"Replace the RUC!"

We have frequently posted, first here in 2007, and more recently here and here, about the little-known group that controls how the US Medicare system pays physicians, the RBRVS Update Committee, or RUC.

Since 1991, Medicare has set physicians' payments using the Resource Based Relative Value System (RBRVS), ostensibly based on a rational formula to tie physicians' pay to the time and effort they expend, and the resources they consume on particular patient care activities. Although the RBRVS was meant to level the payment playing field for cognitive services, including primary care vs procedures, over time it has had the opposite effect, as explained by Bodenheimer et al in a 1997 article in the Annals of Internal Medicine.(1) A system that pays a lot for procedures, but much less for diagnosing illnesses, forecasting prognoses, deciding on treatment, and understanding patients' values and preferences when procedures and devices are not involved, is likely to be very expensive, but not necessarily very good for patients.

As we wrote before, to update the system, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the RBRVS Update Committee. The RUC is a private committee of the AMA, touted as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments. However, the identities of RUC members are opaque, and the proceedings of the group are secret.

To expand on the penultimate point, the current page on the AMA web-site that describes the RUC only lists its members in terms of their specialties and organizational affiliation. Their names do not appear. A response to a previous post by me on the subject by the then Chair and Chair-Elect of the RUC suggested that the RUC membership is not quite secret. They stated that "a list of the individual members of the RUC is published in the AMA publication, Medicare RBRVS 2009: The Physicians Guide." This publication is available from the AMA here for a mere $71.95 (although now with the notation that the product has been "discontinued.") However, the book is not on the web, or in my local or university library, and I have no other way to easily access it. Thus, the RUC membership is at best relatively opaque.

To expand on the ultimate point, as Goodson(2) noted, RUC "meetings are closed to outside observers except by invitation of the chair." Furthermore, he stated, "proceedings are proprietary and therefore not publicly available for review."

The fog surrounding the operations of the RUC seems to have affected many who write about it. We have posted (here, here, here, and here) about how previous publications about problems with incentives provided to physicians seemed to have avoided even mentioning the RUC. Up until 2010, after the US recent attempt at health care reform, the RUC seemed to remain the great unmentionable. Even the leading US medical journal seemed reluctant to even print its name.

That changed in October, 2010.  A combined effort by the Wall Street Journal, the Center for Public Integrity, and Kaiser Health News yielded two major articles about the RUC, here in the WSJ (also with two more spin-off articles), and here from the Center for Public Integrity (also reprinted by Kaiser Health News.) The articles covered the main points about the RUC: its de facto control over how physicians are paid, its "secretive" nature (quoting the WSJ article), how it appears to favor procedures over cognitive physician services, etc.

So the RUC became less anechoic.  Now, four months later, there is more news.  A new site called "Replace the RUC!" has now appeared, with the following introduction:

This site has been developed - see here for our backgrounds - to help primary care physicians and other interested individuals obtain verifiable background from reputable sources on:

* The evolution and structure of the US' medical payment system.
* How it came to devalue primary care and favor specialty services.
* How that has translated to lower quality care at far greater expense in the US.

We believe the overwhelming majority of American primary care physicians are deeply frustrated with the differences in how primary and specialty care are valued by the current system, and the havoc that system has wrought throughout health care and the nation.

The first step to remedying this situation is for the primary care medical societies to visibly and loudly withdraw from participation in the RUC, de-legitimizing the process.

That said, this effort is most decidedly NOT primarily about getting primary care physicians more money, but bringing our health system back into homeostasis.

We have previously noted that there are many unanswered questions about the RUC:

• How did the government come to fix the payments physicians receive? Government price-fixing has not been popular in the US, yet this has caused no outcry.
• Why is the process by which they are fixed allowed to be so opaque and unaccountable? Why are there no public hearings on the updates, and why is there no input from practicing physicians or organizations other than those related to the RUC?
• How did the RUC become de facto in charge of this process?
• Why does the AMA keep the membership of the RUC so opaque, and give no input into the RUC process to its general membership?
• Why is the RUC membership so dominated by procedural specialists? Why were primary care physicians, who made up at least a sizable minority of physicians when the update process was started, not represented according to their numbers?
• Why has there been so little discussion of the RUC and its responsibility for an extremely expensive health care system dominated by high-technology, expensive, risky and invasive procedures?

We welcome this new site as a way to answer these questions, and more importantly, as a way to develop more rational incentives within the health care system.

Note that "Replace the RUC!" will be added to our link list.

References



1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. (Link here.)
2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. (Link here.)

Send Mercenaries, Guns, and Money? - Cerberus Tries to Buy Jackson Health

The latest twist in the tale of one of the US great safety-net public hospitals raises some interesting questions.  As reported by John Dorschner in the Miami Herald, Jackson Health System has had some bad times:

the system, ... has served for a century as Miami-Dade County’s safety net healthcare system for the poor and uninsured. But money and management woes in recent years have pushed the system to the brink of failure time and again. Last week, its executives said it would run out of cash in July unless drastic measures are taken.

The Bid for Jackson Health

The latest drastic measure proposed was a take-over by a for-profit corporation, one that we have heard of before:

A Massachusetts hospital chain led by a Cuban American heart surgeon with family ties to Miami has sent Jackson Health System a non-binding 'expression of interest' letter, offering to take over the financially troubled public hospitals, invest $600 million in capital and assume $500 million in debt.

The $1.1 billion offer from Ralph de la Torre of Steward Health Care System was delivered Tuesday morning to members of the capital committee of the Public Health Trust, Jackson’s governing body.

Questions Appear Immediately

The proposed deal immediately raised questions and concerns. The very nature of the deal was unclear:

Trust member Ernesto de la Fe said he wasn’t sure if the company was proposing a straight-out sale, while other board members said they thought the offer envisioned 'a public-private' partnership.

Also, in a follow-up story by the same reporter, there were questions about the rapid time-table,

Jackson is in such difficult financial conditions – its executives warn it may run out of cash in July – that many leaders are willing to consider a sale, but they wondered whether the 90-day timetable set by Steward Health Care System is realistic and what the deal might mean for the 500,000 uninsured persons in Miami-Dade County.

There were questions about the company which proposed to buy Jackson:

'We need to know a lot more about this company,' said Sal Barbera, an adjunct professor at Florida International University and a former hospital executive.

Steward has existed only since November, when Cerberus Capital Management finalized a $895 million deal to turn six Catholic hospitals into a for-profit entity. Steward has since bought two other small hospitals. Altogether, the Steward system has 1,565 licensed beds. Jackson has 2,100. De la Torre has been a hospital executive for less than three years.

That’s 'a very short track record,' said Mark Rogers, a Trust member and former chief executive of the Duke University Hospital.

Would the Mission be Upheld?

The issue of whether a private, for-profit company would respect the mission of a safety-net hospital came up quickly,

Alan Sager, a health policy professor at Boston University, said some Steward facilities are money losers in poor neighborhoods. 'Some of us had a lot of questions' about the Cerberus take-over and how the investment company could squeeze returns for investment out of hospitals that were struggling as nonprofits.

'We asked repeatedly. We never received answers,' Sager said.

He said his fear is that patient care will be reduced to make profits. 'I think there should be concerns about preserving essential patient care in Dade County' if Steward took over Jackson, he added.

'If the object is merely to cut costs to make money … then that is not the right approach for Jackson,' said Rogers, the former Duke executive. 'Clearly some costs have to come out, but we have to invest in new programs to maintain the quality of medical care that Jackson has always provided.'

One day later, John Dorschner again writing for the Miami Herald raised more questions about why a large private equity company would want to buy a money-losing public hospital system? First he noted,

While the human face on the $1.1 billion bid to buy Jackson Health System is a Cuban-American heart surgeon with strong family ties to Miami, a vast and powerful entity looms in the background: Cerberus Capital Management.

The company, named for the mythological three-headed dog that guards the gates of Hades, is one of the biggest private investment firms in the United States, and it is the owner of Steward Health Care, the Boston hospital group that this week said it is interested in buying Miami-Dade’s public hospitals

So,

The question that perplexes some Trust members is why such a big-time investment firm would be interested in a healthcare system with three public hospitals that lost $244 million in fiscal 2009, is expected to lose $105 million in fiscal 2010 and is projected to run out of cash in July unless drastic measures are taken.

The concern, again, was whether Cerberus would uphold the current mission of the hospital system:

Trust Treasurer Marcos Lapciuc said Thursday that Cerberus is 'in the driver’s seat' on this deal, not Steward. 'They are going to expect some return on their investment. This is not going to be charitable donation,' he said.

Of course, the central mission of the current Jackson Health System would seem to be charitable.

To build the health of the community by providing a single, high standard of quality care for the residents of Miami-Dade County

The implication of "single, high standard" is that applies to all residents, regardless of financial status or ability to pay.

More Questions

The CEO's Short Term Focus

There is good reason to question whether Steward Health Care, formerly Caritas Christi, and now owned by Cerberus Capital Management would uphold that mission. As we noted recently, the Steward Health Care CEO seems to have a very short-term focus, suggested by the track record of the Cerberus CEO, who quickly left an organization he had aggressively promoted, suddenly switched from the Republican party to become a big contributor to the Democratic party, abandoned his medical license after developing a good reputation as a cardiovascular surgeon, and famously was quoted, "burn the boats on the beach, baby." Would he support the long-term commitment needed to make both the Massachusetts based and now the proposed Florida based hospitals, most of which are safety net hospitals, succeed?

"Leakage Reduction" - a Threat to Physicians' Professionalism?

As we also noted recently, the main tenet of his business plan seemed to be to reduce "leakage," to make sure patients who start within the system are referred within the system and do not "leak" elsewhere. The problem with this is that physicians are supposed to decide how to manage patients, and specifically to decide where to refer patients in the patients' interests, not just to keep money flowing to the health care system. "Leakage reduction" may possibly threaten physicians' first commandment, to make decisions to maximize benefits and minimize harms to individual patients, before all other considerations. Also, as we noted earlier, since Steward Health Care purchased not only some Massachusetts hospitals, but a big network of physician practices, there could be a risk that the physicians who are now employed by a private equity group would be pushed to make referral decisions for financial reasons, rather than in the best interests of the patients.

Note that a recent (posted 9 February, 2011) advertisement for a Senior Medical Director (physician leader) of the Caritas Christi Network Services, the physician group owned by Steward Health Care LLC, said the Director's first goal would be:

This position will have a leadership role in all aspects of the CCNS system, including responsibility and accountability for:
- Lead/Mentor/Support IPA based Medical Directors (at both the IPA and Pod level) to achieve Medical Management goals and objectives in Quality, Leakage, Utilization, and Risk performance

Keeping Company with Gun and Ammunition Manufacturers and "Mercenaries"

There are also questions about whether the corporate culture of Cerberus Capital Management would be compatible with the management of safety-net hospitals. Cerberus has some current investments in firms whose operations seem oddly askew from providing medical care to patients regardless of their ability to pay.

First, Cerberus owns the biggest manufacturer of firearms and ammunition in the US. As reported by BusinessWeek last year,

Cerberus had more than DPMS [Firearms] in its sights. From April 2006 to January 2008 it bought three other firearms companies: Bushmaster, Remington, and Marlin. And it kept adding to its collection. Cerberus now controls 13 brands in a holding company it created, Madison (N.C.)-based Freedom Group. With sales of $848.7 million in 2009, Freedom Group is the largest gun and ammo maker in the U.S. That means Stephen A. Feinberg, Cerberus' founder and managing member, is the country's top civilian gun magnate.

In addition,

Luth, the rifle maker, says that when he arrived at Cerberus' Park Avenue offices to negotiate a deal in 2007, he discovered that Feinberg and several of his partners 'are real gun guys.'

Also, as reported by the New York Times, Cerberus recently bought one of the biggest "private military contractors,"

DynCorp International, the private military contractor, said on Monday it has agreed to sell itself to Cerberus Capital Management for $1.5 billion, as the private equity industry continues to return to its core business of deal-making.

Cerberus will pay $17.55 a share for DynCorp, a 49 percent premium to Friday’s closing price of $11.75. DynCorp now has 28 days under a 'go-shop' provision within the deal agreement to find a higher and better offer.

While DynCorp has continued to win new contracts from the federal government, it has also been the subject of controversy over the years for its assignments in Iraq.

That controversy was amplified in an article in The Nation by Jeremy Scahill, entitled "The Mercenary Owners, They Are a Changin' (Sort of)

Blackwater and DynCorp, the two leading mercenary firms servicing the US wars in Iraq and Afghanistan have both undertaken steps toward significant structural changes over the past month. In the case of DynCorp, the ownership of the whole business seems to be changing hands, while Blackwater is dumping its private air force.

Cerberus Capital Management, one of the largest private equity firms in the US announced April 12 it was buying DynCorp, the massive, publicly traded company, which is akin to the Wal-Mart of the private security industry, for $1 billion in cash. Cerberus counts among its big wigs former vice president Dan Quayle, who often represents the company internationally. DynCorp has had its share of scandals over the years, including whistle blower allegations that personnel have engaged in organized sex-slave trading with girls as young as 12 and allegations its personnel have assaulted journalists. It has been rebuked by the State Department for its 'aggressive behavior' in interactions with European diplomats, NATO forces and journalists in Afghanistan. A 2007 US government audit of DynCorp's work in Iraq found that the State Department 'does not know specifically what it received for most of the $1.2 billion in expenditures under its DynCorp contract for the Iraqi Police Training Program.' More recently, the company was in the news facing allegations its training of the Afghan National Police was shoddy, including allegations its trainees didn't know how to adjust the sights on their AK-47s. If the Cerberus deal goes through, it will mean that the publicly-traded DynCorp will go private, meaning that it will be infinitely more difficult to get information on the company.

Cerberus seems to have had a dream of owning its own mercenary business for at least a few years. In April 2008, the company was reportedly looking to buy Blackwater. The deal apparently fell through because of concerns over Blackwater's reputation.

Summary

So we have come a long way from 1980, when the US American Medical Association gave up the rule that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  (See posts here and here.)   Now we have private equity firms buying or trying to buy formerly non-profit safety net hospital systems to be included in portfolios that can include gun and ammunition manufacturers and private armies.  Now we have physician networks owned by private equity firms focused on choking off "leakage."  Such ownership may initially inject lots of money into the system, and may eventually profit the new private owners, but what will we give up in this brave new world of commercial safety-net hospitals and for-profit physician practices?

As we said before,.... Deals that turn not-for-profit hospital systems into privately held for-profit systems ought to be scrutinized with extreme skepticism. Furthermore, once such deals are made, the results ought to be watched extremely closely to make sure they do not put private gain ahead of individuals' and the public's health. For-profit hospitals have generally not lived up to the promises they made to provide quality, accessible health care at a cheaper price.  It is yet to be seen whether private equity running for-profit hospital systems (and physicians networks) will do any better.

Coda

The title requires apologies to Warren Zevon, who famously performed "Send Lawyers, Guns and Money."

MedInformaticsMD in WSJ again: No Patient Will Ever Say, 'Quick, Watson, the Needle!'

Following along the lines of my Jan. 2011 post IBM's Watson, Jeopardy, and "Revolutionizing Medicine" , the Wall Street Journal published this Letter to the Editor by me today:

Wall Street Journal

LETTERS
FEBRUARY 25, 2011

No Patient Will Ever Say, 'Quick, Watson, the Needle!'

Regarding Ray Kurzweil's "When Computers Beat Humans on Jeopardy" (op-ed, Feb. 17): Librarians often receive requests for information as cryptic as "Jeopardy!" clues, from people who are sometimes not even sure what they're seeking. Watson is, in essence, a librarian that retrieves facts.

Regarding natural language processing and fact-retrieval systems like IBM's Watson, medicine is about cognition. It's about human judgment born of experience in dealing with ambiguity, not just of language but also, and this is critical, of observations, findings, lab data, image interpretation, etc. It is about human intuition, assemblage and the integration of a huge amount of disparate information in ways not well understood even by its practitioners. The end result is not just the recall of a piece of information, obscure as the information might be.

I consider predictions of Watson spearheading cybernetic miracles in medicine to imply just as grandiose a valuation to the technology as the statements I heard two decades ago about the health information technology of the day, or even today, "revolutionizing medicine." That has not happened.

A cybernetic librarian is no physician. As for me, for now I'll stick to people in my own medical care. Let Mr. Kurzweil see the machine for his ailments.

Scot Silverstein, M.D.

Philadelphia

I am pleased that my counter-marketing-hype opinion on the meme of health IT "revolutionizing medicine" was deemed fit to print by the Journal.

Those in senior leadership positions, as are included in the WSJ's readership, need to see that meme challenged.

-- SS

Three Years Later, A Congressional Investigation of the Deadly Adulterated Heparin

Slightly more than three years ago, we first posted about the case of the deadly adulterated heparin.  (A case summary is appended to the end of this post, and nearly all our posts are here.)  The case is of fundamental importance because it involves the failure of pharmaceutical companies to fulfill their core mission, to supply pure, unadulterated drugs.   Three years later, how the heparin was adulterated, and who was responsible are still unknown.

So now, it seems, there will actually be an official investigation.  As reported by Alicia Mundy in the Wall Street Journal,

The House Energy and Commerce Committee is conducting a formal investigation into the contaminated-heparin crisis of 2008, saying it wants regulators to figure out who was responsible for adulteration linked to 81 U.S. deaths.

The panel's chairman, Rep. Fred Upton (R., Mich.), and two colleagues sent a letter Wednesday to the Food and Drug Administration asking for documents on whether the agency pursued possible culprits in China and pushed the Chinese government for more information.

'The committee is investigating the unsolved case of who contaminated the U.S. supply of heparin,' a blood thinner used by about 12 million Americans annually, said Mr. Upton, joined by Reps. Clifford Stearns (R., Fla.) and Michael Burgess (R., Texas).

Better late than never, I suppose. In March, 2008, I called the case "outrageous," and called for an investigation. You really did hear it here first on Health Care Renewal. So three years later, an investigation has actually begun.

The latest WSJ article noted:

'There is substantial public interest in solving this case' because more than 80% of the standard heparin supply in the U.S. today comes from China, the lawmakers wrote. About 16% of all pharmaceutical ingredients in the country are imported from China, they wrote.

Also,

'There is reason to believe all or some of the individuals responsible for the adulteration are still actively engaged in the Chinese pharmaceutical supply chain, and pose a continuing threat to pharmaceutical products imported to the U.S.,' the lawmakers wrote.

However, why this "substantial public interest" and the existence of "a continuing threat" did not lead to an investigation earlier is still completely obscure.

The article hinted at some partisan discord in the committee that will do the investigation:

Over the last two years, Mr. Burgess and the Energy and Commerce Committee's then-top Republican, Rep. Joe Barton of Texas, pressed the FDA for information on the agency's inspections of Chinese heparin facilities and on the extent of cooperation from national and local Chinese authorities.

At the time, Republicans were in the minority. Their inquiries didn't constitute a committee investigation, and they couldn't demand nonpublic information from the FDA or call hearings. They now are in the majority and have those powers.

The implication is that the Democrats on the committee blocked the investigation. Why they would have blocked an investigation when the executive branch was in Republican hands, and why the matter could not have been investigated in another congressional committee, or by some other organization, is unknown.

So, again, better late than never. An investigation could at least be the beginnings of accountability for the very well paid pharmaceutical company leaders who up to now have denied all responsibility for failing their most important responsibility, to provide pure, unadulterated drugs.

As we have said again and again, as long as the leaders of health care organizations are not held accountable for the results of their decisions on health care quality, cost, and access (even in such extreme quality violations as those resulting in multiple patient deaths), we can expect continuing decisions that sacrifice quality, increase costs, and worsen access, but that are in the self-interest of the people making them.

To really reform health care, we must hold health care organizations and their leaders accountable (and not blame all the problems on doctors, other health care professionals, patients, and society at large).

Case Summary

- We have posted several times, recently here, about the tragic case of suddenly allergenic heparin. Although heparin, an intravenous biologic anti-coagulant, has been in use for over 70 years, serious allergic reactions to it had heretofore been rare. Starting late last year, hundreds of such reactions, and now 21 deaths were reported in the US after intravenous heparin infusions.All the heparin related to these events in the US was made by Baxter International.


- We then learned that although the heparin carried the Baxter label, it was not really made by Baxter. The company had outsourced production of the active ingredient to a long, and ultimately mysterious supply chain. Baxter got the active ingredient from a US company, Scientific Protein Laboratories LLC, which in turn obtained it from a factory in China operated by Changzhou SPL, which in turn was owned by Scientific Protein Laboratories and by Changzhou Techpool Pharmaceutical Co. Changzhou SPL, in turn, got it from several consolidators or wholesalers, who in turn got it from numerous small, unidentified "workshops," which seemed to produce the product in often primitive and unsanitary conditions. None of the stops in the Chinese supply chain had apparently been inspected by the US Food and Drug Administration nor its Chinese counterpart.

- We found out that the Baxter International labelled heparin was contaminated with over-sulfated chondroitin sulfate, a substance not found in nature, but which mimics heparin according to the simple laboratory tests used in the Chinese facilities to check incoming heparin. (See post here.) Further testing revealed that the contamination seemed to have taken place in China prior to the provision of the heparin to Changzhou SPL. (See post here.) It is not clear whether Baxter International or Scientific Protein Laboratories had inspected most of the steps in the supply chain, or even knew what went on there.

- The Baxter and Scientific Protein Laboratories CEOs did not seem aware of where they got the heparin on which the Baxter International label was eventually affixed. But one report in the New York Times alleged that Scientific Protein Laboratories would not pay enough for heparin to satisfy any sources other than the small "workshops."


- Leaders of all organizations involved, Baxter International, Scientific Protein Laboratories, Changzhou SPL, the Chinese government, and the US Food and Drug Administration, and the US Congress assigned blame to each other, but none took individual or organizational responsibility. (See post here.)  Note that SPL was recently bought out and taken private, making its current leadership even less transparent (see post here).  A 2010 inspection of an SPL facility by the FDA revealed ongoing manufacturing problems (see post here).

- Researchers (who turned out to have financial ties to a company which is developing an anti-coagulant drug that could compete with the heparin made by Baxter International) investigated the biological mechanisms by which the contamination of the heparin lead to adverse effects, but no one investigated further how the contamination occurred, or who was responsible. (See post here.)

- Hundreds of lawsuits against Baxter have now been filed, so far without resolution. (See post here.)  Efforts to make documents to be used in these cases public so far have not succeeded (see post here).

- A government report which attracted little attention warned of the dangers of pharmaceutical ingredients made in China and subject to virtually no oversight. (See post here.)

-  Despite requests from the US, the Chinese government did not investigate the production of the heparin that lead to the deaths (see post here.)

Hat tip to the Postscript blog.

Windows 7 Service Pack 1 "Glitches": Why Personal Computers are Problematic, and Perhaps Should Not Be Mission Critical Components in Hospitals

A technical note on computer unreliability, and a series of followup critical questions relative to health IT:

I run Windows 7 Professional on one of my computers, a very unspecial 4-5 year old Micro Center machine, the PowerSpec 6001, using conventional components. The machine was upgraded with 2 Gb RAM and an ATI Radeon 9600 series video card, to run the Aero "eye candy."

It has run satisfactorily since I installed Windows 7 Professional (32-bit version) on it last year.

I am not a computer amateur. [I do, however, admit to being a Radio Amateur - Extra class - ed.] Further, I meticulously keep the machine current with Microsoft security patches, use Symantec anti-virus which I also keep updated, check my disk for errors, and only visit major well-known, nationally prominent websites using the machine.

So yesterday, Windows 7 Service Pack 1 appeared in my "Software updates" list from Microsoft, after being released to the general public.

It was explained that this Service Pack improves performance, reliability and security [i.e., it is intended to update all the many, many bugs, unreliabilities and security holes of the operating system since its inception - ed.]

I confirmed my machine met the specs for it, and allowed the computer to download and install Service Pack 1.

That was my mistake.

After installation, the machine could no longer reboot Windows.

The flying color patches of the first screen appeared ... and then the machine suffered a hard reboot (going back to the BIOS-initiated memory checks and screens, etc.), as if I'd pressed the front panel hardware RESET button this machine has.

An automated "wizard" that came up and tried to figure out why the machine would not restart failed to do so.

I asked the machine, therefore, to roll back to the state it was in prior to the Service Pack 1 (SP1) "upgrade" via a "Restore Point", a feature Windows permits using the "system restore" capability. The SP1 installation automatically creates a Restore Point (image of the prior state of the OS) on the machine just before installing itself.

The machine works again, but ... (and that is a big "but"):

• The Service Pack is not installed. Therefore I am not running the latest protections, and do not know what will happen in the future with respect to patches and upgrades. Maybe the Service Pack will get its own Service Pack at some point to fix it, so it can fix my computer;
  

• The Service pack installation, without warning and rather rudely, erased my prior computer Restore Points of the past few weeks, leaving only the Restore Point it created just before inflicting itself on my machine. Just to thumb its nose at me, it also left two Restore Points from back in November, which would require me to then re-install a lot of software and updates at the very least. I cannot even try a Restore Point of, say, last week after other updates;

• I attempted to view the system error logs to determine what caused the failed Service Pack Install. Surprise! The Event Viewer and Task Scheduler management consoles I use to review system operation no longer operated, instead producing this lovely, extremely explanatory message: "MMC cannot initialize the snap-in", followed by hexadecimal gibberish that any doctor or citizen can easily decipher:

Such explanatory error messages! "MMC cannot initialize the snap-in. The snap-in might not have been installed correctly. Name: Event viewer. CLSID: FX: {b05566ad-fe9c-4363-be05-7a4cbb7cb510}." Click to enlarge.

• Attempts to look up the error on the Web produce gobs and gobs of amateurish "legible gibberish", indirection, misdirection, guesswork, and speculation, some of it from Microsoft itself;

• To add insult to injury, typical of poor user interaction design, I could not copy-and-paste the error, but had to type it (partially, fortunately, thanks to Google);
  

• Much of the material was in very broken English (where's those language translators promised to us for some 50 years now by computer scientists?)

• My attempts at repairing the damage by running the command "SFC /scannow" (system file check) to check and repair critical windows files showed that the Service Pack "Upgrade" also corrupted a number of critical Windows system files - despite the "Restore Point" rollback. Great Scott!
  

• SFC repaired the files and produced a log of gibberish that's thousands of pages long for me to ferret out what got damaged (ironically, just like the records from a few weeks of my mother's EMR-error-related hospitalization, at appx. 2,900 pages of legible gibberish);
  

• The repair did not restore the missing functionality;

• Attempts to reinstall supporting packages such as .Net framework also do not restore the functionality;

• Attempts to reinstall the Service Pack produce the same results, a crash on initial restart after the installation and need to roll back, erasure of several Restore Points I manually created, along with re-corruption of the critical system files previously repaired by the SFC /scannow command.
  

• I have no way of knowing what else is broken or may malfunction;
  

• While not rigorous, reports on the web show a significant percentage of others having problems with the "Service Pack" as well. Russian Roulette, anyone?
  

Russian Roulette, anyone?

All this was after many months of Microsoft "Beta testing" the Service Pack. (Perhaps it was really "Alpha testing?")

Similar issues occurred with the former Microsoft OS, Windows XP (now in its third major service pack since its release in 2002, with patches still coming on an almost weekly basis).

Fortunately, I have backup images of my entire disk, but the inconvenience and time wasted is quite irritating - and I will still not have the latest security patches after I roll back my machine to my latest disk image.


One should note that these "glitches" are just in the Operating System (OS) itself. Third-party applications (such as EMR and CPOE sytems, middleware, interfaces, etc.) suffer the same type of problems...for instance, the life-and-limb-threatening "glitches" that occurred at Trinity Healthcare after an EMR "upgrade."

Further, OS "glitches" can cause unexpected application "glitches", and vice versa. Complexity on top of complexity...

Note that machines running similar software are on the "servers" that are the heart of major enterprise systems such as EMR's and CPOE's, that communicate with enduser workstations.

Now, several simple questions:

• Who knows what other "glitches" the Service Pack introduced to my machine, that will "bite me" (or patients) later?

• Are these the machines we want our doctors and nurses to depend upon, since they increasingly regulate every medical transaction that occurs?

• Has the software become too complex to be entirely reliable, maintainable and secure?

• Does the average hospital have the staff to effectively deal with issues such as the above?

• Do these "glitches" raise the risk and the cost - therefore reducing the ROI, already low (see reading list) - of experimental health IT to even more unsatisfactory levels?

Finally:

• Would the average person tolerate such behavior from their car? In their aircraft? (Oops, the brakes don't work properly in 13.5% of cars after the parts upgrade, and that altimeter is simply crazy ...)
  

-- SS

Feb. 24 late night addendum:

Deciding to play with this mayhem, and knowing I was going to be wasting a lot of time, I first backed up my deranged machine to an external disk (~ half an hour) to preserve my files. I then restored my machine from an external disk backup image to its condition in mid-Nov. 2010 [thinking perhaps something more recent caused the SP1 to fail]. That took another half an hour. I then attempted to install the SP1 again. That took another hour or more.

Same results - machine crash after the "circling window panes" display.

I let the "Startup Repair" wizard run. It failed with the following informative messages. In a superb example of poor user design, I had to jot the messages down on paper, as it made no offer to print them, or load them into a thumb drive, etc. - although it did offer to send the error messages to Microsoft, a neat trick as the software components to drive the computer's wireless network adapter were not loaded:

Problem details - System Repair
Problem signature:

1- 6.1.7600.16385
2- 6.1.7600.16385
3 - unknown
4 - 21201077
5- AutoFailure
6 - 3
7 - BadPatch

OS version - 6.1.7600.2.0.0
Local ID - 1033256.1
Root cause - a patch is preventing the system from starting [no fooling - ed.]
Repair Action
System file integrity check and repair
Result = Failed.
Error code = 0xa

Then for added fun, I started the machine up in 'Safe Mode' (using the F8 key at startup). It came up, but told me it was doing a System Restore due to the failure to configure the Service Pack. After about 20 minutes of frantic disk activity, the machine rebooted - and immediately crashed as before.

I am rerunning the Startup Repair wizard again, asking it to restore my system, but I predict it will do so with the original remaining problems of non-functioning components that started this whole mess - if it works at all.

This is all absurd. It is a massive waste of time, a result of poor programming, uninformative, cryptic error messages (what? computers don't have enough storage for useful error messages?), poor (nonexistent) documentation, inadequate attention to the user experience, condescension of the user, inability to report the problems back to HQ automatically due to lack of forethought about a compromised machine's ability to access the network, software unreliability, and probably a host of other issues I haven't thought of yet because I'm tired after all this fritter.

Not to mention, it is potentially destructive of data to those who suffer this problem but did not keep backups. They warn you beforehand - but the installation agreement you "sign" is of the Ross Koppel/David Kreda "hold the vendor harmless" variety.

This experience is a metaphor for the state of health IT (with "glitches", "workarounds", unexplained errors, etc.), and of the dangers of computer worship.

-- SS

Feb 25 addendum - further experimentation based on web comments about SP1, such as running a pre-SP1 readiness checking utility by Microsoft, emptying the /temp folders, renaming the "software distribution" folder, clean booting, etc. all produce the same result: crash of the machine on reboot.

And there's no computer doctor to call for an appointment to fix the problem.

-- SS

Wendell Potter's "Deadly Spin"

We recently discussed how Wendell Potter, author of Deadly Spin, has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.  I finally had a chance to read the whole book, which should be read by anyone interested in concentration and abuse of power in health care.

Let me summarize some of its main points.

The Unholy History of Public Relations

Mr Potter set "PR" in its historical context, and noted parallels among the modern deceptions he recounts and how the father of PR white-washed tobacco companies, and with the propaganda and disinformation used by 20th century totalitarian states to cement their rule.

How Deceptive PR Changed the Course of Health Care

As noted earlier, Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, "Sicko," and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers.  He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded. 

Making More by Providing Less Care

Mr Potter catalogued the tactics insurance companies use to reduce care and increase revenue, such as rescision, elimination of coverage for groups with high costs, the use of high deductibles disguised as "consumer choice," etc.

The Tactics of Stealth Health Policy Advocacy

As noted in our earlier post, Mr Potter described "charm offensives;" the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including "astroturf," (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering.  He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Why Good People Do Bad Things

Mr Potter provides some insight into the rationalization and compartmentalization that allow apparently upstanding people to peddle deceptive PR.

Memes Metastasizing

Mr Potter noted how memes are created to fit short term goals.  My observation is that these memes may then acquire lives of their own that then may have long term adverse effects.  Think about "the best health care system in the world," fears of "government bureaucrats," but not corporate bureaucrats running health care, to what the label "junk science" may be applied, and where fears of the "nanny state" came from.

Summary

Mr Potter seems to be the only known example of a defector from the ranks of the leadership of modern corporate health care prompted by conscience.  Anyone who finds this blog useful should find his book at least equally useful.  (To those from outside the US:  although most of Mr Potter's experience was with the US system, the role of PR in society here is likely not that different from its role in other developed countries.)

I hope to return to some of the issues he raises in more detail from time to time.

Bravo, Wendell Potter, for returning from the "dark side."

 Note that I have added Mr Potter's blog to our blog-roll.