The Ether Way

Bringing Resuscitation into the 21st century, or Seeing is Believing...

2009-09-20T09:28:18-07:00

I do a fair amount of trauma anesthesia. An important part of trauma bay resuscitation is a quick and dirty transcutaneous ultrasound evaluation; Heart, pleural space, liver, spleen, bladder.

Fifteen years ago, one of my partners had a patient develop pulseless electrical activity (PEA) in the middle of an ortho case. (Well, actually, the story is so old that the patient developed what was then called electro-mechanical dissociation, EMD; same thing, different era…)

Anyway, she dropped a TEE (we were in a mixed cardiac practice), diagnosed a saddle embolus, the patient’s chest was opened, thrombectomy was performed, and he survived (not without a stormy course, of course.)

I recently was discussing ACLS with a young cardiology colleague, and we were both discussing the ACLS “cookbook.” We were talking about the least-common-denominator limitations of the ACLS system, and pretty quickly fell onto the usefulness of echo in sorting out PEA. Virtually all the non-metabolic etiologies of PEA (and tachycardia/hypotension) are amenable to echo diagnosis, and the windows required are not particularly difficult to grab; it’s basically a ventricular view. We’re not looking to diagnose aortic stenosis here. And an echo is instantly confirmatory (or not!) of asystole or v-fib. Ever see a v-fib which proves to be a lousy ecg signal with what is in fact, PEA with a beating, empty heart? I have.

There are a few implications of this discussion, some theoretical, some tactical.

First, my anesthesiology colleagues resent having to maintain ACLS certification; as one of them put it, “it’s like making a master chef take remedial sauce-making every two years.” I am such a "master-chef'," and I couldn’t disagree more, for three reasons.

First, I have seen too many codes botched by “bread-and-butter” anesthesiologists over the past two decades to harbor any illusions about the “master chef” designation of anesthesiologists a decade or more out of training. Many of them are right there, but some of them are not.

Secondly, ACLS is about a team approach to a high-tempo crisis. The team expects certain behaviors from the leader; if the leader does not fit her management style into a response pattern expected by the conditioning of the team, confusion and disorganization are the consequence. Especially with the young generation of clinician nurses, they need explanations to be comfortable, and once you have established your familiarity with the standard therapies, they will accept variation with brief explanation. I am reminded here of innovators like John Coltrane, whose extraordinary trail blazing virtuosity was validated by his equally extraordinary command of the the traditional ballad-bebop forms. You gotta start from terra-cognita on your way to terra-nueva (we’re leaving out terra-incognita here…)

Finally. Things change. Aloha, bretylium and procainamide, welcome, Amiodarone. You can't ell the players without a program.

But I digress. I feel strongly that we ought to have a simple echo (like a sono-site; there is a great subcostal view to the right here) available at EVERY code, and the team ought to be trained to get the

windows that tell you what you need to know to diagnose the mechanical causes of PEA. It’s time. There are no disposables, so it’s a one-time cost. If you are being fussy about sterility, a sandwich bag with a tie-wrap, or a transderm-type occlusive sticky will do. I suppose you could have the ultrasonography team respond to every code as an alternative. But that seems like overkill, and in any case, crowds the room. It's time to do the (inevitable) validation work with and without. After all, an artist is only as good as his tools...

Seeing it from Both Sides

2009-09-11T11:34:15-07:00

As the debate over health care reform waxes on, both sides have turned up the rhetoric, and moderate or reasonable voices on either side are being shouted down and lambasted.

On the Pro-Reform side, there is this recent commentary from Don Wycliff in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0903wycliffsep03,0,2484870.story

He astutely points out that the federal government is already deeply engaged in providing or facilitating health care for millions of US citizens. His list includes the following entities, all of which would have to be eliminated to get the federal government ‘out’ of health care.

- Medicare

- Medicaid

- VA health care

- Military Health care

- Indian Health service

- the Surgeon General

- the CDC and the NIH.

A few observations:

- I’ve already written a substantial amount about the failures of the VA system, and how remarkably disinterested anyone appears to be in fixing them. The current movement is no exception: there is no discussion of fixing the problems that everyone admits plague the VA system. Veterans with the means to do so obtain their care elsewhere. If the VA is a barometer of how the feds will deliver health care, then the results are cause for concern, not optimism. Also concerning is that there is little discussion from either side about fixing the VA. We owe it to our veterans to do vastly better, regardless of how the current debate goes.

- Medicaid is not entirely a federally run program ,it is administered locally by the states, and has generated a patchwork quilt of coverage that verges on ridiculous. The hospital where I work is located near the Indiana border, and is the closest tertiary care center for the hundreds of thousands of people who live in nearby Indiana. We can care for their insured, but not for their Medicaid.

- Medicare is a big bite, too big for this post. Let’s just say that as Medicare demands more and pays less, care for medicare patients is going to be increasingly difficult to obtain.

- The Indian Health Service is worthy of its own post, but I am unlikely to ever get around to generating it. The spectrum of people who provide care for the IHS includes some of the very best doctors I have ever met, to doctors who cannot obtain any other employment.

- The NIH provides little care, and the CDC almost none at all. Both represent enormous public good, and very worthwhile outlays of federal tax dollars. While libertarians represent that the free market would create both entities if the feds did not; the fact that nothing resembling either one exists in any other country makes me certain that this contention is absolutely wrong.

On the other side of the debate is this break down of the numbers by Dennis Byrne, also published as a commentary in the Chicago Tribune:

http://www.chicagotribune.com/news/opinion/chi-oped0825byrneaug25,0,7272374.story

First, the commentary on this one, which is posted below the article itself, is fairly typical of the partisan bomb-throwing that has been going on. The president may have wanted honest discussion, but this topic has provoked both sides to talk at each other, not to each other.

Byrne’s numbers:

- 46 million uninsured, of them:

- 9.5 million illegals

- 12 million eligible for some sort of government program, but have not bothered to sign up. Given the nature of government bureaucracy, this is unsurprising.

- 9.1 million people who are between jobs and temporarily uninsured.

- 7.3 million families with an income greater than $84,000/yr

- and finally, about 8 million working poor, without insurance.

First, if we’re not going to cover the illegals, we shouldn’t include them in the count.

Second, the 7.3 million families with an income of 84k or higher are either living as a free people should be allowed to, or a group of free riders who should be made to pay or play.

Third, the temporarily uninsured are truly uninsured. For almost everyone who is unemployed, the cost of continuing their employer sponsored health plan would consume their unemployment benefit. If they want to eat, they cannot continue their health insurance.

Fourth, make it easier for those eligible to sign up for the government programs that already exist. Be warned: doing this will increase the expense of these programs. Interestingly, if this number is correct, Obama could generate health care for most of these people with a minimal investment in supporting and expediting their enrollment. This would not require an overhaul in the system, but would require the money to care for an additional 12 million people.

Fifth, understand that the real issue here are the 8 million working poor and the 9.1 million between jobs.

Finally, there are ways of controlling health care costs that have not yet been incorporated into the language of any of the bills under consideration:

http://townhall.com/columnists/HughHewitt/2009/09/04/without_tort_reform,_it_isnt_health_care_reform_--its_a_plaintiffs_lawyers_protection_act?page=1

Mr Hewitt is correct and very clever to have thought of this.

Brits throwing Granny Under the Tram?

2009-09-11T11:04:42-07:00

A century-and-a-half ago, give or take a few years, a clinical/philosophical battle raged around the issue of surgical anesthesia. A school of thought, the "heroic" school, asserted that no morbidity or mortality was justified for the mere alleviation of pain and suffering, and they plainly rejected ether or chloroform on that grounds. Citing scripture and asserting a belief that pain was necessary for healing, they nevertheless gave way before a utilitarian understanding that the advantages of surgical anesthesia were worth some risk, and a relatively high risk it was. While anesthesia enjoys a mortality rate of probably 1:250000 now, in 1850 it was probably more like 1:300 give-or-take.Over the decades the same utilitarian calculus has been worked countless times for every therapy, from antibiotics (anaphylaxis! Stevens Johnson syndrome!) to elective cholecystectomy (bleeding! infection! Death!). A weighing of risk versus benefit.

In this case, The Liverpool Care Pathway, a protocol for providing comfort to patients who are judged by their caregivers as being close to the end-of-life, has been indicted as theoretically precipitating untimely death. The indictment is anecdotal opinion, but is reasonable in its concern; that the withholding of nutrition and hydration, and the administration of narcotics and sedation for the amelioration of pain can provoke death in a patient who in fact might not have otherwise died near term.How does this differ from the decision to extirpate an otherwise healthy 35 year old's gall bladder, based upon their colicky intolerance of mexican food, knowing that there is a distinct, if rare, incidence of death? Well, I suppose one could argue that the 35 year old is able to give informed consent, although I have yet to believe that any lay patient understands the risk of pulmonary embolus or common duct ligation.

Could it be the relative imminence of death inherent in the decision to withdraw support? If so, then the issue is merely one of popular lack of understanding, since nothing is quite so dramatically imminent as a saddle pulmonary embolus in an otherwise healthy 35 year old.

Or are we uncomfortable because they are potentially "burying their mistakes" beyond the reach of oversight by virtue of the very nature of the intervention (or withdrawal thereof).

Or is it that there is an insidious dual-agency conflict here, with the care team acting as an economic agent of the state, callously inducing health care efficiencies by knocking off granny a couple of days, (or weeks?) early. Well, maybe. And maybe, the anecdotal warning of the experts is just that; a warning that one must be particularly careful about diagnosing futility prior to instituting self-fulfilling care plans. As they say in drowning resuscitation, the patient is not dead until they are WARM and dead, as a reminder that hypothermia can mask a survivable situation. And just maybe in turn, that warning was grasped by a controversy-hungry newsperson, preying upon the public mistrust of impersonal beaurocracy to gin up a little newsProbably it's all of the above, but the question remains, do the benefits of not forcing the dying to linger in suffering outweigh the risks of early death for the few who might have lived a little longer, or supersede the concern that compassionate facilitation becomes hard-hearted sacrifice for the "public good."

I'm with Ross Douthat in his recent op-ed on "slippery-slope"-ism in euthanasia. (And the Liverpool Care Plan certainly is euthanasia though late term euthanasia it may be.) On my list of likely slopes to slide down, the euthanasia-as-cost savings risk is pretty far down my worry list, Sen Grassley and citizen Palin notwithstanding.

So, who's organ is it, anyway?

2009-08-26T12:36:42-07:00

I don't get it. In the American capitalist way, we let 45,000,000 people live on the verge of bankruptcy because they can't afford health insurance; it's the "free market." We let kids live in rotting homes in dangerous neighborhoods with bad schools. Why? because their folks can't or won't work. It's the "free market." We let people swelter in the summer and freeze in the winter if they can't afford energy costs. We let people wander through the streets homeless because they have psychiatric disease. All free market based policies.

But organs? Not a free market. Selling organs is illegal. Verboten. c'est defendu. The organ procurement businesses make a ton of money, which they pay out to their employees and boards because they are "not for profit" (snort, snort, chuckle, chuckle). The hospital makes top dollar, as do the pharmaceutical companies that provide the immuno-suppressants. But for the donors and their families; nothing. nada. zip. "The good feeling that comes from having saved a life."

As a consequence, we have a shortage of organs, and a nightmare of a procurement system that is willy-nilly inefficient, with the kind of s ub-rosa black market that we all piously denounce as it periodically bubbles to the surface in the media, where some rich guy buys an organ outright and pays some willing team to install it. Sounds like a UK-style two-tiered healthcare system to me; doesn't it to you?

Ayn Rand was sometimes right (well, frequently, actually); selfless acts seldom go unexploited; in this case, the benefit redounds to that perennial villain, the insurer who gets the organ for free. I can't think of a less deserving beneficiary. And don't insult me with some macro-economic argument about how the organ costs would just be passed along as higher premiums; the private health insurance business is the next best thing to being able to print your own money, but don't get me started!

I'm a yellow dog democrat and a Wisconsin democrat, so I believe in markets; regulated markets; and no black market would benefit more from being brought in from the darkness to the light than the organ market. Imagine that the family of the deceased received a payment of $10,000 for a kidney, or $20,000 for a liver or heart; organ availability would skyrocket, poor families would have funeral expenses defrayed, or might have the money to pay for an education or other needed care. If living donations were allowed, they would require a guarantee from the recipient's insurance company that all expenses incurred as a consequence of complications of the donation procedure would be covered; fair is fair. Probably the government (medicare, medicaid would not participate in paying for living organ donation; too dangerous) I could spend the rest of the day refining the regulatory aspects of this scheme, but you get the idea.

So, does this seem despicable? No more despicable to me than the self-righteously hypocritical ways in which we manipulate free market principles when it suits us. A regulated market in organs, especially cadaver organs, would solve a significant societal problem; the scarcity of such biomaterial, and it ought to be put on the table...

And Now for Something Completely Different, Not!

2009-08-18T13:14:53-07:00

'May you live in interesting times' - an ancient Chinese curse that people understand more deeply as they get older.

First, there is this very nice apology for how the US health care system stacks up to those of Europe, and why the most commonly cited statistic - life expectancy - is stacked against the USA:

http://www.chicagotribune.com/news/columnists/chi-oped0816chapmanaug16,0,1666314.column

Americans (US, not Canadians) pay more than other countries for our health care, but the data Chapman reviews suggests that we get what we pay for - the best cancer and heart care in the western world. This is not a fact trumpeted by the advocates of health care reform.

More ironically, while many are concerned that opposing health care reform might get them reported to the White House and added to the 'enemies list', it is pretty clear that criticizing the NHS is regarded as somewhere between disloyal and treason.

http://news.bbc.co.uk/2/hi/uk_news/politics/8200817.stm

I especially liked this quote:

"If 80% of Americans are getting better health care than we are in the UK then we ought to ask why, and we ought to ask how are we going to deliver equally good results."

which speaks for itself. The performance of the NHS is clearly an issue in UK politics, far more so than most proponents of health care reform in the US acknowledge.

The most troublesome thread in the BBC story is the outrageous deceptions perpetrated by parties on both sides of this debate - in the UK! In that sense, the US and UK political systems are alike.

In follow-up to my recent posts about the black market in organs, there is this news item from today:

http://news.yahoo.com/s/ap/20090818/ap_on_re_us/us_black_market_kidneys

I have no way of verifying the facts of this story, or following up on the allegations. This story names names. It would seem as if several regulatory bodies would now have an imperative to conduct an investigation of some sort.

Finally, on a lighter note, some scientists have a great sense of humor:

http://news.bbc.co.uk/2/hi/science/nature/8206280.stm

The Blackest of Black Markets 2

2009-08-10T16:37:09-07:00

If the story from New Jersey is bad, this story from the BBC is worse (1). It describes, in a low-key and matter of fact way, the story of how more than 600 organs harvested from dead donors (Britons) were transplanted into recipients who were not UK citizens. It seems that about 2% of the organs transplanted from dead-donors in the UK over the past 10 years went into these ‘private’ patients. In considering this story, it is important to postulate a few things:

1. The news article is brief, but the real story is likely enormous. We don’t know all of the details.

2. While it is certain that almost all of these organs were transplanted into recipients who have benefited from them, their allocation almost certainly took place outside of the ‘need’ based allocation system that was otherwise in place. The news article skirts this critical issue: it is very likely that organs were allocated to one recipient, and then diverted to another by the receiving transplant team.

3. It is unlikely that these recipients paid for the costs of their hospitalization. I may be wrong, but I do not believe that the NHS has any means of ‘billing’ private patients for these kinds of services. Once again, the BBC story is vague verging on obscuring, but it seems implausible that anyone but the transplant surgeon was paid for this ‘private’ service. The allusion to billing other EU healthcare systems in the future supports this suspicion.

4. It is highly likely that some centers have never performed a ‘private’ transplant. If this is the case, it means that other centers likely had a fairly active ‘private’ transplant business.

5. It is certain that there are other instances of ‘private’ transplantation that this inquiry did not discover. They may have missed 2% or they might have missed 200%. The incentive for the NHS is to downplay the numbers. That this inquiry was led by a former NHS official, and not by a sworn law enforcement officer, reveals that they wanted to sweep this under the rug, not shine the light of day on what transpired.

Why is the BBC story so understated? Because the real scope and magnitude of the story and the associated corruption is staggering. A few comments:

1. The tone of the inquiry is mild, verging on lapdog. ‘No evidence of wrongdoing’ Worse, no mention of how much money changed hands, or where it went. Reads more like a whitewash than an independent investigation to this foreigner. Once again, a serious inquiry would have required a more empowered and independent investigator. The individual commissioned by the NHS to conduct this inquiry likely had personal connections to many of those involved, and was a health care administrator, not a detective, inspector, or auditor.

2. There is no dispute that these international recipients paid someone for their transplant. How much money changed hands, and who got how much, is left unsaid.

3. Citizens who state a willingness to donate their organs generally do so with the understanding that their organs will be allocated to other participants in the system. In this case, donors expected that other Britons would get their organs. My guess is that none of them (deceased or their families) believed they were consenting for someone else to sell their organs.

4. Were these organs allocated by need? Almost certainly not. This is likely the most dangerous question in this essay. Given that over 600 of these procedures were liver transplants, that means that as many as 600 people had to wait at least a little bit longer for their turn. This compels the next question: how many people died waiting because an organ that might have gone into them went into a ‘private’ patient? What is the body count from this activity? The NHS should be able to ascertain who was on the list when, who might have gotten these organs, and what happened to them. While any number that you might generate from this activity would be a guess, a body count of 1 or 2 would justify the mildness of this report, whereas a body count of several hundred would appropriately generate outrage.

5. Once again, this is not an activity performed by a couple of rogue surgeons in a back-alley clinic. These transplants took place at major medical centers, and required the active participation of a host of physicians (hepatologists, intensivists), heavy utilization of hospital and scarce resources (pharmacy, blood bank), the active cooperation of the hospital administration itself. If you were to view this as a criminal enterprise, then the list of co-conspirators would encompass a significant percentage of the physicians and hospital administrators involved in transplantation in the UK. This is almost certainly the explanation for the very understated spin by the BBC. If everyone involved were disciplined, there might be almost no one left to do the clinical work.

6. The NHS is chronically short on operating room time, ICU beds, hospital beds, and consultant availability. The opportunity or indirect cost of the private transplant program is that it appropriated at least 600 OR days, 600 ICU days, thousands of ward bed days, and a host of other resources that were created for the use of the NHS. Has anyone bothered to count this cost?

7. The outside view is that government bureaucracy can track every penny and every widget. The reality is that tracking is extremely difficult, and opportunities for corruption abound, even in the NHS. The NHS pays all of its employees poorly, but gives them command of great resources. It should not surprise anyone that a black market for human organs might arise in the midst of such an environment.

8. The decision to ban private transplants altogether suggests that the NHS recognizes that it is incapable of managing some or all of the aspects of this activity(or unwilling).

There is no one or correct way to view the story that underlies this story in the BBC. It could be that this was another program that crept from a small and altruistic beginning into a heavy drain on NHS resources before it was reigned in. This spin is entirely consistent with the BBC story. Alternatively, you could contend that NHS physicians diverted (stole?) organs intended for transplant into Britons and sold them to foreigners. For all we know, real fortunes were made by a small number of the people involved. This would represent organlegging, with physicians as the leaders of this blackest of black markets. Sadly, the BBC story deprives us of the details to distinguish the former from the later.

1. http://news.bbc.co.uk/2/hi/health/8177826.stm

The comments to the first part of this post have flabbergasted me. Dr Mastromarino has received very long jail sentences after trials in 2 different states. If there had been any legitimate aspect of his activities, it is very unlikely that he would have faced any jail time at all. Additionally, instead of recruiting funeral homes hundreds of miles apart in different states (New York City, Rochester, New Jersey,and ,Philadelphia) it would have made more sense for him to recruit several dozen in the New York City area. Cadavers are everywhere, willing co-conspirators to his activities were apparently rare.

h ttp://www.jo219.com/intlbronze/Selling-the-Dead-Funeral-Homes-Scavenge-Body-Parts-for-Big-Bucks.shtml

The Blackest of Black Markets

2009-08-04T15:57:45-07:00

In the1970s, science fiction author Larry Niven envisioned a world where the rich were so anxious to procure organs for transplantation that the death penalty was expanded from murder to traffic infractions(1). The liberal application of the death penalty and the likely unconsented harvesting of organs from the condemned in China is a variant of the world that Niven envisioned (2). Multiple sources report that the timing of executions in China, as well as the way they are carried out (a single bullet into the back of the head of the condemned) is intended to optimize organ recovery. Niven also wrote stories of criminal gangs that kidnapped people and sold their organs to those desperate for a transplant. He termed this practice ‘organlegging.’ For more than a decade, the western press has run stories of organ selling and organ theft in other countries, most commonly 3rd world countries such as Brazil(3). Such stuff has been fodder of supermarket tabloids and internet conspiracy theorists far more than serious news outlets.

The desecration of the dead and profiteering from the sale of their tissues has been a source of sensational news in recent years. It is generally accepted that taking tissue from the deceased without the knowledge or consent of their families is a grisly and heinous crime, to be punished with severe criminal penalties, as in the case of the Michael Mastromarino and his company, Biomedical Tissue Services(4). Please note, BTS had two sets of victims, the families of the dead, and the recipients of the hopelessly inferior tissues BTS was selling. The most disturbing part of this story is that this is not a story of a couple of sleazeballs in the basement of a single funeral home, but a collection of funeral home directors and employees in 4 cities in at least 3 states. A lot of people had to look the other way for years. For the medical profession, the saving grace in this story is that none of the principles was a health care professional.

Patients with end stage organ failure are miserable, and many become desperate for the transplant that could improve their everyday existence. Those with means become willing to expend enormous sums of money to jump to the head of the line, even in first world countries. The purchase of organs from living donors is explicitly illegal in most of the western world; any market that facilitates the transfer of organs from living donors to paying recipients is (at least presently) properly viewed as a black market. The existence of such black markets is the inevitable consequence of any schema that allocates organs by needs instead of means; where a need based allocation system is utilized instead of a free market. Recent news items shed some light on this, the black market of organ donation.

The FBI recently arrested a man (previously mistakenly identified by myself as a Rabbi) in New Jersey who is alleged to have brokered the sale of kidneys from donors in Israel to recipients in the US. Press reports represent that he purchased the kidneys for $10,000 from the donors, and was selling them to the recipients for $160,000 (5). They also imply that he had been in this unusual line of business for at least a decade. A few observations are in order:

- we don’t in fact know how many times the accused successfully orchestrated such a transfer. It could be once, it could be dozens of times.

- even if he managed to pull it off once, it would have required an entire network of health care providers to look the other way. Quite seriously, the surgeon and transplant coordinator (and likely the transplant nephrologists as well) had to be aware that this was an ‘international’ kidney donation that circumvented all of the usual channels.(‘so where did you say this kidney came from?')

- as with all black-markets, the broker is the one who makes all of the money. In this instance, maybe more than anyone else involved.

- the Black Market value of a kidney is presently somewhere between 10 and 160 thousand dollars. No one can say what the open market value would be, but it would almost certainly be lower for the buyer and higher for the seller.

Please note, while it is generally agreed that organs should be allocated according to need, I am not opposed to the notion that people should be able to sell their organs. Other physicians have argued the myriad risks and benefits that would arise if this was allowed(6). A regulated market in live kidney donation would likely decrease the cost to the purchaser and increase the compensation to the donor, at the expense of the profit margin of the broker.

Why now, and not 30 years ago when Larry Niven first imagined this? There are likely multiple causes or explanations. The internet, email, and cellular communications have dramatically simplified the logistics. Increased ease arranging the wire transfer of funds and increased international trade have made it much easier to ship anything of value across international borders. Even the increased volume of organ transplantation has made the expertise, equipment, and drugs required to do this more available than ever before. Perhaps more importantly, the community of health care providers, including physicians, may have learned to ‘look the other way’ over the past quarter century.

If the allegations in this case are upheld at trial, it will be proof positive that there is a black market in organs in the US.

1. http://en.wikipedia.org/wiki/Organlegging

2. http://en.wikipedia.org/wiki/Organ_theft

3. http://findarticles.com/p/articles/mi_m1134/is_n8_v107/ai_21191220/

4. http://www.foxnews.com/story/0,2933,199099,00.html

5. http://www.cnn.com/2009/CRIME/07/23/nj.corruption.kidney/

http://www.latimes.com/news/nationworld/nation/la-na-nj-corrupt24-2009jul24,0,922290.story

6. http://jama.ama-assn.org/cgi/content/full/288/13/1640

http://jme.bmj.com/cgi/content/extract/29/3/137

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2802%2908030-3/fulltext

The trouble with tribbles...

2009-06-19T11:12:36-07:00

All bad precedents begin as justifiable measures. -Julius Caesar

Desperate measures for desperate diseases

So, as my co-author, Mike reminds me, I've been absent a looong time. Not without reason, mind you; it has been a tough year, and the clouds are only now beginning to clear. More on this later,( and in another post), but as both a provider and user of the health finance system (and as a beneficiary and victim in both roles, I might add), I have a pretty interested vantage on the healthcare reform ball-game.

So, today's post is about Atul Gawande's gate crashing, delivered suspiciously-on-schedule article, "The Cost Conundrum" which appeared in a recent issue of the New Yorker. You can find it here. Every word is true, (validated by my personal experiences), as far as it goes...

If you are short on time or attention, link to the article, and skip what I am about to say. What he says is more interesting.

Yo may recall that Gawande, a general surgeon from the midwest, a physician child of physician parents, was a principal in the Clinton Healthcare reform braintrust as a young man. He subsequently completed a surgery residency, published a couple of books of New Yorker essays, and generally manages to nicely write stuff that is interesting to lay readers and medical professionals at the same time. (medical professionals might like his essay "On Washing Hands" which appeared in the NEJM. You can find it here.)

I don't want to critique "The Cost Conundrum" here; rather, I want to justify my post title. I have received links to this article now three times, excluding the one from my co-author, Mike, which was inexplicably lost in the ether (or my untamed gmail account...) That's incredible, exceeded only by solicitations to invest in Nigerian phishing schemes to move large sums money into my bank account, and the stupid morphed picture of the pig-nosed child with "swine flu." To use the term of art, the Gawande article has "gone viral," and will be a powerful influence in the coming reform battle and in Dr Gawande's role in that debate. (Oh, if you don't get the allusion in the title, go find the episode of star trek; it's worth it...)

So, finally and surely as Roosevelt exploited radio and Kennedy, TV, the Obama administration has mastered the web, not only as a tool of campaigning, but as a tool of legislating, which is a fish, as they say, of another garage (sorry). I am reminded as I write this, that much of what the Obama campaign did was based on foundation laid by a physician, Howard Dean, and he deserves an acknowledgement.

I muse, that the pace of technology being what it is, the current Iranian dissident movement is the first full-bore application of the next generation technological socio-political weapon; texting and twittering. I shall leave it to my betters to draw the obvious analogies between politics and war, and the role of new technologies in determining such contests. I will say that, where once I understood technological advance to be primarily physical (faster computers, more powerful weapons) I have come to a broader view which includes less tangible tools, i.e. ideas, logisitical advances, and the like. My more thoughtful colleagues will be saying "well dah," but after all, I was primarily an engineer.

I will not enter the fray on the merits of the current round of healthcare reform. But my initial quotations summarize my opposing feelings adequately, anyway.

Lost in Cyberspace

2009-04-29T16:38:58-07:00

Once again, I have to thank my colleague Richard Cook for calling to my attention several news items, all of them relevant to my recent posts about Information Technology and health care.

Backround: Wait-times in England's NHS are long, very long, and have been a source of growing dissatisfaction with the NHS. The resultant political pressure has produced programs to 'manage' and decrease wait-times. Recording and reporting wait-times has become a major marker of performance for the NHS.

Claim: With the power of computers, we should be able to very accurately track every patient and their progress. A computerized information system will enable the NHS to very accurately track wait-times.

Reality: One of the largest NHS trusts in England has 'lost' lists containing at least two thousand patients.
What is the consequence? All of these patients waited well in excess of the 18 weeks (yup, you read that correctly - more than 4 months) for the treatment that their GP prescribed.

http://www.computerweekly.com/blogs/tony_collins/2009/04/barts-responds-to-criticisms-i.html

http://www.computerweekly.com/Articles/ArticlePage.aspx?ArticleID=235815&PrinterFriendly=true

How did this happen? No one knows for sure. There are at least two plausible explanations; neither of them is a cause for optimism. The first is that the electronic tracking system is so complex that it is almost impossible to track information as its purchasers and operators intend. This is very plausible. The second possibility is that the NHS trust, recognizing that it didn't like the report it was going to generate(e.g. their wait times were terrible), decided to torpedo their IT system, which would deflect criticism from their overall inability to deliver quality care in a timely fashion. There are other possible explanations, but these two suffice.

To their credit, the administrators of the trust elected to forego issuing a mandatory report on wait-times, because they had absolutely no confidence in the data used to generate the report. So much for precision tracking. Sadly, this precedent will make every consumer of information eminating from the NHS wonder about its reliability. Bad data, whether favorable or unfavorable, can only generate further problems for the NHS. Discussions based on conjecture are worse, but seem inevitable.

Champions of CHIT will contend that experts should, given time and resources, be able to implement a system that works. The experience NHS thus far reveals the lie beneath this. Two of the 4 major contractors have walked away from $ 1 billion + deals, taking a loss just to get out. The is a maelstorm of criticism of the product of the remaining vendor.

http://www.guardian.co.uk/society/2009/apr/28/nhs-it-cerner-computers-hospitals

We are forced to conclude while it is possible for CHIT to permit precision tracking of patients, that there are no vendors on this planet that have been able to generate a product that might work for the NHS, at least not yet.

This problem is not unique to England, Australia has similar failures looming on the horizon:

http://www.theage.com.au/articles/2009/04/16/1239474999842.html

The Australian story also suggests that the system they have implemented has little or no capability to improve medication safety, one of the major motivators of the mandates to procure such systems.

One final point: These failures receive much less play in the English press than they would in the US press, because all of the 'subscribers' to the NHS have become accustomed to the exceedingly long wait-times associated with the system. They're not subscribers or consumers as much as they are sheep, herded by the leadership of the NHS. They don't even bleat in protest of this kind of failure. No US hospital would survive the aftermath of a failure like this - except one run by the government....

The Pen is Mightier than the Computer

2009-04-14T08:58:02-07:00

When it comes to Computerized Health Information Technology (CHIT), also known as the Electronic Medical Record (EMR), the pen is mightier than the computer.

Why? Because regulators and billing professionals seek comprehensive documentation, and believe that more information generates a clearer, more useful picture of what is happening (and has happened to) a particular patient. Malpractice attorneys and quality experts lust for this level of detail, as it will afford them the opportunity to point out the myriad failings of the health care system, and serve as a perch from which they can direct the continuous improvement in the quality of care. Patients, anxious that critical elements of their medical story might be lost or unappreciated, are anxious that every caregiver have complete and total awareness of the details and trajectory of their medical history. While noble, this aspiration is part of the problem with CHIT, and perhaps the major obstacle to its being a solution to any problem in medicine.

The relentless quest for higher resolution of detail has driven a relentless increase in the detail provided. Unfortunately, the coding available is often a poor fit for the clinical information (a mild dilation of the aorta classifies out as an aortic aneurysm, the former something that bears minding over decades, the later a potentially life threatening medical problem that commands close follow-up). Worse, much of this coding is generated by administrators remote from the bedside, and who typically are deprived of the information required to code accurately. The imperative to code something, anything, invariably trumps accuracy, and little inaccuracies creep in to the documentation in droves at this point. Please note the shift in language from record to documentation in the last sentence. Only outsiders regard such documentation as containing useful information about a patient; you will likely never meet a healthcare provider who has this view. You will never hear ‘Could you please request Mr H’s medical and billing records from his hospitalization at memorial hospital?’ Not gonna happen. In fact, practitioners know that there is more noise than information in this documentation, which is why they do not and have never had any interest in it. It is almost certainly the case that the cost of improving the accuracy of this documentation far surpasses any benefit that might accrue to the patient. The fantasy that you can monitor the quality of health care from this perch, or improve it, is, well, a fantasy. This has not stopped major players from falling for this, hook, line, and sinker:

http://www.boston.com/news/nation/washington/articles/2009/04/13/electronic_health_records_raise_doubt/?page=full
(this is a news story of how the incorporation of such billing information completely corrupted a Google medical record).

Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.

http://content.nejm.org/cgi/content/full/358/16/1656
(this is a nice piece from the NEJM about the pitfalls & failures of the current crop of EMRs. The authors describe the practitioner driven to keeping note-cards on his patients)

http://ukpmc.ac.uk/articlerender.cgi?artid=1023477
(this is a manuscript about sign-out sheets – the most common form of shadow chart – I am a co-author).

Why is the pen mightier than the EMR? Before the modern era, the chart contained whatever information practitioners caring for the patient thought would be useful to others, either at present, or in the future for review. Writing with a pen is effortful and time consuming. It forces the writer to abstract and extract critical information, and to synthesize whenever and wherever possible. Information is only duplicated if it is essential to the story that is being told. The pen permits the writer to organize a note as they see fit, incorporating information wherever it makes sense to them. If a picture saves a thousand words, then a sketch is likely to be incorporated into the note. Notations in the medical record call the readers attention to what the writer thinks is important and why it is deemed so. The exclusion of extraneous information is as critical as the inclusion of crucial information. Charts that are a concatenation of such notes are exceptionally useful in telling the stories of patients, but are a thing of the past (sadly, an increasingly remote past). I have an ICU colleague who writes 3-7 sentence notes about patients. His notes are as brilliant as they are concise, and everyone who reads them admires them, and envies his ability. In almost every instance, his notes are the only thing worth reading in the chart. While such brevity is possible with the EMR, it is not cultivated by it. Worse, synthesize seems to be an unnecessary undertaking whose execution is poorly supported by the EMRs of the present.

How will we know an effective EMR when we see one? Easy. The story of the patient will not merely discoverable, but self-evident. Practitioners will cease making shadow-charts, because they will no longer be worth the effort. Stalinist regulation to compel this might create the appearance of success, but only in the minds of the regulators and administrators who generated it. Sharp end practitioners would be profoundly hampered by any such mandate. Indeed, any regulation at all of shadow medical records is likely to significantly hamper medical care, which is why almost no one studies them, and why there is little or no discussion of them outside of the community of practitioners.

The fantasy is that the chart is the repository of all of the facts of a patients care. The reality is that the chart should tell the story of a patient’s care, clearly and concisely. Anyone who reads it should come away with the patient’s story, not a mountain of seemingly vaguely related facts, as is the case with the EMRs of today. The pen promotes this, the EMR of the present actively obstructs it. For now, the pen is indeed mightier than the EMR.

An article about CHIT that everyone should read!

2009-04-10T08:07:32-07:00

The article here:

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=590411&pageID=1&sk=&date=

highlights several important problems with the electronic medical record.
- Cutting and pasting is easy, writing is hard. Hence EMRs are filled with mountains ofduplicate information, and almost nothing about what happened to a patient, or why. The article intimates that a single 3x5 card might contain more useful information about a patient than megabytes of EMR.
- Rather than improving practitioners ability to withstand audits,they may create a circumstance where it is dificult or impossible for a practitioner to survive one. The article points out that required documentation and coding may not be supported by individual systems (this will require constant updating). The absolute lack of concordance between documentation and effort severs a long established assumption: that extensive documentation reflects extensive contact and participation.

Stay tuned for further details!

Update on CHIT

2009-03-04T06:18:49-08:00

Since my last post on CHIT, the economic stimulus package has been passed, and includes on the order of $20 billion to support the development of electronic medical records. A few observations:

- The UK had a nationalized health care system, with standardization at many levels, for decades before it embarked upon its still floundering efforts to create an electronic medical record. The amount budgeted is far less than what the UK has spent thus far. The population of the US is several times larger than the UK, our health care system is nearly completely decentralized, and there is little standardization outside of health care directly provided by the US government. It is likely that several times this amount would be required to arrive at the same point as the British – which is close to nowhere. In short, the amount allocated is not even close to enough to begin to deal with the US problem, let alone craft any functioning product. If the US experience replicates the UK experience, then the amount of money budgeted is far, far short of what will be required.

- How is this money to be spent? This is not a trivial question, but in fact a central question. There are major vendors of CHIT in the US, but their business model is of proprietary software and databases. The kind of portability and accessibility that proponents of the EMR (Electronic Medical Records) tout are anathema to the business models of these vendors. Are the feds to choose one (and compel the scrapping of the competitors)? If history has taught us anything, it is government granted monopoly to any private corporation is a prescription for delay, cost overrun, inefficiency, and corruption. Are the Feds to start from scratch? Are they to stipulate some sort of standard? Either would have the effect of undoing a substantial percentage of the experience and investment in systems to date.

- Can we even find efficient use for the money that has been allocated? Quite seriously, no one has ever had this kind of money to spend on the development of an EMR before. We’re clearly not ready to commence production, and we may not even know where we are in development. Can there possibly be enough researchers and developers to efficiently and effectively utilize $20 billion dollars in funding? The most likely answer? Somewhere between doubtful and inconceivable. Make no mistake: the funds at issue will generate a huge number of ‘instant experts’ and draw everyone with remotely relevant experience into the endeavor. Sadly, there is no one with a large scale success to be recruited, because no one has had success on a large scale.

It's All CHIT To Me

2009-02-04T10:44:59-08:00

There is enormous enthusiasm for Clinical Health Information Technology both from within health care and from the outside as well. There is enormous enthusiasm for provide rapid access to information about patients, with widespread belief that such systems will improve the quality of care and the satisfaction of both patients and providers. There is no question that, on a small scale, such systems can work, and work extremely well. For instance, my own direct experience with my own department's pre-op clinic software, designed and developed by a clinician, was simply phenomenal. Satisfaction with locally developed systems is generally quite high. More broadly, the larger the scale, the lower the performance and satisfaction.

Our new administration is calling for increased utilization of CHIT at the national scale, and seems poised to spend a substantial amount of money for this purpose. Once again, it makes sense to evaluate the English experience. The results are not encouraging. Worse, the bad news does not seem to have traveled well across the Atlantic. My colleague Richard Cook has been following this story for some time, and you can read his bog posting about it here:

U.K. NHS computer system on verge of collapse & implications for the U.S investment in CHIT

There is also an interesting article, forwarded to me by him, here:

http://business.timesonline.co.uk/tol/business/industry_sectors/technology/article5636437.ece

His other posts on the subject in the RIsks forums are also very much worth reading:

http://catless.ncl.ac.uk/Risks/25.44.html

This one is both erudite and humorous:

http://catless.ncl.ac.uk/Risks/23.81.html#subj6.1

Like so many things in health care, it is far easier to get this woefully wrong than most outsiders appreciate. As importantly, the financial costs of these failures are staggering. The vast majority of CHIT systems in use or under development today have cost far, far more than projected, and taken far longer to go-live than their proponents represented. Put differently, I am not aware of any system that was completed on time and under budget.

In 2002, Cedars-Sinai in LA tried to bring up an electronic medical record. A caregiver revolt forced them off-line, back into the functional world of paper and pen.

Here is follow-up from the Cedars-Sinai implosion from years ago:

http://www.washingtonpost.com/wp-dyn/articles/A52384-2005Mar20.html

And finally, even when you go live with such systems, you confront potentially insuperable security and privacy problems:

http://www.latimes.com/news/local/la-me-cedars-sinai23-2008dec23,0,6381180.story

http://www.consumeraffairs.com/news04/2006/05/va_laptop.html

Be certain: in this, the electronic world mirrors the real world: security and easy access/ease--of-use struggle to co-exist. Secure systems will be painful to their users, and easy to use systems will be riddled with security vulnerabilities.

Merry BIS-mess to you!

2008-12-30T20:07:10-08:00

So. Plenty of oxygen was consumed discussing/arguing/debating the merits of the secret-recipe Aspect BIS cerebral monitor at this year's ASA. Isn't this getting old? First, my disclosures. I have no financial interest in or support from Aspect medical (in fact, given the state of the economy, I have no financial interest or support from anything, aside from my ever-shrinking clinical income.) Second, I use the BIS every day, on almost every case I do longer than 15 minutes, paralyzed or not. I even use it on most functional (awake) craniotomies. I have been known to shave the occiput in order to place a BIS array for ACOM aneurysm clippings (yup, we still do them here, now and then). I liiike it. I've used it at least a thousand times.

But it does have its limitations. Like last month, when a young lumbar patient on 2% Sevo and fent with a reading of 42 "BIStles" (that's what I call 'em-why not?) in one epoch, did his best unconscious imitation of upward facing dog the next... (yes Ira, I know-the brain is not the spinal cord.) Do a hundred BIS cases without paralysis and you'll understand in your gut what I mean. But I still like it.

As monitors go, in my practice, the BIS is worth about 1 pulse-ox units (pou). By comparison, the gold standard monitor, the pulse-ox is a perfect 10 pou's. The Pulse ox is the most perfect anesthesia monitor that ever was, or could be (anybody besides me old enough to remember that feeling in your gut upon hearing a surgeon say "the blood looks dark"?) Blood pressure, maybe 7 or 8 pou's. Gas monitor, about a 6. The ECG, 2 or 3. This score is obviously my subjective weighting of the sensitivity and specificity of each monitor for keeping my patients (and me) out of trouble, and can certainly vary based upon each individual patient's specific situation (for instance, a person with a history of SVT intuitively derives much more utility from intraop ecg monitoring than a fit 20 something, in whom the ecg almost never tells me anything I don't know from the plethysmograph.)

Don't get me wrong, I use them all; why not? Maybe it was my gadget-deprived anesthesia childhood; manual BP, precordial steth, and a "bullet" ecg monitor (encased in a torpedo-like tube so it wouldn't blow up the room, literally, when we still had flammable anesthetics around... ) As Dr Estafanous, then chief of cardiac anesthesia at Cleveland clinic said when I visited 25 years ago, "We ENJOY a swan ganz catheter on every heart." Well put, I thought. There is no physical morbidity associated with any of these monitors, save that implied by Kruel's law; (Kruel was my wise, then young, Wisconsin professor) who used to say "no data is better than bad data." They are inexpensive in application, and I like gadgets. The same applies to nerve stims (about 1pou) and temp (same).

The problem, of course, is Aspect, who are economically motivated evangelists. They are black-and-white, believe-or-be-damned proselytizers who want to argue all of us into imagining the BIS R.O.I. (whoops! I meant ROC) looks like the white cliffs of Dover, rather than a soapbox derby track. They are aided in their mysticism by the lack of a true neuro-correlate of consciousness. Therefore, the BIS clinical criterion is not unconsciousness; it is depth-of-anesthesia (DOA); which is a horse, as they say, of another color. What does DOA (perhaps an unfortunate acronym) mean clinically. Hell if I know. The semantic distinctions here are, ahem, shall we say, convenient?
OR, as Alfred E Smith said "No matter how thin you slice it, it's still baloney."

IF you can't get anesthesia, amnesia will do...

The literature is nicely seasoned with memory-during -anesthesia studies, parsing explicit vs. implicit and the like. As anesthesiologists, we are phenomenologists. Along this axis, we are mostly seeking to avoid catastrophic recall. That is, as all anesthesiologists and anesthetists will immediately understand, is about wide-the-heck-awake-during-surgery torture.. We have no way to know for sure the state of consciousness of a paralyzed patient, save as they have explicit, or measurable implicit memory, give-or-take a tourniquet-isolated arm study or two. This is not true, by the way, for non-paralyzed patients, who can obviously provide volitional motor feedback; ie, a sock in the jaw, if they are not deep enough... And this, in turn, because memory deposition seems to be more susceptible to abolition by inhalation agents than consciousness, which in turn is more sensitive than movement. We see it every case. On emergence, first they move, then they reach for the tube, then they open their eyes to command, all some minutes before they remember anything.

Catastrophic recall happens two ways; A) the vaporizer was dry, because we didn't check and fill it, or B) we didn't turn on the vaporizer (or in tiva, the pump). During TIVA, we can also forget to rig it up right, too, I suppose. Not delivering anesthetic is like forgetting to deploy your retractable landing gear prior to touchdown; It happens rarely, but it does happen in the absence of a cockpit alarm/annunciator to remind the pilot. All desflurane vaporizers have level/output alarms; no agent=obnoxious alarm. This eliminates a systematic cause of inadvertent intraop awareness. I intuit that this happens more frequently in loooong, middle of the night cases, where the anesthesiologist slows his/her monitor scan rate and drops the vaporizer out of that scan loop because the level changes soooo sloooowly. So why doesn't every vaporizer have a level alarm? Beats me? I just work here, but if I were the APSF, I'd be lobbying for a mandatory changeover.

Forgetting to turn on the vaporizer is a different problem. It is certainly an AUTOMATIC part of every induction sequence, which makes it a problem. Anything that interrupts the induction sequence flow (yelling surgeon, difficulty with airway) and takes the operator out of their routine threatens that step. I use a three check induction routine, based loosely upon my Wisconsin three-check vial label confirmation. At UW, we were taught to check the vial label when we picked it up, when we drew it up, and when we gave it. I check that the vaporizer is on when I push hypnotic, when I turn on the vent, and when I start the chart..

What about the gas monitor alarms? The are great for cruising on long stable cases, but since they are not adaptive, they have the unfortunate tendency of attracting attention at exactly the wrong times; immediately peri-induction and at emergence, when information flow is high. As a consequence, most monitors default to a zero% low agent parameter (Don't yours colleague?) and require pro-activity post induction to reset the low level alarm, and to set it back down on emergence; otherwise the anesthesiologist must hit alarm disable every two minutes, also disabling all other alarms (ie apnea, saturation) as a consequence. A sorry state of affairs, for which there is little excuse now, given the processing power inherent in even the least sophisticated physiologic gas monitors; It would be a simple matter, for instance, to link a low inhalation agent alarm parameter to the mechanical ventilator. It might take a little tweaking, but I can already envision the algorithm.

Finally, of course, there is the old standby known to every pilot; the checklist. Why have we resisted anesthetic checklists for so long? This is one of those issues like ACLS certification. We feel like our professional boundaries are being threatened on the one hand, then we see a QA report where some anesthesia numb-skull has given four 300mg boluses of amiodarone to a vfib patient over ten minutes the next day (he got confused with lidocaine!!?)

And, why have we been beating around the bush on this issue for so long? Perhaps, if we can just shake loose from the fog of BIS info-mercial marketing for a moment, we can get to addressing their valid concern with intraop awareness and institute some appropriate systematic fixes that don't necessarily involve buying their machines. But I do like them...

Big Brother: Coming Soon to a Hospital Near You!

2008-10-08T11:07:20-07:00

A prevailing belief in the modern world of health care is that outcomes would be a lot better if people would just do what the best-evidence dictates. In clinical practice, best evidence is incarnate in guidelines and protocols generated by societies, associations, and various empowered committees in hospitals and health care organizations. Concerns about conflicting outcomes in the clinical literature, the extension of the results from the study population to patients in general, and whether the cost of the program is worth the payoff are all safely classified as reactionary obstructionism by the leaders of this revolution. Pay 4 Performance was sold as a way to reward those who conform to ‘best practice.’ While it continues to have advocates, sharp-end practitioners have collectively come to the realization that P4P is a hoax intended to further reduce payments (mostly government) to health care providers.

http://docsurg.blogspot.com/2008/07/oops-p4p-slip-is-showing.html

It is already the subject of caustic irony, published in top-shelf peer reviewed journals:

http://jama.ama-assn.org/cgi/content/full/300/3/255

Finally, it is a dark day when Dilbert is smack-on about the world of health care:

http://www.dilbert.com/strips/comic/2008-09-03/

Where does all of this leave us? Well, at the highest levels, the backers of best-practice believe that the problem is that we have not gone far enough. Like the British generals prior to the Somme, their belief is that success requires the same template executed on a larger scale. In this instance, the belief is that practitioners routinely ignore best practice, in spite of whatever the documentation they generate might represent. Hence the only way to verify what happened is to create an enduring, reviewable record.

http://www.arrowsight.com/public/as/html/Medical/videos.asp

While the vendor appears to be marketing comprehensive systematic nearly prospective review; in reality such evaluations are certain to be extraordinarily expensive. Worse, performing them on a large scale would require an enormous number of hours, which would only be affordable if the work was done by less-skilled reviewers, or exported ‘off-shore.’ Realistically, this record will be used to ‘look back’ and determine the causes of bad outcomes. Do those who will be using this system for this purpose possess the necessary expertise (e.g. training as the NTSB would require)? I am unaware of any evidence to support this assertion; in fact, I would be flabbergasted if this was the case. Even in their infomercial, it is clear that they are focused on ‘Who are the bad actors?’ rather than ‘Why aren’t these practitioners doing what we want?’ This is not a trivial distinction; it is the difference between mindless, punitive inspection and actually the kind of human factors analysis necessary to improve performance (see The Inspections Will Continue…..). Woe to the ‘bad practitioner,’ this technology provides a mechanism to acquire evidence and levy sanctions.

Beware the briar patch. While many hospital administrators thirst for information this detailed, most do not realize that it could consume all of their time, and generate liability on a scale that they previously have not encountered. Some observations for health care organizations that are contemplating purchasing this technology:
1. If you don’t sanction practitioners for failure to comply, you’ll have to justify that decision. If you apply sanctions appropriately, there may be no one to do the work.
2. If practitioners comply with all applicable regulations and guidelines, economic failure is certain in any but the most lucrative practice environments. Nothing will get done.
3. Conflicting guidance will create organizational conflict. Where guidelines conflict, practitioners will either act in accord with their best judgment, or worse, compel institutions to generate guidance. This technology requires the organization to have an opinion about best-practice in every domain.
4. Legally, the enforcer assumes all of the risk. Plaintiff’s attorneys will love this: it makes the hospital/clinic accountable for every action of every practitioner. There will be no excuses for either not knowing or not acting.
5. The ‘rules’ you enforce had better be defensible in the face of litigation and continuously up-to-date. Every single one is likely to be tested in the courts.

Of this I am certain: this technology will be a weapon to silence counter-revolutionaries and reactionaries.

This post was written by Mike O'Connor