Fred Schulte on Investigative Journalism: "Race to electronic health records may come with a price"

Investigative reporter Fred Schulte of the Center for Public Integrity has written up his experiences on his investigation of upcoding and Medicare billing inflation due to the effects of EHRs.

The piece is of interest in regard to, at the very least, the personal recollections of how an investigation comes to be and is conducted.

I thought his piece would be of interest to HC Renewal readers.  It is at the site of the American Association of Healthcare Journalists and entitled "Race to electronic health records may come with a price."

(The result of the investigation is the series entitled "Cracking the Codes.)


Fred Schulte

This work contributed substantially and materially to a reluctant HHS and ONC deciding it was time to actually investigate the issue.

(Perhaps sometime soon HHS and ONC may also seriously investigate health IT safety, and take more than Milquetoast action.)

-- SS

I Wonder if Dr. Bob Wachter Has An IP Audit Trail For Comment Submissions To His Blog?

In my Jan. 2010 post "More on Perversity in the Healthcare IT World: Is Meditech Employing Sockpuppets?" I described how I found that perverse, defamatory and even deranged comments were submitted to comment threads on this blog and elsewhere about my posts. 

Unfortunately for the writer, the IP's of his submissions recorded in the Sitemeter IP audit trail for HC Renewal were of a health IT vendor, Meditech, as described in the post.  Even after the post, the abuse continued.  Only after I contacted the General Counsel of that organization did the abuses stop.

At Bob Wachter's blog "Wachter's World" I have been following a quite serious Sept. 2012 post entitled "Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem".  The post concerns the effects EHRs have on clinician cognition.  Dr. Wachter thoughfully concludes:

... All in all, I am pleased that UCSF went with the Epic system and I remain a fan of electronic health records. And Larry Weed was right: we must have a structure to record what is happening to our patients, and his problem-oriented approach remains the most appealing one. (Ultimately, one wonders whether natural language processing will make such a structure less important, in the same way that I no longer pay much attention to filing documents on my Mac now that its search function is so powerful.)

But the time is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive forcing functions, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. Let’s show these computers who’s boss, and put the “A” [clinician assessment - ed.] back in SOAP.

The post is followed by a largely thoughftul comment thread of dozens of comments.

A new comment has appeared as follows, from an anonymous user "EPIC" whose self-submitted URL is "epic.com":

Epic December 7, 2012 at 9:48 am #
 
Physicians – thanks for your thoughts. However, we are not mind-readers and we can only work within the bounds of our archaic code. If you think you have it rough, you should hear what we hear from the nurses, you know, the underpaid ones that actually provide patient care and have to put up with your whining, bossiness, and superiority complexes. Anybody can memorize A&P. It takes common sense to use a computer. Perhaps time spent complaining could be more effectively be used in Epic ClinDoc training. Gotchya…

The problems of health IT are all due to whining, complaining, bossy, conceited physicians who just won't learn how to use the EHR properly...who, by the way, lack common sense and should just shut up and read the manual ... gotchya!

The response I've left requires no additional comment:

S Silverstein, MD December 7, 2012 at 3:18 pm #
 
To whomever left the reply “Physicians – thanks for your thoughts” under the pseudonym “EPIC”… Your comment is, quite simply, perverse. It reflects an unfitness for you, if the comment is serious, to be involved in any aspect of healthcare.

Your comment might have been at least humorous if it referred to, say, IT issues in a nail parlor or pizza shop.

We are discussing, however, IT problems in patient care, that affect everyone, including the most ill of patients who expect the healthcare system to focus on their needs.

Further, you show a lack of understanding of what the National Institute of Standards and Technology (NIST) has recently made plain: the concept of “use error”:

——————–
… The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized.

[3] “Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions - ed.], misuse of color-coding conventions, omission of information [or poorly presented information - ed.], etc.
——————–

Take your perverse attitudes and ignorance elsewhere. Preferably far from your nearest healthcare facility.

Scot Silverstein, MD
Drexel University, Philadelphia
http://hcrenewal.blogspot.com


I am curious if the IP audit trail, if any, of Dr. Wachter's blog shows the IP of "Mr. Epic" and whether the IP shows the comment was truly coming from EPIC itself.

-- SS

How an interview for Kaiser Health News rekindled memories of health IT dysfunction in the 90's that persist in the 10's

I was interviewed in my home yesterday by Jay Hancock, Senior Correspondent, Kaiser Health News about my background, how I got to the current point in my Healthcare Informatics career, my opinions on the state of health IT in 2012, and related matters for a possible article:

Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics. KHN’s mission is to provide high-quality coverage of health policy issues and developments at the federal and state levels. In addition, KHN covers trends in the delivery of health care and in the marketplace.

KHN is an editorially-independent program of the Kaiser Family Foundation, a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible analysis and information on health issues.

Mr. Hancock has quoted me regarding health IT in the past in his current role and when he was a reporter for the Baltimore Sun, for instance in the April 2012 article "Health insurers’ push to diversify raises ethical concerns" that appeared in the Washington Post as well, and the Nov. 2011 article "Advice to hospitals: Be careful what you bill for" in the Baltimore Sun.

Mr. Hancock wanted to get an understanding of me, the person.  In doing so, I dug out some of my past technology "toys" to show him at the onset of the interview.  Ironically, doing so reminded me of some irritating occurrences in the past that both inform present views, and served as early experiences in why health IT suffers the problems it does.

I will illustrate by showing some of the devices I presented to Mr. Hancock in order for him to better know my interests/knowledge of technology, and then presenting the unpleasant recollections that doing so brought on.

Bear with me for a few moments (and pictures).

I showed Mr. Hancock devices I'd built and/or used in teaching such as (click to enlarge):


An infrared-sensing heart monitor I built in 1980 during a clerkship in biomedical engineering, Boston University Hospital, 1980

Inside the heart monitor.  I etched and drilled the printed circuit boards myself.

A 3-transistor breadboard shortwave radio I built as a kid.

A somewhat more sophisticated radio kit.  My Heathkit HW-101 ham radio transceiver, built myself over several months when I was a medical trainee.  Also built its matching power supply box, not shown.

HW-101 innards, top view.  Not exactly a simple device.

HW-101 underside of chassis.  Each and every one of those solder connections was done by me.  In bulding it, I learned how each circuit worked (and had to debug it when, on initial powerup, smoke rose due to a defective ceramic capacitor and two bad tubes, one of which glowed a delightful cherry-red.)

My Heathkit H8 computer, introduced 1977.  Intel 8080 processor. One of the first personal computers.  In true minicomputer style, the 8080 general registers, accumulator/flags register, program counter, stack pointer, and memory addresses were directly accessible via the front panel pushbuttons and the split-octal display.

Inside the H8.  I used this to teach computer and CPU architecture to Medical Informatics  postdoctoral fellows at Yale School of Medicine.  I did not, and do not believe healthcare IT leaders should be mere “appliance operators.”

My TRS-80 Model I running VTOS 4.0, a pre-IBM PC precursor to LDOS 5 and TRSDOS 6.  All were far superior to MS-DOS of any flavor in my opinion.

TRS-80 Model I about to undergo repair by me.

As I mentioned before the pictures, unpacking from their storage boxes and showing this personal technology brought out numerous formative memories, and not always good ones, from my CMIO (Chief Medical Informatics Officer) days.

Seeing all this, it may be easier to imagine why, as a CMIO in the mid 1990's I was offended when patronized by hospital IT personnel about how an information system  in an invasive cardiology cathlab, a critical care area, could not be moved from unstable Windows 3.1 to Windows NT to prevent frequent crashes and data loss because “Windows NT needed RAID disk arrays” and other B.S., and also by similar personnel patronizing me on my serious concerns about ICU patients put at risk of infection by improper hardware for a biohazard-prone environment.  (See http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story and http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU.)

I was further reminded about how I was alarmed by the selfsame hospital IT "experts", lacking healthcare and medical informatics knowledge and experience, simply ignoring my counsel, as if medicine was a harmless parlor game to be played, winner take all.  And likewise regarding hospital senior management who's hired me in the first place - at least one of whom expressed to me more concern for the career advancement of the IT staff than for patient safety.

The latter ICU incident, in fact, directly led to my starting to write about health IT issues on the Web in 1998.  Sadly, my colleagues, as well as former students and mentees, tell me little has changed.

That type of territorial, political behavior might perhaps be more appropriate (or at least hardly harmful) in a nail salon or pizza parlor, but not in an ICU or cardiac cath lab.

Yet today's health IT domain is rife with leadership by health IT amateurs** [see note below] who patronize, bully and play nasty politics with healthcare informatics-educated clinicians and specialists, and accuse clinicians of being "Luddites" for resisting bad health IT pushed on them by hyperenthusiasts (Ddulites) who ignore the downsides.  

Good Health IT ("GHIT") is defined as IT that provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician’s hands, keeps eHealthinformation secure, protects patient privacy and facilitates better practice of medicine and better outcomes. 

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.  

What is lost in these dysfunctional dynamics is that the true "customer" who suffers is the patient.  Patients come to the hospital sick and with expectations that the personnel there will put the patients' interests first.  If they are injured or leave in a pine box, they care little about whose political empires were threatened by internecine and/or industry battles over IT.

Mr. Hancock's Kaiser Health News profile of me, if published, should prove interesting.   It will probably mention my own relative's injury and death related to health IT, and may cite the Complaint itself, a public document.  

I will link to it when it if and when it appears.

-- SS

** (Amateur, used in the same sense that I am a radio amateur licensed by the government after a series of written exams, but not a professional telecommunications engineer, knowing I would not want to, nor should be allowed to, lead a mission critical telecommunications project.)

-----------------------

Feb. 18, 2013 Addendum:

The article was published as here.

-- SS  

The Parts of Professionalism We Are Not Supposed to Discuss

A recent article in a a relatively obscure medical ethics journal dared to approach some important aspects of medical ethics that medical ethicists fear to discuss, but did not address the reasons for this fear or what to do about it. (Glenn JE. The eroding principle of justice in teaching medical ethics.  HEC Forum 2012; 24: 293-305.  Link here.)

The Basic Ethics Case - A Prescription for the Patient's Spouse?

Glenn began with a case typically discussed in medical school ethics courses:

a scenario where a standardized patient asks the student at the end of the examination if his prescription can be written in his spouse’s name as the spouse has health insurance which includes prescription drug coverage while the patient does not.

This

poses the question as to whether it is ethical for physicians to deceive third party payers to secure coverage for their patients.

The Politically Correct Way to Teach the Case

Glenn stated that there is a politically correct way for faculty to teach this case:

 Though we are never expressly instructed to tow [sic] a party line, there is a 'correct' answer to this ethical quandary as far as the institution we work for is concerned. Students who express a willingness to practice deception of third party payers for the good of their patients are to be commended for having their heart in the right place. However, we discuss many reasons why this action would not be a good solution to the problem. One of the issues is that to do so would be committing fraud.

Now, of course, writing a prescription for a patient who does not actually need the drug in question, understanding that the patient will give the drug to someone else who does not have insurance coverage to pay for it, is dishonest.  However, the larger point that Glenn made is that it is not politically correct to allow discussion about why the patient made such a request in the first place, and that this ought to be troubling.

Note that Glenn did not explain how he inferred what the "correct" answer was, nor its actual source within the institution.

Over the first few years of having this conversation with young medical students, I have always come away feeling empty and flat. Framed as a session on the ethics of 'truth telling,' the conversation and the readings we provide to prepare for it works to obfuscate the much larger ethical issue impossible to tackle in an hour’s time. In essence, 'truth telling' is only a secondary ethical issue at play. The more important ethical issue is a question of social justice: what commitment do doctors have to poor patients and making sure that they get the health care services that they need?

Social Justice as Part of Professionalism, and its Avoidance

The article by Glenn then emphasized that some of the original conceptions of physicians' professionalism included social justice.  A definition promulgated by Herbert Swick in 2000 expressly included these relevant competencies.  Physicians ought to:
-  subordinate their own interests to the interests of others
-  respond to social needs and work toward the benefit of the communities in which they live and serve
-  adhere to the core humanistic values of honesty and integrity, compassion, altruism, empathy, respect for others, and trustworthiness.


Glenn noted that these three competencies, however, have been turned into a more narrow imperative, that

doctors should treat patients with an equally high quality irrespective of their race, ethnicity, gender, religion or cultural background according to what is best for them. In most codes of professionalism, however, class is not expressly implicated.

Note that Glenn did not question why the issues of race, ethnicity, gender, religion, or cultural background became important in this context.  He did further question why the issue of class did not.  While

 The professionalism code adopted by the American Board of Internal Medicine in 1999 was bolder and specifically states that doctors are to advocate for 'the best possible care [for their patients] regardless of the ability to pay'

Glenn asked

 But where in the medical school curriculum do we teach medical students to be strong patient advocates and take on third party payers and hospital administrators? We now discuss the importance of prescribing generic drugs and we warn against the influence of big pharma, but when do we teach students to rebel against the high cost of medical education that drives students toward boutique medicine and fields of specialty care that offer the most money and most comfortable lifestyles?

Furthermore, he noted,

 When it comes to justice in medical ethics instruction, the parameters of the discussion are usually constricted to focus on the conservation of health care resources and rationing care rather than providing more care to more patients.

So, now seemingly getting to the key question,

We have created an entire system where all the middlemen that stand between a patient and her health care are expecting to get rich. No oath or professionalism curriculum is structured to teach medical students how to ethically and morally navigate through that. How did the terms of the debate get so co-opted by the health care economists?

The Key Question also Avoided

However, after this build up, Glenn then had trouble grappling with that question.  He noted that the prices of various parts of US health care are rarely questioned, and wrote about some of the particular issues in pricing new technologies, including the costs of development of new drugs, the tax treatment of drug development, and whether the licenses drug companies obtain from universities to develop drugs are fairly priced.  He also touched on the rising cost of medical school tuition and students' consequent assumption of large levels of debt.  This was interesting, and provided some useful references, but never really directly addressed the key questions above: why was the discussion framed in terms only of current health economics, and more importantly,  why did he and other ethicists feel they could not openly discuss any larger issues?

Only at the very end of the article did this appear

the structure of our current medical system has created a network of health care providers, researchers, purveyors and administrators who have strong financial incentives to work against the best interests of patients. This situation makes it difficult to talk with students about the ethical principle of justice in any meaningful way that is not hypocritical, leaving it seldom emphasized relative to the other three core principles of medical ethics.

Glenn did not further explain these "financial incentives," detail further who had them, explain how they "work against the best interests of patients," and most importantly, explain how these incentives make "it difficult to talk with students about the ethical principal of justice in any meaningful way that is not hypocritical."  He concluded only

 How can we cultivate within our students an understanding of the threats to medical professionalism posed by the conflicts of interest inherent in the various financial and organizational arrangements in the practice of medicine?  We start by not shying away from the conversation.

Summary

So Professor Glenn argued that social justice has been considered part of health care ethics, and that ethicists should teach about it by questioning the current economic arrangements within the health care system.  He then suggested that ethicists have been somehow pressured not do raise such questions, and that this pressure has something to do with perverse incentives and conflicts of interest prevalent within health care.  However, he never actually addressed who pressured the ethicists, how the pressure was applied, and how that pressure was related to conflicts of interest.

Thus, it seems that authors in scholarly health care journals may now hint that there are certain things one must not discuss, that are taboo to discuss in health care, but cannot actually say what exactly is taboo, and why it became that way.  Thus, the article by Glenn seems related to what we sometimes coyly call the "anechoic effect,"  that the issues we discuss on Health Care Renewal often do not seem to be considered topics of polite conversation.  But in a strange recursive way, the article never could quite manage to discuss what it is it said others cannot discuss, which in a way just further validates the importance of the anechoic effect.

The Glenn article is reminiscent of another article we posted about.  That article, by Souba and colleagues,  found that there are many "elephants," that is,  unmentionable subjects, in academic medicine,  However, that article also never clearly defined what these unmentionable subjects actually are, other than subjects that displease those in power.  Thus this too reinforced just how taboo these topics are.  Even those willing to admit that taboo topics exist are still unable to name them.

At least the Glenn article did suggest, however vaguely, a relationship between conflicts of interest and the anechoic effect.  We have documented that individual and institutional conflicts of interest are rampant in health care, including, and probably particularly academic medicine.  For example, pharmaceutical companies (and also all sorts of other health care corporations) may pay medical school faculty members and administrators (as consultants, "key opinion leaders," speakers, advisers, even board members).  The leaders of academic medicine seem particularly prone to such conflicts. For example, a majority of US medical school department chairs have significant financial relationships with health care corporations (see post here).  We have shown how top medical school leaders may simultaneously serve on the boards of directors of health care corporations (see post here). Such health care corporations may now also support various aspects of medical academia (through research grants, "unrestricted" and other educational grants, other gifts to hospitals and universities, etc).  Financial conflicts of interest may help to directly enrich many faculty and academic leaders, and indirectly enrich them by enriching their organizations. People who are personally profiting from relationships with health care corporations are unlikely to question such relationships.  The leaders of organizations which depend on funding from such corporations are unlikely to question whether conflicts of interest might lead to corruption.  People whose colleagues, friends, family members, or supervisors are personally benefiting from conflicts of interest may hesitate to challenge such relationships.   Since these relationships permeate the economics of health care, is it any wonder that the entire topic has become taboo?  

So the first step in challenging this taboo is to acknowledge it exists, and to not "shy away" from discussing it, as Glenn suggested.  People are beginning to acknowledge there is an elephant in the room.  Now we have to describe the elephant, discuss the elephant, and eventually figure out how to get the elephant out of the room.     

Hat tip - to the Medical Professionalism Blog.

The Life of a Clicker, and Putting the "A" back in "SOAP"

A brief post.

I found these two recent links worthy of perusal:

The Life of a Clicker - by a Family Physician - describes how EHRs have turned physicians into "clickers", at their own expense, and double-binds them - damned if they do, damned if they don't.

Electronic notes as "yard sales" - one has to wade through a huge pile of garbage to find a single useful item A comment to a post on Bob Wachter's blog.

Indeed.

-- SS