Onward

In upcoming posts, I plan to pursue two main themes.  The first is a more comprehensive exploration of what determines eating behavior in humans, the neurobiology behind it, and the real world implications of this research.  The reward and palatability value of food are major factors, but there are others, and I've spent enough time focusing on them for the time being.  Also, the discussions revolving around food reward seem to be devolving into something that resembles team sports, and I've had my fill.

The second topic I'm going to touch on is human evolutionary history, including amazing recent insights from the field of human genetics.  These findings have implications for the nutrition and health of modern humans. 

I look forward to exploring these topics, and others, with all of you in the coming months.

Gartner: Famous Last Words on National Health IT - "Don't Fear Progress"

From time to time I review old articles about health IT via Google and other search engines.

Found this analysis/prediction/statement of confidence, by a research analyst at IT consultant company Gartner Group. Emphasis mine:

Don’t Fear Progress

by Brian Burke | April 17, 2009 | 1 Comment

In an open letter blog to President Obama, Burton Group Senior Analyst Joe Bugajski opines that President Obama is spewing “delusional visions of a nation-covering, interoperable, secure, private, reliable, accurate, and instantaneous electronic healthcare data network is at best terrifying and at worst pernicious.” OK – I had to look up ‘pernicious’. It’s not good.

Mr. Bugajski goes on to relate a horrifying personal experience in which he ended up in a clinic and then a hospital that both used electronic health records. He relates the story of his stay in which electronic health records hindered rather than helped and concludes that most health care professionals “longed for handwritten charts hanging at the foot of every patient’s bed.” While I don’t doubt his experience, and I disagree that building a national health information network is an unsound idea.

In fact, the National Health Services (NHS) in the UK is several years into its ‘Connecting for Health‘ program and has already built a nation-covering, interoperable, secure, private, reliable, accurate, and instantaneous electronic healthcare data network. The UK is reaping the benefits of improved treatment and cost savings. You can read additional background in my research note, Toolkit: Enterprise Architecture for the U.K.’s National Health Service (Case Study)

Mr. Bugajski is correct that the initiative will be large and costly and I also agree that the US government should approach the program with caution. But the benefits are enormous – it’s about saving lives! While I sympathize with Mr. Bugajski’s unfortunate experience, I believe moving forward on this initiative is truly one of the bright spots in President Obama’s stimulus plan.

Problem is, the NHS program to build a "nation-covering, interoperable, secure, private, reliable, accurate, and instantaneous electronic healthcare data network" failed, as I wrote at my Sept. 2011 post "NPfIT Programme goes PfffT."

The success of this program was long in doubt, as expressed by the UK's own House of Commons public accounts (audit) committee as here, published 27 Jan 2009 (four months before the optimistic Gartner piece) entitled "The National Programme for IT in the NHS: Progress since 2006 - Public Accounts Committee."

In fact, I had been writing skeptically about that program for years, including at this query link and at my academic site.

I don't fear progress.

What I fear is cybernetic hyper-enthusiasm masquerading as progress, especially when it wastes money - in this case conservatively estimated at £12.7bn - and harms patients.

-- SS

The First Law of Thermo still doesn't violate The Second Law

Well, I've been meaning to weigh in on the Bray overfeeding study (Effect of Dietary Protein Content on Weight Gain, Energy Expenditure, and Body Composition During Overeating) that made a bit of a splash a little while back. George Bray is especially hated by ardent low carb advocates because he wrote a particularly unfavorable review of GCBC published in Obesity Reviews.   Bray is what Adam Kosloff refers to as a "Calorie Wizard":

Regardless of diet, it is a positive energy balance over months to years that is the sine qua non for obesity. Obese people clearly eat more than do lean ones, and food-intake records are notoriously unreliable, as documented by use of doubly labelled water.  Underreporting of food intake is greater in obese than in normal-weight people and is worse for fat than for other macronutrient groups.  Accepting the concept that obesity results from a positive energy balance does not tell us why energy balance is positive.  This depends on a variety of environmental factors interacting with the genetic susceptibility of certain individuals.  Weight loss is related to adherence to the diet, not to its macronutrient composition.

Read more »

Because you can never have too much fun ...

In honor of Jimmy's podcast with the new leader of the Insurgency, Peter "War on Insulin" Attia, MD, I've gotta introduce the latest in my series of Lego superhero analogies.  Attia is younger and considerably more photogenic than Taubes and puts a fresh face on the movement.  When Taubes introduced Attia on his blog, I just couldn't help but think "Boy Wonder" ... and it all started to fall into place.  

The "Dynamic Duo" of Taubes and Attia will from now on be known as Fatman and Glucagon here at the Asylum!  These two shall patrol Glutton City in their Fatmobile protecting its citizens from the dastardly deeds of team CICO. 

No analogy would be complete without identifying the everyday alter-egos of these two.  In the role of Bruce Wayne, we have none other than Jimmy Moore (has anyone ever seen Taubes and Moore in the same place at the same time?), and in the role of Dick Grayson, we will have Adam Kosloff.

Yours truly, of course, shall play the role of Catwoman ;-)  Nah, let's make that Carbwoman!!

Update:  I went looking for Lego Bruce Wayne and Dick Grayson.  Had luck with the first, but not much with the second.  Except that I came up with something even better.  It seems that Dick Grayson got tired of being Batman's sidekick and struck out on his own as Nightwing.  I think this scenario fits Kosloff better ... we'll call him Gateking.  So allow me to introduce you to Jimmy Moore, as himself in Bruce Wayne's role, and Gateking!  Jimmy is holding on to Gateking's black box for him while he fights off the Calorie Wizards with his pool noodles.

Another Cautionary Tale about Conflicts of Interest: the CEO's Stretch Limousine, Golden Parachute, and Slush Fund

It remains fashionable in academic medicine to tolerate, if not celebrate conflicts of interest as necessary to support the "collaboration" needed for "innovation," while minimizing their risks (e.g., look here). 

Recently, another cautionary tale about how conflicts of interest signal the risk of all sorts of unpleasantness has appeared in the media.

A Sentinel Event: the First Conflicts Uncovered

In 2009, we wrote about some conflicts of interest at Wyckoff Heights Medical Center in my hometown of Brooklyn, NY.  The New York Daily News had reported that Dr. Addagada Rao, the hospital's chief of surgery was simultaneously the president and part-owner of a Caribbean medical school that funneled medical students to clerkships at Wyckoff.  The hospital's CEO, Rajiv Garg, was an investor in the same school.  At the time, I wrote,

This story illustrates another twist on conflicts of interest affecting the leaders of not-for-profit health care organizations. Many of the smaller not-for-profit hospitals, of which there are thousands in the US, may have minimal conflict of interest policies, which may be minimally enforced, without much transparency or accountability. The coziness of the leadership culture of such smaller institutions may preclude anyone within the culture from asking tough questions. The results may be total confusion as to whose interests particular leaders are serving. In particular, the interests of each hospital's patients may get lost in the shuffle. In this case, the interests of medical students may also get lost in the shuffle. Although the institutions involved may be small, and hence the conflicts may seem small in terms of their monetary value, they aggregate to contribute to the moral miasma that now is the atmosphere of health care.

You heard it here first.

The CEO's Golden Parachute

Fast forward to 2012. In January, the Daily News again reported that CEO Garg had been ousted, but that

Trustees at Wyckoff Heights Medical Center asked to consider a whopping $875,000 severance payout for its former CEO are balking at the package....

It seems that Garg's attorney claimed

They were on the verge of bankruptcy when he arrived. He reduced the debt by tens of millions of dollars.

However,

the hospital’s financial situation remains grim. According to the work group’s final report, Wyckoff’s liabilities are $91 million greater than its assets and it is saddled with $114 million in long-term debt.

So here is yet another example of a CEO personally profiting while his or her organization's finances fester.

The Chauffeured Cars, the Stretch Limousine

The the Daily News began chipping away at the other ways CEO Garg benefited from his leadership of the fiscally troubled hospital. A notable symbol of these benefits was a stretch limousine:

The ousted CEO of a debt-riddled Brooklyn hospital had his security guards ferry friends to the U.S. Open and his wife around town in a stretch limo, the Daily News has learned.

Rajiv Garg, the disgraced honcho of Wyckoff Heights Medical Center, also enjoyed his own commutes in the hospital-issued ride — a sleek, black $33,000 Lincoln Royale.

Garg rolled in style,

The beleaguered hospital bought the fancy car — equipped with a mini-bar, four champagne flutes and a fridge for chilling Dom Pérignon — last summer for Garg It also owned two other cars for his use, sources said.

Several times a week, the limo was dispatched to take Garg’s wife from her job near the hospital to the couple’s midtown apartment, said an employee.

Sometimes, it picked her up and then swung by the hospital to get Garg and whisk them to dinner before dropping them home, sources said. Two or three times a month, the limo picked her up at home and took her shopping.

'I haven’t had a raise in seven years,' said the employee. 'They always tell us they don’t have any money. They spent it on cars.'

The limo has comfy leather seats with room to spare for six passengers and a stereo system capable of drowning out highway noise when Garg and his wife were driven in it to Washington.

More Conflicts of Interest Discovered

Then the Daily News started to reveal conflicts of interest beyond the ones we discussed in 2009:

Then-trustee Frank Chiarello was in a partnership that loaned money to hospital entities, according to a list of board members’ conflicts the Daily News eyeballed. The $2.5 million loan had an 18% interest rate, sources said, costing the hospital hundreds of thousands of dollars.

Chiarello, a real estate exec, resigned from the board last week.

Another trustee who quit the board last week, attorney John Rucigay, serves as a lawyer for other trustees, owns real estate with other trustees, and rents space to the Polish and Slavic Federal Credit Union — whose head of operations is yet another Wyckoff trustee, Agnieszka Poslednik.

Additional trustees on the conflicts list first reported by Crain’s New York Business, include Andrew Boiselle, whose Cebco Check Cashing Corp. does check-cashing business with hospital employees, and attorney Fred Haller, who provides legal services to Wyckoff employees about issues not related to the hospital.

Slush Funds and Bribes

Last week, the Daily News reported about findings by a judge that the CEO kept slush funds used to pay bribes:

Wyckoff Heights Medical Center kept a secret bank account that a former CEO used to bribe a disgraced state assemblyman, an upstate judge said in a court decision.

Orange County Supreme Court Judge Elaine Slobod’s decisionk brought to light new details about the Bushwick hospital’s alleged dealings with Tony Seminerio (D-Far Rockaway), who died in a North Carolina prison last year.

The bank account used for the Stockholm St. hospital’s payoffs to the corrupt pol belonged to 397 Himrod Corporation.

Former Wyckoff board chairman Emil Rucigay originally set up the company to buy real estate for the hospital to turn into a parking lot, the judge’s order said.

The bank account was kept active — though the corporation was dissolved in 2001. The bank account still had approximately $130,000 in it in 2008.

“[Wyckoff’s] CEO was using monies in the Himrod account to bribe Seminerio,” Slobad wrote in her decision last week, referring to Dominick Gio, who was the hospital’s head honcho at the time.

Gio refused to talk a reporter last week. Wcykoff’s interim CEO Ramon Rodriguez also declined to comment.

Money from the Himrod account was used to make payments totaling $15,000 to Seminerio, other court filings charge.

A Lexus, a Bentley, Oh My

Then the story really hit the big time when the New York Times picked it up yesterday. That report added some colorful details about how magnificently the CEO traveled:

In August 2009, Mr. Garg said, he fell asleep at the wheel and crashed his Lexus into a truck. He then lost his license. Asked why in the interview, he said he was not certain, though he offered several explanations, including unpaid tickets and previous accidents.

He then used the hospital’s cars — a Lincoln Town Car and a Cadillac Escalade — for himself and his family around the clock. They were driven by two security guards on overtime, a hospital official said.

He parked his other car, the $160,000 Bentley, at Wyckoff and had the hospital put the vehicle on its own insurance policy.

The limo only came later,

Mr. Garg said in the interview that he suspected that the drivers of the Town Car and the Escalade were eavesdropping on his conversations. So he had the hospital purchase a used stretch limousine for about $33,000.

Yet More Conflicts of Interest Discovered

The Times story also found more conflicts of interest. Some involved CEO Garg:

Mr. Garg introduced hospital officials to Skyscape, a provider of mobile medical references, in which he had a financial interest. Wyckoff signed a contract with the company worth at least $38,700, hospital records show, though the deal eventually fell through.

Others involved hospital trustees. This example might have affected patient care at the hospital:

Dr. Theophine Abakporo arrived at Wyckoff in 1996 from Harlem Hospital to work in emergency medicine. Originally from Nigeria, he said he found his way to the top blocked by what he believed was a clique of doctors at Wyckoff.

In 2009, according to data provided by MapLight.org, Dr. Abakporo, an American citizen, began donating money to the campaign of Representative Edolphus Towns, the Democrat who represents a nearby area. Mr. Towns, a longtime board member of Wyckoff, had by then been replaced by his chief of staff, Albert Wiltshire, on the board.

Dr. Abakporo gave $1,000 to the Towns campaign, then $750, according to election records.

With Mr. Wiltshire’s support, Dr. Abakporo became chairman of emergency medical services.

This example might also have affected patient care:

With his solicitous manner and tailored sport jackets, Gary Goffner, a pharmacist who serves on Wyckoff’s board, has long endeared himself to customers and doctors alike.

He inherited his pharmacy, Kraupner, from his father, a prominent Bushwick landlord as well as a pharmacist, who died recently. It is an old-fashioned store, crammed with supplies, the opposite of an orderly Rite Aid.

It is also a half-mile walk from Wyckoff, a disadvantage Mr. Goffner overcame through a contract that gave him exclusive access to Wyckoff patients as they were being discharged, and allowed him to keep an employee at the hospital to promote his business.

In summary, the Times found,

According to internal hospital documents, 13 of the hospital’s 22 board members declared at least one conflict of interest.

Summary

So, from a single story about conflicts of interest affecting the CEO and a medical leader at the hospital, we have gone to stories about widespread conflicts of interest affecting the hospital's board and leadership, about lavish payments and benefits to the CEO while the hospital's finances suffered, and allegations (by a judge) of bribes and slush funds. 

Recall that the Institute of Medicine's report on conflicts of interest in medicine and health care defined conflicts of interest as “circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest.” While no particular conflict of interest is guaranteed to cause someone to abuse entrusted power, conflicts of interest create the risk of such abuse. The case of the leadership and governance of Wyckoff Heights Medical Center shows how such risks may manifest.

Yet we have noted again and again how leaders of supposedly mission-oriented non-profit medical organizations seem to be ignoring these risks while pursuing ever more money from health care corporations. We noted how the Chancellor of the University of California-San Francisco "has no qualms" about faculty's financial relationships with industry. Just this week at Brown University, my alma mater, while discussing a new conflicts of interest policy, we heard,

'People do have conflicts of interest, and it’s not the end of the world,' said Janet Blume, associate dean of the faculty.

Conflicts of interest may not lead to the apocalypse. However, they certainly may lead to all sorts of unpleasantness. As Joe Collier stated, “people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult." Conflicts of interest clearly lead to conflicted, and confused thinking, and such thinking may lead to bad decisions, and hence bad outcomes for patients' and the public's health. Worse, as the IOM asserted, conflicts of interest are a risk factor for outright corruption.

True health care reform might start with a reasoned discussion, based as much as possible on evidence, about the risks as well as the supposed benefits of conflicts of interest affecting those who make decisions about individual patients' health care, and about public health and health care policy.

Experiments on Top of Experiments: Threats to Patients Safety of Mobile e-Health Devices - No Surprise to Me

As noted by columnist Neil Versel at MobiHealthNews.com in a Mar. 14, 2012 post "Beware virtual keyboards in mobile clinical apps":

... Remember the problems Seattle Children’s Hospital had with trying to run its Cerner EMR, built for full-size PC monitors, on iPads? The hospital tried to use the iPad as a Citrix terminal emulator, so the handful of physicians and nurses involved in the small trial had to do far too much scrolling to make the tablet practical for regular use in this manner.

[From that post: As CIO magazine reported last week, iPads failed miserably in a test at Seattle Children’s Hospital. “Every one of the clinicians returned the iPad, saying that it wasn’t going to work for day-to-day clinical work,” CTO Wes Wright was quoted as saying. “The EMR apps are unwieldy on the iPad.” - ed.]

Thank heaven it was a small trial, instead of a typical forced rollout to an entire clinical community. Someone seems to have grasped the experimental nature of the effort.

Well, there may be a greater risk than just inconvenience when tablets and smartphones stand in for desktop computers. According to a report from the Advisory Board Co., “[A] significant threat to patient safety is introduced when desktop virtualization is implemented to support interaction with an EMR using a device with materially less display space and significantly different support for user input than the EMR’s user interface was designed to accommodate.”

The report actually is a couple months old, but it hasn’t gotten the publicity it probably deserves. We are talking about more than user inconvenience here. There are serious ramifications for patient safety, and that should command people’s attention.

Unfortunately, far too little about health IT safety commands people's attention. It's merely assumed that either 1) health IT is inherently beneficent, or 2) the risks are deliberately ignored for - I'm sorry to note - profit and career advancement.

How many CIOs or even end users have considered another one of the unintended consequences of running non-native software on a touch-screen device, that the virtual, on-screen keyboard can easily take up half the display? “Pop-up virtual keyboards obscure a large portion of the device’s display, blocking information the application’s designer intended to be visible during data entry,” wrote author Jim Klein, a senior research director at the Washington-based research and consulting firm.

How many CIO's have considered unintended consequences of such experiments-on-top-of-experiments (i.e., handheld or other lilliputian computing devices on top of the HIT experiment itself)? Probably few to none.

The typical hospital CIO, usually of an MIS background and generally lacking meaningful backgrounds in research, computer science, medicine, medical informatics, social informatics, human-computer interaction, and other research domains, are usually "turnkey-shrinkwrapped software implementers." In fact, most have backgrounds woefully inadequate for any type of clinical device leadership role. They may even lack a degree of any kind, as major HIT recruiters over the past decade expressed the following philosophy ca. 2000:

I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman. (Healthcare Informatics, "Who's Growing CIO's".)

I wonder just how many CIO's "from the school of hard knocks" were put into action by those groups.

Back to the MobiHealthNews.com article:

... Klein said that users have two choices to deal with a display that’s much smaller than the software was designed for. The first is to zoom out to view the whole window or desktop at once, but then, obviously, users have to squint to see everything, and it becomes easy to make the wrong selection from drop-down menus and radio buttons.

Or, users can zoom in on a small part of the screen. “This option largely, if not completely, eliminates the context of interaction from the user’s view, including possible computer decision-support guidance and warnings, a dangerous trade-off to be sure,” Klein wrote.

In either case, the virtual keyboard makes it even more difficult to read important data that clinicians need to make informed decisions about people’s health and to execute EMR functions as designed.

Good observations. Two points:

1. As far back as the mid 1990's in my teaching of postdoctoral fellows in my role as Yale faculty in Medical Informatics, due to the limited screen real estate I uniformly presented the following 'diagram' regarding my beliefs about handheld devices (then commonly known as PDA's) as tools for significant EHR interaction:

Mid 1990's wisdom: small handhelds as desktop replacements at the bedside - just say "no"

This was before today's hi-res screens on small devices, but the limited real estate and its ramifications were obvious to critical thinkers who knew both medicine and medical informatics, even in the mid 1990's.

Similarly, experiments with HP95 handheld PC's running DOS failed miserably in a similar time frame at the hospital where I later became CMIO. (One benefit: I did get to salvage two of the devices from the trash bin for my obsolete computer collection!):

HP95LX - full DOS computer equivalent to an IBM PC (except, of course, for screen size).

Therefore, IMO the Advisory Report findings of 2012 merely verify what was obvious almost two decades ago.

Small devices are adjuncts only, suitable for limited uses (and only after extensive RCT's with informed consent even then, in my view).

2. Another issue that arises is more fundamental. The article notes:

“It seems clear that running even a well-designed user interface on a device significantly different than the class of devices it was intended to be run on will lead to additional medical errors,” Advisory’s Klein commented.

The critical thinking person's question is: who knows if the "class of device" the app was "intended to run on" is itself appropriate or optimal?

Commercial clinical IT (with the exception of devices that require special resolutions, pixel densities, contrast ratios etc., such as PACS imaging systems) is usually designed for commercially available hardware.

That means the same size/type of computer monitor you obtain at Best Buy or Wal Mart.

Is that sufficient? Is that optimal?

As in my Feb. 2012 post "EHR Workstation Designed by Amateurs", who really knows?

Click to enlarge. A workstation in an actual tertiary-care hospital ICU, 2011. How many things are wrong here besides the limited display size? See aforementioned post "EHR Workstation Designed by Amateurs".

These systems are not robustly cross-tested in multiple configurations, such as multiple-large screen environments vs. single screen, for example.

In summary, performing an experiment with small devices on top of another experiment - the use of cybernetic intermediaries (HIT) in healthcare that is already known to pose patient risk - is exceptionally unwise.

It would be best to decide what the optimal workstation configuration is, as applicable to different clinical environments, in limited RCT's with experts in HCI strongly involved, before putting patients at additional risk with lilliputian information devices that only a health IT Ddulite could love.

Ddulites: Hyper-enthusiastic technophiles who either deliberately ignore or are blinded to technology's downsides, ethical issues, and repeated local and mass failures.

-- SS