HealthMemes: A "Healthcare Disruptive Innovation" custom Google search site

In my March 2009 post "Disruptive Innovators at Healthcare Renewal: Disruptive to whom, exactly?" I wrote about a fascinating site "HealthMemes: Tracking Conversations About the Future of Health" at http://in3.org/health/ that linked to some of the posts here.

The site is a blog of the organization International Informatics Institute (IN3.ORG) and identifies latest trends in health care disruptive innovations (innovations that go "outside the box").

In that post I opined that:

... If there are disruptive innovators, then there must be a whole taxonomy of people who are not disruptive innovators.

The taxonomy might go something like this:

• disruptive innovator
• soothing, tradition-bound innovator
• disruptive imitator (the antonym of innovator)
• tradition-bound imitator
• disruptive non-contributor
• tradition-bound non-contributor
• disruptive demolisher
• tradition-bound demolisher (perhaps an oxymoron)

Disruptive innovators, thus, are disruptive to the interests of a wide variety of others.

Now, the site has created a custom Google search that searches over 80 healthcare blogs, news sites and research sources considered "disruptively innovative" and used in the daily Health Memes postings. Healthcare Renewal is one of those sites as are some of our favorite others.

The "Healthcare Disruptive Innovation" custom Google search is at http://in3.org/health/sources.php and includes quite an impressive collection of sites.

Take a look.

-- SS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mr Schmidt,

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

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

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

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

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

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

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

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

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

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

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

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

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

-- SS

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

Ode to the Paperless Society

I thought this comment to a piece on "Healthcare IT myths" was worthy of wider distribution. (The full piece is also a worthwhile read by itself; disclosure - my work is cited.)

Here is the comment:

bill waters iii md says:
January 8, 2010 at 3:57 am

James Fallows, in a recent Atlantic Monthly, writes that, unlike paper in any of its forms–which retains images –computer software, disks, and drives contain only magnetic impulses that can dissipate. Furthermore, anything over 5 years old runs the risk of there being no software or hardware which can read it. In the coding cubicle of a famously “wired” hospital, I recently noted scores of pigeonholes containing packs of forms.

With the advent of electronic methods to manipulate and store data, business has between 1980 and 2000 quadrupled its production and utilization of paperwork.

Hence:

ODE TO THE PAPERLESS SOCIETY
By Bill Waters, MD

Write on the beach, the tide will erase;
Write on the dune, the wind will deface;
Write on the disk, time will show its hand;
Remember now—they’re all just sand.*

But papyrus and parchment are so well made
The Dead Sea Scrolls will never fade.
The vaunted electron will soon turn to vapor
And its principal product is still just—paper.

____
*For those in Washington, we’re talking about
silicon, get it?

There is wisdom in this short piece, as well as a certain charm.

-- SS

Abbott Laboratories Settles

Another day, another settlement, this time,as reported by Reuters:

New York Attorney General Andrew Cuomo said Abbott Laboratories (ABT.N) and French drugmaker Fournier have agreed to pay $22.5 million to settle a multistate lawsuit that accused them of conspiring to block generic forms of their TriCor treatment for triglycerides.

The drugmakers will pay the money to New York, 22 other states and the District of Columbia, Cuomo said in a news release on Thursday. About $4.5 million goes to New York.

The lawsuit, filed in Delaware federal court in March 2008, alleged Abbott and Fournier schemed to block generics when competitors started to develop versions of TriCor, used to treat a type of blood fat that increases the risk of heart disease.

Cuomo said Abbott and Fournier made minor changes to TriCor that provided no clinical benefit, but were meant to prevent pharmacists from dispensing less-expensive generic versions of TriCor.

The states alleged the drugmakers also thwarted generic competition by filing baseless patent-infringement suits against generic drugmakers, thereby securing a monopoly for blockbuster TriCor.

The ongoing march of legal settlements of charges of various kinds of wrongdoing by diverse health care organizations is a reminder of the pervasiveness of bad conduct by such organizations. We have commented repeatedly (see some posts here) such settlements, including the "corporate integrity agreements" now frequently attached to them, seem to have done little to deter bad behavior. Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior.

While each new entry in the ongoing march of settlements merits a few lines in the business media,separately, or in the aggregate these settlements rarely get noticed by health services or health policy research, or receive attention in health policy circles.  Nor do the contrasts between the conduct revealed by such settlements and the rosy public relations of the settling companies attract much attention.  For example, Abbott Laboratories proclaims its "promise,"

We are here for the people we serve in their pursuit of healthy lives. This has been the way of Abbott for more than a century - passionately and thoughtfully translating science into lasting contributions to health.

Our products encircle life, from newborns to aging adults, from nutrition and diagnostics through medical care and pharmaceutical therapy.

Caring is central to the work we do and defines our responsibility to those we serve:

We advance leading-edge science and technologies that hold the potential for significant improvements to health and to the practice of health care.

We value our diversity - that of our products, technologies, markets and people - and believe that diverse perspectives combined with shared goals inspire new ideas and better ways of addressing changing health needs.

We focus on exceptional performance, a hallmark of Abbott people - worldwide - demanding of ourselves and each other because our work impacts people's lives.

We strive to earn the trust of those we serve by committing to the highest standards of quality, excellence in personal relationships, and behavior characterized by honesty, fairness and integrity.

We sustain success - for our business and the people we serve - by staying true to key tenets upon which our company was founded over a century ago: innovative care and a desire to make a meaningful difference in all that we do.

The promise of our company is in the promise that our work holds for health and life.

The settlement of allegations about a scheme to maintain a monopoly on a profitable drug raise doubts about the company's committment to "earn the trust of those we serve" through "behavior characterized by honesty, fairness and integrity."  Whether the disconnect between this settlement and the "Abbott Promise" will affect the stratospheric earnings of Abbott executives (for example, in 2008, the total compensation of Abbott CEO Miles D White was $28,335,494 per the company's 2009 proxy statement) is a question that could be put to the company's Board of Directors.  Perhaps our readers at Yale University might want to ask Dr Robert J Alpern, Dean of the Yale  School of Medicine, who just joined the Abbott Board of Directors in 2008 about that.

Two New Challenges to a Healthcare Cybernetic Utopia: Yet More Hurdles Exposed

At "2009: a Pivotal Year in Healthcare IT" I concluded that 2009 had proven to be a critical year in HIT, due to authoritative publications on HIT difficulties and related issues that appeared that year.

It was good to see the critical thought processes and the scientific methods inherent in modern medicine applied to the irrational exuberance and marketing-dominated field of healthcare IT.

It seems in 2010 the trend may continue.

Two new very interesting publications have recently come to my attention regarding the complications that can, and are, introduced by HIT.

These complications are worsened by the "boatload of cash," as one author expressed it, that is helping fuel what I term an irrational exuberance, or purchased exuberance, in this technology and its use in social re-engineering in medicine.

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

The first publication of note is a newsletter "Medical Risk Management Advisor" from ProAssurance Indemnity Company, Inc. and affiliates, a provider of medical insurance for clinicians. It can be downloaded here (PDF). It advises:

On choosing an EHR system:

Be sure to obtain physician input and review of the software prior to purchase to ensure it meets the needs of your practice. Consider talking to other medical practices already using the software, not only to assist in your decision, but to anticipate flaws or errors existing users may have encountered. Lastly, establish a process to address problems discovered after implementation.

"Anticipating flaws or errors existing users may have encountered" seems to be at odds with nondisclosure clauses in heathcare IT contracts, but this insurer seems to have gotten the message that HIT is not a perfected technology by a long shot.

On Alert fatigue:

Physicians may ignore e-prescribing alerts for a variety of reasons (e.g., excessive alerts or alerts that are not clinically useful). Again, input from physicians prior to implementation can help prioritize and choose alerts appropriate to the practice.

That the advice has to be given by an insurance company to healthcare organizations that "input from physicians prior to implementation" is crucial reflects a pathology, whose root is within the paternalistic and patronizing IT culture.

This culture and occupation has invaded medicine and supplied endless predictions of utopia for at least the past thirty years, in a domain it generally understands at the level of a layperson.

On "additional features" creating risk: [HIT incurs risk? How can the tool touted to revolutionize medicine incur risk? - ed.]

For example, some software programs require a diagnosis listed with each prescription. Consider the following: a patient is on Depakote for bipolar and seizure disorders, but the e-prescribing system only notes bipolar disorder because of its one-diagnosis limitation by design.

Subsequently, the patient becomes manic and the on-call psychiatrist starts the patient on lithium for the bipolar disorder. Checking the e-prescribing system, he notes Depakote was prescribed for bipolar disorder so he titrates the Depakote to discontinuation.

The patient has a seizure during the titration which leads to death.

The on-call psychiatrist assumed the patient was on Depakote solely for bipolar disorder and not seizures. If the diagnosis feature had been more extensive or had not been used with the software, the on-call psychiatrist might have explored further before discontinuing the Depakote.

Again, input from physicians prior to implementation may help prevent potential risks.

(According to Socky the Meditech Sockpuppet, such events are impossible.)

On Interoperability:

Another issue is whether your e-prescribing system fully integrates with pharmacy systems. Using the previous example, what if the diagnosis was changed in the psychiatrists’ system, but the pharmacy system did not automatically update this information? Be sure to investigate the compatibility of your system with others in your area. Not all pharmacies have e-prescribing capabilities. Many rural areas do not have the broadband internet access required.

It is unfortunate that the HIT vendor community is based on a business-computing model. That culture is extremely territorial. Seamless interoperability will be a long time in coming in HIT.

On Medication Reconciliation:

Physicians and pharmacies may find it difficult to trust the completeness and currency of the medication history and reconciliation, since medication histories often derive from multiple sources. Continue to verify medication histories with patients, and update records accordingly.

What? Actually not rely on the computer? What kind of extremist anti-health IT Luddite advice is this insurer proffering?

On Indemnity or "Hold Harmless" agreements:

Finally, be cautious about entering into hold harmless agreements with software vendors. Your ProAssurance policy excludes from coverage liability assumed under any contract or agreement, unless the liability would be imposed by law in the absence of the contract or agreement. It covers only the insured’s professional liability and not the liability of another party that the insured may assume through an indemnity agreement. If you are asked to sign such an agreement, you should have your attorney carefully review the agreement and your insurance policy.

I did not think of this issue when I wrote my July 2009 JAMA letter to the editor and a fuller posting on this issue at my Drexel HIT difficulties website here.

In addition to violating their fiduciary responsibilities and Joint Commission Safety Standard obligations, hospital executives signing nondisclosure and hold harmless agreements may be putting their organizations under undue financial risk if a HIT-related catastrophe occurs.

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

The second publication of note is an article from the IEEE (Institute of Electrical and Electronics Engineers). A Jan. 6, 2010 IEEE Spectrum article entitled "More Hurdles Appear in U.S. Electronic Health Record Adoption" has been published. I would actually have entitled it "More Hurdles Exposed in U.S. EHR Adoption", but that's not important now.

What is important, once again, is the Management Information Systems (business computing) approach to healthcare IT. The typical convoluted licensing arrangements for this software (really a virtual clinical tool that happens to reside on a computer) has created this fine mess:

The first was a story from a few months back that [the IEEE author] ran across recently from the Washington State Spokesman-Review about Inland Northwest Health Services suing the owner of Deaconess Medical Center, which the paper said alleged breach of "contracts and bad faith dealings that imperil the region's acclaimed electronic medical records network.

It is a bit complicated, but in essence, in 1994, Spokane's Deaconess Medical Center, Providence Holy Family Hospital, Providence Sacred Heart Medical Center & Children's Hospital and Valley Hospital & Medical Center established the non-profit Inland Northwest Health Services (INHS) as a way to merge competing lines of business and to oversee them. One of the things INHS did was to invest in electronic medical records using MEDITECH's technology. [You mean this Meditech? - ed.]

Apparently, Community Health Systems, a Tennessee company that bought Spokane's Deaconess Medical Center and Valley Hospital & Medical Center in 2007 decided that it was going to start charging INHS $150,000 a month to use the MEDITECH license, claiming that Deaconess Medical Center was owner of the license. INHS says that Deaconess transferred ownership to it years ago.

The Spokesman says some 38 hospitals along with many private practices and clinics are affected by the dispute.

The upshot of all this is that license ownership of the underlying EHR technology will likely be a big issue in the future as more regional health information networks are started, as will be technology lock-in (INHS has been using MEDITECH technology for 13-years, and it moving to another EHR is unlikely to be an easy or inexpensive proposition). Neither issue has appeared much in the EHR literature.

Yes, indeed, except once again I would have written:

The upshot of all this is that license ownership of the underlying EHR technology will likely be a big disaster in the future...

... as the HIT vendors will likely only allow their profitable licensing practices to be pried from their cold, dead fingers (metaphorically speaking, of course).

Then, this on EHR patient data trafficking:

... there was also a story in the American Medical News in late November about the Cleveland Clinic giving $1 million to a start-up company called Explorys to "commercializing the patient database search system Cleveland Clinic developed." The Cleveland Clinic has a very extensive EHR system and data base of patient information that it now wishes to exploit.

As I mentioned last month, there was a report by PricewaterhouseCoopers LLP that found 76% of healthcare executives surveyed felt that all the data being collected in their EHR systems was going to be their organization's greatest asset over the next five years. It also found that the executives only felt they could recoup their investments if they could exploit that information in some way.

The IEEE author largely addresses health IT failure as an impediment to such EHR patient data trafficking. In my Oct. 2009 post "Health IT Vendors Trafficking in Patient Data?" I came at the issue from an ethical and legal angle. I wrote:

This practice [trafficking in EHR patient data] raises numerous questions:

• Meaningful informed consent issues: as an example, of 1000 patients at one of the facilities using this vendor's HIT products, what percentage would be able to tell me they know their data is being trafficked to pharmaceutical companies and other organizations for profit?

• Healthcare data ownership and stewardship issues: who, exactly, extracts the data for aggregation and sale? Hospital employees properly trained and bonded (i.e., Healthcare Information Management professionals) regarding privacy of patient data? IT personnel lacking such credentials and experience? HIT vendor employees?

• De-identification issues: what processes are being used to de-identify data? Who is performing it? At some point before the data is de-identified, it is protected information in identifiable form. Is access to the data during de-identification audited in any way, and if so, by whom? If not, why not? (Also see article on re-identification below.)
  

• Legal issues: who is, by contract, liable for data breaches that occur in the transfer process?

• Fiduciary issues: as I expressed in my July 22, 2009 JAMA letter to the editor regarding "vendor hold harmless" and IT defects gag clauses, are hospital executives further violating their fiduciary responsibilities by signing HIT contracts that surrender ownership of patient data to third parties? (see my posts "JAMA letter: Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" and "Inquiry to Joint Commission on points I raised in my JAMA letter on HIT" for more on those issues.

• Pharma integrity issues: with the many stories on this blog and others about ethically questionable pharma practices such as ghostwriting, manipulation of clinical research, suppression of research, pushing drugs on physicians and patients for unapproved off-label uses, etc., what are these organizations going to do with the data? Who will have access to it, and will their access be audited? Are they going to resell it? Might they try to re-identify data to locate individuals of interest? And so forth.
  

Serious consideration of these issues in vendor-led healthcare data trafficking becomes more imperative in the face of just how easy it is to "re-identify" data:

Ohm, Paul: "Broken Promises of Privacy: Responding to the Surprising Failure of Anonymization" (August 13, 2009). University of Colorado Law Legal Studies Research Paper No. 09-12. Available at SSRN: http://ssrn.com/abstract=1450006

In Dec. 2007 I'd also presented to the IEEE Medical Technology Policy Committee on some of these issues in "To the Moon in a Hot Air Balloon: Why is Clinical IT Difficult?". In response, they introduced me to the term "resilience engineering" in the sense that healthcare IT was lacking in that particular characteristic:

The term Resilience Engineering represents a new way of thinking about safety. Whereas conventional risk management approaches are based on hindsight and emphasise error tabulation and calculation of failure probabilities, Resilience Engineering looks for ways to enhance the ability of organisations to create processes that are robust yet flexible, to monitor and revise risk models, and to use resources proactively in the face of disruptions or ongoing production and economic pressures.

Health IT as a cybernetic miracle? As I've stated before, healthcare is a harsh environment for cybernetics, talent to accomplish the needed IT and medical culture changes essential to successful computerization in medicine is grossly mismanaged by the HIT and hospital industries, and reality is a harsh mistress.

-- SS

Socky the Meditech Sockpuppet on Vacation?

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

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

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

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

Health IT Expert Socky the Sockpuppet!

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

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

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

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

Would that be perverse enough to attract attention?

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

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

-- SS

1:00 PM Addendum:

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

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

/sarc

-- SS

To Whom Does a Leading "Off-Shore" Medical School Owe its Allegiance?

We have noted how existing US medical schools seem unwilling to invest or reward teaching (see post here.)   It is no secret in academic medicine that for years, US medical schools have been unable to train enough students to meet the country's current demand for doctors.

Brain Drain
Hence, a significant proportion of physicians practicing in the US were trained by medical schools in other countries.  One well-known adverse consequence of our disinclination to put sufficient resources into medical education is "brain drain," the migration of physicians from countries with severe physician shortages and major unmet health care needs to the US.  (For more discussion of this issue, see our 2005 post here, and also Mullan F. The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810-1818. Link here.)

At the end of 2009, the St Petersburg (Florida) Times published an investigative report which showed some further adverse effects of the US disinclination to support medical education sufficient to meet the country's needs. 

Ross University and Its Problems

The report profiled the problems at one important "off-shore" medical school.

Ross University School of Medicine may be the biggest medical school you've never heard of.

For decades, the school on the Caribbean island of Dominica has been accepting U.S. students whose poor test scores make it impossible for them to get into medical schools in the States.

And though Ross is 1,500 miles from the mainland, U.S. residents who attend the school, and about two dozen other offshore medical schools, qualify for federal student loans.

That has meant more than $150 million a year in government-guaranteed aid for Ross, which has about 3,500 students, double the biggest U.S. medical school.

Ross and other foreign medical schools say they're responding to U.S. demand for new doctors as the population ages.

And there's no question that these schools have produced thousands of practicing physicians. There are more than 80 Ross graduates in the Tampa Bay area alone.

But federal regulators are taking a closer look at evidence suggesting taxpayers and students may be getting shortchanged by foreign medical schools.

• At Ross, fewer than one-third of the students finish in four years, compared to nearly 100 percent at U.S. medical schools. [And as reported later in the article, the six-year graduation rate is only 66% - editor]

• Since Ross, like other Caribbean medical schools, doesn't have a teaching hospital, it pays hospitals stateside for students' clinical training, with wide variations in quality.

• Students of foreign medical schools like Ross graduate with higher average debt, $235,000 compared to the average $158,000 owed by graduates of U.S. medical schools, according to an August report to Congress by regulators.

• About 20 percent of Ross graduates fail to land a residency, the key to a license to practice in the United States. If they cannot pay their student debts, taxpayers are left holding the bag.

The article concludes with:

In a report to Congress in August, the group that accredits offshore medical colleges recommended that the schools raise standards and improve reporting on everything from test scores to graduation rates to total cost.

[Michael] Rendon, the former Ross registrar, said he agrees with the need to stiffen entrance requirements.

'We want doctors but we can't give that kind of money to everyone who's chasing a dream of being an M.D.,' he said. 'We need to be a little bit more discriminating about who those tax dollars go to.'

Based on what I wrote above, these criticisms do seem very "US centric." It seems obvious that a school based in the tiny Commonwealth of Dominica, with a population of little more than 72,000, and an estimated gross domestic product of $726 million in 2008, (according to the CIA factbook), might have trouble meeting US standards.  But instead of trying to do so, wouldn't it be better if the school could concentrate on training physicians to practice in the Caribbean region?

But wait, it is not so simple... 

Who  Really Owns Ross University?

It is true that the missions of most of the medical schools outside of the US which make substantial contributions to the US physician workforce are mainly to train physicians to practice within their countries.  But that description hardly applies to Ross University.  Per the St Petersburg Times,

Robert Ross, a commodities trader in New York, opened his medical school in 1978 in a motel in Dominica's capital at the suggestion of an employee whose son couldn't get into medical training in the States. By 2000, Ross had sold majority interest in both the medical school and an affiliated veterinary school in St. Kitts to a group of New York investors. Three years later, both schools were acquired by DeVry, [Inc] for $310 million.

Ross is the only offshore medical school owned by a publicly traded corporation, which must disclose more financial data than privately owned schools.

Last year, DeVry, better known for its tech training schools, reported $165.7 million in net income after taxes. But the company also reported an additional $140 million in tax-free income from the Ross operations.

"Ross University" describes itself as:

Ross University is one of the largest and most successful medical educators in the world – and remains one of the great secrets in medical education.

Since opening in 1978, Ross has been committed to our students with a rigorous curricula that mirrors the education of its U.S. peers.

I see nothing obvious on the "Ross University" web-site that mentions DeVry Inc. 
But "Ross University" and "Ross University School of Medicine" are really just operating subsidiaries of DeVry Inc, which does describe itself as:

one of the largest publicly held, international, higher educational organizations in North America, is the parent organization for DeVry University, Ross University,....

This raises questions whether the US students who apply to the medical school know they will be taught by a for-profit US corporation?


Who Leads Ross University?
 
Note that the CEO of DeVry Inc, and his lieutenants most responsible for medical education at Ross University do not seem to have the sort of qualifications you would expect from those in charge of a "unviversity" and a medical school.  Per the DeVry Inc., web-site:

Daniel Hamburger:

Daniel Hamburger is President and Chief Executive Officer of DeVry Inc.

Hamburger joined DeVry in 2002 as Executive Vice President, responsible for DeVry’s online operations and Becker Professional Review. He was named President and Chief Operating Officer in 2004, and Chief Executive Officer in 2006.

Prior to DeVry, Hamburger served as Chairman and Chief Executive Officer of Indeliq (pronounced 'in-DELL-ik'), now owned by Accenture Learning. In addition, his previous experience includes serving as Division President of WW Grainger's Internet Commerce group, growing revenues from $10 million to over $100 million in one year. Previously, Hamburger started the Internet Services Group for RR Donnelley’s Metromail division, and was responsible for its venture capital investments. He also served as a consultant with Bain & Company in London, Warsaw and Boston.

Hamburger graduated in 1986 from the University of Michigan with bachelor's and master's degrees in Industrial Engineering. In 1990, he earned an MBA from Harvard Business School.

Dr Thomas C Shepherd:

Dr. Thomas C. Shepherd has been the president of Ross University since 2004. In this position, Dr. Shepherd is responsible for the operations of the School of Medicine, located in Dominica,....

Prior to joining Ross University, Dr. Shepherd was the president of Bastyr University, a Washington-based university with multiple offerings in healthcare education. Prior to Bastyr he co-founded Royale Healthcare, Inc., a hospital management company in North Carolina, to provide hospitals and health systems throughout the United States with management and consulting services. He has served in senior management roles for a variety of [for-profit] hospitals and healthcare systems, including Hallmark Healthcare (now Community Health Systems), American Healthcorp, Inc., and HCA.

Dr. Shepherd received a bachelor of science degree in business administration cum laude from Fairleigh Dickinson University in 1972, a master’s degree in hospital administration from George Washington University in 1975, and a doctor of health administration from the Medical University of South Carolina in 1999.

William Hughson:

William Hughson is President of the Medical and Healthcare group at DeVry Inc.

Hughson joined DeVry from DaVita Inc., a leading provider of dialysis services in the United States. At DaVita, he managed a wide number of business units including co-founding DaVita at Home, and founding DaVita Rx. Prior to that, he headed Ultra Lucca from 1997-1999, which under his guidance, rebranded itself A.G. Ferrari Foods and more than doubled in size. Previously, Hughson was president and chief financial officer of Noah’s New York Bagels, which he helped to grow from one to 39 stores. Hughson began his career in the Capital Markets Division of Morgan Stanley in 1986 and subsequently worked at Bain & Company in 1990.

He received his bachelor’s degree in English from Williams College and graduated from the Stanford Graduate School of Business with a master’s in business administration.

For their pains, Mr Hamburger had amassed 548,666 shares of DeVry stock, worth $30,966,709, at today's price of $56.44/share, and received $3,454,711 in total compensation in fiscal 2009, while Mr Shepherd had amassed 74,950 shares, worth $4,230,179,  and received $714,688, according to the 2009 DeVry Inc proxy statement.

Yet none of the three top leaders of DeVry Inc with responsibilities for the Ross University medical school subsidiary are physicians, have any obvious direct clinical or biomedical scientific experience, or have any educational expertise or experience.

Conclusions

So here we have a new kind of example of what laissez faire unregulated capitalism has wrought for US health care.  The medical school in tiny, impoverished Dominica exists only to train physicians for the US not for Dominica, or the Caribbean area.  Nonetheless, the school does not do a great job: one-third of its students do not graduate even in six years, and one-fifth of those graduates never even start a residency.  Yet the students pay more than $30,000 a year in tuition, and graduate with an average debt much higher than US trained medical students.   In fact, the school is actually a subsidiary of a large, US for-profit corporation, although it is not clear if this is made obvious, or even revealed to prospective students.  The leaders to whom the school report to seem to have no expertise or background in clinical medicine, biomedical science.   Yet they are handsomely rewarded for their lack of relevant expertise and experience, and apparently for the poor performance of their graduates.

There is something really perverse about a nation that spends $2.3 trillion a year on health care, yet does not spend enough on medical education to educate the physicians it needs, while drawing physicians from unregulated, for-profit schools located in less developed countries, but owned by US corporations.

Spectranetics Settles

I could not let this story, which came out just before the new year, completely slip by.  As reported by the Colorado Springs Gazette:

Spectranetics, the Colorado Springs-based medical-laser manufacturer, will pay $5 million to resolve federal government allegations that the company illegally imported and marketed unapproved medical devices, the U.S. Department of Justice said Tuesday.

Spectranetics will not face criminal prosecution, although it 'has accepted responsibility for its conduct' and agreed that 'officers and employees who acted on behalf of the company engaged in multiple areas of wrongdoing,' according to a Justice Department news release.

The investigation had been under way since at least Sept. 4, 2008, when agents from the U.S. Food and Drug Administration and Immigration and Customs Enforcement raided the company’s Springs headquarters, seeking information and correspondence.

Spectranetics manufactures sophisticated medical lasers used to clear blockages in coronary and leg arteries.

At issue in the federal probe were allegations that Spectranetics imported medical devices and provided them to physicians for use in patients without federal regulatory approval, the Justice Department said.

Also, Spectranetics allegedly conducted a clinical study that didn’t comply with federal regulations, while it also promoted products for which it hadn’t received FDA approval or clearance, according to the Justice Department.

Spectranetics’ actions caused false claims to be submitted to Medicare from 2003 to 2008, the agency also alleged.

Spectranetics will pay $4.9 million in civil damages to resolve the claims, the Justice Department said. In addition, the company said it has agreed to a future forfeiture of $100,000 in cash or property.

Spectranetics has also instituted measures to prevent similar conduct and will cooperate in 'an ongoing criminal investigation,' the agency said.

Also ongoing are a class-action lawsuit initiated by shareholders, and possibly a US Securities and Exchange Commission investigation. The Gazette also noted,

The company also went through a management shake-up; then-President and CEO John Schulte resigned a few weeks after the September 2008 raid.

Another day, another settlement of charges of wrong-doing by a health care organization.  So my stock response is xataloging legal settlements seems to be a useful way to assess the sorts of bad behavior manifested by large health care organizations (see some posts here). However, as we have said frequently, such settlements, including the "corporate integrity agreements" now frequently attached to them, seem to have done little to deter bad behavior. Usually, the companies involved only need to pay fines, and no individual who performed, directed or approved unethical or illegal acts will suffer any negative consequences. I submit once again that such fines are viewed merely as costs of doing business by the affected companies, and do not deter future bad behavior.

As seems standard operating procedure for such settlements, the fine in this case was barely more than a financial speed bump, given that the company had revenues of about $104 million in 2008 (per its 2008 annual report).  At least the CEO who was in charge at the time of the admitted wrongdoing actually lost his job.  However, presumably he was able to leave with at least the 792,354 shares of stock, currently worth $5,340,466, based on today's price of $6.74, 2.5% of outstanding shares which he beneficially owned prior to his departure, according to the company's 2008 proxy statement.

I once again submit that would-be health care reformers who want to improve care, reduce costs and improve access should advocate for real negative consequences for people who implement, direct or approve the various versions of fraud, kickbacks, and miscellaneous wrongdoing, corruption and malfeasance we have discussed on Health Care Renewal.

IT Religion and Windows 7 "God Mode"

I've written in the past that IT has become something of a religion, with computers as an altar or shrine, programmers and technicians as clergy, programming a sacrament, and an irrational exuberance and "faith" prevailing about the computer's miraculous capabilities despite growing literature to the contrary. Of course, my focus has been on computers in medicine.

I am generally very happy with Windows 7. Microsoft has done well, but this caught my attention:

Understanding Windows 7's 'GodMode'
CNET News
January 4, 2010 12:41 PM PST

Although its name suggests perhaps even grander capabilities, Windows enthusiasts are excited over the discovery of a hidden "GodMode" feature that lets users access all of the operating system's control panels from within a single folder.

By creating a new folder in Windows 7 and renaming it with a certain text string at the end, users are able to have a single place to do everything from changing the look of the mouse pointer to making a new hard-drive partition.

... To enter "GodMode," one need only create a new folder and then rename the folder to the following:

GodMode.{ED7BA470-8E54-465E-825C-99712043E01C}

Once that is done, the folder's icon will change to resemble a control panel and will contain dozens of control options.

I've tried it, and it works. Upon renaming a new desktop folder as above, the folder actually transforms into the following icon and label:



Then, on opening the "God Mode" icon a comprehensive list of control options appears. Very convenient and useful.

While the name was clearly intended to be humorous, I think that the originators of this name could and should have come up with a less theistic name. Not on religious grounds, but on psychological ones - i.e., the impact such nomenclature might have on IT personnel.

I'm already seeing comments such as "Did you know that you can become a God? Well, at least on Windows 7!" on IT enthusiast sites...

The culture of IT is already patronizing enough towards end users, thank you very much.

I felt the same way ca. 1976 when visiting professors from MIT implemented the programming language "Logo" on Boston University's IBM 370-based RAX timesharing system. The RAX/370 monitor command for restarting after a Logo interpreter fault was "RESAT GOD" (resume at symbolic address 'God', a symbol defined by the professors to represent an address in the 370's user program address space). Since the Logo interpreter was in beta, I had to type that Charlton Heston-esque command often...

Note: having spent some time in Saudi Arabia, I'm not sure how well this Windows 7 holiness will go over in that part of the world...

-- SS

Addendum: I've discovered that renaming a folder to, say, "Bob.{ED7BA470-8E54-465E-825C-99712043E01C}" creates an icon with identical capabilities, but with a ... somewhat less presumptuous name. :)

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

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

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

Merriam-Webster dictionary:

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

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

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

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

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

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

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

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

IT Guy said...

It's the March of the Ludites.

Thanks for a very funny post.

January 4, 2010 12:28:00 PM EST

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

IT Guy said...

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

January 4, 2010 1:33:00 PM EST

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

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

Even the blogger profile is blank, click to enlarge:




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

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

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

#28 Programmer [at HIStalk blog - ed.]

October 20th, 2009 at 11:57 am

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

[i.e., "Programmer" -- who I soon show is also "IT Guy" -- opines that in comparing clinical adverse event rates pre- and post healthcare IT installation, all you need is a large enough sample size, which then nullifies or cancels out, for example, changes occurring over time that are not related to the intervention, and other potential confounders in a pre-post comparison. If only evaluation studies in healthcare informatics were that simple ... it is concerning that IT vendor personnel might have such beliefs - ed.]

And the fact that a teaching professor at a major university has virtually no understanding of statistical analysis makes me say “at least I don’t have to worry about losing my job to one of his students."

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

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

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

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

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

For example:

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

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

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

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

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

The pattern has remained consistent.

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

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

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

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

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

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

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

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

-- SS

Addendum 1/5/10:

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

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

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

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

Steve Lucas

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

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

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

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

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

It also follows that, if this analysis is true, the defamatory attacks left at HIStalk and here at HC Renewal would have been made with foreknowledge of their falsity and with malice.

Not a particularly wise HIT vendor strategy with the HIT industry under investigation by US Senator Grassley (see Oct. 2009 PDF letter to a number of vendors and management consultant firms here).

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

-- SS

One Small Step Towards Reducing Conflicts of Interest Affecting Academic Medical Leaders

Two articles, one in the New York Times by Duff Wilson, the other in the Boston Globe by Liz Kowalczyk, brought the issue of the conflicts of interest generated by leaders in academic medicine sitting on the boards of health care corporations to wide attention.  The news was that Partners Healthcare, the large hospital network that includes two of Harvard University's main teaching hospitals, for the first time is limiting the role its leaders can take on such boards of directors.  As written by Duff Wilson,

The owner of two research hospitals affiliated with the Harvard Medical School has imposed restrictions on outside pay for two dozen senior officials who also sit on the boards of pharmaceutical or biotechnology companies. The limits come in the wake of growing criticism of the ties between industry and academia.

Medical experts say they believe the conflict-of-interest rules at the institution, Partners HealthCare, go further than those of any other academic medical center in restricting outside pay from drug companies. The rules, which became effective on Friday, impose limits specifically on outside directors who guide some of the nation’s biggest companies.

Senior officials at the two hospitals, Massachusetts General and Brigham and Women’s Hospitals in Boston, must limit their pay for serving as outside directors to what the policy calls 'a level befitting an academic role' — no more than $5,000 a day for actual work for the board. Some had been receiving more than $200,000 a year. Also, they may no longer accept stock.

The proper pay for time spent on board meetings under the new policy was calculated at $500 an hour for a 10-hour day, said Christopher Clark, a senior lawyer at Partners and director of a new office for interactions with industry. Stock and options were banned because they tie the director’s fortunes to company profits.

As far as I know, this policy is the first instance of a US not-for-profit academic medical institution limiting the role its leaders and/or faculty may take as directors of for-profit health care corporations. So it is an important step. Furthermore, also as far as I know, the coverage this news item received on Sunday is the first time this issue has been discussed openly in the mainstream media.

A New Species of Conflicts of Interest

On the other hand, we first discussed the conflicts posed by leaders of academic medicine sitting on the boards of for-profit health care corporations in 2006 on Health Care Renewal, calling it a "new species of conflict of interest" at that time.  Since then, we have found many other examples of such conflicts.  We noted that sitting on a corporate board is a particular problem for an academic medical leader because a corporate director has a legal obligation to advance the profits and financial fortunes of the corporation he or she serves. As Robert AG Monks put it, corporate directors are supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  This legal requirement ties a corporate board member far more tightly to the interests of the corporation than do the obligations of, for example, a consultant to the corporation. 

Moreover, some have charged that many for-profit corporate board members are just cronies of the top corporate leaders.For example,

Tthe cronyism of major corporate boards, especially those in the finance area, has become legendary. Rubber-stamp directors who rarely buck the chairman or challenge the CEO are unfortunately all too common. These boards did not serve either their companies or shareholders well.

[per Ritholtz B. Bailout Nation.  Hoboken, NJ: John Wiley & Sons, 2009. pp. 198-199.]

In that case, this would only makes things worse, tying board members to the personal interests of top managers of health care corporations, rather than to the interests of the entire stockholder population.

A (Baby) Step in the Right Direction

Given the potential severity of board of directors level conflicts of interest for academic medical leaders, any step that reduces them deserves applause.  That being said, Partners Healthcare's restrictions on these conflicts are at best baby steps in the right direction.

Note that the new policy only affects a small number of people.  Liz Kowalczyk wrote, "the policy affects roughly 25 vice presidents, clinical department heads, and other top executives...."  So it neither affects lower ranking clinical leaders, or Partners' own board.

The policy's limit on directors' compensation ($500/ hour, or $5000/ day, assuming a 10-hour day, which would annualize to $1,040,000 per year assuming an 8-hour day, and $1,300,000 assuming a 10-hour day), might be comparable to the current exaggerated earnings of top Partners' executives, but substantially exceeds the compensation of most practicing physicians or medical academics, and hence does not seem to be a very significant limitation.  Requiring payments be made in cash rather than stock options might be regarded as an improvement rather than a restriction. 

The policy does not restrict the number of boards a Partners leader may sit on.

Finally, the policy does not do anything substantial to manage to conflicts generated by board members' legal obligations to their companies and stockholders, nor their tendency to become cronies of top corporate management. 

Are Conflicts of Interest Even a Problem?

While acknowledging the new, slightly restrictive policy, top Partners leaders did not seem to want to acknowledge that there is any downside to academic medical leaders sitting on health care corporations' boards.  For example,

'We thought it was a very good idea to have institutional officials serve on boards, but we did not want to have personal enrichment,' [former Partners Chief Academic Officer and current Professor] Dr. [Eugene] Braunwald said.
[NY Times]

Note that for most people, $500/hour appear to be personally enriching.  

Also,

'These relationships also have significant benefits,' ... [Christopher Clark, director of Partners Office for Interactions with Industry] said. 'They give us some insight into how the companies work and how they are doing, and making sure the companies are aware of the academic perspective.'
[Boston Globe]

Mr Clark did not note the many other ways to see how companies work and to communicate the academic perspective to them which do not involve academic leaders being paid by these companies.

Dr Dennis Ausiello, chief of medicine at Massachusetts General Hospital, said

Pfizer and other companies were crucial to translate academic research into drugs that benefit patients. At Partners, he has oversight of a research, ventures and licensing office that seeks to commercialize the hospitals’ intellectual property.

'I’m very proud of my board work,' he said. 'I’m not there to make money. I certainly think I should be compensated fairly and symmetrically with my fellow board members, but if my institutions rule otherwise, as they have, I will continue to serve on the board.'

While drug companies do make products that are good for society, could they not continue to do so without academic leaders on their boards? If Dr Ausiello did not care about his compensation, why did he continue to accept it?

So it is hardly clear that Partners Healthcare's leadership even now would credit Harvard Professor Emeritus and Editor Emeritus of the New England Journal of Medicine Dr Arnold Relman's point of view,

I think that’s a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company.

It’s happening more and more around the country. If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government and they will no longer deserve the tax exemption or anything else. They will be part of industry itself.

Indeed. But at least now, the issue may be apparent to more people than just the dedicated readers of Health Care Renewal.  The more it is discussed, the more academic medical leaders may realize how much credibility they would gain if they were seen as impartial experts and dedicated physicians, rather than the protectors of corporate stockholders, or worse, the cronies of corporate bosses.

ADDENDUM (4 January, 2010) - see also comments by Professor Margaret Soltan on University Diaries, Merrill Goozner on the GoozNews blog, and Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog.

ADDENDUM (6 January, 2010) - see also comments by Dr Daniel Carlat on the Carlat Psychiatry Blog.