e-HealthExpert.org - Primum non nocere

By Dave Chase In a piece for the New Yorker, Dr. Atul Gawande outlined how, early in the 1900s, more than forty per cent of household income went to paying for food and food production consumed roughly half the workforce. Beginning in Texas, a wide array of new methods of food production were tested. After many [...]

By DAVID FRIEDMAN Reductions in the cost of genetic testing and improvements in what we know about what it tells us produce obvious benefits; if you know you are  likely to have some particular medical problem, you may be able to take precautions against it. But they also have at least one potential downside. The [...]

By Jane Sarasohn-Kahn There are few issue areas within the Beltway of Washington, DC, that have enjoyed more support across the political aisle than health care information technology. In 2004, George Bush asserted that every American would/should have an electronic medical record by 2014. Since then, Democrats and Republicans alike have supported the broad concept [...]

By Kent Bottles, MD Anyone who is concerned about the future transformation of the United States clinical delivery system should pay attention to the Care Innovations Summit. The selection of presentations as well as the content that was discussed says volumes about where CMS believes payment is headed. Speaker after speaker stated that decreasing the [...]

By Darrell Moon Forget Washington and the political debate over Obamacare. The real battle for the future of health care is being fought in the world of business, where tens of thousands of companies have seen their financial well-being undermined by skyrocketing employee health costs. Although few people realize it, employee health costs have now [...]

By ROBERT REICH One of the few things Mitt Romney and Newt Gingrich agree on is that President Obama is turning America into “European-style welfare culture.” In his standard stump speech Romney charges Obama with creating a nation of dependents. “Over the past three years Barack Obama has been replacing our merit-based society with an [...]

By Shannon Brownlee Imagine yourself in front of your computer, looking up information about a drug prescribed by your doctor. Your Internet search tells you that there is a cheaper, maybe even a generic version available, but you have just paid top dollar for the brand name drug. You also learn that another treatment may [...]

By Avik Roy Today, the U.S. House of Representatives will vote on H.R. 1173, the Fiscal Responsibility and Retirement Security Act of 2011, sponsored by Rep. Charles Boustany (R., La.). This two-page bill would repeal the fiscal disaster known as the CLASS Act, Obamacare’s new long-term care entitlement, which was “suspended” by the Obama Administration [...]

By Russ Richmond, MD The world is awash in data. It is estimated that the amount of digital information increases ten-fold every few years, with data growing at a compound annual rate of 60 percent. The big technology company Cisco has forecast that by 2013, the amount of traffic flowing over the internet annually will [...]

By John Goodman Just about everybody in the health policy blogosphere has noted with disappointment the failure of Medicare’s demonstration projects to reduce the costs of care. Recall that these are critical to President Obama’s challenge “To find out what works and then go do it.” If nothing works, the fallback weapon in Obama Care [...]

Despite rising investments by venture capital firms, the health IT field as a whole is poised for no more than 5 to 10 percent growth this year, financial analysts who attended a panel discussion hosted by the Nashville Health Care Council this week predicted.

Factors conducive to continued growth include the impending conversion to ICD-10, the analysts said in remarks reported by Healthcare IT News. "I foresee a slightly better 2012, with the emphasis on slightly," said Darren Lehrich, managing director of Deutsche Bank Securities.

John Moore, founder of Chilmark Research, made a similar prediction in a blog post last month. "There will be plenty more [electronic health record] sales in the year to come, but over 2012 we will also see EHR sales growth begin to plateau and level off by end of Q4 '12," he wrote.

The main reason for these forecasts is that EHR sales have been driven by the government's financial incentives. To get that money, physicians and hospitals have to show Meaningful Use; and if they have not already implemented clinical systems, they're unlikely to meet the criteria in time to get the full amount of federal largesse.

However, there are other issues that could affect sales growth of individual companies in the next year or two. One is how much effect the Stage 2 Meaningful Use criteria will have on EHR vendors. If it is difficult to meet the certification requirements in Stage 2, some firms undoubtedly will drop out. That leads to the other question: Will the disappearance many of the current vendors boost sales of the surviving companies?

Even Stage 1 Meaningful Use undoubtedly has increased the big vendors' sales as physicians with minimal EHRs converted to more capable systems. But the market has already consolidated to some extent. Five vendors accounted for more than half of the Meaningful Use attestations last year, and some observers think that fewer than 10 companies own most of the market. If that's the case, the disappearance of many smaller firms won't have much impact on the survivors.

Nevertheless, venture capital firms see gold in health IT. They poured $633 million into the field last year, InformationWeek Healthcare reported. That was the highest amount since 2001, when they invested $759 million.

To learn more:
- read the Healthcare IT News story
- watch this video recap of the event 
- see the Chilmark Research blog post
- check out an InformationWeek article on venture capital investment
- see an article on Meaningful Use attestation

Related Articles:
Implementation supported needed for small practice EHR adoption to take off in 2012
Provider hesitation, confusion key to slow EHR market growth

Some hospitals pay thousands of dollars more than others for big-ticket medical devices, according to Government Accountability Office (GAO) investigators, The Wall Street Journal reported.  From defibrillators to hip replacements to drug-eluting stents, a portion of those higher costs are coming out of Medicare's pockets.

The report released today surveyed 31 hospitals and found, for example, that one hospital paid $8,723 more than another for an identical implantable cardioverter defibrillator, which typically costs between $16,445 and $19,007. The cost of stents varied by as much as $828 from the typical cost of $1,700 to $1,800 each.

The report "raises serious concerns over the prices hospitals and Medicare are forced to pay for implantable medical devices," said Montana Democrat Max Baucus, chairman of the Senate Finance Committee, who requested the GAO study.

The GAO report says lack of price transparency hampers hospitals' ability to be "prudent purchasers" of medical devices.

Device makers say their products represent only a small portion of the $2.8 trillion in annual health spending and that greater savings could be found elsewhere, according to WSJ. Although confidential price agreements are in part to blame, price transparency could increase costs by discouraging sellers from offering discounts, David Nexon, an executive vice president of the Advanced Medical Technology Association, a device trade group, told WSJ.

Drivers of medical device costs includes healthcare organizations' desire to look better than competing hospitals, as well as doctors who demand hospitals provide them with specific devices, even if identical but less-expensive models are available. The GAO report highlights that latter problem and said contracts between manufacturers and hospitals often forbid price disclosures even to doctors, making it harder to steer doctors to less-expensive options, according to WSJ.

In some cases, hospitals bound by such contracts resorted to using color-coded stickers to help doctors distinguish between cheaper or more expensive devices on stock shelves, the report said.

To learn more:
- read the WSJ article (subscription required)
- see the GAO report (.pdf)

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Cost, usability keep many docs skeptical of health IT

Computerized tests used to determine whether football players and other athletes can return to competition following a concussion aren't always reliable and arguably are relied upon too much, a study published this week in the Journal of Clinical and Experimental Neuropsychology concludes. The study's authors, according to an announcement, find that some tests don't measure functional and metabolic impairments of the brain. What's more, cognitive performance measured by the most scientifically-validated of the tests currently being used--Immediate Post-concussion Assessment and Cognitive Testing (ImPACT)--usually normalizes within three weeks of a concussion, according to the authors, but that doesn't necessarily mean the injured athlete being tested is fully healed. Additionally, they say, such tests can actually harm recovery. Announcement

Since Enthoven called for the break up of the physicians' "guild," and handing over its supposed power to managers, (see post here) managers have taken over from physicians and other health care professionals as leaders of health care organizations.  Unfortunately, most of these managers are generic, often lacking knowledge and experience in health care, and understanding of its core values.  Instead, such generic managers may rely on the current management dogma.  The perils of doing so are illustrated by an analysis of the recent expose of conditions at Apple manufacturing plants in China.

The Apple Expose

The New York Times summarized in a landmark article how bad it is to work in factories building Apple products under contract in China.  Workers endure harsh conditions, toiling up to six days a week, 12 hours a day.  Meanwhile, banners remind them to "work hard on the job today or work hard to find a job tomorrow."  Workers may be exposed to hazardous, even poisonous materials (like n-hexane used to clean components).  Workers have died in explosions due to inadequate control of combustible dust. Over 18 workers at one factory attempted or committed suicide within two years.

The article suggested that while Apple managers may be well-intentioned, and "want to improve conditions in factories," the bottom line is more important:
that dedication falters when it conflicts with crucial supplier relationships or the fast delivery of new products.
In fact, because of its rigid insistence on cost control, its suppliers are sorely tempted to push their workers too hard:
Apple typically asks suppliers to specify how much every part costs, how many workers are needed and the size of their salaries. Executives want to know every financial detail. Afterward, Apple calculates how much it will pay for a part. Most suppliers are allowed only the slimmest of profits.

So suppliers often try to cut corners, replace expensive chemicals with less costly alternatives, or push their employees to work faster and longer, according to people at those companies.

'The only way you make money working for Apple is figuring out how to do things more efficiently or cheaper,' said an executive at one company that helped bring the iPad to market. 'And then they’ll come back the next year, and force a 10 percent price cut.'
So,
'You can set all the rules you want, but they’re meaningless if you don’t give suppliers enough profit to treat workers well,' said one former Apple executive with firsthand knowledge of the supplier responsibility group. 'If you squeeze margins, you’re forcing them to cut safety.'
William Black's Analysis: Employee Control Fraud and the Race to the Bottom

Writing in the Huffington Post, William K Black showed how Apple executives' relentless focus on cost could drive a race to the bottom. He began by analyzing Apple executives' explanation for out-sourcing their production:
'We shouldn't be criticized for using Chinese workers,' a current Apple executive said. 'The U.S. has stopped producing people with the skills we need.'
He noted that it is absurd to suggest that the US does not have workers with the technical skills necessary to build Apple products. He suggests, however, that these are not the skills that matter.
The suppliers want engineers and managers who will selectively apply their substantive skills. American engineers and managers cannot be counted on to provide the necessary selectivity. Apple's suppliers' often seek managers willing to order their workers to exceed the lawful workweek, to refuse to pay them for significant portions of the wages they have earned, to unlawfully employ child labor, and even to coerce abortions.
So, in the n-hexane example,
The engineer did not order the workers to use the nerve poison because he hated the workers. It was 'just business.' The nerve poison reduced cleaning time, so an engineer knowingly ordered the workers to use it and scores of other engineers did nothing to prevent the usage.
Note that Black calls this employee control fraud, deceiving the employee that he or she is working in a reasonably safe environment, and that employee health and safety is a concern, when in truth the only concern is the bottom line.

So what Apple executives, and by analogy, other multi-national corporate executives want are underlings, particularly middle and line managers who will do anything, anything to cut costs and improve the bottom line. This will produce the race to the bottom:
What we are observing is the essence of a Gresham's dynamic in which bad ethics drives good ethics out of the market.

Two aspects of this Gresham's dynamic are obscene, and both are produced by neoclassical economics dogma. Calling this process 'creative destruction' is baseless and dishonest. It is the fraudulent destruction of honest businesses, professions, and labor.
Black concluded:
firms that are anti-employee control frauds are likely to commit other forms of control fraud. Apple and its Western counterparts have driven the creation of an Asian network of fraudulent firms that has distorted international trade, hollowed out U.S. manufacturing, and created a bizarre hybrid: quasi-communist crony capitalism. It boggles the mind that theoclassical economists celebrate the corrupt result as the essence of creative destruction. The network is corrupt. It will not play by the rules. Firms like Apple help create the perverse incentives that encourage the network to cheat. Surviving U.S. manufacturing firms are whipsawed by the powerful Gresham's dynamic that the frauds produce. U.S. firms and workers are constantly pressured to reduce wages and workforce to try to compete with the foreign frauds. This is the 'Road to Bangladesh' strategy that has caused U.S. working class wages to stall for decades. Europe is retreating along this same road at an even more rapid rate. The Gresham's dynamic tilts the world in favor of fraudulent firms operating in fraud-friendly nations. The Race to the Bottom in Health Care
Note that we have written about numerous examples of executives of US health care organizations putting revenue ahead of the health care mission, ahead of workers' morale, ahead of patients' and the public's health. Some of these examples involve executives of nominally non-profit organizations that are supposed to have charitable purposes. (Look under our heading of mission-hostile management.)

In fact, just yesterday, Dr Carl Elliott, writing for the Chronicle of Higher Education, summarized how pharmaceutical companies have out-sourced clinical research. The resulting commercial clinical research have generated conditions as bad for the research subjects as those endured by the Chinese electronics workers above:
If the past decade had an emblematic moment for clinical research, it was probably November 12, 2005, the day when Bloomberg Markets published its cover story, “Big Pharma’s Shameful Secret.” In that issue, Bloomberg reporters laid out the story of SFBC International, a contract research organization in Miami that was paying undocumented immigrants to test the safety of new drugs in a seedy motel. The SFBC owners had converted the lobby into a large waiting area with plastic chairs, and they were housing their research subjects six to a room. The medical director of the research site was unlicensed to practice medicine; the Institutional Review Board that approved many of the studies was owned by the wife of the company vice-president; and the converted motel, which had been cited for fire and safety violations, was eventually demolished. Nonetheless, SFBC had become an astonishingly successful enterprise. Just a few years before the Bloomberg Markets report, Forbes had named SFBC one of the most admired small businesses in America. Virtually every major pharmaceutical company had tested drugs with the company. In fact, with 675 beds, the converted motel was the largest research facility in North America.Note: see our relevant posts here on SFBC International, and on contract research organizations.

Moreover, such out-sourcing has produced the sort of race to the bottom described by Black, but this time involving one of the US most important health care institutions, academic health care:
the more important reason is money. In medical schools, faculty members are often expected to generate their own salaries, either by seeing patients or getting grants and contracts. Likewise, academic departments are often expected to be financially self-sufficient, with as little support as possible from central administration. 'Eat what you kill' is the phrase used, without irony, by medical school deans and department heads. And if you are not killing it with NIH grants, you probably need to be killing it with AstraZeneca or Pfizer.

This system has not been good for human subjects, but it has not been good for academic physicians either. According to a recent study of over 5,000 faculty members at U.S. medical schools, 51 percent of respondents said that the administration is only interested in me for the revenue I generate.' Thirty-one percent said that their institution discourages altruism; 27 percent said that it does not reward clinical excellence; and over half said that it does not value teaching. Nearly half of respondents were considering leaving their current jobs; almost a third were considering leaving academic medicine altogether. Asked if their values lined up with the medical schools where they worked, over half said no. And just in case you are wondering why these physicians are not standing outside the building with picket signs, protesting the injustice of the system, the survey offers another clue. Thirty percent of respondents agreed with the statement, 'I am reluctant to express my opinion for fear of negative consequences.' [This was from an abstract by Pololi L et al.  See our relevant post here.]

Of course, this survey does does not exactly match up with the happy propaganda disseminated by the media-relations offices at most medical schools. Instead, it offers a picture of alienated, demoralized physicians, unhappy in their jobs, pressed to work according to values that repel them in order to prop up an institution that views them primarily as instruments to generate profit. In this environment, contract research makes perfect sense. It may not require much intellectual work, but it pays the bills and keeps the authorities happy. And if medical schools don’t really value intellectual work anyway, that may well be enough.So the pressures on medical school faculty are little different from those on corporate middle management.  Their only role is to make money, mainly so that the top leaders can become multi-millionaires, and woe unto them if they object.
Summary

What is missing in all this is any organized opposition to the race to the bottom. As long as top executives can make nearly unlimited money, as long as they can do so by making their subordinates put revenue ahead of all else, as long as there are no countervailing forces, the race to the bottom will continue.

To stop it, we need some combination of efforts by honest government regulators, professional and trade organizations, civil society organizations including non-profit organizations and NGOs that really care about patients' and the public's health, and finally an activated, and properly outraged public.

As long as we think that a laissez faire policy allowing continual market dysfunction to continue, the good times for executives will keep rolling, over all of the rest of us.

The intrepid hospital and physician office pioneers leading the charge toward accountable care organizations have learned some key lessons about IT--its role, its limitations and its challenges.

A recent article published in Health Data Management delves into the topic with gusto. It covers a lot of ground, but for CIOs, there are some specific, important tips worth following to help as you evaluate the ACO path for your own institutions, including:

Data exchange: You can't do without it: The Northern Adirondack Region Medical Home Project, based in Plattsburgh, N.Y., has connected electronic health records for its 26 group practices, five hospitals and nine payers to a statewide regional data exchange, according to the HDM article. The EHRs do some of the heavy lifting--allowing doctors to order lab tests, view results and prescribe meds. But the data exchange helps docs keep track of their patients outside their own practice, giving them access to hospital discharge summaries, ER visit records, and medication lists from other providers, the story explains.

It's a daunting task, though, and one that took more than 18 months to get all the interfaces built, testing completed, and bugs worked out.

Data exchanges can have unexpected benefits, too. For example, health information exchange group Michigan Health Connect has turned its data exchange into a central communications/referral hub, HDM reports. More than 200 physician offices are tied into the system, and using referral forms the HIE added to the platform, they now can search for referring physicians, and even complete and forward the referral paperwork online.

Technology needs to automatically update MDs on patient admissions: Any worthwhile ACO will have to give physicians tools to know where their patients are receiving care. In particular doctors need to be notified immediately when a patient presents at the emergency room, so they can help manage the incident. Cox Health Plans, which has applied to participate in an ACO-like bundled-payment program under Medicare, is testing out a "virtual hub" technology for just this purpose, alerting physicians to ongoing exacerbations, HDM reports

Vendors, payers may not be on board: The biggest IT obstacle to an ACO's technology progress isn't always the hospital's budget. In some cases, proprietary vendors aren't willing to put in the time or money to interface or integrate their systems with other multi-system exchanges. Heidi Moore, a member of the Northern Adirondack project's executive board, admits her practice's primary EHR vendor wouldn't create an interface to the state HIE. The result: "Our former vendor had no national vision," she tells HDM. "We had to make a horribly difficult choice to drop them."

Payers, too, may be late to the ACO party, technologically speaking. Our sibling publication, FierceHealthPayer revealed a few weeks ago that insurers are years behind in upgrading their core IT systems. A new study showed that while half of payers want to participate with new business models like ACOs, more than three-quarters say they can't do it from a technology standpoint. 

Home monitoring tops IT wish lists: One big technology gap that could sink ACOs is at-home monitoring of chronically ill patients, Jim Adams, managing director of The Advisory Board, tells HDM. In particular, it will make patients more accountable for following their treatment protocols, and adhering to diet, medication or other regimens--all of which are important to keep outcomes high. "Accountability will be pushed out to the patients," he says.

For just this purpose, Richard Lopez, CMIO for Massachusetts ACO Atria Health, recommends ACOs include a patient portal where patients can request prescriptions and appointments and view lab results--all as ways to keep them engaged in their care. 

To learn more:
- read the Health Data Management article

Related Articles:
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Upgrading IT not a one-time occurrence for payer success
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After more than a year of development, a group of business students at University of California, Merced, are launching the first test of their Valley Telehealth Program.

The pilot will focus on women with gestational diabetes in the Central Valley region of the state. Overall diabetes rates there are 9.4 percent, several points above the 7.8 percent average for the rest of the state, according to a report in CaliforniaHealthline.

The project is starting in Dos Palos, a small town near Merced, Calif. Study participants will be given at-home glucose monitors that can transmit their testing results to physicians. They'll also have e-visits with physicians, including specialists, about gestational diabetes, diet, nutrition and other topics, rather than traveling the 30 miles or more to the physician's office.

There certainly is precedent for telehealth to shave costs for diabetic patients. We reported on a study in the journal Health Affairs last fall that found telehealth interventions, substituted for clinic-based care, cut costs an average of eight to 13 percent.     

Another, far larger, study in the U.K. showed that telehealth could cut ER visits by 15 percent, and ER admissions by 20 percent. 

Data from a pilot in Oregon found reducing a patient's need for transportation to and from physician visits, is low-hanging fruit for a telemedicine program. That state's OHSU Telemedicine Network reported saving patients and insurers $500,000 in transportation costs over a two-year period.

Interestingly, the VTP program isn't being run by a healthcare organization, but by business students with the university chapter of Students in Free Enterprise. SIFE is a global nonprofit organization that encourages its students to use business concepts to create sustainable projects for underdeveloped regions of the world, according to Healthline.

If the pilot succeeds, students plan to expand it to the entire Central Valley. "The statistics in the Central Valley are comparable to a third-world country," Jared Calinisan, a UC-Merced business major and SIFE project manager, tells Healthline. "By targeting [these] patients and helping them prevent those complications, it also cuts down on fees for hospitals."

The pilot is working through regional medical centers Mercy Medical and Merced Diabetes Center. At least six other hospitals in the Valley have been set up with high-speed connections and telehealth equipment, however, and may ultimately join in the larger project. 

To learn more:
- read the CaliforniaHealthline article
- get more detail from the VTP website 

Related stories:
Telcare glucose meter earns kudos for cellular connectivity
Study: Telehealth cuts patient deaths by 45%
Telehealth helps lower spending on chronically ill patients
Oregon telemedicine network saves $500K in transportation costs

The Cleveland Clinic goes straight to the front of the class for its website--but Mayo Clinic gets it knuckles rapped. 

In a "website smackdown," Inc. magazine examines the online presence of two healthcare giants and finds that one "understands its target audience and serves that audience's needs extremely well [while] the other just doesn't get it."

The article is a good reminder that healthcare organizations must design websites for their customers--not for themselves. Although hospitals and health systems often highlight information about world-renowned research, details about fancy imaging and robotic technology, or photos of beautiful buildings, site visitors are much more likely to be looking for quick answers to key information, such as phone numbers, directions and visiting hours.

Rochester, Minn.-based Mayo Clinic falls down in this category, Inc. notes.

"There is virtually nothing on the homepage that is designed to help patients, families of patients, or people looking for assistance from the hospital," the article says. "After much searching, you can find (in a tiny font and in a sub-navigation) 'Request an Appointment' and 'Find a Doctor.' What you won't find is a phone number, directions, or anything else that might be of real use."

Ouch.

The primary navigation on the Cleveland Clinic site gets much better marks for clearly leading visitors to contact information, locations and directions, doctor search, appointments and patient and visitor information, Inc. says.

Ohio-based Cleveland Clinic emerges the winner in health information and find-a-doctor features, as well.

Inc. magazine's opinion notwithstanding, both organizations are well-regarded in the healthcare field for their efforts in online communications, including social media.

Earlier this year, Mayo Clinic, which has its own social media network and has hosted three annual healthcare social media summits, earned the top spot on a list of 20 healthcare organizations with "inspiring" social media strategies.

But the two clinics are hardly the only healthcare organizations to get poor marks for website design.

A recent study by The Journal of Healthcare Management, for example, assessed U.S. hospital and health system websites' performance based on accessibility, content, marketing reach, technology, design and maintenance--and found them wanting.

The mean overall score for the U.S. health systems included in the study was 6.37 on a 10-point scale, indicating that hospital and health system websites have significant room for improvement, Eric Ford, the Forsyth Medical Center distinguished professor at the University of North Carolina-Greensboro and one of the study's authors, wrote.

Neither Mayo Clinic nor Cleveland Clinic made it into the study's list of the top nine sites.

To learn more:
- read the full Inc. magazine comparison of the Mayo and Cleveland Clinic websites
- see the Eric Ford's healthcare website research summary
- learn more about 20 hospital and health system social media strategies

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I recently wrote about the explosion of business spam.

One of my blog commenters introduced me to Unsubscribe.com which provides a free, timesaving, easy to use unsubscribe utility.

Numerous times a day, I click on an email scroll to the unsubscribe area, have to figure out the proprietary unsubscribe functionality of the business spammer, retype my email address, and hope it works since unsubscribe sites are generally slow and unreliable.

With Unsubscribe.com, I just download a plug in for my email client (apple mail), and simply click on the unsubscribe icon whenever unwanted email appears in my inbox.   The unsubscribe servers use natural language processing to figure out the unsubscribe methodology and send the unsubscribe request.

It has easily saved me 15 minutes a day.

Of course the ultimate answer would be for advertisers to act more ethically.   I had a great conversation with Dave Smith, Compliance Officer for Constant Contact about their efforts to enforce email advertising best practices.    A few items

1.  They ask their clients to certify pre-existing business relationships or opt-in before sending email.   Some clients do not follow this policy guidance the Constant Contact compliance team does their best to identify and stop abuses by their customers.

2.  They created "Safe Unsubscribe" to make it easier for recipients to remove themselves from mailing lists.   It really works - Safe Unsubscribe does actually stop the flow of advertising.

3.  They will honor a  global "do not call" designation for all email newsletters if such a request is made to the compliance department.

My wife uses Constant Contact for her NKG Art Gallery Newsletter, so I'm not opting out of all communications just yet.   Only a small portion of my business spam comes from advertisers using Constant Contact - a tribute to their ethical marketing compliance efforts.

A utility to automatically unsubscribe and a company using a compliance team to reduce unwanted email.    That's cool!

In my Aug. 2009 post "Why Siemens Healthcare Fails", I wrote:

I note that I used to admire German engineering rigor, but after seeing ill conceived, misguided position ads like the following from Siemens Healthcare, I am having sincere doubts about that country's current prowess in that domain.
My admiration fell another notch. I now see this, in a Feb. 1, 2012 article from HealthData Management entitled "User Unfriendly" on the flaws in commercial health IT that present a poor user interface/user experience (at the expense, ultimately, of you, the patient). The article's browser title bar somewhat subliminally reads "Physicians gripe that EHR's are not easy to use but improvements are coming":

... There's also no mechanism for publicizing problems with EHR interfaces, unlike the FDA's process for issues with medical devices. [User interface expert Prof. Ben] Shneiderman describes a case where a physician found a bug in an EHR that created a danger to patients. "He contacted the supplier because he thought it was something other users should know about, and the response was, 'Oh, we know-we're working on it,'" Shneiderman says. "The physician said, What? You know about it and you haven't notified everyone?' Contrast that with the Federal Aviation Administration, where problems with airplanes are publicized within hours."

The IOM report calls for substantial loosening of those contractual restrictions. "The committee views prohibition of the free exchange of information to be the most critical barrier to patient safety and transparency," the report says. "The committee urges the [HHS] Secretary to take vigorous steps to restrict contractual language that impedes public sharing of patient safety-related details. Contracts should be developed to allow explicitly for sharing of health I.T. issues related to patient safety." The report also says there should be a central place to report and publicize known issues with EHR software.
Siemens apparently has a different idea on taking responsibility for the user interfaces of their products:

Siemens Healthcare Chief Medical Officer Don Rucker, M.D., says the secrecy issue is overblown. "There are trailer loads of information out there on each of these big systems, and there are so many end users that you can just call up your pal at the next hospital."
There are trailer loads of information out there, and it's up to the end user physician to find the information and sort through it?

... Sounds perfectly reasonable to me. /not/

There are so many end users that you can just call up your pal at the next hospital [for guidance on user interface complexities and errors]?

Also sounds perfectly reasonable. /not/

... Except, I think most EMR vendors and user-organizations sort-of disable Remote Assistance, Remote Desktop and similar programs. Even "print screen" is usually either disabled or forbidden from sharing with that "pal at the other hospital." Might have something to do with security and IP protection.

Ever try to guide someone through a complex computer interface over the phone, blind, with no real-time mutually viewed visuals? It's not easy, but ... physicians and nurses have PLENTY of time for such fritter, what with the little other work they have to do.

I also think saying busy physician, nurse and other clinical customers should "depend on their pals at the next hospital" for information on health IT difficulties is a rather condescending and patronizing statement to make (to be charitable), a low-class, garage-mechanic attitude, but that's just me.


There's no secrets. Let the doctors sort through trailer loads of information, or call their pals at the next hospital to get how-to information on how to navigate our absolutely wonderful user interfaces.


Why does Siemens fail?

This type of statement is a very good clue.

-- SS

In describing ICD-10 for a recent Hospitals & Health Networks commentary, Albert Oriol, chief information officer at Rady Children's Hospital San Diego, says that healthcare executives "only wish" the process was comparable to the buildup of Y2K. "Unlike Y2K ... the effort isn't relegated to the IT back office. This time, massive education will be required of IT's customers along the revenue cycle, which, let's not forget, begins with clinical documentation." Regardless, Oriol recommends taking a positive approach to the implementation. "Call me a control freak, but I'd rather get the pieces we can control in order," he says. Commentary