Gatling Gun

I have often heard the refrain that while away from one's home in Terre Haute, one can withdraw money from an ATM machine in Timbuktu. So, why can't my medical records from birth be called up instantly from the Timbuktu Regional Hospital if I fall unconscious at the Festival au Désert and forgot my wallet?

In other words, computing in the banking industry is perfected, so why can't healthcare get its act together? (Irrespective of the sea change of difference between simple financial data and incredibly complex medical data.)

Not so fast, health IT Ddulites:

New York Times
February 9, 2012
Users of Citibank Bill-Pay App Charged Twice
By BEN PROTESS

A program error at Citibank was not detected for months.

Citigroup’s effort to become “the world’s digital bank” has encountered a snag. ["Glitch" is the health IT-specific term - ed.]

A technical bug caused Citi, the nation’s fourth largest bank by deposits, to double the charge for customer payments in recent months. Some customers using their iPads to settle their cable bill or mortgage payment, for example, actually paid twice, according to customers and a bank official.

The problem, which began in July but went undetected by the bank until December, prompted bogus payments big and small. Some customers quickly spotted the redundant transaction and complained to Citi, while other consumers were caught off guard when the bank recently notified them of the discrepancy. The snag even led some unsuspecting customers to overdraw their accounts, though a bank spokesman said that was rare.

Citi has traced the error to its nascent iPad application. Other mobile applications and the bank’s broader online bill payment system were immune from the problem, the bank said.

But a few clients who were charged twice said they had not used an iPad to pay bills. And the Citi spokesman declined to disclose the number of customers caught up in the mishap, saying only that it amounted to “a limited number of clients.”

[It would appear that Citi was not in complete control of its systems; the systems were in control of Citi - ed.]

Instead, the spokesman said that fewer than 2 percent of Citibank transactions executed through an iPad were counted twice. The spokesman would not elaborate on the number of iPad transactions at Citi, citing concerns about releasing proprietary data.

[2% of a very large number is still a large number - ed.]

... While Citi may be the first company to stumble with the iPad, it is far from the only bank to encounter electronic hiccups. Customers have long been befuddled by accidental A.T.M. withdrawals and so-called transaction gaps, where a customer pays online but the transaction fails to process. A number of regional banks have also double-dipped with customer payments and even JPMorgan Chase, the nation’s biggest bank, recently had a minor brush with duplicate online withdrawals.

The mishaps, while minor, underscore the risks that customers face when banks wade into the fledgling world of online banking.

[That's peanuts compared to the risks they face when hospitals wade into the fledgling world of electronic medical records and CPOE - ed.]

While banks are scrambling to please customers who prefer clicking a mouse to dealing with tellers, the industry is learning that new technologies come with some growing pains.

“It’s a challenge for banks to keep up with the device proliferation — everything is moving very fast,” said David Albertazzi, a senior analyst with Aite Group, which advises financial institutions on technology and regulatory issues. “It is very important that financial institutions balance speed-to-market versus safety and soundness.”

[Healthcare seems immune from that wise caveat. 'Full steam ahead, icebergs be damned' seems the siren call for IT in that domain - ed.]

... Last year, JPMorgan Chase owned up to its gaffe, a technical hitch with an online cash transfer system, within a day. “People make mistakes. Unfortunately, we made one twice,” Ryan McInerney, Chase’s chief executive of consumer banking, told customers, who received a $25 cash bonus for their troubles.

[Every excuse term in the book's been used here - growing pain, hiccup, snag, bug, hitch, flaw - except one - 'incompetence' - ed.]

Citi’s response, however, appears to have been not nearly as prompt. The error began in July, within days of the bank introducing its gleaming new iPad application. The coming-out for the application included a press release announcing the “new standard for digital banking” with a “one-of-a-kind app.”

... “EBusiness professionals at retail banks — and other financial institutions — should pay close attention to what Citibank has done, particularly its willingness to experiment and try out new ideas in a brand-new channel,” Forrester Research, a technology research company, said in a report.

[Healthcare IT is a big experiment, except it's not just dollars and cents that can get farkled - ed.]

But almost immediately, a smattering of anonymous customers began posting concerned comments online, wondering whether it was their own fault — the product of double-clicking. Then fingers began to be pointed at the bank. One online commenter posting on the company’s Apple store Web site called the application “very unreliable.”

In late December, the bank tracked the error to an internal flaw. A technical command on the bank’s iPad application, it turned out, was wrongly set to redo transactions that had initially failed.

The bank began alerting customers to the snag in mid-January, and made another round of calls this week, including to clients who say they had not paid their bills through the iPad.

... Citi has had other technology problems in the last year. Last summer, the bank disclosed that hackers had stolen the names and addresses of hundreds of thousands of North American credit card customers. A week later, the bank revised its estimates, saying that about 80 percent more customers had been ensnared than previously thought.

The breach, which did not include Social Security numbers or security codes, was a lesson for Wall Street firms. Big banks, experts say, are now more reluctant to estimate the scope of a problem in case the numbers grow.

“It’s very challenging to really pinpoint the number of customers affected,” Mr. Albertazzi said. “It’s the nature of the beast.”

If these growing pains, hiccups, snags, bugs, hitches, and flaws are the "nature of the beast" in electronic banking systems, one can only wonder why banking is held up to be the "gold standard" that healthcare has to equal.

Healthcare has a long tradition and obligations to implement new technologies with the greatest of caution and care, using clinical trials based on the scientific method, and with informed consent. Banking lacks such traditions. The healthcare IT industry has largely abandoned them.

While a bank's computing may make a mistake with a decimal point, a hospital's computer errors can injure or kill people.

The current rush to universal health IT needs to slow down. Further, HIT industry pundits need to stop making comparisons to other industries that are both irrelevant and unwarranted.

-- SS

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The Texas TMAP Trial as Illustration of a Systematic Stealth Marketing Campaign

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A Critical Review of a Critical Review of e-Prescribing ... Or Is It CPOE?

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Health IT: Ddulites and Irrational Exuberance

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More cybernetic miracles: 14,000 patients failed to receive follow-up outpatient appointments

14,000 is a lot of patients to miss followup appointments. I do not think this feat could have been accomplished via paper:

Morecambe Bay missed 14,000 outpatients
E-Health Insider.com
7 February 2012
Lyn Whitfield

University Hospitals of Morecambe Bay NHS Foundation Trust is working through a backlog of 14,000 patients who failed to receive follow-up outpatient appointments because of administrative and IT problems.

And problems with disappearing ink and Fido, the office canine, chewing up charts, but mostly the IT.

The report of an investigation into the backlog paints a damning picture of failures at the trust, which became the first to introduce the Lorenzo electronic patient record system as part of the National Programme for IT in the NHS.

That would be, the failed National Programme for IT in the NHS, the NpfIT that went Pffft (perhaps the world's most expensive onomatopoeia, at a mere £12.7bn).

The report says the problems go back many years and have their roots in a ‘mismatch’ between demand and capacity at Morecambe Bay, as well poor management and risk practices and a culture of avoiding blame.

However, it also says the trust missed a big opportunity to identify and tackle the problems when it introduced Lorenzo [a health IT system - ed.] in June 2010, and that staff work-arounds contributed to the ultimate size of the backlog.

That is, workarounds to system flaws and 'glitches.'

Eventually, there were 37,000 access plans on the Lorenzo system for which a guaranteed access date had been missed. Many of these plans were duplicates or had not been closed.

However, 14,000 patients needed to be seen and were divided into cohorts so the trust could deal with them. All these patients should have been seen by the end of March.

For the future, the report says the trust needs to establish better systems, find ways to make sure that the board knows what is going on, encourage staff to take responsibility for dealing with problems, and curb the “mal-use” of Lorenzo by imposing “sanctions” on staff if necessary.

Once again, blaming the IT users and punishing them for not conforming to the diktats of the IT and its designers.

It also says the findings of the report, and the importance of “electronic, standardised and systematic management of outpatient follow-ups” should be shared with all providers, in case others are suffering the same problems on a smaller scale.

"In case?" It sounds like they don't even know.

... when a backlog was identified during the data cleansing process for the introduction of Lorenzo, the trust failed to recognise it as a clinical problem.

Instead, to try and solve another administrative problem – the constant cancellation of clinics – the trust introduced a ‘partial booking’ system. Patients who needed a follow-up in more than six weeks were asked to call for an appointment.

“No arrangements were made to account for the 1,000 or so calls that the clinical clerks would receive per week, whilst still trying to man the reception desk and administer the clinics,” the report says. “This created chaos and confusion for patients and staff alike.”

Sounds like a government operation to me.

Patients were often offered late appointments – “some of which arrived with the patient only after the clinic had taken place.”

All of this caused patient and GP complaints, but because they seemed to relate to administrative problems, their real, clinical nature was overlooked.

In the middle of all this, outpatient staff complained that Lorenzo was slow – although the report says there is no evidence that it was slower than the system it replaced [ignore the users - their complaints are all 'anecdotal' - ed.] – and that it was more complicated to complete a booking.

As a result, “many staff found ways around that were quicker, but these were responsible for patients having multiple access plans, which helped to label the problem as administrative.”

You never have to work around something that is not in your way.

Floor walkers initially monitored such “inappropriate” use, but this stopped once Lorenzo had stabilised. [The computer police...how charming. - ed.]

Morecambe Bay is the first and most prominent of the ‘early adopter’ sites for Lorenzo, which was due to be implemented in the North, Midlands and East by CSC [an American management consulting firm - ed.] as local service provider.

The problems at the trust, CSC’s failure to complete the ‘early adopter’ programme, and critical reports from watchdogs and MPs on progress, have thrown a new LSP deal into doubt.

I presume they mean critical reports from MPs like this, and other reports like this from Parliament's Public Accounts Committee a few years back that stated, among many other findings, that:

... The [NPfIT] Programme is not providing value for money at present because there have been few successful deployments of the [U.S. Cerner] Millennium system and none of Lorenzo in any Acute Trust. Trusts cannot be expected to take on the burden of deploying care records systems that do not work effectively. Unless the position on care records system deployments improves appreciably in the very near future (i.e. within the next six months), the Department should assess the financial case for allowing Trusts to put forward applications for central funding for alternative systems compatible with the objectives of the Programme.

Charming.

CSC announced last week that it was going to lay off 500 staff, including 46 from iSoft, which developed Lorenzo, and which CSC bought last year.

I'm sure that will help speed up software remediation.

-- SS

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Perhaps Hospitals Don't Care Much That EHRs Can Be Dangerous, Because EHRs Lets them Attract 'Good Paying Customers' And Exclude the Old and Poor

This comes as no surprise to me. I believe it may help explain hospital's cavalier attitudes towards the risks of today's commercial health IT.

It's all about money.

We already knew that (for example, see my Feb. 2011 post "Does EHR-Incited Upcoding (Also Known as 'Fraud') Need Investigation by CMS, And Could it Explain HIT Irrational Exuberance?"), but the following news adds to the pecuniary motivations:

Kaiser Health News

Critics say hospitals cherry pick best-paying patients
By Phil Galewitz
KHN Staff Writer

Feb 05, 2012

When the oversized postcard arrived last August from Provena St. Joseph Medical Center promoting a lung cancer screening for current or former smokers over 55, Steven Boyd wondered how the hospital had found him.

Boyd, 59, of Joliet, Ill., had smoked for decades, as had his wife, Karol.

Provena didn't send the mailing to everyone who lived near the hospital, just those who had a stronger likelihood of having smoked based on their age, income, insurance status and other demographic criteria.

The nonprofit center is one of a growing number of hospitals using their patients' health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether they have children or pets at home.

Hospitals say they are promoting needed services, such as cancer screenings and cholesterol tests, but they often use the data to target patients with private health insurance, which typically pay higher rates than government coverage. At an industry conference last year, Provena Health marketing executive Lisa Lagger said such efforts had helped attract higher-paying patients, including those covered by "profitable Blue Cross and less Medicare."

Not to mention helping exclude those covered by Medicaid, or the uninsured.

Strategy Draws Fire
While the strategies are increasing revenues, they are drawing fire from patient advocates and privacy groups, who criticize the hospitals for using private medical records to pursue profits.

I don't recall anywhere on the releases at area hospitals saying they would be using their own clinical data for marketing purposes (which likely involve third party contractors). It might be in the fine print, however. I also don't recall any place to sign and give informed consent to the use of experimental medical devices such as the EHR's used to collect the marketing data, either, but that's addressed elsewhere on this blog such as here.

Doug Heller, executive director of Consumer Watchdog, a California-based consumer advocacy group, says he is bothered by efforts to "cherry pick" the best-paying patients.

"When marketing is picking and choosing based on people's financial status, it is inherently discriminating against patients who have every right and need for medical information," Heller says. "This is another example of how our health system has gone off the rails."

I would go beyond "off the rails." How about, straight to perverse? EHR data is used to attract paying customers and then expose them to risk of being maimed due to the disruptive nature of the HIT itself.

Deven McGraw, director of the health privacy project at the Center for Democracy and Technology in Washington, says federal law allows hospitals to use confidential medical records to inform patients about things that may help them.

"If it's technically legal, we can do it, and who gives a damn about the ethics?" is what is being expressed here.

"You want health providers to communicate to patients about health options that may be beneficial to their health," McGraw says. "But sometimes this is about generating business for a new piece of equipment that the hospital just bought."
Using such information for marketing "creeps closer to the line," between what is legal and what is not, she says.

And helping recoup the costs of that hundred-million dollar EHR setup, too.

... Tess Niehaus, vice president of marketing at St. Anthony’s Medical Center in St. Louis, says the approach has been quite successful and makes no apologies for going after the most lucrative business.

"We are here to serve everybody but we market for good paying patients because it preserves our ability to serve everyone," she says. [And the ability to proffer generous executive salaries and raises - ed.]

"Good paying patients?" Does that imply there are bad paying patients? (Might those "bad paying patients" be predominantly the elderly and/or minorities?)

While the practice is legal, most people would be shocked to know their records may be shared with nonmedical personnel and outside firms to help hospitals attract business, says Pam Dixon, executive director of the World Privacy Forum, an advocacy group based in California. "I am really bothered by the overabundance of information that is flowing that is unnecessary and risky," she says.

As I've written before, don't worry, your most sensitive data's safe in the hands of the extremely skilled health IT professionals at most hospitals.

While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to – additional tests and procedures, including surgery.
"It's all about downstream revenue," says Patrick Kane, senior vice president of marketing at Cape Cod Healthcare in Massachusetts who used such approaches at Wellmont Health System in Kingsport, Tenn. "The old adage in business is that it’s easier to sell an existing customer new services, rather than find a new customer."

So much for medical professionalism and conservatism. At least Mr. Kane admits it's all about money.

... Provena's Lagger says the approach boosted the system's bottom line so it could serve people regardless of insurance status. "This is a means to an end," she says.

The ends don't always justify the means, but that may be a hard concept for some in today's amoral culture to understand.

... Much of the expertise for such campaigns is provided by three consulting firms -- CPM Marketing of Madison, Wis., Medseek of Birmingham Ala. and New York-based Thomson Reuters. They typically charge hospitals $100,000 a year or more.

CPM, which merged in November with Denver, Colo.-based HealthGrades, a health ratings firm, added 100 new hospitals last year to give it a total of 400. Medseek works with more than 250 hospitals and Thomson Reuters, with 150.

Remember Darrin Stevens on Bewitched? "Larry, I've got a great idea for a new campaign! Let's troll for patients using their private data! Never mind that I have donkey ears today... that darn mother in law of mine, Endora!"

The targeting worked in the case of Boyd, who called the number on the back and scheduled the CT scan a few days later. The $169 test showed his lungs were clear, but found potential blockages in coronary arteries that his Provena-affiliated doctor is monitoring.
"In hindsight, I’m glad I had the test," he says.

No mention of patients who had unnecessary testing and interventions that led to bad outcomes ... or patients injured by the very EHR systems that make such marketing possible.

-- SS

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