As Records Go Digital, Cultures Clash - Part 2

At "As Records Go Digital, Cultures Clash, Bringing to Life Secrets the Health IT Companies Don't Want You to Know" I wrote of the used-car nature of the healthcare IT market, where lemon laws do not seem to exist and "physician buyer beware" seems a defining characteristic.

The Huffington Post Investigative Fund now has a report of their own on this phenomenon:

Shopping for Health Software, Some Doctors Get Buyer�s Remorse

By Emma Schwartz
Huffington Post Investigative Fund
Jan. 29, 2010

Computerizing American medical records within five years is a key goal of federal health policymakers, but disputes between some doctors and their technology vendors highlight the many challenges for individual medical practices making the conversion.

Bankrupt vendors leaving orphan software and inaccessible data, vendors misappropriating others' software for their own products, fights over source code, and "doctors left holding the bag" are just a few of the factors that clinicians have to face.

A nightmare scenario:

Robert Cameron wasn�t much of a technology buff, but the orthopedic surgeon knew he wanted to get rid of all the paper in his nine-physician practice in Pensacola, Fla. So he bought an electronic medical records system from a California-based company called Acermed.

Cameron�s group spent more than $400,000 on the software, but the system still never fully worked and even confused patients� scheduled visits, according to a lawsuit the doctors filed against the technology company in 2006. Acermed filed for bankruptcy in September 2007, complicating the doctors� attempts to recover their expenses.

The effort to go digital �was a disaster,� Cameron says now.

... Cameron�s Florida doctors group, Gulf Coast Orthopaedic Specialists, looked at half a dozen companies before signing with Acermed in April 2005. After installing the first part of the system, they alleged in their lawsuit, the scheduling software �malfunctioned causing patient appointment[s] to disappear.� Also, the billing system was not feeding claims back to insurers, which over the next six months nearly ran the practice into bankruptcy itself, the complaint alleged.

[Perhaps an ancient TRS-80 programmed by a medical student in Microsoft BASIC would have done better? - ed.]

Gulf Coast doctors continued to alert Acermed to the problems, but the company was unable to fix them, the lawsuit stated. They weren�t the only ones having trouble. Two other doctor groups�one in Florida, another in Tennessee�had also filed suit against Acermed, alleging similar problems. Gulf Coast filed its suit in October 2006. Acermed stated in court documents that the doctors had no basis for their claim.

[In other words, disappearing appointments and failed billing never happened and it was all in the doctors' imagination - ed.]

As it turned out, Acermed had been dealing with problems of its own. In July 2006, a federal judge ordered Acermed to pay more than $750,000 for using some of the source code from another vendor it had once worked with to develop its own electronic medical record software in 2004.

[In other words, the company misappropriated part of its computer program from elsewhere - ed.]

Gulf Coast�s lawsuit was still pending when, in September 2007, Acermed filed for bankruptcy. Company officials at the time said that the reason for their bankruptcy was the financial impact of legal bills, not problems with their software.

In January 2008, Ophthalmic Imaging Systems of Sacramento, Calif., bought Acermed and renamed it Abraxas Medical Solutions with Acermed�s former chief executive Michael Bina as president.

In an email, Bina said he does not �represent AcerMed any more and would not like to comment on its behalf.� He said that one of his conditions for joining Abraxas had been that it continued to service Acermed customers, and that �many clients� of AcerMed have stayed with the new company.

[A musical chairs question - who, then, does represent the old company if not the president of the company that now supports the old company's products? - ed.]

One of those clients, Tony Cattone, general manager of a 70-doctor medical practice in New Jersey, said in an interview, �they have lived up to their commitments and it�s working fine.�

[Until the new company does the same as the old, that is - ed.]

Several other doctors said they were left with loan payments for a system they never received.

And today, the Gulf Coast group still hasn�t entirely gotten rid of paper. In December 2008, the doctors settled their lawsuit with Acermed for an undisclosed amount. They invested in a different electronic system, but the doctors aren�t entirely happy with the new one either, said Alan Trest, the group�s technology manager. With the current system, doctors have to type rather than dictate notes. Some aren�t willing to make that transition because they say it takes them more time. So the group still pays for transcriptions.

�They haven�t really completely bought into the idea,� Trest said.

See the full story at the above link.

I note that "revolutionizing medicine" via IT still seems somewhat unlikely when the IT industry conducts itself more poorly than the used car industry.

-- SS

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A Fire Burning

Its official, I just had my first shoot for A Fire Burning, my new film about my comeback into whitewater kayaking, and training for the 2011 World Freestyle Kayak Championships.
It was a little weird at first filming myself, but after awhile I got into it and feel like I am talking directly to the viewer. Being the camera operator and the subject adds a whole new twist and I think I like it. I think it will make the film a lot more intimate and I think the viewer is going to get sucked in and involved. Plus it was fun, which is my main goal.
We are having our first pre-production meeting on Monday and begin the official shoot 10 Feb up on the Kaituna River.
I am really excited to be kayaking again and am feeling stronger than ever. I have just been training on flat water this week, but so far so good. I am also cycling 2 hours a day, doing yoga for an hour+, and meditation 1 hour in the morning and 1 hour at night.
So my days are pretty full. I am reserving Saturdays to do my artwork and take the day off from training.
My whole goal is to have balance, and make room for everything that's important, which is something I was lacking last time I was training.
I am feeling good and happy and healthy and will be making regular posts about the progress of the film and how my training is going.

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What Happens When "We'll Manage it the Way We Damn Well Want"

Back in the early days of Health Care Renewal (2005, to be exact), we first wrote about some very strange actions by the management of Phoebe Putney Health System.  At first, we noted that the Phoebe Putney responded to a reporter's inquiry about lavish travel expenses pertaining to the system's Cayman Islands health insurance subsidiary by saying, "We own it. We'll manage it the way we damn well want."

Then the story got far more convoluted.  In 2006, we wrote about the over the top response to anonymous faxes challenged hospital management's commitment to the institution's mission.  The system CEO compared the fax senders to "terrorists."  After the local district attorney handed over his investigative records to hospital system private investigators, the investigators allegedly threatened a local accountant whom they accused of sending the faxes.  Allegations that the district attorney received campaign funding from and may have had other financial ties to the hospital system surfaced.  The district attorney indicted the accountant and a physician colleague on charges of burglary and assault in the absence of any police report of such crimes.  We commented that regardless of the outcomes of the legal case, the hospital system's management's actions seemed at variance with its stated mission.

Now, in 2010, the case is in the news again.  Since our last post, according to the Atlanta Journal-Constitution, the prosecution of the accountant, Mr Charles Rehberg, and physician, Dr John Bagnato, failed.  The district attorney, Ken Hodges,

provided the information gathered through the subpoenas to Phoebe Putney, which the hospital system used to file a civil suit against Rehberg and Bagnato -- a suit that was ultimately dropped. Rehberg then countersued Phoebe Putney, and that case was settled out of court for an undisclosed sum.

Meanwhile, more ties between Hodges and the Pheobe Putney system turned up:

Hodges' decision to run for attorney general elevated the case from a localized matter to one of statewide import. While still a prosecutor in Albany, Hodges received political contributions from Phoebe Putney executives and individuals connected to the hospital system, and his wife was hired as public affairs manager at Phoebe Putney's hospital in Albany.

Since leaving the prosecutor's office in Dougherty County, Hodges has gone to work for the Baudino Law Group, which represents Phoebe Putney. According to records Phoebe Putney must file with the Internal Revenue Service, the hospital system paid Baudino more than $8 million for the fiscal year ending July 31, 2008, the most recent data available.

Now, it is Rehberg who is suing Hodges, for abuse of power. "Charles Rehberg's suuit essentially accuses him and another prosecutor of filing criminal chargest that they knew to be based on fabricated information." A preliminary hearing took place yesterday.

So, in summary, two individuals sent anonymous faxes that charged that the Phoebe Putney system failed "to fulfill its charitable obligations as tax-exempt entity."  Hospital system executives accused them of terrorism, and hospital system investigators allegedly threatened them.  However, a criminal investigation by a district attorney with alleged financial ties to the hospital system ended without any convictions.  A lawsuit by the system against the individuals was dropped.  A suit by the indviduals against the hospital system was settled by the system.  A suit by the individuals charging that the then district attorney abused his power by basing criminal charges on false information is pending. 

So what did the hospital system's management's actions in this case have to do with the system's stated values? -

Phoebe pursues its mission through a patient-centered environment of care reflecting high standards and promoting a balance of professional preparation and service, continuous improvement and based on core values where:

* PEOPLE come first, are treated with dignity and respect, and diversity of culture and thought is respected.
* RELATIONSHIPS are built on honesty and integrity.
* REPUTATION is built on trust and pride.

In fact, the Phoebe Putney management's pursuit of Mr Rehberg and Dr Bagnato seems diametrically opposed to these values, intended to crush all criticism of management by any means. Once again, we see leaders of once-respected not-for-profit health care institutions whose main goal seems to be consolidating their power and thwarting criticism.

I say again, to truly reform health care, our health care organizations must be lead by those who put the institutions' missions ahead of their self-interest, who manage according to the mission rather than "the way we damn well want."

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Why The Apple iPad Will Not Revolutionize, Change the Game, Transform or Create New Paradigms in Medicine Anytime Soon

The announcement of the Apple iPad has been accompanied by the usual irrationally exuberant, buzzword-laden statements and bellicose grandiosity from the IT punditry about how it will "revolutionize" or "transform" medicine.

However, this will not occur anytime soon, for in medicine, the device may help solve a portability and visibility problem (compared to PDA's), but it will not solve this problem: the mission hostile user experience.

The solution to that problem will require significant human magic.

-- SS

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The iPad and Healthcare

Several folks have asked - will the iPad revolutionize healthcare?

The answer is Yes and No.

My ideal clinical device is

*Less than a pound and fits in white coat pocket

*Has a battery life of 8-12 hours (a full shift)

*Can be dropped without major damage

*Has a built in full keyboard, voice recognition, or very robust touch screen input

*Provides a platform for a variety of healthcare applications hosted on the device or in the cloud

Netbooks and laptops are too heavy, too large, and do not meet my battery life requirements.

The iPhone is too small for reliable data entry.

The Kindle is a great device but not a flexible application platform.

The iPad comes closer to my requirements than other devices on the market.

However, the ideal clinical device would include a camera for clinical photography and video teleconferencing.

Entering data via the touch screen with gloved hands may be challenging on a capacitance touch screen.

Holding the iPad with one hand means hunt and peck typing with the remaining hand.

The device is a bit large for a white coat pocket, may be hard to disinfect, and may not be tolerant of dropping onto a hospital floor.

I look forward to trying one to validate these assumptions.

My general impression is that it is not perfect for healthcare, but it is closer than other devices I've tried.

It will definitely be worth a pilot.

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Food Allergy Molecule Discovered

So why do some people have an allergic response to something like peanuts and milk, while others have no such response. Researchers are a step closer to answering that question.

In a recent study led by Yong-Jun Liu, M.D., Ph.D., at the University of Texas M.D. Anderson Cancer Center, Houston, scientists singled out the molecule that specifically directs immune cells to develop the capability to produce an allergic response. It's called thymic stromal lymphopoietin (TSLP), and these researchers believe it is the key to why food allergies develop in some people.

Information from this study may allow scientists to target this molecule in their efforts to treat and cure food allergy. Here's the abstract for those with a scientific brain.

This research is being conducted with a grant through the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

Here's their press release of this encouraging new study.

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More California Medical Centers Plagued by Quality Problems While Their Executives Get Bonuses for "Improved Patient Care"

Earlier this week, we noted that while executives at one University of California medical center were getting large bonuses supposedly for "improved patient health," the hospital was being cited for serious health care quality deficiencies.  Now, more stories have appeared that raise questions about the rationale for the generous bonuses handed out to multiple top hospital executives at University of California hospitals. 

University of California - San Diego

First, in alphabetical order by city, the San Diego Union-Tribune reported on penalties for poor quality care announced by the California Department of Public Health:

UCSD Medical Center in San Diego was fined $50,000.... The state said the hospital staff failed to follow its surgical policies and procedures, which resulted in a patient having to have a second surgery to remove a foreign object � a guide wire that was left in the patient when a central venous catheter was inserted into the patient�s right femoral vein in the groin area in January 2009. The wire migrated into a chamber of the patient�s heart.

The procedure was done by a first-year intern and supervised by a third-year resident.

This marks the third time the state has penalized UCSD, with the first penalty issued in May 2008 and the second in May 2009.

However, a few days earlier, the Union-Tribune had reported:

Despite criticism from union leaders and rank-and-file employees, University of California regents yesterday overwhelmingly approved $3.1 million in incentive payouts to 38 medical center executives.

The payouts mean, for instance, that former UC San Diego Medical Center CEO Richard Liekweg will receive $136,174 in performance pay for the last fiscal year, added to his base of $660,500.

Regents justified the payments by noting that incentive programs are common in the health care industry, and necessary to compete for top talent.

'It�s the way this industry works,' said Regent William De La Pena, an ophthalmologist and medical director of eye clinics throughout Southern California.

At UCSD Medical Center, 10 senior managers will receive a combined $754,650 for surpassing goals set in areas ranging from improved patient safety to increased revenue. The bonuses amount to 14 to 23 percent added to executives� salaries.

University of California - San Francisco
Meanwhile, the San Francisco Chronicle reported that a major University of California - San Francisco teaching hospital was also cited by the state Department of Public Health for quality problems:

San Francisco General was fined $25,000 for leaving a piece of surgical gauze in a patient who underwent an eight-hour operation for two types of cancer in September 2008. The foreign object was discovered about three months later and was removed without surgery during an office visit.

The Chronicle also reported a possibly major breach in the confidentiality of patient records at the UCSF Medical Center:

Medical records for about 4,400 UCSF patients are at risk after thieves stole a laptop from a medical school employee in November, UCSF officials said Wednesday.

The laptop, which was stolen on or about Nov. 30 from a plane as the employee was traveling, was found in Southern California on Jan. 8.

There is no indication that unauthorized access to the files or the laptop actually took place, UCSF officials said, but patients' names, medical record numbers, ages and clinical information were potentially exposed.

The security breach is UCSF's second in recent months. Last month, UCSF officials revealed that a faculty physician responding to an Internet 'phishing' scam potentially exposed the personal information of about 600 patients.

However, despite these obvious quality problems, the San Francisco Business Times reported

University of California regents approved $500,000 in bonuses to six top officials at the UC San Francisco Medical Center, part of a package of $3.1 million in payments to 38 hospital executives across the UC system.

In an interview last week with UCSF Chancellor Susan Desmond-Hellman, she said that the executive bonuses were tied to meeting specific performance goals, such as reducing clinical infections and increasing satisfaction ratings by patients. She also pointed out that additional payments of $14.3 million to the UCSF Medical Center�s 6,600-strong workforce were approved earlier.

The UCSF officials awarded bonuses were:

* Mark Laret, chief executive officer, $181,227;
* Ken Jones, chief financial officer, interim chief operating officer, $89,162;
* Larry Lotenero, chief information officer, $66,045;
* John Harris, chief strategy and business development officer, $63,196;
* Susan Moore, finance director and interim chief financial officer, $53,261; and
* Sheila Antrum, chief nursing/patient care services officer, $49,280.

Summary

So, in summary, multiple executives at three major University of California medical centers received generous bonuses.  The rationale for these bonuses, given out at a time when the university system was under major financial constraints, was that they were incentives for exemplary performance and patient care. 

Yet almost simultaneous with announcement of the bonuses were news reports indicating serious patient care problems at the same medical centers.  The point I am NOT trying to make is that the care at any of these medical centers is bad.  The examples of quality problems were limited.  I am sure that many other major medical centers hae had such quality problems as well.  However, the cases cited above were sufficient to argue that the care at these medical centers was not outstanding, not exemplary.  Yet, the bonuses were awarded not for acceptable performance or average quality.  Their rationale was exceptional performance and quality.  Thus, the rationale for the performance bonuses seems at best naive, if not foolish. 

I would suggest, instead, that the sorts of bonuses given out at the University of California are a product of the current management culture that has been infused into nearly every health care organization in the US.  That culture holds that managers are different from you and me.  They are entitled to a special share of other people's money.  Because of their innate and self-evident brilliance, they are entitled to become rich.  This entitlement exists even when the economy, or the financial performance of the specific organization prevents other people from making any economic progress.  This entitlement exists even if those other poeple actually do the work, and ultimately provide the money that sustains the organization. 

Although the executives of not-for-profit health care organizations generally make far less than executives of for-profit health care corporations, collectively, hired managers of even not-for-profit health care organizations have become richer and richer at a time when most Americans, including many health professionals, and most primary care physicians, have seen their incomes stagnate or fall.  They are less and less restrainted by passive, if not crony boards, and more and more unaccountable.  In a kind of multi-centric coup d'etat of the hired managers, they have become our new de facto aristocracy. 

Or as we wrote in our previous post, executive compensation in health care seems best described as Prof Mintzberg described compensation for finance CEOs, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit." As it did in finance, compensation madness is likely to keep the health care bubble inflating until it bursts, with the expected adverse consequences. Meanwhile, I say again, if health care reformers really care about improving access and controlling costs, they will have to have the courage to confront the powerful and self-interested leaders who benefit so well from their previously mission-driven organizations.  It is time to reverse the coup d'etat of the hired managers.

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Vegan Pizza

At home, our vegan cooking is based on seasonally fresh fruits and vegetables, homemade tofu, and the basic idea that every ingredient should be savored for its special qualities.

Our vegan pizzas are freshly baked crusts topped with pesto, tomatoes, broccoli, and mushrooms.

Recently, we discovered a remarkable Vegan Pizza restaurant close to Boston - Peace O'Pie, Gourmet Vegan Pizza in Allston.

This is not a pizza joint with a veggie pizza. It's an entirely Vegan restaurant owned and operated by vegans. Fresh, organic produce is the core of every Pizza. There are no refined sugars. Even the whole wheat crust and pizza sauce are organic.

We recently had a great Hawaiian Pizza and The MD (herb roasted onions and zucchini). The "cheese" used is Daiya, a wonderful food made from tapioca flour and ground peas that tastes and stretches like Mozzarella.

Even the building is eco friendly - the counter front is bamboo, the ceiling tiles are recycled, and the countertops are made from PaperStone.

Everything is freshly made.

I highly recommend Peace O'Pie for vegans and non-vegans alike. It's pizza you can feel good about.

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A Privacy Breach

Today, Beth Israel Deaconess and UCSF issued press releases about a complex situation.

Over a year ago, an employee of BIDMC who had authorized access to data for quality improvement activities placed clinical data (not financial or social security number data) for approximately 2,900 patients on a thumb drive. The employee left BIDMC and went to work in California for UCSF. While at UCSF, the employee copied the thumb drive to a UCSF owned laptop in order to demonstrate quality improvement reporting. The laptop was stolen, then recovered. There is no evidence that the data on the laptop was accessed.

BIDMC takes this situation very seriously and notified the patients, Health and Human Services, and the media.

As with other challenging situations I've discussed such as the CareGroup Network Outage and the Limitations of Administrative Data, it is my intent to openly share lessons learned with my colleagues and the industry. By writing about the process, I hope to encourage policy and technology improvements at healthcare institutions throughout the country to protect privacy.

A few thoughts

1. Make sure you have a policy requiring that all mobile storage devices be secured. BIDMC has a written policy and is revising it to be even more restrictive.

2. To further mitigate risk, encrypt all laptops. BIDMC has implemented McAfee Safeboot for this purpose. Harvard Medical School has licensed PGP Whole Disk Encryption for this purpose.

3. Educate employees about the policy and technology best practices to protect privacy. A learning management system is great for this.

4. Sanction employees who violate the policies

5. Implement new technologies that scan/restrict data transfers in the organization i.e. scan email for medical record numbers or patient identified information sent non-securely.

The combination of strong policies, state of the art technology, and education is required to protect patient data.

In this case, an authorized employee took data in violation of policies and placed it on technology not controlled by BIDMC. Likely, the laptop data was not accessed but you can be sure that additional education, broad communication with patients, and close collaboration with government and the media will be our next steps.

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The Grant Programs from ONC

How do you spend $2 billion dollars wisely and quickly on Healthcare IT?

Here's ONC's complete grant funding plan

Regional extension centers (RECs) $643 million

Health Information Exchange $564 million

Workforce Training Programs $118 million

Beacon Communities $235 million

Strategic Health Advanced Research Projects (SHARP) $60 million

Nationwide Health Information Network/Standards and Certification $64.3 million (details are pending)

These are the major initiative but there are are other smaller contracts and projects, hence the total above is less than $2 billion.

Regional extension center and Health Information Exchange funding will be announced before the end of January.

Beacon Community applications are due February 1 and work will begin in March.

SHARP grants were due January 25.

The FOA for Nationwide Health Information Network/Standards and Certification will be issued soon.

I've agreed to be a project advisor to groups applying for every one of these grants.

I'm most directly involved in Beacon Communities submission for Greater Boston.

I'll post our Beacon Community plan on my blog as soon as I am able.

If any grant naming me as a collaborator or advisor is funded, I will post the details in the interest of full disclosure.

January 2010 has been one of the most intense months of my career - we got the IFR, the NPRM, HIT Standards Committee and Workgroup efforts, HITSP's finished deliverables, and nearly $2 billion in grant opportunities, all happening at the same time.

The secret is to limit your involvement in national, regional, and local Health IT projects so that you are maximally challenged, not overwhelmed. Best of luck to all who are applying.

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Allergy Friendly Food Banks

I got a disturbing e-mail last week that a Boy Scout troop had been turned down when they offered to help organize food at our local food bank.

Why?

The food bank was out of food. There wasn't anything to organize.

Our community rallied and many of us shopped in our cupboards and grocery stores and sent food over to the food pantry.

I do think sometimes about families in need who may also deal with food allergies. Our jars of peanut butter and boxes of macaroni and cheese may not help those folks.

That's why I love what Dee Valdez has done. She's on a mission to open gluten free food banks across the country. She started with one in Loveland, Colorado. Dee, also known as "Gluten-Free Dee", has partnered with companies, including Pamela's Products, to provide gluten free products to those in need.

Don't you just love this? Check in with your local food pantry today and see what they need. People in all of our communities go to bed hungry many nights. That should not be...

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Drowning our Sorrows in Ketchup: Novartis Settles, Appoints Former Heinz Executive CEO

Here's the latest corporate health care marcher in the legal settlement parade, as reported in the Wall Street Journal.

Swiss drug giant Novartis AG said its U.S. subsidiary struck a plea agreement with U.S. investigators to resolve criminal allegations regarding the company's promotion of the epilepsy drug Trileptal, and agreed to pay a $185 million fine.

Federal investigators have been carrying out civil and criminal investigations of Novartis' marketing of the drug, including allegations that it promoted the drug for uses for which it is not approved by the Food and Drug Administration, an illegal practice known as 'off-label' marketing, Novartis said in a statement Tuesday as it announced fourth-quarter results.

To resolve criminal allegations, Novartis said it agreed to plead guilty to a violation of the U.S. Food, Drug and Cosmetic Act, and to pay a fine of $185 million.

It has become a drearily familiar ritual. We have now discussed numerous instances of large health care corporations pleading guilty to criminal charges and/or settling civil allegations of unethical behavior.  In the current case, like nearly all the others, the corporation will pay what seems to be a huge fine.  However, the amount is a pittance compared to the corporation's revenue, and is likely to be viewed as only a small cost of doing a very lucrative business by corporate executives.  In very few cases does any individual suffer any negative consequence for approving, ordering or implementing the unethical behavior. 

Thus, I would argue that these cases remind us how unethical the health care "business" has become, but the way they have been resolved will fail to deter future bad behavior.  A large fine's impact can be spread among share-holders, employees, and clients/ customers/ patients, and hence poses no threat to executives planning the next bit of unethical behavior. 

In fact, the most notable aspect of the current case is that the corporation involved in not run out of the US, but rather out of Switzerland, showing that this pattern is not exclusively an American one.

There is an interesting juxtaposition to this case, however.  At the same time this settlement was announced, Novartis disclosed its new CEO.  A Wall Street Journal commentary opined, that the " New Novartis Chief Needs Surgery Skills."  Ironically, the new CEO is hardly a surgeon.  Here is a summary of his background.

Mr. Jimenez began his career in the United States at The Clorox Company, and later served as president of two operating divisions at ConAgra. In 1998, he joined the H.J. Heinz Company, and was named President and Chief Executive Officer of the North America business. From 2002 to 2006, he served as President and Chief Executive Officer of Heinz in Europe.

Before joining Novartis, he was a NonExecutive Director of Astra-Zeneca plc, United Kingdom, from 2002 to 2007; and was an advisor for the private equity organization Blackstone Group, United States. Mr. Jimenez joined Novartis in April 2007 as Head of the Consumer Health Division and was appointed to his present position in October 2007.

Mr. Jimenez graduated with a bachelor�s degree from Stanford University in 1982 and with an M.B.A. from the University of California, Berkeley, in 1984.

I would guess that all that expertise marketing ketchup will come in handly preventing the need for more settlements of illegal marketing practices.  Seriously, we have discussed the logic and evidence behind the assertion that health care corporations ought to be run by people with relevant experience and values.  We wish Mr Jimenez well, but hope that he realizes that if he is to prevent future events that could throw his company into disrepute, he ought to lean heavily on people who understand medicine and biomedical science, and who support physicians' core values.

More broadly, I again suggest that real US health care reform would need to deal with both these issues.  We need to have rigorous regulation of health care organizations that has the power to deter unethical behavior that may risk patients' health.  We need to have leaders of health care organizations who actually understand health care and share its values. 

Two hat tips to the PharmaGossip blog (here and here).

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BIDMC Data Marts

At BIDMC, our clinical systems are written in a hierarchical database called Cache - a very fast transactional system with great reliability and disaster recovery features.

However, for population health, quality, and performance analysis, we export our clinical care data into over 80 data marts build with SQL Server 2008.

These data marts are focused on specific reporting areas such as pharmacy, radiology, lab, and O.R. They are designed and maintained by an IS team within Clinical Information Systems. Updates generally occur daily and are managed via SSIS packages.

BIDMC data marts are used to support ad hoc queries by analysts as well as standard reporting via Performance Manager, a web-based, self-service reporting application developed by BIDMC IS. Some of the key content areas and uses for the data are shown in the graphic above.

One of our most powerful data marts is the BIDMC/Joslin Diabetes registry, which uses a Master Patient Index to link all the records of the two institutions together into one reporting infrastructure. It identifies all diabetic patients and consolidates a variety of relevant clinical and operational data into a single data mart optimized for tracking and reporting. Data elements include laboratory results Hemoglobin A1C and cholesterol, blood pressure, and outpatient medical and vision care appointments. In addition to data from BIDMC, the registry includes laboratory and vision care data from Joslin, providing a complete picture for BIDMC patients who also receive diabetic care at Joslin.

We've identified the person whom we believe is the Primary Care Physician and generated web-based reports for PCPs to validate that patients in the registry actually have diabetes. Surprisingly large number don't have diabetes. Diabetes was coded, for example, in ordering an A1C as a "rule out". We've also designed management reports that measure compliance with guidelines for diabetes care. We hope to leverage this infrastructure as part of our Beacon Communities grant application and make it available as a model for diabetic care throughout the community.

Our data marts, combined with the community quality data center hosted by MAeHC, provide us all the tools we need to improve quality and efficiency in our inpatient, ED, and ambulatory practices throughout greater Boston.

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As Records Go Digital, Cultures Clash, Bringing to Life Secrets the Health IT Companies Don't Want You to Know

Yes, as records go digital, cultures clash: the culture of medicine, and the culture of the Barbary pirates.

The following story perhaps brings to life much of the advice from a candid HIT vendor (who happens to also be a physician) in my post "10 Secrets the EHR Companies Don't Want You to Know":

As Records Go Digital, Cultures Clash
By Sammy Mack, Health News Florida

Jan 22, 2010

A group of Broward County doctors looking to switch to electronic medical records say the result has been a massive headache: surprise charges, inadequate training and even blocked access to patient files.

... Experts say a culture clash between mid-career physicians and tech-savvy software vendors can translate into mismatched expectations. They tell the buyer to beware.

And with federal incentives now in play, they say there is bound to be further conflict.

�I get upset just talking about it,� said Dr. Arleen Richards, a Plantation physician and one of the doctors who signed a contract with Castranova. [An IT supplier - ed.] "When you look back in retrospect, you�re like, �how did this happen?�"

Physicians are too trusting of IT salespeople, that's how. I recommend considering an IT purchase as you would consider purchasing a used car.

Richards says Castranova promised a cheap, easy piece of software that would increase efficiency in filing insurance claims. The price tag: $10,000 plus the cost of some new computers.

... After signing up, Richards learned she would have to pay a $2,500 licensing fee for each provider in her office, to qualify for the stimulus funds. In addition, she said Castranova hit her with almost $15,000 in charges to install new computers--charges she didn't authorize. [cf. Secret #5: Determining how much a specific EHR costs is going to be difficult, and you are going to be nickel-and-dimed every step of the way! - ed.]

$10,000 for the software, plus previously undisclosed per-user licensing fees and $15,000 to install what are probably commodity computers available at Newegg for a few hundred dollars? If true, the term for this "gotcha" is: ripoff.

Castranova said he doesn�t understand how she could think the computer charges were unauthorized. After all, he said, someone had to let him into her office to install the machines.

A contract that clearly specifies such "materials and labor costs" is the standard when, say, a plumber fixes your toilet.

This is especially true when those costs exceed the cost of the product itself, the software. These IT added costs should always be presented to clients up-front, above board, in writing and in a manner that could not cause misconceptions or buyer's remorse. If this did not occur here, then that is a problem.

Another of the doctors in a tiff with Castranova, Fort Lauderdale internist Paul Preste claims Castranova didn't provide adequate training after installing the electronic records system.

Preste's office manager, Donna Golden, said there was a day-long training and that Castranova�s employees came to the office on a number of occasions, but she noted some practitioners had to start from scratch after decades of paper records.

One day of training on a complex information system? That is a joke.

In another complaint against Castranova, Dr. Linda Kaplan said she too was surprised by charges on her invoice. When they first met, Castranova recognized her as a former medical editor at the local NBC television affiliate. She said he offered to waive her software and training fees if she would endorse the product [cf. Secret #3: Even that EHR-using physician you've been referred to may have been paid off! -ed.]

Kaplan agreed, but she said she was unimpressed with the system once it was installed in her Hallandale Beach office. She was reluctant to drum up business when she wasn't a satisfied customer.

Kaplan said Castranova was displeased with her lackluster endorsement and locked her out of some 600 patient records on his server. He billed for the software system anyway. [cf. Secret #6: Your patient data will be a bargaining chip to prevent you from leaving an EHR company! - ed.]

"We are holding your patient information hostage. Pay up."

I sincerely hope for this vendor's sake that none of those 600 patients suffers an adverse outcome during the "records blackout." This information is not exactly chopped liver.

Here is perhaps the most concerning statement in the article:

No agency tracks electronic medical records disputes, but experts said feuds like these are not uncommon ... Linda McMullen of the Florida Medical Association said she's starting to hear similar stories of spats between doctors and software vendors.

As the government pushes health IT on to unwary physicians, physicians need to educate themselves on the wiles of the IT profession ... fast.

(HC Renewal and my academic site on HIT dysfunction are two examples of where to start.)

Advice in the article:

Maxwell, the software consultant, said doctors can avoid some of the grief by thoroughly researching their options before buying an electronic records system. She encouraged medical offices to shop around and set a five-year budget that includes the cost of scrapping a system if it doesn't work out.

Draw up an exit strategy for retrieving data if something goes wrong, she counseled. And get expert help reviewing contracts. [I note that data migration is never cheap, and never easy - ed.]

"The people that have had problems just went out and bought one (electronic medical records system)," she said, as opposed to researching the software and the company behind it.

Fine advice. However, this reality belays the arguments about health IT being a deterministic convenience, saving money and improving efficiency. IT is often a headache and a money pit in and of itself.

Physician buyer beware, indeed.

-- SS

Addendum Jan. 31:

Also see my comments on a Huffington Post Investigative Fund story about physician HIT buyer's remorse.

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Soft Power Health Official selection NY International Film Festival and Jury Prize Mammoth Mountian Film

Soft Power Health has just been announced as an official selection in the New York International Film Festival and has received the Jury Prize in Action Sports at the Mammoth Mountain Film festival in California.

SOFT POWER HEALTH
What an incredible and inspiring documentary! Dr Jessie Stone should win a humanitarian award for her efforts. Dr Stone helps people in Uganda receive mosquito prevention sleeping nets to prevent malaria, contraceptive education and much more. Polly Green has done an excellent job with professional videography & editing as well as some amazing shots. Very informative and a must see documentary!
Anoo Cottoor
Executive Artistic Director
New York International Film Festival

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UCI Medical Center Fails Inspection, UCI Executives Get Bonuses

Back in the early days of Health Care Renewal, we had many occasions to write about problems with the leadership of the University of California - Irvine (UCI) medical school.  Starting in late 2005, we posted  about various management problems at the institution, involving its liver transplant service, cardiology division, and bone marrow transplant service, (see posts here and here) which lead the new chancellor of the campus to "acknowledge a failure of leadership and accountability" (see post here.) Slightly more recently, we noted the almost 20 year history of questionable financial relationships that involved one of UCI's "biggest stars" in clinical researach and several pharmaceutical companies (see post here).  Then, in 2007, we wrote about some strange contracting practices involving UCI and a local orthopedic practice (see post here).

So it was deja vu all over again when last week the Los Angeles Times reported about the latest batch of problems at UC Irvine Medical Center:

Federal investigators found scores of problems at UC Irvine Medical Center during a fall inspection that again put the troubled hospital's Medicare funding at risk, according to report released Thursday.

In an 85-page report on their surprise October inspection, regulators said they observed poor oversight and mistakes by UCI doctors, nurses and pharmacists, leading to inadequate care that in some cases harmed patients.

Among the findings:

* An 82-year-old man was mistakenly given a narcotic patch by a medical resident, without approval of doctors or pharmacists. The patch led to an overdose that required emergency intervention and may have contributed to his death a week later.

* A patient in the neuropsychiatric unit fell twice in three days and despite yelling 'Help me, doctor, help me,' suffered a head injury and had to be taken to intensive care.

* An on-call resident did not respond to repeated emergency pages from nurses in the neurological intensive care unit, where a patient with an irregular heartbeat languished for more than an hour.

* Pharmacists failed to monitor and store drugs correctly, allowing nurses to carry narcotics in their pockets and inject patients without proper oversight.

The report comes a year after investigators from the Centers for Medicare and Medicaid Services documented repeated examples of poor oversight at the hospital and threatened to cut Medicare funding.

In July, Medicare officials issued a finding of immediate jeopardy after investigators discovered that five UCI patients had received overdoses because nurses using pain medication pumps were not properly trained. UCI officials immediately began training nurses to use the pumps, the finding was lifted within 24 hours and the hospital submitted a plan of correction.

However, the 2010 continuation of the sad tale of UCI adds an interesting contrast.

UCI nurses said Thursday that many of the latest problems stem from understaffing and other cost-cutting, even as the facility turned a $54.2-million profit last year and the chief executive earned an $83,250 bonus.

'This is a problem of money. To provide extra training, extra staffing, is money,' said Beth Kean, California Nursing Assn. director for UC nurses, including 1,000 at UCI.

Terry A. Belmont, who took over as the hospital's chief executive last year, disputed that the facility was understaffed.

The new wrinkle in the UCI saga seems to be that now the leadership of UCI has been raking in bonuses while the mismanagement of the organization apparently continues.

Indeed, also last week several California newspapers reported on a series of bonuses granted to the top executives of the University of California system.  For example, per the Los Angeles Times,

The University of California regents Thursday approved the controversial payment of $3.1 million in performance bonuses to 38 senior executives at UC's five medical centers.

The regents emphasized that the payments were linked to improved patient health and stronger hospital finances and said they were important tools to attract and retain talent. They said the bonuses were part of a 16-year-old plan funded by hospital revenue, not state funds or student fees. An additional $33.7 million is distributed among 22,000 lower-ranking medical employees.

However, union activists denounced the executive bonuses as unconscionable as other parts of the university were coping with pay cuts and layoffs.

'This is appalling to do this when they are telling the lowest-paid workers to stay in poverty,' said Lakesha Harrison, president of the American Federation of State, County and Municipal Employees Local 3299, which represents about 20,000 UC workers, including hospital technicians and campus custodians.

Some of the union's members get bonuses of about $300 a year, Harrison said. In contrast, the payments to the 38 senior managers range from about $30,100 to nearly $219,000.

The incentives were awarded after the UC medical center system met such targets as reducing catheter-related infections and saving money through group purchases of supplies, officials said.

Among the payments approved Thursday by the regents in San Francisco were $218,728 to UCLA Medical Center Chief Executive David Feinberg, on top of his $739,695 base salary; $181,227 to UC San Francisco medical center Chief Executive Mark Laret, on top of $739,700 in pay; and $87,000, in addition to his $580,000 salary, for John Stobo, the UC system's senior vice president for health sciences.

Corroborating the assertion that the bonus plan is not new is a document that lists executive compensation at the University of California in 2008. (2009 data does not yet seem to be available on the web.) This document noted the following bonuses paid to University of California - Irvine medical leaders in 2008:
- Susan J Rayburn, Executive Director of Clinical Enterprise - Base Salary= $212,700, Bonus=$28,401
- Lisa M Reiser, Chief Patient Care Services Officer - $243,000, $26,507
- Eugene Spiritus, Chief Medical Officer - $310,000, $38,373
- Patricia D Thatcher, Executive Director - HR and Customer Service, Medical Center - $197,547, $17,542
- Cynthia A Winner, Chief Ambulatory Care Officer - $238,200, $24,371
- Maureen L Zehntner, Associate Vice Chancellor/ Chief Executive Officer, Medical Center - $555,000, $74,432

Note that Dr Spiritus, the Chief Medical Officer, did not mention that he was a 2008 bonus recipient when he defended bonuses given to UCI leaders in the LA Times article,

'Everybody's fallible. We just have to make sure we have the right processes in place' to catch errors, said Dr. Eugene Spiritus, UCI Medical Center's chief medical officer.

Spiritus also defended the compensation for hospital managers, saying they need to stay competitive in order to attract and keep talented managers, especially given the cost of living in California.

F Scott Fitzgerald wrote, "the very rich are different from you and me."  These days, it is executives and managers who are very different from you and me. 

Physicians are beginning to dread the notion of "pay for performance," which may mean tiny increases in fees paid to physicians who uncritically follow wooden-headed guidelines based on over-simplified notions of disease, poor measurement schemes, and manipulated and suppressed clinical data. 

However, for health care organization executives, "pay for performance" seems to mean lavish bonuses only tenuously related to any rational notion of performance.  In the example above, it seems that multiple UCI executives earned bonuses for their management of clinical affairs at the medical center in 2008, and at least the medical center CEO earned a bonus in 2009 for "improved patient health" while outside review of the medical center's performance in 2009 revealed "scores of problems" sufficient to threaten withdrawal of Medicare funding.  One wonders about the basis for all the millions in bonuses that have been paid to University of California executives over the years?

In fact, the executive "pay for performance" programs that started in the for-profit corporate world, and now are prevalent in not-for-profit health care organizations, seem to reflect the culture of executive entitlement now so prevalent in the US (and maybe most developed countries.)  First, executives claim credit for any improvements in their organizations, while the workers in the trenches who actually accomplished the improvements get chump change.  Second, when things go wrong, the workers face salary cuts and lay-offs, while the executives' total compensation never seems to go down. 

As we mentioned before, executive compensation in health care seems best described as Prof Mintzberg described compensation for finance CEOs, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit." As it did in finance, compensation madness is likely to keep the health care bubble inflating until it bursts, with the expected adverse consequences. Meanwhile, I say again, if health care reformers really care about improving access and controlling costs, they will have to have the courage to confront the powerful and self-interested leaders who benefit so well from their previously mission-driven organizations.

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The January Meeting of the HIT Standards Committee

At the January 20, 2010 meeting of the HIT Standards Committee, we had an important discussion of the Interim Final Rule and Notice of Proposed Rulemaking.

Doug Fridsma presented this powerpoint about the Interim Final Rule. Slide 3 illustrates the linkage between Meaningful Use objectives, Certification criteria and standards. It's a 1:1 mapping - every objective has certification criteria. Every certification criteria has standard(s) requirements. Slides 5-8 document the differences between the HIT Standards Committee recommendations and the IFR. You'll see that most of the base standards recommendations from the HIT Standards Committee (based on a foundation of HITSP work) were included in the IFR.

We discussed several key questions.

Why does the IFR lack detailed implementation guidance?

The IFR is a regulation, which means that the details provided in it are hard to change. By providing base standards but enabling implementation guidance to be published separately from the regulation itself, ONC allowed evolution and refinement of more specific guidance.

Why does the IFR identify architectural approaches to transmission, REST and SOAP but not transaction orchestration?

ONC is spending $60 million on reference implementations of transmission/transport software for the NHIN, some of which will be very simple (RESTful)

Will there be APIs developed by vendors, especially for routing patient summaries per the patient preference?

ONC is trying to balance regulation and market forces, believing that PHR vendors will come together and create a common API for patient data transmission if it is required by meaningful use.

Karen Trudel from CMS presented this powerpoint about Notice of Proposed Rulemaking.

It contains many questions and requests for comment. The comment period closes March 15 and we'll see revisions of the NPRM that are directly related to comments. Likely most revisions will be deletions and changes, but if additions can be justified based on the comments, they are possible.

Each Workgroup chair presented their workplaces for the next 6 weeks and the next 6 months. The workgroups will all make comments about the IFR to the entire HIT Standards Committee for its review at the February 24 meeting. The Committee will forward its consolidated comments to ONC by March 1.

You'll see substantial work on vocabularies and implementation guidance including security/privacy over the next 6 months.

The sense of the HIT Standards Committee is that ONC did a great job on a tight timeframe. The comment period will add the final polish.

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Information From Food Allergy Assistant Readers

I've gotten some requests from readers to post their items of interest to the food allergy community. I wanted to pass these along:

Teresa posted a quirky, but fascinating article called “20 Weird Allergies That Actually Exist”.

Leeanne is giving away some allergy friendly candy on her blog. The offer is only available until Jan. 26, so hop on over for the chance to win.

I wrote a blog for Peanut Allergy.com recently about new peanut allergic mice which should help researchers with treatment and a cure for peanut allergy.

Don't forget the FAAN and Divvies Cookie Recipe Contest. The deadline is Feb. 15. Grand prize is a trip to Great Wolf Lodge.

Cooking Allergy Free has released an iPhone app to help those who need to prepare allergy friendly food.

Anyone in the market for a new grill? Reader Joseph W. sent me a link to his site where he reviews stainless steel grills.

So keep sending in your helpful info and the Food Allergy Assistant will help get the word out.

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The Price is What?

Many in the US believe that a free market in health care is a good idea.  Some actually assert that the US health care system amounts to a free market. 

More evidence against that assertion was provided this week by an article in our local paper, the Providence Journal, by Felice Freyer. For the first time ever, the Rhode Island state health insurance commissioner published a report comparing what insurers pay different hospitals for the same services:

If you had surgery at Kent Hospital, your insurer would pay Kent significantly more than if you had the exact same procedure at South County Hospital �� even if the same doctor did the work.

On average, Kent is getting paid nearly twice as much as South County for inpatient care, according to a new report from the health insurance commissioner that is causing a stir across the state�s health-care industry.

It is well-known that hospitals get paid different amounts for the same services. But the report, for the first time, reveals the winners and losers, and quantifies the disparities �� with numbers showing the differences to be greater than many people thought.

The factor determining which hospitals are paid the highest rates, according to the report, is whether the hospital is part of a group. Such hospital systems have the clout to negotiate higher prices than independent hospitals.

'We�ve never had this kind of data [before],' said Christopher F. Koller, state health insurance commissioner. 'The results and analysis show that higher payments to hospitals are associated with system affiliation, and the current contracting method does not appear to encourage the fair treatment of providers.' There is no evidence connecting higher pay to higher quality, he said.

What is striking is the reason why such a comparison has never appeared up to now:

Koller�s report shines a flashlight beam into the murky world of hospital finance. Hospitals negotiate privately with insurers to establish how much they will be paid for each service. These talks are largely unregulated, and always private, so that no hospital knows exactly what its neighbor is being paid. All are forbidden by contract to reveal their rates.

Koller collected data from Blue Cross & Blue Shield of Rhode Island and UnitedHealthcare of New England concerning payments to 11 acute-care hospitals in 2008. He is the first public official to obtain this confidential information, saying he was entitled to it because a 2004 law requires him to promote the affordability of health care and ensure the fair treatment of providers.

Thus, the prices of commonly used medical services provided by hospitals were largely secret.

On obvious requirement for the function of a free market is price transparency. When making a purchasing decision, one needs to know what prices different sellers charge.

In a recent commentary in the Wall Street Journal, Alan S Blinder, a Princeton economics professor, and former Vice Chairman of the Federal Reserve Board, described the basic requirements of a free market:

When economists first heard [movie character Gordon] Gekko's now-famous dictum, 'Greed is good,' they thought it a crude expression of Adam Smith's 'Invisible Hand' � which is one of history's great ideas. But in Smith's vision, greed is socially beneficial only when properly harnessed and channeled. The necessary conditions include, among other things: appropriate incentives (for risk taking, etc.), effective competition, safeguards against exploitation of what economists call 'asymmetric information' (as when a deceitful seller unloads junk on an unsuspecting buyer), regulators to enforce the rules and keep participants honest, and�when relevant�protection of taxpayers against pilferage or malfeasance by others. When these conditions fail to hold, greed is not good.

Clearly, one cannot have appropriate incentives when prices are secret. Secret prices are also a glaring example of "asymmetric information." (Hospitals know what different insurance companies pay them for specific services, but not what the companies pay other hospitals for those services. Insurance companies know what they pay to different hospitals for the same services, but not what other companies pay. Patients, physicians, policy-makers and the public heretofore had no idea what any hospital was paid by any insurance company.)

The question begged is why neither hospitals nor health insurance companies wanted to make the prices public. One wonders if it were fears of looking incompetent (by paying to much, or charging to little), or worse, of revealing collusion. One also wonders if it were fears of revealing how anti-competitive is the current way of doing business.  At the time of data collection, Rhode Island had only two health insurers.  As noted above, large hospital networks got the highest prices.  Price differences did not obviously relate to quality of care, or costs of teaching programs. 

Note that we previously discussed secret agreements between a dominant health care insurance company and the largest hospital system in our northern neighbor, Massachusetts, and how these agreements resulted in payments to that system far greater than those paid to any other hospital.  I suspect that secret deals resulting in wide pricing discrepancies are the rule, rather than the exception in the US, and that such deals overwhelmingly favor the largest organizations, but not the best care. 

As we have been saying repeatedly since we started Health Care Renewal, the leadership of the large organizations that now dominate health care lacks accountability and transparency, and often fails to exhibit integrity and honesty.  Deliberately concealing price information obviously is an example of failing to be accountable and transparent. 

Now that the events have conspired to slow the US health care reform juggernaut, maybe we can reconsider whether meaningful health care reform can be accomplished without improving accountability, integrity, transparency and honesty of health care oganizations and their leaders.

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Many Diagnosed With Peanut Allergy may Not Be Allergic

A study was recently conducted to determine if those patients who test positive for peanut allergy through a blood or skin test could really tolerate peanut. Of the 933 children who tested positive for peanut allergy, the majority didn't have a peanut allergy when orally challenged. Isn't that something????

Now, this is not something to be tried at home; however, it may be something worth discussing with your allergist. I know that my peanut allergic child has never had peanuts, nor has he been orally challenged to peanuts. We're just going with the allergy on the basis of blood and skin test results.

In the same study in The Journal of Allergy and Immunology also used component-resolved diagnostics (a more sophisticated blood test) to determine if they could find differences between the children with peanut allergy and those who could tolerate peanut. Researchers determined that component-resolved diagnostics may indeed help in determining whether or not a person truly is peanut allergic.

I'm finding this all very interesting. I don't want to put my child through inaccurate tests. I really want to know if a food is dangerous for him or not!

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Cool Technology of the Week

As the home CIO, I need to manage our household IT infrastructure - iMacs, MacBooks, wireless, archival storage, printers, and Internet connections. We're an intense user of bandwidth internally and externally.

In an effort to reduce travel, I use video conferencing technologies - Cisco Telepresence, iChat, and H323 via Polycom software. I do large file transfers.

My wife, who teaches digital photography at the Boston Museum of Fine Arts School and Bentley University, manages all her courseware and photography assignment review via the Web.

My daughter uses bandwidth extensively for school research projects, media (music/video), and social networking.

I've been an early adopter of FiOS and the 20 megabit down/20 megabit up service as part of my teleconferencing pilots.

My cool technology of the week is that FiOS is now available with 25/25 or 35/35 megabit service to all home customers. This means that your home will likely have more bandwidth than your office or school. This means that your home infrastructure will be an enabler and not a rate-limiting step.

To me, bandwidth has significant implications for society. The potential applications for that bandwidth will shape the way we work and play. Video teleconferencing and working at home will become more common. This means that we'll be able to save all those commuting hours and reduce our energy bills. Data intensive research, once limited to universities, can be done anywhere. Home wireless devices have unimpeded access to media. Novel home telephony, video delivery, and large software downloads are enabled.

In the 1980's when I ran a small software company, I made software patches available via 300 baud dial-up modems. Anything more than a few megabytes was problematic to download.

Today, downloading gigabytes of software takes a few minutes.

Having a fiber connection to the home and using that fiber for voice, video, and data have eliminated my dependency on any office or institution. It's made me more productive and given me the tools I need to support the 24x7 connectivity requirements of the CIO lifestyle.

Most importantly, my family is no longer constrained by any bandwidth issues - I no longer hear "Internet is slow, I cannot do my work, my software updates take too long." The home CIO has high customer satisfaction.

25 or 35 megabits to the home. That's cool!

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Operation Aurora And a Widespread Reluctance to Discuss IT Flaws: Is Universal Healthcare IT Really a Good Idea in 2010?

In an essay that ties together recent expos�s of serious IT security flaws (starting with Operation Aurora) and a culture of secrecy that pervades the IT industry and industries who use IT, I ask the question:

Is universal healthcare IT really a good idea in 2010?

The complete essay is at my academic site at this link.

Operation Aurora was a cyber attack, conducted in mid-December 2009 and apparently originating in China, against Google and more than 20 other companies, including Adobe Systems, Juniper Networks, Rackspace, Yahoo, Symantec, Northrop Grumman and Dow Chemical.

The attack used "0-day" vulnerabilities (newly discovered and unknown to the software vendor, i.e., "day zero" of the vendor's knowledge of the defect) in Microsoft's Internet Explorer. One target was Google's email service, Gmail. It is not unrealistic to suspect that successful break-ins to that service could have gotten dissidents jailed or killed. Entire countries have warned users to switch to other browsers, at least until a vulnerability fix can be found. I find this stunning.

I also bring to bear recent reports of a culture of secrecy among IT vendors and users about these defects and vulnerabilities. This culture of secrecy seems prevalent in health IT, with perhaps even higher stakes for people (patients) when systems malfunction.

The essay is long-ish and at times technical.

The IT issues it addresses, though, are at the root of why I believe the current push in health IT is a bad idea and that we need to "slow down" to a more temperate pace.

Again, the full essay is here.

-- SS

1/24/2010 Addendum:

It appears Microsoft has known about the Internet Explorer bug since Sept. 2009.

The flaw was in the Microsoft Security Response Center's (MSRC) queue to be fixed in the the next batch of patches due in February but the targeted zero-day attacks against U.S. companies forced the company to release an emergency, out-of-band IE update.

Actually, this was not a "zero day attack", but a "120 day attack." One wonders if EHR vendors have similar queues.

-- SS

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Stress Acceleration

When I think back on my high school experience, I remember an 8am-3pm school day, a cross country/track workout from 3p-5p, a snack until 6pm, and an hour of reading or problem sets. After that, my time was my own to experiment with early microprocessor circuits, tinker with building a hovercraft (powered by a used vacuum cleaner motor) or do personal writing (I entered dozens of essay contents as a teen). Weekends were filled with bike riding up and down the coast of California, SCUBA/snorkeling in local marine preserves, or helping around the house. Summers were filled with outdoor pursuits and low key internships.

My daughter is 16 and is experiencing the typical modern public high school schedule - classes from 7:30 or 8:30am to 2:30pm, a bit of after school community service or exercise, and then 8-9 hours of homework per night, typically ending at midnight or 1am. I've talked to other parents and found this schedule to be typical. Homework might include hundreds of pages of reading, the creation of a complex research paper, and the self teaching of advanced genetics. Given that this level of intensity is the norm, colleges consider a high grade point average in honors/AP classes plus near perfect SATs to be just a starting point.

I was not a Pulitzer prize winner, first violin for the local symphony or the lead in a Hollywood film as a teen, yet this is the kind of achievement that appears on today's college applications. Harvard admits 4% of its applicants.

In my 20's the work day began at 9am, ended at 5pm, and did not span into weekends. There was no email. Fax was an emerging technology. Overnight shipping did not exist. Modems were 110 baud.

Today's work day (not just for me but for many) is 24x7x365 with 50% more filling each day than was previously possible because hundreds of email saturate mobile devices with a constant stream of new work.

My Martin Luther King Day ("a national holiday") had 3 meetings, 500+ email, 2 conference calls and 5 projects. People used the day to catch up and now that the office is wherever your laptop and cellular are, it was a full workday for many.

Does this acceleration of stress bother me? Over the years of medical training and leading large complex organizations I've learned to adapt to just about anything. For every issue there is a process to resolve it.

Is it sustainable for society? I don't think so.

Just as humans were not content to run a 4 minute mile or ascend Everest with supplemental oxygen, we seem to be demanding more of ourselves and our families than is rational or healthy. We're becoming a nation of multi-taskers with ADHD, doing more, in shorter time, but not necessarily living happier, more satisfying lives.

Can we sit and enjoy a meal without thinking about work or checking email? Can we go to a movie or concert for an evening without needing to stay connected? Can we turn off our social networks for a week without suffering withdrawal?

The level of stress I see around me is leading humanity to increase consumption of pharmaceuticals (have a problem - take a pill), eat poorly, and reduce the baseline of human kindness (driven in Boston lately?).

My grandfather did not attend college. My father completed more education by 21 than my grandfather did in his lifetime. I completed more education by 21 than my father will in his lifetime. My daughter will complete more education by 21 than I will in my lifetime. Where does it stop?

At some point, we have to wake up, turn off our Blackberries, set limits on tolerable stress in our lives and regain our civility.

Can we reduce the size of our homes, the number of cars in our garages, and our lifestyle burn rates to enable us to work less and improve the quality of life?

I'm not worried about me - I've developed the discipline to leave my stress outside the home. I do worry about my daughter, her future children, and the generations to come.

Just as a parachuter accelerates at 32 feet/second/second until reaching terminal velocity, there is a point in our existence as humans that stress acceleration will take us to terminal velocity in the quality of our lives.

It is my hope that high schools/colleges, employers, and policymakers think about the terminal velocity we're approaching and open the parachute against stress acceleration before it's too late.

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Senator Grassley asks hospitals about experiences with federal health information technology program

At a brief Oct. 24, 2009 posting "Washington Post: EMR's No Cure-All; Sen. Grassley Sends Letter of Inquiry to health IT vendors" (link) I mentioned an Oct. 16, 2009 letter to major healthcare IT vendors from Senator Charles E. Grassley (ranking member of the United States Senate Committee on Finance) initiating a Senate investigation of corporate practices. That letter is here (PDF).

A followup investigation has now begun by Sen. Grassley of hospitals themselves. Here is a link to his Senate website and a copy of the new letter dated Jan. 20, 2010.

This followup letter is being sent to:

Banner Health, Brigham & Women's Hospital Case Western Reserve University Hospital Health System, Catholic Healthcare West, Cedars Sinai Children�s National Medical Center, Geisinger Medical Center, Hackensack Hospital, HCA TriStar, Intermountain Healthcare, Indiana University Hospital, Jefferson Regional Medical Center, Kaiser Permanente System, Marshfield Clinic, Massachusetts General Hospital, Mayo Clinics, Memorial Hermann Healthcare System, Methodist Hospital of Indiana, North Shore-Long Island Jewish Health System, Palo Alto Medical Foundation, Rainbow Babies and Children�s Hospital, Saint Mary Mercy Hospital, Seattle Children�s Hospital, Stony Brook University Medical Center, Trinity Hospital System Tufts Medical Center, University of California San Francisco Medical Center, University of Pennsylvania Health System, University of Pittsburgh Medical Center, University of Virginia Medical Center, and Vanderbilt University Hospital.

According to Huffington Post Investigative Fund reporters Fred Schulte and Emma Schwartz in "Electronic Health Records Probe Expands to Hospitals", these organizations were chosen based on both "positive and negative" press reports, complaints, whistleblowers, and Grassley's own research. The Huffington Post quoted Sen. Grassley's spokesperson Jill Gerber in that regard.

The questions are probing:

1. Please describe in detail your facility�s process for identifying HIT products for purchase and choosing an HIT vendor(s).

a. What is the personnel structure of those involved in the purchase?
b. To what extent do physicians and other health care providers within your facility provide input regarding the specific HIT items to be implemented within your facility?
c. Who or what department within your facility is responsible for making HIT purchase decisions?

I have been writing for years on the strategically unsound practice of hospitals leaving these processes up to business IT (MIS) personnel and other non-clinical management, perhaps only then seeking a qualified physician information technology expert - or more typically, appointing a figurehead physician IT amateur - after the acquisition. That person is tasked with "making it all work" and convincing other doctors to use the technology.

(I use the term "figurehead" in that the incumbent Clinician Director of HIT or Chief Medical Information Officer/CMIO usually is an "internal consultant" with no direct control over resources or personnel, a Director of Nothing or Chief of Nothing if you will. I use the term "amateur" in the same sense that I am a telecommunications amateur, fine for an avocation but not for a lead role in a mission-critical setting.)

2. Three of the companies that I wrote to in October 2009 informed me that they do not manufacture HIT software or hardware, but instead assist their health care clients, such as hospitals, with the implementation and management of HIT systems. To what extent do you contract with such entities to assist with the purchase, implementation and/or management of HIT products in your facility?

I have also written on the huge amount of precious healthcare money wasted on management consulting companies for health IT, when a fraction of that money could pay for in-house, permanent expertise.

3. Please describe the training process implemented in your facility to familiarize employees with new technology systems.

a. How does your facility budget for HIT training?
b. What are the vendors� roles in helping your facility train in the use of their products?

I sincerely hope these hospitals have not "shorted" training. On the other hand, that these systems require extensive training to use properly is part of the problem. Finally, no manner of training can compensate adequately for mission hostile health IT.

4. Does your facility have any policies or processes governing the reporting of problems or concerns by your health care employees related to the HIT products or systems implemented in your facility? If so, please provide a description of the policies or processes. If not, please explain why not.

I would have added "effective policies or procedures" to that question.

5. When patient care and/or safety problems related to HIT systems arise, how are these problems reported within the facility and what is the process or mechanism for addressing them?

a. Are these problems also reported to the HIT vendor, and if so, what is the process for reporting them?
b. If patient care and/or safety problems related to HIT systems are not routinely reported to the HIT vendors, please explain how your facility decides which problems or issues are reported to a vendor and/or addressed by a vendor and which problems are addressed internally by the facility.

These are questions about fundamental processes of quality control of the IT devices themselves. It would perhaps be a criminal affair if pharmaceutical companies and medical device companies did not have such processes in place regarding their products.

6. Please describe in detail any system your facility has in place to document, track, catalogue, and maintain complaints, concerns or issues related to HIT products that may directly or indirectly involve or impact the delivery of care or patient safety.

One would think there would be a robust database or library of such issues at every hospital deploying HIT. Not having such a resource would in my opinion reflect negligence in both the IT and clinical domains. It will be interesting to see the contents, or if they do not exist, the reasons why.

7. Please provide a list of HIT problems or complaints that have been identified by or reported to your facility since January 2008 that directly or indirectly impacted patient safety or the delivery of care, including any complications or adverse events that have occurred as a result of HIT product design and/or usability. Please describe whether and how each of those problems or complaints was resolved and whether these issues have resulted in a change in policy to prevent the problem in the future.

The answers should prove interesting. Hopefully, "near misses" are accounted for in prior questions.

8. Does your facility have policies regarding the discussion of problems in your HIT systems with other health care facilities or with government officials or any individuals or entities outside your facility? If so, please describe those policies. To what extent are these policies driven by contractual agreements with the HIT vendors, and to what extent do they stem from internal processes? Please provide examples of contracts with HIT vendors that include non-disclosure clauses.

Considering the widespread and uncomfortably similar stories people in my field have been hearing for quite awhile (in my case, for the past fifteen+ years), and as I have written before, there seems to be very little cross-institutional knowledge sharing on HIT pitfalls.

It was, in fact, not easy to get a book about HIT problems published for a wide audience - even in a de-identified form - in 2009. Most accounts of health IT consist of what Greenhalgh calls "sanitized accounts of project success."

These accounts are of little didactic value in helping other organizations avoid known deleterious practices (such as talent mismanagement, internal strife, failure to adapt IT to the environment, over-reliance on vendor promises, contract pitfalls, etc.) leading to HIT failure.

9. Some of the HIT vendors stated specifically in their responses to me that they do not include language that would hold them harmless for failures of their products or for the company�s own negligence or recklessness. However, they may include provisions that spell out the vendor�s and the health care client�s respective legal responsibilities and obligations in the use of the product. For example, one vendor stated that it is accountable for the performance of its product as long as the client uses the product appropriately. Another vendor stated that it is not liable when harm or loss results from the client�s use of the product in diagnosing and/or treating patients.

a. Do any of the HIT vendors include language in their contracts with your facility that could be considered �hold harmless� provisions, i.e., the transferring of liability associated with the services or products provided to your facility, or otherwise limit their liability? If so, please provide a copy of sample contracts containing such provisions.

Denial of inclusion of "hold harmless" provisions on the one hand, and statements about being "accountable for the performance of its product as long as the client uses the product appropriately" (whatever that means) and "not [being] liable when harm or loss results from the client�s use of the product in diagnosing and/or treating patients" (what are such systems for, playing Pong?) on the other hand, seem to be at odds.

10. What is the relationship between your facility and any HIT vendors?

a. HIT vendors that manufacture software, hardware and/or other products purchased by health care facilities have stated in their responses to me that they do not offer any financial incentives for purchasing their products, such as shares in the company or financial interests in a particular product. At least one vendor stated, however, that it does offer financial incentives in the form of discounts based on purchase size. Another vendor said that health care clients may receive royalty payments when the clients collaborate with the vendor to develop a product. What financial interest, if any, does your facility have in HIT vendors and/or their products?

b. Do the vendors offer your facility and/or any of your health care providers any financial incentives for purchasing the vendors� products? If so, please describe the types and value of the incentives.

These are clearly questions about conflict of interest. My best advice to these organizations is "be honest."

11. Did your staff, health care providers and/or facility receive any payments, product discounts, or other items of value from any vendor for discussing and/or promoting that vendor�s HIT products? If so, please list the different types of payments and discounts and their value.

This is a question along the lines of the "Key Opinion Leaders" nurtured by pharmas with a green fertilizer that comes from trees, not cows. One vendor did seem to indicate that this occurs in the "10 secrets the EHR companies don't want you to know" essay here.

While that essay must be taken with a grain of salt, it would not surprise me to find out the HIT industry and the pharma industry share practices in common. Today's B-schools and our current dishonest culture produce the leaders and officers of both, after all.

-- SS

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