Yes, the OS and filesystems on our EHR servers were hacked and our data encrypted for ransom, but "no medical information was looked at or compromised"

On this blog I have an entire series of posts regarding EHR crashes that point out an absurd-on-its-face and, in fact, insulting boilerplate executive response to the EHR unavailability:

"BUT patient care has not been compromised." 

The posts can be accessed via the query link http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised.

It seems I may need another, related indexing term when EHRs get hacked and ransomware is inserted:

"BUT no information was looked at or compromised."

I've seen this in various incarnations several times now. 

For instance, see my Feb. 18, 2016 post "Hollywood Presbyterian Medical Center: Negligent hospital IT leaders allow hacker invasion that cripples EHRs, disrupts clinicians ... but patient safety and confidentiality not compromised" at http://hcrenewal.blogspot.com/2016/02/hollywood-presbyterian-medical-center.html and my March 29, 2016 post "Bad health IT at Medstar Health: FBI probing virus behind outage" at http://hcrenewal.blogspot.com/2016/03/bad-health-it-at-medstar-health-fbi.html.

This type of statement suggests that thieves who are able to gain access at highly granular levels of a server's filesystem and OS in order to encrypt the contents and insert the ransomware are "honest thieves" who would not look at the PHI for purposes of identity theft, or even sadistically alter data for purposes of causing harm.  In other words, it's the executives reassuring the populace that the thieves have honor.

The latest example:

Novato firm remains silent about ransomware attack on patient records
Richard Halstead, Marin Independent Journal
08/13/16
http://www.marinij.com/article/NO/20160813/NEWS/160819914

Officials at a Novato [California, https://en.wikipedia.org/wiki/Novato,_California - ed.] company that provides medical billing and electronic medical records services to many Marin physicians aren’t talking about a ransomware attack on their system this month that left doctors unable to access patient records for more than 10 days.

Ten days without charts is unprecedented in the paper world, except perhaps after a major physical catastrophe.

Clearly, the refrain "BUT patient care has not been compromised" would be absurd under such conditions.

Lynn Mitchell, CEO of Marin Medical Practice Concepts, issued a terse email on Aug. 4 confirming that her company had paid a ransom to regain access to its data. She wrote, “To date, there is no evidence that any patient information was accessed, transferred or otherwise compromised.”

Honest thieves were involved.

Since then, Mitchell has declined to comment on how many patient medical records were involved, how Marin Medical determined that the records weren’t compromised and whether the company reported the security breach to law enforcement or — as required by law — the state Attorney General’s Office and U.S. Department of Health and Human Services.

“We have nothing further to add at this time,” Mitchell said in an email Thursday.

Not specifying how such a determination was made significantly decreases the credibility of an already non-credible assertion, in my view.

Joe Cohen, an information technology consultant based in Greenbrae, said, “They claim no information was looked at or compromised. I don’t believe it.”

Cohen, whose personal data is in Marin Medical’s system, said he is worried that whoever encrypted the company’s files may have copied the data before demanding the ransom.

That's a best-case scenario, considering the possibility of deliberate or accidental alteration or corruption.

Typically in such ransomware attacks, a sophisticated computer virus finds its way into a victim’s system when an unsuspecting employee opens an email attachment. The virus encrypts the system’s data and attackers essentially hold the data hostage until the owners of the information pay a ransom, typically in an untraceable digital currency such as Bitcoin.

"Finds its way into a victim's system" is a rather mild way of saying "invades a victim's system due to inadequate security precautions."

Carl Chapman, operations manager of the Northern California Computer Crimes Task Force and an inspector in the Marin County District Attorney’s Office, said Marin Medical did not report the extortion to his task force.

“Typically, people don’t report them because I think it is well known throughout information technology departments that we are unable to unlock the information,” Chapman said.

... In 2012, the state began requiring businesses and government agencies to notify the attorney general on breaches affecting more than 500 Californians. The law applies to any business or agency whose unencrypted personal information was acquired, or reasonably believed to have been acquired.

I'd say it's more likely that organizations that don't report such crimes want to keep their victimhood due to negligence out of the public spotlight.

According to a report issued by the Attorney General’s Office in February, in the past four years the attorney general has received reports on 657 data breaches affecting a total of more than 49 million records of Californians. ... health care, which accounted for 16 percent of breaches, is starting to see an increase in hacking breaches as the sector transitions to electronic medical records. ... the “most vulnerable information in health care was medical information, such as patient records, and Social Security numbers.”

That level of incidents leads me to state the following:

• Lack of EHR interoperability, so often complained about, is actually a good thing in 2016, as it may limit the scope of individual breaches of EHR security; and

• The utopian dream of a national health information network connecting the entire country's EHR systems is a very, very bad idea in 2016 and should be postponed.  Reality is a harsh master, and the risks are clearly great in 2016 due to the immaturity of computer security.

More on ransomware:

Gordon [Amy Gordon, a partner in the Chicago law firm of McDermott Will & Emery LLP] said in addition to encrypting data, ransomware may also transfer information to a remote location.

“In this day and age, people’s personal information is valuable,” Gordon said, “so unfortunately some of these hackers may be selling this information in addition to getting the ransom from the hacked entity.”

The thieves are already taking a significant risk, and smart thieves would certainly be expected to maximize their haul..

In February, Hollywood Presbyterian Medical Center in Los Angeles paid a ransom of $17,000 in the hard-to-trace digital currency Bitcoin in order to regain access to its data.

Then in March four more organizations fell victim: MedStar Health, which operates 10 hospitals throughout the District of Columbia and Maryland; Chino Valley Medical Center in Chino and Desert Valley Hospital in Victorville, California; and Methodist Hospital in Louisville, Kentucky.

The first two incidents are covered in the aforementioned posts.

John Hall, who operates Sausalito Networking, a small system integration firm, said, “If someone hits a hospital they can usually get a lot of money because the hospital needs to get the darn patient data.”

Indeed, making them among the most pliable of victims.

Hall said several of his clients — a small construction company, a tax advisory firm and a medical facility — have been hit by ransomware attacks recently. He said he is advising all of his clients to install special anti-ransomware software.

Bret Lowry is the founder of Florida-based WinPatrol, which produces the anti-ransomware software that Hall recommends.

“This year ransomware attacks have just exploded,” Lowry said, “because organized crime has gotten involved and is using it to make money.”

That is not surprising to me.   Further evidence the "ready, aim, fire" push to national health IT by our government and IT industry with little consideration to risk, now in a stage of coercive penalties for non-users, once again has been proven to have been reckless.  As examples of the government and industry leaders downplaying risk:

March 6, 2013
On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 1
http://hcrenewal.blogspot.com/2013/03/on-ehrs-see-no-evil-hear-no-evil-speak.html

March 8, 2013
On EHR's: See No Evil, Hear No Evil, Speak No Evil: Part 2
http://hcrenewal.blogspot.com/2013/03/on-ehrs-see-no-evil-hear-no-evil-speak_8.html

In the first post I noted this:

... The head of CCHIT, Mark Leavitt, has penned the following at iHealthBeat: 

June 19, 2009 - Perspectives 

Health IT Under ARRA: It's Not the Money, It's the Message

by Mark Leavitt 

... Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers are easily affected by fear mongering.

Fear mongering.  Right.

In the second I noted this:

... Blumenthal, at the time Director of ONC at HHS had reportedly stated that:

http://www.massdevice.com/news/blumenthal-evidence-adverse-events-with-emrs-anecdotal-and-fragmented

... [Blumenthal's] department is confident that its mission remains unchanged in trying to push all healthcare establishments to adopt EMRs as a standard practice. "The [ONC] committee [investigating FDA reports of HIT endangement] said that nothing it had found would give them any pause that a policy of introducing EMR's [rapidly and on a national scale - ed.] could impede patient safety," he said.

The "nothing" includes 44 injuries voluntarily reported to FDA and 6 reported deaths in an enviroment where few know where to report such things and where no reporting requirements exist, and a statement from the head of CDRH at FDA that due to systematic impediments to accurate knowledge the known figures likely are a small fraction ("tip if the iceberg") of the actual occurrence.

Further:

Chapman said, “In the cases we’ve investigated, all of the leads go to Eastern European countries for which we don’t have the ability to do any further investigation. I’m not aware of any federal agencies that are specifically working on ransomware.”

In other words, the hackers cannot be identified nor brought to justice.

Under these conditions, continued pushes for interoperability and mass networking of multiple EHR's is simply reckless.  The proper caution calls for a slowdown in those efforts until security issues are under reasonable control.  However, the past decade has shown that "caution" seems an abstract concept to our government and industry with respect to the health IT sector.

Finally:

"BUT no information was looked at or compromised" is a phrase that also needs to be backed up by robust proof, because it rings as hollow as, or perhaps more hollow than "BUT patient care has not been compromised." 

-- SS

Stanford authors: Evolutionary Pressures on the Electronic Health Record - "Deimplementing the EHR could actively enhance care in many clinical scenarios"

A brief post.  In this new JAMA article by Stanford authors:

Evolutionary Pressures on the Electronic Health Record
http://jama.jamanetwork.com/article.aspx?articleid=2545405 

Donna M. Zulman, MD, MS^1,2; Nigam H. Shah, MBBS, PhD³; Abraham Verghese, MD⁴

I note the passage:

... Deimplementing the EHR could actively enhance care in many clinical scenarios. Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.7 Many phenotypic observations (the outline of a cigarette packet in a shirt pocket, or spotting neurofibroma, fasciculation, or rash) change the diagnostic algorithm and are easy to miss when work revolves around the computer and not the patient.

I predict pushback against such a bold and contrarian "de-implementation" assertion (contrarian to the hyper-enthusiast and industry narratives, that is).

The authors continue:

There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale. Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped. Better medical record systems are needed that are dissociated from billing, intuitive and helpful, and allow physicians to be fully present with their patients.

 

I also wrote the primary author with a link to an alternate solution to de-implementation that can "allow physicians to be fully present with their patients", namely, my Aug. 9, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

 

-- SS

Politicians get a very bitter taste of the very same medicine they've forced onto clinicians and the public

This is a case of education - I hope - by fire on electronic information security, and why "going electronic" can be a risky business.  This is a lesson deeply needed by our government leadership who have been pushing an unfettered national rollout of electronic medical records systems, despite known and exploited security concerns of EHRs, among other concerns discussed at this blog.

I've written dozens of posts, just based on casual searches of news, illustrating breaches of healthcare information technology security and privacy of information, as have others focusing primarily on these issues such as Patient Privacy Rights DOT org (https://patientprivacyrights.org/).  

Examples of my own occasional posts in this domain are at query links such as:

http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality

http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy

http://hcrenewal.blogspot.com/search/label/computer%20security

Our wise political leaders, however, have been pushing this technology, despite its numerous drawbacks  - full steam ahead - on clinicians and patients, now under the gun of Medicare payment cuts for "refuseniks."

Now, the political leadership has just gotten a bitter taste of the dish they've been serving up:

Hacker releases cell phone numbers, personal emails of House Democrats
By Daniella Diaz, CNN
Updated 4:04 PM ET, Sat August 13, 2016
http://www.cnn.com/2016/08/12/politics/guccifer-2-0-hacker-dnc-dccc/

The hacker who goes by "Guccifer 2.0" is claiming credit for the release of personal cell phone numbers and private email addresses of Democratic House members.

The data -- posted to their WordPress blog on Friday night -- also contains the contact information for staff members and campaign aides.

In the trove of information released on Friday "Guccifer 2.0" also uploaded files to the blog post that contains login information to subscription services used by the Democratic Congressional Campaign Committee, including Lexis-Nexis and Washington newspapers ... In addition to lawmakers' personal information, the hacker uploaded documents analyzing candidates for Florida's 18th congressional district, and a fundraiser memo to House Minority Leader Nancy Pelosi about Morgan Carroll's congressional campaign in Colorado.

In a statement, DCCC Press Secretary Meredith Kelly said: "As previously noted, the DCCC has been the target of a cybersecurity incident, and we are cooperating with federal law enforcement in their ongoing investigation. We are aware of reports that documents claimed to be from our network have been released and are investigating their authenticity."

Rep. Adam Schiff of California, the ranking Democratic on the House Intelligence committee, suggested a law enforcement probe is necessary. 

Perhaps a probe of the competence of those responsible for electronic security hired by our wise government officials should come first.

"The unauthorized disclosure of people's personally identifiable information is never acceptable, and we can fully expect the authorities will be investigating the posting of this information," Schiff said.

But it's just fine to keep rolling out insecure electronic records systems.

... The hacker wrote in the blog post, "It's time for new revelations now. All of you may have heard about the DCCC hack. As you see I wasn't wasting my time! It was even easier than in the case of the DNC breach."

Remarkable incompetence on the part of the politicians.

... The hack of the DNC was originally discovered as being two separate breaches, both by hacking groups identified by cybersecurity experts as working for the Russian military and intelligence complex. One hack was said to have lasted a year and targeted internal communications, the other was for a few months and targeted opposition research on Donald Trump.

 

Federal investigators had tried to warn the DNC months before, sources told CNN, but by the time the suspected Russian hackers were kicked out of the systems damage had been done: Nearly 20,000 emails between a handful of DNC officials were dumped on the web by WikiLeaks as the Democratic National Convention was kicking off. The emails showing opposition to Vermont Sen. Bernie Sanders during the primary led to the resignation of DNC Chairwoman Debbie Wasserman Schultz on the eve of the convention and departure of more party officials later.

The politicians of both parties behind the EHR mandate, in effect at least since the HITECH Act of 2009, should have heeded those questioning EHR security before mandating a national rollout.  My only comment is that I hope the politicians unabashedly pushing EHR's on the public may have learned a valuable, needed, and well-deserved lesson about electronic information security from these events.  

However I am not optimistic about that.

-- SS

Ioannidis et al.: What Happens When Underperforming Big Ideas in Research [such as Healthcare IT Exceptionalism] Become Entrenched?

Some years ago, John P. A. Ioannidis, MD wrote this piece:

"Why Most Published Research Findings Are False", John P. A. Ioannidis, PLoS medicine, 2005 August; 2(8): e124

He wrote:

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.

In other words, in the all-too-common insufficiently powered studies, and even seemingly robust studies in domains with small effect sizes, financial interests, prejudices and other factors more often than not produce false results.

Ioannidis and co-authors recently took their sword to "underperforming Big Ideas in research" (including the "miracles" touted by hyper-enthusiasts such as in genomics and in cybernetics), via a new JAMA viewpoint piece:

What Happens When Underperforming Big Ideas in Research Become Entrenched?
Michael J. Joyner, MD1; Nigel Paneth, MD, MPH2; John P. A. Ioannidis, MD, DSc3
JAMA. Published online July 28, 2016. doi:10.1001/jama.2016.11076
http://jama.jamanetwork.com/article.aspx?articleid=2541515

For several decades now the biomedical research community has pursued a narrative positing that a combination of ever-deeper knowledge of subcellular biology, especially genetics, coupled with information technology will lead to transformative improvements in health care and human health. In this Viewpoint, we provide evidence for the extraordinary dominance of this narrative in biomedical funding and journal publications; discuss several prominent themes embedded in the narrative to show that this approach has largely failed; and propose a wholesale reevaluation of the way forward in biomedical research.

The key word is "narrative."   As per Hayek, those with little real-world operational experience, i.e., intellectuals and academics, often the uncritical cheerleaders for electronic records despite considerable downsides, have only the "narrative" upon which they base their beliefs in healthcare IT exceptionalism:

It is perhaps the most characteristic feature of the intellectual that he judges new ideas not by their specific merits but by the readiness with which they fit into his general conceptions, into the picture of the world which he regards as modern or advanced. . . . As he knows little about particular issues, his criterion must be consistency with his other views and suitability for combining into a coherent picture of the world. . . . It is the intellectuals in this sense who decide what views and opinions are to reach us, which facts are important enough to be told to us, and in what form and from what angle they are to be presented. Whether we shall ever learn of the results of the work of the expert and the original thinker depends mainly on their decision.

(I can add that blogs have to some small degree ameloriated "whether we shall ever learn of the results of the work of the expert and the original thinker", but only to a small degree.)

The "general conception" in cybernetics is that computers are a silver bullet in any domain, and can only result in massive improvements. 

My experience for the past twenty+ years in the Electronic Medical Records/clinical information technology domain, where quality, safety, usability, confidentiality, and other critical real-world issues have been ignored in favor of EHR hyper-enthusiasm, supports Hayek's observations regarding prevalent unfettered beliefs in healthcare IT exceptionalism.

Ioannidis et al. state the factual situation with EHR technology unapologetically, clearly and succinctly:

... The financial and clinical benefits predicted from shifting to EHRs have also largely failed to materialize because of difficulties in interoperability, poor quality, and accuracy of the collected information; cost overruns associated with installation and operation of EHRs at many institutions; and ongoing privacy and security concerns that further increase operational costs.

I would change "interoperability" to "operability."  Otherwise, they're quite correct.  For example, the "Big Data" hyper-enthusiasts quite irrationally believe data from these systems - as they are today -  will somehow "revolutionize" medicine, while at the very same time the IT industry itself and its pundits ignore fundamental precepts of computer science, information science, biomedical informatics, biomedicine and biomedical research itself. 

Some of the hyper-enthusiasts have made predictions that are astonishingly naive, delusionally grandiose and just plain perverse, e.g., see for instance my Jan. 2014 post "Computers + a few docs can manage 'an entire city', and other cybernetic miracles" at http://hcrenewal.blogspot.com/2014/01/computers-few-docs-can-manage-entire.html . 

The new JAMA paper continues:

... These features make the use of EHRs for research into the origins of disease, as proposed in the Precision Medicine Initiative, highly problematic.No clearly specified targets for either improved outcomes or reduced costs have been developed to assess the performance efficiency of EHRs.

Those targets were never specified, but The Market seems to have corrected for that, e.g., via this Jan. 2015 letter from ~40 different medical societies:

 Full letter to HHS available at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf

The authors continue:

... Although it is difficult to argue for a return to paper records, any claim of future transformation of the medical record should include well-defined accountability and review mechanisms. Otherwise, the health care system may become hostage, wasting increasing resources to continuously upgrade electronic technology without really helping patients.

It is clear to me that the health care system and its clinicians are already hostage to the cybernetic hyper-enthusiasts, as evidenced by letters such as the above and many other sources about the mayhem being caused, e.g., a small sampling on this blog at query links http://hcrenewal.blogspot.com/search/label/glitch, http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20difficulties and http://hcrenewal.blogspot.com/search/label/medical%20record%20confidentiality.

Finally, I disagree with the authors that "it is difficult to argue for a return to paper records."

Paper has its proper place, and "paperless" is a utopian dream of the hyper-enthusiasts that causes significant damage to the primary role of clinicians - to take care of patients.  I make this argument (with a real-world, highly successful example of my own creation) at my Aug. 9, 2016 post "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html.

In summary, the authors of this JAMA piece clearly and succinctly break through the "narrative" about hyper-enthusiast dominated fields, including clinical information technology and the belief in 
healthcare IT exceptionalism.
 
Sadly, theirs is almost a single voice in a wilderness dominated by the hyper-enthusiasts - and the profiteers.

-- SS

Transparency International Asks Health Care Professionals About Health Care Corruption

Transparency International, the global NGO that studies and fights corruption, seeks information from health care professionals about health care corruption.  The details are in the official announcement below.  If you are a health care professional, please consider responding to this survey. 

Invitation to participate in a corruption in healthcare survey
Transparency International’s health programme has commenced a new research project to identify the major types of corruption in the health sector. We feel that this research piece will contribute to understanding the corruption vulnerabilities in the health sector and ultimately improve the availability and use of health information to hold governments accountable.

This will feed into the World Health Summit in October, where Transparency International has been invited to run the opening session. We'll also be displaying results from the research on our website and will feature interviews with people about their experiences.

As part of our research, we're keen to hear from as many healthcare professionals as possible. This is to enable us to hear about your experiences of corruption and what you consider corruption to be.

At this stage, we do not want to influence your thoughts - more capture them. A survey has gone online and we would be grateful if you could fill it in and distribute to your peers. 

The survey contains ten questions and can be completed in ten minutes. The survey will run until the end of September.

Given the sensitivity of the subject, the survey is anonymous unless you would like to talk to someone about your experience. At the end of the survey there is an option to leave your contact details.

We're looking forward to hearing your thoughts.

Best wishes,

Michael

Michael Petkov
Programme Officer
Pharmaceuticals & Healthcare Programme
Transparency International UK
michael dot petkov at transparency dot org dot uk

The link to the survey is here.

How the System is Rigged - Johnson and Johnson Board Member Pretends to be Independent Brookings Institution Scholar

Fears that "the system is rigged" may cause the lack of trust marring this year's political season. These fears are not baseless.

Dr McClellan of the Brookings Institution on Drug Prices

A recent series in the New York Times focused on the biases of the think tank "independent scholars" whose work is used to justify much policy making.  An article entitled "Think Tank Scholar or Corporate Consultant? - It Depends on the Day" actually provided a health care example that was much worse than what the title implied.

It noted that

Dr. McClellan, a former commissioner at the Food and Drug Administration who until January was a senior fellow at Brookings, has been a go-to expert for the federal government as it debates how to cope with surging costs of prescription drugs.

In particular, Dr McClellan has opined on the increasingly recognized problem of ever-rising drug prices, and on one class of drugs that we have discussed on Health Care Renewal.

At public events, Dr. McClellan emphasized the extraordinary progress by the pharmaceutical industry in coming up with treatments for diseases like diabetes, H.I.V. and hepatitis C.

'Lots of diseases have been transformed,' Dr. McClellan said at a hearing in November sponsored by the Department of Health and Human Services. He ran through a series of slides prominently stamped with Brookings’s name. He also argued that even though these drugs were very expensive, they were worth it given the improvement in a patient’s quality of life.

'They are, over all, a pretty good deal,' Dr. McClellan said, referring to treatments for hepatitis C. One such drug, manufactured by Johnson & Johnson, generated $2.3 billion in sales in its first full year, representing about 7 percent of the company’s overall drug sales in 2014. The pills cost $66,000 for a standard 12-week regimen.

Little Evidence that New Drugs for Hepatitis C Represent "Extraordinary Progress?"


Note that despite Dr McClellan's enthusiasm, there is no good data from clinical trials that show that the new drugs for hepatitis C have long-term clinical benefits.  As we wrote here last month....

In fact, starting in March, 2014, we have posted about the lack of good evidence from clinical research suggesting these drugs are in fact so wondrous.  The drugs are now touted as "cures," at least by the drug companies, (look here), and physicians are urged to do widespread screening to find patients with asymptomatic hepatitis C so they can benefit from early, albeit expensive treatment.

However, as we pointed out (e.g., here and here)
-  The best evidence available suggests that most patients with hepatitis C will not go on to have severe complications of the disease (cirrhosis, liver failure, liver cancer), and hence could not benefit much from treatment.
-  There is no evidence from randomized controlled trials that treatment prevents most of these severe complications
-  There is no clear evidence that "sustained virologic response," (SVR), the surrogate outcome measure promoted by the pharmaceutical industry, means cure. 
-  While the new drugs are advertised as having fewer adverse effects than older drugs, it is not clear that their benefits, whatever they may be, outweigh their harms.

Furthermore, health care professionals and researchers with heftier credentials in clinical epidemiology and evidence based medicine than mine have since published similar concerns.  These included
- a report from the German Institute for Quality and Efficiency in Health Care (the English summary is here)
- an article in JAMA Internal Medicine from the Institute for Clinical and Economic Review (1)
- a report from the Center for Evidence-Based Policy (link here)
- an article in Prescrire International (2)

These publications and your humble scribe noted that the clinical trials or other types of clinical research about new hepatitis C treatment published in the most prominent journals had numerous methodologic problems that all seemed likely to make the new drugs look better, perhaps intentionally.  (See posts here,  here, and here.)

In July, 2016 we had written about the enthusiasm for these drugs expressed by Mr Bill Gates, chairman of the Gates Foundation.  Maybe one can somewhat excuse Mr Gates, who is hardly a clinical research expert, for this unjustified enthusiasm.  (Although maybe someone at his foundation, given its emphasis on global health, should have briefed him to the contrary.)

Why Was Dr McClellan So Unjustifiably Enthused?

Give Dr McClellan's background, why was he not more skeptical about the the supposed miraculous properties of hepatitis C drugs?.  His biography, provided for the US Department of Health and Human Services Pharmaceutical Forum, suggested he ought to know something about clinical research.  It stated,  

Mark McClellan, MD, PhD, is a senior fellow and director of the Health Care Innovation and Value Initiative at the Brookings Institution. Within Brookings, his work focuses on promoting quality and value in patient centered health care, and he leads the Richard Merkin Initiative for Payment Reform and Clinical Leadership.

A doctor and economist by training, he also has a highly distinguished record in public service and in academic research. Dr. McClellan is a former administrator of the Centers for Medicare & Medicaid Services (CMS) and former commissioner of the U.S. Food and Drug Administration (FDA), where he developed and implemented major reforms in health policy. These include the Medicare prescription drug benefit, the FDA’s Critical Path Initiative, and public-private initiatives to develop better information on the quality and cost of care. Dr. McClellan chairs the FDA’s Reagan-Udall Foundation, is co-chair of the Quality Alliance Steering Committee, sits on the National Quality Forum’s Board of Directors, is a member of the Institute of Medicine, and is a research associate at the National Bureau of Economic Research. He previously served as a member of the President’s Council of Economic Advisers and senior director for health care policy at the White House, and was an associate professor of economics and medicine at Stanford University.

From time to time, McClellan advises U.S. government officials on health care policy issues. In his capacity as a health policy expert, he is the co-director of the Bipartisan Policy Center’s Leaders’ Project on the State of American Health Care; co-chair of the Robert Wood Johnson Foundation Commission to Build a Healthier America; and chair of the FDA’s Reagan-Udall Foundation. McClellan is also co-chair of the Quality Alliance Steering Committee, sits on the National Quality Forum’s Board of Directors, is a member of the Institute of Medicine of the National Academy of Sciences, and is a research associate at the National Bureau of Economic Research.

McClellan holds an MD from the Harvard University–Massachusetts Institute of Technology (MIT) Division of Health Sciences and Technology, a PhD in economics from MIT, an MPA from Harvard University, and a BA from the University of Texas at Austin. He completed his residency training in internal medicine at Boston’s Brigham and Women's Hospital, is board-certified in Internal Medicine, and has been a practicing internist during his career.

However, that biography left out one important item.  Per the NY Times article,

There was no mention in a video of the event that Dr. McClellan joined Johnson & Johnson’s board of directors in October 2013, or that he earned nearly $530,000 over the past two years in overall compensation from the company. That is in addition to his salary at Brookings, where he is one of the top-paid scholars, with $353,145 in wages and other compensation from the think tank in 2014, tax records show.

I suspect that most attendees at the conference had not read our 2013 post on Health Care Renewal that noted Dr McClellan's transit through the revolving door that ended up with his position on the Johnson & Johnson board.

Dr McClellan's Chronic Failure to Disclose His Johnson and Johnson Board Membership

Despite the fact that Dr McClellan's position on the Johnson & Johnson board of directors is public, as are the identities of all the members of US publicly held corporations, Dr McClellan has seemingly made a point of avoiding its mention when he assumes the persona of health care policy expert.

For example, he did not disclose it in some recent publications on aspects of health policy that likely would relate to Johnson & Johnson's interests.  These included:
- a 2014 Brookings report entitled "Improving Health Care While Reducing Cost Growth: What is Possible?"(3) in which he is only described as "Director, Health Care Innovation and Value Initiative, Senior Fellow, Economic Studies; The Brookings Institution."
- a 2014 article on "Health Reform and Physician-Led Accountable Care" in JAMA(4) which simply noted Dr McClellan came from the Brooking Institution, and which contained the assurance that all authors completed "the ICMJE Forum for Disclosure of Potential Conflicts of Interest and none were reported."
- a 2015 article on increasing "pharmaceutical innovation" in Health Affairs(5) which similarly only described Dr McClellan as "senior fellow and director of the Health Care Innovation and Value Initiative at the Engelberg Center for Health Care Reform at Brookings."

Furthermore, Dr McClellan's new employer, Duke University, currently provides a biography which also omits any mention of his position on the Johnson & Johnson board.

Dr McClellan Denies any Conflict of Interest

The NY Times article suggested that Dr McClellan may think his position at Johnson & Johnson is irrelevant to his day job as health policy expert.

Dr. McClellan, in a statement, disputed any suggestion that he might have had a conflict.

'My entire career in academics, government and public policy has focused on evidence-based ways to improve health and restrain costs for consumers, and my extensive track record speaks for itself,' he said.

I suppose that Dr McClellan might have justified his failure to disclose his membership on the Johnson & Johnson board of directors by his perception that this membership caused no conflict of interest.

How Board Membership May Cause Severe Conflicts of Interest

I will omit detailed discussion of all the evidence that even receiving small gifts may affect thinking and actions through the social obligation to reciprocate.  Yet Dr McClellan did not just receive small gifts.  He is a member of a corporate board of directors.

 In 2006, we first noticed that leaders of academic medicine also were serving as board members of large for-profit health care corporations.  The first example we discussed was that of Marye Anne Fox, Chancellor (equivalent to president) of the University of California - San Diego, and hence the person to whom the University of California, San Diego School of Medicine and its academic medical center report. The conflict was between this position, and her service as a member of the board of directors of Boston Scientific, a medical device manufacture, and the board of directors of Pharmaceutical Product Development Inc., a contract research organization.

Later that year, we discussed a "new species of conflict of interest."  At that time we wrote:

Medical schools and their academic medical centers and teaching hospitals must deal with all sorts of health care companies, drug and device manufacturers, information technology venders, managed care organizations and health insurers, etc, in the course of fulfilling their patient care, teaching, and research missions. Thus, it seems that service on the board of directors of a such public for-profit health care company would generate a severe conflict for an academic health care leader, because such service entails a fiduciary duty to uphold the interests of the company and its stockholders. Such a duty ought on its face to have a much more important effect on thinking and decision making than receiving a gift, or even being paid for research or consulting services. Furthermore, the financial rewards for service on a company board, which usually include directors' fees and stock options, are comparable to the most highly paid consulting positions. What supports the interests of the company, however, may not always be good for the medical school, academic medical center or teaching hospital.

As Robert AG Monks put it, board members must "demonstrate unyielding loyalty to the company's shareholders" [Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  (Of course, after the global financial collapse of 2008 made us sadder and a little wiser, we realized that many board members actually seem to have unyielding loyalty to their cronies among top management.)  However, in any case, the stated or actual interests of a member of the board of a health care corporation, like a pharmaceutical company or medical device company, could be very different and at odds with the mission of not only academic medical institutions, but of think-tanks professing to provide unbiased policy relevant research.

Presumably, were Dr McClellan in a situation in which he had an opportunity to promote Johnson & Johnson's interests, such as speaking at an influential conference about drug prices, and failed to uphold the company's interests, stockholders could consider legal action against him for failing in his fiduciary responsibilities.  Thus the mind boggles at how Dr McClellan could believe that his role as a corporate director does not pose a conflict of interest for him in his better publicized role as think tank and now academic health care policy expert.

Discussion

It is hardly news that US health care is broadly dysfunctional, that it suffers from ever rising costs, and questionable quality, while access has only somewhat improved after the 2009 Affordable Care Act.  The big question is why these problems seem so intractable.

Our latest case illustrates that the problem may be that health policy making is dominated by people with conflicts of interest.  In the current case, one of the more influential voices on health care policy turns out not to have just a garden variety conflict of interest.  He actually has a duty to uphold the corporate interests of one of the biggest US drug, biotechnology and device companies.  Could one really expect such a man would have a serious interest in controlling health care costs, especially those driven by the prices charged by drug, biotechnology, and device makers?

A system in which the top "independent" health policy experts may have conflicts of interest, may even be members of boards of directors of health care corporations, certainly suggests a system that has been rigged. 

As we have said again and again, the web of conflicts of interest that is pervasive in medicine and health care is now threatening to strangle medicine and health care.  Furthermore, this web is now strong enough to have effectively transformed US health care into an oligarchy or plutocracy.  Health care is effectively run by a relatively small group of people, mainly professional managers plus a few (lapsed?) health care professionals, who simultaneously run or influence multiple corporations and organizations.

For patients and the public to trust health care professionals and health care organizations, they need to know that these individuals and organizations are putting patients' and the public's health ahead of private gain. Health care professionals who care for patients, those who teach about medicine and health care, clinical researchers, and those who make medical and health care policy should do so free from conflicts of interest that might inhibit their abilities to put patients and the public's health first.

Health care professionals ought to make it their highest priority to ensure that the organizations for which they work, or with which they interact also put patients' and the public's health ahead of private gain, especially the private gain of the organizations' leaders and their cronies.


 References

1. Ollendorf DA, Tice JA et al. The comparative clinical effectiveness and value of simeprevir and sofosbuvir in chronic hepatitis C viral infection. JAMA Intern Med 2014;174(7):1170-1171. Link here.
2. Sofosbuvir (Sovaldi), active against hepatitis C virus, but evaluation is incomplete. Prescrire Int 2015; 24: 5- 10. Link here.
3.  McClellan M, Rivlin AM. Improving Health Care While Reducing Cost Growth: What is Possible?
Engelberg Center for Health Care Reform at Brooking; 2015.  Link here.
4.  Mostashari F, Sanghavi D, McClellan M. Health reform and physician-led accountable care: the paradox of primary care physician leadership. JAMA 2015; 311: 1855-56.  Link here.
 4.  Daniel GW, Caze A, Romine MH, Audibert C, Leff JS, McClellan M. Improving pharmaceutical innovation by building a more comprehensive database on drug development and use.  Health Aff 2015; 34: 319-327.  Link here.

More on uncoupling clinicians from EHR clerical oppression

At my August 6, 2016 post (link) I wrote of my belief that "best practices" for EHR evolution call for:

... a return to paper (specialized forms depending on the setting) for clinical data capture by busy doctors and nurses, and data entry into a computer via clerical personnel.

I presented a late 1990's real-world experiment in creating such a system for invasive cardiology in the Delaware hospital system, Christiana Care Health System, where I was CMIO at that time.

As at the links http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story and https://web.archive.org/web/20140316024627/http://cci.drexel.edu/faculty/ssilverstein/scotsilv/invascard.htm (the latter a May 2002 article in the journal "Advance for Health Information Executives" written by myself and the project executive sponsor at the time), the "experiment" was a deliberate move away from the "doctors as clerical employees" article-of-faith of the health IT hyper-enthusiasts.

Hyper-enthusiasts ignore the downsides of what is a belief system based on articles of faith, one of whose 'sacraments' is that paper must be abolished in medicine.

In fact, an attempt to implement such a paperless system, "Apollo" as the commercial system was known, in a cath lab performing 6,000 procedures/year proved impossible.  The busy clinicians, doctors, nurses and technicians simply did not have enough time to enter data directly into a computer.  Maneuvering around a computer application, dealing with its designber-centric menus, drop-downs, icons, widgets, annoying messages, input limitations, outright crashes with data loss, etc. was both inappropriate, and in fact impossible, in such a setting.

In 2016, one of the largest complaints of hundreds of thousands of U.S. physicians and nurses is that they spend more time interacting with the computer than with patients.  Patients complain they cannot get eye contact from clinicians - who are tethered to a computer screen entering data - during "live" encounters.

It is my belief there is no solution to this problem, other than decoupling clinicians from data input and returning to paper for data entry, that is, specialized forms as in the aforementioned post.  Data input needs to be returned to clerical personnel as in the aforementioned invasive cardiology system.

The output side (with, of course, significant user-centered redesign) can remain computerized; as long as the paper forms are also made available via document imaging.

The forms for invasive cardiology looked like this, and were subject to revisions as needed.

Physician's data collection form, side 1.  Click to enlarge.

Physician's data collection form, side 2

Cath technician/nurse's data collection form, side 1

Cath technician/nurse's data collection form, side 2

The EHR itself was freed from "legacy" limitations regarding rapid customization, essential in medicine.  It was designed with the ability to rapidly incorporate changes and modifications to the dataset as needed, matching the changes to the forms.

Below I am showing some of the reports that this system produced regularly, as designed by the team of programmers, executives and cardiologists, under my medical informatics leadership. I used to do "real" informatics, e.g., leading the data modeling of entire clinical subspecialty domains and developing advanced IT based on those models, until seeing that the commercial sector was damaging the field of HIT, and medicine itself, with horribly bad health IT leading to letters such as the January 21, 2015 letter to HHS at http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf.  It was then, in the early 2000s, that I turned my attention to writing about the industry's deficits.

The major advantage of the cardiology reports shown below concerned accuracy, including the case report itself whose language and organization was also developed for optimal clinical organization and  readability -- unlike the reams of "legible gibberish" that emanates from commercial EHRs then and today.  See my post "Two weeks, two reams" at lhttp://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html for more on that issue.

Quality data input into the system, being freed from the accuracy-impairing aspects of busy clinicians as clerical employees, and the resultant reports saved the organization close to $1 million in the first year and led to a better understanding of what worked and what didn't in treating blocked coronary arteries.

Click to enlarge:

Some statistical reports, and sample computer-generated case report front page

An evaluation of the project by the national organization, the Society for Cardiac Angiography and Interventions, was that the accomplishments were "exceptional."

All this was achieved without direct clinician data entry - and deliberately so due to the distractions of that process having failed in the same setting in prior organizational attempts, without medical informatics expertise.  Perhaps, more accurately, I should say "medical informatics expertise in someone who also thinks critically about all issues involved, including adverse effects, of IT."  Clinicians could supplement each section of the forms data if needed via dictation, which was directly transcribed by humans into the cardiology server.

"Clerical work for clerical employees, clinical work for clinicians" was the theme of the project.

Breaking from the almost religious belief that paper is to be abolished at all costs was the key to creating really useful and well-accepted health IT, even in this exceptionally busy critical care setting.  It was still being used over a decade later, ca. 2008 and may still be now.  I have not been back for a visit since then.

One argument might be made that hospitals cannot afford enough clerical employees to do all the data input.  I maintain that, with hospitals spending upwards of $100 million for EHRs, and with the data being used and sold profitably by a wide variety of stakeholders who contribute nothing for the medical data they obtain (EHR makers, insurers, regulators to name just a few), transcriptionists could be afforded.

Of course:

Physicians with simply too much free time on their hands - the majority, it might seem, based on the behavior of the EHR hyper-enthusiasts and government pundits - and who enjoy giving away the fruits of their labor for others' profits could still enter data directly into the computer.  If they want to.

I note that if physicians really were empowered, the current status quo of clinicians as unpaid data-input personnel for those who profit from the data likely would never have come to pass.

Entering orders would still be done by clinicians, although that process and the process of alerts and reminders also needs a major reworking, such as use of advanced NLP to allow a more natural input of orders.

In summary, in the late 1990s the gospel of eliminating paper from medicine, and of clinicians needing to perform clerical work, were challenged and shown to be false narratives and injurious to health IT progress in a critical care setting, invasive cardiology.

The lessons learned are more valuable today as they were then, considering that health IT experiment is failing on a wide scale today, with significant clinician rancor.  The CEO of the American Medical Association perhaps summed it up best when he referred to HIT as "the digital snake oil of the early 21st century" as at http://www.ama-assn.org/ama/pub/news/news/2016/2016-06-11-a16-madara-address.page.

Correction calls for abandoning cybernetic fetish words like "paperless" and a more appropriate allocation of computer-related tasks.  "Clerical work for clerical employees; clinical work for clinicians."

-- SS

Weird emails from Independence Blue Cross via its IT outsourcing partners: showing yet more health IT industry trust-destroying incompetence

In the past week I've received two emails that made me highly suspicious of medical/insurance identity theft.

The emails came from Independence Blue Cross, ibx.com, into the email account I receive normal mailings from them, and seemed to indicate someone had created an unauthorized user account (I redacted my email address below):

Aug. 5, 2016:

From: noreply@ibx.com
Date: Fri, Aug 5, 2016 at 7:19 PM
Subject: User Created
To: [my email address redacted]

User Created With UserId - userId20392, Password - password20392

July 27, 2016: 

From: noreply@ibx.com
Date: Wed, Jul 27, 2016 at 1:59 PM
Subject: User Created
To: [my email address redacted]

User Created With UserId - userId1546, Password - S04bd9u3tR

These userid's and passwords did not work at ibx.com's website, but my concern was that, if these were false accounts, the creator could have logged in and changed the password.

After the first email I left a message with the IBX fraud line, but heard nothing in response.

The metadata (IP headers) of the messages looked like this (I redacted my email address):

Delivered-To: [my email address redacted]
Received: by 10.237.44.68 with SMTP id f62csp1992388qtd;
        Fri, 5 Aug 2016 16:20:27 -0700 (PDT)
X-Received: by 10.36.77.145 with SMTP id l139mr7340323itb.19.1470439227798;
        Fri, 05 Aug 2016 16:20:27 -0700 (PDT)
Return-Path: 
Received: from cnxsgusgma01.cnxuat.com ([216.183.110.200])
        by mx.google.com with ESMTP id q123si19839234iof.67.2016.08.05.16.20.27
        for ;
        Fri, 05 Aug 2016 16:20:27 -0700 (PDT)
Received-SPF: softfail (google.com: domain of transitioning noreply@ibx.com does not designate 216.183.110.200 as permitted sender) client-ip=216.183.110.200;
Authentication-Results: mx.google.com;
       spf=softfail (google.com: domain of transitioning noreply@ibx.com does not designate 216.183.110.200 as permitted sender) smtp.mailfrom=noreply@ibx.com
Received: from IBCSGUSGAA01.cnxuat.com ([192.168.230.147]) by cnxsgusgma01.cnxuat.com with Microsoft SMTPSVC(8.5.9600.16384);
  Fri, 5 Aug 2016 19:19:39 -0400
Received: from ibcsgusgaa01.cnxuat.com ([127.0.0.1]) by IBCSGUSGAA01.cnxuat.com with Microsoft SMTPSVC(8.5.9600.16384);
  Fri, 5 Aug 2016 19:19:58 -0400
From: noreply@ibx.com
To: [my email address redacted]
Message-ID: <1180377472 .11989.1470439198021.javamail.ibcsgusgaa01="" ibcsgusgaa01="">
Subject: User Created
MIME-Version: 1.0
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Return-Path: noreply@ibx.com
X-OriginalArrivalTime: 05 Aug 2016 23:19:58.0024 (UTC) FILETIME=[E1DD4C80:01D1EF6F]
Date: 5 Aug 2016 19:19:58 -0400

User Created With UserId - userId20392, Password - password20392

After the second, I called IBX.  I was told it is a "malfunction", that these emails were not anything nefarious, other subscribers were affected, and that it "would be corrected soon."

I had already looked up the "Received from" header cnxsgusgma01.cnxuat.com [216.183.110.200]:

# ARIN WHOIS data and services are subject to the Terms of Use
# available at: https://www.arin.net/whois_tou.html
#
# If you see inaccuracies in the results, please report at
# https://www.arin.net/public/whoisinaccuracy/index.xhtml
#
#
# The following results may also be obtained via:
# https://whois.arin.net/rest/nets;q=216.183.110.200?showDetails=true&showARIN=false&showNonArinTopLevelNet=false&ext=netref2
#

Connecture, Inc. INFLOW-7524-7780 (NET-216-183-110-192-1) 216.183.110.192 - 216.183.110.255
Inflow Inc. INFL-AR-1 (NET-216-183-96-0-1) 216.183.96.0 - 216.183.127.255

Other IP's in the header appear to be of local (internal) workstations at the companies involved.

Who are these mysterious companies from which these emails seem to have originated?


Connecture, Inc:

http://www.connecture.com/the-connecture-difference/

Health insurance has entered the consumer age. Be ready. (We are.)

While there is almost universal agreement that health insurance will predominantly be distributed online in the near future, few American consumers have yet to experience it. In fact, most Americans have very little experience shopping for health insurance at all – let alone while making sense of numerous and often deceptively similar plans.

All of that is changing. Reform, the health insurance industry’s efforts to become more efficient, and Americans’ affinity for doing business online are all converging in the form of health insurance exchanges that present users with unprecedented freedom of choice.

Choice, of course, leads to questions. Which plans does my doctor participate in? Do they address my health needs? What about my family and my children? What happens if I need to go to the emergency room? How much will it cost – not just this month but year round? Am I eligible for a subsidy, and if so how much? In short, what’s the best plan for me and my family?

In health insurance, there are no cookie-cutter answers. That’s why health insurance exchanges and online distribution systems must do far more than enable consumers to enroll for coverage.

That’s where we come in. For more than 15 years we’ve focused on a singular goal: To create online systems and exchanges that empower Americans to choose the right health insurance plan online with confidence the first time, and every time.

Inflow Inc.

http://www.bloomberg.com/research/stocks/private/snapshot.asp?privcapId=105889

As of January 4, 2005, Inflow, Inc. was acquired by SunGard Availability Services, Inc. Inflow, Inc. provides facilities-based information technology outsourcing solutions to companies with critical business and network applications. The company offers its services in three primary lines: application hosting and management, business continuance and disaster recovery, and enterprise data-center management. Its application hosting and management services include application hosting and colocation, multi homed internet access, security services, application and infrastructure management, and network and system development. The company’s business continuance and disaster recovery services consist of business continuance planning/consulting, managed storage services, and content distribution services. Inflow’s enterprise data-center management services comprise onsite data-center management, operational support system management, data-center development, data-center audit services, data-center migration assistance, and business process documentation. Inflow, Inc. was founded in 1997 and was based in Thornton, Colorado.

Emphases mine.

So, perhaps millions of Independence Blue Cross customers are receiving emails that would reasonably cause suspicion in this day and age for identity theft, from companies that gloriously promise:

To create online systems and exchanges that empower Americans to choose the right health insurance plan online with confidence the first time, and every time.

To provide facilities-based information technology outsourcing solutions to companies with critical business and network applications

Confidence is the last thing the emails I received on behalf of ibx.com inspire in me.

If this information is being spilled (to the subscriber's own email account, but who knows where else?), I can only fear that other information is not quite secure, and wonder if these "ghost accounts" are just a glitch, or insiders spying on PHI, or other effects of either massive bugs or hacker attacks.

IT companies and companies that outsource their critical IT to others (including health IT makers and health IT buyers such as hospitals) - and the IT service providers themselves - need to really, really get their houses in order.

They need to stop beta-testing buggy software upon their customers (or live patients in the case of clinical IT).

Problems like this reflect significant and trust-busting incompetence, at best.

-- SS

Give Support to Mothers Who Can not breastfeeding

ASI is one type of food that meet all elements of the baby's needs, either physical, psikologisosial, and spiritual. Breastfeeding is very important for child development. But not all mothers can enjoy breast-feeding her child.
Mothers who managed to give exclusive breastfeeding until the child is two years old, would be proud. But unfortunately, sometimes mothers who managed to give this to her baby's first food, labeling of mothers who are less fortunate. In fact, such action is not very good.

"It is not good to label mothers who did not breastfeed. Because we did not know what had happened. Better help and support, "said Dr. Purnamawati S Pujianto, SpA (K), MMPed of Parents Care Foundation (YOP), when the seminar "Breastfeeding Is a Relationship" in the framework of World Breastfeeding Week 2016, which was held at the Ministry of Health of the Republic of Indonesia,
The aid in question according to him did not have the money or gifts, and also does not have to be expensive. "You can help by providing inputs, well what could be improved lifestyle or eating them," he said.
So better, give your support to help them achieve exclusive breast feeding her baby. Be mother to become a backrest and can give good advice and useful.
"Therefore, it will never diminish the value of a mother who was unable to breastfeed her child. And it does not mean that the mother can not raise a child meant well, "he said.
And for mothers who can not breast feed her, never desperate to keep trying different ways that breastmilk out. "Breastfeeding is a natural process and natural, so try to be patient and give yourself time," he said.

Common Causes of Cheating Men

Sex is not always the reason the man was having an affair. Research conducted a psychotherapist find the psychological reasons behind the man affair.
M. Gary Neuman, a psychotherapist who is also the author of The Truth About Cheating conducted a survey of 200 men who had an affair. The results were quite surprising. Approximately 48 percent of men surveyed said they had an affair for emotionally unsatisfied.

Neuman explained, men are more sensitive than that during this time people had expected. Men also want to be respected and admired. If they do not get in a relationship that followed, they will switch to other people.
The tendency to whom they turn not too surprising. According to the same survey, some people seek satisfaction in the office. Even 40 percent of men admitted having an affair with a coworker.
According to Neuman, coworkers women are more likely to admire the men and their work performance, citing Goodhousekeeping page Business Insider,
But more surprising than this study, beauty and physical attractiveness had little role as the reason they have affairs. Proven 88 percent of those surveyed revealed that they were having an affair with someone who is not as beautiful as their wives. Meanwhile, 68 percent of men who cheat feel guilty and realize that they are doing wrong.

4 Benefits of Orgasm in Men

Not only avoid prostate cancer, men who regularly orgasm have better health. In one study, regular ejaculation can memningkatkan opportunity to rid cancer-promoting genes. New cells will be formed after the sperm out. Old cells and cancer will be pushed out when ejaculation.
Here is are the benefits of orgasm in men other than getting rid of prostate cancer,

1. Increase kosentransi
Orgasm can diminish and your mind becomes more relaxed. After the male orgasm will be easier to focus on work because of cognitive increases.

2. Cure insomnia
Orgasm can menyebuhkan insomnia. For the love, the body secretes the hormone oxytocin can make sleep more soundly.

3. Extend the life of
Many studies have shown that an active life in bed can prolong the life of men. Men with reproductive system are active live longer and healthier.

4. Prevent flu
Flu can occur because the immune system was weak. Orgasm will make immunoglobulin A or antibody in the body increases so that the virus that causes influenza will be shut out of the body

NIST workshop "The Role of Standards in Preventing & Mitigating Health IT Patient Safety Risks" perhaps should be titled "The Role of Common Sense in Preventing & Mitigating Health IT Patient Safety Risks Before Rolling Out Bad Health IT Nationally"

Ready, fire, aim.

As I wrote in 2010-12 at "Cart before the horse" posts at http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html and http://hcrenewal.blogspot.com/2012/06/cart-before-horse-part-3-ahrqs-health.html, rolling out health IT nationally before having a firm grasp of its risks was an abrogation of medical ethics and long standing treatises on medical experimentation, including the need for informed consent, dating back to the post-WW2 period.

Ready, fire, aim:  let's roll out health IT nationally, then figure out how to make it safe...

Now we have this "workshop" to be held September 7, 2016:

http://www.nist.gov/healthcare/usability/the-role-of-standards-in-preventing-and-mitigating-health-it-patient-safety-risks-workshop.cfm

The Role of Standards in Preventing & Mitigating Health IT Patient Safety Risks

Purpose:
Health IT Community Technical Workshop for all Stakeholders: Learn and Share Industry Best Practices.

Objectives:
Bring together all Health IT stakeholders to share best practices and review the fundamentals of risk prevention and mitigation that apply to Health IT. Health IT standards are part of the foundation needed to deliver high quality, patient-centric care. The industry continues to gain a better understanding of the relationship between managing risk and providing quality care through the safe use of Health IT.

This forum is an opportunity to receive updates on the latest standards development process related to risk prevention and mitigation, quality assurance and safety-related usability, to find out about recent findings from studies conducted on this subject, and to bring industry stakeholders together to share best practice, and define the path forward for risk prevention and mitigation that apply to Health IT.

Agenda:
Final Agenda (http://www.nist.gov/healthcare/usability/upload/NIST-Workshop-Agenda-7_7_16.pdf)

This workshop is an admission that the industry lacked in understanding "of the relationship between managing risk and providing quality care through the safe use of Health IT" at a time when rollout of bad health IT was pushed like a Miracle Cure by government and industry pundits, and became a national mandate,

To all the boneheads who did push this technology out the door prematurely before its risks and safety were reasonably understood, and/or ignored the "iconoclasts" as they were derogatorily known, thanks for harassing doctors and nurses to the point of exhaustion, harming patients via cybernetic experimentation without consent, and wasting billions of dollars of taxpayer money.  (It would have been a very good thing, I note, if efforts like this had been mandated before my mother's demise of care continuity failure precipitated by bad health IT.)

NIST, this workshop is late, but better late than never.

However, I am increasingly of the belief that this technology is unsuitable for busy clinicians, as long as they bear the clerical burdens, and can never be fixed it that arrangement is not drastically changed.

"Best practices", I believe, call for a return to paper (specialized forms depending on the setting) for clinical data capture by busy doctors and nurses, and data entry into a computer via clerical personnel.

Why do I hold this belief?

I designed such a system for invasive cardiology (a highly complex, critical-care medical domain) 20 years ago that was highly successful and popular, even among busy invasive cardiologists, to replace a direct-computer-entry commercial product from hell.  This is written up at this link: http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story

After modeling the dataset for the domain of cardiac catheterization to a high degree of granularity, the forms were designed and tested collaboratively with the invasivist leaders, as seen below.

The physicians recorded real-time onto the forms, or shortly after they de-gloved.  There were also specialized forms for the cath lab technicians and nurses. Click to enlarge.  Each section could be supplemented via dictation if needed, and the text transcribed and sent to the application server for inclusion on the full cath report, via a direct link from central transcription.

No wasting of clinicians' valuable time and limited cognitive energy navigating lousy EHR user interfaces, interacting with a multitude of mind-numbing icons and widgets, and other frustrations looking to enter critical data.

Physician's data collection form, side 1.  Click to enlarge.

Physician's data collection form, side 2

Cath technician/nurse's data collection form, side 1

Cath technician/nurse's data collection form, side 2

Clerical employees were hired to perform data entry from the paper forms and inquire with the doctors when there were questions about data recorded during the cath.

Forms for less specialized medical domains would be significantly simpler.

Addendum:

Ca. 2007, (non-medical) Siemens Healthcare IT executives in Malvern, PA (a Siemens division now bought out by Cerner) were shown this project by me, still in use just a few miles south of them in Delaware, and deemed it "impractical" for commercialization.  I thought that very sadly ironic considering the incredible engineering prowess and accomplishments world-wide of parent company Siemens A.G.

In my direct first-hand experience, non-medical IT executives are one of the biggest impediments to health IT progress (and safety), in both hospitals and the pharmaceutical industry.

http://www.siemens.com/about/en/
About Siemens
Siemens is a global powerhouse focusing on the areas of electrification, automation and digitalization. One of the world’s largest producers of energy-efficient, resource-saving technologies, Siemens is a leading supplier of systems for power generation and transmission as well as medical diagnosis. In infrastructure and industry solutions the company plays a pioneering role. As of September 30, 2015, we had around 348,000 employees in more than 200 countries. In fiscal 2015, they generated revenues of €75.6 billion.

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