#TSAMastery #af Wisdom In A Moment – What Makes a Hero? A Philosophy He’d Die For! http://ht.ly/1aDQFk
This is default featured post 4 title
Go to Blogger edit html and find these sentences.Now replace these sentences with your own descriptions.
This is default featured post 5 title
Go to Blogger edit html and find these sentences.Now replace these sentences with your own descriptions.
Tuesday, December 28, 2010
New Blog Post: Wisdom In A Moment - What Makes a Hero? A Philosophy He'd Die For! http://bit.ly/fceMdE
How Marketing Mixes Into Medical School Curricula - an Example from Canada
Misery loves company, so here is an interesting case reported by the Canadian Press, via CTV News, about how students in a pain management course at the University of Toronto complained that marketing seemed to have been mixed into their curriculum:
It turned out that:
Dr Jovey defended handing out the free book produced by his part-time employer:
However, it appeared that the "darn good" book's content was biased in favor of Purdue's product, Oxycontin:
A subsequent inquiry has recommended revising the curriculum and dispensing with the drug company funded book.
This is another example of how marketing has infiltrated medical education. It suggests that market influenced education likely includes not only opinions in favor of the specific product being marketed, but distortions of fact to support the product that are hardly evidence-based.
Furthermore, it shows how conflicts of interest facilitate marketing influenced medical education. Note that the bringer of the biased textbooks in this case was being paid honoraria to speak on behalf of the pharmaceutical company, but presumably not to teach the particular course in question. However, his enthusiasm readily carried over to his work in that course.
We have discussed how pharmaceutical marketers regard the "key opinion leaders" whom they pay to speak as salespeople. One would expect salespeople to be enthusiastic for their product even outside of their normal working hours. In my humble opinion, this is why no medical academic should be allowed to simultaneously be a commercially paid "key opinion leader."
By the way, note that this case also suggests how the issues we discuss on Health Care Renewal are relevant globally, not just to the US. I tend to be wary of blogging about cases in other countries, since there may be subtle difference in context across countries that might make interpretation of cases more difficult when viewing them from abroad. However, I think that the facts and language here are straightforward enough for me to be fairly confident about what was going on. Nonetheless, if any Canadian think I have got this wrong, please let me know.
Meanwhile, if anyone is blogging about similar issues from beyond the US shores, please let me know so I can add their work to our blog roll.
Hat tip to Prof Margaret Soltan on the University Diaries blog.
The complaint centered around students being provided a book on managing chronic pain that was funded and copyrighted by the maker of the prescription pain killer OxyContin. The book had been brought in by a non-faculty lecturer with financial ties to the drug company.
It turned out that:
From 2002 to 2006, the pain course was funded by donations, included $117,000 in unrestricted educational grants from four drug companies -- Merck-Frosst, Purdue Pharma, Pharmacia Canada and Pfizer -- although they had no input into course content. Since 2007, the program has been funded solely from faculty budgets.
[Dean of Dentistry Dr David] Mock said Purdue's copyrighted book on pain management had been brought in by Dr. Roman Jovey, an unpaid guest lecturer and co-author of the book who left copies 'for anyone to take.' Jovey, medical director for a chain of clinics called the Centres for Pain Management, is a member of Purdue's speakers' bureau, paid by the company to conduct workshops and lectures.
Dr Jovey defended handing out the free book produced by his part-time employer:
Jovey confirmed he had left copies of the 371-page book, entitled 'Managing Pain: The Canadian Health Care Professionals Reference,' for students.
'It was a gift from Purdue. I'm not at all embarrassed or ashamed. I think it's a darn good book.
"If we all want to be politically correct and have the appearance of being politically correct, then I guess I get it, that nothing that has any kind of pharma logo or name or ownership should be given out to medical students,' he said Wednesday.
'But the losers are the medical students because I think it's a high-quality book, it's very readable and they're deprived of it this year because of this controversy. And I guess they will be in the future.'
However, it appeared that the "darn good" book's content was biased in favor of Purdue's product, Oxycontin:
Dr. Irfan Dhalla said he has concerns about the content of the book, which a medical student taking the course brought to his attention.
'There are definitely things that are not consistent with the evidence,' said Dhalla, a staff physician at St. Michael's Hospital and a lecturer at the university. 'For example, oxycodone ... is listed as a moderate-potency opioid, when I think everybody agrees it's a very strong opioid, up to twice as strong as morphine.'
While it's appropriate to prescribe oxycodone for severe acute pain or cancer pain, Dhalla said the book suggests that physicians can prescribe the drug for chronic non-cancer pain with relative safety for the patient.
'And I think people with experience know that that is just not the case. When you prescribe to people with chronic non-cancer pain, it's very difficult to do that safely,' he said, noting that the book pays little attention to issues of addiction and deaths from overdose.
'The book in several places makes reference to a claim that the rates of addiction if opioids are used for chronic non-cancer pain are very low. And they're not nearly as low as is claimed in the book.'
In fact, a study by Dhalla and colleagues published last year showed prescription rates for opioids -- including OxyContin, a long-acting form of oxycodone -- soared in Ontario over the last two decades, as did the number of deaths linked to the narcotic.
A subsequent inquiry has recommended revising the curriculum and dispensing with the drug company funded book.
This is another example of how marketing has infiltrated medical education. It suggests that market influenced education likely includes not only opinions in favor of the specific product being marketed, but distortions of fact to support the product that are hardly evidence-based.
Furthermore, it shows how conflicts of interest facilitate marketing influenced medical education. Note that the bringer of the biased textbooks in this case was being paid honoraria to speak on behalf of the pharmaceutical company, but presumably not to teach the particular course in question. However, his enthusiasm readily carried over to his work in that course.
We have discussed how pharmaceutical marketers regard the "key opinion leaders" whom they pay to speak as salespeople. One would expect salespeople to be enthusiastic for their product even outside of their normal working hours. In my humble opinion, this is why no medical academic should be allowed to simultaneously be a commercially paid "key opinion leader."
By the way, note that this case also suggests how the issues we discuss on Health Care Renewal are relevant globally, not just to the US. I tend to be wary of blogging about cases in other countries, since there may be subtle difference in context across countries that might make interpretation of cases more difficult when viewing them from abroad. However, I think that the facts and language here are straightforward enough for me to be fairly confident about what was going on. Nonetheless, if any Canadian think I have got this wrong, please let me know.
Meanwhile, if anyone is blogging about similar issues from beyond the US shores, please let me know so I can add their work to our blog roll.
Hat tip to Prof Margaret Soltan on the University Diaries blog.
A Secure Transport Strawman
Over the past few years, I've posted many blogs about the importance of transport standards. Once a transport standard is widely adopted, content will seamlessly flow per Metcalfe's law. We already have good content standards from X12, HL7, ASTM, and NCPDP. We already have good vocabulary standards from NLM, Regenstrief, IHTSDO and others. We have the beginnings of transport standards from CAQH, IHE, and W3C. We have the work of the NHIN Direct Project (now called the Direct Project).
After working with Dixie Baker/the HIT Standards Committee's Privacy and Security Workgroup on the Direct evaluation and after many email conversations with Arien Malec, I can now offer a strawman plan for transport standards.
Based on the implementation guides currently available, the HIT Standards Committee evaluation found the SMTP/SMIME exchange defined by the Direct Project sufficiently simple, direct, scalable, and secure, but stressed the need to develop implementation guidance that is clear and unambiguous. I've received many emails and blog comments about SMTP/SMIME verses other approaches. I believe I can harmonize everything I've heard into a single path forward.
A "little guy" such as a 2 doctor practice in rural America wants to send content to another 2 doctor practice across town. These small practices should not have to operate servers or have to pay for a complex health information exchange infrastructure. Healthcare Information Services Providers (HISPs) should provide them the means to exchange data as easily as Google provides Gmail or Verizon FIOS provides ISP service. All HISP to HISP communications should be encrypted such that the sending practice and receiving practice can exchange data without any HISP in the middle being able to view the contents of the data exchanged.
In my opinion, for this type of exchange
Small Practice 1 ---> HISP 1 ----> HISP 2 ----> Small Practice 2
SMTP/SMIME at an organizational level is the right transport solution. By organizational level, I mean that one certificate is used for the sending organization and one for the receiving organization. There is no need to issue certificates to individual people involved in the exchange.
SMTP/SMIME at an organizational level encrypts, integrity protects, and digitally signs the payload at the point where the message is created. The payload can be sent through multiple intermediaries to the receiver with assurance that the message will be readable only by the intended receiver.
Given the policy guidance to support the little guy, any practice in the country that wants to send any content securely to any other practice without risk of viewing by any intermediary, SMTP/SMIME is sufficient and appropriate.
For other types of exchanges with different policy constraints, TLS is more flexible and functional. In Massachusetts, NEHEN is a federated HIE, enabled by placing open source software within the networks of each participating institution. Server to Server communication is a SOAP exchange over TLS. In this case, the HISP resides within the firewall of each participating payer or provider organization. TLS enables simple, secure transmission from one organization to another. TLS does not require a certificate store. TLS enables REST, SOAP, or SMTP transactions to flow securely because the connection between organizations is encrypted.
Where TLS falls down is in the Direct use case with its policy requirements that no intermediaries between the sender and receiver may have access to unencrypted data. This excludes the case in which the sender uses a HISP as a business associate to package the data as an SMIME message. A sender has no way of knowing what intermediaries the information may flow through, so implementing secured message flows from any sender to any receiver using TLS is untenable.
Thus, our path forward is clear. If we impose a policy constraint that small organizations which use external HISPs should be able to send data securely to other small organizations which use external HISPs such that the HISPs cannot view the data, then SMTP/SMIME with some mechanism to discover the certificates of each organization is the right answer at this time.
If the use case is simpler - secure exchange between HISPs such that the HISPs reside within the trading partner organizations or a relaxation of the policy constraint that HISPs cannot view data, then TLS is the right answer at this time.
The next steps are also clear. Establish SMTP/SMIME as a standard, and secure email using SMTP/SMIME as a certification criteria for EHR technology. Establish standards for X.509 certificates for organization-to-organization exchanges, as suggested by the Privacy and Security Tiger Team.
There you have it - the solution to the transport standards issue for the country - SMTP/SMIME for little guys using external HISPs and TLS for other use cases.
Done! Now it's time to implement and foster adoption.
After working with Dixie Baker/the HIT Standards Committee's Privacy and Security Workgroup on the Direct evaluation and after many email conversations with Arien Malec, I can now offer a strawman plan for transport standards.
Based on the implementation guides currently available, the HIT Standards Committee evaluation found the SMTP/SMIME exchange defined by the Direct Project sufficiently simple, direct, scalable, and secure, but stressed the need to develop implementation guidance that is clear and unambiguous. I've received many emails and blog comments about SMTP/SMIME verses other approaches. I believe I can harmonize everything I've heard into a single path forward.
As with all HIE efforts, policy has to constrain technology. The policy guidance that the Direct Project was given was as follows:
A "little guy" such as a 2 doctor practice in rural America wants to send content to another 2 doctor practice across town. These small practices should not have to operate servers or have to pay for a complex health information exchange infrastructure. Healthcare Information Services Providers (HISPs) should provide them the means to exchange data as easily as Google provides Gmail or Verizon FIOS provides ISP service. All HISP to HISP communications should be encrypted such that the sending practice and receiving practice can exchange data without any HISP in the middle being able to view the contents of the data exchanged.
In my opinion, for this type of exchange
Small Practice 1 ---> HISP 1 ----> HISP 2 ----> Small Practice 2
SMTP/SMIME at an organizational level is the right transport solution. By organizational level, I mean that one certificate is used for the sending organization and one for the receiving organization. There is no need to issue certificates to individual people involved in the exchange.
SMTP/SMIME at an organizational level encrypts, integrity protects, and digitally signs the payload at the point where the message is created. The payload can be sent through multiple intermediaries to the receiver with assurance that the message will be readable only by the intended receiver.
Given the policy guidance to support the little guy, any practice in the country that wants to send any content securely to any other practice without risk of viewing by any intermediary, SMTP/SMIME is sufficient and appropriate.
For other types of exchanges with different policy constraints, TLS is more flexible and functional. In Massachusetts, NEHEN is a federated HIE, enabled by placing open source software within the networks of each participating institution. Server to Server communication is a SOAP exchange over TLS. In this case, the HISP resides within the firewall of each participating payer or provider organization. TLS enables simple, secure transmission from one organization to another. TLS does not require a certificate store. TLS enables REST, SOAP, or SMTP transactions to flow securely because the connection between organizations is encrypted.
Where TLS falls down is in the Direct use case with its policy requirements that no intermediaries between the sender and receiver may have access to unencrypted data. This excludes the case in which the sender uses a HISP as a business associate to package the data as an SMIME message. A sender has no way of knowing what intermediaries the information may flow through, so implementing secured message flows from any sender to any receiver using TLS is untenable.
Thus, our path forward is clear. If we impose a policy constraint that small organizations which use external HISPs should be able to send data securely to other small organizations which use external HISPs such that the HISPs cannot view the data, then SMTP/SMIME with some mechanism to discover the certificates of each organization is the right answer at this time.
If the use case is simpler - secure exchange between HISPs such that the HISPs reside within the trading partner organizations or a relaxation of the policy constraint that HISPs cannot view data, then TLS is the right answer at this time.
The next steps are also clear. Establish SMTP/SMIME as a standard, and secure email using SMTP/SMIME as a certification criteria for EHR technology. Establish standards for X.509 certificates for organization-to-organization exchanges, as suggested by the Privacy and Security Tiger Team.
There you have it - the solution to the transport standards issue for the country - SMTP/SMIME for little guys using external HISPs and TLS for other use cases.
Done! Now it's time to implement and foster adoption.
