Getting Out of Our RUC - "An Open Letter To Primary Care Physicians"

Since 2007, we have been writing about the secretive RUC (RBRVS Update Committee), the private AMA committee that somehow has managed to get effective control over how Medicare pays physicians.  The RUC has been accused of setting up incentives that strongly favor invasive, high technology procedures while disfavoring primary care and other "cognitive medicine."  Despite the central role of (perverse) incentives in raising health care costs while limiting access and degrading quality, there has been surprisingly little discussion about the pivotal role played by the RUC. 

Now there is a movement afoot to replace the RUC.  In a new post on the Care and Cost blog, and the Replace the RUC site, Paul M. Fischer and Brian Klepper urged four approaches:

1. Make the public aware of the RUC’s role and urge the primary care societies to stop “enabling” the RUC through their participation.
2. Recruit experts who can credibly calculate the economic impacts of the RUC’s actions, and who can devise alternative payment methodologies.
3. Demonstrate the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on the RUC.
4. Develop a collaboration between primary care and non-health care business.

They are also urging three specific actions:

1. Contact your primary care society to demand that they withdraw from the RUC.
2. Broaden awareness of what we’re doing and why by rebroadcasting to your primary care colleagues.
3. Get in touch to help us with resources, relationships or approaches that can strengthen this project.

They have set up an electronic petition that people can use to urge the three major medical societies that represent primary care physicians to quit the RUC.

On Health Care Renewal, we have been trying to make the systemic problems with with the leadership of health care organizations less anechoic in the hopes that greater realization that these problems exist would lead to actions to solve them. The regulatory capture by the RUC of Medicare's payment setting mechanism is one problem that really cries out for a solution. In 2007, I called for "an unbiased re-evaluation of the components of the RBRVS by people who are dedicated to doing it fairly, not benefiting one group of physicians, or the organizations that benefit from the increased use of procedures"; and "an unbiased investigation of what went awry with the process used by Medicare to determine physician payments."  Your heard it here first on Health Care Renewal.  It is nice to now have such distinguished company. 

I urge our readers to consider the actions urged above. 

True health care reform will require a transparent, honest, fair process for governments to decide on how they will pay for physicians' care and other health care services and goods. 

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Dr. Scott Monteith on "The Best Compromise" on Physicians and Use of Troublesome Health IT

I have posted two guest posts by Dr. Scott Monteith, a psychiatrist/informaticist, at the Jan. 2011 post "Interesting HIT Testimony to HHS Standards Committee, Jan. 11, 2011, by Dr. Monteith" and the Dec. 2010 post "Meaningful Use and the Devil in the Details: A Reader's View".

Here is another, with his permission. He is responding to a talking point from a health IT commentary website that was distributed among the AMIA evaluations special interest group readership.

Dr. Monteith asks some very probing questions. He writes:

I would like to respond to what I see as being one of the most important and challenging “real-life” issues confronting clinicians, and is captured in this excerpt [below, from the multi-vendor sponsored site HISTalk - ed.]:

HisTALK: ... Somewhere between “we vendors are doing the best we can given a fiercely competitive market, economic realities, and slow and often illogical provide procurement processes that don’t reflect what those providers claim they really want” and “we armchair quarterbacks critics think vendors are evil and the answer is free, open source applications written by non-experts willing to work for free under the direct supervision of the FDA” is the best compromise.

That is, this excerpt performs the helpful task of framing “the best compromise” somewhere between two extreme viewpoints.

It would be helpful (at least for me) if this group could discuss what “the best compromise” actually ‘looks like’ in practice. How does one actually understand and live within “the best compromise”?

Let’s start with a relatively simple scenario:

What should clinicians do when they are working with EHRs that have known “problems” that are putting patients at risk, and the problems are not being immediately addressed, either directly or indirectly through, for example, an acceptable “work around,” or other adjustments to the EHR or local business processes?

Should the clinician continue to use the EHR and…

• assume that others (e.g., vendor, IT department, administration, etc.) will fix the problem(s)?

• report the problem(s)? Once? Twice? Three or more times? (How many?) To whom?

• inform the patient of the known problem(s) (if the problem(s) apply to the patient)?

• inform the patient that we do not have a good understanding of how to balance or even understand the risks posed by the EHR, given the dearth of peer-reviewed literature and algorithms? (What is “acceptable risk” for a given EHR problem? Does the EHR-related problem’s risk/benefit analysis change if the patient is in the hospital for a simple, nonlife-threatening problem vs. a complex, life-threatening problem)?

• give the patient the option to NOT use the EHR? (Note that we almost always give patients the choice to refuse other “risky ventures” such as diagnostic procedures and treatments.)

• inform their medical malpractice insurance company of the EHR-related problems?

• submit the problem(s) to the organization’s ethics committee, if there is one?

• report the problem(s) to the organization’s risk management staff?

• report the problem(s) in writing or verbally?

• stop using the EHR?

Etc. (including some combination of things).

Can providers (especially physicians) legitimately rationalize, given our ethical (to patients and our colleagues) and legal obligations (to patients and the state where we are licensed), the use of tools that are posing risks to patients and providers, when those risks are not spelled-out, not well understood, not peer-reviewed, etc.?

(Obviously everything we do has risks, but we are obligated to revel and discuss those risks as noted above. Further, the risks/benefits of a given diagnostic or treatment intervention are the product of peer-reviewed algorithms. Are patient’s aware of the risks associated with their doctor’s or hospital’s EHR?)

Again, the above excerpt suggests that there is a “ best compromise.” But what is/are “the best compromise(s)”?

I joke with friends that I am a “radical moderate” – that is, I usually find myself committed to the “middle ground” in most complex and thoughtful discussions. But when it comes to EHRs, I am finding it difficult to define or understand what a “moderate” or an acceptable “best compromise” looks like.

Given the current EHR exuberance driven by ONC’s incentive dollars and vendor profits (or hoped-for profits), we all know that the “politically correct” approach is to “go along” and be an “early adopter” (without too many protests). But is the politically correct approach really the “best compromise,” especially in light of our ethical and legal obligations?

I am anxious to hear what other people think about this matter. I am sincerely seeking help in better understanding a sensible, real-life “best compromise” for those of us in the trenches.

Note that if we cannot define “the best compromise,” then what does that say about us? How can we justify “getting on board” with patient care tools (e.g., EHRs, eRx’ing, etc.) that are posing risks (known and unknown), with no clear processes for informing patients, not giving patients their choice to use these e-tools, no clear evidence-based risk/benefit analyses, etc.?

My own pithy, initial responses are as follows:

Re: Given the current EHR exuberance driven by ONC’s incentive dollars and vendor profits (or hoped-for profits), we all know that the “politically correct” approach is to “go along” and be an “early adopter” (without too many protests). But is the politically correct approach [i.e, "go along to get along" - ed.] really the “best compromise,” especially in light of our ethical and legal obligations?

No, for the reasons after your comma. [i.e., in light of our ethical & legal obligation - ed.]

One should look to the past for lessons in what the "compromises" might be.

How about the Flexner Report of 1910 as a start?

The treatises on human research protections penned largely after the Tuskegee experiments and the horrors of WW2, such as these as listed on an NIH web page "Office of Human Subjects Research, Regulations and Ethical Guidelines" might also shed some light:

• 45 CFR 46 Protection Of Human Subjects

• Guidelines for Conduct of Research Involving Human Subjects at NIH (Gray Booklet) (pdf file)

• The Belmont Report Ethical Principles and Guidelines for the Protection of Human Subjects of Research

• Nuremberg Code Directives for Human Experimentation

• World Medical Association Declaration Of Helsinki

I further opine:

Re: How can we justify “getting on board” with patient care tools (e.g., EHRs, eRx’ing, etc.) that are posing risks (known and unknown), with no clear processes for informing patients, not giving patients their choice to use these e-tools, no clear evidence-based risk/benefit analyses, etc.?

Perhaps with the line that "I never make mistakes ... everything I do is an experiment."

The technology is experimental. Perhaps the best way forward is to treat it as such.

In medicine I think there's a rich history of how to conduct proper (and improper) experimental research.

Again, Dr. Monteith raises some critical questions that need to be answered.

Or, more correctly, needed to be answered a long time ago, and long before planned national rollouts of healthcare information technology.

-- SS

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Australian ED EHR Study: An End to the Line "Your Evidence Is Anecdotal, Thus Worthless?"

At my Sept. 2010 post "The Dangers of Critical Thinking in A Politicized, Irrational Culture" I lamented that while my early mentor in biomedicine Victor P. Satinsky MD taught the wise credo "critical thinking always, or your patient's dead" in the 1970's, our culture had become so perverse that this credo had been largely supplanted with:

"Critical thinking anytime, and your career's dead."

That post was in reaction to continued heckling on a professional mailing list, the American Medical Informatics Association (AMIA) Clinical Information Systems Working Group (cis-wg). On this list, Oregon Health Sciences University professor William Hersh expounded on how the evidence of health IT dangers was largely "anecdotal" therefore to be discounted, and how I, specifically, "didn't know the literature on health IT."



In that post I put the lie to the latter figment. On the former prevarication Dr. Jon Patrick, author of the recent thorough dissection of problems with the ED EHR system being rolled out in public hospitals in New South Wales, Australia (see my Mar. 5, 2011 post "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts"), hit the ball out of the park:

Prof. Patrick to AMIA cis-wg:



I think such defences are particularly unuseful especially with respect to the dismissal of personal stories and experiences as "anecdotes", hence committing them to the realm of folklore. I offer these notions as a counterpoint.



Discounting Anecdotes:



1. Is a perfidious and specious act.



2. It denies early warning signs of problems.



3. It denies a voice and disempowers the working clinical community who have to operationalise decisions made by others.



4. It denies a route to process improvement within an institution - which is most important for EBM and incremental review of local processes.



5. It defends software manufacturers from fault rectification - cuts off even a need to deliberate on it. Critics of the value of anecdotes are squarely on the side of the faulty and deficient manufacturer.



6. A rule of project management is that projects consist of 3 components, cost, quality and time and if their needs to be a compromise it has to be on quality. Anecdotes are early warning signs of such a compromise.

Prof. Patrick had to once again put the lie to this refrain at a comment on the HISTalk blog yesterday, where the anonymous proprietor had written in a review of Patrick's EHR study:

... On the other hand, I wouldn’t say it’s [Prof. Patrick's Cerner FirstNet study] necessarily unbiased, it focuses on implementation of a single department application that didn’t go well for a variety of reasons (despite many successful FirstNet implementations elsewhere), it uses the unchallenged anecdotal comments of unhappy users who make it clear they liked their previous EDIS better, and it nitpicks (I wasn’t moved to find a pitchfork when I learned that the primary keys in the Millennium database aren’t named consistently).



[Considering the complexity and changeability of healthcare and the corresponding software lifecycle, I duly note that that latter attitude about 'failing to find pitchforks' regarding breaches of sound software engineering practices seems to be a symptom of the larger health IT disease that Prof. Patrick writes about - ed.]

Dr. Patrick then knocked the ball out of the Southern Hemisphere with a comment of his own about anecdotalism and a link to an expansion of the aforementioned ideas he'd shared on "discounting anecdotes":

Prof. Patrick to HISTalk owner:



Your Comment “it uses the unchallenged anecdotal comments of unhappy users ” is not only unfair but unreasonably inaccurate. The comments made by the users are the Directors of 7 EDs and so they have a right to carry authority by virtue of the experience but also the number of 6 out 7 presenting a view of Firstnet as unfit for purpose has numeric validity, which they justify with about 20+ pages of their comments – see Part 2 Appendix 2.



I would also point readers to my editorial about the role of personal experiences being the most useful information to understand the nature of socio-technical failures. http://aci.schattauer.de/en/contents/archive/issue/1124/manuscript/15463/show.html

The essay at that link, "The Validity of Personal Experiences in Evaluating HIT", is an editorial in Johns Hopkins informaticist Chris Lehmann's brilliant new journal "Applied Clinical Informatics."



The editorial is available free, and is a must-read for anyone in a decision-making or managerial role in mission critical domains, including our elected representatives.



In the editorial Dr. Patrick concludes. similarly to his earlier AMIA mailing list opinion:

... the denial of recounted personal experiences in discussion and analysis of HIT is biased and specious and has the effect of:



1. Denying early warning signs of problems.



2. Denying a voice for the working clinical community who have to operationalise decisions made by others and thus disempowers them.



3. Denying process improvement within an institution – which is most important for Evidence Based Medicine and incremental review of local processes.



4. Discourages staff from engaging in any form of process improvement hence worsening the sense of disenchantment.



Every legitimate personal experience of a HIT deserves to be considered on its merits lest we wish to retreat from process and product improvement. Mechanisms of censorship both implicit due to contrived processes of disinformation and disempowerment or explicit due to contractual specifications will lead to more waste, lost productivity, contempt for the providers, and distress among frontline staff rather than increased productivity and improved patient health and safety as we all desire.

In my view, the drivers or motivators for the "anecdotalist" accusation are these, singly or in combination:

• Too much "education" to see the nose on one's face, as in, to think zebras and unicorns instead of horses when hearing hoofbeats outside one's midwest U.S. abode (eggheads);
  
  
• Too little common sense (fools), as in Scott Adams' example: "IGNORING ALL ANECDOTAL EVIDENCE - Example: I always get hives immediately after eating strawberries. But without a scientifically controlled experiment, it’s not reliable data. So I continue to eat strawberries every day, since I can’t tell if they cause hives";
  
  
• Too much concern for the possible interruption of flow of money or power in one's direction (gonifs).
  
  

In conclusion, the anecdotalist refrain of "your evidence is anecdotal" [therefore of little or no value] when used repetitively against competent observers is the refrain of eggheads, fools and gonifs.



In healthcare, the end result is "your patient's dead."



My "anecdotal relative" injured in a mid-2010 HIT mishap is sadly an example.



[June 2011 addendum: my relative, after much suffering, has now died of complications of the "anecdotal HIT mishap" - ed.]



As for myself, I am a Markopolist (see my Sept. 2010 post "Health IT: On Anecdotalism and Totalitarianism").



-- SS

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What to do about the state of the ED EHR's in NSW?

At my post yesterday "On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts", I've come down pretty hard on internal and external (i.e., human interface) sloppiness in mission critical IT systems.

In my view, the flaws that create randomly-occurring errors, combined with a mission hostile user experience highly and especially inappropriate in the hectic and unpredictable ED environment, turn these systems into slot machines. The jackpot, however, is not wealth. It's injury or death.

I've been asked, "So - what to do about the state of the ED EHR in NSW?"

Here are some simple initial suggestions:

A. For the time being: securing and implementing a paper backup (pen & paper) with scanning and document imaging retrieval system (integrated or standalone) as an 'EHR supplement", in order that really critical info can be steered in that direction.

Clinicians are already avoiding the EHR system and not entering or minimizing data, or using other "workarounds." Therefore, informationally and safety-wise, a document imaging/retrieval system for paper would probably be a net plus.

ED charts are not Tolstoy novel-length, as a matter of fact. There would not be many pages per patient, but even small morsels of key information collected easily and quickly, then retrieved easily, and presented clearly, cleanly and rapidly, as on a sheet or three of physical, then virtual parchment, can have enormous value.

B. Clinicians and responsible executives and officials should start demanding that the ED EHR vendor release its full conceptual and logical data models so that others can, competitively (including the original vendor if they wish), cleanse it and redo a user interface that meets the needs of NSW ED's. The latter should be determined collaboratively with the key stakeholders, and developed using agile, iterative and incremental methodologies, not the usual stale Management Information Systems approach. (I.e., the mercantile, manufacturing and management computing paradigms that are ill-fitting to healthcare informatics as further explained at my post here.)

That way moving data over to the "redone" new system would not be a nightmare. Or perhaps less of a nightmare than an entirely new extant system from another vendor (which would likely have similar flaws anyway and need similar rework).

The closed-system, locked-in-to-one-vendor paradigm that's apparently holding the ED's of an entire state of the fine country of Australia hostage must end. Let the best organization win.

As I also observed in the aforementioned post, the UK, having their own HIT issues (see my Aug. 2010 "Battle of Britain" post at this link), apparently learned something, as evidenced in:

Health Informatics — Application of clinical risk management to the manufacture of health software. UK National Health Service, DSCN14 (2009), formerly ISO/TS 29321:2008(E).

and

Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software. UK National Health Service, DSCN18 (2009), formerly ISO/TR 29322:2008(E).

Perhaps those in the U.S. and in VK-land (amateur-radio speak for Australia; I am KU3E here in the U.S.) can also heed these documents and their recommendations.

-- SS

Mar. 8, 2011 addendum:

Prof. Patrick has added a new section to his report, entitled "The Future Pathways for e-Health in NSW." It is available at this link (PDF).

It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, magical thinking about the technology, and lack of accountability):

More on the Pathways at my post here.

The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation.

--SS

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The Rise of the Corporate Physician - the End of the (Health Care) World As We Know It?

In discussing how concentration and abuse of power threatens health care professionals' values and professionalism, we have discussed how ostensibly academic institutions value faculty more for their earning power than their academic abilities.  We have discussed how financial relationships between physicians and drug, biotechnology, device and other companies risk abuse of entrusted power.  But up to now, I have been comforted by the hope that physicians in small independent practices who do not have such conflicts of interest are trying to uphold their professional values, even as they were buffeted by the perverse incentives imposed by managed care organizations/ health insurance companies and government insurance (e.g., US Medicare whose payments are controlled by the RUC).

However, a recent article in SmartMoney suggests that the end of the independent physician is nigh:

Remember the solo family doctor? In places like Springfield, it has become increasingly likely that she's collecting a paycheck from a large regional hospital—and practicing medicine according to the hospital's strict playbook. The experience in Springfield is just a needle prick compared with what's going on nationwide. At least one in six doctors—more than 150,000 nationwide—now works as an employee of a hospital system. And with about half of recent medical school graduates deciding to work for hospitals and many established doctors looking to unload their practices amid the tough economic climate, what was a trickle of change has turned into a torrent. Jim Pizzo, a Chicago-area hospital consultant, says the blistering pace of these mergers is leading some colleagues to joke that there are two types of physicians today: 'Those employed by hospitals and those about to be.'

So we are seeing physicians who practiced solo or in physician-lead, physician-run group practices becoming employees of large health care organizations. And here on Health Care Renewal, we know how most large health care organizations are run.

This appears to be an unintended consequence of our recent US health care "reform" law:

But hospital executives also believe that buying doctors' practices could yield a big payday, thanks to a different provision in the health care law. The law will encourage doctors and hospitals to share some payments when treating each patient; as collaborative teams, they could earn bonuses for holding down costs and meeting quality markers. 'The real question for everyone is how that pie—that money—is going to get split up,' Goertz says; hospitals think they'll have the upper hand if they employ the doctors that they're sharing their banana crème with. And that's touched off a flurry of mergers everywhere—from Seattle to Roanoke, Va.

The name of these supposedly collaborative organizations, which are turning out to simply be hospital systems which have purchased physicians' practices and now employ physicians, is "accountable care organizations," which now appears ironic at least.

The article detailed some of the adverse effects to be expected when accountable care organizations become hospital systems with employed physicians providing patient care.

Increased Costs with Decreased Care

Ruth Taylor, a 44-year-old woman in Bozeman, Mont., started seeing Robert Hathaway as her doctor during college, and she stuck with him through everything from routine blood tests to a kidney transplant. Taylor, a professional nurse with warm blue eyes, describes Hathaway as a 'classic small-town doctor' who knew all his patients by name and socialized with them at local basketball games; he was accessible and thorough—even catching a health problem of hers that other doctors had missed. But after Hathaway sold his practice to the local hospital, Taylor says, things began to sour. She was more likely to be assigned to see the physician assistant rather than Hathaway himself. And when she went in for a comprehensive physical (also run by the assistant) in late 2008, she was charged $360, more than double what she'd paid for a workup in previous years.

Imposition of Dysfunctional Health Care Information Technology

On this blog, Dr Scot Silverstein frequently posts about how poorly designed and implemented commercial health care information technology may have harms that outweigh any benefits, and how these systems are rarely objectively evaluated. Employed physicians are likely to be required by their new executive overlords to use commercial health care IT that benefits the managers and their strategies, but may not benefit patient care:

Last spring Hospital Sisters tried to shift all of its Springfield medical offices to electronic medical records simultaneously. But there wasn't enough tech support to deal with all the problems physicians ran into on day one, and wait times spiked at the system's walk-in locations. Nenaber, a soft-spoken 64-year-old with wire-rim glasses, sounds acquiescent about the situation. 'We're getting the hang of these things,' he says slowly, sitting at his desk overlooking a gas station and a strip-mall parking lot. But his practice is still waiting for its electronic payoff

Increasing Prices by Providing Care in the Hospital

Now that the acquisition spree is in full swing, some experts worry that price increases could become the dominant narrative for patients. When hospitals run medical practices, federal law allows them to add substantial 'facility fees' to patients' bills to cover overhead expenses. The new bosses also often rip equipment like X-ray machines and MRIs out of the physician's office, preferring to have patients get those tests from radiologists at the hospital. That, too, can cost patients. A consumer with a high-deductible Aetna plan, for instance, would pay up to $1,400 for an MRI of her back at the University Medical Center at Princeton, N.J., according to data that the insurer makes available to its members. The same scan would cost about a third as much at nearby Radiology Affiliates of New Jersey, a nonhospital facility. Based on a review of insurance databases and state regulatory records, that's a fairly typical price gap

Increasing Prices by Market Domination

Price increases also have the potential to bleed outward—affecting not only the patients of the absorbed doctor, but also the cost of health care citywide. That's because when hospitals sit down at the bargaining table with insurers, they're almost always able to negotiate higher payment rates for their big groups of doctors than a lone physician with little bargaining power

Despite the usual spin provided by the would-be monopolists:

Fast-growing hospital systems, including Hospital Sisters and Bozeman Deaconess, say that their growth will eventually make care more efficient and bring costs back down, since they'll be able to cut back on unnecessary care and duplicate tests

I am sure that the 19th century robber barons made the same pitch about increasing efficiency. Of course, the efficiency mainly benefits the insider managers.

By the way, of course, the hospital systems own public relations machines and lobbyists are now busy attacking any restrictions on such concentrations of power, while the hospital managers figure out how to game the system to increase their market domination before the regulators notice:

As more patients face such disruptions, regulators are taking notice. In October, the Federal Trade Commission and the Department of Health and Human Services met with doctors, insurers and other health officials to discuss the referral and pricing problems that could arise from 'accountable-care organizations'— those new groups of hospitals and doctors that will share financial incentives. The Federal Trade Commission will offer guidelines on what's permissible by midyear. But hospitals are already lobbying for accountable-care groups to be exempt from antitrust and antifraud rules, even as they scoop up more and more medical practices. Under current regulations, officials in Washington must green-light all mergers involving companies valued at more than $63 million. But by buying up tiny medical practices one at a time, critics say, hospitals stay below the threshold and avoid getting much attention. And by the time regulators settle on more-formal legal guidelines, those mergers may be hard to undo, says Cory Capps, a Washington economist specializing in health care antitrust issues.

Excess and Unnecessary Utilization via "Leakage Control"

With big hospital systems now owning physician practices, and practicing physicians directly answering to executives, the push will be on to maximize use of the most lucrative services. Once the hospital systems have made employees out of the physicians, it is easy to pressure their own employed physicians to refer patients to the hospital units that can bill most lucratively:

By their own admission, most hospitals are eager to keep patient referrals under the same corporate umbrella, to save on costs and share medical records but also to boost revenue. The hospitals say they wouldn't force an internist, for example, to refer a patient with heart problems to their own cardiologists, but critics say there's certainly financial pressure. Under a little-noticed regulation that took effect in 2007, hospitals are allowed to pay doctors less if they don't do enough internal referrals.

Doctors in Bozeman and Springfield who granted interviews said they didn't feel pressure to be 'team players' with referrals. But some of those who've left large health systems tell a different story, including Mark Callenberger, an orthopedist in Merritt Island, Fla. Callenberger says that the hospital group where he used to work urged him to direct more patients to the MRI machine owned by the hospital. The doctor preferred a more advanced machine at a private practice that he says offered clearer pictures. But after he ignored the recommendations, Callenberger says, the hospital told his office manager to schedule patients at the hospital's MRI anyway, leaving him to perform surgery using 'crummy images.' (The hospital declined to comment on Callenberger's case but says its doctors can use whatever facilities they choose.) Patients may never know about these power struggles, because doctors aren't required to disclose how they choose specialists. And while patients who ask can always see a specialist outside the network, in practice few are likely to challenge their doctors' judgment, says Bruce A. Johnson, a Denver health care lawyer. 'Face it, when we're really sick,' says Johnson, 'if the doctor tells us to jump off a roof, we'll probably consider doing it.'

Note that we discussed (here and here) the example of a for-profit hospital system with a large number of physician employees pushed to choke off "leakage" of patient referrals outside the system.

Summary

The overarching problem is that employed physicians now must answer to managers and executives who may put financial goals, and their own enrichment, ahead of physicians' values, and specifically will choose increased revenue over providing the best possible care to individual patients:

. Executives here are also hoping to push the needle further—standardizing everything from how long patients wait on hold to the ease of parking at the doctor's office (valets, luxury-restaurant style, are one solution under consideration).

Still, Mikell acknowledges, 'doctors don't want follow-the-directions, cookbook medicine.' And for many physicians, the idea of following new rules triggers a much larger unease at giving up their independence—a feeling of loss, both for the businesses they built and for their patients. Back in Bozeman, Blair Erb, the sole cardiologist in town, is a picture of resignation as he prepares to sign a contract with Deaconess. 'I feel defeated,' Erb says, looking around at the office furniture he and his wife, Liz, chose from a catalog years ago. The weathered ranchers and bundled-up women that come through his door mostly express disbelief when they hear that this frank-talking Tennessee native will sell his practice. His staffers say they're not looking forward to the questions the hospital's medical records system will soon prompt them to ask patients. (Do you wear a bike helmet regularly? Do you have a smoke detector?) 'We'll try to retain as much professional independence as possible,' Erb says, gazing at the hospital building, whose bulk he can see through his window. 'But the fact of the matter is, we'll have a new master.'

So I for one do not welcome our new executive overlords.

We have posted about numerous examples of health care organizational leaders who put their own enrichment ahead of the mission. Now even ostensibly non-profit hospital systems are increasingly competing against for-profit systems. We have seen, as noted above, an example of a for-profit system that seems to betting everything on a business strategy to reduce "leakage" of patient referrals.  We can expect that non-profit hospital systems will have to act more like for-profit systems, and the perverse financial incentives given the managers of all hospital systems will lead to pressure on physicians to forgo their responsibilities to provide the best care to individual patients in favor of actions that will bring in the most money in the shortest time.

We seem to be witnessing the rise of the corporate physician, the rise of a physician who must first answer to managers who never committed to putting patient care first, who may have no sympathy for physicians' core values, who may receive huge incentives to maximize short-term revenue no matter what. Such a rise of corporate physicians would be unprecedented in the US, and I believe in any developed country.

The rise of the corporate physician would require patients to put their trust in corporations, rather than individual doctors, in the era of the global financial collapse, in the new gilded age.

We may be seeing the end of health care world as we know it. The upcoming brave new world of health care may be worse that we can imagine.

What is to be done? - I rarely have ventured into specific policy suggestions, but I think that the consequences of the well-intended "accountable care organization" blunder may be so severe that I must so venture now. We must derail the movement towards "accountable care organizations." Any movement to make organizations more accountable cannot do so by making most professionals into employees answering to the sorts of ill-informed, incompetent, self-interested, conflicted or even corrupt leaders that we have been writing about for more than six years on Health Care Renewal.  We need to make it impossible for for-profit companies to employ physicians to take care of patients.  Maybe we need to think about making it impossible for for-profit companies to provide patient care at all, and for for-profit companies to sell health insurance.  Meanwhile, we need to ensure the accountability, integrity, transparency, and honesty of leaders of health care organizations.

If we do not reverse the current trends, anyone who wants good health care may have to look for it somewhere other than in the US.

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On an EMR Forensic Evaluation by Professor Jon Patrick from Down Under: More Thoughts.

Note: the reports to which this post refers are available as a set of PDF's from the University of Sydney, NSW, Australia at this link (12 Mb, .zip folder), or at "A study of an Enterprise Health information System" at http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146.

March 6, 2011 addendum. Also see my new post "What to do about the state of the ED EHR in NSW?"

Over ten years ago now, 1999 in fact, I started my healthcare IT difficulties website.

That site, "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" now resides on a Drexel University server in Philadelphia, Pennsylvania USA at this link, and used as a teaching resource.

I started the site after observing, for lack of a better description, "crazy stuff" in the commercial healthcare information technology sector.

Crazy stuff such as EMR systems for ICU's that crashed regularly and spread pathogens around, EMR's for invasive cardiology cath labs that were an informational jumble and abyss and that also issued regular General Protection Faults and died, lack of Medical Informatics expertise (and actual disdain for it) in healthcare IT projects, grossly incompetent IT leaders, and hospitals uncritically and enthusiastically buying these products as if they were a plug and play, proven technology.

To make matters worse, I also observed executives expressing a hostile indifference to glaring deficiencies.

My observations about health IT and about responses to my counsel brought to mind the biblical passage:

"Give not that which is holy unto the dogs, neither cast ye your pearls before swine, lest they trample them under their feet, and turn again and rend you." - Matthew 7:6

I was never afforded the opportunity to perform a forensic analysis of the internals of these systems, being that I was not allowed to obtain the software or "schematics" of the data structures. In fact, to make the cardiology system usable, I ordered the IT staff to simply discard the internal data dictionary, relational data structures, input screens, and analytic routines, and rebuild them - from scratch - using a proper Medical Informatics-based, cardiology domain expert-driven, iterative and incremental (agile) approach.

The result was a resounding success, and was described in a written report as "exceptional" by national specialty association reviewers invited to evaluate the effort.

(A success for which, I might add, I and my enlightened executive sponsor were paradoxically demonized by the IT department and hospital executives; cf. Matthew 7:6.)

Now, an Australian researcher of considerable computer and database expertise, Professor Jon Patrick at the University of Sydney, has put considerable ink to a forensic evaluation of the internals and external reactions to an EMR system "built in America", Cerner Firstnet.

Professor Patrick holds a Ph.D. from Monash University. He came to the University of Sydney from Massey University, New Zealand, where he held the foundation Chair of Information Systems. Professor Patrick won Australia's national Eureka science prize in 2005 for developing a natural language processing system that detected financial scams in web pages at the behest of the Australian Government.

FirstNet is an ED EHR that government officials decided must be installed in ED's of public hospitals throughout the Australian state of New South Wales. Promo material below, click to enlarge:

FirstNet promo material, page 1. Click to enlarge. (Hmm ... Is there a subliminal message in the picture of the doctor and nurse?)

FirstNet Promo material, page 2. Click to enlarge.

The initiative's been underway for several years, and the result is a group of apparently very unhappy Wal-Mart shoppers. (I guess the correct line would be "unhappy Big W shoppers" for those Down Under.)

Prof. Patrick had written a preliminary essay on the issue entitled, in rhetorical question-style, "The Story of the Deployment of an ED Clinical Information System: Systemic Failure or Bad Luck?" back in 2009. He apparently found himself in considerable hot water for doing so due to 'pushback' as I described at "Academic Freedom and ED EHR's Down Under: An Update". However, his university stood by him in defense of academic freedom (and of the sanctity of those in the healing arts, I might add).

He's spent the intervening time expanding the analysis of the ED clinical system and its deployment considerably, right down to the fine nuances of relational database design in complex domains (such as biomedicine).

As I wrote in an initial post "A Study of an Enterprise Health information System - Finally, an Informatics Scientist Does A Rigorous Review of a Commercial EHR System, by Cerner", the TOC of his new analysis are these (the files are available as a .zip archive at this link):

3.0 Part 0 - Executive Summary
3.1 Part 1 - A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck? First published here in Oct 2009, revised Dec 2009.
3.2 Part 2 - Discussions with ED Directors: Are we on the right track?
3.3 Part 3 - Discussions with Software Performance Experts.
3.4 Part 4 - Conceptual Data Modelling.
3.5 Part 5 - Database Relational Schema and Data Tables.
3.6 Part 6 - Coalescing the Analyses of the ER Diagrams, Relational Schemata and Data Tables.
3.7 Part 7 - The Integrated Assessment.
3.8 Part 8 - Future HIT Regulation Proposals.
3.9 Part 9 - Ockham's Razor of Design. Published at the IHI conference, Nov 2010 Washington.

I have been reading these sections, and have found the technical sections (parts 4-6) highly informative about a major suspicion I've held for many years.

I suspected chaos in the health care IT software engineering process, with inadequate attention to quality, rigor, fine detail, resilience engineering, talent management and other practices essential in development of mission critical products of any type.

Prof. Patrick's forensic analysis, while not proof of my concerns, certainly supports them. If Boeing produced aircraft with malfunctioning engines, broken seats, defective flaps, tires that blew on landing, and rust right out of the factory (like the Chevy Vega of old?), one might suspect the development and manufacturing environment could be substantially problematic.

The theme of apparent violations of fundamental precepts of relational database design run consistently through his analysis of the FirstNet product.

Without getting too technical (which I can, having written successful relational database-based clinical information systems of considerable complexity for challenging environments, with novel user interaction design besides), I see evidence of developmental chaos.

Examples: primary key-foreign key inconsistencies and problematic usages ("keys" are flags used to link sets of information about some object or entity, such as a patient to their diagnoses or meds), internal field nomenclature faux pas (there are best practices on how to do this to enhance software quality and maintenance), cryptic documentation , "stale bits" (old code and data) from past iterations remaining to create "glitches", unreliabilities and new problems, and other technical sins apparently abound.

These can be read about in sections 4-6 of Prof. Patrick's analysis. The issues can be summarized as he did in the part 6 Abstract:

Consistent weaknesses in sections of the Millenium clinical information System (CIS) are revealed in the combined study of the ERD (entity-relationship diagram), logical schema and the data tables. PK (primary key, i.e., unique identifier) values are not always defined unambiguously at the design level and data tables reveal inconsistencies in declarations and data validation. There is evidence that keys are managed by software within the application rather than by the in-built functions available in the database management system leading to less confidence in data integrity.

He goes on to relate:

The [technical design] weaknesses in terms of clinical work practices, that have been identified are only likely to show up in occasional circumstances with a combination of processing and data values separated in time. [In other words, the resulting errors are unpredictable, and depend on variable factors about the patient's data and user's attempted actions that cannot be predicted ahead of time - ed.] Staff are not likely to associate one instance of missing or mis-processed data with another. This spasmodic nature tends to lull staff into a false sense of security that the mis-processing is either inconsequential or an accident of their own making. We recommend that each and every mis-processing experience be recorded as accurately as possible so that appropriate computational forensic analysis can correctly identify if weaknesses in the underlying technology have been the source.

These are dead-serious matters, literally. One's well being in an ED should not depend on random chance. If you are the "lucky patient" who Wins the Lottery or Hits the Jackpot on health IT mis-processing, or whose clinicians are distracted by user experience flaws, "workarounds", demoralization or other issues, you might end up maimed - or in the grave.

The ED EHR Slot Machine. Click to enlarge. You've hit the ED EHR mis-processing jackpot! Perhaps today is a good day to die...

I do not believe mission critical software for, say, avionics, or for implantable medical devices, suffers such sloppiness. (In part due to regulation, which health IT lacks entirely in the U.S.).

The UK, having their own HIT issues (see my Aug. 2010 "Battle of Britain" post at this link), apparently learned something, as evidenced in:

Health informatics — Guidance on the management of clinical risk relating to the deployment and use of health software. UK National Health Service, DSCN18 (2009), formerly ISO/TR 29322:2008(E).

and

Health Informatics — Application of clinical risk management to the manufacture of health software. UK National Health Service, DSCN14 (2009), formerly ISO/TS 29321:2008(E).

That said, I will now comment in more detail on a part of the analysis readily understandable by 'database laypeople': part 2, "Discussions with ED Directors: Are we on the right track?" (again, probably a rhetorical question).

In this section, candid discussions were held with the Directors of seven Emergency Departments in New South Wales public hospitals assessing the impact of the introduction of the FirstNet information system into their ED's. The effort has been ongoing for approximately the last 5 years.

Numerous themes remind me of my own observations as in my aforementioned Drexel health IT difficulties site:

The implementation processes of the HSS [governmental Health IT support, a.k.a. Health Support Services - ed.] were criticised for refusing to acknowledge the validity of complaints, failing to fulfil promises, creating an ineffective change process, refusing to consult clinicians, using strategies to disenfranchise participation by clinical staff, and introducing a technology that doesnʼt fit their needs.

All of these themes are familiar to me, and are representative of the phenomena of non-clinician, IT-centric arrogant ignorance, paternalism, leadership-pyramid inversion (i.e., the facilitators thinking and acting as if they are the enablers of healthcare), playing nasty politics with clinicians to avoid work, and minimizing job and results-evaluation discomfort for those lucky enough to secure cushy IT jobs in health IT support.

In determining the clinical documentation needs of staff, the Directors claim that the HSS ignores the needs of staff. Directors report over-supply of irrelevant information and under-supply of needed information in the clinical interfaces. ["Legible gibberish" - ed.] The environment consists of counter-intuitive interfaces where data is entered by one person in one part of the system so that it is not discoverable by another person.

The interfaces have inappropriate sizing of objects, confusing functions, redundant steps, unused functions and cluttered interfaces. These difficulties have resulted in increased time usage on the system resulting in decreased time with patients for no gain in administrative or clinical outcomes. Staff minimise their use of the system to as little as possible with work arounds being constantly developed and improved. Staff morale has been clearly degraded with accompanying loss of respect for the HSS and more generally NSWHealth’s authority.

These concepts are described and illustrated in my multi-part essay on the healthcare IT mission hostile user experience at this link. They represent major deviations from good information science, information presentation and human-computer interaction (HCI) precepts.

... Workarounds in using the system are the most obvious tangible response of staff to the functions of the system they consider unsatisfactory. The key aspect of workarounds is that they constitute a subversion of the policy processes created by the software that the staff are not prepared to collaborate with. Some of these strategies may even compromise the legal status of the records in the system: such as not signing documents, unrecorded alterations to documents, and test results not attached to patient records.

... Another form of staff protest workaround is the strategy by staff to avoid using the system by either having other people [presumably underlings - ed.] do the work on the system, inserting minimal amounts of information thereby reducing the value of the information and passing information to other staff verbally.

Workarounds to IT obstacle courses and booby traps, as noted by Koppel, Wetterneck, Telles & Karsh in "Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety", J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23, increase, not reduce, the risk of EHR-mediated medical errors. I wrote about their findings at "Business v. clinical computing: Workarounds to Barcode Medication Administration Systems" at this link.

It should be kept in mind that these are mission-critical systems for use in a fast-paced ED, not tracking systems for widgets - or for lab rats.

The lack of appropriate reporting functionality of the system has had a serious impact on the critical work of the Directors on process improvement ... It was evident in talking to the Directors that they have antennae highly tuned to the processes happening in their departments and the public health issues that emerge from their patients.

On a daily, weekly and monthly basis they review single cases, collections of common cases, and variations in established disease profiles to understand the success of their work and to detect emerging new trends or potential new disease outbreaks. At an administrative level they are asked to review cases either because of the return of new test results or due to complaints or reviews from other bodies.

The FirstNet installation has removed all the reporting functionality the directors had in their previous system EDIS while destroying their information sources for process improvement, and their mechanisms for creating and collaborating in research projects. This, in turn, has led to a loss of motivation to enter data further degrading the value of the data held within the system.

Reducing the value of a tool to people, and decreasing their ability to perform their jobs (especially when they take great professional responsibility and pride in those jobs) predictably leads to demoralization, demotivation and a cascading path down a whirlpool of failure.

The disadvantages of the system for day to day operations is well demonstrated by the issues around the ordering system. It is stated to be overly complex and requires a large deal of repetitive information to be input for multiple orders on one sample, plus specialist data entry knowledge that requires every joint order to have exactly the same timestamp. Ordering was the first accession where staff recognised that information is sometimes sent to the wrong staff, both arriving where it shouldn’t and not arriving where it should.

... Further mis-processing is seen with the cancellation of orders when a patient is transferred to a hospital ward from the ED. The results of orders, particularly radiology, often need to be checked by senior staff, but the system has no functionality to enable efficient processing of orders that have normal results, and thereby require no further attention.

I do recall another EHR system, by the same vendor I believe, where an "upgrade" in the recent past led to orders ending up in the wrong places (link):

... Computers at a major Midwest hospital chain went awry on June 29, posting some doctors’ orders to the wrong medical charts in a few cases and possibly putting patients in harm’s way.

The digital records system “would switch to another patient record without the user directing it to do so,” said Stephen Shivinsky, vice-president for corporate communications at Trinity Health System. Trinity operates 46 hospitals, most in Michigan, Iowa and Ohio.

[In other words, data entered by clinicians was going into the wrong charts. How many charts were involved? Does the hospital system even know, I wonder? - ed.]

Less than two weeks later, an unrelated glitch caused Trinity to shut down its $400 million system for four hours at 10 hospitals in the network because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, he said.

Not to pick on this vendor; these "glitches" seem to be occurring in many HIT vendor's products.

All this, dear readers, is simply madness.

... Patient record retrieval is an important aspect of the staff work with patients, therefore its efficiency and accuracy is of vital importance to the activities of the ED. Staff were particularly pointed about the deterioration of this functionality in FirstNet compared to the previous system EDIS. [ED information system - ed.] There were cases where records could not be found, confusion about where data was stored in the patient record with different staff writing the same information into different parts of the record, and the [manual] rewriting of records [requiring a large amount of additional labor and time, not exactly a commodity in an ED -ed.] due to insertion of content into the wrong record.

These are critical issues. If you can't get information out of a computer in a timely fashion, what you have is a very expensive doorstop. I also note that a document imaging system that images hand written charts would not have these problems...

Prof. Patrick addresses the oft-heard canard that such complaints are the complaints of "Luddite doctors", old dogs who simply don't want to learn new tricks:

The staff in the ED are now generally experienced at using some form of clinical information system, many for over 10 years. This experience gives them a keen sense of what is possible with technology as well as the deficiencies in the existing systems. Combining this experience and knowledge with a sense of professional responsibility for process improvement enables them to judge quite acutely when a system is well designed or not. Hence their observations about elements of systems that are not parsimonious enough for optimal clinical efficiency deserve to be respected.

That it even needs to be written that the opinions of experienced medical professionals on the tools they are coerced to use by non-medical outsiders "deserve to be respected" gives testimony to my observation of a cross-disciplinary invasion of healthcare by the IT profession (among others).

Workflow and dataflow and the continuity of these processes are vital to the smooth running of a complex socio-technical process. ED staff have shaped these flows over a period of years and socialised all staff into the streaming. The directors have found that with the workflow of staff needing to use both clinical and nursing notes at the same time, their separation in FirstNet is deleterious. One department considered that the many nursing and medical notes accumulated over a day had to be kept in a single continuous sequence in the clinical record. Their workaround was to keep the one note page open for 24 hours to maintain the needed continuity in the patient record and avoid staff using a significant amount of time at the computer searching for needed information.

Nemeth and Cook explain how an ED EHR can be developed and marketed that interferes with, not supports, the workflows common in ED"s worldwide, in "Hiding in plain sight: What Koppel et al. tell us about healthcare IT", J Biomed Inform. 2005 Aug;38(4):262-3:

... On the surface, healthcare work seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain. Occasional visitors to this setting [i.e., IT personnel, non-medical bureaucrats, etc. - ed.] see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it.

The technical work that clinicians perform is hiding in plain sight. [Hiding from the uninformed, that is - ed.] Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it. Progress in healthcare IT systems relies on scientific data on the actual, not the perceived, nature of day-today operations.

It increasingly seems the only place the faux-expert, healthcare-facilitor, cybernetic snake oil salespeople are going ot learn this simple lesson is in the courtroom...

A recent article in the press has presented evidence that access block times in EDs across the state of NSW are worsening.

As regards causality, it perhaps takes being an IS dept. director in a hospital - or holding elected office - to be unable to recognize the nose at the front of one's face.

Prof. Patrick wraps up this section of his forensic analysis as follows:

A number of conclusions can be drawn from the study:

1. Staff are entirely dissatisfied with the SBB and they feel that the deliverables have significantly failed to match the promises.

2. The Directors see that the HSS have failed in their support of the frontline of emergency care across the Sydney basin and their practices are decidedly lacking in proper engagement with the user community which should be their primary concern.

3. Some of the consequences of the HSS decision not to provide the reports needed by the Directors have lead to them being seriously hampered in being able to monitor the quality of their own department’s practices and wider changes and trends in community health.

4. The inefficiencies introduced by this technology have lead to a litany of complaints about its behaviour that have gone unheeded over the past three years.

5. It has lead to major strategies to work around the system by staff at all levels, to the point of complete avoidance by some staff.

The major consequences of these failings in the eyes of the ED directors are:

• Lost productivity and inefficiencies,
• Increased risks to patients,
• Disillusionment of staff and loss of morale.

Considering my own relative's injuries originating in an ED EHR mishap, I think I can safely add to Prof. Patrick's final tally an additional item:

• Patients have been harmed.
  

This is not a pretty picture.

I'm confident the Australian legal system abhors negligence as much as our own here in the U.S. If patients are injured and/or die as a result, considering that the Programme leadership and IT vendors knew - or should have known - of these deficits, it would not surprise me if criminal negligence charges begin to appear.

These issues are not exactly rocket science, and an expanding literature base has been appearing in recent years. See, for example, my recent post "An Updated Reading List on Health IT" at this link.

I can only add that my own relative was nearly killed as a result of a number of the phenomena described in Prof. Patrick's analysis.

More on other sections of his report at another time.

-- SS

March 6, 2011 addendum:

Also see my new post "What to do about the state of the ED EHR in NSW?"

-- SS

Mar. 8, 2011 addendum:

Prof. Patrick has added a new section to his report, entitled "The Future Pathways for e-Health in NSW." It is available at this link (PDF).

It inoculates against most of the 'Ten Plagues' that bedevil health IT projects (such as the IT-clinical leadership inversion, magical thinking about the technology, and lack of accountability):

More on the Pathways at my post here.

The de facto "National Program for IT in the HHS" here in the United States needs a similar inoculation.

--SS

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Here Comes the Judge! A Quick Thought on Cybernetic Medicine: Why Can't Computers Also Do Law?

At my Jan. 2011 post "IBM's Watson, Jeopardy, and Revolutionizing Medicine" I lamented that with every new computer advance since the 1950's, soon to follow was a prediction of cybernetic advancements in medicine, such as this:

... A Watson-like system can take that information and co-relate it against all the medical journals and relevant information, and say, "Here's what I think and why," while showing its evidence for how it came up with the conclusion, according to Frase [vice president of industry solutions and emerging business at IBM Research].

The following recently occurred to me in the early morning hours as I watched the sun rise:

I wonder why there are no suggestions of replacing lawyers with computers.

After all, a Watson-like system can take lawsuit information and co-relate it against all the legal journals and relevant information, and say, "Here's what I think and why," while showing its evidence for how it came up with the conclusion. No need for lawyers and their cognitive processes and judgment!

Right?

The judge could be replaced by a cyber-judge. Judge Alex and Judge Judy, you've met your match. Here comes the cybernetic judge...

Order in the Court, Cause Here Comes the Judge! Click to play video.

A set of Watson-like systems could even serve as a jury, being capable, as we know, of flawless human judgment.

... The jury findings, your honor Judge Watson are:

Bob Watson: defendant is guilty by algorithm.
Mary Watson: defendant is guilty by algorithm.
Judy Watson : defendant is guilty by algorithm.
Frank Watson: defendant is guilty by algorithm.
Tom Watson: defendant is ... xoxooxo1011001%$&#@#

(Oops, sorry, your cybernetic Honor, Tom's primary CPU crashed.)

Think of the possibilities...

Perhaps Watson could even be programmed to, say, determine if a proposed law is constitutional or not? No more Supreme Court!

Like medicine, cybernetic practice of law should be child's play, no?

-- SS

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