Wednesday, February 21, 2018

Tales from the DOG Patch: Numero Deux

A tip of the hat to Dr. Roy Poses, who did a nice job summarizing the first blast from the DOG Patch. (For those who missed it, it's a distillate of all the dander we've mustered in recent health policy debates as they veer more and more toward the utterly surreal.) Dander omnium gatherum, hurled willy-nilly at the gentle readers of HCRenewal. Ready or not, another dispatch from the DOG Patch.

Dr. Shulkin at the VA. We commented on the recent posting, also from Dr. Poses, dealing with VA Secretary David Shulkin's "apparently scandalous travel" to Europe way back in July. We've known Shulkin for a long time. He cares about good government but you'd never know that from his own OIG's hatchet job charging "serious derelictions." A lot of this is in the above linked post, as well as related articles in most newspapers. Today however we learn from John Kelly that the secretary's "job is safe." Unless, that is, "other stuff comes out." One of the better Trump appointees, Shulkin now gets to walk the tightrope while political hacks lower down in the VA try to undermine him. His crime: Seemingly dragging his heels on doing himself out of a job. Lots of folks (viz. White House insider and Wisconsin brewmaster Jake Leinenkugel) looking to privatize VA health care. Shulkin understands the great value--despite the many depredations and flaws still enormously popular with its patients--of the institution that began with the Philadelphia Naval Home around the War of 1812. These guys circling the wagons inside the White House represent the swampiest of Washington swamps. Let Shulkin be Shulkin.

Mr. Azar goes to Washington. And tips his hand. In our first DOGpatch dispatch we wondered aloud which way the new HHS Secretary would head after being sworn in. First indications are now in. He wants, in the interest of "affordable" premiums, to issue junk insurance. It sure fits into the grand scheme of things, White House-style. If you can't do in Obamacare in one swell foop, grind it down underfoot one feature at a time. So ideological. So unfair. Individual mandate already on its way out. Now comes waivers allowing cheap policies, policies that're not ACA-compliant, to go to cherry-pickers without regard to pre-existing conditions. Extending short term cruddy policies from three months to a year might benefit a few healthy young workers--maybe the ones states like Wisconsin and Indiana (wrongly) believe, via their ideological GOP governors, they'll lure back to their states. But the cost could easily become lots of the sicker folks whose premiums will become unaffordable. We see the hand of Mike Pence's Indiana favorite, Seema Verma, in all of this. Hey, if they're sick throw 'em under the bus. Your corporate donors want their cheap labor pool back. And, then, what's Azar's long game? To ingratiate himself solidly with executive branch insiders in order to do something that Trump says he wants--most temptingly, new ways to jawbone drug prices down--for his vaunted base? That's something Azar could probably pull off. Will he even try?

Putting the Attack on Expertise in Perspective. A book from about a year ago, Tom Nichols's The Death of Expertise, is summarized nicely in the latest number of Harvard's alumni magazine. I mean, of course that's where you'd find it. Most of our "thought leaders," elite consultants, and favored members of the punditocracy come from elite west- and east-coast institutions. Of course the loudest plaints will come from their ranks. But Nichols is a little different. He has government experience and teaches in a variety of institutions while trying to reach the public. The book is a little repetitive but its gist can be found here, apparently unencumbered by paywall. We'll have to wade into this short book and see who and what and where Nichols points the finger. But we know all the isms already. Narcissism. Post-modernism. Managerialism. Consumerism. All rampant in clinical medicine, academic medicine and health policy. Nichols is rightly worried about the casualness and fecklessness with which people now in power approach everything from nuclear war risk to cyber-threats to the role of professionals in managing health. He's pessimistic.

Monday, February 19, 2018

The Case of the Brew Master's Plot - Was the Veterans Affairs Secretary's Travel Spending Scandalous, or Was He Framed in a Plot to Oust a Political Moderate?

"Come, Watson, come! The brew is afoot."

The Veterans Affairs Secretary's Apparently Scandalous Travel

On February 14, 2018, the Washington Post reported that the Department of Veterans Affairs (VA) Inspector General (IG) severely faulted travel arrangments made for a trip to Europe by the Department's Secretary, Dr David Shulkin.

Veterans Affairs Secretary David J. Shulkin’s chief of staff doctored an email and made false statements to create a pretext for taxpayers to cover expenses for the secretary’s wife on a 10-day trip to Europe last summer, the agency’s inspector general [IG] has found.

Vivieca Wright Simpson, VA’s third-most-senior official, altered language in an email from an aide coordinating the trip to make it appear that Shulkin was receiving an award from the Danish government, then used the award to justify paying for his wife’s travel, Inspector General Michael J. Missal said in a report released Wednesday. VA paid more than $4,300 for her airfare.

At first impression this seemed like just another travel scandal for the administration, which seemed to have made a practice of appointing top agency leaders who felt entitled to high-end travel options.  The Post article noted,

Shulkin is one of five current and former Trump administration Cabinet members under investigation by agency inspectors general over travel expenses, an issue that forced Tom Price to resign as health and human services secretary in the fall. Shulkin and other Cabinet officials have said their travel, often on private and military planes or to speak at political events, was approved by agency ethics officials.

One Republican Congressman immediately called for Dr Shulkin to resign because of "corruption," according to the Atlanta Journal Constitution.

As of February 16, 2018, VA Chief of Staff Viveca Wright Simpson did resign, according to CNN.

A Murky Brew

"the foam thickens"

On closer reading, however the details of the current case were at least somewhat murky.

The IG charged that the VA Chief of Staff, Viveca Wright Simpson, had altered an email to make it appear that Dr Shulkin would receive some sort of award at the US Embassy in Copenhagen, which would have apparently justified paying for Shulkin's wife's travel.  Yet, "In an interview with investigators, Wright Simpson said she did not recall whether she altered the email, Missal wrote."

The Secretary and his wife received tickets for events at the Wimbledon tennis tournament.  Dr Shulkin stated that the person who gave them the tickets was a friend of his wife, but the IG noted that when called, the person who gave them the tickets could not recall his wife's first name.  However, later that person provided a statement saying

The investigators unexpectedly called me on my mobile phone whilst I was driving on a very busy highway,

then,

I felt like the investigators were twisting my words and trying to put words into my mouth.

The IG concluded that the awarding of tickets was improper, Ms. Gosling gave a gift of the Wimbledon tickets, valued at thousands of dollars on the secondary commercial market, because of Secretary Shulkin’s official position.” However, "Shulkin’s attorneys said the secretary was not prohibited from accepting the tickets, because Gosling neither does nor seeks to do business with VA."

The IG also contended that a VA staffer was excessively helpful in making travel arrangements for Dr Shulkin's wife, and that some travel expenses were poorly documented.

Finally,

In his formal response to Missal, Shulkin wrote that VA staffers suggested his wife’s travel be paid for by the agency. He called the inspector general’s portrayal of the trip 'entirely inaccurate' and said it 'reeks of an agenda.'

'It is outrageous that you would portray my wife and me as attempting to take advantage of the government,' he wrote.

Of course, a high government official in trouble for this sort of thing might make that sort of response.

But wait, there is more, including substantial evidence about that "agenda."

A Political Plot?

Political Appointees Scheme to Oust Dr Shulkin

One day later, a New York Times story suggested it was all a lot more complicated.  The background is that

Dr. Shulkin was an unexpected but popular choice for secretary. After the 2016 election, Mr. Trump considered several critics of the department as possible nominees to head the agency. But to the relief of most veterans’ organizations, he chose Dr. Shulkin, a moderate who headed the agency’s health care system under President Barack Obama.

Dr Shulkin also is a fan of having the VA continue to directly provide care to most of its veteran clients/ patients. Note that,

The department currently operates its own health system, with more than 1,200 hospitals and clinics across the country where about nine million veterans receive treatment at little or no cost to them.

However,

Some conservatives, including some advisers to the White House, [who] favor gradually dismantling that system and allowing veterans to choose to receive taxpayer-subsidized care from private doctors instead.

Veterans’ groups have overwhelmingly opposed that idea. But Mr. Trump promised during his election campaign that 'vets will have the right to go to a V.A. facility or the right to see a private doctor or clinic of their choice — whatever is fastest or best for the vet.'
Note that those who favor privatizing or out-sourcing VA health care functions have apparently provided no evidence from clinical or health services research that doing so would provide benefits to veterans that outweigh their harms.  Nonetheless, it appears that some VA officials who were political appointees of the Trump administration did not think Dr Shulkin was doing enough to privatize VA sevices.

In December, according to congressional staff members, political appointees in the department quietly bypassed the secretary to advance legislation that would open the way for more privately provided health care for veterans. The bill was introduced by Senator Jerry Moran, Republican of Kansas, who has received substantial campaign donations from the Koch brothers.

Meanwhile, the NYT reported that a campaign began to remove Dr Shulkin.

An email sent in December by Jake Leinenkugel, the White House senior adviser on veterans affairs, expressed frustration with Dr. Shulkin and listed ways to topple the leadership of his department once key legislation was passed.

The email was addressed to Camilo Sandoval, a former data manager for the Trump campaign who was given a political post at the department. In it, Mr. Leinenkugel, a former brewery executive, wrote that although he initially had a positive impression of the secretary, they had fallen out over staffing and policy issues.

The tactics proposed for this sort of an in-house coup were:

Mr. Leinenkugel, who has an office in the department, proposed 'solutions' in the email, including using a continuing investigation of the secretary’s travel to remove Dr. Shulkin’s chief of staff, Vivieca Wright Simpson; replacing the deputy secretary, Thomas G. Bowman, with Mr. Leinenkugel; and replacing Dr. Shulkin with a 'strong political candidate.'

Re that "strong political candidate":

Mr. Leinenkugel’s suggested replacement for Dr. Shulkin would be likely to spark controversy: Michael J. Kussman, a former under secretary who has been associated with Concerned Veterans of America, a group funded largely by the billionaire conservative activists Charles G. Koch and David H. Koch that advocates shifting spending on veterans’ health care to the private sector.

Note that Mr Leinenkugel apparently has no training, experience, or expertise in medicine, health care, or public health.  Rather he is a former executive of a family owned brewery that had been sold off to MillerCoors (look here).  Mr Leinenkugel did serve as a Marine for six years, but in the Phillipines, and Korea, apparently not seeing combat (look hereand here).  As the executive and presumably part owner of a substantial brewery, it seems doubtful that he ever had to personally seek care at a VA facility.



Furthermore, Mr Leinenkugel was working with Camilo Sandoval, a former data operations manager for the Trump campaign, with no known health care or public health background, or military experience (look here).

Dr Shulkin Fights Back and the Influence of More Political Operatives Revealed

Dr Shulkin suggested that the alleged plotter might not have been acting to promote the best interests of veterans, saying
he was investigating a number of political appointees in his department for misconduct and possible removal. On Thursday, he spoke directly to the White House chief of staff, John F. Kelly, about concerns that political appointees were trying to undermine his agency, according to department officials.

'If there are people here who don’t want the V.A. to succeed, I want them out,' Dr. Shulkin said in the interview.

Whether Dr Shulkin will prevail is a big question.Turmoil at the department seems to be growing.  Last week the Washington Post quoted unnamed White House officials who said Mr. Bowman, the deputy secretary, would soon be fired as a “warning shot” to “knock Shulkin down a peg or two” for not pushing harder for privatization.

Also, per the NY Times,

In another sign of division, John Ullyot, a former top Trump campaign official who now runs the press office, told staff members in an email on Wednesday that reporters’ requests for comment should not be forwarded to the secretary or deputy secretary; instead, he would be referring them all to the White House.

The move forced Dr. Shulkin to do much of his communication with the media over the travel investigation on his personal cellphone.

Then, per CNN on February 16, Viveca Wright Simpson, VA Chief of Staff, had resigned, and in response Dr Shulkin stated,

'This was a personal decision,' Shulkin said, adding that Wright Simpson called him on Friday morning to inform him. 'She just didn't feel that it was the right thing for her and her family to continue in that type of environment.'

Furthermore, her replacement, Peter O'Rourke, appears to be something of a political appointee,

the VA announced that Peter O'Rourke would replace Wright Simpson as chief of staff, effective immediately. O'Rourke currently serves as executive director for VA's Office of Accountability and Whistleblower Protection. O'Rourke's job will be 'ensuring that the department works closely with the White House going forward,' according to a statement from VA Press Secretary Curt Cashour.

O'Rourke is a Navy and Air Force veteran and previously worked for Trump's presidential campaign, according to his LinkedIn profile.

Furthermore,also on Feb 16, Pro Publica in conjunction with Politico published a long article on the background to the political dispute about privatizing or out-sourcing VA clinical functions.  It turns out that this is been going on for a while, and that the privatization/ out-sourcing agenda is mainly being pushed by the Concerned Veterans for America (CVA), a group backed by the Koch brothers.

The Pro Publica article provided more information about the roster of de facto political commissars attached by White House operatives to the VA.  One was Darin Selnick, a retired Air Force Captain, who had a career as a business consultant, and led "faith-based" initiatives at the VA under President George Bush, according to his LinkedIn profile. I can find no evidence he has any training,  experience or expertise in health care or health policy.

Trump picked Darin Selnick for the 'landing team'that would supervise the transition at the VA. Selnick had directed CVA’s policy task force, which in 2015 recommended splitting the VA’s payer and provider functions and spinning off the latter into a government nonprofit corporation.

Then,

He joined the VA as a 'senior advisor to the secretary.' Though he reported to Shulkin, he quickly began developing his own policy proposals and conducted his own dealings with lawmakers, according to people with knowledge of the situation. In mid-2017 Shulkin pushed him out — sort of.

Selnick left the VA offices and took up roost in the White House’s Domestic Policy Council. There he started hosting VA-related policy meetings without informing Shulkin, according to people briefed on the meetings.

Another was Dr Shulkin's own press secretary, Curt Cashour.  According to his LinkedIn profile, he previously worked for Republican Scott Walker's campaign for governor of Wisconsin, is not a veteran, and has no health care or health policy training, experience or expertise. Cashour also was a former staffer of Representative Jeff Miller:

Jeff Miller, then the chairman of the House veterans committee. Miller, who retired from Congress in January 2017, was a close ally of CVA and a scathing critic of Obama’s VA.

Miller became one of the first congressmen to endorse Trump, in April 2016. He did so a few weeks after attending a meeting of the campaign’s national security advisers. (That meeting, and the photo Trump tweeted of it, would become famous because of the presence of George Papadopoulos, who is cooperating with investigators after pleading guilty to lying about Russian contacts. Miller is wearing the light gray jacket in the front right. Now a lobbyist with the law firm McDermott Will & Emery, he didn’t reply to requests for comment.)

At one time, Dr Shulkin directed Cashour to

update its motto, to be inclusive of servicewomen. (Adapted from Abraham Lincoln’s second inaugural address, the original reads, 'To care for him who shall have borne the battle and for his widow, and his orphan.' The new version would read: 'To care for those who shall have borne the battle and their families and survivors.')

Cashour told The Washington Post the motto wouldn’t change. A few days later, the secretary’s strategic plan went out using the updated, gender-neutral motto. Cashour then denied the change a second time, telling the Post that was 'not VA’s position.' A new document with the Lincoln quote restored subsequently appeared on the VA’s website. Shulkin was stunned at being disobeyed by his own spokesman, two people briefed on the incident said. (Cashour denied defying the VA secretary. “The premise of your inquiry is false,” he told ProPublica. Cashour said Shulkin never approved the letter regarding the updated motto and authorized the restoration of the original one.)

So, to summarize, Dr Shulkin, a previous appointee of President Obama, who was appointed to head the Department of Veterans Affairs by President Trump, with the unanimous approval of the Senate, was under seige because he did not support proposals to privatize or out-source many of the VA's clinical functions.   The main functions of the VA involve providing health care to Veterans.   Out-sourcing/ privatization was mainly supported by a Koch backed organization, the CVA, apparently for ideological reasons, but not apparently based on evidence that it would provide benefits to veterans that would outweigh its harms.  Much of the seige work was accomplished by Trump administration political appointees, none of whom had training, experience or expertise in health care or health policy. 

Summary and Discussion

Dr David Shulkin, a holdover appointee of President Obama who was nominated to be Secretary of Veterans Affairs by President Trump, was alleged by the VA Inspector General to have committed various ethical violations involving a trip to Europe the Secretary took with his wife.  This appeared to be just the latest in a string of travel-related scandals by top officials of the Trump administration.

When this was first reported, I was inclined to see Dr Shulkin as an entitled, and conflicted  former health care executive who ran afoul of the government's strict ethical standards.  (Dr Shulkin's official VA biography lists his previous positions, including "chief executive roles at Morristown Medical Center, and the Atlantic Health System Accountable Care Organization. He also served as President and CEO of Beth Israel Medical Center in New York City." His 2016 federal financial disclosure, according to Open Secrets, listed assets of $9,342,201 to $24,966,000.  Also, he had served on advisory boards and boards of directors of numerous commercial health care firms, and held stock options from some of these positions.)

Note that the NY Times editorial page just supported that position, lumping his case with that of other Trump cabinet members with "dubious ethics."

But on review, his travel improprieties did not seem as serious as those of some other administration figures (for example, now ex-Secretary of Health and Human Services Dr  Tom Price, had flown multiple times on private aircraft costing the government hundreds of thousands of dollars, per Politico.)

Furthermore, subsequent reports raise doubts about whether Dr Shulkin committed any improprieties, and suggested rather that he was targeted for removal because he was insufficiently "political," presumably meaning insufficiently beholden to President Trump, and unenthsiastic about dismantling the VA health system and handing its work over to the commercialized health care private sector.  Furthermore, considerable opposition to Dr Shulkin came from within his own department, apparently organized by political appointees devoted to Trump, and an ideological agenda of privatization and out-sourcing, who seemed to be acting like old-style Stalinist political commissars.


Note that USA Today just reported that three big veterans' groups weighed in with their support for Dr Shulkin, suggesting that his travel misdeeds were minor, and his efforts to improve care for veterans major.

But what really happens remains something of a mystery.  Perhaps a modern day Sherlock Holmes would help?



In any case, the events do not reflect well on the Trump regime management of the Department of Veterans Affairs.  Either it placed an entitled, and possibly previously conflicted physician in charge, who was then cavalier about government ethics rules; or worse, it put in charge a perhaps politically clumsy physician who was nonetheless dedicated to the welfare of veterans, but then undermined him when he proved to be insufficiently politically loyal, and perhaps not interested enough in promoting private commercial health care interests ahead of veterans' care. 

Nothing in this story suggests that the Trump regime really cares that much about veterans, other than as means to political ends and to economic benefits to corporate cronies.  Note that privatizing VA clinical functions would provide a huge new patient population to private, including for-profit hospital systems, many of which may not be equipped to deal with the needs of veterans who need rehabilitation for complex and severe injuries, or suffering from the extreme psychological effects of the battlefield.  Privatizing would also presumably provide a physician pool suddenly free from tight VA restrictions on conflicts of interest, who would suddenly become vulnerable to drug, device, biotechnology and other companies bearing money.

Speaking of true health care reform in the time of Trump seems almost silly, but true health care reform requires putting patients' and the public's health ahead of private greed and lust for political power.

Thursday, February 15, 2018

Welcome to the DOG Patch: first in a series?

Lately my dander is up so often and so copiously, over what's happening in health care and the world at large, I'm exhausted. Covered with nasty dander. Cowering under the sheets. Others seem to share this dysphoria. But I found if not a cure, at least a palliative. There's so much dander I can scrape it off with a great big shovel and toss as much as I can your way. Here's my first Dander Omnium Gatherum, or DOG, from the Cetona DOG Patch. Remember, these stories are all DOGs.

  • Litmus Test for New HHS Secretary. The new sheriff at Health & Human Services, Alex Azar, has barely had a chance to wipe his feet in front of the now ironically-named Hubert Humphrey Building in DC. And already the attorney and former Eli Lilly big shot gets his big shot at letting us know whether he'll go up against his fellow plutocrats when it comes to the Affordable Care Act. WaPo has a good story on how, in Idaho, Azar's fellow rich white guy, multi-million dollar livestock owner and red state governor Butch Otter, is considering a truly insidious gem of a way to gut sick folks' access to health care in the Gem State. Allow insurors to sell ACA-noncompliant policies, which, if the sheriff doesn't come to town and say not on my watch, allows risk pools to be invidiously divided. Which of course drives up sick folks' premiums to untenable levels. What's it going to be, Alex?
  • Opioid Addiction Industry: the Gift that Keeps On Giving. Hard to be snarky when so many people are dying including my own patients. But I'll try anyway. Actually, this is a slightly more hopeful comment than my recent ones on the depredations inflicted by this industry, especially Purdue Pharma and its founders from the Sackler family. Can you guess the cost to society of this crisis? Oh, about a trillion dollars in the past decade and a half. I'd not seen it quantified heretofore, but Altarum has given it a go here. In any case, pressured by who knows who--for sure not HCRenewal, but maybe some inordinately publicity-shy latter generation Sackler family members--Purdue just announced they'd no longer promote OxyContin to providers. Oh, wait. Could it have anything to do with the fact that doctors are sick of them? Or, even more likely, that earlier this week Senator Claire McCaskill (D-MO) released a report on the back-door support this industry's been slipping to advocacy groups. A telling quote: "'The question was: Do we make these people suffer, or do we work with this company that has a terrible name?' said U.S. Pain founder Paul Gileno, explaining why his organization sought the money." Read McCaskill's report here.
  • The Soul of the Texas GOP. What's it got to do with health policy and HCRenewal? Antivax, folks, antivax. In Houston--not exactly the most rabidly extreme, left or right, among Texas cities--a PAC and Facebook (surprise surprise) offshoot called "Texans for Vaccine Choice" is mounting a challenge to Republican Sarah Davis, re-election candidate for the state legislature. (This is in the heart of Texas medicine: Baylor, M. D. Anderson, etc. Seems an awful lot of ultraconservatives go to Harvard Law then come back to Texas. This challenger edited an in-house law review featuring Ted Cruz and Neil Gorsuch.) Seems Davis committed the mortal sin of opposing a proposal to prevent physicians from vaccinating foster children. I guess this is normalized. In Texas we already knew there's a rift between business moderates and ideologues. And anti-vaccination is rampant nationwide, backed by celebrities. Rugged individualism, and resistance to empathic concern for one's neighbors, has brought us antivax, the gun death epidemic, and so so much more. It's all about choice, folks. Texas GOP seems to be divided on this matter, actually, so again, Watch This Space.
  • California Probes Aetna Medical Director. Funnily enough, I can easily see how and why this happens. But it don't make it right. The insurance commissioner in the Golden State is investigating Aetna after one of its medical directors (who's now moved on) admitted to CNN that he never looked at any of the patient files he was adjudicating for health care approvals. (Aetna, of course, denies.) How could this happen, you ask? Guy (under direction from non-physician bosses) sits there and judges patients' futures without a glance at their records? If you ever sat on hold for an hour waiting for one of this guy's lieutenants, typically nurses or even lower-rung than that, you wouldn't ask. Then you argue for an hour with the nurse. Sometimes (s)he sees the light and coaches you in how to game the system--which didn't really need to be gamed in the first place--but you end up outraged at the arbitrariness. Then this guy, in the present instance family physician Jay Ken Iinuma MD, pushes out the denial letter to your patient. You appeal. Eventually, if you had your act together in the first place, on behalf of your patient, you win. The inefficiency of it of course is just the point. I appeal. Many don't. Aetna makes out. And our system costs double anyone else's.
  • Tech Industry: the Impossible Dream. It's fun to tilt at windmills a la Don Quixote. Tech entrepreneurs--I know a lot of them--come up with a lot of great ideas. Most are DOGs. But a few are pretty neat. Here's one just maybe in the latter group. Year before last, in the Research Triangle of North Carolina, some IBMers came up with a patient-centered navigation tool whereby sick folks could look up symptoms and see their options. The company is already defunct. “'The short answer is nobody really used [it],' according to Ateev Mehrotra from Harvard. 'For a variety of reasons, they just forgot about it. This is what I would say in my defense: I still think it’s a good idea.'” But this one's a little bit complicated. Mehrotra, who spends a fair amount of time investigating such tools, had previously authored a BMJ article showing that a whole bunch of these tools, net net, are right about half the time at best. A Kaiser article on the matter noted that "[h]alf the sites had the right diagnosis among their top three results, and 58 percent listed it in their top 20 suggestions." Jury's out on this one. On top of which, the only tech applications, thanks to ACA and HITECH, that've really made it in the health care marketplace are EHRs (see InformaticsMD's many great pieces in this blog) and--actually a little better--patient portals. For now, they may just be crowding everything else out.
  • When are Ted Cruz and Diane Feinstein on the Same Team? Rarely. But WaPo now reports an instance of "real change to drug pricing being ignored by Congress." The so-called CREATES act is procompetitive in the generic space. It's supported by the ultraconservative FreedomWorks caucus, AHIP, and AHA. So why not pass it? It got left out of the recent deficit-swelling spendthrift legislation that broke the back of the threatened Can you spell Big Pharma? What's there to be said. The drug lobby and the gun lobby together practically run this country. Is it a democratic country? Do patients, who're also voters, count? Or do lobbyists' contributions to the characters writing the legislation? Oh, wait.... Why do I even pose that as a question?
  • Postmodernism Yet Again. Dr. Poses, your editor, has written eloquently and often in this blog about the baleful effect of pomo thinking on modern science and medicine, especially in the scientific and medical education spaces. This writer has stayed away from the topic, mostly because they believe the postmodern "turn" since the 1970s has been confined largely to the realms of architecture and the academy. (Lots of the academy.) But the topic is suddenly very much in the news again of late, mainly because of the truthiness--or lack thereof--on the part of so many political actors. A recent NY Times piece by Thomas Edsall, entitled "Is President Trump a Stealth Postmodernist or Just a Liar?", is especially juicy. Edsall has a truly admirable Rolodex of people to whom he can reach out and ask the question embodied in his title. If "truth is not found but made," than who among us can be righter than the next guy--say our president? Some on Edsall's Rolodex made the point that pomo just made it a lot harder to rely glibly on western "grand narratives." That much we can concede, for sure. But the truth (whoops) is: we're left in a state of ambiguity. A decade or so ago historian Charles Rosenberg, in a superb essay based on his book Our Present Complaint, said this of the "inconveniently subjective object, the patient [creating] the characteristic split screen that faces today’s clinician": we're left with "a feeling of paradox, the juxtaposition of a powerful faith in scientific medicine with a widespread discontent at the circumstances in which it is made available. It is a set of attitudes and expectations postmodern as well as quintessentially modern." But maybe the last word should go to New Republic columnist Jeet Heer, who quotes Fredric Jameson in characterizing pomo as the "transformation of the ‘real’ into so many pseudoevents." In other words, the fractionation of our political and cultural understandings of policy and society. As Roger Cohen recently wrote, the fact that politicians and lobbyists have so successfully divided us into warring tribes, where everything and everyone is self-serving and convinced of its own reality, there's the real danger. And many traditional institutions, outside of those still harboring Received Truth, have abdicated their former bridging roles along with in loco parentis.
Cetona looks forward to hearing your responses to any of these emanations from the DOG Patch.

Wednesday, February 07, 2018

New article in J. of General Internal Medicine calls for simplifying EHRs

At my January 31, 2018 Healthcare Renewal blog post "The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging" at http://hcrenewal.blogspot.com/2018/01/the-inevitable-downgrading-of.html, I opined that the downgrading of the clinician-facing components of EHRs was essential and inevitable. A new editorial in the Journal of General Internal Medicine makes similar points: ​Electronic Health Records: a "Quadruple Win," a "Quadruple Failure," or Simply Time for a Reboot?
Journal of General Internal Medicine
Michael Hochman


"Perhaps most importantly, there must be a dramatic and thoughtful simplification of EHR documentation templates: it should not take over 200 mouse clicks and more than 700 key strokes to complete one ambulatory encounter."

Indeed.

And this statement, seen frequently at this site, also appears:



"Put simply, EHRs must be redesigned around the needs of clinicians and patients rather than billers and administrators."

The article also makes many other points about the technology I've been writing about for decades, such as the now-obvious grossly exaggerated claims about benefits and cost savings, and others:

... many of the predictions about the benefits of EHRs have yet to materialize to the extent predicted. Though EHRs have facilitated some substantial improvements—the ability for clinicians to access charts from any wired location, electronic transmission of prescriptions, and enhanced tracking of population health measures, to name just a few—they have also resulted in numerous unintended consequences. Noteworthy concerns include egregious medical errors resulting from design glitches, charting templates filled extensively with meaningless boilerplate, the common practice of pasting old notes that makes it difficult to know which documentation is “real,” “alert fatigue” due to excessive EHR warnings (note that some warnings are essential, such as on critical actions with possibly serious consequences, e.g., on confusing screens that can be described as "hot spots for user input error" - ed.), and even reduced communication among clinical team members.

Note that you saw the idea about EHR simplification on Healthcare Renewal first.

-- SS

Are You With Us, Dr Gu? - Vanderbilt Suspended Surgical Resident Allegedly Due to Patient's Mother's Compaints About His "Taking a Knee" on Social Media

In the US, our political situation seems to be leading to new threats to free speech in academic medicine. 

Background: Dr Gu's Activism 

 his story was first reported by The Chronicle at Duke University, and here it is in chronological order

Congressional Subpoena about Fetal Tissue Research

Dr Eugene Gu is a pediatric surgical resident at Vanderbilt University Medical Center (VUMC).  He has a history of political activism starting at least since he was a medical student.

As a third-year student at Duke Medical School in 2012, Gu earned a Howard Hughes Medical Institute fellowship, allowing him to perform fully-funded research at Stanford Medical School. There, he worked with stem cells.

In particular,

he performed the first successful fetal kidney and fetal heart transplants in immunocompromised rats—a project funded by family, friends and small angel investors, he said. The ultimate goal was to help babies with congenital heart and kidney diseases.

In order to do this research,

Gu obtained the tissue from third-party StemExpress, not directly from patients.

He was rewarded with a congressional subpoena:

in March of 2016, Gu was subpoenaed by Congress for his work.

Rep. Marsha Blackburn (R-TN) put the subpoena into motion after manipulated videos tried to 'make it as though Planned Parenthood employees were selling fetal tissue in violation of federal law.'

Several subsequent investigations found 'no evidence of wrongdoing' by Planned Parenthood.

Congress said it subpoenaed him and other researchers at this time to 'get the facts about medical practices of abortion service providers and the business practices of the procurement organizations who sell baby body parts.'

Gu called it a 'witch-hunt' along with StemExpress CEO Cate Dyer in a joint op-ed in Nature.

The Association of American Medical Colleges issued a statement supporting the sort of research Gu was doing, signed by dozens of top medical schools, including Duke and Stanford.

Lawsuit After President Trump Blocked Dr Gu on Twitter

Dr Gu was not shy about replying to President Trump on Twitter.

Gu said the tweet that got him blocked by the 45th President of the United States poked fun at his infamous 'covfefe' typo:
'Trump often announces changes in national policy exclusively from his personal Twitter account,' Gu said. 'It has become a de facto town hall in the modern era of social media. Not being able to participate in the conversations underneath his tweets is like being silenced from the public sphere.'

This lead Dr Gu to become party to a lawsuit against Trump for blocking him and other Twitter users from this public forum.

The Knight First Amendment Institute filed a complaint on behalf of him and six other Twitter users blocked by President Trump in the Southern District of New York July 11. The group alleged that preventing citizens from accessing his account, a 'public forum,' was in violation of the First Amendment.

Dr Gu Suspended

After having demonstrated that he was not in agreement with President Trump and some of his supporters on a number of issues,

The now-Vanderbilt University Medical Center (VUMC) resident was placed on paid administrative leave for nearly two weeks on Nov. 9. He says it might have to do with a patient’s mother complaining that he took a knee on Twitter to protest white supremacy.

She wrote two public Facebook posts identifying herself as the patient’s mother that kicked Gu out of the room and prevented him from caring for her son because of Gu’s actions. She did not respond to multiple requests for comment from The Chronicle.

The Chronicle journalists did a little digging,

According to emails obtained by The Chronicle with the name of the patient and their mother redacted to protect patient privacy, VUMC administration officials discussed investigating all the mother’s complaints regarding his social media posts on Nov. 8. That day, Seth Karp, chairman of the department of surgery, requested that someone document the mother's complaints about Gu and get them to him by the end of the next day, Nov. 9.

One day later, Gu was placed on administrative leave.

VUMC did not return more than a dozen requests from the Chronicle for confirmation that Karp is involved in personnel decisions over more than a week, over email and the phone.

A later article in The Chronicle noted

on Monday, VUMC denied that he was placed on leave due to his kneeling after a wave of social media criticism and reports from major news outlets covering The Chronicle’s story.

'The assertion that Dr. Gu was disciplined because of his expression of political or social views in social media is untrue,' the new statement read. 'All of VUMC’s actions relating to Dr. Gu’s progress as a surgery resident have been and will continue to be based on his performance and his adherence to VUMC policies.'

The VUMC statement further said:

He has been advised of the need to adhere to VUMC’s social media policy, which requires that persons who are identified as representatives of VUMC clearly state that their views are their own. He has also been advised that resident physicians should be professional and respectful in their interactions and communications with and about one another,...

How Dr Gu might have violated the medical center's social media policy, or how his tweeting might have amounted to unprofessional or disrespectful communications with colleagues was not made clear.

According to his Twitter account, Dr Gu is still a resident at Vanderbilt but is seeking to transfer elsewhere.

This case apparently was also covered in a single story in the Tennessean, and inspired a single op-ed by a medical student in the Toronto Star. Beyond that, it has been anechoic in the news media or scholarly medical literature.

The Toronto Star op-ed suggested:

This is a cautionary tale for any resident physician. Medical trainees are at the mercy of the hospitals that employ them because mandatory residency education is a prerequisite for board examination and certification. Without these, a physician cannot practice independently.

Due to this power imbalance, physicians-in-training are averse to any action that would put themselves at professional risk, including political advocacy that may be perceived as contrary to an institution’s value system. The stakes are simply too high.

The real question, however, is whether society wants its physicians to also be advocates.

Discussion and Conclusions

This case suggested that at least the leadership of one prestigious university medical center is very uncomfortable at best, with its residents publicly expressing certain political opinions, even clearly outside the confines of the hospital.  Whether the leaders felt licensed by the President of the United States, who had banned the person at the center of this case from following him on Twitter, is a reasonable question.

It may not be unreasonable to expect physicians and physician-trainees, as medical professionals, to avoid getting into political arguments with patients.  However, it is unreasonable to expect physicians to avoid making any public political comments that could ever be expected to offend any patient or relative.

And this case also raises the question of whether it was the patient's mother's offense, or the Department Chairman's offense, that mattered.

Attempts to censor political speech in academia are unfortunately not rare (see the website of FIRE, the Foundation for Individual Rights in Education, for many examples).  However, they have not seemed to be that frequent in medical education. (Our most recent example was from 2015.)

I wonder, though, if the ongoing attacks on free speech and the free press (e.g., look here and here) by the current President and his cronies are emboldening censorship in US society.  The President does set the tone and agenda for the country.  A president who personally threatens free speech and a free press will encourage other would-be censors to crawl out of the woodwork. 

We will only be able to restore the freedoms promised in our Constitution, and ostensibly inherent in the nature of academic organizations, if we can get a new president who upholds the worth of these freedoms, and actually will preserve, protect and defend the Constitution of the United States.

Monday, February 05, 2018

Free Press? Don't Need No Stinkin' Free Press - Center for Medicare and Medicaid Services (CMS) Tries to Intimidate Modern Healthcare Journalist

Remember the good ol' days, when most US challenges to free speech or the free press in health care came from aggrieved corporate or academic managers?  Now government health agencies have gotten into the act, never mind First Amendment guarantees of free speech and a free press.

CMS Attempted to Intimidate a Journalist for Modern Healthcare

This story first appeared on the blog of the Association of Health Care Journalists, and has now been summarized in only one media outlet, The Hill.  Per Felice Freyer, the Vice President of the AHCJ, Virgil Dickson, a reporter for Modern Healthcare, wrote a

Jan. 23 story about the abrupt resignation of Brian Neale, an official who oversaw Medicaid and helped move it in more conservative direction.

After providing statements from [director of the Center for Medicare and Medicaid Services (CMS) Seema] Verma and Neale, Dickson quoted 'industry insiders' who said the departure was prompted by 'some sort of disagreement between Verma and Neale that erupted in the past few days.' He also mentioned that one source said Neale had been concerned about the workload. 

That rather bland report seemed to displease the management of CMS.  Ms Freyer noted,

After the article appeared, Dickson received an email from Brett O’Donnell, a communications contractor working for CMS. O’Donnell called reports of a disagreement or workload problems 'false speculation' and said it was 'irresponsible' to mention them without more details.

Dickson stood his ground, noting that the information came from multiple, reliable sources. But he agreed to speak with Neale for clarification, and subsequently added Neale’s denial of a disagreement.

That was not enough for Mr O'Donnell:

The next day, O’Donnell wrote to Dickson’s editor, Matthew Weinstock, asserting that the article was inaccurate and demanding that the references to workload and the disagreement be excised. O’Donnell’s email also stated: 'Short of fully correcting the piece we will not be able to include your outlet in further press calls with CMS.'

The next week,

 Virgil Dickson, Washington bureau chief for Modern Healthcare — believed the agency was making good on its threat on Thursday when, he said, his phone went mute during a CMS press call and a woman’s voice told him he was not allowed to participate. An editor later confirmed with CMS officials that he had been banned from press calls, Dickson said.
The Context of the Intimidation


CMS is, of course, a government agency, and so must heed the First Amendment of the US Constitution, part of the Bill of Rights,

Congress shall make no law ... abridging the freedom of speech, or of the press

Nonetheless, this appeared to be a clear attempt to intimidate a reporter trying to uphold the tradition and guaranteed Constitutional right of freedom of the press.  As Ms Freyer wrote,

the attempt to alter a story by threatening to cut off access raises deep concerns among journalists.

'Administrator Verma seems to think she can bury inconvenient facts by threatening reporters with blacklisting,' said Ivan Oransky, M.D., president of the Association of Health Care Journalists, the world’s largest organization of reporters, editors, and producers covering health care.

'That tactic won’t work – truth will out,' Oransky said. 'But the very act of trying to stifle a press report is a frightening assault on the First Amendment. AHCJ intends to vigorously protest this bullying.'

Furthermore,


Aurora Aguilar, editor-in-chief of Modern Healthcare, told AHCJ that the incident is unlike anything she has seen in more than 20 years in journalism.

'I don’t think I’ve ever come across a situation where I was asked to remove something from a story in a way that felt like censorship,' she said.

Making this all the more extraordinary, consider some more background.  Modern Healthcare is hardly some revolutionary pamphlet, and Virgil Dickson was not aspiring to be another Thomas Paine.  As Ms Freyer wrote,

Aguilar said Dickson is known as a thorough and fair reporter. Modern Healthcare, whose subscribers are chiefly executives from health care systems and insurance companies, publishes articles about CMS once or twice a day.  

As an aside, Mr O'Donnell, who seemed to be acting as Seema Verma's bully, is not a CMS, or government employee.

O’Donnell, the consultant who threatened to blackball Modern Healthcare, is not a member of the media affairs offices for CMS or for HHS.

He was only described as a "contractor."  He also is a contractor with a checkered past.

He is a Republican strategist who has helped GOP candidates in their political campaigns. In 2015,O’Donnell pleaded guilty to lying to U.S. House ethics investigators about how much campaign work he did with money that came from office accounts rather campaign accounts.

The USA Today story linked above further stated that his guilty plea

is the first time anyone has been charged with a federal crime for lying to the House Office of Congressional Ethics, which was set up in 2008 to vet allegations against lawmakers and staff and recommend further action to the House Ethics Committee.

The charges against him included,

during his interview with OCE investigators, O'Donnell 'knowingly and intentionally made several false statements to OCE in an effort to minimize and conceal the true nature and scope of his role as it related to [Broun's] campaigns.' For example, he told OCE investigators, 'I never felt like any of my campaign work was expected as part of my duties.'

Summary and Discussion

It appears that  respected reporter for a well-known US health care business publication was barred from participation in CMS conference calls after some rather mild reporting on his part offended CMS leadership.  There seemed to be an attempt to intimidate the reporter by a federal "contractor" paid by CMS, a contractor who was a criminal, that is, who had pleaded guilty to a federal crime of lying to the Conressional Ethics office. 

 How far have we descended.

On Health Care Renewal we have been writing about attempts to limit free speech or free discussion in the press in the health care sphere for more than 10 years.  Through 2015, nearly every case we discussed involved large academic institutions, hospital systems, or for-profit health care corporations trying to limit criticism of their products, actions, leadership, etc.

I do not recall any serious cases involving US government agencies.  After all, the US has a long tradition of freedom of speech and the press, enshrined in our constitution.

However, in 2016, we started viewing with alarm the implications of candidate then President Donald Trump's apparent attempts to intimidate the press and citizens who exercise their rights of free speech (e.g., look here).  Now we have a US government health agency slipping into the role of thought police, and using the hired services of a federal criminal to intimidate a journalist.

The anechoic effect is now being shrouded in much deeper shadows.  We may need a new Thomas Paine.

ADDENDUM 13 February, 2018 - This post was republished in OpEd News on February 12, 2018.

Friday, February 02, 2018

Fish gotta fly, birds gotta swim: more on the opiate crisis

At so many levels, the current opiate crisis, and the way in which various actors are seeking to cope with it, proves rich in intriguing detail.

For starters, it needs to be memorialized that there is a judge in Ohio--like Pennsylvania a fascinating political see-saw state--who's actually trying to do something about this crisis.

Daniel Polster, a Clinton appointee and approaching two decades on the bench, has convened all the parties caught up in the current crisis. Metaphorically locking them all in a room and saying "we'll solve this problem and maybe you get outa this room," he included players not even directly involved in the case, which had been brought against Purdue Pharma and several other opiate producers by the attorneys-general of a whole bunch of states. Known for his proactive pragmatism in problem-solving around multiple disputes brought before him, Polster wants a settlement that will actually save lives instead of just scoring political points.

We find this extraordinarily laudable in today's climate. It sure as hell isn't happening on Capitol Hill. Equally extraordinary in the legal proceedings is the participation of Ohio GOP former senator, career politician, now Ohio AG, and gubernatorial candidate Mike DeWine.

Unlike his Wisconsin colleague Ron Johnson, who points the crisis finger at Medicaid, DeWine sees the log that Big Pharma has poked into his constituents' collective eye. As Ohio's opiate-related death rate heads toward a new 2018 record of 5000, he sees that pharma executives, led especially by the Sackler family, misled the medical profession for years.

Interestingly, in all the current spate of articles on Polster's efforts--here and here and here--the Sackler name appears not at all, and that of their company, Purdue, appears in very few places.

Instead, accounts now appearing provide the usual bewildering lawyerly jockeying around what an ultimate settlement, with drug producers funding addiction-relief measures (in return no doubt for class relief, freedom from the slammer, and CFOs' ability to take predictable write-offs), might look like. Thus for example when we hear about Purdue it's because its general counsel is castigating DeWine for withdrawing from an AG-driven (40-some-odd of them!) probe of her company. (And this lady is a former US Attorney for southern New York!)

Games people play. DeWine of course remains very interested in getting private sector money to help alleviate this crisis.

It's actually gratifying to see this whole case play out. It hinges obviously on a civic-minded judge willing to take all the heat that'll come his way from banging all these heads together. It also hinges on having less purely ideologically-minded people who, regardless of their party affiliation, are more interested in solving a godawful health crisis than they are in feathering their career plans with support from The Base.

And that goes for The Base from either ideological extreme.



Thursday, February 01, 2018

Disastrously conceived, managed, and implemented U.S. Coast Guard EHR leaves our Coast Guard heroes safer ... after reversion to paper records

Sometimes, the typical EHR mismanagement debacles that I have been writing about since at least 1999 leave patients safer.  This is one such example.

I note that the contents of this blog, as well as my still-extant Drexel website "Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties" (http://cci.drexel.edu/faculty/ssilverstein/cases/) and many other resources about healthcare IT mismanagement and failure, are available free of cost.  They could have saved the Coast Guard many millions of dollars if their contents had been reviewed and taken seriously.

(I take no pleasure in making these observations.)

As a consequence of just the latest example of gross health IT mismanagement, a forced reversion back to paper will be far safer than this catastrophically bad health IT would have been, had it been turned on:

After failure of EHR program, Coast Guard needs to find new solution ASAP, watchdog says
Zaid Shorbajee
Fedscoop News
January 31, 2018
https://www.fedscoop.com/failure-ehr-program-coast-guard-needs-find-new-solution-asap-watchdog-says/
The U.S. Coast Guard must urgently find and implement a new electronic health records system, the Government Accountability Office says in a report, after a past project that took half a decade failed and left the organization using a paper process.

The Coast Guard began working with Wisconsin-based Epic Systems in 2010 to implement a new EHR system, dubbed Integrated Health Information System (IHiS). Over the following five years, the project faced multiple setbacks and delays, according to the GAO. IHiS was ultimately scrapped in 2015, with nearly $60 million spent as of August 2017 and some payments still to be made.

The Coast Guard came away with no software or equipment from the project to be used for the future. To make matters worse, in the two years since IHiS’s cancellation, the Coast Guard had to also decommission its two legacy EHR systems because they did not comply with international standards.


Put more simply, $60 million and counting went down like the Titanic in a five-year project.  Why?

The GAO report says the project failed because of “financial, technical, schedule, and personnel risks.” At a House Transportation and Infrastructure Committee hearing on Tuesday, Coast Guard representatives admitted fault.
“What began as a project to develop a simple electronic health record increased in scope and expanded into a much larger concept which added work life and safety services,” said Rear Adm. Erica Schwartz, the Coast Guard’s director of health, safety and work-life. “This project lacked appropriate oversight and governance and resulted in a project that had significant mission creep, untimely delays and increased cost.”

First, I am impressed that Coast Guard representatives took some responsibility. 

However, health IT projects with deficient oversight, governance, financial, technical and other defects have been the constant topic of my writings, and that of some others in Medical Informatics, dating back two decades.  It seems the lessons learned from past failures such as at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases and at this blog via query link http://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20failure may be beyond the comprehension of what can be called "the usual IT suspects."

With no system to fall back on, the Coast Guard has been working with a mostly paper-based process to manage health records for about 50,000 service members.

I find that, in fact, comforting.  The Coast Guard service members are safer compared to what would have transpired if this Frankenstein system (as with the fictional Golem by that name) had actually become "live."

The report doesn’t identify the names of any of the vendors. Epic Systems did not respond to request for comment, but the company’s website says it fulfilled the terms of the agreement and that its software was ready to live when IHiS was cancelled.

The Coast Guard did not respond to request for comment on whether the software was indeed ready.

I believe the vendors to be the usual Beltway Bandit suspects, and I am not sanguine about EPIC's reports.  That's just my personal opinion, of course.  However, just prior to embarking on this post I have begun to review an EPIC chart of a deceased patient, and find a pile of legible gibberish that, had I documented that way as a medical student, would have earned me the "Professor Kingsfield" treatment regarding a U.S. ten-cent piece and a phone call to my mother (https://www.youtube.com/watch?v=_wOUMd3bMRI).

Testifying at the same hearing, David Powner, who directs IT management issues at the GAO, listed several indicators of IHiS’s poor management. Among the things that slowed it down were questions about whether the Coast Guard was using appropriate funding sources, limited security features in the system, failure of the Coast Guard to properly follow its own acquisition process, and the non-involvement of executives who should have been involved.

The GAO report notes while the Coast Guard created several governance boards to oversee the planning of IHiS, the Chief Information Officer was not included on any of them.

That omission is, in a word, an extreme example of IT mismanagement.

“You could have the best project management on these technology projects, but if you don’t have executives that are accountable and breathing down the neck of project managers – that’s what makes this stuff work,” Powner said at the hearing.

He also expressed concern about the paper process currently in place, calling it “inefficient and dangerous.”

It is a shame that the IT world seems to lack altruism, teamwork, cooperation, etc. and instead needs to be brow-beaten into producing reasonable products.   (In what field is altruism, cooperation, shared responsibility and teamwork relatively common?  Answer - medicine.)

As far as paper being "inefficient and dangerous", I ask: compared to what?  Bad health IT?  See my Jan. 31, 2018 essay "The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging" at http://hcrenewal.blogspot.com/2018/01/the-inevitable-downgrading-of.html for more on that issue.

In fact, I hope the Coast Guard is using a efficient document imaging management system at present with their paper.  If not, that is yet another blunder.

The GAO report says that the Coast Guard did not formally identify any lessons learned from the failed IHiS project.

Perhaps because bureaucracies and their IT personnel are unteachable?  That is perhaps not an entirely unreasonable conclusion after all the writing I've done or read since my entry into Medical Informatics at Yale School of Medicine in 1992.

Finally, if the Coast Guard needs a new leader for this initiative, I offer my services. 

I would demand, however, unfettered hire/fire authority, as well as a Sherman tank as my office, such as my father (lower right) used to transport around Europe in WW2.


My father, lower right, somewhere in Europe ca. 1944-5.

-- SS

Wednesday, January 31, 2018

The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging

In recent days, I've posted about current articles on the destructive nature of today's vastly over-complex, burdensome EHR technology.  These posts included "Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records" at http://hcrenewal.blogspot.com/2018/01/physicians-harassed-by-onerwhelming.html
and "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html.

There are many other earlier articles of a similar nature discussed on this blog, e.g., the May 2017 post  "Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records" at http://hcrenewal.blogspot.com/2017/05/death-by-thousand-clicks-leading-boston.html for one, and others retrievable by query links http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20dissatisfaction, http://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20failure and similar.

Here's another recent article along the same lines that just appeared in the prestigious New England Journal of Medicine:

Perspective
Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians
Alexi A. Wright, M.D., M.P.H., and Ingrid T. Katz, M.D., M.H.S.
January 25, 2018
N Engl J Med 2018; 378:309-311
http://www.nejm.org/doi/full/10.1056/NEJMp1716845

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

I note that, unlike this primary care physician, many physicians have to learn numerous EHR's and use them simultaneously if they provide services at different healthcare systems. 

Channeling the satirical medical internship novel "House of God" and its "law #11" (https://en.wikipedia.org/wiki/The_House_of_God, full movie at https://www.youtube.com/watch?v=bPllfH9YREA), these poor souls are probably constantly thinking "find me the EHR that only triples my work and I'll kiss your feet."

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

That is a prescription for suboptimal performance and increased risk of harm, on its face.  There is little to argue on that point.  I personally would not want an airline pilot, let alone a physician, providing me services who is "disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

Increasing clerical burden is one of the biggest drivers of burnout in medicine. Time-motion studies show that for every hour physicians spend with patients, they spend one to two more hours finishing notes, documenting phone calls, ordering tests, reviewing results, responding to patient requests, prescribing medications, and communicating with staff.1 Little of this work is currently reimbursed. Instead, it is done in the interstices of life, during time often referred to as “work after work” — at night, on weekends, even on vacation.

That is, quite frankly, an absurd workload deleterious to provider AND patient well-being.

“EHRs can be a double-edged sword, because they give you more flexibility about where you work, enabling physicians to get home for dinner,” argues Tait Shanafelt, professor of medicine at Stanford University and a leading researcher on physician burnout. “But physicians are working a staggering number of hours at night, and this has enabled organizations to continuously increase productivity targets without changing the infrastructure or support system, effectively adding a whole extra workweek hidden within a month.”

Imagine trying to force "a whole (uncompensated) extra workweek hidden within a month" to the workload of a union member of, say, the Transport Worker's Union.  It would result in an instant labor strike ... or worse.

... Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.3

I rest my case on the increased-risk-of-harm issue.

I seem to be one of the first to recognize, or at least start writing openly about, the bad leadership of the health IT field and the dangers of the bad health IT produced as a result.  My observational skills and critical thinking capabilities led me to start writing on these issues circa 1999, after my experiences as postdoc and faculty in Medical Informatics at Yale School of Medicine/Yale-New Haven Hospital and then as CMIO at the Christiana Care Health System in Delaware. 

That writing is largely retained at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases, in a website I have not updated in several years due to time constraints related to the EHR forensics work I have been doing in the legal and law enforcement sectors.

It is clear my concerns are now proven correct and are now being echoed by large sectors of the physician and nursing communities.   My concerns were obvious, I opine, to anyone of reasonable critical thinking and observational skills, who were not affected by conflict of interest.  That is, those without profitable connections to the health IT industry.

I now make a prediction for the future that, once again, seems obvious to me:

Today's EHRs, especially the sections for narrative clinician documentation, will be downgraded from their "template madness" time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper.  Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s' as at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html, but paper nonetheless.  Data extraction of these notes for financial purposes will be done, once again, by coders.


A small sample of why physicians and nurses burn out from EHRs.

Debate if you will, but that is my prediction for the future.  I feel it inevitable considering the unintended/unexpected terrible consequences and realities of this technology.  "New curtains" (that is, tidying up the user interfaces) will not suffice.  This is a prediction from one of the first Medical Informatics professionals to start openly writing about EHR difficulties almost two decades ago. 

-- SS