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 [...]

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.

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

Reposted from KevinMD blog on another aspect of the health IT mission hostile user experience. Emphases and comments in [red italics] are mine:

How algorithm driven medicine can affect patient care
by Jeffrey Parks, MD

Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a “pre-op checklist” to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don’t want to give antibiotics inappropriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right? [No - wrong - the idiots who designed your system forgot that robotic medicine is bad medicine - ed.]

Well, you’d be surprised. [No, actually, I'm not. I'd have been more surprised to see a system not impeding critical medical decisions tailored to the individual patient - ed.]

You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes “please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis [that sounds a bit like begging - ed.] ,” the antibiotic will not be sent to the patient’s floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on “protocol” and “quality care metrics.”

Similarly, the 60-minute timeline for pre-operative antibiotic administration can be problematic. I have had patients come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 10:30am. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn’t administered until 60 minutes before the scheduled OR time, just like the algorithm dictates — despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. [This is how EHR-induced malpractice occurs, readers. Guess who bears liability? - ed.]

And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened [this time, due to luck - ed.], but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It’s just astounding. [It's astounding the surgeons don't simply use a scalpel on the computer terminal network and power cables to protect their patients - ed.]

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements [a workaround to a 'feature' that turns medical judgment on its head - ed.] for therapeutic antibiotics because the default mode is to override a licensed physician’s clinical judgment. [Not mentioned is who is overriding that judgment through cybernetic proxy - ed.]

This is what I’m talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

I will simply add that these issues are one of poor design and implementation, with IT getting in a physician's way regarding tailoring of care to the individual patient.

An inviolable rule in health IT is - or needs to be -

"You should not have to work around something that is not in the way."

There is nothing to debate or discuss on this issue.

-- SS

Feb. 3, 2012 addendum:

Some IT person (anonymously, of course) tried to argue and debate anyway; however, they did not even do basic homework. See their comments in the comments box.

By David Williams How many times have you read about the staggering shortage of nurses? It’s routine to see numbers in the hundreds of thousands tossed around – representing the seemingly insatiable demand for nurses from an aging population. I’ve always been suspicious of these estimates. First, it’s not how the economy works. We’re not [...]

By Merrill Goozner It’s too bad former Massachusetts Gov. Mitt Romney doesn’t want to talk about his state’s health care reform legislation on the campaign trail. If he did, he’d have a pretty good story to tell. The reform plan, which President Obama used as a model for the national reform, lifted the number of [...]

By Joe Flower Ten existential questions will make the difference between stumbling into the future and thriving The questions have changed. The key strategy questions that the C-suite must be asking—and getting answers to—are different now than they were in the past, even from what they were last year. Most of today’s health care CEOs [...]

By David Dranove Preface: In the past few weeks Governor Romney has received withering criticism for his support for the Massachusetts Health Plan and his seemingly hypocritical opposition to Obamacare. Frankly, his responses to this criticism have not been stellar. I sometimes wonder if he realizes that he is on firm ground here. So as [...]

By Seth Roberts Bryan Castañeda, who lives in Southern California, told me this: The law firm I work at specializes in toxic torts. We represent people who have been occupationally exposed to chemicals and are now sick, dying, or dead. Most of our clients have been exposed to benzene and developed some kind of leukemia. [...]

By ROBERT LASZEWSKI Last week’s State of the Union speech was notable because the President hardly mentioned the new health care reform law. Avoiding what is supposed to be the centerpiece domestic accomplishment of President Obama’s first term stuck out like a sore thumb. He said almost nothing because the Obama team simply doesn’t know [...]

By Molly Kantor As a third year medical student, I spent one afternoon each week at a health clinic at a community hospital affiliated with my medical school. This health clinic was focused on primary care for patients with HIV, and many of our patients were poor, homeless, immigrants, or uninsured. Many were also living [...]