Healthcare IT Amateur Kathleen Sebelius Resigns - Good Riddance

The Secretary of the U.S. Department of Health and Human Services (HHS) is resigning.

Press reports say she is resigning in large part due to the Exchange Website debacle.   This from the New York Times:

Health Secretary Resigns After Woes of HealthCare.gov
http://www.nytimes.com/2014/04/11/us/politics/sebelius-resigning-as-health-secretary.html?_r=0

... Officials said Ms. Sebelius, 65, made the decision to resign and was not forced out [Yeah, right - SS]. But the frustration at the White House over her performance had become increasingly clear, as administration aides worried that the crippling problems at HealthCare.gov, the website set up to enroll Americans in insurance exchanges, would result in lasting damage to the president’s legacy.

It's not as if there's no literature out there on how to create good health IT.  Doing so is not a state secret.  Simple (and free, unlike the hundreds of millions spent on incompetent beltway-bandit 'consultants') Google searches on the term "healthcare IT failure" or similar return ample resources that could have prevented the "lasting damage to the president's legacy."

Way to go, Ms. Ex-Secretary.  Another health IT amateur bites the dust, as my early computer mentor, Philadelphia's George Washington High School math instructor Fred Holzwarth (http://www.historicbuckscounty.org/nths/HISTORIA/PDF/Historia_Nov2005.pdf) would have said.

However, even worse ... far worse ...

Under this Secretary of the Department of Health and Human Services, the principal watchdog agency over medicine and medical device safety under her aegis, the FDA, found that:

... products with health management heath IT functions, includes software for health information and data management, medication management, provider order entry, knowledge management, electronic access to clinical results and most clinical decision support software.

Products with health management health IT functions are of sufficiently low risk and thus, if they meet the statutory definition of a medical device, FDA does not intend to focus its oversight on them.

Thus, patients are condemned to injury and death, probably at ECRI Deep Dive study levels [1], for the foreseeable future (see my post on that FDA decision at my April 9, 2014 post "FDA on health IT risk: reckless, or another GM-like political coverup?" at http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html).

This is especially outrageous at the time massive investigations are ongoing about the 13 deaths caused by apparent coverups of a faulty General Motors ignition switch.

It was your FDA agency, Ms. Ex-Secretary.  You own that decision.

Good Riddance, indeed.  

The person at this link: http://hcrenewal.blogspot.com/2011/06/my-mother-passed-away.html would certainly agree, if she were alive; she is not thanks to the very devices your FDA just perversely found to be of "sufficiently low risk."

-- SS

Note:

[1]  In 9 weeks in 36 PSO-member hospitals, 171 IT mishaps sufficient to cause harm were voluntarily reported; 8 injuries occurred, some severe, and 3 deaths may have been the result.  See http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html.

A New And Quite Perverse Hospital Ploy to Defend Medical Malpractice - Blame the Dead Patient?

I did not think hospitals would ever get to the level of perversity, in defense of EHRs and EHR-related malpractice, seen herein.

Just a few days ago I came across the following article on a web search.

It is an astonishing story of a 49 year old man who died in part because an ED physician in a Suffern, NY hospital did not know how to use the EHR that had life saving diagnostic information within, and the hospital attempted to BLAME THE PATIENT for not "explaining his medical history thoroughly enough" to the ED doctor.

You read that correctly.

Family Awarded $3.4 Million After ER Misses Aneurysm

http://blogs.lawyers.com/2012/02/family-awarded-3-4-million-after-er-misses-aneurysm/
Posted February 17, 2012 in Medical Malpractice by writer Aaron Kase

It’s gospel in health care– if you have chest pains, get to the emergency room, especially if you have a history of heart problems. But an inexperienced ER doctor in New York thought his patient’s complaints weren’t serious, and sent him home with muscle relaxers. The result was deadly.

A Rockland County jury Wednesday awarded $3.4 million to the family of Michael McKenzie, who was discharged from the Good Samaritan Hospital in Suffern in 2007 after complaining of chest pains and other symptoms consistent with a serious heart problem. The hospital determined that McKenzie, 49, was not having a heart attack, then ER doctor Michael Kane diagnosed him with a muscle strain and sent him home with muscle relaxers.

Two days later, McKenzie was found dead in his house by his 10-year-old son, killed by an aortic aneurysm.

The hospital should have found the aneurysm, argued Anthony DiPietro, the attorney for McKenzie’s family.”They just blew it,” says DiPietro, who headquarters his practice in New York City. “He had textbook signs of an aortic dissection [bleeding into the wall of the main artery that carries blood from the heart]: Chest pain, back pain, shortness of breath, sudden onset, woke him up from sleep, and he wasn’t doing any activities when it happened.”

Compounding the hospital’s error, McKenzie had a history of heart problems that should have pointed them toward the correct diagnosis. In 2003, he had been diagnosed with a dilated aortic root, or enlarged artery, with is a huge red flag for a future rupture. Good Samaritan knew about the dilated root because they had noted it in his chart during a heart procedure McKenzie had undergone the year before his death.

But the doctor, who had been at the hospital less than a month and was working unsupervised, never knew about McKenzie’s history. Why not? Because he didn’t know how to use the hospital’s electronic medical records system.

That's beyond pathetic, but it gets worse.  Far worse:

“He admitted it as part of his deposition,” DiPietro says. “They equivocated. First they said the system wasn’t working [an apparent attempted mistruth - ed.], but then he said he really didn’t know how to use it yet.” According to a local news report, the doctor was certified in obstetrics and gynecology at the time, and didn’t receive his certificate in emergency medicine until the following year.

The hospital argued that the aneurysm wasn’t present when McKenzie visited their ER–despite the fact that his certificate of death stated it had been present for days. The hospital also claimed that McKenzie was responsible for his own death because he didn’t explain his medical history thoroughly enough– the same history that was documented in the hospital’s own records. 

Let me repeat that for emphasis:

The - hospital - also - claimed - that - McKenzie - was - responsible - for - his - own - death - because - he - didn’t - explain - his - medical - history - thoroughly  - enough– the - same - history - that - was-  documented - in - the - hospital’s - own - records.

A hospital dares blame a likely frightened-out-of-his-wits patient presenting to their ED with chest pain, back pain, shortness of breath, of sudden onset that woke him up from sleep, for his own death?   

That, readers, is the most perverse hospital behavior I have ever encountered since entering medicine in 1977 (actually 1972-3 in summer NSF programs at Hahnemann Hospital in Philadelphia).

Not to mention, of course, that said patient cannot defend himself, because he's dead and buried...

In fact, in a highly unusual move, the judge in the case allowed doctors to recount conversations they had with McKenzie to the jury, statements usually prohibited under New York’s “Dead Man’s Statute” designed to keep hearsay out of the courtroom. 

It's a very special hearsay indeed when the hear-sayers know the patient is in his grave and cannot respond.

The tilted playing field notwithstanding, the jury nevertheless found the hospital negligent and awarded $3.4 million to McKenzie’s widow, two adult daughters and now 14-year-old son. The money couldn’t come soon enough– the widow, now sole provider for her son, recently lost her job and their home went into foreclosure. “Hopefully this will allow them to keep the house,” DiPietro says.

The ironically-named hospital planned an appeal:

A Good Samaritan spokesperson said the hospital plans to appeal.

I will attempt to find if the dockets are publicly accessible.

So, to recap, an ED doc didn't know how to use an EHR that contained lifesaving diagnostic information misses an aneurysm, the patient dies, and the defense attempts to blame the patient for his own death for (allegedly) not telling the doctor thoroughly enough about his own medical condition, i.e., the frightened, in-severe-pain patient didn't know medicine but should have - doesn't everyone?

Blaming dead patients or their families for harm from medical misadventures is absolutely horrifying.  It shows disrespect for the dead and is depraved, especially coming from a hospital, I think any prospective patient would agree.

-- SS

More Perversity on Health IT Risks, and ... EHR Sense from Nurses on "Nurse Talk", a Syndicated Radio Show

As I mentioned on July 2 at this post, in a June 25, 2013 Bloomberg News article "Digital Health Records’ Risks Emerge as Deaths Blamed on Systems" by technology reporter Jordan Robertson an EHR-harms case in which I am (unfortunately) intimately involved as substitute plaintiff is mentioned: that of the death of my mother.

I'd previously written about EHR-related electronic encounters with truly perverse individuals at my Jan. 2010 post "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" at http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html.

There were quite a few thoughtful comments in the reader comments of the June 25, 2013 Bloomberg article, but also the typical callous, incompetent and/or bizarre comments that an anonymous forum invites (really, semi-anonymous, as the website tracks IP's of commenters).  The anonymous comment below stood out from the rest as a worst-case example of perverse defense of health IT (it may have been removed by now):

Pharm Aid 1 week ago

I'm surprised at the poor quality of reporting in this article. 

First, Scot Silverstein has been on jihad against electronic medical records LONG before his dear mother passed away in 2011.  According to Silverstein's own website, he opposed EMRs back as far as 2009.

Second, the article fails to mention Silverstein's conflict of interest here - he works in this space.  Essentially, Silverstein contacts a vendor of EMRs, offers his "consulting" services.  This totally smacks of a shakedown to me.  If they don't hire him, he criticizes them and claims they are killing people.  Don't take my word for it, check out his website and blog.

Third, the number of medical errors from paper-based records is staggering.  According to a study from 7 years ago, a staggering number - 23% - of patients at one health system had medication errors attributed to illegible paper-based charts.  This is roughly consistent with other studies, including the epic IOM report on errors in medicine.

Let me point out the perversities.  I am assuming the comment was not simply deliberately false character assassination and that the writer believed what he/she was writing - which if not, would show the industry's cheerleaders in an even worse light than if the assumption is the poster believes what he/she wrote:

• No expression of sympathy or remorse at my mother's death, whatever the cause.

• Gross and almost humorously silly caricature of my "consulting" (which is as expert witness) and defamatory comments.

• Gross mischaracterization of this blog and my Drexel Univ. healthcare informatics teaching site at http://www.ischool.drexel.edu/faculty/ssilverstein/cases.

• A mysterious invocation of some unnamed article on paper records at one health system.   I note that N=1 for both the mysterious unnamed study and its subject institution, representing the absolute worst regarding drawing conclusions, especially conclusions that we need to spend hundreds of billions of healthcare dollars on what today is largely bad health IT (see definitions of good and bad health IT at the aforementioned Drexel site).

• An apparent mischaracterization of the "epic" 1999 IOM report "To Err is Human"on errors in medicine (http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf).  It's clear that many if not most medical errors have nothing whatsoever to do with documentation, either paper or electronic (I made that point at my Dec. 2010 post "Is health IT the solution to the wrong problem?" at http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html).  From that 1999 IOM report's summary:

... Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities.

•  As to "[my] claims that EHRs are [injuring and] killing people", I merely report what others find - that still others deliberately dismiss (e.g., as "anecdotal") - or ignore. Just the latest example is the ECRI Deep Dive study (http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html).  171 health information technology-related problems voluntarily reported during a nine-week period to the ECRI Institute PSO from just 36 hospitals.  Eight of the incidents reported involved patient harm, and three may have contributed to patient deaths, said the institute.  Other examples appear at HC Renewal.

In summary, there is someone out there who reads Bloomberg and who either 1) supports health IT, but lacks empathy, lacks judgment, and lacks scientific and critical thinking skills or 2) is simply a confabulator and liar.

Perversity regarding health IT needs sunlight - lots of it.

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

Here's some of that sunlight in a talk program on "Nurse Talk", a nationally syndicated radio show by and for nurses.

Nurse Talk is heard on the air in major metropolitan areas on both the West and East Coasts, and worldwide on the Internet, and has partnerships with the largest groups of nurses in the country.

Listen to the July 3, 2013 program "RNs DeAnn McEwen and Michelle Mahon on Electronic Medical Records" at http://nursetalksite.com/2013/07/03/rns-deann-mcewen-and-michelle-mahon/.

-- SS

Three Golden Parachutes and Some Unexpected Sequels

Golden parachutes are an always fascinating aspect of executive compensation in health care.  I have collected three relatively recently revealed stories about golden parachutes given to government and non-profit hospital system CEOs, at least two of which involve unexpected, and also fascinating sequels.  They will appear in order of the apparent size of the parachutes.

Santa Clara Valley Health and Hospital System

Santa Clara Health and Hospital System is a county (government) system of moderate size in California.  Last week, the compensation given its outgoing CEO in 2010 was revealed by the San Jose Business Journal:

Former Santa Clara Valley Health and Hospital System CEO Kim Roberts walked away with an impressive chunk of change when she abruptly left the job in February 2010.

According to a city and county salary report released from the State Controllers Office, the position earned a little over $1 million that year.

A county spokeswoman confirmed that the total included accrued vacation, sick leave and other payments Roberts was entitled to.

The salary was the highest in the Bay Area for public employees in 2010.

Note that

Roberts was hired as CEO in March 2007 with a five-year contract. The agreement included a starting salary of $285,744 with annual salary adjustments, severance and other benefits.

The issue here is that Ms Roberts was the CEO of a local government run health system. Traditionally, the pay given to people in such positions is closely scrutinized by politicians and tax payers, and hence is usually less than that given out by private, non-profit hospital systems, much less for-profit ones. Nonetheless, while it appears that Ms Roberts got something more than $700,000 worth of compensation beyond her usual salary in her last year, the nature of this compensation, and the justification for it is unclear.

Erlanger Health System

The story that got my attention appeared two days ago in the Chattanooga Times-Free Press:

After more than a month of negotiations, Erlanger trustees reversed a previous vote and approved a controversial $728,000 severance package for outgoing CEO Jim Brexler.

Trustees voted 4-4 against the same severance package in December but voted 5-4 to approve it during a 30-minute meeting Monday morning.

More detail about the package:

The approved agreement provides 15 months of severance for Brexler, worth about $713,000. He also keeps his Erlanger health coverage for 18 months, paying his employee portion, a benefit worth about $15,000.

This story is actually a complex sequel. We discussed CEO compensation at Erlanger Health System, an academic medical center affiliated with the University of Tennesse, a year ago. At that time, we noted that a substantial bonus given to then CEO Jim Brexler was based on favorable financial results in the previous year, but did not apparently take into account the more recent decline in the system's finances. That bonus was justified by the typical paean to the leadership's "real expertise in health care" by one member of its board.

By last month, however, Erlanger's finances had deteriorated dramatically. A Free Press article then stated,

Erlanger hospital employees have been asked to take 12 days off in the next two months, consider voluntary buyouts and face possible layoffs as Chattanooga's only public hospital bleeds money.

The hospital has lost more $6 million in the last five months, half of that in November.

The reason for this accelerating misfortune deterioration remain unexplained. Apparently, CEO Brexler had decided to depart, for also unclear reasons, two months earlier:

In October, the hospital announced CEO Jim Brexler would retire at the end of the year.

At that time, the board had voted to give him the severance package described above, but then suddenly began to reconsider after how bad things were became clear:

The board voted earlier this month not to give Brexler a more than $700,000 severance package, but the issue may be brought back up, board members have said.

It was unclear whether the decline in Erlanger's finances had to do with its relationship with another troubled hospital, Hutcheson Medical Center, as described in another Free Press article:

Despite a new board, new management and the infusion of a $20 million line of credit, a struggling North Georgia public hospital continues to lose money.

Erlanger at Hutcheson, formerly known as Hutcheson Medical Center, lost more than $9 million in the first five months of the 2012 fiscal year, which began in July. It lost the most -- $2.7 million -- in September.

Hutcheson board Chairman Corky Jewell could not be reached for comment last week.

The hospital's administrator, Debbie Reeves, and other management personnel were not in the office the week between Christmas and New Year's, according to spokeswoman Haley Johnson.

The publicly funded hospital in Fort Oglethorpe had been losing about $1 million a month, defaulted on a $35 million bond and laid off 75 employees in fiscal year 2011.

In May, Erlanger Health System took over management of the hospital and extended up to $20 million in credit to it.

Apparently inflated compensation to Hutcheson's CEO was also a subject of one of our posts from about a year ago. At that time, we wrote, "despite a major financial loss, lay-offs and service discontinuations, and a bond default," the CEO got "bonus and incentive compensation" in 2009.

So, to summarize, despite major financial problems, Hutcheson Medical Center's CEO got a bonus and incentive compensation in 2009. As its situation got worse, it was taken over in some sense by Erlanger Health System, whose CEO also got a bonus despite increasing financial problems in 2010. Thereafter, the finances of Erlanger really declined, its CEO announced his retirement, and still will collect a golden parachute.

Thus Erlanger Health System's golden parachute for its outgoing CEO symbolizes the anti-gravitational powers of executive compensation. While lavish executive pay is often justified by short-term financial results, health care executives seem to be able to just keep collecting more and more until they have to flee. Health care seems to more and more be run for the benefit of self-interested insiders.

Also, this case demonstrates how skeptical we ought to be of the breathless praise for health care executives and managers and the uncritical touting of their latest advances and initiatives.  (By the way, we posted here, just before it became apparent how badly Erlanger's finances were collapsing, about its breathless advertisement of a "new service excellence program" for Erlanger employees run by the Ritz-Carlton hotel chain.  One wonders whether the attention to the peripheral ahead of core responsibilities this denoted could have been one reason for the system's decline.) 

And we are just working our way up to our big case....

University of Chicago Medical Center

This story actually dates back to 2009, but was first revealed briefly in late 2011, in Becker's Hospital Review,

The other three highest-paid hospital CEOs in Chicago in 2010 include the following:
• James Madara, MD, and Ken Sharigian, University of Chicago Medical Center: $7.9 million
Note: This includes severance for Dr. Madara, who resigned in Oct. 2009. Mr. Sharigian served as the interim in 2010.

A little more detail came out in a side-bar to a story on executive compensation in higher education by the Chronicle of Higher Education:

James L. Madara, dean of the school of medicine and chief executive of the medical center, U. of Chicago
Total compensation: $7,038,944
Mr. Madara’s base salary was $1.3-million, and he received $2.5-million in severance pay.

There was also a hint of why this was so interesting:

Mr. [sic] Madara stepped down after seven years as dean and three as chief executive to return to the faculty. He resigned amid controversy over his management decisions, such as a plan to redirect medical-center patients to neighboring hospitals, according to local news reports.

A little digging shows there was more to it than that. Recall our recent post that discussed the "Urban Health Initiative," a program ostensibly meant to direct some patients, allegedly mainly poor patients, to more appropriate health care venues, allegedly away from the Emergency Department of the university medical center, and again allegedly to make room for patients who need and whose insurance can pay for more lucrative services.

By February, 2009, the Wall Street Journal reported that

In February, two high-ranking doctors quit their administrative posts to protest the plan, saying it could lengthen already long waiting times for patients who visit the ER.

In particular,

The two doctors who gave up their administrative posts in Chicago were Dr. Vanden Hoek, who stepped down as interim chief of emergency medicine, and pulmonology researcher Joe G.N. Garcia, who had been chairman of medicine. The doctors still can practice medicine at the hospital.

About a dozen other doctors from the emergency room and other departments had signed a letter of protest over the hospital administration's plan to reduce the number of beds available to emergency patients in the ER and other units.

Three months later, as reported by Chicago Business,

Some University of Chicago Medical Center faculty members are accusing CEO James Madara of putting hospital finances ahead of research and teaching.

A letter delivered to Dr. Madaar last month and signed by 76 faculty members asserts that, since adding the hospital CEO title in 2006, Dr. Madara has lost focus on his role as a dean of the Hyde Park medical center's vaunted research and academic enterprise. A preocccupation with hospital profits and an 'insular management style' have 'disenfranchised' the faculty, the letter says.

By that month, according to the Wall Street Journal,

More than 190 doctors at the University of Chicago Medical Center signed a letter to trustees protesting plans to reduce the number of beds available to emergency patients as 'unnecessarily risky' and a threat to patient safety.

The plan was put on hold by the university president a few days later. Dr Madara resigned in August.

So, somewhat like the case above, this involved a hospital system CEO who got a very large golden parachute after leaving under fire, not for declining revenue, but for his role in overseeing a program of questionable ethics, one possibly bad for patients, and having lost the confidence of some important proportion of his medical faculty.

He did not, however, go off quietly into the night. His next stop was Leavitt Partners (as noted in this AMA press release), founded by former President George W Bush administration Secretary for Health and Human Services James Leavitt.

As we noted here, Leavitt Partners advertises that it "advises clients that invest in health care and food safety." It does not publicize its client list, but that list apparently includes Alliance Health Networks, whose press release noted that Leavitt Partners "will help it expand its presence in the US health industry and beyond "(look here); and Connextions, Inc, whose press release noted that it would work with Leavitt Partners to " refine existing health insurance exchange models for federal and state governments, as well as private sector organizations that are navigating health care reform law," (look here.)  Mr Leavitt joined the board of Medtronic last year (look here). 

Then, however, he got back into the CEO business.  While still maintaining a role at Leavitt, in 2011, per the AMA release,

The American Medical Association (AMA) today named James L. Madara, M.D., as its new Executive Vice President and Chief Executive Officer. Dr. Madara will assume leadership of the nation’s oldest and largest physician group on July 1.

That news release noted his past positions,

the Thompson Distinguished Service Professorship and deanship at the University of Chicago Pritzker School of Medicine, where he was the longest serving Pritzker dean in the last 35 years. Subsequently, he added the responsibility of CEO of the University of Chicago Medical Center, bringing together the university’s biomedical research, teaching and clinical activities.

Perhaps not surprisingly, it did not mention the controversies at the medical center that preceded his resignation, nor his sizable golden parachute, nor his ongoing role at Leavitt Partners.

So, the American Medical Association claims to represent all US physicians and their values. It turns out that its current Executive Vice President and CEO is a former hospital system CEO who departed under fire with a golden parachute beyond any severance package a practicing or academic physician would dream about.  He also is a former and current consultant with a firm lead by one of our better recent examples of beneficiaries of the revolving door.  We have come a long, and the wrong way since the AMA asserted, "the practice of medicine should not be commercialized, nor treated as a commodity in trade." (See this post.)

This story is not just about the ridiculous compensation given to health care executives, and how this provides perverse incentives and suggests that many health care leaders have become insiders who put their self-interest ahead of the health care mission. This story is also about the connectedness of these insiders, and how they appear to control nearly every part of health care.

The Moral of the Stories

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

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

Barry Chaiken, MD, MPH: "Let's be patient" with experimental devices that harm patients

At an interview of Barry Chaiken, MD, MPH, FHIMSS, former Chairman of the Board of health IT trade group HIMSS and chief medical officer of Imprivata, a company specializing in healthcare IT security, Chaiken pleads for the following special accommodations for Health IT relative to other medical sectors:

... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.

[Why are the health IT applications bad to begin with, I ask? - ed.]

I note the following.

• If 'we're' still learning (and I don't include people with genuine clinical computing expertise in that subgroup, but it does include the plethora of amateurs in the commercial health IT industry), then the technology is experimental.
• Worse, it's unregulated - a major special accommodation in and of itself.
  
• These sentiments about "being patient" would be appropriate - if the subjects of this experimental technology that vendors need to be "given a chance" to make better were experimental lab rats.

Instead, the subjects of the experimental technology are unwitting, unconsenting human beings, who are being used as experimental test subjects for software development, and being put at risk, injured and indeed killed by the disruptions these experimental technologies cause.

Under these realities, the position presented by Chaiken is, in my opinion, ethically perverse.

That such sentiments come from someone who holds the MD degree and who I assume took the Hippocratic oath in some form is stunning.

In the health IT industry, "Primum non nocere" seems to have been replaced with "Kybernetik über alle."

Further, the commercial health IT vendors have had the good part of five decades to "get it right." How long is long enough?

Their software is unavailable for detailed evaluation and open critique of the user experience by impartial experts, unlike open source EHR's like VistA CPRS, demo version available at this link where anyone can:

• Download the latest version of CPRS today and get access to new features including graphing functionality
• Use the software as if you were a provider by entering orders, entering documentation, retrieving reports (and graphs) and viewing alerts and notifications that help with decision support
• Learn first hand how VA’s electronic health record system works

Personally, I've had to use stealth simply to obtain and post graphical representations of some simply inexcusable commercial HIT interface sins (link). Why should a secretive industry be given additional special accommodation?

Dr. Chaiken goes on to state:

Let’s hold them accountable if they don’t [make the applications better]. Absolutely, hold them accountable if they don’t; and the marketplace, I hope, will be able to make those choices and hold them accountable when they don’t. But, we’re still learning.

Again, I'm not sure who the "we're" refers to, but "holding companies accountable" will not really help victims of the experiments who are seriously injured or killed.

A better solution, as I have written on this blog (such as at my Nov. 2008 post "Should The U.S. Call A Moratorium On Ambitious National Electronic Health Records Plans?" and at other sites as well:

Protect patients. Constrain the health IT experiment temporally and geographically, and apply the laws, customs and regulations of medical experimentation until this industry "has learned" whatever lessons Chaiken thinks they need to learn, e.g., from decades of Medical Informatics, Social Informatics, Computer Science, HCI and other research. None of these fields - last time I looked - are classified or protected intellectual property. Share information on patient adverse outcomes and near misses, instead of concealing them and contractually gagging users from openly speaking about problems.

That would be the ethical approach.

Further, how many more decades should we wait for the health IT industry to figure out how to look for better leaders beyond the "school of hard knocks" bias that's existed for at least the past decade? How many substandard health IT leaders were placed in hospitals the past few decades as a result of outrageous attitudes like these below from the major recrutiers, centered on spreading the wealth?

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

[No, that line about 'being consumed with patient care issues' as a strike against health IT leadership didn't come from a Scott Adams business-idiot parody cartoon - ed.]

As in clinical medicine itself, if you're going to be anywhere near patient care and making decisions affecting its delivery, a degree damn well "gets you something."

At about the same time the above appeared in Healthcare Informatics, a generalist IT recruiter wrote me this:

... What is happening to MDs trying to change careers is providing a window into broader issues about professionals in society today - narrow training, pigeonholing in the marketplace, difficulty making lateral and cross-industry transition, what a handicap it is to be creative, entrepreneurial, or cross-disciplinary in the current marketplace, and the wasted intellectual capital represented by the high caliber of individuals who can't find ways to fruitfully plug themselves into the marketplace.

I continue to be amazed at this general phenomenon...the remarkable quality of a number of candidates I've met, and the lack of recruiters' ability to get them in the door of good companies. The interesting part of the story is that when I am able to get access to high level execs in some of these companies (not just IT, but devices, pharmaceuticals, etc. also) they are dismayed at the quality of those that they hire. They know that something is wrong in how the recruitment process is working. (eg, one of the major device cos. just devoted the time of 1 FTE in Human Resources to 'finding innovative ways of identifying and recruiting good talent into the company.')

Whose fault were the outrageous, deleterious hiring practices prevalent in this industry that contributed materially to its production of substandard products, hiring practices that persist to this day? (See example here.)

Why should we be "patient", and "give them [yet more chances] to figure out the right way to do this", and why should patients permit themselves to continue to be guinea pigs to such a sloppy, cavalier industry?

I note that Chaiken's credentials appear to fit the template, as colleague Roy Poses describes at various posts including here, of an "executive isolated from the real world of health care" and member of the superclass. From the interview linked above:

... According to your LinkedIn profile, you’re CMO for Imprivata, CMIO for Symphony Corporation, and CMO of DocsNetwork. You’re on a couple of advisory boards, you own a vineyard, and you just finished your term as chair of the HIMSS board.

Perhaps that helps explain the mantra of "computers [and profit] first, patients second."

Finally, in answer to my own question above "Why are the health IT applications bad to begin with", I suggest complacency, incompetence, willful ignorance, and negligence (including criminal negligence) as possible answers.

-- SS

Addendum:

The following in today's WSJ caught my eye ("What we've learned from the Gulf spill", Michio Kaku, July 20, 2010):

The nagging question is: Why did it take so long? Why couldn't they have capped the leak months ago? For three agonizing months, BP's engineers and executives were essentially making things up as they went along, conducting a billion dollar science project with the American people as guinea pigs. The basic science of stopping oil leaks at 5,000 feet below sea level should have been done years ago.

Concepts are similar. With just a few edits, we have this:

The nagging question is: Why is it taking so long? Why couldn't they have learned to create useful health IT decades ago? For at least thirty agonizing years, Health IT vendors' engineers and executives were essentially making things up as they went along, conducting a multibillion dollar science project with the American people as guinea pigs. The basic science of producing safe, effective, usable health IT should have been done years ago.

-- SS

Socky the Meditech Sockpuppet on Vacation?

[Note: this post is written semi-satirically, but the issues it addresses are dead serious.]

It seems Socky the HIT Sockpuppet, a.k.a. anonymous heckler and physician-ridiculer “IT Guy” here as well as "Programmer" at the HIStalk blog, whose psyops appeared to emanate from Massachusetts HIT company Meditech ("over 2,200 customers worldwide"), has disappeared.

I imagine that my post "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" had something to do with the sudden silence.

I'd conducted a forensic exercise in that post using the publicly accessible Sitemeter access logs for this blog. The analysis pointed straight to that company.

Health IT Expert Socky the Sockpuppet!

That HIT company-based trolls would resort to psyops to support diffusion of tools that are eliciting widespread complaints from physicians — about the tool’s interferences with patient care, in fact — and ridicule those physicians is perverse, whether company-sanctioned or not.

It is not uncommon for company competitive intelligence and corporate communications personnel to monitor blogs. Aggregators actually sell information about what's being said in blogs and other new media back to the companies themselves, for enhancing market awareness among other purposes. It would not at all surprise me if companies were resorting to anonymous online harassment of those whose views they do not like.

In the case of HIT, however, everyone reading this could one day be a victim, or have loved ones who could be a victim, of defective health IT.

Imagine, say, Northwest Airlines conducting online psyops to discourage and discredit those fighting for better security screening of passengers.

Would that be perverse enough to attract attention?

By the way, it was rather unthoughtful for the perpetrator to have carried out these activities considering that I had conducted this research (PPT) a few years ago, a fact they might have been aware of if they had bothered to follow the HIT literature.

Anyone listening in the U.S. Senate or House of Representatives? (The visitation logs of this blog also show "hits" from those IP's.) Perhaps you should perform some health IT vendor forensics of your own.

-- SS

1:00 PM Addendum:

Socky, ya still out there? We'd love to hear from you!

Domain Name (Unknown)
IP Address 12.11.157.# (Medical Information Technology) [Meditech - ed.]
ISP AT&T WorldNet Services
Location
Continent : North America
Country : United States (Facts)
State : Massachusetts
City : Milford
Lat/Long : 42.1544, -71.521 (Map)
Language English (U.S.)
en-us
Operating System Microsoft WinXP
Browser Internet Explorer 6.0
Mozilla/4.0 (compatible; MSIE 6.0; Windows NT 5.1; SV1; GTB6.3; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.04506.30; .NET CLR 3.0.04506.648; MS-RTC LM 8)
Javascript version 1.3
Monitor
Resolution : 1024 x 768
Color Depth : 16 bits
[Who uses 1024x768 @ 16 bit color depth anymore? Can't this rich HIT company afford better? - ed.]
Time of Visit Jan 7 2010 11:28:16 am
Last Page View Jan 7 2010 11:36:41 am
Visit Length 8 minutes 25 seconds
Page Views 2
Referring URL
Visit Entry Page http://hcrenewal.blogspot.com/2010/01/socky-meditech-sockpuppet-on-vacation.html
Visit Exit Page http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html
Out Click News 1/6/10 | HIStalk
http://histalk2.com/2010/01/05/news-1610/
Time Zone UTC-5:00
Visitor's Time Jan 7 2010 11:28:16 am
Visit Number 645,750

/sarc

-- SS

More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?

(Note to readers: also see my Jan. 7, 2010 followup post "Socky the Meditech Sockpuppet on Vacation?")

At "Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?" I observed that cavalier dismissals of physician reports on HIT unusability and difficulties fit quite well the definition of "perverse:"

Merriam-Webster dictionary:

Perverse (adj).
Etymology: Middle English, from Anglo-French purvers, pervers, from Latin perversus, from past participle of pervertere
Date: 14th century

1 a : turned away from what is right or good : corrupt b : improper, incorrect c : contrary to the evidence or the direction of the judge on a point of law
2 a : obstinate in opposing what is right, reasonable, or accepted : wrongheaded b : arising from or indicative of stubbornness or obstinacy
3 : marked by peevishness or petulance : cranky
4 : marked by perversion : perverted

In a later post, "An Honest Physician Survey on EHR's" I reported on the comments submitted by hundreds of physician members of the American Association of Physicians and Surgeons (an organization mainly of physicians in private practice who strongly support physician independence and other conservative views, founded in 1943) in a 2008 survey about HIT:

AAPS - PHYSICIAN ATTITUDES & ADOPTION OF HEALTH INFORMATION TECHNOLOGY (PDF)

The common theme in their feedback was how HIT in its present form disrupted private practice physicians, distracted them from the physician-patient relationship and impaired their ability to properly care for patients. See the above-linked post and AAPS survey report.

An anonymous, usually lively and even combative reader "IT Guy," who claims to be an IT professional at an HIT vendor, on occasion leaves comments to my HIT posts.

These are typically in the form of unsubstantiated refutations of the material in the posts, and ad hominem attacks in the unmitigated defense of HIT, e.g., referring to this writer as "a teaching professor at a major university who has virtually no understanding of statistical analysis" or as a "grandstanding self-promoter" (See, for example, here at January 5, 2010 8:53:00 AM EST. Read the entire thread.)

In the latest case, "IT Guy" commented on my report of the AAPS HIT survey responses as follows:

IT Guy said...
It's the March of the Ludites.

Thanks for a very funny post.

January 4, 2010 12:28:00 PM EST

I failed to see the humor in dozens of adverse comments about HIT from private practice physicians, and replied with a link to my initial post about HIT industry perversity mentioned above, which elicited the even more perverse response:

IT Guy said...
No one is dissmissive of legitimate concerns. Luddites are a different story. Most of the "concerns" in that diatribe are of the Luddite variety.

January 4, 2010 1:33:00 PM EST

In other words, a survey of physician concerns is a "diatribe" and it is up to the "IT guys" to determine which physician concerns are "legitimate" and which are of the "Luddite" variety.

"IT Guy" remains anonymous and has been so since he first started posting comments here, despite prodding to reveal his identity to better facilitate an understanding of where his/her viewpoints arose. He/she has neglected to do so.

Even the blogger profile is blank, click to enlarge:




Now, I welcome anonymous comments and have a thick skin - to a point. When the comments go ad hominem or perverse, I do consider deleting them.

However, when such comments are potentially revelatory of major issues, I promote and amplify them - as now. Read on.

This person also apparently uses the anonymous moniker "Programmer" at the HIStalk blog where he similarly attacks my comments made under my actual name S Silverstein or under MedInformaticsMD. The HIStalk site owner actually edited out defamatory comments made about me in Oct. 2009 at HIStalk comment #28 at this HIStalk comment thread and apologized for this entry on his blog:

#28 Programmer [at HIStalk blog - ed.]October 20th, 2009 at 11:57 am

Yes, it’s that simple. If you select for pre-IT and post-IT data and use a large enough sample size the other factors with equal out. If the sample size is large enough you should have a relatively small margin of error.

[i.e., "Programmer" -- who I soon show is also "IT Guy" -- opines that in comparing clinical adverse event rates pre- and post healthcare IT installation, all you need is a large enough sample size, which then nullifies or cancels out, for example, changes occurring over time that are not related to the intervention, and other potential confounders in a pre-post comparison. If only evaluation studies in healthcare informatics were that simple ... it is concerning that IT vendor personnel might have such beliefs - ed.]And the fact that a teaching professor at a major university has virtually no understanding of statistical analysis makes me say “at least I don’t have to worry about losing my job to one of his students."

[Latter sentence was removed by HIStalk owner - ed.]

Now, back at HC Renewal see this combative comment thread where "IT Guy" a.k.a. "Programmer" refers to that removal, and repeats the above statistical faux pas and ad hominem ("just to make sure I read the whole thing"), and adds another ad hominem for good measure. I let them remain. (Comment dated October 20, 2009 1:35:00 PM EDT.) HIStalk's "Programmer" and HC Renewal's "IT guy" are apparently one and the same.

Getting to the core of this posting, I repeat, when such comments are potentially revelatory of major issues in HIT, I promote them - as here.

The raison d'être for this posting is an interesting pattern:

Before "IT Guy" posts comments at HC Renewal, "hits" appear from a major health IT vendor's IP in our publicly-accessible Sitemeter log, with outclicks to the comment sections of posts where "IT Guy's" comments then appear.

For example:

Domain Name (Unknown)
IP Address 12.11.157.# (Medical Information Technology) [Meditech - ed.]
ISP AT&T WorldNet Services
Location
Continent : North America
Country : United States (Facts)
State : Massachusetts
City : Milford
Lat/Long : 42.1544, -71.521 (Map)
Language English (U.S.)
en-us
Operating System Microsoft WinXP
Browser Internet Explorer 6.0
Mozilla/4.0 (compatible; MSIE 6.0; Windows NT 5.1; SV1; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.04506.30; .NET CLR 3.0.04506.648)
Javascript version 1.3
Monitor
Resolution : 1024 x 768
Color Depth : 32 bits
Time of Visit Jan 4 2010 11:49:49 am
Last Page View Jan 4 2010 12:55:12 pm
Visit Length 1 hour 5 minutes 23 seconds
Page Views 12
Referring URL
Visit Entry Page http://hcrenewal.blogspot.com/
Visit Exit Page http://hcrenewal.blogspot.com/
Out Click 0 comments
https://www.blogger.com/comment.g?blogID=9551150&postID=4799128165855153590&isPopup=true
Time Zone UTC-5:00
Visitor's Time Jan 4 2010 11:49:49 am
Visit Number 643,748

At the time of the outclick, there were "0 comments" to that post, as shown in the log above. Shortly after, IT Guy's aforementioned "Funny March of the Luddites" comment appeared ... as comment #1.

Likewise today, several "hits" appeared from IP 12.11.157.# with outlinks to the comment thread, for instance as seen below when only 23 comments were present, mostly from "IT Guy", Dr. Poses and myself:

Domain Name (Unknown)
IP Address 12.11.157.# (Medical Information Technology)
ISP AT&T WorldNet Services
Location
Continent : North America
Country : United States (Facts)
State : Massachusetts
City : Milford
Lat/Long : 42.1544, -71.521 (Map)
Language English (U.S.)
en-us
Operating System Microsoft WinXP
Browser Internet Explorer 6.0
Mozilla/4.0 (compatible; MSIE 6.0; Windows NT 5.1; SV1; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.04506.30; .NET CLR 3.0.04506.648)
Javascript version 1.3
Monitor
Resolution : 1024 x 768
Color Depth : 32 bits
Time of Visit Jan 5 2010 9:38:07 am
Last Page View Jan 5 2010 9:57:40 am
Visit Length 19 minutes 33 seconds
Page Views 3
Referring URL
Visit Entry Page http://hcrenewal.blogspot.com/
Visit Exit Page http://hcrenewal.blogspot.com/
Out Click 23 comments
https://www.blogger.com/comment.g?blogID=9551150&postID=4799128165855153590&isPopup=true
Time Zone UTC-5:00
Visitor's Time Jan 5 2010 9:38:07 am
Visit Number 644,308

After that, more comments from "IT Guy" appeared starting with ... #24.

The pattern has remained consistent.

Now, the evidence is circumstantial but it does not take a Sherlock Holmes to realize it is quite likely this commenter is an employee of a healthcare IT vendor named in the above links, Medical Information Technology, Inc., a.k.a. Meditech.

I am concerned that a possible employee of an HIT company - any HIT company -- might find physician concerns about HIT as serious as those expressed in the AAPS survey "funny" and "of the Luddite variety." I also am concerned that an employee might think that in situ pre-post evaluations of the technology need not take into account possible confounders.

If this person is an HIT vendor employee and IT professional at this HIT company or any other -- I think it likely he/she holds such a position at some HIT company and such attitudes -- then a number of questions are raised:

• How common is this attitude among HIT vendor employees? Is this a systemic problem?

• How do such attitudes translate into satisfying customer requests for remediation of HIT defects and problems?

• Should HIT vendors be doing better due diligence in their hiring practices to assure they hire IT personnel with a service mentality and who understand that clinicians are the enablers of medicine, they the facilitators? (A point my graduate healthcare informatics students are taught and grasp readily.)

At the very least, perhaps employees of HIT companies (such as the one in the logs above at Meditech, whoever they may be) should pay more attention to improving HIT, rather than spending 1 hour 5 minutes 23 seconds reading 12 posts here during business hours.

"IT Guy" is welcome to continue submitting anonymous comments, but if they contain ad hominem they will be deleted.

-- SS

Addendum 1/5/10:

A HC Renewal reader with an MBA non-anonymously relates the following (emphases mine):

In reading this thread of comments I have to believe IT Guy is a salesperson. My only question is: Were you assigned this blog or did you choose it? We had this problem a number of years ago where a salesperson was assigned a number of blogs with the intent of using up valuable time in trying to discredit the postings.

In my very first sales class we learned to focus on irrelevant points, constantly shift the discussion, and generally try to distract criticism. I would say that HCR is creating heat for IT Guy’s employer and the industry in general.

I find it sad that a company would allow an employee to attack anyone in an open forum. IT Guy needs to check with his superiors to find out if they approve of this use of his time, and I hope he is not using a company computer, unless once again this attack is company sanctioned.

Steve Lucas

I think that is an interesting possibility - someone paid to disrupt. It fits, and again invoking Sherlock Holmes, there is the means, the motive and the opportunity. Time for another definition:

Sock puppeting: "the act of creating a fake online identity to praise, defend or create the illusion of support for one’s self, allies or company." (NY Times)

If true (unfortunately for the salesperson), I make this observation:

To most of the readers of Healthcare Renewal, who find a focus on irrelevancy and irrationality to be signs of foolishness and hysteria (we clinicians have seen it all, by the way), this salesperson has nothing to sell.

Another perversity also comes to mind. If what Mr. Lucas suggests is indeed occurring, a company behind such actions would be exhibiting self destructive behavior in trying to disrupt and discredit those who could actually help them to make better products and be more competitive. I remind that patients are the true "customer."

It also follows that, if this analysis is true, the defamatory attacks left at HIStalk and here at HC Renewal would have been made with foreknowledge of their falsity and with malice.  I have informed the company's General Counsel of this information and hope that will be sufficient to cause the harassment from their company to cease.

Defamation, I also add, is certainly not a particularly wise HIT vendor strategy with the HIT industry under investigation by US Senator Grassley (see Oct. 2009 PDF letter to a number of vendors and management consultant firms here).

Having worked in pharma, however, another self-destructive industry due to its internal pathologies, I've seen worse done to critics. Incidentally, another probable blog troll/sockpuppet comment from that industry is in the comments section at this Jan. 2008 post.

-- SS