COVID-19: It's Now Time for Health IT Vendors to Traffick in Patient Data

In numerous posts at this blog, I've brought up the issue of hospitals and health IT sellers extracting and exchanging/selling (ostensibly) anonymized clinical data from their EMR systems.  The buyers are varied, from pharma and PBM's to academic researchers to government, and likely many others.

This practice is not new.  For example, see my Oct. 7, 2009 post "Health IT Vendors Trafficking in Patient Data?" at https://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html.

An example of EMR vendor (Cerner) data sales of "anonymous, HIPAA-compliant, EHR-derived data" for analysis. 
Cerner and EPIC are among the largest enterprise EMR sellers in the world.

Also see my November 12, 2019 post "Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans - Time to Refuse Use Of EMR's In Your Healthcare?" at https://hcrenewal.blogspot.com/2019/11/googles-project-nightingale-secretly.html.  In that post I cited an article on Google's efforts in this domain:

Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans

By Katabella Roberts

November 12, 2019

https://www.theepochtimes.com/googles-project-nightingale-secretly-gathers-personal-health-data-on-millions-of-americans_3143843.html

Google has been working with one of the largest healthcare systems in the U.S. to collect and analyze the personal health information of millions of citizens across 21 states, The Wall Street Journal reports.  The Tech giant reportedly teamed up with St. Louis-based Ascension, the largest non-profit health system in the country, last year, and the data sharing has accelerated since summer.

Code-named Nightingale, the project saw both companies collect personal data from patients, which included lab results, doctor diagnoses, and hospitalization records, as well as patient names and dates of birth.

Google said it plans to use the data to create new software that will improve patient care and suggest changes to their care.

More recently, a court review of a noncompete clause-related lawsuit "FLATIRON HEALTH, INC. v. Carson" at https://scholar.google.com/scholar_case?case=7629237467560597212, received by me via a Google alert I have active on EHR-related litigation, describes the market for medical data in more detail.

For instance:

... Flatiron's largest line of business is its real-world evidence ("RWE") service, which converts raw clinical data from patient records into a structured format so that the data can be used for research purposes.[3] After structuring the data, Flatiron aggregates the data into data sets. Flatiron generates revenue by selling data sets to biopharmaceutical companies, as well as some regulatory agencies and researchers...

... Flatiron has developed methodologies and software systems for gathering, curating, and analyzing data from electronic health records. For example, to curate data, Flatiron has formulated rules governing how Flatiron converts information conveyed by physician notes, or other raw data in a patient record, into numeric values for variables in Flatiron's data set...

... Flatiron develops and implements these methods and systems using cross-functional teams consisting of software engineers, oncologists, clinical data specialists, data entry personnel, and others. For example, Flatiron's clinical data team writes policies and procedures to govern how Flatiron's data entry personnel curate data from unstructured records, and Flatiron's research oncology team must generally sign off on those policies and procedures. Research oncologists also describe clinically relevant concepts and rules, which software engineers incorporate into Flatiron's software codes.

This is one of numerous companies who perform services like this.  (Disclaimer:  I have no connections, financial or other interests, or involvement in this company, or others like it, whatsoever.)

Some observations:

1.  Expertise for analysis of EHR-derived datasets is relatively common.

2.  Enterprise EHR systems are widespread and are capturing highly-detailed, relatively standardized data that is easily extracted, as compared to paper records.

3.  Nearly all COVID-19 patients treated in hospitals in the United States, and in other countries with widespread EHR adoption, will have detailed data stored about their demographics (including residences and recent travel), medical and social history, medication history, pre-existing medical conditions, timelines of their signs and symptoms, chronological results of labwork and imaging studies showing response (or not) to therapy, and so forth.

4.  While systems may not be "interoperable", extraction of a uniform constrained dataset from the major EHR systems is both straightforward and, apparently, done regularly for commercial and/or research purposes.

5.  Therefore, in view of the current medical and mass economic upheaval, and what seems to be increasing public impatience and distrust of the experts:

I believe and recommend that anonymized, HIPAA-compliant datasets on COVID-19 patients should be made available ASAP, for example, on an HHS website.

This would allow leveraging of widespread expertise in analysis of the data for crucial purposes including, but not limited to (just off the top of my head): a better understanding of just who is susceptible to getting severe symptoms and ARDS from COVID-19; the role of co-morbidities in outcomes; comparative effectiveness research on new and experimental treatments (such as the currently controversy-provoking hydroxychloroquine/zithromycin/zinc triad); comparison of strategies in use of mechanical ventilators; and others.

One of the motivations of widespread EHR adoption (including government incentives, and, after a few years, penalties for non-adopters) was the potential of EHRs for enabling "virtual clinical trials" to be conducted.

Up to now, EHRs have largely been an albatross to practicing physicians and nurses, who are called upon - mandated, actually - to perform a massive amounts of clerical work in data entry, in addition to clinical work. 

It's time IMHO to leverage and democratize EHR potential, not just for the benefit of high-paying data customers.

(I don't think what I describe is happening on a significant scale; I believe the data is being kept on a short leash.  I would appreciate knowing if this is not correct.)

Finally, I note that politics and the data analytics I describe don't mix well.

-- SS

The Big Spin Out: 2020 Revolving Door Update

In  2020, cases of the revolving door accumulated quickly. 

The Old School Outgoing Revolving Door

Let us begin with cases of the old fashioned outgoing revolving door, that is, of people leaving leadership positions in governmental bodies which regulate health care or make health care policy, then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made.

Dr Vindell Washington from National Coordinator for Health Care Information Technology to Alphabet

Per FierceHealthCare, January 7, 2020:

Alphabet, the parent company of Google and Verily Life Sciences, continues to bolster its ranks of healthcare experts with the latest hiring of Vindell Washington, M.D.

Verily Life Sciences hired Washington as its new chief clinical officer as part of its health platforms team, Verily Life Sciences representative Kathleen Parkes confirmed to FierceHealthcare Tuesday.

Washington served as the national coordinator for health IT from August 2016 to January 2017.

As one of the highest health IT policy leaders, Washington brings to Verily a deep understanding of the industry. He is an emergency medicine physician by training.

So he moved from a position with significant influence over government health IT policy to a big IT company involved in health care.  Admittedly though, this moves comes three years after he left the ONC.

Dr Kate Goodrich from Chief Medical Officer of the Center for Medicare and Medicaid Services (CMS) to Humana Inc

Per Louisville Business First, January 17, 2020:

Humana Inc. has hired away a key regulatory insider from the federal government.

Dr. Kate Goodrich will leave the chief medical officer role at Centers for Medicare & Medicaid Services in February. Politico reported Thursday Goodrich will become a senior vice president for the company.

CMS is the agency that oversees both Medicare and Medicaid, the government-backed health plans. Goodrich was also director of the Center for Clinical Standards and Quality, the CMS website states.

Note that Humana's business is heavily influenced by the actions of CMS.

Humana's core business is providing Medicare Advantage plans, a private version of the federal health plan for seniors. It has about 4.1 million members in Medicare Advantage plans, according to its latest financial disclosure.

The Medicare Advantage segment brought in about $37.1 billion of revenue in the nine months ended Sept. 30, 2019.

Mary Sumpter Lapinski from Government Affairs at Bristol-Myers-Squibb to Counselor to the Secretary of the Department of Health and Human Services (DHHS) for Public Health and Science, then to Vice President of Global Governance Affairs for Greenwich Biosciences


Note that in this case, someone recently reported as transiting the outgoing revolving door has also had in the past transited the incoming revolving door.

Per a Buzzfeed News article, January 24, 2020 (which also discussed the larger revolving door problems involving the pharmaceutical industry and the Trump administration):

Mary-Sumpter Lapinski, who worked in government affairs for Bristol-Myers Squibb from 2002–2007, served as a counselor to the health and human services secretary for public health and science. As of April 2019, Lapinski is the vice president of global government affairs for biopharmaceutical company Greenwich Biosciences.

Again, most recently she moved from a senior position in DHHS affecting public health and science to a biotech company.

Roxana Weil, Lead Toxicologist from the Center for Tobacco Products at the Food and Drug Administration (FDA) and Gabriel Muniz who inspected tobacco manufacturers for the FDA to Juul Labs Inc

Per Bloomberg (via the Detroit News, February 5, 2020):

Juul Labs Inc. has hired former Food and Drug Administration employees and is recruiting more researchers as it prepares for a crucial regulatory hurdle that will determine the future of the top U.S. e-cigarette maker.

So

Roxana Weil, formerly a lead toxicologist at the agency’s Center for Tobacco Products, joined Juul as principal scientific adviser in September. Gabriel Muniz, who worked in an FDA division that inspects tobacco manufacturers, joined Juul last month as a director of regulatory compliance.

Note that

The company and its peers must submit applications to the FDA by May 12 in order to continue selling their products. The deadline is a defining moment for the e-cigarette industry, which has been under fire following a surge in teen vaping and a lung-injury outbreak that sickened thousands and was later tied to THC.

For Juul, securing a swift clearance is critical. The company has seen its once-rich valuation drop since the broader vaping backlash began. Failing to win the FDA’s blessing could shut it out of a market it has dominated.

So they moved from regulating tobacco to a company essentially involved in selling tobacco analogues.  Note that the tobacco company Altria made a major investment in Juul (look here.)

The Au Courant Incoming Revolving Door

In the Trump era, many people have come through the incoming revolving door, that is, people with significant leadership positions in health care corporations or related groups have attained leadership positions in government agencies whose regulations or policies could affect their former employers.

There are two recent examples

Brad Smith, Chief Operating Officer of Anthem's Diversified Business Group to be Director, Center for Medicare and Medicaid Innovation (CMMI) at the DHHS

Per FierceHealthcare, January 6, 2020:

The Trump administration has selected Brad Smith to serve as the director of the Center for Medicare and Medicaid Innovation (CMMI), where he will oversee the creation and stewardship of value-based payment models.

Smith most recently was the chief operating officer of Anthem’s Diversified Business Group, a division of the insurance giant that includes provider services. He was also the co-founder and CEO of palliative care services company Aspire Health.

Anthem is a health insurer which provides Medicare supplements and Medicare Advantage programs, so its business is greatly affected by any changes in how Medicare or Medicaid makes payments.

Amanda Adkins, Executive for Cerner Corp, Now Running for the House of Representatives as a Republican

This could be called a running start that will likely lead through the incoming revolving door.

Per the  Kansas City Star, January 23, 2020:

Cerner executive Amanda Adkins has taken a leave of absence from the company to focus on her campaign to unseat Democratic Rep. Sharice Davids.

Adkins, a former Kansas Republican chair, launched her bid for Kansas’ 3rd congressional district in September, but initially planned to remain as Cerner’s vice president of strategic growth through the campaign.

But as of last week, according to a company spokeswoman, Adkins went on unpaid leave after from her role after 15 years with the health care IT giant.

Note that the Star article, unlike the others quoted above, provided at least a slightly detailed discussion of why this (potential) move poses a conflict of interest:

The Kansas City-based company is a major federal contractor with a $10 billion contract to design a new health care records system for the U.S. Department of Veterans Affairs. The new system is expected launch later this year.

Federal election rules prohibit federal contractors from giving directly to federal candidates. Craig Holman, a lobbyist for Public Citizen, a national group which advocates for tougher ethics standards, said Adkins’ unpaid leave protects Cerner from violating this rule.

But Holman said the fact that she can return from leave after the election still raises questions about a conflict of interest since she could end up on committees with oversight of the company’s contracts if elected to Congress.

'The conflict still persists,' Holman said in a phone call. 'The fact that she has not resigned and remains an employee of Cerner means that conflict of interest remains front and center.'

Summary

Sigh.  So while there is much discussion of corruption in high places, and its potential link to high crimes and misdemeanors, the revolving door quietly spins on well-oiled hinges, as it has for years, including many years before the current administration.  

So as we have repeatedly said,  most recently in October, 2019, ...

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.

The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.

Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans - Time to Refuse Use Of EMR's In Your Healthcare?

I have long written that leadership of EMR technology by the wrong people will create exceptionally adverse outcomes, clinically speaking. 

The same appears true socially.  In fact, adverse social outcomes (especially with regard to societal power structures) is one of the pillars of the domain of Social Informatics, the field that studies social impacts of new information & communication technologies (ICTs), about which I've taught and written.  (See http://www.dlib.org/dlib/january99/kling/01kling.html)

Now there's this stunning new story regarding clinical data trafficking. 

Original article is at the WSJ by Gerald F. Seib here: https://www.wsj.com/articles/google-s-secret-project-nightingale-gathers-personal-health-data-on-millions-of-americans-11573496790, but it's behind a paywall:

Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans

By Katabella Roberts

November 12, 2019

https://www.theepochtimes.com/googles-project-nightingale-secretly-gathers-personal-health-data-on-millions-of-americans_3143843.html

Google has been working with one of the largest healthcare systems in the U.S. to collect and analyze the personal health information of millions of citizens across 21 states, The Wall Street Journal reports.  The Tech giant reportedly teamed up with St. Louis-based Ascension, the largest non-profit health system in the country, last year, and the data sharing has accelerated since summer.

Code-named Nightingale, the project saw both companies collect personal data from patients, which included lab results, doctor diagnoses, and hospitalization records, as well as patient names and dates of birth.

Google said it plans to use the data to create new software that will improve patient care and suggest changes to their care.

First and foremost, the focus of this "project" is the hackneyed cybernetic miracle we've been promised for decades, the "Artificial Intelligence" that will "revolutionize" medicine. 

I view this concept as massively over-hyped and likely fraudulent, an effort to salvage the very same promises made of the entire EMR project on which has been spent hundreds of billions of dollars (more likely beyond the trillion range by now), while waiting for Godot. 

Those monies could have been better used to provide world-class healthcare for an entire population, especially considering the lack of evidence of the miracles promised.


   

CMS: "we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."  [But let's spend hundreds of billions of dollars anyway.]  Click to enlarge.

... Patients and doctors were not notified that their data is being shared, and did not give their consent, according to the report.

One individual who was familiar with the project told the Journal that at least 150 Google employees already have access to much of the data on tens of millions of patients.

I have already written that the entire national EMR project is a mass human-subjects experiment without informed consent that can maim or kill patients in many different ways, including clinician distraction and IT error, among others.  I also note that as I've been involved in litigation support over the past decade, I've been exposed to what really happens without the filter of the press and the IT industry.  (The verdict in the last case in which I testified about Bad Health IT, for example, went to the deceased plaintiff's heirs - amounting to more than $16 million; others were in a lower but still multi-million dollar range.  Yet, you likely will never read about these in the HIT literature)

I believe this new account of clinical data trafficking is, more likely than not, true. It is a development I've fully been expecting for at least a decade now. (See my February 26, 2012 post "Proposed new Consumer Privacy Bill of Rights: Is It Too Late For Healthcare?" at https://hcrenewal.blogspot.com/2012/02/proposed-new-consumer-privacy-bill-of.html and my Oct. 7. 2009 post "Health IT Vendors Trafficking in Patient Data?" at https://hcrenewal.blogspot.com/2009/10/health-it-vendors-trafficking-in.html).

This new development would represent an invitation to massive deliberate or inadvertent abuse, and is likely a massive violation of the HIPAA Privacy Act, despite claims to the contrary.

Just hours after the secret project was revealed, the two companies announced the collaboration in a press release, in which they said the joint project would see Ascension’s data moved onto Google’s Cloud platform.

The statement said the joint project aims to “optimize the health and wellness of individuals and communities and deliver a comprehensive portfolio of digital capabilities that enhance the experience of Ascension consumers, patients, and clinical providers across the continuum of care.”

More cybernetic miracles promised for the true believers, expressed in the typical IT-magic phraseology.  Plenty of profits, too.

Eduardo Conrado, Executive Vice President of Strategy and Innovations at Ascension, said: “As the healthcare environment continues to rapidly evolve, we must transform to better meet the needs and expectations of those we serve as well as our own caregivers and healthcare providers.

The "transformations" needed are to scale back the IT and the bureaucracy that burdens good clinicians and consumes massive amounts of $, and the reduction of waste on worse-than-useless Bad Health 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, compromises patient privacy, lacks evidentiary soundness or otherwise demonstrates suboptimal design and/or implementation. 

More corporate mumbo-jumbo:

“Doing that will require the programmatic integration of new care models delivered through the digital platforms, applications, and services that are part of the everyday experience of those we serve.”

The partnership will also explore artificial intelligence and machine learning applications to help improve clinical quality, and effectiveness, patient safety and increase consumer and provider satisfaction, according to the statement.

The data collected by today's EMRs is subject to inaccuracy for multiple reasons mentioned at this blog, including perverse incentives, clinician harassment and cognitive overload, time limitations, forced entry of some data to move further on in the record, and others.  Further,  the Bad Health IT systems used to collect and display it exposes patients to risk and injury.  "AI" will not solve these "issues."

Tariq Shaukat, President of Google Cloud, added: “Ascension is a leader at increasing patient access to care across all regions and backgrounds, particularly those in disadvantaged communities. We’re proud to partner with them on their digital transformation.

"Digital transformation" is, quite frankly, the same BS as "IT revolutionizing healthcare" that I'd heard since at least the mid-1990s (see my post "Bill, Have You Lost Your Mind?" at https://hcrenewal.blogspot.com/2006/07/bill-have-you-lost-your-mind.html where I reposted my earlier memorialization of such baldly overwrought and preposterous claims.)
 

“By working in partnership with leading healthcare systems like Ascension, we hope to transform the delivery of healthcare through the power of the cloud, data analytics, machine learning, and modern productivity tools—ultimately improving outcomes, reducing costs, and saving lives.”

More billions of dollars are to be transferred from patient care to the IT industry. 

These $ could be far better spent, IMHO, on care delivery, including to the disadvantaged and minorities, and in rethinking the current health IT morass.  (See my Jan,. 2018 post "The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging" at http://hcrenewal.blogspot.com/2018/01/the-inevitable-downgrading-of.html).

I have passed the newly-released articles on this matter to attorneys with access to the national trial lawyers' listservs, where the merits of "Project Nightingale" can be considered from the perspective of non-toothless patient's rights advocates.

FINALLY:

I believe invasive healthcare data trafficking projects like this, with potential for massive abuses, provide reasonable justification for patients to REFUSE the use of EHR's in their care.  Paper works just fine.  In fact, when the IT goes down, it's what hospitals and doctors go right back to, and the PR always claims that "patient care was not compromised."

-- SS

11/15/2019 Addendum:

There is a whistleblower (https://www.theguardian.com/commentisfree/2019/nov/14/im-the-google-whistleblower-the-medical-data-of-millions-of-americans-is-at-risk):

I didn’t decide to blow the whistle on Google’s deal, known internally as the Nightingale Project, glibly. The decision came to me slowly, creeping on me through my day-to-day work as one of about 250 people in Google and Ascension working on the project.

When I first joined Nightingale I was excited to be at the forefront of medical innovation. Google has staked its claim to be a major player in the healthcare sector, using its phenomenal artificial intelligence (AI) and machine learning tools to predict patterns of illness in ways that might some day lead to new treatments and, who knows, even cures.

Here I was working with senior management teams on both sides, Google and Ascension, creating the future. That chimed with my overall conviction that technology really does have the potential to change healthcare for the better.

But over time I grew increasingly concerned about the security and privacy aspects of the deal. It became obvious that many around me in the Nightingale team also shared those anxieties.

After a while I reached a point that I suspect is familiar to most whistleblowers, where what I was witnessing was too important for me to remain silent. Two simple questions kept hounding me: did patients know about the transfer of their data to the tech giant? Should they be informed and given a chance to opt in or out?

The answer to the first question quickly became apparent: no. The answer to the second I became increasingly convinced about: yes. Put the two together, and how could I say nothing?

-- SS

Google is shutting down its cloud-based Google Health, a Personal Health Record service

Google is shutting down its cloud-based Google Health, a Personal Health Record service, by the end of the year.

I wrote:

"Who'da thunk it? -- Personal Health Record project with big corporate sponsors not working out so well ..."

and

"Label me skeptical: Personal Health Records as healthcare panacea?"

both in 2007.

Considering the education and expertise one needs to really manage (and comprehend) health records robustly, let me state that I consider the entire concept of the "personal heath record" inane.

You heard it here first.

-- SS

Google CEO Eric Schmidt on Healthcare IT Once Again

At the Jan. 11, 2011 WSJ health blog, in an article entitled "JP Morgan Healthcare: Google’s Schmidt on Open Source and Health IT", Google CEO Eric Schmidt is cited as saying:

... One solution to the problem may be to take the electronic-medical record architecture out of the hands of the corporate world, suggested Google CEO Eric Schmidt at the JP Morgan Healthcare Conference last night.

“If I were not doing what I’m doing and I wanted to do something in health care … I would go to all of the research universities and would try to figure out where the best, interesting IT software is that can be open-sourced,” he said at a health-IT panel discussion. “My guess is that a platform like that would be remarkably different from the platforms that we are using today,” he said.

First, a comment on language, which perhaps I should more accurately describe as a critique of IT culture:

“A platform like that?”

As at my post "Does the CEO of Google Use Google? - And: Platform, Platform, Who's Got The Platform?" early last year Schmidt also said –

“As computer scientists, this [that is, why docs haven’t embraced databases to help them sort through medical information] is a platform database problem, and we do these very, very well, as a general rule. And it befuddles me why medicine hasn’t organized itself around these platform opportunities.”

At that post I also pointed out that the successful practice of medicine is not a 'platform database' or any other reductionistic information retrieval problem, and that such a "platform opportunity" was seized upon decades ago:

DXplain was developed starting in the mid 1980's by medical informatics researchers who actually know this domain, and which offers this explanation and warning: "DXplain uses an interactive format to collect clinical information and makes use of a modified form of Bayesian logic to derive clinical interpretations ... DXplain does not offer definitive medical consultation and should not be used as a substitute for physician diagnostic decision making."

I note that IT personnel like to refer to “platforms”, “solutions” – a rather presumptuous term – “paradigms”, and other buzzwords to mask the fact that what they’re referring to are more commonly known as “hardware” and “software” and arrangements thereof.

It is a word that implies lack of knowledge about the complexities and realities of medicine – including that health IT problems will not be solved via a “platform.”

I wrote more on “platformania” at this link.

I do agree strongly with Schmidt on the following from the recent WSJ posting:

Schmidt said that using such an open-source strategy — giving programmers the freedom to modify and distribute software [an agile computing methodology - essential to health IT development and lifecycle - ed.] — is a proven way to fix disparate software architectures. It’s the same development strategy that brought about the modern internet and “all the other technologies that you use every day.” ... Part of the problem in designing and discussing a new standard is that the current focus is on the companies involved rather than the patients.

That's been done, too, as in the OpenVista /WorldVista efforts.

I merely add that an erroneous approach to "focusing on the patients" (and the clinicians using the IT, i.e., a user-centric approach in the terminology of Social Informatics) will have results just as suboptimal as the current designer-centric approach to health IT. Designing health IT that "focuses on the patients" and that eliminates unintended consequences - i.e., "doing health IT well" - is wickedly harder than it sounds.

Most importantly with regards to Mr. Schmidt's most recent thoughts on academia:

The National Research Council did study a number of the best academic centers and in a 2009 report found quite clearly that even there, “Current Approaches to U.S. Health Care Information Technology are Insufficient.” See http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572

They did recommend the solution, and it's not a "platform":

“In the long term, [Health IT] success will depend upon accelerating interdisciplinary research in biomedical informatics, computer science, social science, and health care engineering.”

That means forgoing the current national rush to EHR, which is decidedly a medical experiment without patient consent.

In any case, I am impressed that a major information technology CEO has recommended a patient centered approach to health IT, agile methodologies, open source, etc. - true sacrilege towards today's health IT ecosystem.

(Note to Google and Mr. Schmidt: In "Who Can Solve Healthcare IT's Challenges? Part 1 - Google" I wrote that:

... This [HIT] dysfunction takes the form of corporatization of HIT, creation of myths about its magic bullet capabilities in "revolutionizing healthcare" ... In "A Biomedical Informatics Manifesto" I addressed the domain expertise I feel is most needed.

I did not, however, address the "who" as in "what organization(s)." What organizations, that is, have the resources (e.g., financial and infrastructure) to make useful, usable, national, interoperational HIT happen? What organizations have the innovative track record to effectively engage the best specialists to make it happen?

One example comes to mind immediately. It was suggested by an expert in IT and bioinformatics I correspond with, Felix Fulmer.

Google.

These folks are innovative. Their services are reliable, fast (when is the last time Google was down or took a long time to provide query results?), widely available, cost effective (many services available for free!), and a true technological tour de force.

Google, I am available should you seek true competitive advantage, and avoidance of paths that lead to health care IT failure such as you once attempted here. However, somehow I am sure your HR department would probably find my sometimes "edgy", critical-thinking approach to matters of national import "disruptive."

Disruptive to what, exactly, I'm not sure, but disruptive to - something - is good enough in today's "PC", outcomes-be-damned corporate culture.)

-- SS

Does the CEO of Google Use Google? - And: Platform, Platform, Who's Got The Platform?

Over at the WSJ health blog, reporter Jacob Goldstein's Jan. 8, 2010 post "Google CEO & Harvard Surgeon Talk Health IT" quotes Google's CEO:

"Google’s CEO Eric Schmidt doesn’t know why docs haven’t embraced databases to help them sort through medical information."

[Schmidt said] ... So when you show up at the doctor with some set of symptoms, in my ideal world what would happen is that the doctor would type in the symptoms he or she also observes, and it would be matched against the data in this repository

[such as DXplain? -- which we learn from a - er, um, Google search - was developed starting in the mid 1980's by medical informatics researchers who actually know this domain, and which offers this explanation and warning: "DXplain uses an interactive format to collect clinical information and makes use of a modified form of Bayesian logic to derive clinical interpretations ... DXplain does not offer definitive medical consultation and should not be used as a substitute for physician diagnostic decision making"? - ed.]

... Then this knowledge engine would use best practices, and all the knowledge in the world to give physicians some sort of standardized guidance. This is a generalized form of the checklists that you’re talking about …

As computer scientists, this is a platform database problem, and we do these very, very well, as a general rule. And it befuddles me why medicine hasn’t organized itself around these platform opportunities. [No - the successful practice of medicine is not a 'platform database' or any other reductionistic information retrieval problem - ed.]

I note that IT personnel like to refer to "platforms", "solutions" - a rather presumptuous term, "paradigms", and other buzzwords to mask the fact that what they're referring to are more commonly known as "hardware" and "software" and arrangements thereof.

Does this "platform opportunity" view reflect naïveté about the complexities of medicine and medical decision making, or does it reflect something else? Could this "befuddlement" be construed as calling physicians obtuse? Is this yet another example of what I referred to in my post "Healthcare IT Failure and The Arrogance of the IT Industry" and other writings as a cross-occupational invasion of medicine by IT?

IT personnel seem to have a propensity to offer healthcare-related opinions far outside their own areas of expertise -- or if in healthcare organizations, edicts - based upon the narrow view of their own relatively linear and deterministic fields. The risk is, especially when coming from high perches, that such opinions and edicts can result in deleterious actions (e.g., government initiatives).

In an absurdist reductio ad absurdum, deliberately made absurdist due to many years of exposure to equally absurd (to those with actual domain experience) "who needs medical school/residency/patient care experience to profess on medical matters?" attitudes:

Why don't physicians offer the advice that Google could improve its search algorithms, or Intel and AMD their microprocessors, by utilizing intelligent psittacine platforms as in this British Broadcasting Company (BBC) video narrated by a true technology expert, Captain James T. Kirk?

Kirk did have a (computerized) physician son: Nomad!

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

Quite seriously, physician reluctance to "embracing databases" and health IT in general is not about database platforms. I only wish it were so simple.

The WSJ seems to understand this. In a Jan. 12, 2009 article by reporter Bret Stephens entitled "Can Intelligence be Intelligent?", the observation is made that technology is a mere facilitator, and intelligent, well trained, experienced, critical-thinking people are the enablers of any complex field that requires human judgment. They must be unfettered by machine and bureaucrat:

... Terrifying as the thought may be to many of its current practitioners, the true art of intelligence requires, well, intelligence. That is a function neither of technology nor of "systems" [a.k.a. "platforms" - ed.], which begin as efforts to supplement and enhance the work of intelligence and typically wind up as substitutes for it. It is, instead, a matter of experience, intellect, initiative and judgment, nurtured within institutions that welcome gadflies in their midst.

I've left the following comment at the WSJ health blog:

Mr Schmidt,

If you’d like to learn more about why many physicians are reluctant to embrace clinical IT, you might also do a Google search on “healthcare IT failure” and similar terms.

Need I say anything more about the irony of that advice?

I'd also noted a fixation on "platforms" as solutions to biomedical problems (best when they come in shrinkwrapped, off the shelf, "on the IT roadmap" packages!) in my June 2008 post "An Open Letter to Merck CEO Richard Clark on Merck's Mission to Rediscover the Wheel."

A nonmedical research IT leader, who'd found a move from basic research to clinical IT "quite an eye opening experience" (i.e., a domain in which she had little or no experience but was paradoxically appointed to lead) talked all about "platforms" in Bio-IT World:

... We've invested a lot in some core platforms; we need to start translating that into results in the clinic at some point. And so having people who have an understanding of what does that really take to help inform the earlier research directions, the platform directions [i.e., research direction = platform direction - ed.], is a key theme...We already have siloed platforms to show that data, we need to integrate it more than it is... combining the results data from clinical samples with the associated patient data, what's that platform?

Platform, platform, platform. Who's got the platform?

My comments to that CEO in my Open Letter were that this was the wrong mindset and question, based upon an IT person's focus on information technology. This is as opposed to a focus on information science and on facilitating people in interacting with data and information in order to gain actionable knowledge, i.e., an information science and human-computer interaction-based approach that those in medical informatics thought about long ago.

In line with the conclusions of Greenhalgh et al. [1] who called for "eschewing sanitized accounts of successful projects" and instead recommending studies of clinical IT in organizations that “tell it like it is” using the de-identified critical fiction technique, I'd written on how conflation of information technology and information science impaired R&D in pharma at my essay "Sure path to R&D failure: Conflation of IT with information science in the pharmaceutical industry."

That piece and the aforementioned Open Letter were written before Merck sold itself to Schering-Plough in a "reverse merger" due to the unsustainability of doing business from an empty wagon of new products, a sign of just how well this IT-centric "platformania" has been working out for R&D.

In the information science-centered view and approach, the "platform," a.k.a. computer technology, is merely a canvas and facilitator, the artist (clinician or scientist) and the brush wielded by them being the primary enabler of and contributor to the masterpiece.

Unfortunately, I don't think anyone is "home" in pharma or in the HIT sector anymore to parse these ideas; in fact I've only recently learned that the people I did work with who could parse these ideas into creative reality were laid off by the very IT people making such statements and asking such questions.

IT personnel perhaps need to move away from their reductionist platformania. (Perhaps they are confusing "platforms" with "pixie dust.") Rather, they need to start thinking in terms of facilitating clinicians and scientists through domain specific and individualized-to-need information science and HCI innovation that arises of true cross-disciplinary expertise.

They need to leave creation of cybernetic miracles to people such as Irwin Allen and George Lucas. And platforms to carpenters.

-- SS

[1] Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method. Greenhalgh, Potts, Wong, Bark, Swinglehurst, University College London. Milbank Quarterly, Dec. 2009. Available at: http://eprints.ucl.ac.uk/18821/

Was Google lobbying Washington for HIPAA exclusion of their PHR effort?

At "Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?" I expressed great concern about what I term the cross occupational intrusion of the IT industry into healthcare.

My major concern in that post was how the information technologists at Google, even with nearly unlimited access to capital (and therefore to the world's informatics expertise) badly mismanaged a Personal Health Records (PHR) project through commission of a most fundamental biomedical information science blunder (quite distinct from IT; most IT technologists and MIS personnel really stink at biomedical information science). They tried to map relatively ungranular, imprecise, and often misused billing codes back to enduser-viewable diagnoses, resulting in easily predictable patient panic and mayhem.

As usual in HIT: it's possibly even worse.

I am quite concerned about a letter from the consumer education and advocacy organization Consumer Watchdog.org and their allegations that Google has been lobbying Congress to be excluded from HIPAA provisions on privacy and forbidding sales of medical records. The letter, dated April 22, is here (http://www.consumerwatchdog.org/resources/LtrSchmidt042209.pdf).

Considering that Google is heavily into the PHR space, and even worse, considering they made an Informatics 101 error in attempting to map billing codes into user-viewable diagnostic data, I would (and I'm sure others would as well) view such attempts if they indeed occurred as ominous, a true heavy handed intrusion of the IT industry not only into the affairs of medicine but into what really is another human rights issue. (I'd pointed out another potential HIT-related human rights issue at the post "UPMC as Proving Ground for IT Tests On Children".)

I would be interested in additional information on the Google lobbying issue, especially from those at Harvard and other academic centers who have been involved in the Google PHR initiative.

I have shared these concerns with the American Medical Informatics Association (AMIA) clinical information systems workgroup (cis-wg) and the people & organizational issues workgroup (poi-wg) as well.

I hope the Consumer Watchdog allegations are not accurate, because if they are valid, the implications of national EHR grow increasingly unsettling.

Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?

Simply amazing. One of the richest and most "leading edge" IT companies in the world with almost unlimited resources and access to expertise commits one of the most fundamental biomedical information science (a.k.a. informatics) blunders, as in the taxonomy in my post here, at the level of "likely to cause patient harm in short term if uncorrected."

I have repeatedly written over at least the past ten years that applying the leadership and methodologies of business IT to clinical computing is both ill conceived and dangerous, as business computing and clinical computing are two very different computing subspecialties, the latter requiring quite specialized leadership and approaches.

I've written it at academic sites, in magazines, in newspapers, and other venues.

Yet, as we have observed at HC Renewal regarding other flavors of healthcare mismanagement and malfeasance, these words seem to suffer an anechoic fate.

Here we go again with another example of what appears to be gross mismanagement of clinical IT by business IT personnel and organizations. The following type of debacle is sooner or later going to kill patients and must end, immediately:

Boston Globe
Electronic health records raise doubt
Google service's inaccuracies may hold wide lesson ["may?" - ed.]
By Lisa Wangsness, Globe Staff
April 13, 2009

WASHINGTON - When Dave deBronkart, a tech-savvy kidney cancer survivor, tried to transfer his medical records from Beth Israel Deaconess Medical Center to Google Health, a new free service that lets patients keep all their health records in one place and easily share them with new doctors, he was stunned at what he found.

Google said his cancer had spread to either his brain or spine - a frightening diagnosis deBronkart had never gotten from his doctors - and listed an array of other conditions that he never had, as far as he knew, like chronic lung disease and aortic aneurysm. A warning announced his blood pressure medication required "immediate attention."

"I wondered, 'What are they talking about?' " said deBronkart, who is 59 and lives in Nashua.

DeBronkart eventually discovered the problem: Some of the information in his Google Health record was drawn from billing records, which sometimes reflect imprecise information plugged into codes required by insurers. Google Health and others in the fast-growing personal health record business say they are offering a revolutionary tool to help patients navigate a fragmented healthcare system, but some doctors fear that inaccurate information from billing data could lead to improper treatment.

(Addendum April 19: a first hand account of this problem is at e-patients.net here.)

What manner of amateurs made and approved the decision to map semantically and often medically imprecise, and often deliberately overstated or misused billing codes to diagnoses, and then display the diagnostic terms to a user - ANY user, patient or "learned intermediary" - in an electronic health record?

Not to mention how poorly conceived and implemented many of the HIT billing systems themselves are, making billing data even less trustworthy...

Injecting humor into a most somber post,
Homer succinctly summarizes the situation.

It is common knowledge to any competent person in healthcare informatics that doing what was done by Google Health is prone to create exactly the kind of situation that occurred.

Insurance data, by contrast, is already computerized and far easier and cheaper to download. But it is also prone to inaccuracies, partly because of the clunky diagnostic coding language used for medical billing, or because doctors sometimes label a test with the disease they hope to rule out, medical technology specialists say.

One does not have to be much of a "specialist" to make this realization. Almost anyone who's ever practiced medicine could probably have told Google's designers, developers and programmers this. This raises a number of questions, which also do not require a specialist to raise:

• What were the designers, implementers and management of this project thinking?
  
• Who was leading the project?
  
• What were there backgrounds?
  
• Who made the decision to implement in this manner?

Danny Sands raises the obvious:

"The problem is this kind of information should never be used clinically, especially if you don't have starting or ending dates" attached to each problem, said deBronkart's primary care doctor, Daniel Z. Sands, who is also the director of medical informatics at Cisco Systems.

Indeed.

Personal health records, such as those offered by Google Health, are a promising tool for patients' empowerment - but inaccuracies could be "a huge problem," ["could be?" - ed.] said Dr. Paul Tang, the chief medical information officer for the Palo Alto Medical Foundation, who chairs a health technology panel for the National Quality Forum.

For example, he said, an inaccurate diagnosis of gastrointestinal bleeding on a heart attack patient's personal health record could stop an emergency room doctor from administering a life-saving drug.

And when such an event occurs and a patient is harmed or killed, who then is held accountable - and who is held harmless? (Oh wait ... we know the answer to that question thanks to Koppel and Kreda...)

This "billing data" issue and other EHR issues like it are not rocket science, they are Medical Informatics 101.

I've seen such issues before, such as at "AOL kerfuffle: information technology vs. information science, a distinction lost at industry's peril" and at "On Intel's and Walmart's prescription for Healthcare IT."

I summed the problem up like this at the post "A Biomedical Informatics Manifesto":

Biomedical Informatics as a specialty might as well be invisible. Amateurs** rule HIT.

(** Amateur in the sense that I am a radio amateur, not a telecommunications professional and would not deem myself appropriate to design and run a critical telecommunications project).

Perhaps, though, I should have added "amateurs rule HIT, and even worse are too often managed by incompetents."

I believe Google should conduct a top to bottom investigation of the management chain and the decision making process that led to such a fiasco, which can only further erode public confidence in electronic health records at a time of national distrust in Big Business and Big Medicine.

Those who made such design and implementation decisions without appropriate input from those who know better, or worse, those who might have overridden or ignored such counsel, should be dealt with appropriately. (If it were me, I'd ask for their resignation, but that's my opinion.)

Clinical medicine, Electronic Health Records and patients' well being are not an information technologists' learning lab.

Also of concern to me, this is the type of data our government seems to be touting for use in Comparative Effectiveness Research. (It is also of concern to me in this regard that our new Secretary of HHS was the former Kansas commissioner for insurance from 1994 to 2002, and such billing data is likely where the majority of her experience with medical datasets resides.)

Finally, like the financial schemes of the past decade, I can only wonder when the computational House of Cards that is being built in healthcare as a result of the quasi-religious Syndrome of Inappropriate Overconfidence in Computing, and worship of its priests, the IT Whiz Kids and consultants to whom domain expertise is optional, will come crashing down.

-- SS

Addendum:

A physician correspondent who wishes to remain anonymous writes (emphases mine):

[The Boston Globe article] could not have come at a better time.

Just today, a spouse had his "home grown" PHR for his wife who was hospitalized with multiple medical problems, including advanced metastic breast cancer and complex vascular disease. He has an elaborate PHR with history, treatments, allergies, medication lists, etc.

It was so impressive that when this 80ish year old patient was admitted, he gave the medication list from the computer to the physicians and nurses. It appeared so reliable that not one health care professional bothered to question it or reconcile it with the labels on the bottles (everyone is so busy nowadays clicking and scrolling the computer silos for information).

As it turns out, he left out a decimal point on a dose of a potent medication that should have been 2.5 mg. The computer printed a legible list (with other errors too) stating the dose of this med was 25 mg per day (10 times too much). It was ordered that way by the doctors. It got to the pharmacy, but somewhere in this complex chain, a non physician non nurse individual got the dose to the patient correctly as 2.5 mg [fortunately, the error was caught, this time. What about next time? - ed.]

Being a detective with an eye for detail and a stickler for accuracy, I happened to notice the error when the spouse was showing off his PHR to me.

Again, this is one case with potentially dangerous consequences of a pervasive error generated in the PHR by flawed data entry. It was not a Google or Health Vault device, but I cannot believe that these companies have garbage filters on their devices to prevent the "garbage in, garbage out" syndrome. Good medical care is being subverted by these experimental devices.

Upon scratching the surface of PHR, EMR, and CPOE devices' functional impact on the administration of medical care, the dangers are widespread. This toxicity is covered up from scrutiny by the "non-disclosures" and "hold harmless" contractual obligations described in the Koppel and Kreda report.

One wonders how many incidents like this happen every day and are being concealed by the HIT industry and the pundits profiting handsomely from selling defective HIT devices. I am quite concerned that nobody really knows. This is not science.

On a final sobering note, as the "hold harmless" and "defects gag" clauses are purged from HIT contracting, which they will most certainly be, I would suggest the many amateurs in HIT obtain some very solid liability insurance covering patient harm related to their systems and their advice.

For they may just find themselves as defendants answering questions on the witness stand in front of a hungry plaintiff's attorney, a jury of average citizens, bereaved relatives of patients who were harmed via IT misadventure, and questions composed by people of my background. These questions will place the true nature of their expertise and qualifications to be tooling around with medical care under severe scrutiny.

That will likely not be very pretty.

-- SS

April 22 addendum:

In comment #15 to this post Matthew Holt issued this filled with absolutes ad hominem comment ...

Seriously, MedInformaticsMD, you are so pissed off with everyone in IT [everyone? - ed.] that you're now part of the problem [problem of vendors creating bad IT? - ed.] Do you seriously think that the people at BIDMC, Google and everyone else in health IT (even Cerner) just dont give a shit? [I cannot read minds. I can only see results - ed.] Or do you think that they might be trying to figure out how to solve these problems [of course they're trying to solve problems, but good intentions without requisite ability and expertise are inadequate in healthcare - ed.], and perhaps could you some constructive help. Rather than a barrage of attacks on anything they try to do. [Anything? You mean, such as in this post praising Google in areas where they do leverage their expertise properly? -ed.]

Perhaps my direct Chairman of Medicine-after-patient-mishap tone in offering the most constructive of criticism - i.e., don't embark on medical projects in which you are over your head, find people who do know the domain and let them lead, don't release anything in medicine without appropriate, rigorous premarket trials - upset him. In addition to the inserts above, in the comments section I replied:

I'm sorry you feel that way.

I'm not sure what "problem" you're referring to, but if it's harming patients due to badly implemented HIT, I'm certainly not part of that problem.

As just one example, my website on HIT difficulties serves as a resource read internationally on how to best avoid HIT errors, has been online for a decade, and is quoted in one of the newest and best books on HIT, specifically "Medical Informatics 20/20."

Did anyone at BIDMC, Google or Cerner ever read it? Did you ever read it? If not, why not? It is in fact the first link that comes up on a google search on "healthcare IT failure", for example. Do they take it seriously? If not, why not?

I believe they were negligent on this project. This suggests they need to give a bit more of a s--- about their work, expecially since real, live patients are involved and the mistake made was so fundamental.

Finally, see my post "A Software Engineer's Eloquence on Health IT" for what I consider an attitude of someone who really does give a s--- about such matters.

Finally, I see no links to my decade-old academic website on HIT difficulties over at Matthew's blog. One wonders why. It may have to do with a tension between the statement that "the Health Care Blog (THCB) has acquired a reputation as one of the most respected independent voices in the healthcare industry" and the post "A Shout out to our sponsors."

Healthcare Renewal has no sponsors and does not take advertising. We report, you decide.

-- SS

Who Can Solve Healthcare IT's Challenges? Part 1 - Google

In previous posts on the National Research Council report on HIT, the Joint Commission Sentinel Events Alert on HIT, and many others on HC Renewal I've alluded to my belief that a root cause of the state of healthcare information technology (high cost, low diffusion, poor usability, poor interoperability, low reliability, questionable benefits, lack of features most helpful to clinicians, etc.) is - to be frank - industry dysfunction.

Poorly led, mismanaged, conflicted, opportunistic, sometimes even unethical vendors, overly pushy marketing, less than stellar consultants, well-paid but of course "objective" clinical Key Opinion Leaders (KOL's) and spokespeople, and ossified strategy and tactics are examples of this dysfunction.

One merely needs to read statements such as came from the former head of the UK's CfH national program for Health IT to see how these issues can play out (I've seen them up close and personal, but I'm just a 'little guy' in HIT, so I shall defer to Mr. Granger on this).

This dysfunction takes the form of corporatization of HIT, creation of myths about its magic bullet capabilities in "revolutionizing healthcare" (I call this "bellicose grandiosity") and leadership by business IT professionals. The influence of the latter seems far out of proportion to their expertise in biomedical affairs.

I've written about the perils of the overarching assumption that supports this leadership model: that clinical IT is a subspecies of MIS (management information system), and that the methodologies and approaches for development, deployment and lifecycle of the latter are appropriate for the former.

In essence, true innovation is hampered by the current HIT ecosystem structure. See my HIT ecosystem essay here and another essay on the HIT industry by Dr. Jonathan Bertman here , the latter perhaps being taken with a grain of salt due to self-disclosed industry connections of its author. (Full disclosure: I have no financial stakes, stocks, or other tangible interests of any kind with any HIT vendor, consulting company, or any other concern related to HIT, and I take no consulting fees from them for any purpose whatsoever.)

How can the goals of innovation, alignment to user needs, quality, costs, accessibility, interoperability, context sensitive linkages to external science, etc., be met?

Or, perhaps the question really is, who - what organization(s) - can best provide those characteristics and features?

In "A Biomedical Informatics Manifesto" I addressed the domain expertise I feel is most needed.

I did not, however, address the "who" as in "what organization(s)." What organizations, that is, have the resources (e.g., financial and infrastructure) to make useful, usable, national, interoperational HIT happen? What organizations have the innovative track record to effectively engage the best specialists to make it happen?

One example comes to mind immediately. It was suggested by an expert in IT and bioinformatics I correspond with, Felix Fulmer.

Google.

These folks are innovative. Their services are reliable, fast (when is the last time Google was down or took a long time to provide query results?), widely available, cost effective (many services available for free!), and a true technological tour de force.

Billions of web pages are constantly crawled and indexed and content made available in a "world library computer" manner that just a few years ago would have been considered true science fiction. And the complexity of this process is hidden in a simple user interface, with excellent user interaction design. I'd studied and written about IR (information retrieval) issues just as the WWW was beginning, and what Google has created in those years is truly impressive.

They also offer their own ASP-model applications (here), have seemingly unlimited storage capabilities, and a true international presence. They get things done, and don't mess around or offer excuses for lack of performance.

They host millions of blogs at blogger.com for instant editing and retrieval, anywhere, anytime, including this one.

They already have Google Health, a Personal Health Records service. (Addendum April 2009: some problems developed there due to apparent deviations from best IT practices, see this post).

Perhaps this organization exemplifies the kind of "can do" attitudes and accomplishments needed to solve decades-long disappointments in HIT.

The major HIT vendors certainly don't seem to be part of the solution. In certain cases of the more prominent ones such as Cerner, cook-the-books HBOC - now McKesson, TDS-AllTel-Eclipsys etc., I repeatedly hear exasperating stories about their products that confirm an impression I had after meeting some of the top HIT CEO's some years ago when I was a CMIO - that the CEO's and top lieutenants of these companies are , let's just say, not the sharpest pencils (one reason I have no financial stakes in these companies!)

Note: I also have no financial stakes, stocks, or other tangible interests in Google of any kind, nor receive any income from them, nor have I spoken to anyone at or associated with Google about the thoughts contained in this essay.

-- SS