penalize their own most vulnerable. The most vulnerable who are in fact societally the most valuable. But since the AMA appoints the RUC, it is complicit in this autocannibalism, and therefore in the demise of physician worklife coherence. In his interview, Stanford CWO Shanahan states as much when we speaks of the particularly burdensome consequences of burnout among primary care physicians.

(That Sinsky now spends some significant part of her time at the AMA is a good portent, we have to admit.)

So what are we left with? Earlier we said this is a multi-political problem. Look at the sources of the three causes of burnout discussed above.

• The opiate crisis clearly stems from industry. Big Pharma, with one company, Purdue, allegedly leading the charge over several decades, gets the nod here. Not, as Wisconsin Sen Ron Johnson seems to think, the availability of Medicaid funds for addicted patients. Score one for private sector iniquity.
• The EHR crisis clearly stems from Big Government. And probably, equally, industry, although when it started out the folks who brought you all the deficient EHRs were small entrepreneurs, nothing like Big Pharma. Score one for public sector iniquity.
  
  But Big Government brought them into the Bigs. Using by and large the wrong metrics. Medical managerialism then kicked in, bought the package, and went for the gold in them thar IT hills. That's the story of HITECH and even ACA as they sought out tech panaceas--the classic American technological imperative that brought us everything from the Interstate Highway System to the Moon Shot to the War on Cancer. And now this.
• The relationship between public clinical needs and physician organizational resource mismatches is internal to the medical profession. "We have met the enemy and he is us." Score one for autocannibalism in a classic profession unable to regulate itself now, if it ever could before, in the face of all these new external forces.

Put all this on a SWOT analysis chart and you have a recipe for disaster. The one thing that both Big Medicine and Little Medicine had going for them in years past was autonomy and coherence. The autonomy couldn't survive in the 21st century, but the coherence--the sense of meaning derived from applying science to the individual patient--could have and should have. It is a flame still not extinguished. But faced with the forces we've discussed here, it is a flame flickering, just barely.

And the solution, like the problem, comes from every part of society. It therefore brooks no easy or solitary solution from either the left or the right extremes of political philosophy.

Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records

In yet another example of the clerical overload caused by bad health IT, physicians find themselves drinking from a fire hose through cybernetics.  This, in the field of dermatology, let alone critical care specialties:

Physicians Overwhelmed by Messaging From Electronic Medical Records
MedicalResearch.com Interview with: Matilda W. Nicholas, MD, PhD
Duke Dermatology
January 29, 2018
https://medicalresearch.com/author-interviews/physicians-overwhelmed-by-messaging-from-electronic-medical-records/39671/

MedicalResearch.com: What is the background for this study?
Response: I have found many physicians overwhelmed by the electronic messaging feature in Electronic Health Record systems (EHRs). I found there was very little published about this phenomenon, particularly for specialists. So, we set out to take a look at the volume and effect these systems have. 

MedicalResearch.com: What are the main findings?
 Response: We found that, on average, clinicians receive 3.24 messages per patient visit, for an average of about 50 messages per full day of clinic. The number of messages also correlated with poor reported work life balance for dermatologists.

Those 50 messages are in addition to whatever messages physicians receive through their other, personal accounts.  The number is likely far higher in more generalized and more critical care subspecialties such as internal medicine on the one hand, and, say, ICU medicine on the other.

MedicalResearch.com: What should readers take away from your report?
 Response: As previous studies have shown, physicians are spending much more time in non-direct patient care and less time with patients. This is bad for everyone involved. Targeting methods to decrease this burden would be important in improving patient care and physician wellbeing ... We are planning on examining the messages sent directly from patients more closely, hoping to target higher risk patients to decrease post and inter-visit messaging.

As at my Jan. 28, 2018 post "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html and many, many others, cybernetics are proving a distraction from - and actually a deterrent to - the practice of good medicine.

With the increasing outcry of physicians and nurses against EHRs and the oppressive demands the systems place on them, and the burnout these systems cause (see the numerous posts on burnout at query link http://hcrenewal.blogspot.com/search/label/burnout), I'm increasingly of the opinion these systems are not fixable.

There is only so much that can be accomplished with surface changes to user interfaces, without substantive changes to physicians' work expectations. 

The true problem that nobody seems to want to deal with - the proverbial elephant in the living room -  is expectations of clinicians doing oppressive amounts of clerical work, in addition to their patient care responsibilities.

(Note that in this essay I am not addressing other critical drawbacks to this technology such as crashes, lack of security including growing record theft, ransomware attacks on EHR's, and so forth.)

In my view, the only solution to these problems are separation of clinicians from clerical duties (see my August 9, 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html), and the use of data-entry personnel, as I set up in the Invasive Cardiology Clinical Database at Christiana Care Health System in Delaware (http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story) so many years ago. 

Of course this will likely never happen, because it's an expensive labor proposition.

Based upon my EHR forensics/expert witness work since 2010, I also believe physicians can expect no help from the public or the government on this.  The issues seem above the public's heads (with the exception of those injured or killed by bad health IT, who - or whose heirs - seem to learn very fast about the drawbacks), and conflict with the bureaucratic goals for control of medical finance.

Physicians need to take control of their occupations, for there is no help coming from government or the public regarding cybernetic oppression. The only way repair of the profession can happen is through unionization, such as I saw in my work in the public transit industry.

If physicians are unwilling to take that step, then they will have to accept being servants to the bureaucracy, and being endlessly stressed, distracted and harassed by their cybernetic overlords.

-- SS

Medical Economics: Highly experienced physicians lost to medicine over bad health IT

The title of the article is actually "Physicians leaving profession over EHRs", but that title omits the real impact of the phenomenon: seasoned physicians, along with their medical expertise, judgment and experience, are lost to the pool of people entrusted to provide care thanks to poorly designed and badly implemented IT:

http://cci.drexel.edu/faculty/ssilverstein/cases/
Bad Health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

This is yet another article observing that the trajectory of health IT is not what the pioneers who taught me Medical Informatics intended:

Physicians leaving profession over EHRs
Medical Economics
Keith Loria
January 24, 2018
http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-leaving-profession-over-ehrs

Until recently, most doctors created their own workflows and utilized only the technology they were comfortable using. But with the implementation of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 to stimulate the adoption of electronic health records (EHR), many physicians are finding things a bit too stressful.

In fact, a new study in Mayo Clinic Proceedings showed that physicians who are uncomfortable using EHRs are more likely to reduce hours or leave the profession.

I think it very fair to say that a majority of physicians are "uncomfortable" or at least "highly displeased" using today's EHRs.  Evidence for this assertion includes, among others, the Jan. 2015 letter from approximately 40 medical societies including AMA, American College of Physicians, American College of Surgeons, and many sub-specialty societies expressing their displeasure directly to HHS. 

See my January 28, 2015 essay "Meaningful Use not so meaningful: Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing" at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html, and the Medical Societies letter itself at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.

The research showed that while EHRs hold great promise for enhancing coordination of care and improving quality of care, in its current form and implementation, it has created a number of unintended negative consequences including reducing efficiency, increasing clerical burden and increasing the risk of burnout for physicians.

Typical of the anodyne stories in the media on bad health IT, the issue of causing increased risk and actual patient harm is omitted.

Tom Davis, MD, FAAFP, who practiced family medicine for almost 25 years in the greater St. Louis area, says the primary reason he walked away from a successful practice was the EHR, citing its use, the ethics and the burden.

“I had 3,000 patients, many I’ve known for a quarter century, a few hundred of which I delivered, all immensely valuable relationships—and all burned to the ground mostly because of the burdens of the HITECH Act,” he says. “The demands of data entry, the use of that data to direct care and my overall uncertainty about how medical data was used in aggregate all helped poison the well from which my passion for serving my patients was drawn.

In other words, his expertise, knowledge and experience, and valuable personal relationships (enhancing trust and the obtaining of the best medical histories) with his patients was sacrificed to, in essence, utopians' notions of cybernetic medicine and the wants of the financialization-of-medicine sector.

He believes that the information collected through the EHR is being used (at least in aggregate) for purposes other than the direct benefit of the individual patient so it would be unethical for him to represent otherwise to the patient. 

I had previously written on this site about the EHR companies trafficking in medical data, as in my October 7, 2009 essay "Health IT Vendors Trafficking in Patient Data?" at http://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.

In the research realm, formerly working with one of the key figures in the now-defunct Human Genome Diversity Project at Yale, I myself am personally aware of indigenous peoples refusing to take part in data collection by western scientists because they feared misuse of the data. 

I was right; the researcher proposed, and may have experimented with, using the genetic data to perfect a "forensic" identification capability essentially based on ethnic ("population") origins. 

I wrote on these issues at my September 8, 2005 essay "Academic abuses in biomedicine vs. Indigenous Peoples: The Genographic Project" at http://hcrenewal.blogspot.com/2005/09/academic-abuses-in-biomedicine-vs.html and my July 26, 2007 essay "Informed consent, exploitation and 'Developing a SNP panel for forensic identification of individuals'" at http://hcrenewal.blogspot.com/2007/07/informed-consent-and-developing-snp.html.

I thus opine Dr. Davis' concerns are quite legitimate.

As far as the burden, he notes he spent about four minutes of keyboard time for every minute of face-to-face time with a patient.

That is a huge waste of clinician time, with few proven benefits (at least outside the financial world) and known risk, e.g., ECRI Institute's yearly "Top ten technology risks in healthcare" where health IT is usually highly ranking on that list, such as at my April 2014 essay at http://hcrenewal.blogspot.com/2014/04/in-ecri-institutes-new-2014-top-10.html.

Ramin Javahery, MD, chief of adult and pediatric neurosurgery at Long Beach Memorial, Long Beach, California, says there are obvious financial pressures that drive people out of private practice into a larger corporate structure, but the changes in the workplace brought about by EHRs are also driving older doctors to retire rather than deal with the costs or increased work required.

“Younger physicians who are comfortable with typing, computers and the truncated patient interactions generated by EHRs do not resist its presence,” he says. “Older physicians, however, are more likely to lack those comforts. When faced with a less comfortable work environment, they choose to retire, especially since many have saved enough to be comfortable financially.”

Where do I even start?  Older doctors have a wealth of experience and hard-earned wisdom that is being sacrificed to the whims of those who think the medical robots of "Silent Running" are just on the horizon, it seems...

These robots could perform surgery.

Regarding younger (i.e., less experienced) physicians and the "truncated patient interactions generated by EHRs", those are two deleterious results of the technology.  Less experience combined with less patient interaction, plus the distractions imposed by EHR-related clerical work, create increased risk of error and patient adverse consequences.   There is little to debate on that point.

Kevin Gebke, MD, a family and sports medicine practitioner at Indiana University Health in Indianapolis, says the issue is not fear, rather it’s a matter of dramatic workflow change.

“EHRs were not designed by practicing clinicians and are not intuitive regarding the different processes that take place during a patient encounter,” he says. “Physicians must often choose between communicating with the patient and navigating within the records to enter or view relevant data. That can fragment care during a patient visit.”

His experience with EHRs is it has slowed down his workflow, causing a significant decrease in productivity.

The issue is certainly not "fear" or physicians being "Luddites", as I've pointed out in my March 11, 2012 essay "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html. 

The tension is not between doctors who "fear" technology or are Luddites, vs. the modernists.  Rather, the true tension is between clinician pragmatists and technology hyper-enthusiasts ("Ddulites") who ignore technology's clinical downsides.

“Spread this decreased capacity to see patients across the country and we then have a magnified shortage of primary care providers,” Gebke says.

That shortage is, in fact, at odds with national policy on re-populating the pool of generalists to reduce costs.

Because of this, he believes a way to keep physicians from leaving the profession over EHR issues is to get them involved in design and improvement processes.

EHR redesign can only accomplish so much.  I have reached the point where I believe the only solution to this seeming conundrum is to stop focusing on computers, and decouple physicians and nurses from cybernetic oppression.  See my August 9, 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html. 

I observed:

... In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients.  Patients complain they cannot get eye contact from clinicians - who are tethered to a computer screen entering data - during "live" encounters.

It is my belief there is no solution to this problem other than, where appropriate and advantageous, decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post.  Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

Finally, the predictable "things are getting better and utopia is just around the corner" ending to articles on the impact of bad health IT ends this Medical Economics article:
  

Things are improving

Munzoor Shaikh, director of West Monroe’s healthcare and life sciences practice in Chicago, says that while some doctors are leaving medicine due to technology learning curves, the industry is past the EHR implementation phase and has entered an EHR optimization phase where the user experience on the physician side should be improving.

“Those who have more patience than others have stuck around; hopefully this optimization phase will save some more doctors from leaving,” he says. “That said, there are some physicians who are fundamentally not built for this tech-driven world.”

The final line is nothing short of outrageous.

The truth is, there are all to many clinical information systems that are fundamentally not built for the good-practice-of-medicine-driven world.

-- SS

More on the Opiate Abuse Epidemic: Where Again Does the Finger Point?

In a recent blog post we pointed to conservatives' efforts to implicate Medicaid funding as somehow causative of, or at least promoting, the opiate "crisis." After all, funding for medications means people will use, and sometimes abuse, those medications. Meds they might otherwise ill be able to afford. (Implied solution: cut Medicaid.)

We also alluded to some of the logical fallacies in such thinking. Here, though, let's take it to another level: the blame game, where does it lead? Where does the finger point? Those who agree with Ronald Reagan that government is the problem, not the solution, fall into the trap of blaming public action and civic institutional development for the ills of our society.

But gosh, why is it that private actors get a bye? Isn't it possible that something other than public action could end up being the culprit? What creates this blind spot?

For one thing, those (they're discussed in the blog link above) who point fingers at Medicaid overlook inconvenient truths. Take the state-by-state data. True, West Virginia is among the top states, as it happens, for both Medicaid and addiction rates. But then look at New Hampshire. With Ohio, it is a close second for addiction but affluent enough to be near the bottom of states receiving Medicaid/CHIP. Somehow the great conservative logicians seem to miss data like this.

For another thing, when you go from the "faceless bureaucrats" to the families that run things in this country, there's the matter of privacy. There's a queasy feeling about ratting out your private "friends," even when they're not really friends at all. Even when they're polluting your environment or selling you (in our new parlance) some newly slavered S on toast. And private actors, once in the, well, let's say billionaire realm, can manage to protect their brand even while working behind the scenes to ruin--allegedly--people's health through false advertising. Turns out New Hampshire doctors prescribe opiates at about double the national rate, responding not to government but to private (Big Pharma) signals.

Such private matters have been the case, allegedly, with the family that brought you all the flavors of the pharmacologic gift that keeps on giving: oxycodone. We know this is the case especially, more recently along with fentanyl, with this drug in its most controversial form, Oxycontin. Oxycontin was brought to your local pharmacy by the still barely-known Sackler family. It's a dramatic story of a family out of Brooklyn by way of the medical schools of Glasgow and then the boardrooms and development offices of some of this nation's most prestigious citadels of culture.

Two recent discussions of the Sacklers point to their possible culpability in spreading a false gospel of SOAP: a Safe Opiate Administration Policy. Last fall we considered blogging on the first of those discussions in The New Yorker. But it's hard to access some literature hidden behind paywalls, so we held off. Now, however, a shorter and in a number of ways more accessible piece on the Sacklers now emerges in The Guardian.

The New Yorker piece, by investigative reporter and staff writer Patrick Radden Keefe, shows how this family of physician-entrepreneurs built an "empire of pain," as he styles it, starting as far back as the mid-20th century. This was the era of Estes Kefauver's aggressive committee hearings. But even congressional inquiry was no match for the aggressive advertising tactics and casuist hyperprofessionalism--hiding behind the degree--tactics of an Arthur Sackler, who "caught Kefauver in an error," notes Keefe, "and said, 'If you personally had taken the training that a physician requires to get a degree, you would never have made that mistake.'”

In related fashion, for health care the Sackler Brothers were among the first to use the megaphone of social media as a tool, in its primitive mid-century form, for disseminating messages to a gullible medical profession. They were sales geniuses, understanding the nudge-value of throwing money around. They created Medical Tribune, one of the most successful and impactful of what came to be known as throwaway journals These throwaways hit doctors' mailboxes on a daily basis. (Medical Tribune was biweekly but there were lots of others.) Conflict of interest? Why do you ask? Potentiating the message that opiates were safe, especially when there was a "clear need" for such agents? Question answers itself.

Toward the end of the last century, the story of the Sackler family and opiates took two other important turns. In 1995 OxyContin received FDA approval for moderate-to-severe pain. (Not long after, in the great tradition of the Revolving Door, the very FDA official who oversaw the drug's approval left the agency and went to work for the Sacklers at Purdue.)

Some of us recall that that was about the time an alarming tsunami of patients began to flood through our doors. Their complaint was stereotyped: months or even years after a mild-to-moderate injury, long after full healing could easily be documented, "If I don't take this medicine I get my pain back." Awareness of addiction was just about as conspicuous in its absence for us and our patients alike.

Some time also in the mid- to late-twentieth century, Sackler family largesse in the funding of the arts became an international phenomenon. While family names appeared conspicuously on galleries in prestigious institutions around the world, on the company website they equally conspicuously disappeared from the list of directors--up to eight in all.

This past week, New York journalist Joanna Walters, in The Guardian, related the story of Nan Goldin, a renowned Brooklyn artist-photographer. Goldin went from a case of tendinitis to a full blown OxyContin addiction that turned her into a recluse for three years. It is accessible with no paywall and makes intriguing reading. We watch Goldin out herself as an addict and valiantly seek to mount a counter-messaging movement. Goldin's verdict: "I don't know how they live with themselves."

And so here we are. Private actors buy their way forward into the benign and beneficent ranks of the cultured plutocracy. They do so while covering their tracks backward as the real vectors of an epidemic. (See Arthur Sackler's fascinating 1987 obituary in his own journal, extolling the "Renaissance Man" and implying he received medical school training at NYU.)

Meanwhile, the logicians in Washington, DC, still parrot Ronald Reagan that "government is the problem." No, Wisconsin Senator Ron Johnson, government, of which you are allegedly a part, is not the problem. Unless you're it. Those whom you protect with your flawed logic and equally flawed ideology are the problem. We suppose it's no wonder that last year, at an event in the state that both you and the Speaker of the House call home, Donald Trump kept calling Paul Ryan "Ron."

Not just bad health IT, but SPECTACULARLY bad health IT

I define bad healthcare IT as:

... IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, lacks evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. (http://cci.drexel.edu/faculty/ssilverstein/cases/)

Here is an example of not just bad health IT, but SPECTACULARLY bad health IT.

I offer no additional commentary because 1) I am tried from having to pick apart the work product of health IT amateurs who create nightmare systems, and other fools, and 2) none is needed.

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From KevinMD blog:, https://www.kevinmd.com/blog/2018/01/16-page-note-little-information-help-physicians.html:

A 16-page note with little information to help physicians

NIRAN S. AL-AGBA, MD | PHYSICIAN | JANUARY 19, 2018

My pediatric practice is one which harkens back to days long ago when physicians knew their patients and pertinent medical histories by heart. My 81-year-old father and I were in practice together for the past 16 years; he still used the very sophisticated “hunt and peck” to compose emails. The task of transitioning to an electronic record system seemed insurmountable, so we remain on paper. Our medical record system has not changed in almost five decades. I would not have it any other way.

This past spring, he walked into my office shaking his head in disbelief after thumbing through a stack of faxes.

“Can you believe this 16-page emergency room note has no helpful information about the patient?”

This was not a shock to me. The future of medicine will include robots who are paid to collect reams of useless data to provide nothing in the way of health or care. Regardless, the government and third-party payors will extoll upon the virtues of their inept system as life expectancy falls.

Fifty years ago, there was a close relationship between a physician and their patient grounded in years of familiarity. Physicians took a history, performed a physical exam, and developed an assessment and plan. Diagnosis in a child with fever would be descriptive, like bacterial infection, otitis media, fever of unknown cause, or viral illness. Parents were advised to provide supportive care, involving clear liquids, fever medication, and follow up precautions if the child worsened.

At the dawn of the technological age, the effortless simplicity previously existing between physicians and patients has all but evaporated. It was traded away without our consent, relegating the role of physician to that of a data-entry clerk. Physicians are discouraged from synthesizing information and utilizing it to guide our decision making. Today, a 16-page document “appears” to contain crucial elements such as chief complaint, past medical and surgical history, medication list, and allergies. However, the information is then followed by more than a dozen pages of waste.

The particular case to which my father was referring involved a 5-year-old child with fever. The provider documented the sexual history of this child, whether he was single or married, and whether or not he had children of his own. My dad and I started chuckling as we contemplated collecting this kind of extraneous information from a child who had not even entered puberty. As one would suspect, our young patient was single, as in not married; he had no children (which is physiologically impossible), and his years of formal education were noted: “not pertinent to his medical situation.” Interestingly enough, I volunteer at the school where this young boy attended kindergarten; his classroom was next door to the one with my second oldest child. Three of his classmates were out with febrile illnesses; however, technology cannot incorporate this kind of alternative data.

We kept reading and laughing. Occupational history was recorded as not on file; running a bustling lemonade stand in his neighborhood apparently was not clinically relevant. It came as quite a relief that at the tender and impressionable age of five, this boy had managed to steer clear of regularly smoking cigarettes. It was comforting to discover he had never used smokeless tobacco either; and for some reason, I never thought to inquire about such things before (insert eye roll). He also denied alcohol use, restoring my faith in the fact that not every youngster was consuming alcohol during their formative childhood years.

Just when I thought things could not get more absurd, I came upon the sexual history; contemplating whether or not a five-year-old child was engaging in consensual intercourse was nauseating. I reminded myself that data entry clerks were devoid of emotion and instead were tasked with collecting “critical” details to practice by protocol. Sexual history: Not on file.

The final summary and diagnosis section was the most entertaining part, which read: “primary diagnosis: none.”  Seriously, are you kidding me? No diagnosis? This is the future; technology will seal the fate of our profession as one entirely devoid of the need for any cognitive skills. This earth-shattering conclusion after sixteen (16!) pages of documentation was utterly astonishing. Despite the considerable time and effort invested asking a febrile five-year-old whether he was married or having consensual sexual intercourse in his spare time, little to nothing was provided in regard to healthcare.

At this point, my father and I laughed so hard that tears were running down our cheeks. There is no other reasonable response to the sheer waste of time, resources, and education invested in becoming a physician. Doctors have spent decades honing their clinical skills and should be entitled to choose the documentation method they find most effective and efficient. Some physicians find electronic records helpful and should be encouraged to use them. My pediatric practice will keep surviving on a shoestring, a prayer, and good old-fashioned paper. It warms my heart to know each chart note contains helpful information and not one human being leaves with “none” as their diagnosis.

Footnote: Page 16 states, “This chart is intended to document the majority of the information from this patient’s visit today. Other items, such as the patient’s care timeline, are reported elsewhere and should be reviewed to better understand this encounter.” (More eye rolling.)

By all means, if 16 pages did not cut it, twenty more should make sense of arriving at no diagnosis. Forgive me for not running out and requesting those records immediately.

Niran S. Al-Agba is a pediatrician who blogs at MommyDoc

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As I stated above, I am not adding additional commentary, because none is needed, even for health IT hyperenthusiasts who might blame these doctors for being "Luddites."  (Hopefully.)

-- SS

Will the New Conscience and Religious Freedom Division of the US Department of Health and Human Services Help Health Care Professionals Challenge Morally Objectionable Acts - Like Bribery, Fraud and Other Criminal or Corrupt Practices?

For a long time we have argued that health care corruption is a major cause of health care dysfunction.  We have documented numerous cases in which health care professionals were exposed to or involved in actions, including fraud, bribery (also known as kickbacks), and other corrupt or criminal practices, to which they likely had moral objections.  We have also noted that in such situations, health care professionals often have little recourse, particularly in academic institutions.

The New Conscience and Religious Freedom Division of the US Department of Health and Human Services

So perhaps a new initiative of the US Department of Health and Human Services could relieve health care professionals besieged by unethical and immoral practices.  Per the Washington Post (on January 18, 2018),

The Trump administration on Thursday announced the creation of a new conscience and religious freedom division aimed at protecting doctors, nurses and other health-care workers who decline to participate in care that goes against their moral or religious convictions.

Speaking at an event featuring Republican lawmakers and religious leaders, Acting Health and Human Services Secretary Eric Hargan noted that many of the nation's hospitals, clinics and hospices are run by faith-based groups. And many have found themselves forced to provide services or referrals that violate what they believe.

'For too long, too many of these health-care practitioners have been bullied and discriminated against,' he said.

While federal officials did not immediately offer details about the new enforcement office, a Conscience and Religious Freedom section appearing Thursday on the HHS site — showing a female health-care worker in a Muslim headscarf — provides some hints. The description of the division's mandate cites abortion, sterilization and assisted suicide as examples of the types of procedures that would be covered. But the language is broad, and health experts said it appears likely to also cover a host of other scenarios, such as treating transgender patients or those seeking to transition to the opposite sex.

HHS said the protections will apply to discrimination or coercion of  'providers who refuse to perform, accommodate or assist with certain health-care services on religious or moral grounds.' They would also apply to training and research activities, according to the department.

Immoral Practices to Which Health Care Professionals Might be Exposed

On Health Care Renewal, we have focused on unethical, self-interested, conflicted and corrupt or criminal practices of the leadership of health care.  So, for example, we have seen cases in which -

- Physicians and other health care professionals were lured into financial relationships with large health care corporations which created obvious conflicts of interest, especially when they were induced to help market those corporations' products (often in the guise of "key opinion leaders,"), and often without disclosing their conflicts, making their marketing deceptive.  Health care professionals might resist such relationships, or be morally offended by their colleagues' and supervisors' acceptance of such relationships.

 - Top executives of hospitals, hospital systems, and other health care provider organizations may have perverse incentives that lead them to put short-term revenue ahead of good patient care, education or research.  Health care professionals might be morally offended by such mission hostile management, and its effect on the quality of patient care, and the integrity of education and research.

-  Leaders of government agencies may transit to or from commercial entities which might be subject to their agencies' regulations or policies.  This has been called the revolving door, and can be considered a form of health care corruption.  Health care professionals might be morally offended by the regulations or policies of agencies led by people who have come through, or will go through the revolving door.

-  Health care professionals have often been affected by outright crime, such as fraud, bribery or kickbacks, or other criminal or corrupt practices.  For example, there have been many cases in which the marketing of drugs, devices, or other health care products and services to which health care professionals are exposed has been fraudulent. There have been many cases in which health care professionals have received bribes or kickbacks to use or prescribe certain products. Health care professionals might be morally offended by fraudulent marketing, being pushed to accept bribes or kickbacks, or working with colleagues who have accepted same.

Keep in mind that many health care professionals come from mainstream Judaism, Christianity or Islam.  All accept the Old Testament as a fundamental guide.  The Bible contains many exhortations to avoid immoral behavior, most famously the Ten Commandments.

[The Ten Commandments - in an ancient synagogue in Tzfat, Israel]

Some quotes from the Old Testament about the sorts of immoral behavior listed above:

Do not pervert justice or show partiality. Do not accept a bribe, for a bribe blinds the eyes of the wise and twists the words of the innocent. [Deuteronomy 16:19]

Justice, justice shalt thou follow, that thou mayest live, and inherit the land which the LORD thy God giveth thee. [Deuteronomy 16:20]

Bread of falsehood is sweet to a man; But afterwards his mouth shall be filled with gravel. [Proverbs 20:17]

He that walketh righteously, and speaketh uprightly; He that despiseth the gain of oppressions, That shaketh his hands from holding of bribes, That stoppeth his ears from hearing of blood, And shutteth his eyes from looking upon evil; He shall dwell on high; [Isaiah 33:15 -16]

A wicked man taketh a gift [bribe] out of the bosom, To pervert the ways of justice. [Proverbs 17:23]

So for most health care professionals, the actions in health care that may be most morally repugnant would be bribery, kickbacks, fraud, and other forms of corruption or criminality going on around them.  In theory, and on paper, the new Conscience and Religious Freedom Division ought to be a powerful force to combat health care corruption.

Summary - What Were They Thinking?

Somehow, though, I am guessing that the people who came up with this new initiative were not thinking about anti-corruption efforts.

First I would note that the announcement was made by Acting Health and Human Services Secretary Eric Hargan.  We discussed Mr Hagan here. A hint: the post was entitled, "Worst Health Care Revolving Door Case So Far? - From Lobbyist to Acting Secretary of Department of Health and Human Services."  Mr Hargan is a lawyer who spent years as a lobbyist for health care corporations prior to being nominated to be acting secretary.

As we noted earlier, the revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

So I must say I am morally offended that Mr Hargan is now the Acting Secretary of DHHS.  So I really do not think he and his cronies in the department were thinking about people morally offended by fraud, bribery, kickbacks or other criminal or corrupt practices, including the revolving door, when they set up this new division.  Moreover, as the Post article stated,

The description of the division's mandate cites abortion, sterilization and assisted suicide as examples of the types of procedures that would be covered. But the language is broad, and health experts said it appears likely to also cover a host of other scenarios, such as treating transgender patients or those seeking to transition to the opposite sex.

Also,

The announcement, which comes one day before abortion opponents' annual March for Life, represents the latest move by the Trump administration to allow individuals and institutions to opt out of providing certain services or benefits based on such objections. In 2017, the administration issued new rules allowing exemptions for more employers, including for-profit businesses, from providing no-cost contraceptive coverage through their health insurance plans.

So,

House Majority Leader Kevin McCarthy (R-Calif.), for one, said the previous administration expected health care workers 'to conform' rather than follow their religious beliefs. 'What a difference a year makes,' he added.

Roger Severino, director of the department's Office for Civil Rights, echoed that theme, saying that 'HHS has not always been the best keeper of this liberty.' Health-care workers' complaints to his office have increased in recent years, he said.

'Governments big and small have treated conscience claims with hostility instead of protection, but change is coming, and it begins here and now,' Severino said.

And Montse Alvarado, executive director of the Becket Fund for Religious Liberty, a nonprofit law firm, stressed, 'It is important to recognize that we have come to a point where a division like this would be necessary.' What happened under the previous administration, she said, resulted in 'forcing Americans to choose between their beliefs and their livelihood.'

IMHO, the people who came up with the idea of this new division completely ignored the religious and moral beliefs of a majority of Americans.

Many health care professionals have had to choose between their beliefs - that fraud, bribery, kickbacks or other corrupt practices are morally wrong - and their continued employment.  I would submit that their are more cases of health care professionals offended by such actions than their are health care professionals offended by abortions and the provision of contraception.

Furthermore, given the description of the Division's statement of conscience rights:

Conscience protections apply to health care providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds.

Federal statutes protect health care provider conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in these services based on moral objections or religious beliefs.

It seems that it ought to provide protections to people who object to fraud, bribery, kickbacks or other corrupt practices on religious or moral grounds.  So maybe those of us who are exposed to such practices ought to see whether the division itself is real, or some new kind of fraud. 

Big Bang Theory of Health Care: Ever Since 1967

Hold on to your hat: it all comes together now. Looking at events in our nation's capital, in a strange fever dream, The Big Bang Theory just came to me. No, call it the Big Fecal-Bang Theory, as I read about how our national leadership proceeds from one inanity to the next.

But when it comes to health care, and wiping out the safety net using false premises, inanity kills. So this is worth writing. But to see how it all ties together, we have to go back over half a century.

Where else can you read about the hidden connections between Hollywood, health insurance in the US of A, Really Bad Tax Cuts, Wisconsin cheese-eaters, opiate addiction and Really Bad Logic?

We will conclude with the antics over the past year of Senator Ron Johnson of Wisconsin in the annals of health care. But to pull it together we have to back to just over fifty years ago. Take a walk back to 1967.

That year two events occurred involving two major characters of the day. Hollywood!

The first was the ascent of an actor named Ronald Reagan, perhaps our first media-celebrity politician, to his first term as California governor. Some time later, eyeing higher office, he was insisting government-is-the-problem-not-the-solution. A mantra carried through ever-bigger megaphones until we arrived at the present day s-house.

California, of course, as a whole is now far less likely to throw up right wing politicians onto the national stage. (Rep. Issa is leaving it as we speak.) But our great expanse of red fly-over country still belches forth people like Paul Ryan and Ron Johnson to bollix up health care and pretty much everything else.

The second event worth recalling from 1967 is the grand Oscar-winning Mike Nichols and Buck Henry collaboration, The Graduate.  Forget about the stars. They're still in the news for all sorts of peculiar things. Remember Mr. McGuire? Until our current president trumped him with a potty-mouthed single-word viral epithet, Mr. McGuire was the single-word champ, with his fatherly diatribe to Dustin Hoffman on the future: plastics.

(The actor, Walter Brooke, who was among other things a big Thomas Jefferson enthusiast, was reportedly so enthused by his role that he remained forever wistful about his own failure to invest in plastics. Starting in 1968, though, many more did take the fictitious Mr. McGuire's advice, earning tidy sums in life imitating art.)

Show biz carrying over into the public square: Nothing New.

A decade or so later and now far from Hollywood, another family, that of today's Senator Ron Johnson saw the same writing on the wall. They launched a company in Wisconsin now called Pacur. A bit off-subject to explore just how much credit this intrepid midwestern businessman-turned-politician can take for single-handedly pumping up a company that specialized in plastic extrusions.

But by 2016-2017, Johnson had done just that in spades. And now according to multiple sources he allegedly uses the recent tax-cut legislation to win all sorts of special concessions for plastics from the GOP leadership in exchange for pushing that legislation forward. (See the cheesemen's connection with each other and the alt-right here and here.)

Simultaneously in 2016-2017, according to the reliably right wing organ Washington Examiner, Johnson was already now making a prefatory argument about Medicaid and how it might be responsible for the opiate crisis. That this took my breath away is what, in the event you're still reading, prompted the screed I'm now writing.

So first the boys from Wisconsin enact a bodacious and totally not needed nay harmful tax cut, favoring the wealthy. But long before its success was assured the cheese boys were preparing the ground for the dismantling of Medicaid. First you create a deficit by handing out tax breaks to rich friends. And donors. Then you produce the "evidence" for where the resulting deficit can be addressed, on the backs of poor patients.

That this evidence is specious is almost beside the point. It appeals to the Base, if that's still big enough (it is until November 2018 proves it isn't) to make a difference in pushing through the proverbial Drowning-of-the-Baby-in-the-Bathtub.

But the striking logic used by Johnson allows us to conclude with observations on the multiple fallacies of reasoning commonly committed by the increasingly extreme proponents of this grand new idea of repealing the twentieth century. Brings us right down to today--January 17, 2018--and the hearings Ron Johnson held on the vestiges of the Affordable Care Act and Medicaid expansion. Allegedly they were "trying to link Medicaid expansion to the opioid abuse epidemic."

The notion--now soundly disproved, if such things matter, by actual evidence--that decent health insurance gave more people access to prescription drugs, including opiates, and was therefore harmful as an unintended consequence, is as laughable as is climate change denial. But why should that stop them when "it's just common sense"? (I paraphrase.) The new line of attack on Medicaid is like so much other demagogic off-the-skids reasoning coming to us from extremists of every ilk.

They suffer from so many logical fallacies it's hard to know where to start. (But a good place is here, at UT El Paso.) The argument-from-pathos: "trust your gut." Too, the related biases of Confirmation and Availability, allowing for these wingers' selective use of "evidence" that only seems to bolster their view: "more people with addiction have Medicaid that those who don't."

Say what? See also: the Big Lie Technique. Over-generalization. The Post Hoc Propter Hoc Fallacy, famous ever since the Hippocratic writings. This last one is key: "Disco caused AIDS."

Or, more to the point, as a thought experiment, imagine what could be next when your parents and grandparents stand to lose some or all of their Medicare coverage. Analogous to what the boys of the GOP are doing with Medicaid--a cheap shot and easier target than Medicare.

"Evidence is now showing that addiction to death is far more common among people who have Medicare. Death is bad. Let's gut Medicare." The people don't count. What counts? Plastics!

"Hot Spot For User Entry Error": Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

A short post.

I believe this WaPo story vividly demonstrates issues I've seen in what Australian colleague Dr. Jon Patrick & I call "bad health IT." 

We came up with the simple-to-comprehend terminology "Good health IT/Bad health IT" in his living room in Sydney after my presentation to the Health Informatics Society of Australia in 2012 on health IT trust (http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html), to replace my earlier terms "health IT done well" vs. "done poorly."

It was not just "one employee who pushed the wrong button."  A team of apparently incompetent IT personnel and utterly incompetent IT managers - completely devoid of any understanding of human-computer interaction - were, in essence, standing behind this this employee and guiding his hand.

The Hawaii mishap vividly demonstrates bad IT in the most critical of settings - badly conceived, designed & implemented, lacking appropriate safeguards, usually by people who do not know the domain, and often who are, dare I say, lacking common sense.

Questions that the incident raises include:

• How [in God's name] were such critical items as "Test missile alert" and "Missile alert" (the real thing) residing in the same menu?  Who came up with such bad, terse labeling as well?  [A "hot spot" for user entry error] 
• Why were there no reasonable safeguards? 
• Why was it easy for anyone to make a big mistake?
• Why was no system in place for rapid retraction?

The answers translate back to - well, I probably don't need to say it.

Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

Washington Post

Amy B Wang  

January 14, 2018
https://www.washingtonpost.com/news/post-nation/wp/2018/01/14/hawaii-missile-alert-how-one-employee-pushed-the-wrong-button-and-caused-a-wave-of-panic/

... Around 8:05 a.m., the Hawaii emergency employee initiated the internal test, according to a timeline released by the state. From a drop-down menu on a computer program, he saw two options: "Test missile alert" and "Missile alert."

This is  a classic example of what can be called a "hot spot for user entry error."

... He was supposed to choose the former; as much of the world now knows, he chose the latter, an initiation of a real-life missile alert.

... "Based on the information we have collected so far, it appears that the government of Hawaii did not have reasonable safeguards or process controls in place to prevent the transmission of a false alert," Pai said in a statement.

... Part of what worsened the situation Saturday was that there was no system in place at the state emergency agency for correcting the error, Rapoza said...."In the past there was no cancellation button. There was no false alarm button at all,"

.... "Part of the problem was it was too easy - for anyone - to make such a big mistake," Rapoza said. "We have to make sure that we're not looking for retribution, but we should be fixing the problems in the system.

It would not be unreasonable to predict that U.S. armed forces were put on alert, perhaps even scrambling fighter planes near the Korean peninsula - moves that other countries could detect.

This "mishap" could have caused N. Korea or other hostile country to react, and led to catastrophe.

The utterly incompetent IT personnel and their utterly incompetent managers who birthed such a cornucopia of IT atrocities should be severely punished.

-- SS

Jan. 16, 2018.  Update, update.  Who's got the button?

This new WaPo story shows the "unholy" menu - a jumbled mess.

https://www.washingtonpost.com/news/morning-mix/wp/2018/01/16/that-was-no-wrong-button-in-hawaii-take-a-look/?utm_term=.147cc4852c8e

Was this designed by an expert in human-computer interaction?  I think not...

Incredible.

-- SS