ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR

ETHICS TURNAROUND (sort of) by NIH INSTITUTE DIRECTOR

What a difference a month makes. When I went on vacation in June the Director of NIMH, Thomas Insel, was stonewalling about his relationship with Charles Nemeroff. Insel wanted to put distance between himself and the poster boy for conflict of interest in academic medicine. The heat was on Insel because of revelations that he helped Nemeroff get a new position at Miami after his fall from grace at Emory. Insel also gave a green light for Nemeroff to reapply for NIMH grant funding, and he appointed Nemeroff to new research review committees. These actions were widely seen as efforts to help Nemeroff get back into circulation. It didn�t help that people called attention to past favors and lobbying by Nemeroff on behalf of Insel.

Things continued to unravel, and on about June 29 Insel placed a disclaimer on his official blog. Insel here allowed that his earlier official statements �may be viewed as misleading.� This softening of Insel�s position was picked up June 29 by the Chronicle of Higher Education. Not only was Insel�s disclaimer on his official weblog undated, it is mealy mouthed and it was widely criticized � here and here, for instance � as further evidence of Insel�s disingenuousness.

By July 7 we learned of further revisions to Insel�s position. In response to pressure from Senator Charles Grassley (R-Iowa), Insel issued a mea culpa in which he agreed that Nemeroff�s actions constituted �an egregious violation of NIH policy and University rules.� Insel also acknowledged that his willingness to help Nemeroff �may have created the appearance of favoritism. In retrospect, I regret that my actions� appear inappropriate for a Federal research official given my past association with Dr. Nemeroff.� This new statement also was raked over as further evidence of Insel�s dissembling � see here and here and here.

Nowhere in Insel�s new self serving statements is there any apology for his ill advised appointment of Nemeroff to new Federal research review panels. This signals once again that Insel just doesn�t get it when it comes to his crony Nemeroff. It is not in the job description of an NIH Institute Director to taint research review panels with compromised and sanctioned scientists.

Keep in mind that the appearance of malfeasance and impropriety most often occurs in the presence of malfeasance and impropriety. That is a standard Bayesian proposition that Insel seems not to grasp.

In light of these developments, who can take seriously the work Dr. Insel says he has done to develop a new NIH initiative on ethics? The leadership of NIH tacitly acknowledged this problem when they recently extended the period of comment on the new ethics proposals. This was done specifically to mend the regulatory hole that Insel and his crony Nemeroff walked through when Insel assured Pascal Goldschmidt at Miami that Nemeroff could go right ahead to apply for new NIMH funding. Left to his own initiative, Insel kept the hole wide open. His July 7 statement to Senator Grassley that "I do not condone the gap in our policy that allowed (Nemeroff) to avoid the penalty implemented by Emory by moving to another university�� rings hollow: actions speak louder than words, and Insel had many months in which he could have closed the gap before the present scandal surfaced.

How much longer can NIH tolerate an ethical prevaricator as an Institute Director?

Bernard Carroll

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Primary Care and the HC Renewal RUC-kus

Dr. Richard Baron, a Philadelphia internist who's unusual in that he's both a private-practice clinician and a well-published and -respected academic (he was recently ABIM Chair), has been mixing it up in the pages of the New England Journal.

To readers of this blog, it'll be useful armchair review: not just because the theme of generalist clinicians' decline should concern us, but because the blog itself comes into play!

The topic of the day: why primary care doctors are in trouble. Why they're (my words, perhaps, not his) so prone to burnout. And why they're not replacing themselves.

In his original April 26, 2010 article, Baron provided a "snapshot" from his own group practice to address the question, "What's keeping us so busy in primary care?" The piece repays reading if one wants the gory detail on just how tedious and time-consuming the "long tail" of primary care has become.

Largely because of demands of third parties, primary care providers are mired in the briar patch of making money for other people instead of themselves, through myriad pre-authorizations, forms, renewals, and all the other parts of the glue that keeps health care going.

We already knew a lot of this, at least tacitly. But what's wonderfully useful about Baron's above piece was that (a) he spelled it out crisply, (b) he did so with lots of numbers people could cite, and (c) did so in such a highly visible and prestigious venue.

Now, in the latest number of the NEJM, Baron mixes it up with a couple of critics.

First I have to wonder aloud, just how did the journal pick these particular two letters? (Or maybe the author did? Hard to believe they were the only two.) Typical--and this is something else it would be easy to measure in the Journal's correspondence pages--in that they both come from the ivory tower, not the trenches where Baron himself labors.

The first letter, from a non-clinician at the Palo Alto Medical Foundation Research Institute, lamely posits the value of the electronic health record in identifying staffing needs for primary care. We happen to know not only that Baron's practice was a very early EHR adopter, but Dr. Baron himself has published eloquently on the sundry limitations of the EHR.

In response, Baron gently reminds the Palo Alto ivory tower-dweller that very few practices can afford a registered nurse--even if the EHR could somehow magically discern the need for such a presence.

A second writer chimes in from the equally rarefied reaches of the AMA's Relative Value Update Committee, or RUC, "appointed by the American Academy of Neurology." This writer avers that "the value assigned for evaluation and management is the same for all specialties," which clearly is the RUC's take on things but is fairly jaw-dropping to the rest of us.

In response, Baron cites R. M. Poses, MD, moderator of the present blog, and a June 1, 2010 HCRenewal offering--Poses has in fact given us many such offerings on the RUC--regarding the "significant structural and political issues" surrounding that body's untransparent deliberations.

Usefully, Baron finally joins others stepping outside the visit-oriented physician payment schema, urging a paradigm shift in which he urges "systems that encourage and support services of high value ... rather than anchoring payment to visits."

This exchange is telling in a number of ways. It shows up the lack of sync between the basic understandings on the part of health policy's chattering classes--those prone to publish and write letters to premiere journals--and of those actually doing the work of primary care.

It also, I'll venture to say, shows up something more elusive about why this predicament is so difficult to fix.

That is, we have, almost uniquely in this country, an imbalance--the imbalance in numbers, slowly evolving over the past century, between generalists and specialists--that's been around so long it's become part of the warp and woof. Something like ubiquitous guns or illicit cannabis, something very difficult to even think of getting beyond.

We've written in this blog about the anechoic effect, how so much of what happens in health care (corrupt executives, nontransparent RUCs, etc. etc.) barely stirs a ripple in the public consciousness. Why that is we'll leave for another day, but it's been lately of interest to more and more folks. (For starters, just plug the term "anechoic" into the HCRenewal search box.)

Add to this, now, what one might call the reverse Robin Hood effect. The result of such an effect is how the RUC and others--many others, in government as well as in industry--have managed to set in motion a specious reasoning process, a process that allows decision makers to justify robbing from the poor to give to the rich.

Understandably, Baron does not go beyond the bland statement that such a process has "militated against appropriate updates for primary care services." But imagine what would happen if the RUC were suddenly, in what really boils down to a matter of power, dominated by people from primary care. Imagine what would then happen not only to reimbursements for cognitive services, but also to practitioners' morale, and to recruitment of medical students into primary care.

History, both recent and not-so-recent, bears out such an assertion. When the UK increased the value of primary care a few years ago, in terms of pounds sterling, it had a salutary effect on non-fiduciary metrics such as recruitment. To quote Gomer Pyle, "surprise surprise surprise."

Indeed, as the Economist reported five years ago (the preceding link may require subscription or library access), price signals worked wonders in making the primary care role more attractive.

Further back, ironically, when procedural specialties had lower status than cognitive specialties--we're talking a couple hundred years ago, now--this controversy would have been simply incomprehensible to patients and clinicians alike.

For those who'd respond, "but back in the wayback, we didn't have all the fabulous benefits of modern procedures," the simple response is, well, stuff and nonsense. The rising tide of science has raised all boats. Not a week goes by that the evidence base doesn't provide new reasons to assay minimally- or non-invasive technologies that are devolved to primary care physicians.

No, underlying Baron's plea is the reverse Robin Hood effect and a simple matter of power. In fact, it's a phenomenon exceedingly well known to sociologists ever since Robert Merton in the 1960s. They call it the "Matthew Principle," after the Gospel of St. Matthew. "To him who has, it shall be given."

But in the US such a system, like that of sub-prime mortgages earlier in the present decade, has finally become so over-evolved it's threatening to topple over of its own weight.

Thus, lobbyists are just now fighting the recess appointment of Dr. Don Berwick not because they think he doesn't understand how these processes work, but because they know that he does. Wish him, and Dr. Baron, luck.

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FIRST IN INDIA

First Indian Scientist to Win Nobel Prize

Sir Chandrasekhara Venkata Raman (C.V. Raman) was the first Indian scientist to win Nobel Prize. C.V. Raman was awarded the 1930 Nobel Prize in Physics for his work on the scattering of light and for the discovery of the Raman effect, which is named after him. Raman effect relates to the inelastic scattering of a photon. When light is scattered from an atom or molecule, most photons are elastically scattered (Rayleigh scattering). The scattered photons have the same energy (frequency) and, therefore, wavelength, as the incident photons. However, a small fraction of scattered light (approximately 1 in 10 million photons) is scattered from excitations with optical frequencies different from, and usually lower than, the frequency of the incident photons. Raman effect is helpful in analyzing the composition of liquids, gases, and solids. 

First Nuclear Power Plant in India

Tarapur Atomic Power Station (T.AP.S.) was the first nuclear power plant in India. The construction of the plant was started in 1962 and the plant went operational in 1969. The 320 MW Tarapur nuclear power station housed two 160 MW boiling water reactors (BWRs), the first in Asia. The Tarapur Plant was originally constructed by the American companies Bechtel and GE, under a 1963 123 Agreement between India, the United States, and the IAEA. The Tarapur Atomic Power Station is under the control of Nuclear Power Corporation of India Limited. Recently, two 540 MW pressurised heavy water reactors (PHWRs) were operationalised at Tarapur. The new reactors were constructed by L & T and Gammon India. Tarapur Nuclear Power Station is the largest PHWR-based power station in India. 

First Satellite Launched by India

Aryabhatta was the first satellite launched by India. It was named after the great Indian astronomer of the same name. Aryabhatta weighed 360kg and was launched by the Soviet Union on April 19, 1975 from Kapustin Yar using a Cosmos-3M launch vehicle.

The satellite had following objectives:

• To indigenously design and fabricate a space-worthy satellite system and evaluate its perfromance in orbit.
• To evolve the methodology of conducting a series of complex operations on the satellite in its orbital phase.
• To set up ground-based receiving, transmitting and tracking systems.
• To establish infrastructure for the fabrication of spacecraft systems.

Aryabhatta carried experiments related to X-Ray Astronomy, Solar Physics and Aeronomy. The satellite re-entered the Earth's atmosphere on 11 February 1992.

India's First Indigenous Satellite Launch Vehicle

SLV-3 was India's first indigenous satellite launch vehicle. The vehicle was launched by Indian Space Research Organisation (ISRO) on July 18, 1980. President A P J Abdul Kalam was the Project Director of SLV-3 The SLV-3 weighed 17 tonne and had a payload of 40 kg. The SLV-3 put 35 kg Rohini Satellite into the orbit. The launch of SLV-3 was a historic landmark for the Indian space programme. It gave ISRO an insight into the conceptualisation, design, development and management of a technically complex multi-disciplinary project. With the launch of SLV-3, India joined a select band of five nations that had this capability. The other five countries are USSR, USA, France, China and Japan. 

India's First Indigenously Built Satellite

Insat 2A was India's first indigenously built satellite. The satellite was launched on 9 July 1992 from Kourou, French Guyana. The satellite had a dry mass of 916kg and it weighed 1906 kg with propellants. The satellite had following payload:

Communication Transponders: 12 C-band, 6 ext. C-band (for FSS), 2 S-band (for BSS), 1 Data relay, 1 search and rescue.

Meteorology: Very High Resolution Radiometer (VHRR) with 2 km resolution in visible and 8 km in Infrared band.

The Insat 2 program was started in 1983. Its objective was to develop an indigenous multi-purpose Geo spacecraft. In 1985, the basic spacecraft configuration was adopted. The configuration called for an on-station dry mass of 860 kg which later rose to 910 kg. The communications payload was increased with six additional 7/5 GHz transponders for a total of 18, plus two S-band transponders. The Insat 2 series consisted of Insat 2A, 2B, 2C, 2D, and 2E satellites. 

India's First Nuclear Reactor

India's First Nuclear Reactor was Apsara. It was also the first nuclear reactor in Asia. Apsara went critical at Bhabha Atomic Research Centre (BARC), Trombay on August 4, 1956. It heralded the arrival of India's nuclear energy programme. Dr. Homi Bhabha himself conceptualised the design of the reactor and the reactor was built entirely by Indian engineers in a record time of about 15 months.

Apsara is a swimming-pool-type reactor loaded with enriched uranium as fuel. The fuel core is suspended from a movable trolley in a pool filled with water. The pool water serves as coolant, moderator and reflector, besides providing the shielding. 

India's First Supercomputer

India's First Supercomputer was PARAM 8000. PARAM stood for Parallel Machine. The computer was developed by the government run Center for Development of Advanced Computing (C-DAC) in 1991. The PARAM 8000 was introduced in 1991 with a rating of 1 Gigaflop (billion floating point operations per second).

All the chips and other elements that were used in making of PARAM were bought from the open domestic market. The various components developed and used in the PARAM series were Sun UltraSPARC II, later IBM POWER 4 processors, Ethernet, and the AIX Operating System. The major applications of PARAM Supercomputer are in long-range weather forecasting, remote sensing, drug design and molecular modelling.

 

 

 

 

 

 

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EASTERN NAVEL COMMAND RECRUITMENT EXAM DATES

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FCI RECRUITMENT

 SELECTION PROCESS:
 

The selection process consists of written test, group discussion and interview. The venue & schedule of written test will be intimated to individual applicants along with the admit card.

The written test will be in English only and in two parts. Part I will consist of 60 multiple choice question of the relevant technical discipline and Part II will consist of 60 multiple choice questions on general aptitude consisting of Reasoning, Data Analysis, Computer Awareness, General Awareness and Current Affairs. On qualifying the Written Test, GD & Interview will be held for short-listed candidates. It is essential to appear in every stage of the selection process.

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Medical transcription outsourcing: Increases efficiency and reduces costs

The role of accurate and timely information in the process of healthcare is undeniable. Medical transcription is the process that assists in creation of patient records ensuring that healthcare professionals have the requisite information by converting audio records of the patient-healthcare professional encounter into text format. However to make the process of medical transcription cost effective and efficient one needs to choose the right option. There are many options available to the healthcare facility for availing medical transcription, like having a team of medical transcriptionists in-house, Independent contractors or by outsourcing to a professional medical transcription service provider.

Though other options for availing medical transcription have some benefits, outsourcing medical transcription has been found to be best way for the healthcare facility to contain costs and increase efficiency.

How does outsourcing medical transcription contain costs?

Reduces cost per line of transcription: Outsourcing medical transcription has the benefit of limiting the cost of medical transcription to just the cost per line of transcription. There are no hidden charges or indirect costs. This makes the cost per line of transcription economical

Eliminates the need for capital investment for medical transcription: The process of medical transcription requires a certain amount of capital expenditure by way of computers, servers, furniture, headsets etc. Outsourcing medical transcription eliminates the need for investment in capital equipment

Reduces the cost of utilities: The cost of utilities like electricity, stationery etc towards the transcription process would be eliminated by outsourcing medical transcription

Eliminates cost of IT towards medical transcription: Executing medical transcription in-house would mean a substantial outlay towards information technology expenses. Outsourcing medical transcription minimizes this investment

Reduces cost of weekend and holiday medical transcription needs: Medical transcription needs of a healthcare facility are not predictable, outsourcing ensures that the varying medical transcription needs of the healthcare facility are provided for without incurring any extra expenses

How does outsourcing medical transcription increase efficiency?

Streamlining turnaround time: By outsourcing medical transcription the healthcare professionals would be ensured of a guaranteed turnaround time. This would ensure that the information needed by the healthcare professional would be readily available for reference as required. This would help increase the efficiency of the healthcare professionals and the support staff

Increased accuracy: Outsourcing medical transcription to a professional service provider would ensure that patient records are created with maximum accuracy. This would ensure that integrity of the information would be preserved thus increasing the efficiency of the healthcare professionals

Advanced technological features providing added benefits: The technology used by the medical transcription service provider, affords healthcare professionals and the support staff with innumerable benefits like automatic uploads and downloads, archiving, remote printing and faxing etc adding up to efficient work flow

Enabling better use of healthcare professional and support staff time: Medical transcription services that are accurate, timely, secure and technologically advance help the healthcare professionals and support focus more on providing quality healthcare rather than other tasks

Accelerating the receivables cycle: Outsourcing medical transcription ensures that patient records are created on time. This in turn ensures that the process of reimbursement takes place on time, thus improving cash flow and the efficient working of the healthcare facility

Outsourcing medical transcription to the right medical transcription service provider can reduce costs and improve efficiency. TransDyne, a leader in the outsourced medical transcription industry offers customized solutions to help healthcare facilities reduce costs and improve efficiency.

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

To avail the advantages of outsourced medical transcription services from TransDyne, click here.

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Where No Hospital CEOs are Below Average

In Lake Woebegon, all children are above average.  Now it seems that hospital CEOs have moved there. 

Ventura County, Where No CEO is Below Average

The Ventura County (California) Star reported on the uniformly high remuneration of the CEOs of local, mostly small, not-for-profit hospitals and hospital systems.

T. Michael Murray reaped $330,545 in 2008 as chief executive officer of St. John�s hospitals in Oxnard and Camarillo. He drew an additional $187,071 in bonuses with $73,113 more in benefits and other compensation.

His total package, according to IRS records, reached $590,729.

And he may have been underpaid, according to a statewide survey of 118 nonprofit hospitals. The report by the Payers & Providers healthcare business publication suggests the base salary for CEOs averaged $514,237.

Kick in bonuses, retirement money, reimbursement for education costs, expense accounts and the average total compensation hit $732,004.

Public records show similarly lofty numbers at Ventura County�s three nonprofit, tax-exempt hospital groups. Gary Wilde of Community Memorial Health System, which runs hospitals in Ventura and Ojai, was the highest paid CEO in 2008. He earned a base salary of $508,682 and his total compensation was $853,528, with much of the additional money placed into a retirement fund that won�t be paid out until Wilde serves six more years as CEO.

Simi Valley Hospital changed its leadership in 2008, with a total compensation of $1.25 million recorded in 990 tax forms for two different CEOs. That�s slightly more than the hospital provided in treatment for poor uninsured patients where there was no attempt to collect payment, though hospital leaders say charity care definitions encompass only a fraction of the total care they provide without pay.

Outside the county, tax records from the Cottage Health System in Santa Barbara showed a base salary of $848,826 for CEO Ronald Werft and other compensation of $546,846. His total topped $1.3 million.

Ken Anderson of the John Muir Health System, which operates hospitals in Walnut Creek and Concord, was the highest compensated CEO in the Payers & Providers study. He made $745,000 in base salary and nearly $7 million in other compensation, much of it deferred over his career for retirement.

Recall that these people are leading relatively small, not-for-profit community hospitals whose missions are to provide health care to the community.  Total compensation ranging from three-quarters of a million dollars to multi-millions seems vastly disproportionate to the jobs and their settings.

Explanations and Excuses
As expected, those supporting the CEOs have all sorts of explanations and excuses:

Hospital leaders in Ventura County and throughout California say the numbers are inflated by retirement plan accumulations that must be included on tax records even before executives qualify to receive the money. They defend the half-million-dollar salaries, with bonuses on top, as the only way to compete with for-profit hospitals for executives who can lead a facility that may employ more than 1,000 workers, drive a community�s economy, provide access to the uninsured and deliver care that saves lives.

'Given the context, it�s not out of line,' said Murray, a CEO with 28 years of experience who is now semiretired after resigning from St. John�s at the end of March. 'I think you need to retain and also attract sufficient talent. I�m not saying there aren�t inappropriate salaries out there. I don�t think mine was one of them.'

Also,

But [economist Sung Won] Sohn said that paying below average is risky.

'When you try to get somebody at $400,000 rather than $700,000 you will get plenty of takers but they�re not competent,' he said. 'Hospitals are so important in the community that you want to make sure it�s run properly.'

Nor does he see any problem with paying more than average if a hospital board wants to reward an executive.

Furthermore,

John Romley, an economist at the Schaeffer Center for Health Policy and Economics at USC, said the amount hospitals spend on executive pay is a sliver of their total expenses and can�t legitimately be blamed for driving the rising cost of healthcare.

'I guess I�m not shocked even though I�m jealous,' he said of the compensation.

Some people were not pleased about this use of health care dollars:

Others worry the compensation may push hospitals into spending more on executives than their nonprofit mission of providing care for the poor. Federal regulations already limit compensation for CEOs of corporations bailed out by the government to $500,000. Similar caps placed on nonprofit hospitals could create dramatic differences, said Ron Shinkman, author of the Payers & Providers statewide survey on CEO salaries.

'You�re looking at close to $39 million that could be used on uncompensated patient care,' he said. 'It�s a lot of money.'

Consumer advocates aim much of their concern at nonprofit hospitals that not only reward CEOs with lucrative paydays but also provide little charity care to poor, uninsured patients. The Payers & Providers research identifies 17 hospitals � all outside of Ventura County � where the total compensation to CEOs exceeded the cost of charity care.

'It would be outrageous if hospitals are paying more to their (entire) executive teams than in indigent care in their community,' said Anthony Wright of Health Access California. 'For some hospitals to provide more to one individual just seems wrong.'

The Mechanism: Ego Bias

The mechanism making CEO compensation constantly increase appears to be simple:

Typically, hospital boards hire consultants to conduct studies showing market averages for comparable hospitals in their regions. They often try to pay somewhere around the 50th percentile.

That�s a reasonable way to do it, but such studies tend to push up the salaries, said economist Sung Won Sohn, who was involved in setting compensation at two Minneapolis hospitals.

'People at the low end try to increase the CEO closer to the average,' said the professor at CSU Channel Islands. 'If everyone does that, the average CEO salary will go up.'

So there you have it. At no hospital is the CEO deemed by a sympathetic (and sometimes crony filled board) below average. If the CEO's compensation has somehow dropped below average one year, it is immediately raised to at least average the next. Apparently almost never is the CEO's pay deemed to be too high.

That notion is corroborated by the assumption by the CEO documented above that all CEOs have "sufficient talent," and the assertion above that anyone who would accept a lower salary would be "not competent."

So every year all the CEOs who had below average compensation the previous year get compensation increased at least to last year's average.  Almost no CEO gets a reduction.  So the average moves up relentlessly year after year. 

Of course, unless all CEOs are exactly alike, some CEOs must be below average. 

So this becomes a great example of the ego bias at work. Ego bias is a common cognitive bias usually discussed in the context of making probabilistic judgments. A simple definition is that people tend to believe that outcomes of what they do, or what a group with whom they identify does will be above average. A long time ago, colleagues and I showed that interns in an intensive care unit judged the survival of their patients on average to be better than their judgments of the mean survival of all patients in the ICU. On the other hand, ICU attending physicians displayed a slightly more sophisticated version of the bias. They judged their patients' survival accurately, but judged the mean survival of their ICU's patients to be higher than it really was. [Poses RM, McClish DK, Bekes C, Scott WE, Morley JN.  Ego bias, reverse ego bias, and physicians' prognostic judgments.  Crit Care Med. 1991 Dec;19(12):1533-9.  Link here.]

So we have the ego bias writ large in judgments made about the performance and compensation of hospital CEOs, at least in Ventura County, California.

The Implications

I agree that paying a CEO more than a hospital's entire expenditures for the care of the poor is unseemly.

However, in my humble opinion, the issue is even bigger than that. It is not so much how much of the hospital's budget goes to executive compensation, but what lessons this teaches CEOs.  I propose they are:
-  I am a wonderful person.   I can do no wrong.
-  If I do wrong, I cannot be punished.
-  I can get rich and powerful doing this.

Of course, as we have written many times, being the CEO of a small community hospital is supposed to be a calling, whose goal is to uphold the institution's mission.  Instead, CEOs are learning to be tin-pot dictators.  Some are probably sensible enough to resist learning this message.  I am afraid many are not.

Furthermore, there is no reason to think that this phenomenon is confined to Ventura County, California, or to small community hospitals.  We have discussed how the management of health care organizations have become unsympathetic to, or even hostile to the mission.  We have discussed their organizations' institutional conflicts of interests.   We have discussed how they have wound up with imperial CEOs. 

The resulting ill-informed, mission-ignorant or mission-hostile, self-interested, conflicted, or even corrupt leadership is a major, but still largely anechoic cause of our health care dysfunction.

As I have said endlessly, true health care reform will require finding well-informed leaders who understand and support the mission, put the mission before their own self-enrichment, and are unconflicted and honest.

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Cool Technology of the Week

My daughter, Lara, served as an intern this Summer at the Tufts Center for Engineering Education and Outreach, testing and developing the next generation of LEGO Robotics. Her lab notebook is a daily blog, which includes a complete video record of all devices she's built.

Her final project and my Cool Technology of the week (I admit the conflict of interest in presenting my own daughter's work as a Cool Technology on my blog) is a mobile robot that traverses a garden, inserts a sensor into the soil, measures the moisture level in realtime, and selectively applies water as needed.

It's fully functional and demonstrated in these videos.

The interesting personal side effect of her engineering Summer was a life choice.

She has been debating a fork in the road - Environmental Science/Studies at places like Connecticut College/Middlebury or Environmental Engineering at places like Tufts/Dartmouth. Both are admirable careers. The Summer has led her to the pursuit of engineering. Per a recent article in the Boston Globe, environmental engineering will be one of the top 30 jobs by 2018, about the time Lara will be seeking employment. I will support whatever she decides, knowing that life will have many forks ahead for her two brains to explore.

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Medical transcription: The role of technology

Healthcare is a dynamic process, with constant discoveries and inventions; thereby any service allied with healthcare has to be dynamic. Medical transcription is a service closely allied with healthcare. Medical transcription is the process of creating patient records by converting the audio records of the patient-healthcare professional encounter into text format. Along with the process of healthcare, the medical transcription process has also evolved, not only to cope up with the changing demands of the healthcare sector, but also with the technological innovations that have taken place.

Medical transcription has evolved from simply being the process of listening and typing, to a service, which offer various benefits making the life of healthcare professionals and the support staff at a healthcare facility easy. One just needs to look at the medical transcription process to realize the role of technology.

What is the role of technology in the medical transcription process?

The process of medical transcription essentially begins when the patient visits the healthcare facility for treatment. The role of technology starts from the very first step:

• Capturing the patient-healthcare professional encounter in the form of dictation
• Transmission to the medical transcription service provider for transcription
• The process of transcription
• Transmssion of finished transcripts to the healthcare facility
• Distribution to the right healthcare professional
• Remote printing and faxing
• Archiving
• Interface with EMR
• Security during the entire process of transcription

It is obvious that technology has an important role to play in the process of medical transcription both in terms of service and security. However technology for medical transcription entails substantial capital outlay. One easy fix to avail the right technical support for the process of medical transcription is to outsource the medical transcription needs to a medical transcription service provider who can provide medical transcription with not only the requisite benefits like accuracy, speed, low costs, security but also provides the right technical support.

What are benefits of outsourcing to a medical transcription service provider with the right technology?

Cost reduction: The right technology for medical transcription not only reduces turnaround time and protects the data during the transcription process but also helps reduce the costs. The cost per line of transcription can be reduced substantially with the use of the right technology by improving quality of audio files, speeding up the transmission process and reducing risk of data loss

Augmenting profitability: The use of technology can add to the profitability of the healthcare facility by quickening the medical transcription process thereby the accounts receivable process. Medical transcription is the first step in the reimbursement process, timely medical transcription ensures that the process of reimbursement can take place in a timely manner improving the cash flow of the healthcare facility

Better focus on core business: Having the technological needs of the medical transcription process taken care of by the medical transcription service provider, helps the healthcare facility focus all its resources on their core business of providing quality healthcare

Provision of quality services: The process of healthcare depends on many inputs, one of them being accurate and timely information. Technology used by the medical transcription service provider ensures that patient records are available on a timely manner to the healthcare professional to enable better decision making

Customer satisfaction: Usage of the right technology by the medical transcription service provider ensures quicker and better service, this leads to customer satisfaction

Reduction of malpractice litigation: The use of right technology ensures reduction in security breaches and capture of accurate and complete information in the patient record, both these factors help reduce risk of litigation

It can be seen that the right use of technology by the medical transcription service provider enables collection, management, sharing and protection of information. Another important benefit of the right use of technology is making it easy to use for healthcare professionals who are constantly challenged for time.

Considering that time is one of the most precious commodities for healthcare professionals, TransDyne believes in using technology that provides multiple features with ease of use. Some of the features of the software and tools used by TransDyne are as follows:

Smart upload: TransDyne offers doctors the choice of using modes of dictation they are already comfortable with. Then these files can be uploaded to the servers to be made available for transcription. Smart upload enables transfer of dictation files from the healthcare facility’s server to TransDyne’s server by checking for new dictations at pre-fixed intervals.

Web Delivery: TransDyne’s web delivery system tackles all issues related with tracking dictations, receiving documents and finding old files form the archives.

Smart Delivery: Smart delivery is an automated program that addresses the automatic downloads, saving files and printing needs of a healthcare facility.

HL7 integration: TransDyne can configure and send healthcare information as HL7 messages to the client’s EMR with no additional costs.

Data Security: TransDyne ensures data security of medical transcription by incorporating security measures like 128-bit data encryption, multi-tiered application architecture, design level security, safeguards, firewall protected networks, sterilized e-mail servers, denial of access procedure and multi modal alerts.

To avail the benefits of outsourced medical transcription from TransDyne, click here

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The Hospital CEO as Debt Collector

Last year we noted that the US Internal Revenue Service (IRS) required more detailed reporting starting in 2009 by US not-for-profit organizations. Many US health insurance companies/ managed care organizations, most hospitals, nearly all medical associations, nearly all disease advocacy organizations, all health care charities, and nearly all medical schools are not-for-profit organizations. We suggested then that this reporting might lead to more transparency about the leadership and governance of these organizations.  The 2009 990 forms seem to be trickling into public view, sometimes leading to some striking disclosures about how US not-for-profit health care organizations are lead.

The California Watch blog just reported about the interesting part-time job of a hospital CEO:

The former president of a Laguna Beach hospital has been operating a debt-collection company that recovered medical payments from his own facility, raising conflict-of-interest questions as the CEO moves to a new hospital in Riverside County.

Bruce Christian ran South Coast Medical Center from 2005 until it was sold in 2009. At the same time, Christian was owner of Metro Republic Commercial Services, a consulting and medical debt-collection firm that provided at least $110,000 in services to South Coast while Christian was a top manager, records show.

South Coast Medical Center disclosed the arrangement as 'self-dealing' in federal tax filings. State law allows self-dealing by board members of nonprofits, typically as long as the body explores other options and determines they are not unduly enriching one of their own.

Of course, I also get to write, but wait, there is more:

Christian was also at the helm of the hospital in 2006 when Adventist hired one of his Metro Republic consultants as interim chief financial officer, tax records show.

Adventist said it appointed the interim CFO when it believed the hospital would be sold quickly.

Additionally, a version of the Metro Republic website in 2006 said the firm supplied South Coast Medical Center with health care financial consulting, managed care-revenue recovery and accounts-receivable services.

The website, which appears to have been offline since 2006, describes Christian as a health industry leader for 30 years who built the Corona-based Metro Republic from a three-person office to one with 150 employees.

Predictably, the response from the hospital and its parent health system was that it was all no big deal.

Adventist Health West, the Roseville-based company that owned South Coast, acknowledged that the arrangement was 'unusual' and 'not the norm' for the firm.

In a statement, Adventist said Christian's firm collected hospital debts for years before Adventist bought the hospital and prior to Christian�s tenure as president and CEO.

Board members were aware of the arrangement. It remained in place while the chain sought to sell the medical facility throughout Christian�s tenure, the statement said.

'Unfortunately, it took much longer than originally envisioned to sell the hospital,' Adventist Health said in a statement. 'Adventist Health continues its deep commitment to providing mission-driven, quality health care to the communities we serve.'

Some thought otherwise:

But allowing a hospital administrator � who can have considerable power over setting prices on medical procedures � to operate as the hospital�s own bill collector presents a thorny conflict of interest, said Ken Berger, executive director of Charity Navigator, a New Jersey-based charity evaluation group.

'Just because the (hospital) board may sanction it doesn�t make it right, appropriate or ethical,' he said. 'The mission of hospitals and the mission to squeeze money out of those that are slow to pay can be quite contradictory. It�s just wrong.'

Another expert thought something ought to be done:

Kathryn Peisert, managing editor for publications at the San Diego-based Governance Institute, said a hospital CEO�s duty is to further the interests of the hospital. As such, she said, Christian should have eliminated all appearances of impropriety and cut ties between the medical center and his consulting firm.

'That�s really a big no-no,' said Peisert, whose organization advises hospital boards. 'I�m surprised some regulatory agencies haven�t been after this.'

We will see if anything will be done, but this conflict of interest seems not to have gotten in the way of Mr Christian's career advancement.

Christian is now chief executive of a Loma Linda University Medical Center campus expected to open in 2011 in Riverside County. A Loma Linda University Medical Center spokesman said the Murrieta campus will not contract with Metro Republic.

As I have said before, I expect that as more 990s dribble out, seemingly as slowly as many organizations can manage, we will see many more examples of these sorts of conflicts of interest, in which top organizational leaders also turn out to be vendors, consultants, etc.

In theory, and perhaps in a golden era in the past, leaders of not-for-profit health care organizations were supposed to regard their work as a calling, and to be primarily concerned with upholding the mission of the organization. Instead, we now see more leaders who seem to regard their organizations as their own personal sand boxes, providing opportunities for play, and sometimes personal enrichment. (Note that Mr Christian's total compensation from the hospital was "$360,000 and $400,000 in salary, benefits and deferred compensation in 2006 and 2007 at South Coast Medical Center.")

Unfortunately, Mr Christian's case demonstrates that leaders who get used to their organizations as personal sand boxes, rather than face punishment,  may be given the opportunity to play in larger venues. One wonders how much he will make at the helm of a new academic medical center, what other side deals he will manage, and how much he will be concerned with the academic and clinical missions.

Once again, I say that true health care reform will only be achieved when health care organizations are lead by people who put the mission ahead of their personal enrichment, and are held accountable for their ability to do so.

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Food Allergy and Dietitians

A new study by Jaffe Food Allergy Institute, at Mount Sinai School of Medicine concludes that pediatric dietitians self-reported their proficiency is only moderate when it comes to food allergy. Dietitians would prefer, and certainly benefit from, more training on food allergy.

Several years ago, our allergist's office hired a dietitian for individuals and families with food allergies. I set up an appointment looking for information on calcium and protein sources for our dairy, egg, nut allergic child. At the time we were also avoiding wheat, soy and corn and I was struggling with preparing balanced, nutritious meals and snacks. During the appointment, I was given hand-outs on specific food allergies. That's about it. She offered little helpful information and I felt like I educated her more than the other way around.

I'm not blaming the dietitian. I just think she was hired due to her credentials and wasn't given satisfactory training in food allergy. There is a need for dietitians who are food allergy savvy. Fortunately ELL and other organizations are stepping up to train dietitians.

Recent similar studies of school nurses and pediatricians have also shown they have limited, and sometimes incorrect, knowledge of food allergies. Those of us in the food allergy circle can help by educating our own school nurses and doctors. Rather than feel upset over their lack of knowledge, pass on relevant research, books and food allergy conference/workshop information. We can all play a role in education.

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Exploring the Charles River

On summer evenings and on weekends I kayak the Charles River, exploring its twists and turns through the western suburbs of Boston.

This section of the river is secluded, quiet, and filled with natural wonders. Here are a few of my favorite spots. Note that I paddle upstream first when I'm fresh, then enjoy the boost of the downstream current when I'm tired.

South Natick to Rocky Narrows - 5 miles/10 miles round trip

I put in my kayak just above the South Natick Dam and paddle upstream under Sargent's bridge, a beautiful oriental footbridge spanning the Charles. I continue past the praying woman statue, which Sargent placed on the south side of the river. For the next 3 miles, the river winds near the Audubon Broadmoor preserve, the Peters Reservation, and a few hidden houses. This section of the river is filled with Herons, Kingfishers, and Wood Ducks. I pass under the Farm Road Bridge and paddle to a narrow canyon in the river, Rocky Narrows, near King Phillip's overlook. When my daughter was young, we used an Old Town Pack single person canoe to paddle from the Farm Road Bridge to the Rocky Narrows Reservation. The entire length is tree lined, filled with muskrats, swallows, snapping turtles, and enormous carp.

Dover to South Natick - 5 miles/10 miles round trip

I put in my kayak at Redwing Bay in Dover. The 29 acre Charles River Peninsula reserve is a hidden gem on Fisher Street near the Cochrane Dam with a great boat launch and walking trails, filled with purple martins, hawks, and milkweed. This section of the Charles is laden with hidden coves and can be very challenging to navigate. It's anything but a straight line through Dover and Wellesley. I pass under the Central Street railroad bridge and along a wider, slower portion of the river going by fields, farms, and estates. I cross Charles River Street and enter Elm Bank Reservation, winding past the intersection of Fuller Brook and Waban Brook (the drainage from Lake Waban where my wife and I walk every morning) which run under an impressive stone bridge built in 1877.

Waltham to Wellesley - 6 miles/12 miles round trip

I put in at Charles River Canoe and Kayak and paddle upstream, quickly passing the freeway overpasses of 128 and entering the isolation of the Leo J. Martin Memorial Golf Course. Once I pass the Park Street bridge, the Charles is surrounded by meadows and secluded woodland, filled with water birds, fish, and muskrats. I paddle through the shallows (about 3 inches deep this time of year) all the way to Wellesley, then turn around at the Cordingly Dam. I retrace my steps and paddle back to my starting point, then continue for 3 miles along the "Lakes" area of the Charles, passing islands (E island, Fox island), the Forest Grove Park, the old Waltham Watch factory, and the Prospect Street Bridge. I turn around at the Moody Street Dam and return to my car. The only downside of the "Lakes" area is that powerboats are permitted. At times, their noise, wakes, and occasionally intoxicated skippers makes kayaking a bit challenging. Once this summer I had to leap from my kayak into the Charles to avoid a powerboat collision!

The Charles River is 80 miles long from its source in Hopkinton (same place the Boston Marathon starts) to the sea. The less traveled upper Charles from Medfield to Waltham is my paddling sanctuary.

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Medical transcription services: Why is it needed?

The process of healthcare is the culmination of several inputs including the education, experience and expertise of healthcare professionals, the right equipments, the right drugs, the right procedures and therapies. The common thread that binds all these together to form the basis of successful patient care is information. Imagine a situation where the healthcare professional does not have access to the right information! That is why it is acknowledged that creation of patient records is important.

Medical transcription provides a important link to the healthcare process chain by documenting the patient-healthcare professional encounter. Medical transcription is the process of converting the audio records of the patient-healthcare professional encounter into text format. The process of medical transcription can be made more efficient and cost-effective by outsourcing the medical transcription process to a professional service provider.

Medical transcription plays an important role in the process of healthcare by creating patient records that serve the following purposes:

• Consistency in treatment: Patient records provide consistency in treatment by capturing all the details exhaustively
• Basis for subsequent visits: Patient records work as a point of reference for subsequent visits of the patient, and help curb duplication of efforts of the support staff
• Ensures patient safety: Patient records ensure patient safety by providing details on:

1. Allergies
2. Dosage
3. Test results

• Billing purposes: The information captured in the patient records form the basis for coding and billing
• Medico-legal purposes: the information captured in the patient record also serves as evidence in case of litigation

It can be seen that creation of patient records is very important to the process of healthcare. Outsourcing medical transcription to the right service provider ensures that the creation of patient records takes place in a timely, accurate, secure and cost effective manner.

The capabilities of the medical transcription service provider needs to be evaluated on the following criteria:

Accuracy: This means the percentage of accuracy of the completed transcripts vis-à-vis what was dictated. A minimum of 99% and above would be acceptable. Care should be taken to pick a medical transcription service provider who has quality check methods in place to ensure accuracy

Turnaround time: Turnaround time refers to the time taken to revert the transcribed report to the healthcare facility. A turnaround time guarantee of not more than 24 hours for normal reports and 4-12 hours for STAT reports given by the medical transcription service provider would be considered ideal

Data security: The medical transcription service provider being outsourced to should be HIPAA and HITECH compliant. The medical transcription service provider has to have adequate security measures to ensure that the confidential data transmitted back and forth is safe and secure.

Pricing: Reduced cost of transcription is one of the main benefits that a healthcare facility hopes to have, from the outsourcing option. Pricing should be fair and reasonable for the services rendered. Pricing method used by the medical transcription service provider should also be transparent and simple so that both parties can verify the same at any stage of the process

Technology: The technology used by the medical transcription company should not only be secure but should also be easy to use, without having to require extensive training.

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

For more details about the advantages of outsourced medical transcription services by TransDyne, click here.

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The July HIT Standards Committee

The July HIT Standards Committee meeting focused on a review of the final Meaningful Use/Standards regulations and the processes for the next stage of our work.

Today, the Federal Register published the Meaningful Use Final Rule (down to 276 pages from 874) and the Standards and Certification Final Rule (down to 65 pages from 228).

Karen Trudel and Doug Fridsma began the meeting with an in-depth overview of Stage 1 Meaningful Use and Standards/Certification criteria.

Key discussion points included:

*EHRs do not have to be certified before the 90 day Stage 1 Meaningful Use demonstration period, just by the end. You can start the demonstration data collection before certification is completed. The entire CMS program begins January 2011, so it's possible to demonstrate Meaningful Use January 1 to March 31 using an EHR that is certified February 15.

*Although the Meaningful Use Menu set contains 10 choices from which Eligible Professionals(EPs) must choose 5, one of those five must be a public health/population health measure. Since there are only two choices for EPs, Immunization reporting and Syndromic Surveillance reporting, every professional must demonstrate one of these two public health transactions to qualify for meaningful use.

*Emergency Departments are now included in Hospital measure computation. This may create challenges for some organizations that have 100% CPOE use in the hospital but 0% CPOE use in the ED. Many hospitals have niche systems in the ED that may not integrate into hospital CPOE workflows. There is no question that the ED should have CPOE, but in 2011, not all EDs will. If a hospital has 60,000 ED visits without CPOE and 20,000 inpatient admissions with 100% CPOE use, the computation of 20,000 patients with medication orders entered via CPOE/(60,000 ED patients + 20,000 inpatient admissions) = .25 and thus will not qualify for meaningful use.

*EHRs must be capable of producing electronic Office visit summaries, as discussed in my previous blog, but meaningful use supports (and requires upon patient request) use of paper.

*It's unclear if Meaningful Use/Stimulus payments are taxable income to eligible professionals. No one has clarified this yet.

*The current standards required for patient summaries are CCR or CCD/C32. The current problem list vocabularies are ICD9 or SNOMED-CT. Although the CCR can use ICD9, the CCD/C32 implementation guide requires SNOMED-CT. It may be that the implementation guide will be relaxed to allow either ICD9 or SNOMED-CT for the problem list vocabulary in the CCD/C32.

*The Syndromic Surveillance Standards required are HL7 2.3.1 or HL 2.5.1. Although 2.5.1 has a detailed implementation guide (Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification), there is no current HL7 2.3.1 guide. It's been retired and is no longer used. Hence it may make sense for ONC to remove HL7 2.3.1 as a possible standard for this transaction. Otherwise it will be challenging to certify the transaction and guarantee interoperability.

*Although no transport standards are currently specified, enabling innovation in this area, it is important than in the future, after we learn more from HIE pilots, NHIN Direct, and Beacon Communities, that some specificity is provided to accelerate interoperability.

*A Smoking status vocabulary has been suggested, but is not a certification criterion.

*Eligible professionals have a choice of quality measures to report (3 core or 3 alternate core plus 3 from a list of 38 measures), thus EHRs have to produce at least 9 quality measures to be certified. The Meaningful Use Final Rule on page 238 states: �In order to permit greater participation by EHR vendors, including specialty EHRs, the certification program will permit EHRs to be certified if they are able to calculate at a minimum three clinical quality measures in addition to the six core and alternative core measures.�

*Medication Reconciliation needs only to be done between institutions not within an institution to satisfy the Meaningful Use measure.

Doug also informed the committee that of the 10 Standards and Interoperability Framework RFPs, two have been awarded - the NHIN RFP to Stanley (a large consulting company) and the Standards Harmonization RFP to Deloitte. It will be interesting to see how the Standards Harmonization activity serves as a successor to HITSP.

Next, Jamie Ferguson discussed the need for a framework to support clinical summaries of all kinds. The committee discussed that a modular, CDA-template-based approach would work well. Efforts such as hData and Green CDA are complementary to this idea. Basically, anyone needing to send a summary document for a particular purpose could assemble CDA templates as needed to create a human readable and computable content package. We also agreed to followup on any modular approaches the CCR authors may be working on.

Jamie updated us on the Vocabulary Task Force and its upcoming hearings. Our hope is to document the requirements for a vocabulary/codeset resource containing all intellectual property needed for Meaningful Use in a web-based repository.

Janet Corrigan and Floyd Eisenberg described the process of work group meetings and information gathering to specify the stage 2 and 3 quality metrics.

I had to leave the meeting to moderate the afternoon session of the ONC/Institute of Medicine Building a Learning Healthcare System conference. I'll blog about that on Monday.

Per Jon Perlin, the afternoon of the HIT Standards Committee meeting including a rich discussion of the Privacy and Security Tiger Team Update by Deven McGraw/Paul Egerman, an Enrollment Workgroup Update, and public comment. During the public comment period, the committee was deeply moved by a speech from the mother of a child with a serious illness. She thanked the committee for all their work to date to empower patients and improve the quality, safety and efficiency of care.

Regulations are final, stakeholders are thankful, and we're making progress! Thanks to everyone who has contributed the process thus far.

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Are Ill-Informed Leaders the Cause of Drug Manufacturing Mishaps?

Fundamental Corporate Failures

In the last few years, there seems to have been an epidemic of once revered companies suddenly unable to perform the most basic functions necessary for their businesses.  Finance firms ran out of money and ended up bailed out or bankrupt.  An automobile firm produced cars that seemed to accelerate out of control.  Another automobile company, once the world's biggest, went bankrupt and had to be bailed out by the government. An oil company took months to cap a blown out well. 

In the health care world, drug companies which could no longer manufacture pure and unadulterated drugs.  Baxter International sold deadly contaminated heparin (post here). Johnson and Johnson sold contaminated or wrongly dosed over-the counter childrens' medicines (post here).

Another Troubled Johnson and Johnson Factory

Now yet more problems have surfaced at a Johnson and Johnson factory.  As reported by the AP:

A dozen recent federal inspections of a Johnson & Johnson factory for heartburn and other nonprescription medicines show a host of violations that could affect the quality and makeup of the drugs.

A new report on inspections at the Lancaster, Pa., factory in the past month indicates a pattern of ignoring rules for manufacturing and quality, failure to investigate problems that could affect the composition of products, carelessness in cleaning and maintaining equipment, and shoddy record-keeping.

In some cases, medicine batches made during equipment failures were not checked for quality.

Food and Drug Administration investigators had to ask for information many times in some cases, and then wait days to get it.

The scope of the problems was large:

The inspection report, released Wednesday, lists 12 different types of violations, from not determining the impact of equipment failures 'on the manufacturing process and products' to incomplete records of investigations into 'unexplained discrepancies' in manufacturing. The latter problem occurs 'whether or not the batch has already been distributed,' the report states.

Some examples were:

_'Laboratory controls do not include the establishment of scientifically sound and appropriate test procedures to assure that drug products conform to appropriate standards of identity, strength, quality and purity.'

_Procedures to prevent 'objectionable microorganisms' from getting into medicines appear not to have been followed.

_'Deviations from written test procedures are not justified.'

_Staff were not following up 'to determine the causes for repeated mix-up of tablets.'

_Written procedures for cleaning and maintenance did not have enough detail about the methods, equipment and materials to be used.

_The plant did not have recent drug production and quality control records readily available to the inspectors, as is required.

_Samples of drug products taken to determine if they met written specifications were not properly identified.

_There was no preventive maintenance program for at least five types of complex manufacturing or testing equipment.

Previous Problems at Johnson and Johnson Factories
Note that just a few days before this hit the news, the Philadelphia Inquirer reported this follow-up from the problems at the plant in Fort Washington, PA run by Johnson and Johnson's subsidiary McNeil Consumer Healthcare

A federal grand jury is investigating problems at the now-shuttered McNeil Consumer Healthcare plant in Fort Washington that triggered the recall of children's Tylenol and other popular pediatric medicines, according to the company.

The existence of the investigation was made public Tuesday by Louise Mehrotra, vice president for investor relations for Johnson & Johnson, McNeil's parent company.

That report reminded us that there have been problems at a third Johnson and Johnson plant:

[Johnson and Johnson subsidiary] McNeil is now dealing with FDA issues at three drug-making facilities, including one in Las Piedras, Puerto Rico.

Problems at the Las Piedras plant last year set in motion the investigation at Fort Washington.

At Las Piedras, FDA inspectors were chiefly concerned about why it took McNeil more than a year to respond to consumer complaints of a musty smell associated with Tylenol caplets produced at the plant. The smell was traced to a chemical used to treat wooden pallets at the plant.

So three Johnson and Johnson manufacturing plants have recently allegedly failed to uphold basic quality standards, and thus have made medicines that ranged from musty smelling to contaminated. Clearly, the most basic responsibility of a drug manufacturer is to supply fresh, pure, unadulterated drugs, and now Johnson and Johnson, a once iconic American drug and device company, seems to be having trouble fulfilling this responsibility.

Caused by Leadership Shortcomings?
It seems that health care firms, like so many others, have been distracted by financing fantasies and marketing marvels from the most fundamental parts of their business. One wonders how responsible are leaders with little understanding of the fundamentals of the fields in which their firms operate, and who seem to just get richer no badly how their firms perform.

Note that the current Johnson and Johnson CEO William C Weldon's background is in "sales,marketing and international management," not manufacturing, engineering, chemistry, or the biological sciences, per the company's 2010 proxy statement.  In 2009, with one factory already under investigation, his total compensation was over $30,000,000.

The Johnson and Johnson board of directors all get more than $200,000 per year in compensation.  The board does include two biologists and two physicians  (Prof Mary Sue Coleman, is "professor of biological chemistry" at the University of Michigan; Michael M E Johns, MD, a physician; Susan L Lindquist, Professor of Biology at Massachusetts Institute of Technology; and David Satcher, MD a physician.)  However, while it also contains the retired CEOs of a telecommunications company, an electronics company, an airline, a food company, and an bank/ finance company,  it does not seem to contain anyone with experience in manufacturing, much less pharmaceutical manufacturing.  

On the other hand, it includes several people with leadership positions in non-profit health care institutions  with whose primary responsibilities their Johnson and Johnson board membership may conflict.  (Mary Sue Coleman is President of the University of Michigan; Michael M E Johns, Chancellor of Emory University, member of the Institute of Medicine, member of the editorial board of JAMA, and chair of the publications committee of Academic Medicine; Susan L Lindquist, member of the Institute of Medicine; Leo F Mullin, Chairman of the Board of the Juvenile Diabetes Research Foundation; William D Perez, Trustee of Cornell University, and Trustee of Northwestern Memorial Hospital;  and David Satcher, board member for the Kaiser Family Foundation.)   

Note that leaders of non-profit academic health care institutions who also serve on boards of for-profit health care corporations often justify the apparent conflict by the need to "have a voice and interact with the business world," as explained (see post here) by a spokesperson for Mary Sue Coleman.  A university president who sits on a corporate board to "understand what the commercial world is doing," may have not learned enough about that world to make sure it is doing it well.

Finally, several Johnson and Johnson board members are former or current leaders of some of the financial firms whose problems lead to the global financial meltdown, or "great recession," (Anne M Mulcahy has been a member of the Citigroup board since 2004, and was on the FNMA board from 2000 to 2004, both nearly failed, and required government bailouts to survive; Leo F Mullin, currently Senior Advisor to Goldman Sachs Capital Partners, a subsidiary of Goldman Sachs, which just settled charges by the SEC that it misled investors; and Charles Prince, CEO of Citigroup from 2003 to 2007.)   Are these the sort of people we should trust to uphold the fundamental quality of drug manufacturing? 

Health care organizations are increasingly saddled with leaders who do not understand the fundamentals of the health care environment, are not pledged to support their missions, and may be distracted by conflicts of interest.  Such leaders may be increasingly responsible for the dysfunction of modern health care.  True health care reform requires leadership that understands the context, and supports the mission without conflict.

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An Open Question on Moral Authority and Healthcare IT

AI recently had the chance to observe my mother's care in a small community hospital.

This was a hospital that, in her last several days there before going back to a nursing home for rehab, went live with a major vendor CPOE. The CPOE was brought in from a parent large hospital where the CPOE had been in use several years.

Just by passing the nursing station/doctor's charting room on my mother's floor and opening my eyes and ears, I saw doctors and nurses struggling to take care of patients while "getting the bugs out of the system."

They had had received some classroom "training" in a static environment, but it was clear they were learning about a lot of "gotcha's" and unanticipated glitches in vivo.

The fact of problems were predictable. In fact, I predicted unexpected difficulties to several of my mother's clinicians before go-live.

There was some skepticism (maybe in my nearly being in tears about my mother, I came off as a bit melodramatic). However, several later told me they "now knew what I was talking about" upon my mother's discharge, just several days into the go-live.

One story I overheard during go-live especially sticks out in my mind.

A newly-admitted patient who needed urgent heparinization did not receive the medication promptly. The patient's physician could not order it, and could not enter the required weight needed to order it, due to some type of 'glitch' or system malfunction. Physicians found no way to override, despite calls to the help desk, attempts by on site IT people and users from the parent hospital, etc.

In the end, the pharmacist simply provided the med using a weight estimate despite no "official" order having been entered into CPOE. I heard that the delay was on the order of "several hours."

Clearly, both technology and people issues were involved ... but I assure the reader, injured or dead patients really don't care exactly how their injury occurred, after the fact (other than in litigation, which doesn't fix the damage or remediate the suffering).

Here, then, is my question:

Where does the moral authority come from to subject live, unsuspecting, uninformed patients to the type of risks the patient whose heparin was delayed was subject to?

What right did the hospital have to NOT inform this patient before admission that a new critical CPOE system was going "live" that day, and that the patient could consider going to another hospital a few miles down the road instead that had no such potential problems?

From the Belmont Report (also see http://ohsr.od.nih.gov/guidelines/belmont.html ), the six fundamental ethical principles for using any human subjects for research are:

• (1) Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent;
• (2) Beneficence: maximizing benefits for the research project while minimizing risks to the research subjects; and
• (3) Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly (the fair distribution of costs and benefits to potential research participants.)
• (4) Fidelity: fairness and equality.
• (5) Non-maleficence: Do no harm.
• (6) Veracity: Be truthful, no deception.

I would like a straight, unspun answer to this simple question:

On the basis of Belmont Report and other medical ethics regulations, where does the moral authority come from for hospitals to put patients through such risks without informing them ahead of time and offering them an opt-out, even if only the continued use of paper in their care?

I have passed this question on to major American Medical Informatics Association mailing lists and await replies.

-- SS

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Medical transcription outsourcing:Benefits of doing it the right way

Medical transcription has always played a vital role in the healthcare process, by creating patient records. Patient records play an important role in both the operational and commercial aspects of healthcare. Therefore it is important to ensure that creation of patient records takes place in an accurate, speedy, secure and economic fashion. Outsourcing medical transcription is an effective fix to ensure this.

What are the advantages of outsourcing medical transcription?

Speed: Outsourcing medical transcription to the right service provider ensures that patient records are automatically created within the promised turnaround time. There is no delay in the process of medical transcription due to factors like employee absenteeism, holiday/weekends etc. Outsourcing medical transcription ensures that the flow of work is constant due to the availability of a large pool of medical transcriptionists who are familiar with the requirements of the healthcare professionals.

Accuracy: Outsourcing medical transcription to the right service provider ensures that patient records are created with maximum accuracy possible. The onus of training the medical transcriptionists to achieve accuracy levels is on the service provider. Moreover accuracy is ensured by putting the transcripts through multiple quality checks, this ensures that any errors that have been overlooked are corrected, ensuring quality transcription.

Security: Outsourcing medical transcription to the right service provider ensures that the medical transcription process is totally secure. The medical transcription service provider would ensure that adequate security measures are taken to secure people, processes, technology and infrastructure.

Accessibility: Outsourcing medical transcription to the right service provider ensures that there is a systematic process in place to deliver the transcripts back to the relevant healthcare professional. This ensures that reports are easily accessible.

Affordability: Outsourcing medical transcription to the right service provider can bring down the cost of transcription while still maintaining the quality of work. Outsourcing medical transcription also has the additional benefit of eliminating indirect cost that would have been incurred by executing medical transcription in-house.

Versatility: Outsourcing medical transcription to the right service provider ensures versatility of services. Factors like different types of reports, new formats, varied templates and transcription needs for different specialties could be provided by the same medical transcription service provider. This ensures that the healthcare facility has a one stop shop for all transcription needs.

Efficiency: Outsourcing medical transcription increases the efficiency of the support staff by saving on both time and other resources like Information technology. The software and tools provided by the medical transcription service provider ensures that tracing dictation files or finished transcripts would be easy through powerful archiving facilities. Moreover additional features like remote printing and faxing makes the work environment more efficient.

Outsourcing medical transcription not only helps the healthcare facility reduce costs and speed up the receivables cycle, but also improves the efficiency of the healthcare facility’s operations. Therefore it is important for the healthcare facility to source the right medical transcription service provider for their medical transcription needs.

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA and HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

To benefit from the advantages of outsourced medical transcription services by TransDyne, click here.

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