The "obesity paradox" is the observation that people with higher fat mass sometimes have better health outcomes than lean people, including a lower overall risk of death. Evidence has been steadily mounting that this finding may be a misleading artifact of the methods used to observe it. Two massive new studies add to this evidence.
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from Whole Health Source http://ift.tt/294UW9t Two huge new studies further undermine the "obesity paradox" healthpolicyandmarket
Rabu, 29 Juni 2016
Still No Questions Asked - Journalists Fail to Challenge Talking Points Used to Justify Million Dollar Plus Executive Compensation at New York Non-Profit Hospitals Health Service Home
It's deja vu all over again. I even get to reuse the introduction of a post from one month ago. As I wrote in May, 2016,...
The problem of ever rising, amazingly generous pay for top health care managers is a frequent topic for Health Care Renewal. We have suggested that the ability of top managers to command ever increasing pay uncorrelated with their organizations' contributions to patients' or the public's health, and often despite major organizational shortcomings indicates fundamental structural problems with US health, and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.
In particular, we have written a series of posts about the lack of logical justification for huge executive compensation by non-profit hospitals and hospital systems. When journalists inquire why the pay of a particular leader is so high, the leader, his or her public relations spokespeople, or hospital trustees can be relied on to cite the same now hackneyed talking points.
As I wrote last year, and last month,
Yet as we discussed recently, these talking points are easily debunked. Additionally, rarely do those who mouth the talking points in support of a particular leader provide any evidence to support their applicability to that leader.
Bit at least most journalists who inquire into hospital executive compensation used to make an attempt to be "fair and balanced" by also quoting experts who question the talking points.
But not so much lately,...
Million Dollar Plus Hospital CEOs in New York
The Journal News, based in the northern New York City suburbs, ran a series of articles about executive pay and perks at NY hospitals and hospital systems. The main aricle in the series is here. A listing of the five highest paid hospital officials is here. A listing of executive perks, and conflicts of interests affecting the hospitals' and hospital systems' board members is here. The main article began,
The article noted that 112 people who worked for non-profit hospitals in the Lower Hudson valley earned more than $1 million. The biggest pay went to the top executives of the biggest systems:
Also,
Note that Dr Sayfer also was given a hospital-paid car and driver.
An accompanying article noted the three other highly paid CEOs in New York state, Warren Hern, CEO of Unity Health Systems in Rochester, $7,490,213; Mark Clement, CEO of Rochester General Hospital, $5,323,856; and Dr Steven Crowin, CEO, New York Presbyterian Hospital, $4,591,728 [who also benefited from a policy allowing first-class or business airfare for flights over 6 hours, and some form of housing allowance.)
Other million dollar plus CEOs in the Lower Hudson valley included John Federspeil, president, Hudson Valley Hospital Center, $2,055,377; Joel Seligman, CEO, Northern Westchester Hospital, $2,043,289; Dr Cary Hirsch, CEO, Bon Secours Charity Health System (Good Samaritan Hospital in Suffern), $1,170,575; Keith Safian, CEO, Phelps Memorial Hospital Center, Sleepy Hollow, $1,494,760; Lawrence Levine, CEO, Blythedale Children's Hospital, $1,701,471, Edward Dinan, CEO, Lawrence Hospital Center, $1,707,780; Dr Craig Thompson, CEO, Memorial Sloan-Kettering Cancer Center, $2,944,926 (who also got first-class or coach airfare for flights over 6 hours, and some form of housing allowance); and Jon Schandler, CEO, White Plains Hospital, $1.799,952.
The Usual Talking Points to Justify Executive Compensation
The Journal News article also included justifications for this munificent pay by hospital officials that used the usual talking points.
We have to pay competitive rates
We have to pay enough to retain at least competitive executives
The spokesman for Northwell Health asserted,
Then,
Also, from Blythedale Children's Hospital,
Our executives are brilliant
Said Michael West, senior attorney for the New York Council of Nonprofits,
Said Rachael McCallen, a Montefiore spokeswoman,
Furthermore, the next week the Journal News publised an op-ed by William Mooney, CEO of the Westchester County Association, which was devoted to defending the pay of his fellow CEOs. It started with indignation against anyone who would question the pay of our fearless leaders,
Then Mr Mooney again hit the talking points.
We have to pay competitive rates
We have to pay enough to retain at least competitive executives
Our executives are brilliant
Also,
In addition, the op-ed concluded with the argument:
And these leaders to more than manage finances. The op-ed implied that hospital CEOs are personally responsible for savings lives. This can be seen in the quote above under the brilliance argument, and later:
This despite the fact that the majority of CEOs in the article above, and indeed the majority of top managers of hospitals and hospital systems are not health care professionals, and cannot take any direct responsibility for patient care. This also despite the assertion by Mr West, the senior attorney for the New York Council of Nonprofits, that "hospitals are run like a business,..."suggesting that the people running them might put money, not "doing something for the public good," first.
Also, note that while Mr Mooney extolled the community based boards whose members made such discerning decisions about executive pay, he did not address these members' numerous conflicts of interests. For example, re some of hospitals and hospital systems with the most highly paid CEOs,
And,
And,
And,
Finally, note that neither the main article nor Mr Mooney's op-ed cited any evidence, even anecdotal, that these particular leaders are so brilliant, or that their hospitals are better than average, even in terms of finance, much less actual care of patients.
No Challenges to the Talking Points
The main article did not include any dissenters who questioned expansive executive pay. An accompanying editorial in the Journal News could only muster some anemic concern. It called multi-million dollar compensation for local non-profit hospital system executives "unsettling." It did contrast ever rising executive pay with the difficulty patients have paying their bills. But it could only muster conclusions that mirror the talking points:
So, all they called for was disclosure of compensation:
Although Mr Mooney seemed to see "aspersions" in the article, and thought "the article implies that hospital CEO compensation is somehow responsible for the continued rise in healthcare costs," and argued that "hospitals do not deserve to have nonprofit status," I could find no such challenges in the Journal News series to the notion that top non-profit hospital managers deserved every penny they got.
Conclusion
Sadly, the ever rising compensation of top health care managers seems to inspiring less, rather than more skepticism in the media. No more is it true that nearly all articles that try to delve into executive compensation at all at least quote some experts who are skeptical of current practices.
The Journal News series included no such attempts at balance. In my humble opinion, while it reported on useful facts, the opinions it contained leaned towards propaganda for managers' current privileged position in health care.
Despite all the blather about how top hospital executives deserve millions of dallars, there are real reasons to be skeptical. As we discussed here, there is a strong argument that huge executive compensation is more a function of executives' political influence within the organization than their brilliance or the likelihood they are likely to be fickle and jump ship for even bigger pay. This influence is partially generated by their control over their institutions' marketers, public relations flacks, and lawyers. It is partially generated by their control over the make up of the boards of trustees who are supposed to exert governance, especially when these boards are subject to conflicts of interest and are stacked with hired managers of other organizations.
While Mr Mooney was indignant that high executive pay may be considered a reason that hospital charges and health care costs are rising, he did not even discuss the argument that the current method of determining such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat. As an op-ed in US News and World Report put it about executive pay in general,
So I get to recycle my conclusions from my last post in this series....
We will not make any progress reducing current health care dysfunction if we cannot have an honest conversation about what causes it and who profits from it. In a democracy, we depend on journalists and the news media to provide the information needed to inform such a discussion. When the news media becomes an outlet for propaganda in support of the status quo, the anechoic effect is magnified, honest discussion is inhibited, and out democracy is further damaged.
True health care reform requires ending the anechoic effect, exposing the web of conflicts of interest that entangle health care, publicizing who benefits most from the current dysfunction, and how and why. But it is painfully obvious that the people who have gotten so rich from the current status quo will use every tool at their disposal, paying for them with the money they have extracted from patients and taxpayers, to defend their position. It will take grit, persistence, and courage to persevere in the cause of better health for patients and the public.
from Health Care Renewal http://ift.tt/295aXiA Still No Questions Asked - Journalists Fail to Challenge Talking Points Used to Justify Million Dollar Plus Executive Compensation at New York Non-Profit Hospitals Health Service Home
The problem of ever rising, amazingly generous pay for top health care managers is a frequent topic for Health Care Renewal. We have suggested that the ability of top managers to command ever increasing pay uncorrelated with their organizations' contributions to patients' or the public's health, and often despite major organizational shortcomings indicates fundamental structural problems with US health, and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.
In particular, we have written a series of posts about the lack of logical justification for huge executive compensation by non-profit hospitals and hospital systems. When journalists inquire why the pay of a particular leader is so high, the leader, his or her public relations spokespeople, or hospital trustees can be relied on to cite the same now hackneyed talking points.
As I wrote last year, and last month,
It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy. We first listed the talking points here, and then provided additional examples of their use. here, here here, here, here, and here, here and here.
They are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).
Yet as we discussed recently, these talking points are easily debunked. Additionally, rarely do those who mouth the talking points in support of a particular leader provide any evidence to support their applicability to that leader.
Bit at least most journalists who inquire into hospital executive compensation used to make an attempt to be "fair and balanced" by also quoting experts who question the talking points.
But not so much lately,...
Million Dollar Plus Hospital CEOs in New York
The Journal News, based in the northern New York City suburbs, ran a series of articles about executive pay and perks at NY hospitals and hospital systems. The main aricle in the series is here. A listing of the five highest paid hospital officials is here. A listing of executive perks, and conflicts of interests affecting the hospitals' and hospital systems' board members is here. The main article began,
New York's nonprofit hospitals paid millions in bonuses to executives and doctors despite a high-stakes battle to reduce health care spending.
As patients struggled to afford rising medical bills, incentive packages for top hospital executives reached seven figures and approached payouts at Wall Street banks, The Journal News/lohud has found.
Perks at the nonprofit hospitals included first-class plane tickets, chauffeurs and country club memberships. Severance and retirement payments mirrored golden parachutes awarded to for-profit corporate executives.
The article noted that 112 people who worked for non-profit hospitals in the Lower Hudson valley earned more than $1 million. The biggest pay went to the top executives of the biggest systems:
Bonuses and payments spiked the highest among executives at the helm of major hospital consolidations, data show.
North Shore University Hospital’s President/Chief Executive Officer Michael Dowling topped the list in 2014. He was paid $10.1 million in salary, bonuses and other pay. That is compared to $3 million in 2010.
Dowling’s payments came as the Long Island hospital and its affiliated organization, then North Shore-LIJ, began its ongoing expansion.
The health system, now Northwell Health, has pushed into the Lower Hudson Valley, partnering with Northern Westchester Hospital in Mount Kisco and other regional providers.
Also,
Dr. Steven Safyer, president and CEO of Montefiore Medical Center in the Bronx, was paid nearly $4.9 million in 2014, including a bonus of $1.3 million.
That's an $800,000 increase from the $4.1 million he was paid in 2010. It came as Montefiore bought bankrupt hospitals in Mount Vernon and New Rochelle, and pushed its expansion northward into Westchester County, which now includes a partnership with White Plains Hospital.
Note that Dr Sayfer also was given a hospital-paid car and driver.
An accompanying article noted the three other highly paid CEOs in New York state, Warren Hern, CEO of Unity Health Systems in Rochester, $7,490,213; Mark Clement, CEO of Rochester General Hospital, $5,323,856; and Dr Steven Crowin, CEO, New York Presbyterian Hospital, $4,591,728 [who also benefited from a policy allowing first-class or business airfare for flights over 6 hours, and some form of housing allowance.)
Other million dollar plus CEOs in the Lower Hudson valley included John Federspeil, president, Hudson Valley Hospital Center, $2,055,377; Joel Seligman, CEO, Northern Westchester Hospital, $2,043,289; Dr Cary Hirsch, CEO, Bon Secours Charity Health System (Good Samaritan Hospital in Suffern), $1,170,575; Keith Safian, CEO, Phelps Memorial Hospital Center, Sleepy Hollow, $1,494,760; Lawrence Levine, CEO, Blythedale Children's Hospital, $1,701,471, Edward Dinan, CEO, Lawrence Hospital Center, $1,707,780; Dr Craig Thompson, CEO, Memorial Sloan-Kettering Cancer Center, $2,944,926 (who also got first-class or coach airfare for flights over 6 hours, and some form of housing allowance); and Jon Schandler, CEO, White Plains Hospital, $1.799,952.
The Usual Talking Points to Justify Executive Compensation
The Journal News article also included justifications for this munificent pay by hospital officials that used the usual talking points.
We have to pay competitive rates
We have to pay enough to retain at least competitive executives
The spokesman for Northwell Health asserted,
The fact that we're located in the New York market ... only increases the competitive pressures on compensation.
Then,
Julius Green, a partner at Baker Tilly, a New Jersey-based accounting firm advising 100 hospitals in the Northwest, attributed expansions and higher pay to growing competition nationwide.
Also, from Blythedale Children's Hospital,
As the [Affordable Care Act] mandates take effect, and the number of insured individuals rise, the need for skilled healthcare workers will surely increase as will the competition for that talent.
Our executives are brilliant
Said Michael West, senior attorney for the New York Council of Nonprofits,
If you're running an organization that has a $500 million budget, you have to have someone with the wherewithal to run it and you have to pay for that.
Said Rachael McCallen, a Montefiore spokeswoman,
Our executives navigate a complex healthcare environment making appropriate investments to ensure a forward-thinking, innovative and responsive care model that provides higher value, lower cost integrated care services.
Furthermore, the next week the Journal News publised an op-ed by William Mooney, CEO of the Westchester County Association, which was devoted to defending the pay of his fellow CEOs. It started with indignation against anyone who would question the pay of our fearless leaders,
While it is fashionable to cast aspersions on high-income earners, the arguments set forth about the compensation levels of area health-care CEOs are misguided and erroneous.
Then Mr Mooney again hit the talking points.
We have to pay competitive rates
We have to pay enough to retain at least competitive executives
Given that a hospital is a community organization, the compensation of their executives is decided by boards made up of community members who base their decisions on research, competitive market analyses and responsible financial projections.
Our executives are brilliant
Running a hospital is a business unlike any other. First and foremost, hospitals are complex organizations that are about protecting and promoting health, and saving lives.
Also,
A hospital CEO is responsible for overseeing and guiding his or her staff through a maze of financial and regulatory challenges while making sure safety and performance standards are at the highest possible levels.
Third, the technology and infrastructure enhancements that today’s hospital CEO must manage are vast and rapidly changing. The staffing required to support all of these disparate functions encompasses a wide range of skill sets and education. A hospital CEO must understand and manage all of those roles, and must keep an eye on the demands and responsibilities of maintaining new technology.
In addition, the op-ed concluded with the argument:
your readers would be better served by reporting on the qualitative and quantitative benefits our community derives from having the best health-care leaders in the nation at the helm of our local hospitals.
And these leaders to more than manage finances. The op-ed implied that hospital CEOs are personally responsible for savings lives. This can be seen in the quote above under the brilliance argument, and later:
Non-profit status is conferred upon an organization that does something for the public good. Saving lives clearly is in the public’s best interests!
This despite the fact that the majority of CEOs in the article above, and indeed the majority of top managers of hospitals and hospital systems are not health care professionals, and cannot take any direct responsibility for patient care. This also despite the assertion by Mr West, the senior attorney for the New York Council of Nonprofits, that "hospitals are run like a business,..."suggesting that the people running them might put money, not "doing something for the public good," first.
Also, note that while Mr Mooney extolled the community based boards whose members made such discerning decisions about executive pay, he did not address these members' numerous conflicts of interests. For example, re some of hospitals and hospital systems with the most highly paid CEOs,
Stephen Friedman was a board member of Memorial Sloan-Kettering in 2014 when the cancer center paid $10.5 million for architectural services from Perkins/Eastman. Friedman’s brother-in-law, identified as Mr. Perkins, is affiliated with the firm, tax filing show. Bradford Perkins is listed as the co-founder and chairman of Perkins/Eastman, according to its website.
Jamie Nicholls was a Memorial Sloan-Kettering board member in 2014. Her spouse was a co-founder of King Street Capital Management, which the hospital paid nearly $700,000 for management fees, tax filings show.
And,
White Plains Hospital disclosed one business transaction involving an interested person. The filing has few details. It reported the name of the interested person as 'Donor #24' and the relationship with the hospital as a 'substantial contributor.' The amount of the transaction was $15,350,345, and the description is 'BUS TRANS.'
And,
New York-Presbyterian paid $440,225 for investment management fees to Coatue Management, which listed its founder and chief executive officer as Philippe Laffont, a hospital trustee, tax filings show.
And,
Kaleida Health in Buffalo paid $121,660 to the Greater New York Hospital Association for participation dues in 2014. James Kaskie, former president and chief executive officer at Kaleida, was also a board member at the association, tax filings show.
Finally, note that neither the main article nor Mr Mooney's op-ed cited any evidence, even anecdotal, that these particular leaders are so brilliant, or that their hospitals are better than average, even in terms of finance, much less actual care of patients.
No Challenges to the Talking Points
The main article did not include any dissenters who questioned expansive executive pay. An accompanying editorial in the Journal News could only muster some anemic concern. It called multi-million dollar compensation for local non-profit hospital system executives "unsettling." It did contrast ever rising executive pay with the difficulty patients have paying their bills. But it could only muster conclusions that mirror the talking points:
Hospitals are quick to defend their executives' rising compensation, and their arguments are good ones. Chief among them is that hospitals must compete for the best top officials, including with for-profit hospitals across the U.S. They say they need to attract and keep leaders who can competently oversee growing health-care systems, meet ever-changing government regulations and improve patient care and satisfaction.
So, all they called for was disclosure of compensation:
Hospital executives deserve fair pay for hard work; taxpayers deserve to know that resources are being used to attain quality care for all.
Although Mr Mooney seemed to see "aspersions" in the article, and thought "the article implies that hospital CEO compensation is somehow responsible for the continued rise in healthcare costs," and argued that "hospitals do not deserve to have nonprofit status," I could find no such challenges in the Journal News series to the notion that top non-profit hospital managers deserved every penny they got.
Conclusion
Sadly, the ever rising compensation of top health care managers seems to inspiring less, rather than more skepticism in the media. No more is it true that nearly all articles that try to delve into executive compensation at all at least quote some experts who are skeptical of current practices.
The Journal News series included no such attempts at balance. In my humble opinion, while it reported on useful facts, the opinions it contained leaned towards propaganda for managers' current privileged position in health care.
Despite all the blather about how top hospital executives deserve millions of dallars, there are real reasons to be skeptical. As we discussed here, there is a strong argument that huge executive compensation is more a function of executives' political influence within the organization than their brilliance or the likelihood they are likely to be fickle and jump ship for even bigger pay. This influence is partially generated by their control over their institutions' marketers, public relations flacks, and lawyers. It is partially generated by their control over the make up of the boards of trustees who are supposed to exert governance, especially when these boards are subject to conflicts of interest and are stacked with hired managers of other organizations.
While Mr Mooney was indignant that high executive pay may be considered a reason that hospital charges and health care costs are rising, he did not even discuss the argument that the current method of determining such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat. As an op-ed in US News and World Report put it about executive pay in general,
But the executive pay decisions made inside corporate boardrooms have an enormous impact in the outside world. Outrageous pay gives top executives an incentive to behave outrageously. To hit the pay jackpot, they'll do most anything. They'll outsource and downsize and make all sorts of reckless decisions that pump up the short-term corporate bottom line at the expense of long-term prosperity and stability.
So I get to recycle my conclusions from my last post in this series....
We will not make any progress reducing current health care dysfunction if we cannot have an honest conversation about what causes it and who profits from it. In a democracy, we depend on journalists and the news media to provide the information needed to inform such a discussion. When the news media becomes an outlet for propaganda in support of the status quo, the anechoic effect is magnified, honest discussion is inhibited, and out democracy is further damaged.
True health care reform requires ending the anechoic effect, exposing the web of conflicts of interest that entangle health care, publicizing who benefits most from the current dysfunction, and how and why. But it is painfully obvious that the people who have gotten so rich from the current status quo will use every tool at their disposal, paying for them with the money they have extracted from patients and taxpayers, to defend their position. It will take grit, persistence, and courage to persevere in the cause of better health for patients and the public.
from Health Care Renewal http://ift.tt/295aXiA Still No Questions Asked - Journalists Fail to Challenge Talking Points Used to Justify Million Dollar Plus Executive Compensation at New York Non-Profit Hospitals Health Service Home
Kamis, 23 Juni 2016
New AMA Presidrnt Andy Gurman, MD on EHRs: " I don't have one, and no one can make me use one." Health Service Home
The love-fest with EHRs continues, to the great chagrin of the believers in fairies, unicorns and cybernetic utopia.
from Health Care Renewal http://ift.tt/28R47cu New AMA Presidrnt Andy Gurman, MD on EHRs: " I don't have one, and no one can make me use one." Health Service Home
Andy Gurman, MD, Takes Reins as AMA President
Jun 17, 2016Gale Scott, HCPLiveThe American Medical Association’s new president, Andrew W. Gurman, MD, known for his affability and quick wit, is not one to seek out controversy.
In an interview before being sworn in this week as the AMA’s annual meeting in Chicago, IL, Gurman said he has no agenda for his tenure at the top of the organization.
Considering the mass hatred of EHRs by physicians (and nurses), the issue of EHR-related harms, compromised patient data security, physician scorecards, and other noxious issues, maybe he should. E.g., see my Jan. 28, 2015 post "Meaningful use not so meaningful: Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing" at http://ift.tt/1BoAqEj.
... Though physicians’ anger over the frustration of using existing electronic health records was a major topic of conversation at the [annual AMA] meeting, Gurman said he had little to add other than no one could make him use one.
“I don’t have an EHR,” he said. Due to the fact that he runs his own practice he found it easier and cheaper just to forgo the enhanced payments he would get under the federal “meaningful use” regulations for converting to electronic records. “I just take the penalties,” he said.
Not every physician can afford the time sink most EHRs represent, and the penalties, unfortunately.
Perhaps on the agenda should be a return to sense regarding physician and nurse documentation, with significant reduction in their clerical burden.
-- SS
from Health Care Renewal http://ift.tt/28R47cu New AMA Presidrnt Andy Gurman, MD on EHRs: " I don't have one, and no one can make me use one." Health Service Home
Rabu, 22 Juni 2016
Reckless indifference to nurse's concerns about bad health IT results in showing her the door? Health Service Home
At numerous past posts I referred to hospital executives' reckless indifference to the concern of seasoned clinicians about bad health IT, such as at http://ift.tt/1bQvbDw
I now see a stunning story of the results of EHR iconoclasty and patient advocacy:
If these allegations are true, a clinician, the Chief Nursing Officer, was shown the door in an act of recklessness for her complaining about bad health IT.
Some definitions:
Bad health IT:
Reckless indifference:
A wrongful termination lawsuit was apparently filed:
These types of gross defects, if true, represent an on its face menace to patient safety.
Further, these issues (and the harm that may result) are well known. In fact ONC's contractor RIT just released a comprehensive review article on health IT problems (see "Report of the Evidence on Health IT Safety and Interventions", May 2016, at http://ift.tt/1VR7iEz).
CEO Ray Hino had the usual refrain seen in so many postings here (under the blog query "Patient care has not been compromised" - http://ift.tt/1qWtnQ0):
Like most others uttering that line as documented, Mr. Hino apparently lacks expertise (e.g., in clinical, IT or Medical Informatics domains) to render such a judgment about patient danger if the EHR did or does exhibit such problems. His bio is at http://ift.tt/28RRvDM.
As to whether patients were harmed, that is irrelevant if the EHR has such defects. Sooner or later, they will be. The issue is risk, not body counts (yet).
There's also this. The EHR in question is not the product of the major EHR vendors but the work of apparent insider:
I really don't think injured or dead patients (or juries) will find those relationships an excuse for bad health IT and the discharge of someone complaining about it.
My expertise is available should the plaintiff so desire.
-- SS
from Health Care Renewal http://ift.tt/28RRrno Reckless indifference to nurse's concerns about bad health IT results in showing her the door? Health Service Home
I now see a stunning story of the results of EHR iconoclasty and patient advocacy:
CNO claims hospital forced her out after she raised concerns about EMR
Becker's Hospital Review
June 14, 2016
http://ift.tt/1URByKg
A former nursing executive at Sonoma West Medical Center in Sebastopol, Calif., has filed a lawsuit against the hospital, alleging she was fired after raising concerns the EMR was a threat to patient safety, reports The Press Democrat.
Autumn AndRa, RN, was serving as CNO of the hospital when she approached CEO Ray Hino and said the EMR, called Harmoni, was unsafe, according to the report.
Ms. AndRa was reportedly terminated from her CNO position April 14 and was offered a position in the intensive care unit, which her attorney Daniel Bartley told The Press Democrat would have been a demotion. Ms. AndRa left the hospital due to alleged harassment, according to Mr. Bartley.
If these allegations are true, a clinician, the Chief Nursing Officer, was shown the door in an act of recklessness for her complaining about bad health IT.
Some definitions:
Bad health IT:
Bad Health IT is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, 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, lacks evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.
Reckless indifference:
Deliberate indifference is the conscious or reckless disregard of the consequences of one's acts or omissions. It entails something more than negligence, but is satisfied by something less than acts or omissions for the very purpose of causing harm or with knowledge that harm will result.
A wrongful termination lawsuit was apparently filed:
... The lawsuit alleges the EMR system mixes patients' records, so information in one patient's chart moves to another patient's chart. It also alleges the EMR has issues tracking and updating patient medications and does not display patient code status information, which informs providers of patients' desired medical interventions, according to the report.
These types of gross defects, if true, represent an on its face menace to patient safety.
Further, these issues (and the harm that may result) are well known. In fact ONC's contractor RIT just released a comprehensive review article on health IT problems (see "Report of the Evidence on Health IT Safety and Interventions", May 2016, at http://ift.tt/1VR7iEz).
CEO Ray Hino had the usual refrain seen in so many postings here (under the blog query "Patient care has not been compromised" - http://ift.tt/1qWtnQ0):
Mr. Hino told The Press Democrat the EMR did not pose any danger to patients, and no patients have been harmed because of software defects.
Like most others uttering that line as documented, Mr. Hino apparently lacks expertise (e.g., in clinical, IT or Medical Informatics domains) to render such a judgment about patient danger if the EHR did or does exhibit such problems. His bio is at http://ift.tt/28RRvDM.
As to whether patients were harmed, that is irrelevant if the EHR has such defects. Sooner or later, they will be. The issue is risk, not body counts (yet).
There's also this. The EHR in question is not the product of the major EHR vendors but the work of apparent insider:
... The lawsuit also names Dan Smith, the developer of the EMR software in question, as a defendant. According to the lawsuit, Mr. Smith "has engaged in retaliation against [Ms. AndRa] and other employees who have voiced concerns that Mr. Smith's electronic medical records system, his self-dealing, and his management of medical and financial decisions are not in the best interests of SWMC and pose life-threatening risks to patient care," reports The Press Democrat.
Not only did Mr. Smith develop the software in question, but he is a significant financial backer and influencer at SWMC. According to a 2015 report from The Press Democrat, Mr. Smith and his wife have contributed nearly $9 million to the hospital in donations and forgivable loans, and he plays a role in "ever major decision" regarding the hospital. Mr. Smith is on SWMC's board of directors.
I really don't think injured or dead patients (or juries) will find those relationships an excuse for bad health IT and the discharge of someone complaining about it.
Mr. Smith and hospital officials declined to comment on the lawsuit, citing pending litigation, according to the report.
My expertise is available should the plaintiff so desire.
-- SS
from Health Care Renewal http://ift.tt/28RRrno Reckless indifference to nurse's concerns about bad health IT results in showing her the door? Health Service Home
Selasa, 21 Juni 2016
Senin, 20 Juni 2016
A Plea from a Traveling Blogger Health Service Home
A thousand apologies - since the Society for Medical Decision Making meeting in London, we have been traveling in the UK, and I have been unable to find the time to post on the blog. But in exchange we have caught up with good old friends, met lovely people, and seen fabulous sights and beautiful country. I plan to return very soon, and then after much catching up, will then resume normal activity.
But a reminder - a comment on our latest post suggested that Health Care Renewal does good work, but requires more effort.
Yet, all our blog posts are written by volunteers who have day jobs or are retired. At the moment, we have no real budget, no paid staff, no investigators, no researchers, no paid legal counsel, much less communications and public relations specialists. If more effort is required, it may have to come from YOU, dear readers. If you think that casting light on the issues we discuss is important, and taking action to improve health care dysfunction is more important, YOU also need to do something.
Of course, we would greatly appreciate contributions to FIRM - the Foundation for Integrity and Responsibility in Medicine, the tiny non-profit organization which we formed to provide support to the blog and similar dissemination, education and advocacy efforts to address health care dysfunction. FIRM is a US 501(c)3 non-profit and so contributions are deductible in the US to the extent provided by law. You can send contributions to FIRM at 16 Cutler St, Suite 104, Warren, RI, 02885, USA. Or email me (info at firmfound dot org) with questions.
If FIRM had real money, maybe we could develop a staff and do a lot more to shine light on the dark side. However, what is really required is effort by more than one organization and a few volunteer bloggers. Consider doing something yourself. Write a guest blog post for us, start your own blog, write a letter to the editor, an op-ed, or a journal article. Write your legislator. Meet with your legislator's staff. Organize a group of like minded people and do something organized. If you are a health professional, try to do your work in a way that will address health care dysfunction.
Howwever, do not expect it to be easy. There are many people personally enriching themselves through the current system. They will do all they can to preserve the status quo. They may command vast marketing, public relations, lobbying, and legal resources (all ultimately paid using other peoples' - often your - money) to maintain the status quo.
Saying something to combat the anechoic effect is hard. Doing something is harder. But if we don't do something, it will all get worse.
from Health Care Renewal http://ift.tt/28IifF7 A Plea from a Traveling Blogger Health Service Home
But a reminder - a comment on our latest post suggested that Health Care Renewal does good work, but requires more effort.
Yet, all our blog posts are written by volunteers who have day jobs or are retired. At the moment, we have no real budget, no paid staff, no investigators, no researchers, no paid legal counsel, much less communications and public relations specialists. If more effort is required, it may have to come from YOU, dear readers. If you think that casting light on the issues we discuss is important, and taking action to improve health care dysfunction is more important, YOU also need to do something.
Of course, we would greatly appreciate contributions to FIRM - the Foundation for Integrity and Responsibility in Medicine, the tiny non-profit organization which we formed to provide support to the blog and similar dissemination, education and advocacy efforts to address health care dysfunction. FIRM is a US 501(c)3 non-profit and so contributions are deductible in the US to the extent provided by law. You can send contributions to FIRM at 16 Cutler St, Suite 104, Warren, RI, 02885, USA. Or email me (info at firmfound dot org) with questions.
If FIRM had real money, maybe we could develop a staff and do a lot more to shine light on the dark side. However, what is really required is effort by more than one organization and a few volunteer bloggers. Consider doing something yourself. Write a guest blog post for us, start your own blog, write a letter to the editor, an op-ed, or a journal article. Write your legislator. Meet with your legislator's staff. Organize a group of like minded people and do something organized. If you are a health professional, try to do your work in a way that will address health care dysfunction.
Howwever, do not expect it to be easy. There are many people personally enriching themselves through the current system. They will do all they can to preserve the status quo. They may command vast marketing, public relations, lobbying, and legal resources (all ultimately paid using other peoples' - often your - money) to maintain the status quo.
Saying something to combat the anechoic effect is hard. Doing something is harder. But if we don't do something, it will all get worse.
from Health Care Renewal http://ift.tt/28IifF7 A Plea from a Traveling Blogger Health Service Home
Kamis, 09 Juni 2016
A Serious Challenge to the 2012 Low-carbohydrate "Metabolic Advantage" Study healthpolicyandmarket
Warning: this post will be a bit more wonkish than usual, because I need to get detailed to make my points. To read a summary, skip to the end.
In 2012, David Ludwig's group published an interesting RCT that suggested a substantial "metabolic advantage" resulting from a high-protein, very-low-carbohydrate diet (VLC) (1). In other words, this diet led to a higher energy expenditure relative to a normal-protein, low-fat diet (LF) over a one month period (a low-glycemic-load, normal-protein diet was in the middle and not significantly different from the other two). Resting energy expenditure (REE) was slightly but significantly higher on the VLC diet, and total energy expenditure (TEE) was elevated by a whopping 300+ kcal/day! I covered the study at the time, describing it as "fascinating" and "groundbreaking", and calling for the study to be replicated so we can be more confident in its unexpected result (2).
This finding has been used by Ludwig, Gary Taubes, and others to support the carbohydrate-insulin hypothesis of obesity, although there is no evidence that the effect was mediated by insulin, and also no evidence that it was mediated by reduced carbohydrate rather than increased protein (3).
Since I published that post, my confidence in the finding-- and particularly the common interpretation of it that reducing carbohydrate intake to a very low level increases REE and TEE-- has gradually been eroding. This is partially because other studies have generally reported that the carbohydrate:fat ratio of the diet has little or no effect on REE, TEE, or fat storage (4, 5, 6, 7, 8, 9, 10).
Read more »
from Whole Health Source http://ift.tt/24DR95q A Serious Challenge to the 2012 Low-carbohydrate "Metabolic Advantage" Study healthpolicyandmarket
In 2012, David Ludwig's group published an interesting RCT that suggested a substantial "metabolic advantage" resulting from a high-protein, very-low-carbohydrate diet (VLC) (1). In other words, this diet led to a higher energy expenditure relative to a normal-protein, low-fat diet (LF) over a one month period (a low-glycemic-load, normal-protein diet was in the middle and not significantly different from the other two). Resting energy expenditure (REE) was slightly but significantly higher on the VLC diet, and total energy expenditure (TEE) was elevated by a whopping 300+ kcal/day! I covered the study at the time, describing it as "fascinating" and "groundbreaking", and calling for the study to be replicated so we can be more confident in its unexpected result (2).
This finding has been used by Ludwig, Gary Taubes, and others to support the carbohydrate-insulin hypothesis of obesity, although there is no evidence that the effect was mediated by insulin, and also no evidence that it was mediated by reduced carbohydrate rather than increased protein (3).
Since I published that post, my confidence in the finding-- and particularly the common interpretation of it that reducing carbohydrate intake to a very low level increases REE and TEE-- has gradually been eroding. This is partially because other studies have generally reported that the carbohydrate:fat ratio of the diet has little or no effect on REE, TEE, or fat storage (4, 5, 6, 7, 8, 9, 10).
Read more »
from Whole Health Source http://ift.tt/24DR95q A Serious Challenge to the 2012 Low-carbohydrate "Metabolic Advantage" Study healthpolicyandmarket
Rabu, 08 Juni 2016
Tranparency International Reports on Massive Corruption in the Pharmaceutical Sector - Media Hardly Notices Health Service Home
Health Care Corruption as a Taboo Topic
Transparency International (TI) defines corruption as
In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
Also,
The report did not get much attention. Since then, health care corruption has been nearly a taboo topic in the US. When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries. On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US, but the topic remains anechoic.
Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here). But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries. Health Care Renewal was practically the only source of coverage in the US of the survey's results.
Transparency International's New Report on Corruption in the Pharmaceutical Sector
Now Transparency International (TI) has tried, and Health Care Reenewal will try again. In June, 2016 Transparency International published a new report entittled
The report's executive summary states:
In my humble opinion, the report is particularly significant in that it classifies as corrupt various kinds of activities that occur within the pharmaceutical sector (and also in other parts of health care) which are often discussed publicly as anything from standard operating procedure through unfortunate errors to unethical behavior. These include many activities which we have frequently discussed on Health Care Renewal. For example,
Manipulation of Clinical Research
We have frequently discussed how pharmaceutical companies, and biotechnology, medical device, and other health care companies and organizations, may manipulate clinical research to enhance the likelihood that is results will favor their products and marketing goals, even if the results are biased, inaccurate, could mislead physicians and patients, and ultimately harm patients. The TI report included:
Suppression of Clinical Research
We have frequently discussed how health care organizations (as above) may outright suppress clinical research when the results fail to support their interests. The TI report included:
Manipulation of the Dissemination of Clinical Research
We have frequently discussed how health care organizations may manipulate the dissemination of clinical research, through various forms of publications, presentations, courses, media summaries, etc, to favor their products and marketing goals, even if the results are misleading and could harm patients. For example, a while back we discussed the problem of "ghost-written" articles appearing in scholarly journals. The TI report included:
Deceptive Marketing
We have frequently discussed how marketing of pharmaceuticals (and nearly everything else in health care) may be deceptive, favoring companies' products and services, but again misleading health care professionals and patients, and ultimately risking patient harm. In the extreme, pharmaceutical companies (and other health care organizations) may resort to bribes or kickbacks. The TI report included:
Other Topics
Finally, the report mentions such issues as the revolving door, regulatory capture, etc, etc, etc
A Striking, and Strikingly Anechoic Report
Again, while the report summarizes information that is likely familiar to most Health Care Renewal readers, what is striking is that it describes manipulation of clinical research, suppression of clinical research, manipulation of dissemination of clinical research, and deceptive marketing as corruption. That is a sentiment rarely heard in the US, and one that appears nearly taboo.
Demonstrating the strength of the taboo, this striking report has gotten almost no attention in the media or scholarly medical and health care literature in the developed English-speaking countries. Let me note the important exceptions, however.
I learned of the report from a brief news item from the BMJ, the prestigious UK journal that seems most at the forefront of championing the integrity of medical and health care research.(1) The only substantial news article I could find on the report was also from the UK, in the Independent. Its sub-title is worth repeating:
Also, there were brief articles in Reuters, and in (web-only) FiercePharma. That is about it so far.
The report itself suggests why it has been so anechoic, just like nearly every other attempt to expose health care corruption to public discussion. Essentially, there is so much money to be made through pharmaceutical (and by implication, other health care corruption) that the corrupt have the money, power, and resources to protect their wealth accumulation by keeping it obscure. In the TI Report itself,
Keep in mind that the money made from corruption does not just go to innocent peoples' retirement funds that are invested in pharmaceutical stocks. It predominantly goes to top corporate executives and managers, and their cronies who preside over the corrupt practices.
I might as well repeat myself once again. As I wrote in 2015,
If we are not willing to even talk about health care corruption, how will we ever challenge it?
So to repeat an ending to one of my previous posts on health care corruption.... if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption. Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage. Yet such action cannot begin until we acknowledge and freely discuss the problem. The first step against health care corruption is to be able to say or write the words, health care corruption.
Reference
1. Torjesen I. Group calls for more to be done to tackle corruption in the pharmaceutical industry. BMJ 2016;353:i3099. Link here.
from Health Care Renewal http://ift.tt/1t8ZulR Tranparency International Reports on Massive Corruption in the Pharmaceutical Sector - Media Hardly Notices Health Service Home
Transparency International (TI) defines corruption as
Abuse of entrusted power for private gain
In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.
Also,
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.
The report did not get much attention. Since then, health care corruption has been nearly a taboo topic in the US. When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries. On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US, but the topic remains anechoic.
Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here). But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries. Health Care Renewal was practically the only source of coverage in the US of the survey's results.
Transparency International's New Report on Corruption in the Pharmaceutical Sector
Now Transparency International (TI) has tried, and Health Care Reenewal will try again. In June, 2016 Transparency International published a new report entittled
Corruption in the Pharmaceutical Sector
The report's executive summary states:
Within the health sector, pharmaceuticals stands out as sub-sector that is particularly prone to corruption. There are abundant examples globally that display how corruption in the pharmaceutical sector endangers positive health outcomes.
In my humble opinion, the report is particularly significant in that it classifies as corrupt various kinds of activities that occur within the pharmaceutical sector (and also in other parts of health care) which are often discussed publicly as anything from standard operating procedure through unfortunate errors to unethical behavior. These include many activities which we have frequently discussed on Health Care Renewal. For example,
Manipulation of Clinical Research
We have frequently discussed how pharmaceutical companies, and biotechnology, medical device, and other health care companies and organizations, may manipulate clinical research to enhance the likelihood that is results will favor their products and marketing goals, even if the results are biased, inaccurate, could mislead physicians and patients, and ultimately harm patients. The TI report included:
As pharmaceutical companies rely on gaining market entry in order to recoup R&D costs, when there is a lack of oversight in clinical trial data publication a conflict of interest exists in which a pharmaceutical company may have an incentive to manipulate clinical trial data. When clinical trial data is manipulated medical literature can become biased with positive findings fabricated, positive findings exaggerated or negative results hidden. This can result in inadequate prescribing patterns because HCPs rely on clinical trial data to make decisions on which medicines to use to treat patients.
Suppression of Clinical Research
We have frequently discussed how health care organizations (as above) may outright suppress clinical research when the results fail to support their interests. The TI report included:
Transparency and access to information through mandatory clinical trial registration, sanctions for not registering results or providing clinical trial information, and the publication of both positive and negative results are commonly discussed as helpful tools to curb corruption. With the European Medicines Agency (EMA) as a notable positive exception, public agencies and authorities do not require R&D-based pharmaceutical companies to make their raw data publicly available, making it impossible to verify whether the reported results are accurate. Based on laws and regulations clinical trial data is considered to be proprietary information, which allows pharmaceutical companies to conceal important data from the public domain.
Manipulation of the Dissemination of Clinical Research
We have frequently discussed how health care organizations may manipulate the dissemination of clinical research, through various forms of publications, presentations, courses, media summaries, etc, to favor their products and marketing goals, even if the results are misleading and could harm patients. For example, a while back we discussed the problem of "ghost-written" articles appearing in scholarly journals. The TI report included:
The practice of ghostwriting is also a risk with clinical trials. Ghostwriting involves the writing of clinical trial publications by industry and then having a highly esteemed researcher pass these findings off as their own without disclosing their actual involvement with the authorship of the article. It is a common practice, particularly in industry led trials. Ghostwriting is done to increase the prestige and reputation of the findings, while simultaneously researchers are able to improve their reputation, which can lead to promotions. Clearly this practice can result in inaccurate results being published.
Deceptive Marketing
We have frequently discussed how marketing of pharmaceuticals (and nearly everything else in health care) may be deceptive, favoring companies' products and services, but again misleading health care professionals and patients, and ultimately risking patient harm. In the extreme, pharmaceutical companies (and other health care organizations) may resort to bribes or kickbacks. The TI report included:
There are several methods for a corrupt pharmaceutical company to unethically market its medicines. At its most simple a pharmaceutical company can bribe a HCP directly with payments so its medicines are more likely to be prescribed. More abstrusely individuals may include a pharmaceutical company’s medicine on the national list that is reimbursed by public funds, in return for an indirect bribe by being sent to inappropriate holiday destinations for lavish conferences.
Corrupt marketing practices also include pharmaceutical companies providing misleading information regarding the safety and efficacy of a medicine to influence doctors’ prescribing habits and encouraging off-label, unlicensed use to increase sales.
Other Topics
Finally, the report mentions such issues as the revolving door, regulatory capture, etc, etc, etc
A Striking, and Strikingly Anechoic Report
Again, while the report summarizes information that is likely familiar to most Health Care Renewal readers, what is striking is that it describes manipulation of clinical research, suppression of clinical research, manipulation of dissemination of clinical research, and deceptive marketing as corruption. That is a sentiment rarely heard in the US, and one that appears nearly taboo.
Demonstrating the strength of the taboo, this striking report has gotten almost no attention in the media or scholarly medical and health care literature in the developed English-speaking countries. Let me note the important exceptions, however.
I learned of the report from a brief news item from the BMJ, the prestigious UK journal that seems most at the forefront of championing the integrity of medical and health care research.(1) The only substantial news article I could find on the report was also from the UK, in the Independent. Its sub-title is worth repeating:
Transparency International says corruption is making a few rich and wrecking the health of some of the world's poorest people
Also, there were brief articles in Reuters, and in (web-only) FiercePharma. That is about it so far.
The report itself suggests why it has been so anechoic, just like nearly every other attempt to expose health care corruption to public discussion. Essentially, there is so much money to be made through pharmaceutical (and by implication, other health care corruption) that the corrupt have the money, power, and resources to protect their wealth accumulation by keeping it obscure. In the TI Report itself,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.
Keep in mind that the money made from corruption does not just go to innocent peoples' retirement funds that are invested in pharmaceutical stocks. It predominantly goes to top corporate executives and managers, and their cronies who preside over the corrupt practices.
I might as well repeat myself once again. As I wrote in 2015,
If we are not willing to even talk about health care corruption, how will we ever challenge it?
So to repeat an ending to one of my previous posts on health care corruption.... if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption. Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage. Yet such action cannot begin until we acknowledge and freely discuss the problem. The first step against health care corruption is to be able to say or write the words, health care corruption.
Reference
1. Torjesen I. Group calls for more to be done to tackle corruption in the pharmaceutical industry. BMJ 2016;353:i3099. Link here.
from Health Care Renewal http://ift.tt/1t8ZulR Tranparency International Reports on Massive Corruption in the Pharmaceutical Sector - Media Hardly Notices Health Service Home
Selasa, 07 Juni 2016
NY Times/Steve Lohr asks "Why the Economic Payoff From Technology Is So Elusive." The answer in medicine is obvious. Health Service Home
In a June 5, 2016 article, New York Times reporter Steve Lohr (http://ift.tt/1wa7enB), who reports on technology, business and economics, asked the following question:
Healthcare becomes the gravamen of the article:
Unfortunately, the advisors who helped him with the article may have provided incomplete information:
Why would anyone expect (good) effects on "quality and costs" of healthcare when the technology is so unfit for purpose in design and implementation that it has alienated most of its users?
While being able to provide fancy charts and check drug-drug interactions (for which a massive and expensive EHR is certainly not needed; a PDA will suffice) is fine.
from Health Care Renewal http://ift.tt/25Km8CI NY Times/Steve Lohr asks "Why the Economic Payoff From Technology Is So Elusive." The answer in medicine is obvious. Health Service Home
Why the Economic Payoff From Technology Is So Elusive
New York Times, Business Day
By STEVE LOHR
JUNE 5, 2016
http://ift.tt/1UwNnVYl
Your smartphone allows you to get almost instantaneous answers to the most obscure questions. It also allows you to waste hours scrolling through Facebook or looking for the latest deals on Amazon. More powerful computing systems can predict the weather better than any meteorologist or beat human champions in complex board games like chess.
But for several years, economists have asked why all that technical wizardry seems to be having so little impact on the economy. The issue surfaced again recently, when the government reported disappointingly slow growth and continuing stagnation in productivity. The rate of productivity growth from 2011 to 2015 was the slowest since the five-year period ending in 1982.
Healthcare becomes the gravamen of the article:
One place to look at this disconnect is in the doctor’s office. Dr. Peter Sutherland, a family physician in Tennessee, made the shift to computerized patient records from paper in the last few years. There are benefits to using electronic health records, Dr. Sutherland says, but grappling with the software and new reporting requirements has slowed him down. He sees fewer patients, and his income has slipped.
Unfortunately, the advisors who helped him with the article may have provided incomplete information:
... “The government funding has made a huge difference,” said Dr. Ashish Jha, a professor at the Harvard School of Public Health. “But we’re seeing little evidence so far that all this technology has had much effect on quality and costs.”
In the face of, among many others, a stunning letter from 40 medical societies to HHS in 2015 that the technology is unfit for purpose (http://ift.tt/1xDWBoW), known and hair-raising defects (http://ift.tt/1CyNB9U), and many other complaints from physicians and nurses (e.g., http://ift.tt/TNpwKl, http://ift.tt/14kkNTo, query link http://ift.tt/TNpySo as just a few examples), such a statement is anserine.
Why would anyone expect (good) effects on "quality and costs" of healthcare when the technology is so unfit for purpose in design and implementation that it has alienated most of its users?
I've written previously about Jha's views in a May 27, 2009 post "Harvard's EMR Justification: We Just Have To Do Something" (http://ift.tt/1UwOc15):
... "I'm not suggesting EHR is going to be a panacea, but the one thing that is absolutely true is there is nothing else out there now that has any more political appeal," Jha says. "Everybody agrees, whether you are a conservative, moderate, or liberal, that we have to do something about healthcare. So the one place where we can all come to agreement is we have to do something about electronic records."
I do not think "political appeal" is a good justification for a multi-billion dollar cybernetic experiment in medicine, where the risks of the technology are considerable and where basic healthcare needs are not being well met among the poor and underprivileged.
Former ONC Chair David Brailer is quoted:
“People confuse information automation with creating the kind of work environment where productivity and creativity can flourish,” said Dr. David J. Brailer, who was the national health technology coordinator in the George W. Bush administration. “And so little has gone into changing work so far.”
Brailer was little better than Jha, and moves the goalposts with a type of circular logic. He appears to be saying that technology that will revolutionize medicine can't work until we change how things are done in medicine so the technology can revolutionize medicine.
The article then quotes one Tennessee physician, a Dr. Sutherland, who is "happy" to accept bad health IT, a resultant pay cut, and increased work:
... Today, Dr. Sutherland’s personal income and the medical group’s revenue are about 8 percent below where they were four years ago. But in 2015, both his earnings and the revenue of Healthstar, which employs 350 people in 10 clinics, increased slightly, by nearly 3 percent from 2014.... Dr. Sutherland bemoans the countless data fields he must fill in to comply with government-mandated reporting rules, and he concedes that some of his colleagues hate using digital records. Yet Dr. Sutherland is no hater. Despite the extra work the new technology has created and even though it has not yet had the expected financial payoff, he thinks it has helped him provide better information to patients.He values being able to tap the screen to look up potentially harmful drug interactions and to teach patients during visits. He can, for example, quickly create charts to show diabetes patients how they are progressing with treatment plans, managing blood glucose levels and weight loss.He is working harder, Dr. Sutherland says, but he believes he is a better doctor. Blunt measures of productivity, he added, aren’t everything. “My patients are better served,” he said. “And I’m happier.”
While being able to provide fancy charts and check drug-drug interactions (for which a massive and expensive EHR is certainly not needed; a PDA will suffice) is fine.
However, anyone who gladly accepts a pay cut, and inconvenience, and harder work due to bad health IT, and is a happy camper with that state of affairs, either suffers from the Stockholm syndrome or has a lot of discretionary income and free time to spare that many clinicians do not.
The article fails to mention the hundreds of thousands of other US docs and others in other lands (e.g., http://ift.tt/1ZaGzS3) who aren't happy at all with health IT as it is today.
---------------------------------------
I sent this email to Mr. Lohr.
From: S Silverstein
To:Steve Lohr
Date: Tue, Jun 7, 2016 at 10:02 AM
Subject: Re: Why the Economic Payoff From Technology Is So Elusive
Dear Mr. Lohr,
In medicine, the answer to this question is straightforward. I don't know if Ashish Jha brought this to your attention, or if he himself is aware of it.
This letter from nearly 40 different medical societies to HHS about bad health IT is specific about how bad the current health IT is:
You should be aware of the letter's contents. I've also attached it to this email.
In academic Medical Informatics, such matters are often ignored, as they run contrary to the narrative that IT will "revolutionize medicine"; I know, as I was Yale faculty in Medical Informatics myself.
The assumption in academic circles and in the Administration (unfortunately) is that "all health IT is good health IT."
Unfortunately, it is not. From my own site "Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties" at http://ift.tt/1T7fFeDssilverstein/cases/ :
Definitions authored by myself and Australian informatics expert Dr. Jon Patrick:
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, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information 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, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, 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, is lacking in evidentiary soundness, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.
It comes as no surprise not to find productivity gains, but instead hundreds of thousands of angry physicians (and nurses), when health IT is mostly bad IT.
The health IT industry itself needs serious remediation before its products will be a boon to medicine.Sincerely,Scot Silverstein, MDDrexel University, Philadelphiap.s. I have not even broached the matter of health IT patient harms.
Patients are being harmed and dying of bad health IT. See for instance the CRICO insurance report at http://ift.tt/1UwOapZfaculty/ssilverstein/PSQH_ MalpractClaimsAnalyConfirRisks EHR.pdf
---------------------------------------
I will add an addendum if I receive a reply.
-- SS
from Health Care Renewal http://ift.tt/25Km8CI NY Times/Steve Lohr asks "Why the Economic Payoff From Technology Is So Elusive." The answer in medicine is obvious. Health Service Home
Jumat, 03 Juni 2016
Clinical Practice Guidelines: Still Conflicted After All These Years Health Service Home
Background: Untrustworthy Clinical Practice Guidelines
Since the 1990s, clinicians have been exhorted to follow clinical practice guidelines (CPGs) to improve their decision-making and patients' outcomes. When Dr Wally Smith and I started teaching a short course (often at the Society for Medical Decision Making meetings) about changing physician behavior, we naively set out to improve decisions by increasing adherence to such guidelines. We first thought that physicians' apparent shortcomings in guideline adherence were due to their lack of knowledge of the guidelines and the underlying evidence, and to their human cognitive limitations.
That approach, however, failed to yield ways to improve adherence. After a while, it occurred to us that there might be other reasons physicians did not follow guidelines, including their lack of trust of the guidelines or the evidence supposedly incorporated within them. We learned that integrity of the clinical evidence base has been severely degraded due to the manipulation of clinical studies by those with vested interests, and the outright suppression of trials for which manipulation does not produce the desired results.
Furthermore, as we became less naive, we learned that the integrity of the guideline development process was also suspect, again due to the influence of those with vested interest. No wonder physicians were suspicious of guidelines, and resisted adhering to them.
In 2011, the prestigious Institute of Medicine released a report on the development of better standards to produce more trustworthy guidelines (Clinical Practice Guidelines We Can Trust. Link here.) We posted about that report here, but noted that it was receiving little other attention, an example of the anechoic effect. The IOM report cited conflicts of interest (COIs) affecting the guideline development process as a major reason such guidelines might be untrustworthy, and suggested a variety of ways to reduce COIs affecting guidelines.
These included in particular:
- Guideline committee members should disclose their conflicts of interest in detail, and these should appear in the guidelines (Standard 2.1, 2.2)
- The number of conflicted committee members should be minimized, and in no case should be a majority of the committee (2.3, 2.4)
- Funders should have no role in guideline development (2.4)
This week, an original article(1) and editorial(2) in PLoS Medicine discussed how guidelines published since the report was produced addressed conflicts of interest.
Article Summary
Below I summarized the article, but presented results somewhat differently than did the authors.
Design
Campsall et al did a cross-sectional study of clinical practice guidelines that appeared in the US Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse in 2012 from national or international organizations, excluding guidelines produced by organizations restricted to allied health professionals, guidelines produced by corporations, or guidelines that had no specific recommendations. They obtained information from the guidelines, the organizations' websites, and surveys sent to the organizations.
Study Population
The study population was 290 guidelines produced by 95 organizations. The response rate for the surveys was 68%. The organizations were primarily professional societies (67%) or disease advocacy groups (21%).
My comment is that therefore this study assessed guidelines mainly produced by non-profit organizations which ostensibly uphold health care professionals' values and/or primarily support patients' interests.
Industry Funding
63% of organizations reported receiving funds from biomedical companies. (It was not clear whether the remainder denied receiving such funding, or provided no information about funding.)
My comment is that the majority of such ostensibly "do-gooder" organizations are nonetheless at least somewhat supported by commercial firms that market health care products, presumably mainly drugs or devices.
Conflict of Interest Policies
Please note that the authors provided results to emphasize the positive, for example, they provided the proportion of organizations which provided specific types of information about COIs or had particular policies to reduce COIs. In most cases, I simply did subtractions to emphasize the negative. Furthermore, the authors further emphasized the positive by choice of denominator, as noted below.
20% of organizations did not provide any information about conflict of interest policies, and 7% asserted the existence of such policies, but did not disclose them. A majority, 55%, did not have disclosed policies that specifically dealt with with conflicts of interest affecting guidelines.
My comment is thus that a majority of these do-gooder organizations did not apparently even begin to address, at least in terms of clear, transparent written policy, the recommendations of the IOM report on trustworthy guidelines.
Measures to Improve Guidelines Trustworthiness by Decreasing Influence of Conflicts of Interest
The authors provided the number of organizations with disclosed policies that addressed particular issues of concern to the IOM in their report on trustworthy guidelines, but made the proportions of such organizations seem larger by using as a denominator the number of organizations that disclosed their entire policies, rather than the total number of organizations which produced the guidelines.
Therefore, they found that of the 60 (out of 95 total) organizations that fully disclosed their conflict of interest policies:
98% required committee members to disclose conflicts of interest;
90% required review of conflicts of interest before guideline publication;
68% required that a majority of guideline committee members be free of conflicts of interest;
92% reported publishing committee members' conflicts of interest within guidelines;
78% did not allow direct industry funding of guideline development
82% did not allow industry participation in selection of committee members
67% did not allow industry to review guidelines prior to publication.
That all sound good, but consider what happens when one uses the total sample of organizations in the denominators.
Therefore, the article also found that of all 95 organizations that produced the guidelines of interest:
38% did not require CPG committee members to disclose conflicts of interest
43% did not require review of committee members' conflicts of interest prior to guidelines development
57% did not require that a majority of guideline committee members be free of conflicts
44% did not report publishing committee members' conflicts of interest within guidelines
48% did not report preventing direct industry funding of guidelines
51% did not report preventing industry participation in selection of committee members
61% did not report preventing industry review of guidelines prior to publication.
My comment is that thus the results suggested that substantial numbers of organizations that produced CPGs did not demonstrate that they were committed to measures that would improve guidelines trustworthiness by reducing the influence of conflicts of interest.
Disclosure of Conflicts of Interest Within Guidelines
Again, it was necessary to recalculate some proportions using the full population of guidelines reviewed as the denominator.
Of the 290 guidelines reviewed:
65% "included disclosure statements regarding direct funding and support"
37% specifically disclosed the absence or presence of direct funding from biomedical companies
However,
49% did not disclose committee members' financial relationships
99% did not disclose relevant financial relationships of the organization (that is, institutional conflicts of interest) that produced the guidelines as a whole
My comment is that substantial numbers of published guidelines were not clearly produced so as to increase their trustworthiness by reducing the influence of conflicts of interest on them.
Did the Guidelines Follow the Organizations' Stated Policies?
The authors commendably provided information about whether the guidelines produced by organizations that disclosed conflict of interest policies followed those polices. They found:
16% of organizations "that reported that committee member conflicts of interested were published in guidelines" produced guidelines that did not include committee members' COI disclosure
61% of organizations that "reported the majority of committee members must be free of conflicts of interest" produced guidelines by committees with majorities of conflicted members
6% of organizations that "reported that industry partners were not permitted to directly fund clinical practice guideline development" produced guidelines which disclosed such funding.
My comment is that thus even of the organizations that stated they had policies in place to improve the trustworthiness of the guidelines they produced by reducing the influence of conflicts of interest, they allowed guidelines to be produced that did not follow those policies.
Authors' Conclusion
Editorialists' Conclusion
The editorial by Bastian(2) was sharper in tone. It included an observation that reinforced my confession of naivete above:
She also noted that the Campsall study did not address all the ways conflicts of interest can influence guideline development:
Finally, she emphasized that we are still a long way from having guidelines that health care professionals and patients can trust:
My Summary
So should physicians trust clinical practice guidelines? At least this article suggests they ought to be very very skeptical of them. The IOM report meant to improve the trustworthiness of practice guidelines seems to be honored mainly in the breach. The likelihood that any given guideline was produced so as to reduce the influence of conflicts of interest on it is low. Even organizations that ostensibly put professional values and patients first in their efforts to develop guidelines seem to often be financially beholden to companies that want to sell drugs and devices. Physicians and patients ought to be concerned that most new clinical practice guidelines may be as much about marketing commercial products as improving medical practice or patients' outcomes.
The current US presidential race has made it evident that we have a lot of disgruntled citizens, many of whom believe our system is rigged to favor the "establishment." I suggest that the more we know about clinical practice guidelines, the more it appears that the health care system is rigged to favor certain parts of the "establishment," the big corporations that market drugs and devices, and their paid part-time hands within medical societies and patient advocacy groups who have turned these ostensibly idealistic, do gooder organizations into part-time marketing machines.
The huge and complex web of individual and institutional conflicts of interest that binds much of the health care system, the government, and industry may be good for the insiders, but is stifling improvement in our dysfunctional health care system. True health care reform would first expose these conflicts, then reduce or better yet, eliminate them, and make health care more about helping patients and less about making money by marketing commercial products.
Musical Interlude
To dispel the darkness a bit, Paul Simon, "Still Crazy After All These Years," 1992 acoustic version:
References
1. Campsall P et al. Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry: a cross-sectional study. PLoS Medicine 2016; DOI;10.1371/journal.pmed.1002029 Link here.
2. Bastien H. Nondisclosure of financial interest in clinical practice guideline development: an intractable problem? PLoS Medicine 2016; DOI;10.1371/journal.pmed.1002030 Link here.
from Health Care Renewal http://ift.tt/1sST5uZ Clinical Practice Guidelines: Still Conflicted After All These Years Health Service Home
Since the 1990s, clinicians have been exhorted to follow clinical practice guidelines (CPGs) to improve their decision-making and patients' outcomes. When Dr Wally Smith and I started teaching a short course (often at the Society for Medical Decision Making meetings) about changing physician behavior, we naively set out to improve decisions by increasing adherence to such guidelines. We first thought that physicians' apparent shortcomings in guideline adherence were due to their lack of knowledge of the guidelines and the underlying evidence, and to their human cognitive limitations.
That approach, however, failed to yield ways to improve adherence. After a while, it occurred to us that there might be other reasons physicians did not follow guidelines, including their lack of trust of the guidelines or the evidence supposedly incorporated within them. We learned that integrity of the clinical evidence base has been severely degraded due to the manipulation of clinical studies by those with vested interests, and the outright suppression of trials for which manipulation does not produce the desired results.
Furthermore, as we became less naive, we learned that the integrity of the guideline development process was also suspect, again due to the influence of those with vested interest. No wonder physicians were suspicious of guidelines, and resisted adhering to them.
In 2011, the prestigious Institute of Medicine released a report on the development of better standards to produce more trustworthy guidelines (Clinical Practice Guidelines We Can Trust. Link here.) We posted about that report here, but noted that it was receiving little other attention, an example of the anechoic effect. The IOM report cited conflicts of interest (COIs) affecting the guideline development process as a major reason such guidelines might be untrustworthy, and suggested a variety of ways to reduce COIs affecting guidelines.
These included in particular:
- Guideline committee members should disclose their conflicts of interest in detail, and these should appear in the guidelines (Standard 2.1, 2.2)
- The number of conflicted committee members should be minimized, and in no case should be a majority of the committee (2.3, 2.4)
- Funders should have no role in guideline development (2.4)
This week, an original article(1) and editorial(2) in PLoS Medicine discussed how guidelines published since the report was produced addressed conflicts of interest.
Article Summary
Below I summarized the article, but presented results somewhat differently than did the authors.
Design
Campsall et al did a cross-sectional study of clinical practice guidelines that appeared in the US Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse in 2012 from national or international organizations, excluding guidelines produced by organizations restricted to allied health professionals, guidelines produced by corporations, or guidelines that had no specific recommendations. They obtained information from the guidelines, the organizations' websites, and surveys sent to the organizations.
Study Population
The study population was 290 guidelines produced by 95 organizations. The response rate for the surveys was 68%. The organizations were primarily professional societies (67%) or disease advocacy groups (21%).
My comment is that therefore this study assessed guidelines mainly produced by non-profit organizations which ostensibly uphold health care professionals' values and/or primarily support patients' interests.
Industry Funding
63% of organizations reported receiving funds from biomedical companies. (It was not clear whether the remainder denied receiving such funding, or provided no information about funding.)
My comment is that the majority of such ostensibly "do-gooder" organizations are nonetheless at least somewhat supported by commercial firms that market health care products, presumably mainly drugs or devices.
Conflict of Interest Policies
Please note that the authors provided results to emphasize the positive, for example, they provided the proportion of organizations which provided specific types of information about COIs or had particular policies to reduce COIs. In most cases, I simply did subtractions to emphasize the negative. Furthermore, the authors further emphasized the positive by choice of denominator, as noted below.
20% of organizations did not provide any information about conflict of interest policies, and 7% asserted the existence of such policies, but did not disclose them. A majority, 55%, did not have disclosed policies that specifically dealt with with conflicts of interest affecting guidelines.
My comment is thus that a majority of these do-gooder organizations did not apparently even begin to address, at least in terms of clear, transparent written policy, the recommendations of the IOM report on trustworthy guidelines.
Measures to Improve Guidelines Trustworthiness by Decreasing Influence of Conflicts of Interest
The authors provided the number of organizations with disclosed policies that addressed particular issues of concern to the IOM in their report on trustworthy guidelines, but made the proportions of such organizations seem larger by using as a denominator the number of organizations that disclosed their entire policies, rather than the total number of organizations which produced the guidelines.
Therefore, they found that of the 60 (out of 95 total) organizations that fully disclosed their conflict of interest policies:
98% required committee members to disclose conflicts of interest;
90% required review of conflicts of interest before guideline publication;
68% required that a majority of guideline committee members be free of conflicts of interest;
92% reported publishing committee members' conflicts of interest within guidelines;
78% did not allow direct industry funding of guideline development
82% did not allow industry participation in selection of committee members
67% did not allow industry to review guidelines prior to publication.
That all sound good, but consider what happens when one uses the total sample of organizations in the denominators.
Therefore, the article also found that of all 95 organizations that produced the guidelines of interest:
38% did not require CPG committee members to disclose conflicts of interest
43% did not require review of committee members' conflicts of interest prior to guidelines development
57% did not require that a majority of guideline committee members be free of conflicts
44% did not report publishing committee members' conflicts of interest within guidelines
48% did not report preventing direct industry funding of guidelines
51% did not report preventing industry participation in selection of committee members
61% did not report preventing industry review of guidelines prior to publication.
My comment is that thus the results suggested that substantial numbers of organizations that produced CPGs did not demonstrate that they were committed to measures that would improve guidelines trustworthiness by reducing the influence of conflicts of interest.
Disclosure of Conflicts of Interest Within Guidelines
Again, it was necessary to recalculate some proportions using the full population of guidelines reviewed as the denominator.
Of the 290 guidelines reviewed:
65% "included disclosure statements regarding direct funding and support"
37% specifically disclosed the absence or presence of direct funding from biomedical companies
However,
49% did not disclose committee members' financial relationships
99% did not disclose relevant financial relationships of the organization (that is, institutional conflicts of interest) that produced the guidelines as a whole
My comment is that substantial numbers of published guidelines were not clearly produced so as to increase their trustworthiness by reducing the influence of conflicts of interest on them.
Did the Guidelines Follow the Organizations' Stated Policies?
The authors commendably provided information about whether the guidelines produced by organizations that disclosed conflict of interest policies followed those polices. They found:
16% of organizations "that reported that committee member conflicts of interested were published in guidelines" produced guidelines that did not include committee members' COI disclosure
61% of organizations that "reported the majority of committee members must be free of conflicts of interest" produced guidelines by committees with majorities of conflicted members
6% of organizations that "reported that industry partners were not permitted to directly fund clinical practice guideline development" produced guidelines which disclosed such funding.
My comment is that thus even of the organizations that stated they had policies in place to improve the trustworthiness of the guidelines they produced by reducing the influence of conflicts of interest, they allowed guidelines to be produced that did not follow those policies.
Authors' Conclusion
Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry appear to be common. These relationships are important because they may influence, through guideline usage, the practice of large numbers of healthcare providers. We believe that to effectively manage conflicts of interest, organizations that produce clinical practice guidelines need to develop robust conflict of interest policies that include procedures for managing violations of the policy, make the policies publicly available, and disclose all financial relationships with biomedical companies.
Editorialists' Conclusion
The editorial by Bastian(2) was sharper in tone. It included an observation that reinforced my confession of naivete above:
With hindsight, I think those of us encouraging better methodology for guideline development in the 1990s took the issue of disclosure of financial interests too much for granted. It seemed so self-evident, it got barely a mention even in national policy on guideline development
She also noted that the Campsall study did not address all the ways conflicts of interest can influence guideline development:
Stelfox and colleagues focus particularly on the organizational conflicts of interest of guideline producers and their policies. They examine the financial interests of the organizations, but not of the individuals employed within those organizations. This same blind spot is evident when it comes to policies about committee members; the financial interests of the organizations that individuals represent tend to be disregarded. Yet these can be substantial, including for patients’ organizations.
Finally, she emphasized that we are still a long way from having guidelines that health care professionals and patients can trust:
Guideline processes without adequate financial conflict management have to become unacceptable to a far wider circle. They need to become unacceptable to influential committee members, to the medical journals that lend so many guidelines additional standing and reach, and to the membership of the professional societies that produce them. Until that happens, for guidelines as for clinical research, it’s a case of caveat lector: let the reader beware.
My Summary
So should physicians trust clinical practice guidelines? At least this article suggests they ought to be very very skeptical of them. The IOM report meant to improve the trustworthiness of practice guidelines seems to be honored mainly in the breach. The likelihood that any given guideline was produced so as to reduce the influence of conflicts of interest on it is low. Even organizations that ostensibly put professional values and patients first in their efforts to develop guidelines seem to often be financially beholden to companies that want to sell drugs and devices. Physicians and patients ought to be concerned that most new clinical practice guidelines may be as much about marketing commercial products as improving medical practice or patients' outcomes.
The current US presidential race has made it evident that we have a lot of disgruntled citizens, many of whom believe our system is rigged to favor the "establishment." I suggest that the more we know about clinical practice guidelines, the more it appears that the health care system is rigged to favor certain parts of the "establishment," the big corporations that market drugs and devices, and their paid part-time hands within medical societies and patient advocacy groups who have turned these ostensibly idealistic, do gooder organizations into part-time marketing machines.
The huge and complex web of individual and institutional conflicts of interest that binds much of the health care system, the government, and industry may be good for the insiders, but is stifling improvement in our dysfunctional health care system. True health care reform would first expose these conflicts, then reduce or better yet, eliminate them, and make health care more about helping patients and less about making money by marketing commercial products.
Musical Interlude
To dispel the darkness a bit, Paul Simon, "Still Crazy After All These Years," 1992 acoustic version:
References
1. Campsall P et al. Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry: a cross-sectional study. PLoS Medicine 2016; DOI;10.1371/journal.pmed.1002029 Link here.
2. Bastien H. Nondisclosure of financial interest in clinical practice guideline development: an intractable problem? PLoS Medicine 2016; DOI;10.1371/journal.pmed.1002030 Link here.
from Health Care Renewal http://ift.tt/1sST5uZ Clinical Practice Guidelines: Still Conflicted After All These Years Health Service Home
Rabu, 01 Juni 2016
Everything Will Be Fine As Soon As The Obamacare Market "Stabilizes"––Not wholehealthsource
from Health Care Policy and Marketplace Review http://ift.tt/1Uew3Fx Everything Will Be Fine As Soon As The Obamacare Market "Stabilizes"––Not wholehealthsource
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