More cybernetic miracles: 14,000 patients failed to receive follow-up outpatient appointments

14,000 is a lot of patients to miss followup appointments. I do not think this feat could have been accomplished via paper:

Morecambe Bay missed 14,000 outpatients
E-Health Insider.com
7 February 2012
Lyn Whitfield

University Hospitals of Morecambe Bay NHS Foundation Trust is working through a backlog of 14,000 patients who failed to receive follow-up outpatient appointments because of administrative and IT problems.

And problems with disappearing ink and Fido, the office canine, chewing up charts, but mostly the IT.

The report of an investigation into the backlog paints a damning picture of failures at the trust, which became the first to introduce the Lorenzo electronic patient record system as part of the National Programme for IT in the NHS.

That would be, the failed National Programme for IT in the NHS, the NpfIT that went Pffft (perhaps the world's most expensive onomatopoeia, at a mere £12.7bn).

The report says the problems go back many years and have their roots in a ‘mismatch’ between demand and capacity at Morecambe Bay, as well poor management and risk practices and a culture of avoiding blame.

However, it also says the trust missed a big opportunity to identify and tackle the problems when it introduced Lorenzo [a health IT system - ed.] in June 2010, and that staff work-arounds contributed to the ultimate size of the backlog.

That is, workarounds to system flaws and 'glitches.'

Eventually, there were 37,000 access plans on the Lorenzo system for which a guaranteed access date had been missed. Many of these plans were duplicates or had not been closed.

However, 14,000 patients needed to be seen and were divided into cohorts so the trust could deal with them. All these patients should have been seen by the end of March.

For the future, the report says the trust needs to establish better systems, find ways to make sure that the board knows what is going on, encourage staff to take responsibility for dealing with problems, and curb the “mal-use” of Lorenzo by imposing “sanctions” on staff if necessary.

Once again, blaming the IT users and punishing them for not conforming to the diktats of the IT and its designers.

It also says the findings of the report, and the importance of “electronic, standardised and systematic management of outpatient follow-ups” should be shared with all providers, in case others are suffering the same problems on a smaller scale.

"In case?" It sounds like they don't even know.

... when a backlog was identified during the data cleansing process for the introduction of Lorenzo, the trust failed to recognise it as a clinical problem.

Instead, to try and solve another administrative problem – the constant cancellation of clinics – the trust introduced a ‘partial booking’ system. Patients who needed a follow-up in more than six weeks were asked to call for an appointment.

“No arrangements were made to account for the 1,000 or so calls that the clinical clerks would receive per week, whilst still trying to man the reception desk and administer the clinics,” the report says. “This created chaos and confusion for patients and staff alike.”

Sounds like a government operation to me.

Patients were often offered late appointments – “some of which arrived with the patient only after the clinic had taken place.”

All of this caused patient and GP complaints, but because they seemed to relate to administrative problems, their real, clinical nature was overlooked.

In the middle of all this, outpatient staff complained that Lorenzo was slow – although the report says there is no evidence that it was slower than the system it replaced [ignore the users - their complaints are all 'anecdotal' - ed.] – and that it was more complicated to complete a booking.

As a result, “many staff found ways around that were quicker, but these were responsible for patients having multiple access plans, which helped to label the problem as administrative.”

You never have to work around something that is not in your way.

Floor walkers initially monitored such “inappropriate” use, but this stopped once Lorenzo had stabilised. [The computer police...how charming. - ed.]

Morecambe Bay is the first and most prominent of the ‘early adopter’ sites for Lorenzo, which was due to be implemented in the North, Midlands and East by CSC [an American management consulting firm - ed.] as local service provider.

The problems at the trust, CSC’s failure to complete the ‘early adopter’ programme, and critical reports from watchdogs and MPs on progress, have thrown a new LSP deal into doubt.

I presume they mean critical reports from MPs like this, and other reports like this from Parliament's Public Accounts Committee a few years back that stated, among many other findings, that:

... The [NPfIT] Programme is not providing value for money at present because there have been few successful deployments of the [U.S. Cerner] Millennium system and none of Lorenzo in any Acute Trust. Trusts cannot be expected to take on the burden of deploying care records systems that do not work effectively. Unless the position on care records system deployments improves appreciably in the very near future (i.e. within the next six months), the Department should assess the financial case for allowing Trusts to put forward applications for central funding for alternative systems compatible with the objectives of the Programme.

Charming.

CSC announced last week that it was going to lay off 500 staff, including 46 from iSoft, which developed Lorenzo, and which CSC bought last year.

I'm sure that will help speed up software remediation.

-- SS

Perhaps Hospitals Don't Care Much That EHRs Can Be Dangerous, Because EHRs Lets them Attract 'Good Paying Customers' And Exclude the Old and Poor

This comes as no surprise to me. I believe it may help explain hospital's cavalier attitudes towards the risks of today's commercial health IT.

It's all about money.

We already knew that (for example, see my Feb. 2011 post "Does EHR-Incited Upcoding (Also Known as 'Fraud') Need Investigation by CMS, And Could it Explain HIT Irrational Exuberance?"), but the following news adds to the pecuniary motivations:

Kaiser Health News

Critics say hospitals cherry pick best-paying patients
By Phil Galewitz
KHN Staff Writer

Feb 05, 2012

When the oversized postcard arrived last August from Provena St. Joseph Medical Center promoting a lung cancer screening for current or former smokers over 55, Steven Boyd wondered how the hospital had found him.

Boyd, 59, of Joliet, Ill., had smoked for decades, as had his wife, Karol.

Provena didn't send the mailing to everyone who lived near the hospital, just those who had a stronger likelihood of having smoked based on their age, income, insurance status and other demographic criteria.

The nonprofit center is one of a growing number of hospitals using their patients' health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether they have children or pets at home.

Hospitals say they are promoting needed services, such as cancer screenings and cholesterol tests, but they often use the data to target patients with private health insurance, which typically pay higher rates than government coverage. At an industry conference last year, Provena Health marketing executive Lisa Lagger said such efforts had helped attract higher-paying patients, including those covered by "profitable Blue Cross and less Medicare."

Not to mention helping exclude those covered by Medicaid, or the uninsured.

Strategy Draws Fire

While the strategies are increasing revenues, they are drawing fire from patient advocates and privacy groups, who criticize the hospitals for using private medical records to pursue profits.

I don't recall anywhere on the releases at area hospitals saying they would be using their own clinical data for marketing purposes (which likely involve third party contractors). It might be in the fine print, however. I also don't recall any place to sign and give informed consent to the use of experimental medical devices such as the EHR's used to collect the marketing data, either, but that's addressed elsewhere on this blog such as here.

Doug Heller, executive director of Consumer Watchdog, a California-based consumer advocacy group, says he is bothered by efforts to "cherry pick" the best-paying patients.

"When marketing is picking and choosing based on people's financial status, it is inherently discriminating against patients who have every right and need for medical information," Heller says. "This is another example of how our health system has gone off the rails."

I would go beyond "off the rails." How about, straight to perverse? EHR data is used to attract paying customers and then expose them to risk of being maimed due to the disruptive nature of the HIT itself.

Deven McGraw, director of the health privacy project at the Center for Democracy and Technology in Washington, says federal law allows hospitals to use confidential medical records to inform patients about things that may help them.

"If it's technically legal, we can do it, and who gives a damn about the ethics?" is what is being expressed here.

"You want health providers to communicate to patients about health options that may be beneficial to their health," McGraw says. "But sometimes this is about generating business for a new piece of equipment that the hospital just bought."

Using such information for marketing "creeps closer to the line," between what is legal and what is not, she says.

And helping recoup the costs of that hundred-million dollar EHR setup, too.

... Tess Niehaus, vice president of marketing at St. Anthony’s Medical Center in St. Louis, says the approach has been quite successful and makes no apologies for going after the most lucrative business.

"We are here to serve everybody but we market for good paying patients because it preserves our ability to serve everyone," she says. [And the ability to proffer generous executive salaries and raises - ed.]

"Good paying patients?" Does that imply there are bad paying patients? (Might those "bad paying patients" be predominantly the elderly and/or minorities?)

While the practice is legal, most people would be shocked to know their records may be shared with nonmedical personnel and outside firms to help hospitals attract business, says Pam Dixon, executive director of the World Privacy Forum, an advocacy group based in California. "I am really bothered by the overabundance of information that is flowing that is unnecessary and risky," she says.

As I've written before, don't worry, your most sensitive data's safe in the hands of the extremely skilled health IT professionals at most hospitals.

While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to – additional tests and procedures, including surgery.

"It's all about downstream revenue," says Patrick Kane, senior vice president of marketing at Cape Cod Healthcare in Massachusetts who used such approaches at Wellmont Health System in Kingsport, Tenn. "The old adage in business is that it’s easier to sell an existing customer new services, rather than find a new customer."

So much for medical professionalism and conservatism. At least Mr. Kane admits it's all about money.

... Provena's Lagger says the approach boosted the system's bottom line so it could serve people regardless of insurance status. "This is a means to an end," she says.

The ends don't always justify the means, but that may be a hard concept for some in today's amoral culture to understand.

... Much of the expertise for such campaigns is provided by three consulting firms -- CPM Marketing of Madison, Wis., Medseek of Birmingham Ala. and New York-based Thomson Reuters. They typically charge hospitals $100,000 a year or more.

CPM, which merged in November with Denver, Colo.-based HealthGrades, a health ratings firm, added 100 new hospitals last year to give it a total of 400. Medseek works with more than 250 hospitals and Thomson Reuters, with 150.

Remember Darrin Stevens on Bewitched? "Larry, I've got a great idea for a new campaign! Let's troll for patients using their private data! Never mind that I have donkey ears today... that darn mother in law of mine, Endora!"

The targeting worked in the case of Boyd, who called the number on the back and scheduled the CT scan a few days later. The $169 test showed his lungs were clear, but found potential blockages in coronary arteries that his Provena-affiliated doctor is monitoring.

"In hindsight, I’m glad I had the test," he says.

No mention of patients who had unnecessary testing and interventions that led to bad outcomes ... or patients injured by the very EHR systems that make such marketing possible.

-- SS

Visceral Fat & Hepatic Fat -- Not one and the same

It seems that any time the discussion of fatty livers developing on ketogenic diets comes around, a spate of confusing discussions tend to ensue.  One of the confusing issues is that ketogenic reducing diets are effective at reducing hepatic fat levels.  However, these studies usually start with a fatty liver and with weight loss comes hepatic fat loss.  If there's a study out there where obese people are simply transitioned from a SAD to an equi-caloric ketogenic diet (85+% fat) demonstrating any change in liver fat accumulation, I'm not aware of it.  However I believe the evidence of rodents on such diets is at least enough to be concerned that the change, if any, would be for the worse, not the better.  

A lot of lean people also think, I can't have a fatty liver because I don't have a pot-belly so I don't have visceral fat.  One of the reasons I thought the Eades' 6 Week Cure for the Middle Aged Middle  book was such a disaster is that the first two weeks were supposedly devoted to detoxifying your liver.  There were several references discussing just that, and a reduction in hepatic fat.  I had high hopes for the book at the time, because I was expecting some science on how to specifically reduce visceral fat.  I was disappointed that there was little if any discussion devoted to this topic.  Let's look at the human abdomen.  For starters, the liver is rather assymetrical.  Additionally, although obesity leads to a higher prevalence of fatty liver, lean T1 diabetics have a rather high incidence of the disease.  Roughly a quarter of those with fatty liver disease (FLD) have normal sized livers, so accumulation of hepatic fat does not necessarily increase the size of the liver.  A normal adult liver has a span of 7-10 cm and an enlarged liver is over 2-3 cm larger.  Still, this does not seem to be sufficient to cause a large belly.  Also note the location of the liver.  Most "bellies" are considerably lower.

Read more »

Rendering Unto Caesar - What the Abramson Family Cancer Research Institute vs Thompson Says About the Loss of the Academic Medical Mission

A case, reported by the New York Times as involving an intellectual property dispute, should create a lot of cognitive dissonance about the state of the academic medical mission.

Litigation Involving the Abramson Family Cancer Research Institute and Dr Craig B Thompson

Here is how the Times outlined the story:

The president of Memorial Sloan-Kettering Cancer Center in New York is in a billion-dollar dispute with his former workplace, a cancer institute at the University of Pennsylvania, over accusations that he walked away with groundbreaking research and used it to help start a valuable biotechnology company.

In a lawsuit, the Leonard and Madlyn Abramson Family Cancer Research Institute at Penn described its former scientific director, Dr. Craig B. Thompson, as 'an unscrupulous doctor' who 'chose to abscond with the fruits of the Abramson largess.'

In particular,

In the suit, the Abramson cancer institute, which has received more than $100 million from the philanthropist Leonard Abramson and his family, says that Dr. Thompson concealed his role in starting Agios, which has attracted investors with a potentially new way to treat cancer. The institute says Dr. Thompson’s actions deprived it of proceeds that could support future research, causing it damages that could exceed $1 billion.

So presumably the Abramson Institute is alleging that Thompson took its intellectual property and put it into Agios, and the Institute therefore wants compensation. Note that the Institute does not appear to be alleging either that Thompson was supposed to be its employee, but actually was working for Agios at the time he was supposed to be working for the institute; or that Thompson hid a a conflict of interest created by his financial relationship with Agios that could have affected how he fulfilled his professional responsibilities there.

Note further that certain other parties declared that they are not part of this dispute. These included Dr Thompson's current employer:

Sloan-Kettering declined to comment, saying it was not a party to the lawsuit....

These also included the University of Pennsylvania:

Susan E. Phillips, senior vice president for Penn Medicine, said that the suit had been filed not by the university but by the research institute, a separate entity. She said the university was investigating the accusations.

The nature of this dispute ought to generate several kinds of cognitive dissonance.

Protecting Intellectual Property vs Upholding the Academic Mission at the University of Pennsylvania

On one of its web pages, the Abramson Family Cancer Research Institute describes its history:

The Abramson Cancer center of the University of Pennsylvania provides each patient with exemplary care though a comprehensive team approach, personalized service, education and outreach, and nationally recognized cancer research programs.

The web page describes the institute as simply part of the larger University of Pennsylvania cancer center, which came to be named for the Abramson family:

Penn's Cancer Center was renamed in 2002 as the Abramson Cancer Center of the University of Pennsylvania, recognizing the Abramson family's $100 million commitment to support comprehensive cancer research and care.

Thus it seems that the Abramson institute is simply a piece of a traditional academic medical center.

The academic mission is traditionally described as the creation and teaching of knowledge. Thus, if an academic institution creates new knowledge, its should then disseminate it, not own it. Of course, in the US, since the Bayh-Dole act was passed, academic institutions were given the ability to patent their discoveries, and began to protect and sequester the knowledge they contained, rather than disseminating it.

In this case, however, one part of a large university and a large academic medical center seems to be concentrating entirely on its right of ownership of intellectual property, not the traditional academic mission. The fact that this dispute has lead to litigation suggests that the academic organization is now intent on protecting, rather than disseminating knowledge. The dispute appears to be between a commercial research company and its allegedly errant former hired manager.

The Abramson Institute: Part or Independent of the Academic Medical Center?  

A little more digging suggests that the nature of the Abramson institute is not as clear as is described in its web-page. A GuideStar search revealed that the institute is actually legally independent from the university. It filed its own 990 form (latest version, covering 2009-2010, here.)

The filing did list various entities, including the Clinical Care Associates of the University of Pennsylvania Health System, and the Trustees of the University of Pennsylvania as "related tax-exempt organizations."

However, this filing should create cognitive dissonance about what the underlying nature of the Institute? Is it part of the University of Pennsylvania and its medical center, or is independent but cooperating?

This dissonance is only enhanced by the ambiguous response of the University of Pennsylvania to the lawsuit. If the Institute is part of the University, then the University ought to be party to the lawsuit, it would seem.

This filing with the US government did underline the Institute's commitment to disseminating research. A description of its tax "exempt purposes" included:

Education - scientists at the Institute actively share their discoveries with the research community, physicians, and students.

As above, this statement of purpose appears not to fit with the filing of a lawsuit to obtain damages due to the alleged taking of intellectual property. If this really were the Institute's mission, would not they want the intellectual property liberated so it could be actively shared? The cognitive dissonance about the mission of the Institute and of the University versus the protection and sequestration of intellectual property is thus increased.

Upholding the Academic Mission vs Staying Uninvolved at Memorial Sloan-Kettering Cancer Center

As an aside, note that Dr Thompson is now not just working for Agios. In fact, he has been President of the Memorial Sloan-Kettering Cancer Center since 2010 (look here). Just like the Abramson Cancer Center, Sloan-Kettering is an academic medical center with the traditional mission of teaching, research, and patient care. Here is its mission statement:

As one of the world's premier cancer centers, Memorial Sloan-Kettering Cancer Center is committed to exceptional patient care, leading-edge research, and superb educational programs.

So one would think that people there ought to be concerned by allegations that its current president took intellectual property without authorization, and that he is "an unscrupulous doctor." If these allegations were to be proven false, they seemingly would represent a major, unwarranted slur on its and his reputation. If they were to be proven true, they would indicate that current leadership might not have the character to uphold the mission. Either outcome would be serious and have serious implications. However, at the moment, this noted academic medical institution has expressed neither outrage about possibly false accusations nor resolve to investigate the matter and then weed out any leaders not devoted to the mission.

Thus, the apparent intention of the leadership of Memorial Sloan-Kettering to stay uninvolved with this case ought to generate more cognitive dissonance.


Summary

The cognitive dissonances evoked by the case of the Abramson Institute vs Dr Thompson ought to inspire questions about what our academic medical institutions have become.  While they proclaim their devotion to research and teaching to improve health and health care, and advance science, they may increasingly act like commercial research organizations whose main goal is to generate increased revenue from products and services, and in this case, from intellectual property. 

It is hard to see how this emphasis on holding onto rather than disseminating new knowledge will be good in the long run for science, learning, or patient care.

We are now a good 30+ years into our ill-fated American experiment about the effects of turning medicine commercial and making health care a commodity. So far, it has yielded the highest costs in the world, but declining access, mediocre quality, and demoralized professionals.  Squabbling among top researchers and leading academic medical institutions over the ownership of intellectual property for the sake of revenue, not dissemination, is the latest symbol of the decline of our health care.

I can only hope that all the parties involved suddenly remember that they are supposed to be creating and disseminating knowledge, not just getting rich. 

for a long time i have been dying to paint my interior doors a deep chocolate brown.  it's one of those things that just needs to "happen" while my husband's away at work (men don't get the importance of a good door color).  i need to buy the paint and just do one door a day.....so here's the thing....once i start, do i do all of my doors or do you think some can be left white??  this could take awhile and i've been known to get bored w/ projects :)

*images courtesy of pink persimmon, allison elebash, southern accents, s.r. gambrel, sketch 42, living inside, domino, cottage living